Recurrence and outcome after complete tumour removal and hyperthermic intraperitoneal chemotherapy in 512 patients with pseudomyxoma peritonei from perforated appendiceal mucinous tumours.

BACKGROUND: Pseudomyxoma peritonei (PMP) usually originates from perforated mucinous appendiceal tumours and may present unexpectedly at surgery, or be suspected at cross sectional imaging. The optimal treatment involves macroscopic tumour removal by cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC). The 10-year Kaplan-Meier predicted disease-free survival is 61%. Some patients with recurrence are amenable to further CRS and HIPEC. AIM: To evaluate the outcomes of re-do surgery in a large single centre series of reoperation for recurrence of peritoneal surface malignancy. METHOD: Retrospective analysis of prospective database of 752 patients undergoing CRS for perforated appendiceal tumours analysed. Routine follow up involved annual CT scans and serum tumour marker measurement. The survival and recurrence in the 512/752 (68.1%) who had complete cytoreduction between March 1994 and January 2012 was calculated by Kaplan-Meier univariate analysis. RESULTS: Overall 137/512 (26.4%) developed recurrence and of those 35/137 (25.5%) underwent repeat surgery. Complete tumour removal was again achieved in 20/35 (57.1%). There were no postoperative deaths and no significant difference in early postoperative complications and length of stay compared to primary CRS surgery. The 5-year survival in the 375 without recurrence, the 35 who had re-do surgery and the 102 who had recurrence with no surgery was 90.9%, 79.0% and 64.5% respectively. CONCLUSION: Approximately one in four patients develops recurrence after complete CRS and HIPEC for PMP of appendiceal origin. Selected patients can undergo salvage surgery with good outcomes.

A pictorial description of extralevator abdominoperineal excision for low rectal cancer.

AIM: Extralevator abdominoperineal excision in the prone position has been reported as a method to improve the poor outcome sometimes observed after abdominoperineal excision (APE) for low rectal cancer. In this paper a pictorial guide is presented describing the key anatomical steps and landmarks of the operation. METHOD: Intraoperative footage of five APE operations filmed in high definition was reviewed and key stages of the operation were identified. Still frames were captured from these sequences to illustrate this guide. An edited video sequence was produced from one of these operations to accompany this paper. CONCLUSION: The prone APE allows improved visualization of the perineal portion of the operation by the surgeon, assistants and observers. It permits clear demonstration for teaching. Prospective evaluation is still required to identify patients who would benefit from extralevator APE.

Relevance of magnetic resonance imaging-detected pelvic sidewall lymph node involvement in rectal cancer.

BACKGROUND: The significance of magnetic resonance imaging (MRI)-suspected pelvic sidewall (PSW) lymph node involvement in rectal cancer is uncertain. METHODS: Magnetic resonance images were reviewed retrospectively by specialist gastrointestinal radiologists for the presence of suspicious PSW nodes. Scans and outcome data were from patients with biopsy-proven rectal cancer and a minimum of 5 years' follow-up in the Magnetic Resonance Imaging and Rectal Cancer European Equivalence Study. Overall disease-free survival (DFS) was analysed using the Kaplan-Meier product-limit method and stratified according to preoperative therapy. Binary logistic regression was used to match patients for propensity of clinical and staging characteristics, and further survival analysis was carried out to determine associations between suspicious PSW nodes on MRI and survival outcomes. RESULTS: Of 325 patients, 38 (11·7 per cent) had MRI-identified suspicious PSW nodes on baseline scans. Such nodes were associated with poor outcomes. Five-year DFS was 42 and 70·7 per cent respectively for patients with, and without suspicious PSW nodes (P < 0·001). Among patients undergoing primary surgery, MRI-suspected PSW node involvement was associated with worse 5-year DFS (31 versus 76·3 per cent; P = 0·001), but the presence of suspicious nodes had no impact on survival among patients who received preoperative therapy. After propensity matching for clinical and tumour characteristics, the presence of suspicious PSW nodes on MRI was not an independent prognostic variable. CONCLUSION: Patients with suspicious PSW nodes on MRI had significantly worse DFS that appeared improved with the use of preoperative therapy. These nodes were associated with adverse features of the primary tumour and were not an independent prognostic factor.

A systematic review of cancer related patient outcomes after anterior resection and abdominoperineal excision for rectal cancer in the total mesorectal excision era.

PURPOSE: It is a widely held view that anterior resection (AR) for rectal cancer is an oncologically superior operation to abdominoperineal excision (APE). However, some centres have demonstrated better outcomes with APE. We conducted a systematic review of high-quality studies within the total mesorectal excision (TME) era comparing outcomes of AR and APE. METHODS: A literature search was performed to identify studies within the TME era comparing AR and APE with regard to the following: circumferential resection margin (CRM) status, tumour perforation rates, specimen quality, local recurrence, overall survival (OS; 3 or 5 year), cancer-specific survival (CSS) and disease-free survival (DFS). Additional data regarding patient demographics and tumour characteristics was collected. RESULTS: Twenty four studies fulfilled the eligibility criteria with Newcastle-Ottawa scores of six or greater. Where a significant difference was found, all studies reported lower and more advanced tumours for APE and 4/5 studies observed more frequent use of neoadjuvant and adjuvant therapies in APE patients. Tumour perforation rates and CRM involvement where reported, were significantly greater for APE. 8 out of 10 studies showing significant differences in local recurrence reported higher rates for APE but no differences were observed with distant recurrence. Where differences were noted, AR was reported to have increased DFS, CSS and OS compared to APE. CONCLUSIONS: Patients treated with AR have lower rates of tumour perforation and CRM involvement and tend to have better outcomes with regard to disease recurrence and survival. However, tumours treated by APE are lower and more locally advanced.

Magnetic resonance imaging-detected lymph nodes close to the mesorectal fascia are rarely a cause of margin involvement after total mesorectal excision.

BACKGROUND: In rectal cancer the management of suspicious magnetic resonance imaging (MRI)-detected lymph nodes lying close to the mesorectal fascia poses an ongoing dilemma. Key decisions in treatment planning are commonly based on the prediction of margin status. However, it is unclear whether a lymph node that appears to contain tumour close to the mesorectal fascia will result in a positive margin. METHODS: Some 396 patients with rectal cancer were included. MRI assessment of mesorectal nodes, the pathologically involved circumferential resection margin (CRM) rate and causes of margin involvement were analysed to establish the clinical significance of MRI-detected suspicious lymph nodes at the resection margin. RESULTS: Fifty (12.6 per cent) of 396 patients had a positive CRM on histopathological analysis, five (10 per cent) solely due to an involved lymph node. Four of the five malignant nodes were not predicted on MRI. Thirty-one of the 396 MRI studies had suspicious nodes 1 mm or less from the CRM. None of these patients had a positive CRM owing to nodal involvement. CONCLUSION: Involvement of the CRM by lymph node metastases alone is uncommon.