Five-year follow-up of the Medical Research Council CLASICC trial of laparoscopically assisted versus open surgery for colorectal cancer.

INTRODUCTION: The UK Medical Research Council CLASICC trial assessed the safety and efficacy of laparoscopically assisted surgery in comparison with open surgery for colorectal cancer. The results of the 5-year follow-up analysis are presented. METHODS: Five-year outcomes were analysed and included overall and disease-free survival, and local, distant and wound/port-site recurrences. Two exploratory analyses were performed to evaluate the effect of age (70 years or less, or more than 70 years) on overall survival between the two groups, and the effect of the learning curve. RESULTS: No differences were found between laparoscopically assisted and open surgery in terms of overall survival, disease-free survival, and local and distant recurrence. Wound/port-site recurrence rates in the laparoscopic arm remained stable at 2.4 per cent. Conversion to open operation was associated with significantly worse overall but not disease-free survival, which was most marked in the early follow-up period. The effect of surgery did not differ between the age groups, and surgical experience did not impact on the 5-year results. CONCLUSION: The 5-year analyses confirm the oncological safety of laparoscopic surgery for both colonic and rectal cancer. The use of laparoscopic surgery to maximize short-term outcomes does not compromise the long-term oncological results. REGISTRATION NUMBER: ISRCTN74883561 (http://www.controlled-trials.com).

Adhesions and incisional hernias following laparoscopic versus open surgery for colorectal cancer in the CLASICC trial.

BACKGROUND: This study investigated adhesive intestinal obstruction (AIO) and incisional hernia (IH) in patients undergoing laparoscopically assisted and open surgery for colorectal cancer. METHODS: In a case-note review of patients randomized to the Medical Research Council's Conventional versus Laparoscopic-Assisted Surgery In Colorectal Cancer (CLASICC) trial, primary and key secondary endpoints were AIO and IH admission rates respectively. RESULTS: Of 411 patients, 11 were admitted for AIO: four (3.1 per cent) of 131 patients in the open arm of the trial versus seven (2.5 per cent) of 280 in the laparoscopic arm (difference 0.6 (95 per cent confidence interval (c.i.) - 2.9 to 4.0) per cent). Thirty-six patients developed IH: 12 (9.2 per cent) after open versus 24 (8.6 per cent) after laparoscopic surgery (difference 0.6 (95 per cent c.i. - 5.3 to 6.5) per cent). Results by actual procedure showed higher AIO and IH rates in the 24.5 per cent of patients who converted from laparoscopic to open surgery (AIO: 2.3, 2.0 and 6 per cent; IH: 8.6, 7.4 and 11 per cent-for open, laparoscopic and converted operations respectively). CONCLUSION: Although this study has not confirmed that laparoscopic surgery reduces rates of AIO and IH after colorectal cancer surgery, trends suggest that a reduction in conversion to open surgery and elimination of port-site hernias may produce such an effect. Registration number for CLASICC trial: ISRCTN74883561 (http://www.controlled-trials.com).

Laser microdissection expression profiling of marginal edges of colorectal tumours reveals evidence of increased lactate metabolism in the aggressive phenotype.

BACKGROUND: The morphology of the invasive margin in colorectal cancer can be described as either pushing or infiltrative. These phenotypes carry prognostic significance, particularly in node negative disease, and provide an excellent model for the study of invasive behaviour in vivo. METHODS: The marginal edges of 16 stage-matched tumours exhibiting these contrasting growth patterns were microdissected. The extracted mRNA was amplified and hybridised to a 9546 feature oligonucleotide array. Selected differentials were validated using real-time polymerase chain reaction and the protein product was interrogated by using immunohistochemistry. RESULTS: After stringent quality control and filtering of data generated, 39 genes were identified as being significantly differentially expressed between the two types of marginal edge. Several genes involved in cellular metabolism were identified as differentials including lactate dehydrogenase B (LDHB) and modulators of glucose transport. CONCLUSIONS: The LDH expression profile differs between the invasive phenotypes. A hypothesis is proposed in which altered metabolism is a cause of contrasting invasive behaviour independent of the hypoxia-inducible factor mediated hypoxic response, consistent with the Warburg phenomenon.

