Pathological responses after angiogenesis or EGFR inhibitors in metastatic colorectal cancer depend on the chemotherapy backbone.

BACKGROUND: Optimal preoperative treatment before colorectal cancer metastases (CRCM) resection remains unclear. This study evaluated pathological responses (pR) in CRCM resected after chemotherapy alone or combined with angiogenesis or epidermal growth factor receptor (EGFR) inhibitors. METHODS: Pathological response was retrospectively evaluated on 264 resected metastases from 99 patients. The proportion of responding metastases after different preoperative treatments was reported and compared. Patient's progression-free survival (PFS) and overall survival (OS) were compared based on pR. RESULTS: The combination of anti-angiogenics with oxaliplatin-based chemotherapy resulted in more pR than when they were combined with irinotecan-based chemotherapy (80% vs 50%; P<0.001). Inversely, the combination of EGFR inhibitors with oxaliplatin-based chemotherapy seemed to induce fewer pR than when they were combined with irinotecan-based treatment (53% vs 72%; P=0.049). Overall survival at 5 years was improved for patients with a pR in all resected metastases compared with those who did not achieve a pR (68.5% vs 32.6%; P=0.023) and this response was the only factor predicting OS in a multivariate analysis. CONCLUSION: The chemotherapy partner combined with angiogenesis or EGFR inhibitors influenced pR in resected CRCM. In our exploratory analysis anti-angiogenic/oxaliplatin-based regimens and anti-EGFR/irinotecan-based regimens were associated with the highest pR. Prospective randomised trials should be performed to validate these observations.

Pseudo-tumoral hepatic tuberculosis: a report of two cases.

Tuberculosis involving the liver in the absence of active pulmonary or miliary tuberculosis is very rare. The inflammatory pseudo-tumoral form is an entity difficult to diagnose. We report two patients, who underwent laparoscopic segmentectomy for suspected malignant tumour. Pathology showed tuberculoid granuloma with central caseous necrosis in both patients. The diagnosis in the first patient was made retrospectively on the resection specimen, whereas an active pre-operative work-up for tuberculosis diagnosis (biopsy and Polymerase Chain Reaction) remained futile in the second patient. The management of pseudo-tumoral hepatic tuberculosis needs a multidisciplinary concertation and a surgical approach is often the best way to ensure the diagnosis.

Laparoscopic treatment in acute complicated diverticulitis: a review of 11 cases.

AIMS: We wanted to test the role of laparoscopy in complicated diverticulitis. METHODS: All acute complicated sigmoid diverticulitis cases were reviewed during the last 6 years (December 1999 to 2006). Patients whose medical treatment had failed and patients admitted with peritonitis underwent emergency surgery. However, only laparoscopic procedures were included in the study. Patients were programmed 2 to 4 months later for laparoscopic elective colon resection if they underwent first lavage and drainage of the peritoneal cavity. RESULTS: Eleven patients were treated by laparoscopic procedures out of a total of 37 who underwent emergency surgical therapy for acute perforated diverticulitis. Laparoscopic resection with primary anastomosis was performed in 2 patients (Hinchey I and IIA). Laparoscopic lavage and drainage was performed in the remaining 9 patients (one stage IIA, three stage IIB and five stage III). Three conversions into open Hartmann were needed (stage III). One patient (stage IIB) was lost during follow-up and reappeared 16 months later in general peritonitis. Two patients needed earlier resection because of persistent symptoms. Three remaining patients had a 2nd stage resection at the allocated time. No postoperative death was encountered. Long-term follow-up (mean 6 months) showed one incisional hernia in a converted patient. DISCUSSION: In perforated diverticular disease, even though laparoscopic lavage and drainage avoids a colostomy and facilitates a 2nd stage resection, few patients have complete resolution of the inflammatory process. Resection remains mandatory after 8 to 12 weeks. In Hinchey stage III, the success rate still remains to be investigated and weighed against the Hartmann procedure or primary resection. Faecal peritonitis and instable patients should not be considered for laparoscopy.

Survival of rectal cancer patients in Belgium 1997-98 and the potential benefit of a national project.

BACKGROUND: PROCARE, a Belgian multidisciplinary project on rectal cancer (RC), will be launched in 2006. Guidelines have been developed, but remain to be implemented. AIM: A population-based study on RC treatment and outcome in Belgium and comparison with recent international benchmarks in order to better define targets that should be reached. PATIENTS AND METHODS: Anonymous data of 3079 patients with rectal cancer registered in the National Cancer Registry in 1997 and 1998 were analysed. Observed (OS) and relative survival (RS) were compared with figures from nationwide projects and multi-centre studies. RESULTS: The 5-yr OS and RS were 46.6% and 58.5%, respectively. For patients with stage I-III tumours 5-yr OS was 57.1% and 5-yr RS 70.1%. Adjuvant or neo-adjuvant treatment was given in 54.8% stage II-III patients who were < 70 years old. There were marked differences between the provinces in the use of radiotherapy for stage II-III patients and in 5-yr RS for all stages. In stage IV, the median OS was 13 months and the 2-yr OS was 28%. Comparison with recent multi-centre trials indicates significant potential benefits from the PROCARE project: an absolute increase of the 5-yr OS by 10 to 20% after chemoradiotherapy and TME in stage II-III patients 75 years old or less, a 7-month increase of the median OS and an absolute 15% increase of the 2-yr OS in unresectable stage IV patients with combined chemotherapy. CONCLUSION: Significant improvement seems to be achievable. Implementation of the PROCARE guidelines with quality assurance through prospective registration in a specific database, however, is a crucial prerequisite for credible audit of performance and feedback to individual teams.

Esophageal replacement: gastric tube or whole stomach?

BACKGROUND: The stomach can be used either in its entirely or as a greater curvature tube for esophageal replacement. METHODS: The study compares the gastric tube (group A; n = 112) to the whole stomach whose lesser curvature is denuded (group B; n = 100) in terms of technical complication and alimentary comfort. The clinical results are substantiated by assessment of the eating performance of patients and control subjects at a test meal, measurement of the gastric dimensions before and after both tailoring procedures, and intraarterial staining of the gastric wall. RESULTS: Major differences between the two groups are cervical anastomosis stenoses (22.3% versus 6% [A versus B]; p = 0.008), fistulas (7.9% versus 1%; p = 0.0209), number of meals and snacks per day (4.6 versus 4; p = 0.0275), sensation of early fullness at meals (52.4% versus 17.8%; p < 0.0001), ratings given to the long-term alimentary comfort (presymptomatic condition = 10 points) (7.6 versus 8.8 out of 10 on average; p < 0.0001), and calories consumed in 1 minute at a test meal (59% [p < 0.05] versus 77% of those consumed by control subjects). The volume of the stomach is reduced by a range of 21.4% to 47.2% after tubulization (group A) whereas it increases by a range of 4.9% to 17.4% after denudation of the lesser curve (group B). Intraarterial staining of the gastric wall reveals the poor vascularity of the upper-most segment of the greater curve. CONCLUSION: Slight increase of the gastric capacity and maintenance of the submucosal vascular network account for the better results achieved with the whole stomach.