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PubMed1998

Resection of colorectal liver metastases: 25-year experience.

The aim of this retrospective study was to analyze survival and prognostic factors in 111 consecutive patients undergoing curative resection of liver metastases from colorectal cancer. In addition, the time periods 1971-1984 and 1985-1995 were compared; criteria for first liver resection did not change with time, whereas the attitude toward re-resection was more aggressive during the latter period. Operative mortality was 6% during 1971-1984 and 0% during 1985-1995 (3.6% for all patients). The crude 5-year actuarial survivals were 19% and 35% for patients operated during 1971-1984 and 1985-1995, respectively (25% for the whole period). Relapse at any site was observed in 52 patients (81%) operated during the first period and in 29 patients (67%) operated during the second period; re-resection was performed in 12 (23%) and 15 (52%) of these patients, respectively. Five-year survival after hepatic re-resection was 29% (no operative mortality). In the univariate analysis, significant determinants for long-term survival were, in descending order, a clear resection margin, high degree of fibrosis around the tumor, absence of extrahepatic metastases (including metastases to the liver hilum), use of an ultrasound dissector, low preoperative serum carcinoembryonic antigen (CEA) level, year of resection (1985-1995), and low/moderate grade of liver tumor. There were no 5-year survivors when extrahepatic metastases were present, the liver tumor(s) had a low differentiation or satellites, or the resection margin was involved with tumor. In the multivariate analysis, the determinants were grade of liver tumor, absence of extrahepatic tumor, few intraoperative blood transfusions, low preoperative serum CEA level, and year of resection (1985-1995). It is concluded that: (1) an increased rate of hepatic re-resection was partly responsible for the improved outcome after liver resection for colorectal metastases during recent years; (2) patients with extrahepatic metastases did not benefit from liver resection; and (3) surgery should be performed with a clear resection margin and minimal blood loss.

Adult↗
PubMed1998

Determinants of survival following hepatic resection for metastatic colorectal cancer.

Hepatic resection remains the only potentially curative treatment for metastatic colorectal cancer. This retrospective review study was undertaken in an attempt to identify factors that influence patient survival following hepatic resection for metastatic colorectal cancer. From January 1978 to December 1993, a total of 301 patients underwent a total of 345 planned hepatic resections for metastatic colorectal cancer. Of those, 245 patients had one resection, 44 had two resections, and 12 had three resections. For all patients the overall median survival was 20.6 months, operative mortality was 1.1%, and overall morbidity was 17.2%. Average hospital stay was 9 days. Statistical analysis included univariate analysis using log rank comparisons, Kaplan-Meier survival curves, and multivariate analysis using Cox proportional hazards regression. The statistically significant factors that influenced survival were distribution of liver metastases, unilobar versus bilobar (p = 0.0001), resected versus nonresected (p < 0.0001), and tumor-free surgical margins versus positive margins (p = 0.001). Surprisingly, the disease-free interval and the original stage of the primary tumor did not predict survival (p = not significant). Other factors that had no influence on survival were type of resection, size and number of liver metastases, ABO blood group, and the number of perioperative blood transfusions. For those patients who underwent resection of unilobar metastases with tumor-free margins, the 5-year survival rate was 29% with a median survival of 35 months and eight survivors > 7 years. In addition, one patient with bilobar disease had survival > 7 years and five patients who had resection of hepatic metastases and extrahepatic cancer simultaneously had survival > 3 years. Our data support the concept that patients with unilobar metastatic disease who undergo surgical resection with tumor-free surgical margins can be afforded a significant opportunity at long-term survival with acceptable morbidity, mortality, and hospital stay. Also, certain patients with bilobar or extrahepatic disease (or both) who undergo complete resection can enjoy a long-term survival. In these subgroups of patients resection should be considered on an individual basis.

Adenocarcinoma↗
PubMed1994

Influence of surgical resection and brachytherapy in the management of superior sulcus tumor.