Patient factors influencing conversion from laparoscopically assisted to open surgery for colorectal cancer.

BACKGROUND: Intraoperative conversion from laparoscopically assisted to open surgery for colorectal cancer is thought to be influenced by several patient factors. Analysis of the Conventional versus Laparoscopic-Assisted Surgery In Colorectal Cancer (CLASICC) Trial data aimed to identify these risk factors. METHODS: Of 488 laparoscopically assisted procedures attempted, 143 (29.3 per cent) were converted to open operation. Patient factors considered in multivariable analyses were age, sex, previous abdominal incisions, body mass index (BMI), tumour site, tumour diameter, pathological tumour (pT) and pathological node (pN) stage, extent of tumour spread from the muscularis propria, liver and peritoneal metastases, and American Society of Anesthesiologists (ASA) grade. As BMI was missing for 30.7 per cent of patients, two approaches were employed: one considered BMI as a possible risk factor and one did not. RESULTS: When BMI was taken into consideration, male sex (odds ratio (OR) 2.07; P = 0.020), BMI (OR 1.10; P = 0.006) and extent of tumour spread from the muscularis propria (OR 1.08; P < 0.001) were independent predictors of conversion. When BMI was not considered, extent of tumour spread (OR 1.07; P < 0.001) and male sex (OR 2.05; P = 0.004) were again identified, as were tumour site (OR 2.11; P = 0.005) and ASA grade (II versus I, OR 0.92; III versus I, OR 2.74; P = 0.012). CONCLUSION: Intraoperative conversion is more likely with larger BMI, in men, patients with rectal cancer, those graded ASA III or when there is greater local tumour spread.

Successful outcome following resection of a pancreatic liposarcoma with solitary metastasis.

Liposarcomas are rare soft tissue tumors, commonly affecting the lower limbs and less commonly the retroperitoneum. Although other organs can be affected, the pancreas is one of the rarest, and metastasis at presentation has never been reported. We describe the case of a 76-year-old gentleman presenting with abdominal pain and an abdominal mass. Imaging confirmed a primary tumor in the body and tail of the pancreas, with a metastatic deposit in the mesentery adjacent to the second part of the duodenum. Biopsy confirmed a liposarcoma, and subsequently a complete surgical excision was achieved. He then received adjuvant radiotherapy and has remained disease free for the next 26 mo.

Assessing the relative costs of standard open surgery and laparoscopic surgery in colorectal cancer in a randomised controlled trial in the United Kingdom.

The role of laparoscopic surgery for the treatment of colorectal cancer is being explored in a multi-centre, randomised clinical trial in the UK, the MRC CLASICC Trial (Conventional versus Laparoscopic-assisted Surgery in Colorectal Cancer). An important end-point of the trial is the cost-effectiveness of laparoscopic surgery compared with that of conventional open surgery. The economic evaluation of this trial has been modelled on that in a similar trial being conducted in the USA in colon cancer. The aim of this paper is to discuss the rationale for modelling the UK trial on the US trial, and to describe the adaptations necessary for the UK trial. The parallel design of the economic evaluation in both trials will provide a unique opportunity to compare the cost implications of incorporating laparoscopic surgery in the UK and the USA, and to determine any cross-cultural differences. The UK trial will also provide information about the cost-effectiveness of laparoscopic surgery in rectal cancer.

A three-dimensional in-vitro model for the study of peritoneal tumour metastasis.

Peritoneal metastasis is a frequent complication of gastrointestinal malignancy. We have developed a three-dimensional model of the human peritoneum that simulates the metastatic process in vitro. Peritoneal fibroblasts were incorporated into collagen lattices, allowed to contract, then overlaid with mesothelial cells. Scanning and transmission electron microscopy showed the model to have similar physical properties to human peritoneum. Mesothelial expression of the beta1 integrin family, the basement membrane proteins fibronectin, laminin, collagen types III and IV, and the cell adhesion molecules ICAM-1, VCAM-1 and PECAM were assessed and showed similar results to in vivo tissue. Gastrointestinal tumour cells seeded onto the model exhibited mesothelial adhesion, cell spreading and vesicle formation, and invasion of the mesothelial monolayer on scanning electron microscopy. Two distinct patterns of tumour cell growth were observed using light microscopy: a superficial spreading layer, and discrete invasive deposits. Invasion was accompanied by disruption of the mesothelial monolayer, degradation and re-orientation of the matrix, and rudimentary tumour cell differentiation. We believe the use of this in vitro peritoneal model will facilitate the study of the molecular mechanisms involved in the metastatic process.

