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Cancer of the sigmoid colon: Left hemicolectomy or sigmoidectomy?
Abstract
Left hemicolectomy is the ideal treatment of sigmoid cancer, but sometimes sigmoidectomy is a safe treatment. We radically treated 102 patients affected by sigmoid cancer: 83 were gross sigmoid cancer treated by left hemicolectomy, 19 were residual cancer after endoscopic polypectomy; of these, 4 underwent left hemicolectomy and 15 underwent sigmoidectomy. No recurrence was observed in the 15 patients treated by sigmoidectomy. In patients with sigmoid cancer accidentally associated with sigmoid diverticulitis, the surgeon should extend the resection up to a left hemicolectomy or follow-up with the patient, but sometimes sigmoidectomy could be safe. The sentinel lymph node technique in colorectal cancer could suggest indications to complementary treatments. However, in the presence of a negative node, sigmoidectomy could probably be planned as a rational treatment. In conclusion, even if more data are required, in some selected cases of sigmoid cancer, sigmoidectomy could be a safe treatment.
... Were R1/R2s described in the study flow? If described, were R1s/R2s included What were R1/non-curative rates Amri et al. (2015) [20] n o 4.3% R1/R2 b Di Cataldo et al. (2007) [21] n o unable to retrieve data b Harris et al. (2002) [22] yes no 28% max a Jagoditsch et al. (2000) [23] yes no 15% Kraemer et al. (2001) [24] yes no Lautenbach et al. (1994) [25] yes no Leung et al. (2004) [26] n o Liska et al. (2016) [16] yes yes (R1 included, R2 excluded) R1 4% (author unable to retrieve R2 data b ) Manfredi et al. (2006) [27] yes no 19.7% Marinello et al. (2015) [28] yes no no response b Michelassi et al. (1991) [29] n o Minsky et al. (1988) [30] yes no 37% max a Olson et al. (1980) [31] yes no 54% max a Park et al. (2016) [32] yes no unable to retrieve data b Radespiel Troger et al. (2004) [33] yes no Sjovall et al. (2006) [15] yes no 4.5%e12.8% ...
... Were R1/R2s described in the study flow? If described, were R1s/R2s included What were R1/non-curative rates Amri et al. (2015) [20] n o 4.3% R1/R2 b Di Cataldo et al. (2007) [21] n o unable to retrieve data b Harris et al. (2002) [22] yes no 28% max a Jagoditsch et al. (2000) [23] yes no 15% Kraemer et al. (2001) [24] yes no Lautenbach et al. (1994) [25] yes no Leung et al. (2004) [26] n o Liska et al. (2016) [16] yes yes (R1 included, R2 excluded) R1 4% (author unable to retrieve R2 data b ) Manfredi et al. (2006) [27] yes no 19.7% Marinello et al. (2015) [28] yes no no response b Michelassi et al. (1991) [29] n o Minsky et al. (1988) [30] yes no 37% max a Olson et al. (1980) [31] yes no 54% max a Park et al. (2016) [32] yes no unable to retrieve data b Radespiel Troger et al. (2004) [33] yes no Sjovall et al. (2006) [15] yes no 4.5%e12.8% ...
... Were R1/R2s described in the study flow? If described, were R1s/R2s included What were R1/non-curative rates Amri et al. (2015) [20] n o 4.3% R1/R2 b Di Cataldo et al. (2007) [21] n o unable to retrieve data b Harris et al. (2002) [22] yes no 28% max a Jagoditsch et al. (2000) [23] yes no 15% Kraemer et al. (2001) [24] yes no Lautenbach et al. (1994) [25] yes no Leung et al. (2004) [26] n o Liska et al. (2016) [16] yes yes (R1 included, R2 excluded) R1 4% (author unable to retrieve R2 data b ) Manfredi et al. (2006) [27] yes no 19.7% Marinello et al. (2015) [28] yes no no response b Michelassi et al. (1991) [29] n o Minsky et al. (1988) [30] yes no 37% max a Olson et al. (1980) [31] yes no 54% max a Park et al. (2016) [32] yes no unable to retrieve data b Radespiel Troger et al. (2004) [33] yes no Sjovall et al. (2006) [15] yes no 4.5%e12.8% ...