We analyzed the results of surgical treatment of all patients presenting with untreated superior sulcus tumors between 1974 to 1991 inclusive at our institution. Most patients received preoperative radiotherapy. We attempted to analyze the influence of surgical resection and intraoperative brachytherapy in obtaining locoregional control and disease-free survival. One hundred twenty-four patients underwent thoracotomy and 100 patients underwent resection. The overall 5-year survival rate was 26% for all patients and 30% for resected patients. Those patients receiving a complete resection achieved a 41% 5-year survival. The best single group were those patients undergoing a lobectomy (versus wedge resection) and en-bloc chest wall resection (60% 5-year survival). We were unable to demonstrate an advantage for the use of intraoperative brachytherapy in those patients with complete resection. For those patients with incomplete resection, the use of brachytherapy combined with preoperative or postoperative external radiation therapy resulted in a 9% 5-year survival. Locoregional failure was significant both in patients with complete resection and in patients with incomplete resection. Adverse prognostic factors included Horner's syndrome, N2 and N3 disease, T4 disease, and incomplete resections. In superior sulcus tumors, every attempt to completely resect the tumor by en-bloc chest wall resection combined with lobectomy and adequate nodal staging remains the surgical treatment of choice together with either preoperative, postoperative, or "sandwich" external radiation therapy.

Adult↗
PubMed2000

Inferior head resection of the pancreas for intraductal papillary mucinous tumors.

BACKGROUND: Patients with intraductal papillary mucinous tumor have a favorable prognosis after surgical treatment. When this neoplasm is located in the head of the pancreas, resection has conventionally required pancreatoduodenectomy. Although pancreatoduodenectomy can now be performed with a low mortality rate, morbidity still occurs frequently. METHODS: Between November 1982 and January 1999, 38 intraductal papillary mucinous tumors of the pancreas were resected at the Chiba University Hospital. Seven patients (18%) underwent inferior head resection of the pancreas. In this preliminary study, the operative technique is presented, and its efficacy in improvement of quality of life is evaluated. RESULTS: Patients with intraductal papillary mucinous tumor underwent resection with no perioperative mortality. After discharge from hospital, 6 patients who underwent inferior head resection were still alive without recurrent disease after a median follow-up of 3 years. However, 1 patient developed peritoneal dissemination and died 18 months after inferior head resection. Patients had regained 98% of preoperative weight 1 year after inferior head resection. N-benzoyl-L-tyrosyl-p-amino-benzoic acid (BT-PABA) excretion test showed the same value before (73%) and after (73%) inferior head resection (n = 7). Pancreatic fistulas occurred more frequently after inferior head resection (38%), but the incidence of major complications was similar between inferior head resection and other types of pancreatic head resection. CONCLUSIONS: Pancreatic function was well preserved, and patients regained 98% of preoperative weight after inferior head resection of the pancreas. The authors concluded that the limited involvement of intraductal papillary mucinous tumors enables the surgeons to perform inferior head resection of the pancreas.

Adenocarcinoma, Mucinous↗
PubMed1998

Complete resection is not required in patients with neuroblastoma under 1 year of age.