The candidate tumour suppressor gene, ING1, is retained in colorectal carcinomas.

ING1 plays a critical role in regulating cell cycle progression and susceptibility to apoptosis. The present study aimed to investigate allelic deletion of, and mutations within, the ING1 gene in colorectal carcinomas. Genomic DNA was extracted from 29 sporadic colorectal carcinomas and samples of adjacent normal mucosa. Losses of heterozygosity of two polymorphic dinucleotide repeat markers close to the ING1 locus at chromosome 13q32-34 were analysed. Single-stranded conformational polymorphisms of polymerase chain reaction amplified regions within the coding sequence of ING1 were examined. Microsatellite instability was noted in 5 (17%) colorectal carcinomas; this confirms selection of a subject sample representative of the population. Neither losses of heterozygosity nor changes in electrophoretic mobility of single-stranded polymerase chain reaction products were detected in any colorectal carcinoma. Thus, in common with tumour suppressor genes such as RB and BRCA2 on chromosome 13q, ING1 appears to be retained intact in colorectal carcinomas.

Differential responses to chemoimmunotherapy in patients with metastatic malignant melanoma.

An open, multicentre non-randomised study was performed to evaluate the activity and toxicity of combination chemoimmunotherapy, consisting of cisplatin, interleukin-2 and interferon-alpha, in metastatic malignant melanoma. Between March 1992 and September 1993, 28 patients with pathologically proven metastatic malignant melanoma, bidimensionally measurable disease and an Eastern Co-operative Oncology Group score < or = 1 were treated with the combination chemoimmunotherapy. The regimen consisted of cisplatin (100 mg/m2 on day 0), interleukin-2 (Proleukin, Chiron, Middlesex, U.K.) 18 x 10(6)IU/m2/d continuous intravenous infusion on days 3-7 and 17-22, with interferon-alpha (Roferon-A, Roche, Hertfordshire, U.K.) 9 x 10(6) U/d subcutaneously on days 3, 5, 7, 17, 19, 21 during the interleukin-2 infusions. The treatment cycle lasted 28 days. Among 27 assessable patients, 5 patients achieved partial responses, for an overall response rate of 18% (95% CI 6-37%). Median progression-free survival was 44 days (range 8-279) and median overall survival was 264 days (range 41-1432). Differential responses were noted in 41% of patients and responses were more frequent in non-visceral disease (skin, lymph node and soft tissue disease) (P = 0.04). These results indicate that differential responses to chemoimmunotherapy are common in patients with metastatic melanoma. This may account for the broad range of response rates reported in the literature.

Simplified quantitation of cytotoxicity by integration of specific lysis against effector cell concentration at a constant target cell concentration and measuring the area under the curve.

Experience with the lytic unit (LU) as a measure of cytolytic efficiency has indicated that its accuracy is limited, even if expressed in a logarithmic format. A new method of quantifying cytotoxicity from effector dilution assays is proposed: the area under the curve (AUC) of the Ig (E/T) ratio vs. percentage cytotoxicity plot, gives an overall measure of lytic efficiency. The AUC derived from the Briggs-Haldane kinetic model is dependent on both the kinetic parameters that determine the efficiency of effector cells (the Michaelis constant KM and the catalytic constant kcat). AUC provides an index of inhibition or stimulation of lysis, independent of whether the modulation is kinetically competitive, uncompetitive or the same AUC value. In practice the method may be applied to interpret simple cytotoxicity assay data, where effector cells are being used in standardised screening for modifiers of the cytolytic response. Illustrative data of LAK cytotoxicity influenced by dose of the LAK response modifiers IL-2, TGF beta, TDSF and 5-FU, show different relationships between lytic units, KM and AUC. These data also show a wide range in the Hill coefficient and would be consistent with a cooperative effect dependent on the effector cell efficacy. This confirms that using LU as a simple measure of cytolytic efficiency could be erroneous and suggest that cytolytic response modifiers can produce a variety of kinetic changes. The AUC method, however, provides a comparative measure of efficiency in these situations, independent of mechanism.