... Were R1/R2s described in the study flow? If described, were R1s/R2s included What were R1/non-curative rates Amri et al. (2015) [20] n o 4.3% R1/R2 b Di Cataldo et al. (2007) [21] n o unable to retrieve data b Harris et al. (2002) [22] yes no 28% max a Jagoditsch et al. (2000) [23] yes no 15% Kraemer et al. (2001) [24] yes no Lautenbach et al. (1994) [25] yes no Leung et al. (2004) [26] n o Liska et al. (2016) [16] yes yes (R1 included, R2 excluded) R1 4% (author unable to retrieve R2 data b ) Manfredi et al. (2006) [27] yes no 19.7% Marinello et al. (2015) [28] yes no no response b Michelassi et al. (1991) [29] n o Minsky et al. (1988) [30] yes no 37% max a Olson et al. (1980) [31] yes no 54% max a Park et al. (2016) [32] yes no unable to retrieve data b Radespiel Troger et al. (2004) [33] yes no Sjovall et al. (2006) [15] yes no 4.5%e12.8% ...
Background: Colon cancer outcomes are now inferior to rectal cancer outcomes. The sigmoid colon is the most common site of colonic cancer. The aim of this review was to investigate the oncological outcomes for sigmoid cancer. Methods: A systematic review and meta-analysis was performed. We included any study of the oncological outcomes for sigmoid cancer such as local recurrence, distant recurrence and disease free survival. A systematic search was conducted in Medline from inception to November 2016. Study quality was evaluated with the Newcastle-Ottawa Scale. The study was registered on PROSPERO (CRD42017069326). Results: The search terms returned 1323 results. We identified a total of 17 eligible studies including 5953 patients. The pooled local recurrence rate was 10.5% in 15 studies with 5148 patients (95% CI 0.07–0.14) and heterogeneity measured by I ² was 94%. The pooled distant recurrence rate was 19.5% (7 studies, 2040 patients, 95% CI (0.14–0.25), I ² 90%). The pooled disease free survival at 5 years was 80.4% (5 studies, 2336 patients, 95% CI 78.6%–82.1%, I ² 11.5%.). The median Newcastle-Ottawa score was 4 out of 9. R1 and R2 resections were excluded or not described in 16/17 studies. Two studies described R1 and R2 rates of 15–20%. Conclusion: The pooled local recurrence rate of sigmoid cancer of 10.5% is higher than contemporary rates of local recurrence of rectal cancer. A large number of papers fail to describe or include R1 resections of sigmoid cancer, which are frequently described as palliative. © 2018 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology
... Для лікування "правих раків" хірурги виконують правосторонню геміколектомію, для "лівих" -лівосторонню. Навіть є ціла низка авторів, які вважають резекцію сигмоподібної кишки не до кінця виправданою з точки зору онкологічного радикалізму [10]. Крім того, вимагає уточнення геномна і протеомна машинерія цих видів раку: BRAF V600E mt, KRAS G12D mt, KRAS G13D mt, KRAS G12 mt та інші. ...
Стаття присвячена вивченню виживаності при колоректальному раку та впливу деяких загальних клінічних факторів на тривалість життя наших пацієнтів. Колоректальний рак (КРР) є актуальною проблемою сучасності та сучасної онкології, оскільки захворюваність на КРР постійно зростає. Вважається, що розвиток КРР у 50 % усіх випадків пов’язаний зі способом життя та тривалим впливом канцерогенів. Генетичні чинники відіграють вирішальну роль у 5-20 % випадків. Встановлено, що від 20 до 50 % хворих на КРР при первинному виявленні вже мають віддалені метастази. Розуміння біології раку товстої кишки ґрунтується на аналізі ступеня агресивності його перебігу, виживаності пацієнтів, впливу проведених оперативних та комбінованих методів лікування на перебіг захворювання та наявності ряду інших факторів, які ще не повністю зрозумілі клініцистам (вплив прихованих метастазів, циркулюючих ракових клітин, генетичних причин тощо). Пухлини проксимального відділу товстої кишки – це пухлини, що локалізуються в сліпій кишці, висхідному та печінковому згинах товстої кишки, тобто власне пухлини правої половини товстої кишки. Чим проксимальніше пухлина була розташована в правій половині товстої кишки, тим довше жили пацієнти. Через 24 місяці спостереження тривалість спостереження за пацієнтами з пухлинами сліпої кишки, висхідної ободової кишки та печінкового кута становила 71,43 %, 63,64 % і 72,73 % відповідно. За період спостереження 32 місяці: 42,86 %, 36,36 %, 18,18 %. За період спостереження 55 місяців: 14,29 %, 9,09 %, 0 % відповідно. Таким чином, біологія була ключовим фактором, оскільки групи були еквівалентними за стадією, частотою ураження лімфатичних вузлів і ступенем диференціації пухлини. Тому, з нашої точки зору, виділення правобічної РТК, р-РТК в окрему нозоформу має клінічно значущий характер: саме в правій половині товстої кишки частіше зустрічається токсикоанемічна форма; рідше (майже ніколи) – обтураційна, значно більш характерна для лівостороннього раку, l-RTK. Як правило, пухлини правої кишки мають такий геномний контекст: гіперметилювання MLH1, мутація BRAF і MSI високого ступеня, тоді як пухлини лівої кишки є мутантними p53 і KRAS.