BACKGROUND/PURPOSE: The prognosis of neuroblastoma (NB) patients when detected before 1 year of age is excellent, particularly in patients whose disease is detected by screening. In some institutions patients with stage I or II NB detected by screening have been observed closely without any treatment. Most showed tumor regression or maturation and are surviving without tumor resection. Resection of infantile NB sometimes is complicated by vascular accidents resulting in vanishing kidney or intestinal infarction. The role of surgery in the treatment of infantile NB therefore is becoming controversial. The authors have treated infants who have easily resectable primary tumors with resection and sampling for lymph node metastases. If the resection of the primary tumor seemed difficult, only biopsy was performed initially followed by chemotherapy with or without resection. The authors analyzed the clinical outcome of the infantile NB in their institution to elucidate the role of surgery in this particular group of patients. METHODS: Thirty-six patients less than 12 months of age were treated between 1982 and 1997. Twenty-five patients who showed no symptoms had NB detected by screening at 6 months. Five patients had stage IVS disease in early infancy. No patients had bone or remote lymph node metastases. N-mycamplification was not detected in any of the 28 tumors examined. There were four diploid and 12 near-triploid tumors. RESULTS: Complete resection was possible in 13 stage I and II patients without any complications. Obvious lymph node metastases were not resected in 13 patients with stage II or III NB. Partial resection leaving gross residual disease was accomplished in three patients with stage III NB. Surgical resection was not attempted in four patients because of unresectability in three patients with stage III or IVS disease and because of marked tumor shrinkage after a short course of chemotherapy in one patient with stage III NB involving the celiac axis. A neonatal cervicomediastinal stage III NB recurred very rapidly after partial resection but started to regress spontaneously 2 months postoperatively. Another neonatal stage II cervical NB progressed to stage IVS with hepatomegaly causing respiratory distress but regressed spontaneously. All the patients are alive and disease free without surgical morbidity. CONCLUSION: All of the 21 patients who underwent partial tumor resection with or without chemotherapy are alive and doing well without tumor, indicating that complete resection is not required in this particular group of patients.

Age Factors↗
PubMed1999

Is resection of pulmonary and hepatic metastases warranted in patients with colorectal cancer?

BACKGROUND: Conventional management of stage IV colorectal carcinoma is palliative. The value of resecting both liver and lung colorectal metastases that occur in isolation of other sites of metastasis is undetermined. OBJECTIVES: Our objectives were to (1) assess the efficacy of resecting both hepatic and pulmonary metastases, (2) investigate the influence of the sequence and timing of metastases, and (3) identify the profile of patients likely to benefit from both hepatic and pulmonary metastasectomy. PATIENTS AND METHODS: Of 48 patients identified with resection of colorectal cancer and, at some point in time, both liver and lung metastases, 25 patients underwent metastasectomy (resection group). The remaining 23 patients comprised the nonresection group. Risk factors for death were identified by multivariable analyses. RESULTS: Median survival was longer after the last metastatic appearance in the resection group (16 months) than in the nonresection group (6 months; P <.001). The pattern of risk also differed; it peaked at 2 years and then declined in the resection group but was constant in the nonresection group. In the resection group, patients with metachronous resections survived longer after colorectal resection (median, 70 months) than patients with synchronous (median, 22 months) or mixed resections (median, 31 months; P <.001). Risk factors for death included older age, multiple liver metastases, and a short disease-free interval. CONCLUSIONS: Younger patients with solitary metachronous metastases to the liver, then the lung, and long disease-free intervals are more likely to benefit from resection of both liver and lung metastases. Patients with risk factors also had better survival with resection than without resection.

Colorectal Neoplasms↗
PubMed1995

Repeat liver resections from colorectal metastasis. Repeat Hepatic Metastases Registry.

BACKGROUND: A retrospective multiinstitutional study was performed to assess survival benefits of patients undergoing repeat liver resection for colorectal metastasis. An updated report is presented here. METHODS: The series comprised 170 patients from 20 different institutions around the world. Mean age of patients was 58 years (range, 28 to 84 years). The mean and median follow-up were 29 and 25 months, respectively. RESULTS: Three- and 5-year overall survival rates were 45% and 32%, respectively. The Dukes' stage of the primary tumor showed a 34% 5-year survival rate for those patients with negative nodes and 30% if nodes were positive (p = 0.42). The disease-free interval between liver resections showed a better outcome for those who had undergone repeated liver resections less than 1 year from the first liver resection (42% versus 23% 5-year survival rates); the difference was not significant (p = 0.58). The number of metastases found and resected at second procedures did not show significant differences in survival and was probably due to selection criteria. Anatomic resections reached a better 5-year survival rate (39%) than wedge resections (21%). The difference was not statistically significant (p = 0.2). The presence of extrahepatic disease and residual liver tumor left behind when repeat liver resection was performed were the most important prognostic variables in survival. Patients with extrahepatic disease had 19% 5-year survival rate, whereas those without disease outside the liver had 36% 5-year survival rate (p = 0.09). Patients with complete resections and those with residual liver disease after repeat resections had 36% and 17% 5-year survival rates, respectively (p = 0.01). Presence of postoperative morbidity after second liver resections did not show a significant negative impact in survival (p = 0.70). Adjuvant therapies were not widely used after liver resections and did not seem to improve prognosis of patients who were treated (39% versus 29% 5-year survival rates, p = 0.9). CONCLUSIONS: Repeat liver resections for colorectal metastasis is a justified approach because surgery remains the only potentially curative treatment. These procedures are relatively safe with low morbidity and mortality rates. Long-term survival (32%) can only be achieved in selected patients.