The response to interferon of NK and K cells from conventionally immunosuppressed and cyclosporine-treated renal allograft recipients.

Interferon is a potent stimulator of natural killer (NK) and killer (K) cell activity in human beings, both these cytotoxic functions representing host defense mechanisms against viral infections and lymphoid malignancy. Both NK and K cell functions are markedly impaired in conventionally immunosuppressed allograft recipients but coincubation of lymphocytes from these patients with purified human lymphoblastoid interferon considerably augments both these activities. Cyclosporine immunosuppression causes only a moderate, but significant, impairment of NK activity--but K cell activity appears to be normal. Again IFN increases NK activity of the lymphocytes of these patients but produces a fall or only moderate increases in K cell activity. We conclude that these data support the functional distinction between NK and K cells and suggest that immunosuppressive agents act at the pre-NK/K cell stage of maturation, though possibly via different mechanisms.

Generation of mouse cytolytic T cells against human concanavalin A blasts. Involvement of non-MHC determinants in the antihuman response.

Normal human peripheral blood lymphocytes (PBL) are incapable of eliciting a significant murine cytotoxic T cell (CTL) response either in vivo or in vitro. However, using a primary in vivo and secondary in vitro stimulation with lectin-activated PBL, Thy-l-positive cytotoxic cells were produced. The antigens that these T-cells identified were independent of the serum source employed in the culture medium used for lectin activation. The cells always preferentially lysed cells from the immunizing individual but were also able to lyse target cells from unrelated individuals, regardless of HLA identity or disparity with the immunizing individual, suggesting the presence of both a private (possibly class II antigens) and public specificity. Using the lymphoblasts of different family members as immunogen and targets there was slight preference of the CTL for HLA-identical targets with no apparent difference between the lysis exhibited against semiidentical and nonidentical subjects. Monoclonal antibodies directed against HLA DR or beta 2-microglobulin failed to inhibit the cytotoxicity observed in these experiments. It is suggested that under these circumstances of xenogeneic education, non-MHC-restricted T cells may become cytotoxic, and this model may serve as a useful probe to investigate some of the less-well-defined aspects of the T cell repertoire.

Changes in human natural killer activity early and late ater renal transplantation using conventional immunosuppression.

The natural killer (NK) cell activity of human peripheral blood lymphocytes falls following major surgical procedures including renal transplantation but in non-immunosuppressed individuals returns to normal levels within the first 72 hr after operation. In renal allograft recipients, if this early postoperative fall is excluded from the analysis, NK cell function appears to follow changes in allograft function, suggesting that in vivo, as has been reported in vitro, NK activity is generated during activation of the alloreactive process. In an additional group of patients whose grafts were functioning for between 3 and 102 months after cadaveric renal transplantation using conventional immunosuppression, NK function was depressed in comparison with that of control subjects. However, some patients who were more than 48 months post-transplant had normal NK cell activity. Collectively, these results suggest that NK cell function may recover despite the continued administration of conventional immunosuppressive agents.

Clinical economics review: the health-care economic implications of minimal access gastrointestinal surgery.

This article reviews some of the health-care economic data that have been acquired in recent assessments of minimal access surgery of the digestive tract, with particular reference to laparoscopic cholecystectomy and laparoscopic surgery for gastro-oesophageal reflux disease.

Neutrophil activation, vascular leak toxicity, and cytolysis during interleukin-2 infusion in human cancer.