Surgery remains the cornerstone in the multidisciplinary treatment of colon and rectal cancer. Many diagnostic, technical, and adjuvant therapies are known to impact the immediate and long-term oncologic results. Guidelines for appropriate cancer-specific management of colorectal cancer should be adhered to so as to optimize the oncologic outcomes. Similarly, patient-specific surgical outcomes are also linked to many systems-based factors, such as appropriate use of perioperative antibiotics, venous thromboembolism prophylaxis, and avoidance of surgical complications.
Extended lymphadenectomy has gained considerable attention as an adjunct to conventional colon cancer surgery with the hope that it may potentially decrease local recurrence rates and improve cancer-specific outcome measures. Despite the enthusiasm surrounding these techniques, it is difficult to establish any additional survival benefit associated with more comprehensive lymphadenectomy strategies when these are performed in addition to conventional colon cancer surgery. Furthermore, these techniques remain unproven by large randomized clinical trials. The appropriate indications for performing extended lymphadenectomy also remain unclear, and there is a lack of standardization with regard to surgical technique. Moreover, there are a number of confounding factors that frequently receive little attention when oncological outcome measures are reported following extended lymphadenectomy in the setting of colon cancer. The purpose of this review is to outline these confounding issues and discuss their impact on reports describing cancer-specific outcome measures following the use of extended lymphadenectomy techniques. Furthermore, this review proposes that in light of the available published evidence, the role of radical lymphadenectomy is currently unproven, with large randomized clinical trials required in the future to determine whether there is a survival benefit for colon cancer patients.
Localized resection of early stage colon cancer is increasingly technically feasible by truly minimally invasive means. Such techniques as endoscopic submucosal dissection (ESD) and Natural Orifice Transluminal Endoscopic Surgery (N.O.T.E.S.) now raise the prospect of focused intraluminal and transmural resection of small primary tumors without abdominal wall transgression. The potential clinical benefit that patients may accrue from targeted dissection as definitive treatment in place of radical operation is not yet definitively proven but may be considerable at least in the short-term. However, oncological propriety and outcomes must be maintained. In particular methods by which regional nodal staging can be assured if standard operation is avoided need still to be established. Sentinel node mapping is one such putative means of doing so that deserves serious consideration from this perspective as it performs a similar function for breast cancer and melanoma and because there is already considerable evidence to suggest the technique in colonic neoplasia may be at its most accurate in germinal disease. In addition, it may already be employed by laparoscopy while solely transluminal means of its deployment are advancing. While the confluence of operative technologies and techniques now coming on-stream has the potential to precipitate a dramatic shift in the paradigm for the management of early stage colonic neoplasia, considerable confirmatory study is required to ensure that oncology propriety and treatment efficacy is maintained so that patient benefit may be maximized.
One hundred and ninety five consecutive, potentially curative resections for adenocarcinoma of the stomach were performed in one surgical department between 1970 and 1989: 76 patients underwent gastrectomy with splenectomy and 119 gastrectomy without splenectomy. Operative mortality was 12% after gastrectomy with splenectomy, but only 2.5% after gastrectomy without splenectomy (p < 0.05). Postoperative complications were also significantly more common when splenectomy was combined with gastrectomy (41% v 14%, p < 0.01). Cumulative five year survival was 45% after gastrectomy with splenectomy, compared with 71% after gastrectomy alone (p < 0.01). When the results of the two groups of patients were compared, stage for pathological stage, no evidence was found that splenectomy improved survival. Application of Cox's proportional hazards model, which makes allowance for other variables such as the T and N stages, showed that splenectomy had an adverse influence on patients' survival. Splenectomy does not benefit the patient and its routine use in the course of radical resections for carcinoma of the stomach should be abandoned.