Adenocarcinoma↗
PubMed1997

Hepatic resection for noncolorectal, nonneuroendocrine metastases: a fifteen-year experience with ninety-six patients.

BACKGROUND: The role of liver resection for hepatic metastases from noncolorectal, nonneuroendocrine (NCNN) cancers is unknown. This study examines a large, single institutional experience of hepatic resection for NCNN metastases. METHODS: Records of 96 patients who underwent liver resection for metastatic NCNN cancer from 1980 to 1995 at a single institution were reviewed. Survival after liver resection in this cohort of patients is reported, and factors predictive of survival are analyzed. RESULTS: Resection was performed for liver metastases from genitourinary primary tumors (n = 34), soft tissue primary tumors (n = 41), and metastases from other primary cancers (n = 21). Extent of liver resection included wedge (n = 32), lobectomy (n = 44), and extended hepatic lobectomy (n = 20). No operative deaths occurred. Overall survival rate after resection at 1, 3, and 5 years was 80%, 45% and 37%, respectively (median survival, 32 months), with 12 actual 5-year survivors. There was no difference in survival according to the type of liver resection, bilateral versus unilateral disease, or resection of extrahepatic disease. Disease-free interval of less than 36 months before discovery of liver metastases, curative resection, and primary tumor group (genitourinary was greater than soft tissue, which was greater than gastrointestinal) were predictors of a significantly better survival by multivariate analysis. CONCLUSIONS: Primary tumor type, disease-free interval, and curative resection predict those patients who benefit from hepatic resection. Hepatic resection for patients with NCNN metastasis has value in carefully selected patients.

Adult↗
PubMed1997

Lung metastases of renal cell carcinoma: results of surgical resection.

OBJECTIVE: The research was designed to evaluate the results of surgical resection of renal lung metastases. METHODS: Between 1960 and 1994, 50 consecutive patients underwent resection for pulmonary metastases from renal cell carcinoma. Mean age was 59 years (range: 40-78 years). Mean time between nephrectomy and pulmonary resection was 3 years (range: 0-18 years). Nineteen patients had solitary metastase, 13 multiple unilateral, and 18 bilateral. Wedge excision was performed in 28 patients, segmentectomy in 3, lobectomy in 17, sleeve lobectomy in 1, pneumonectomy in 5 and biopsy in 3. Twelve patients had repeat resection for recurrent metastases. RESULTS: The resection was complete in 45 patients. Three patients also had a complete resection of limited extra-pulmonary disease. There was one postoperative death and 3 complications. Mean follow-up was 42 months without loss of follow-up. The cause of death was always metastatic recurrent disease. Five-year survival in complete resection was 44%. Only one long survivor was observed in the case of incomplete resection in a patient who had a complete response after adjuvant immunotherapy. Five-year survival for the 12 patients with repeat resections was similar to the overall survival rate (42%). CONCLUSIONS: Resection of renal lung metastases is a safe and effective treatment. No factor influenced the 5-year survival in this series except the complete resection. Extra-pulmonary metastases does not contra-indicate pulmonary resection. In selected patients, repeat resection for recurrent disease is warranted.