BACKGROUND: Recombinant interleukin-2 (rIL-2) therapy for advanced malignancy is usually associated with a vascular leak syndrome (VLS) similar to that seen in severe sepsis. We investigated the possibility that the IL-2-induced VLS may be associated with the presence of circulating activated polymorphonuclear (PMN) leukocytes as occurs in sepsis syndrome. METHODS: Estimation of phenotypic (CD11B/CD18) and functional (H2O2, HOCl) up-regulation of circulating neutrophil activity was made by fluorescence-activated cell sorter analysis and ultraviolet spectrophotometry. Associated systemic cytokine enhancement tumor necrosis factor-alpha by enzyme-linked immunosorbent assay for bioactivity and parallel estimation of clinical evidence of vascular leak syndrome were also studied in human subjects with advanced cancer receiving therapeutic doses of rIL-2. RESULTS: The present studies confirm previous reports that tumor necrosis factor-alpha is released into the circulation during infusional therapy with rIL-2. In addition, we have found that this is accompanied by both phenotypic (up-regulation of CD11b/CD18 adhesion receptor expression) and functional (hydrogen peroxide and hypochlorous acid production) evidence of potent PMN activation. Furthermore, patients showing disease response to treatment have significantly greater production of PMN oxidants. CONCLUSIONS: These data suggest that the VLS seen during rIL-2 infusion in human beings may be attributable to PMN mechanisms similar to those invoked during severe sepsis. Consequently, this study may provide further insights into the mechanism of rIL-2's therapeutic action in advanced malignant disease.

Cholecystectomy is safer without drainage: the results of a prospective, randomized clinical trial.

Drainage after cholecystectomy remains routine despite the lack of scientific supportive data. Numerous clinical studies in the past have attempted to address this controversy but have failed to resolve the issue for different reasons. These include retrospective design, inclusion of only selected cases, and randomization before surgery. In this study 479 patients undergoing cholecystectomy were randomly allocated to a drainage group (a high-pressure suction drain in Morison's pouch for 48 hours) or a nondrainage group. Randomization was performed at the time of peritoneal closure. All patients undergoing cholecystectomy, both elective and urgent, were included and the operations were performed by all grades of surgeons. There were two deaths from cardiopulmonary causes, both in the drainage group. No patient required reoperation in either group. The incidence of both wound infections (15 vs 5; p less than 0.05) and chest infections (56 vs 19, p less than 0.02) was significantly higher in the drainage group. Three hundred fifty-six patients underwent abdominal ultrasonography 72 hours after surgery. The number of subhepatic fluid collections thus detected was significantly higher in the patients who received a drain (17 vs 6, p less than 0.05). None of these collections was clinically significant. The postoperative hospital stay was longer in the patients with drains (10.3 vs 9.1 days), but this difference failed to reach statistical significance. We conclude from this study that the use of a drain after cholecystectomy serves no useful purpose and is potentially harmful. This practice should be abandoned.

Primary adenocarcinoma in an ileostomy: a late complication of surgery for ulcerative colitis.

In the 1950s the treatment of ulcerative colitis was revolutionized by Brooke by way of a colectomy combined with an eversion ileostomy. This procedure is known to be associated with a number of complications that include skin excoriation, stenosis, intestinal obstruction, retraction or prolapse of the stoma, abscess and fistula formation, and ileitis. However, adenocarcinoma arising in the abnormally placed small intestinal mucosa 20 years or more after the initial operation is being increasingly recognized and reported. This article describes one such case and includes an extensive review of the current world literature on the subject of adenocarcinoma arising as a late complication of operation for ulcerative colitis.

Polymorphonuclear leukocyte activation. An early marker of the postsurgical sepsis response.

It has been suggested that major surgery induces polymorphonuclear leukocyte (PMNL) dysfunction, which exposes patients to the development of sepsis. Conversely, the sepsis response and multisystem organ failure in patients after surgery is thought to be mediated by activated PMNLs. In a preliminary attempt to investigate this paradox, we studied functional (hydrogen peroxide production) and phenotypic (the adhesion/complement receptor CD11b) markers of PMNL activation in 28 patients undergoing elective major resectional surgery; 11 (39%) of these patients developed postoperative sepsis (the septic group). The mean (SEM) preoperative level of neutrophil CD11b expression (97.8 [6.2] mean channel fluorescence [MCF] and 101.42 [7.9] MCF; P = .74) and hydrogen peroxide production (109.51 [4.91] MCF and 104.53 [6.3] MCF; P = .5) were similar for the uncomplicated and septic groups, respectively. However, on the first postoperative day, both mean CD11b expression and hydrogen peroxide production were greater in those patients who subsequently developed postoperative sepsis (192.5 [38] MCF vs 128.6 [8.1] MCF for the septic group vs the uncomplicated group, respectively [P < .05], and 120.43 [2.56] MCF vs 109.61 [3.05] MCF for the septic group vs the uncomplicated group, respectively [P < .0001]). We suggest that an exaggerated PMNL activation response to surgery is an early event in those patients destined to develop postsurgical sepsis.