Almost one third of patients with “node-negative” colorectal carcinoma (CRC) develop systemic disease. This implies that these patients have occult disease that is inadequately treated by surgery alone. We have coupled sentinel lymph node mapping and a focused pathologic examination to detect occult nodal micrometastases in CRC. Since 1996, sentinel lymph node mapping has been performed in 100 consecutive patients undergoing colectomy for CRC. Peritumoral injection of 0.5 to 1.0 ml of isosulfan blue dye was performed to demonstrate the sentinel node(s). All lymph nodes in the resection specimen were examined by routine hematoxylin and eosin staining. In addition, a focused examination of multiple sections of the sentinel nodes was performed using both hematoxylin and eosin and cytokeratin immunohistochemical analysis (CK-IHC). Overall, lymphatic mapping successfully demonstrated one to four sentinel lymph nodes in 97 (97%) of 100 patients. These sentinel nodes accurately reflected the status of the nodal basin in 92 (95%) of 97 patients. All five of the false negative cases occurred in T3/T4 tumors, and three of the five occurred during the first 30 cases in the experience. Unexpected lymphatic drainage was encountered in eight patients (8%) and altered the operative approach. Twenty-six patients were node positive by routine hematoxylin and eosin staining. Of the remaining 74 patients with hematoxylin and eosin–negative nodes, an additional 18 patients (24%) were upstaged by identification of occult nodal micrometastases that were missed on routine hematoxylin and eosin staining but detected on multiple sections (n = 5) or by CK-IHC (n = 13). The sentinel lymph nodes were the only positive nodes in 19 cases. Sentinel lymph node mapping may be performed in CRC with a high degree of success and accuracy. A focused pathologic examination of the sentinel node detects micrometastatic disease that is missed by conventional techniques in a significant proportion of patients with early CRC. Further studies are necessary to elucidate the clinical relevance of these micrometastases. (J Gastrointest Surg 2002;6:322–330.)
This review examines the incidence and implications of overwhelming infection in patients who have undergone splenectomy following trauma.
Treatment options for patients with endoscopically removed malignant colorectal polyps are polypectomy alone vs. polypectomy followed by surgery. The aim of this study was to define histopathologic parameters that can be used for clinically relevant treatment decisions.
Five pathologists evaluated 140 polyps for the presence or absence of unfavorable histology. Unfavorable histology was tumor at or near (< or = 1.0 mm) the margin and/or grade III and/or lymphatic and/or venous invasion. Adverse outcome was recurrent and/or local cancer and/or lymph node metastasis.
Adverse outcome was 19.7% (14 of 71), 8.6% (2 of 23), and 0% (0 of 46) when unfavorable histology was present, indefinite (lack of agreement), and absent, respectively (P < 0.0005, present vs. absent). Four patients with cancer > 1.0 mm from the margin had an adverse outcome (2 with lymphatic invasion and 2 indefinite for lymphatic invasion). Four patients with negative resections later developed distant metastases. Eight patients (6.3%) died of disease, and 2 of 69 without unfavorable histology (both indefinite for lymphatic invasion) had an adverse outcome. Interobserver strength of agreement was substantial to almost perfect for margin, grade, and venous invasion and fair to substantial for lymphatic invasion.
This system is usable clinically. Patients with unfavorable histology are probably best managed by resection postpolypectomy, whereas in the absence of unfavorable histology, they probably can be treated by polypectomy only.
In Japan, the standard treatment policy for all potentially curable patients with gastric cancer is radical resection, including extensive lymph node dissection. The extent of lymph node dissection remains a controversial issue in the management of early gastric cancer. A recent trend in the surgical treatment of early gastric carcinoma has been to limit surgery such that a complete cure is achieved and the patient's quality of life is improved. However, approximately 10% of early gastric cancers are reported to be node positive and little is known about the protocol of surgical treatment most appropriate for the treatment of early gastric cancer. In this study, we examined the clinicopathological features that could distinguish node-positive cancer from node-negative cancer.
The clinicopathological features of 26 patients with node-positive early gastric cancer were reviewed from the database of gastric cancer at the Department of Surgery, Sendai National Hospital. They were compared with those of 239 patients with node-negative cancer.
Tumor size, macroscopic appearance, depth of cancer invasion, histological growth pattern and lymphatic invasion were associated with lymph node metastasis. Node-positive patients with early gastric cancer had a poorer survival rate than node-negative patients (P<0.05).
Limited surgery, such as local resection without lymphadenectomy, can be performed for elevated or flat type cancer, or tumor <2 cm in diameter. Lymphadenectomy is recommended to achieve higher possible cure rates for other early gastric cancers.
Increasing evidence supports that the sentinel node (SN) is at greatest risk for harboring metastatic disease. This study describes a novel technique to identify the SN in colorectal carcinoma.
Within 30 minutes of resection, colorectal specimens were injected submucosally with isosulfan blue in four quadrants. Blue lymphatic channels were identified in the mesentery and followed to the blue-stained SN(s), which were then harvested. The specimen was fixed in formalin and subsequently analyzed in the usual fashion. Blue-stained nodes that were negative by hematoxylin and eosin staining were further analyzed by immunohistochemical staining.