Actuarial Analysis↗
PubMed2000

Seven hundred forty-seven hepatectomies in the 1990s: an update to evaluate the actual risk of liver resection.

BACKGROUND: Recent reports highlighting reduced mortality rates to less than 1% after hepatic resections have evaluated the management of selected patients. The current risk of liver resection in unselected patients needs to be more clearly defined to appreciate the actual risk of new indications. STUDY DESIGN: From 1990 to 1997, 747 consecutive patients, including 16 operated in emergency, underwent hepatic resection. Resection was indicated for malignancy in 473 patients (63%). Major resections were performed in 333 patients (45%). An underlying liver disease, including cirrhosis (n = 239) and obstructive jaundice (n = 4), was present in 253 patients (35%). Multivariate analysis of the risk factors for postoperative mortality, morbidity, and transfusion after stratifying patients for the circumstance of the operation and the pathological changes of the remnant liver was performed. RESULTS: There was no intraoperative death and the overall mortality rate was 4.4%. This rate was 25% after emergency liver resection and 3.9% after elective liver resection (p < 0.001). After elective resection, mortality was significantly higher in patients with cirrhosis (8.7%) or obstructive jaundice (21%) than in patients with a normal liver (1%; p < 0.001). Analysis of this subgroup of 478 patients with normal liver showed that the mortality rate was 0% in 220 patients operated for a benign disease and in 263 patients who underwent minor resections. All five deaths occurred in patients with a malignancy and resulted from extrahepatic complications. In patients with a malignancy, the only independent predictor of death was an associated extrahepatic procedure. The incidence of postoperative complications was 22% and was influenced by the American Society of Anaesthesiology (ASA) score, extent of resection, presence of a steatosis, and an associated extrahepatic procedure. The incidence of major complications was 8% and of reoperation 3%. Perioperative blood transfusion was required in 112 of 478 (23%) and was not associated with increased mortality. CONCLUSIONS: The 1% basic risk of elective liver resection on normal liver suggests that indications of resection for malignancy could be extended, unless an associated extrahepatic procedure is needed. Because of this low basic risk, future studies evaluating resection on normal liver should not consider in-hospital mortality as the only end point.

Adolescent↗
PubMedDate not supplied

Comparison of massive vs. repeated resection leading to short bowel syndrome.

Short bowel syndrome can result from either a single massive intestinal resection or repeated lesser resections, which might have prognostic implications. The aim of this study was to compare patient populations and outcome of short bowel syndrome caused by massive and repeated resection. The records of 95 adult patients with short bowel syndrome evaluated over a 20-year period were reviewed. Massive resection was performed in 72 patients (76%) and repeated lesser resections in 23 patients (24%). Patients undergoing massive resection were more likely to be more than 70 years of age (26% vs. 9%, P <0.05). Mesenteric vascular disease was more prevalent among patients undergoing massive resection (39% vs. 9%, P <0.05), whereas Crohn's disease was less prevalent (1% vs. 35%, P <0. 05). Distribution of remnant length, presence of the ileocecal junction, and presence of a stoma were similar. Patients undergoing massive resection were more likely to require parenteral nutrition after the first year (56% vs. 23%, P <0.05). Patients with very short remnants (<60 cm) were more likely to receive parenteral nutrition after massive resection (95% vs. 60%, P <0.05). Thirty-day mortality was higher after massive resection (24% vs. 4%, P <0.05). However, those surviving 30 days had similar survival rates at 1 year and 5 years after massive and repeated resections. Patients undergoing massive vs. repeated resections are different with respect to age, underlying condition, and nutritional support needs. These factors may influence overall outcome in short bowel syndrome. The better nutritional prognosis of patients undergoing repeated resection given similar intestinal remnants may be related in part to enhanced intestinal adaptation.

Adult↗
PubMed2001

Experience with laparoscopic ultrasonography for defining tumour resectability in carcinoma of the pancreatic head and periampullary region.