Interleukin-10. A role in the development of postoperative immunosuppression.

BACKGROUND: The cause of diminished monocyte major histocompatibility complex class II antigen expression after surgery or trauma is unclear. Interleukin-10 (IL-10) regulates inflammatory cytokine production and major histocompatibility complex class II (HLA-DR) expression in vitro. OBJECTIVES: To quantify in vivo IL-10 messenger RNA (mRNA) and protein and monocyte HLA-DR expression after major surgery and to investigate the effects of IL-10 neutralizing blockade on monocyte HLA-DR expression in vitro. DESIGN: Inception cohort study of 48 surgical patients from preoperative status to postoperative day 7 and 9 healthy volunteers (controls). SETTING: Large teaching hospital, Northern England. PATIENTS: Monocyte HLA-DR and cytokine mRNA expression was determined in 32 of 48 consecutive patients undergoing elective major resectional surgery. Mononuclear cells for in vitro studies and serum samples for IL-10 measurement were obtained from the remaining 16 patients. MAIN OUTCOME MEASURES: Monocyte HLA-DR expression determined by flow cytometry, IL-10, and tumor necrosis factor mRNA in peripheral blood mononuclear cells assayed by multiplex reverse transcriptase polymerase chain reaction, and serum IL-10 determined by enzyme-linked immunosorbent assay. RESULTS: Monocyte HLA-DR expression (in mean channel fluorescence units [MCF]) was significantly reduced 24 hours after surgery (MCF [+/- SEM], 32.6 +/- 2.3 vs 16.3 +/- 1.2; P < .001) and remained low during the first postoperative week. A relative increase in IL-10 to G3PDH mRNA ratio (mean [+/- SEM], 0.95 +/- 0.08 vs 0.59 +/- 0.06; P < .01) and serum IL-10 (mean [+/- SEM], 18.1 +/- 4.1 vs 5.4 +/- 0.8 pg/mL; P < .01) was noted on the first postoperative day. A significant correlation existed between HLA-DR antigen expression and the presence of IL-10 mRNA transcript on the first postoperative day (P < .01). Lipopolysaccharide-induced up-regulation of monocyte HLA-DR expression was significantly impaired on the first postoperative day (mean [+/- SEM], 151% +/- 24.4% vs 60% +/- 10.1%; P < .01), but this was partially reversed by IL-10 neutralizing antibody (mean [+/- SEM], 60% +/- 10.1% vs 115% +/- 11.6%; P < .01). CONCLUSIONS: Interleukin-10 gene expression correlates with the fall in monocyte HLA-DR antigen expression in patients undergoing major abdominal surgery and may account for the immunosuppression associated with surgical injury.

Isolation and expansion of lymphocytes from gastrointestinal tumour tissue.

Adoptive cellular immunotherapy (ACI) with tumour-infiltrating lymphocytes (TIL) has met with some success in patients suffering from malignant melanoma. However, the success of this approach hinges on the successful isolation and in vitro expansion of TIL. Viable, IL-2 responsive TIL were obtained from only two of five gastrointestinal primary or 'non-lymph node' secondary gastrointestinal tumours. In contrast, proliferating TIL were successfully expanded from four out of five lymph node secondary deposits from gastrointestinal cancer patients, but these TIL were non-cytolytic. Conversely, proliferating lymphocytes were generated from six out of seven malignant effusions from gastrointestinal cancer patients in the late phase of their disease. Despite the presence of effective anti-tumour cytotoxic activity in one such culture, these lymphocytes failed to proliferate sufficiently for potential clinical use. Consequent upon these findings, we are sceptical that ACI using mononuclear cells infiltrating primary or secondary sites from patients with gastrointestinal cancer will be feasible.