During a 6-month period, 26 patients with adenocarcinoma of the colon and rectum undergoing routine resection were studied. There were 18 men and 8 women ranging in age from 29 to 86 years (median 66). Blue-stained SNs were identified in 24 of 26 specimens. The mean number of SNs identified per patient was 2.8 +/- 1.6. Seventy-three SNs were identified from a total of 479 lymph nodes harvested. The mean number of nodes identified per patient was 18.4 +/-7. A total of 67 lymph nodes in 12 patients were identified by hematoxylin and eosin staining to have evidence of metastatic disease. Fourteen (20%) of these nodes in six patients were stained blue. However, with immunohistochemical staining, only one blue node did not have evidence of metastatic tumor in a lymphatic basin with tumor present. Four patients (29%) whose lymphatic basins were negative by hematoxylin and eosin staining were upstaged by immunohistochemical staining of the SN.
Ex vivo mapping of the colon and rectum is technically feasible and may provide a useful approach to the ultrastaging of colorectal carcinoma.
The sentinel lymph node (SLN) mapping technique has been used in breast cancer and melanoma, and was recently described for colon cancer.
Thirty-five patients with colon cancer underwent intraoperative SLN mapping. One milliliter of 1% isosulfan blue was injected subserosally around the tumor. The first nodal area that was highlighted with blue was identified as the SLN. All lymph nodes underwent examination with hematoxylin and eosin (H&E) stain. SLNs underwent additional sectioning and were stained with CAM 5.2.
Lymphatic mapping adequately identified the SLN in 25 patients (71%). In the 15 cases where the SLNs were negative for metastases, all other non-SLNs were also negative (0% false negative rate). The SLN was the only site of metastases in 6 (17%) of 35 patients. CAM 5.2 staining provided the only evidence of micrometastases in 4 (11%) of 35 patients.
Intraoperative SLN mapping is a feasible technique with a reasonable SLN identification rate (71%). The absence of metastases in the SLNs accurately predicts the status of the non-SLNs. Tumors in 11% of patients were upstaged by the demonstration of micrometastatic involvement, and these patients may benefit from further adjuvant chemotherapy.
Sentinel lymph node (SLN) biopsy may improve staging of colorectal cancer. We tested the feasibility of ex vivo SLN dissection.
Patients undergoing resection of a primary colorectal cancer were included in this study. SLN identification involved ex vivo injection of 1 cc isosulfan blue dye subserosally in the colon or submucosally in the rectum on a separate field. SLNs were cut at 2 mm intervals. Three hematoxylin and eosin-stained (HE) sections were prepared in addition to a middle level for cytokeratin immunostaining.
Twenty-six patients with varying tumor location and stage were enrolled and the SLN was identified in 88% (23/26) cases. Three failures occurred in patients with rectal cancer. The average number of SLN harvested was 2.5. The status of the nodal basin was accurately predicted in 91% (21/23) of patients. Two false negative sentinel lymph nodes were harvested in 2 of 3 patients with stage III/IV colorectal cancer. The SLN upstaged 2 patients as a result of HE stained step sections (n = 1) and immunostaining (n = 1).
This data suggests that ex vivo SLN biopsy is feasible in colorectal cancer. Although ex vivo SLN biopsy does not alter the lymphatic dissection, it may upstage a subset of patients. The ex vivo technique may be less applicable in rectal cancer and false negative results may occur.
The purpose of this study was to determine the factors that are predictive of lymph node metastasis in a small gastric cancer tumor <2 cm in diameter. The clinicopathological features of 17 patients with node-positive small gastric cancer were reviewed from the database of gastric cancer at the Department of Surgery, Sendai National Hospital, Sendai, Japan, and they were compared with those of 131 patients with node-negative cancer. The independent risk factors influencing the lymph node metastasis were determined by multiple logistic regression analysis. Depth of invasion, macroscopic appearance, cancer-stromal relationship, and lymphatic microinvasion were found to be associated with lymph node metastasis. The variables found to be significant risk factors for lymph node metastasis were depth of invasion (P = 0.0250) and lymphatic microinvasion (P = 0.0028). It is possible for even a small gastric cancer tumor to have lymph node metastasis. A surgeon treating a small gastric cancer tumor must consider that although the cure rate is high, >10% of these tumors have lymph node metastases. Because of the possibility of lymph node metastasis, even with accurate knowledge of the depth of cancer invasion, selective performance of local resection or limited surgery with incomplete lymph node dissection is not justified. Accurate preoperative diagnosis and the appropriate decision for surgical indication are important. Large-scale randomized, controlled trials should be performed to show the advantage of limited surgery for gastric cancer.