BACKGROUND: Computed tomography (CT) is currently the most widely available staging investigation for pancreatic tumours. However, the accuracy of CT for determining tumour resectability is variable and can be poor. Laparoscopic ultrasonography (LUS) is potentially a more accurate method for disease staging. The authors' experience of LUS for staging carcinoma of the pancreatic head and periampullary region is described. METHODS: Fifty-one patients with potentially resectable pancreatic tumours defined at CT underwent further investigation with LUS. Twenty-seven patients subsequently had an open laparotomy. The evaluations of tumour resectability at CT and LUS were compared with the operative findings. RESULTS: At LUS, 24 patients were considered to have resectable tumours, 21 non-resectable tumours and six patients were shown to have no pancreatic tumour mass. Twenty-two patients deemed to have a resectable tumour at LUS underwent surgery. Twenty patients were confirmed to have resectable disease and two patients had non-resectable disease. A further five patients underwent surgery. In all five the ultrasonographic diagnosis was confirmed at surgery (four patients with non-resectable disease and no pancreatic tumour in one patient). LUS prevented unnecessary extensive surgery in 53 per cent of patients. For the 22 patients who underwent surgery for potentially resectable disease, the positive predictive value of LUS for defining tumour resectability was 91 per cent. CONCLUSION: LUS is an accurate additional investigation for defining tumour resectability and directing management in patients with potentially resectable carcinoma of the pancreatic head or periampullary region.

Adult↗
PubMed2001

Nonanatomic hepatic resection with a pledgetted suturing technique.

BACKGROUND/PURPOSE: Anatomic hepatic resection is dependent on the segmental infrastructure of the liver, whereas nonanatomic resection is independent of structural planes and is often fraught with excessive bleeding. The authors describe their experience with a novel technique using pledgetted suturing for extensive liver resection in patients with benign or malignant hepatic tumors. METHODS: Four children, (mean age, 24.7 +/- 12.5 months) underwent liver resection for the following hepatic lesions: hepatoblastoma, invasive Wilms' tumor, Caroli's disease, and infantile hemangioendothelioma. In the child with hepatoblastoma, the lesion was considered unresectable by segmental anatomy. A surgical technique was designed in which nonabsorbable 2-0 Teflon felt pledgetted sutures were placed through the liver parenchyma in a nonanatomic resection plane. The mattress sutures were sequentially tied until the resection plane was defined. The resection was sharply completed with a scalpel along the line of pledgetted sutures, independent of hepatic segmental anatomy. RESULTS: Complete surgical resections of the hepatic lesions were obtained in all cases. Estimated blood loss was minimal with a mean of 5.3 +/- 0.9 mL/kg. No patient received a blood transfusion as a result of the hepatic resection. There were no postoperative hepatic complications resulting from the resection. The child with hepatoblastoma had a delayed recovery, resulting in reexploration that ruled out a subphrenic abscess. CONCLUSIONS: The pledgetted suturing technique for hepatic resection is relatively bloodless, safe, easy to perform, and may enable a complete surgical resection of otherwise unresectable lesions. We advocate this technique when approaching a large hepatic lesion that would entail a difficult or incomplete anatomic resection in infants. J Pediatr Surg 36:209-212.

Child, Preschool↗
PubMed1993

Tumor presence at resection boundaries and lymph-node metastasis in bronchial carcinoma patients.

A prospective study was performed analyzing the bronchial resection boundaries of 120 patients operated on for lung carcinoma. The resection boundary, maximum tumor diameter, distance between tumor and resection boundary, and lymph-node stage were analyzed by serial sections of the surgical specimens (lobes and lungs). The following results were obtained: 20/120 cases (17%) displayed microscopic tumor invasion of the resection boundary (R1 status), most frequently adenocarcinoma (21%). The R1 status was closely associated with the distance between tumor and resection boundary and postsurgical lymph-node state (pN stage): all 8 tumors excised at distance 1 mm or less from the bronchial resection boundary revealed bronchial submucous tumor growth, whereas none of the tumors located more than 20 mm from the resection boundary was found to display tumor invasion of the bronchial boundary. Curative resection was noted in all 40 tumors operated at pNO stage and in only 11 cases (69%) of tumors with distant lymph-node metastases (pN3 stage). No relationship between tumor infiltration of the resection boundary and type of resection was seen. The data indicate that a) intra-operative control of bronchial resection boundaries is necessary in all lung-carcinoma patients with central tumor localization less than 20 mm from the proposed resection boundary; b) a "safety distance" between resection boundary and tumor boundary is of specific importance in bronchial carcinoma with lymph-node metastases.

Adenocarcinoma↗
PubMed2000

Endoscopic piecemeal resection with submucosal saline injection of large sessile colorectal polyps.

BACKGROUND: Because endoscopic en bloc resection of large, sessile colorectal polyps is technically difficult, they are usually resected piecemeal. However, piecemeal resection makes it difficult to evaluate the completeness of the resection histopathologically. In this study the efficacy of endoscopic piecemeal resection of large, sessile colorectal polyps was investigated after follow-up greater than 1 year. METHODS: We removed 56 sessile colorectal polyps 2 cm or greater in diameter in 56 patients by using an endoscopic submucosal saline injection technique. Endoscopic examinations were repeated at 3, 6, and 12 months and longer after initial endoscopic resection. If no residual tumor was found endoscopically and histologically, the patient was considered to be "cured." RESULTS: Of the 56 polyps, 14 (25%) were resected en bloc, and 42 (75%) were resected piecemeal. Of the 42 patients treated with piecemeal resection, 23 (55%) required additional endoscopic or surgical interventions. In patients followed 1 year or longer after initial treatment, the cure rate by en bloc resection was 100% (14 of 14) and that by piecemeal resection was 83% (35 of 42). Arterial bleeding occurred in 4 patients (7%) during or after endoscopic resection. In 3 of them, bleeding was stopped by endoscopic clipping, but 1 patient required emergent laparotomy. CONCLUSIONS: Endoscopic piecemeal resection after submucosal saline injection with an intensive follow-up program is a safe and effective treatment for large, sessile colorectal polyps.

Adult↗
PubMed1987

Pelvic recurrence of rectal cancer. Options for curative resection.

Pelvic recurrence is an ominous event after curative resection of rectal cancer and is rarely amenable to re-resection by conventional methods. A method to permit a composite resection of these using the abdominal sacral approach has been described previously. This report updates that experience with resection of pelvic recurrence of rectal cancer in 28 patients. Of these, 24 were done with curative intent, and four were done for palliation (mainly for infected or fungating tumor). All patients had extensive preoperative evaluation by clinical and radiologic tests, and most patients had a long free interval period of approximately 18 months, after their primary resection. Although 47 patients had exploratory surgery, only 29 had local disease amenable to resection and four had palliative resections. About half the patients had had an abdominoperineal resection, half had had an anterior resection, and one third had had previous efforts to resect the recurrence. All but one patient had been irradiated with 3000-11,000 cGy. All but two patients (of the 24 curative efforts) required a formal abdominosacral resection (through S1-2 in 12, S2-3 in 9, and S4-5 in 1). Over half the patients also required a bladder resection. There were three operative deaths (12%); one patient had a cardiac death immediately after operation and two were septic deaths at 35 and 60 days. The survivors generally had relief of sacral root pain and good motor function; most of those previously employed could return to work. The actuarial 5-year survival rate is 25% and median survival is 36 months. Long-term survival over 48 months was recorded in five of 21 surgical survivors (23.8%). Survival in a historic comparative group of 30 patients treated for local recurrence only (mainly by radiation) was 15 months median, and at 5 years the survival rate was 3% (p less than 0.001). In conclusion, selected patients with pelvic recurrence of rectal cancer may be retrieved by and returned to functional life with the composite abdominosacral resection.

Abdomen↗
PubMed2001

The analysis of resectability and survival in pancreatic cancer patients with vascular invasion.

One of the major limitations of curative resection in patients with pancreatic cancer is local tumor extension to the mesenteric vessels. Thus, the purposes of our study were to assess the clinical value of contrast-enhanced spiral computed tomography (CT) in predicting the resectability and survival of patients with pancreatic cancer with suspicious vascular invasion and to assess the influence of curative resection on the survival of these patients. We enrolled 40 patients with pancreatic cancer who were suspected of having an involvement of the adjacent large vessels and who subsequently underwent operation with curative intent in the study. Resectability and survival were correlated with CT findings such as segment length, degree of encasement, and type and number of vessels involved. The survival rate was compared between the curative and palliative resection groups, and survival rate was compared between the resected and unresected groups. Of the 40 patients with adenocarcinoma of the pancreas, 14 had curative resections and 26 had palliative resections. The probability of curative resection was higher in patients with segment lengths less than 2 cm, as compared with segment lengths more than 2 cm. However, there was no difference in survival between the two groups. There were no differences in resectability and survival according to the degree of encasement and type and number of vessels involved. There was no difference in survival between the curative and palliative resection groups. There was no difference in survival between the resected and unresected groups. A survival benefit was not achieved by curative resection in patients with pancreatic cancer with vascular invasion. Therefore, it would be better to avoid aggressive surgery in patients with pancreatic cancer with vascular invasion.

Humans↗
PubMed1993

Preoperative determination of the resectability of hepatic tumors: efficacy of CT during arterial portography.

OBJECTIVE: A multiinstitutional study was performed to evaluate the efficacy of CT during arterial portography for determining the resectability of hepatic tumors. The impact of findings from CT during arterial portography on patients' treatment (i.e., surgical vs nonsurgical) was assessed. In patients considered to have resectable tumors, the accuracy of CT during arterial portography for predicting surgical findings was also evaluated. MATERIALS AND METHODS: A retrospective study was done of 404 patients from three institutions who had CT during arterial portography during the period 1985-1991 as part of preoperative staging to determine the resectability of hepatic tumors. The tumors included metastases from colorectal carcinoma in 197 patients (49%); other hepatic metastases, mostly from adenocarcinoma of the stomach, pancreas, and biliary tree in 123 (30%); and primary hepatocellular carcinoma in 84 (21%). Imaging results were correlated with results of percutaneous biopsy of at least one hepatic lesion in patients whose tumors were considered unresectable. In patients whose tumors were considered resectable, results were correlated with preoperative percutaneous biopsy (obtained in almost all cases) and pathologic examination of a surgical specimen (all cases). Although each case was considered individually, four criteria were used for resectability: (1) accessibility of all lesions to lobar or wedge resection that would yield clear margins, (2) anticipation that residual liver tissue after resection would provide sufficient function, (3) the absence of invasion of central hepatic vascular or biliary structures, and (4) the absence of extrahepatic disease. No specific restriction was made with respect to the number of hepatic lesions present. The accuracy of findings by CT during arterial portography for predicting resectability was assessed in the 146 patients who had tumors that were considered resectable on the basis of imaging findings and had surgery. RESULTS: Of 404 patients, only 146 (36%) were thought to be candidates for resection on the basis of findings from CT during arterial portography. Of these, 122 (84%) actually had resection. The 24 patients who did not have resection included 22 patients with disease understaged or overstaged by CT during arterial portography, one with true-negative findings by CT during arterial portography, and one who died during surgery. The accuracy of findings by CT during arterial portography for predicting results at surgery was 85% for all patients and 91% for the subset of patients who had primary colorectal tumors with hepatic metastases. CONCLUSION: Our experience shows that CT during arterial portography is a useful procedure for assessing the resectability of hepatic tumors. In our study, 64% of patients were spared unnecessary surgery.(ABSTRACT TRUNCATED AT 400 WORDS)

Carcinoma↗