Completeness of pathology reports in stage II colorectal cancer.

INTRODUCTION: The completeness of the pathological examination of resected colon cancer specimens is important for further clinical management. We reviewed the pathological reports of 356 patients regarding the five factors (pT-stage, tumor differentiation grade, lymphovascular invasion, tumor perforation and lymph node metastasis status) that are used to identify high-risk stage II colon cancers, as well as their impact on overall survival (OS). METHODS: All patients with stage II colon cancer who were included in the first five years of the MATCH study (1 July 2007 to 1 July 2012) were selected (n = 356). The hazard ratios of relevant risk factors were calculated using Cox Proportional Hazards analyses. RESULTS: In as many as 69.1% of the pathology reports, the desired information on one or more risk factors was considered incomplete. In multivariable analysis, age (HR: 1.07, 95%CI 1.04-1.10, p < .001), moderately- (HR: 0.35, 95%CI 0.18-0.70, p = .003) and well (HR 0.11, 95%CI 0.01-0.89, p = .038) differentiated tumors were significantly associated with OS. CONCLUSIONS: Pathology reports should better describe the five high-risk factors, in order to enable proper patient selection for further treatment. Chemotherapy may be offered to stage II patients only in select instances, yet a definitive indication is still unavailable.

Treatment of recurrence after transanal endoscopic microsurgery (TEM) for T1 rectal cancer.

PURPOSE: The aim of this study was to evaluate the management and outcome of local recurrences after transanal endoscopic microsurgery for T1 rectal cancer. METHODS: Consecutive patients who underwent transanal endoscopic microsurgery for pT1 rectal cancer at a Dutch referral center (IJsselland Hospital) were registered in a prospective database. Follow-up was according to Dutch guidelines on rectal cancer, with additional rigid rectoscopy and endorectal ultrasound examinations every 3 months for the first 2 years, and every 6 months thereafter. Annual MRI of the lesser pelvis was added during the last 2 years of the study. Patients with local recurrence during follow-up were selected for individual analysis of outcome. RESULTS: Of a total of 88 patients who underwent transanal endoscopic microsurgery for pT1 rectal cancer, 18 patients (20.5%) had a local recurrence. Median time to local recurrence was 10 (range, 4-50) months. Median age at diagnosis of recurrence was 74 (range, 56-84) years. Of the 18 patients, 2 did not undergo further surgery because of concomitant metastatic disease, and 16 underwent salvage surgery, without need for multivisceral resections. No postoperative mortality was observed. In 15 patients (94%), a microscopically negative excision margin was obtained; in 1 patient, the excision margin was microscopically positive. Median follow-up after salvage surgery was 20 (range, 2-112) months. One patient had a local renewal of recurrence, and 7 patients (39%) had distant metastases. At 3 years, overall survival was 31%; cancer-related survival was 58%. CONCLUSIONS: Recurrent disease after transanal endoscopic microsurgery for T1 rectal cancer is a major problem. Although salvage surgery for achieving local control is feasible in most patients, survival is limited, mainly because of distant metastases. Tailoring selection of T1 rectal cancers and exploring possible adjuvant treatment strategies following salvage procedures should be the next steps toward improving survival.

Human Bile Contains Cholangiocyte Organoid-Initiating Cells Which Expand as Functional Cholangiocytes in Non-canonical Wnt Stimulating Conditions.

Diseases of the bile duct (cholangiopathies) remain a common indication for liver transplantation, while little progress has been made over the last decade in understanding the underlying pathophysiology. This is largely due to lack of proper in vitro model systems to study cholangiopathies. Recently, a culture method has been developed that allows for expansion of human bile duct epithelial cells grown as extrahepatic cholangiocyte organoids (ncECOs) in non-canonical Wnt-stimulating conditions. These ncECOs closely resemble cholangiocytes in culture and have shown to efficiently repopulate collagen scaffolds that could act as functional biliary tissue in mice. Thus far, initiation of ncECOs required tissue samples, thereby limiting broad patient-specific applications. Here, we report that bile fluid, which can be less invasively obtained and with low risk for the patients, is an alternative source for culturing ncECOs. Further characterization showed that bile-derived cholangiocyte organoids (ncBCOs) are highly similar to ncECOs obtained from bile duct tissue biopsies. Compared to the previously reported bile-cholangiocyte organoids cultured in canonical Wnt-stimulation conditions, ncBCOs have superior function of cholangiocyte ion channels and are able to respond to secretin and somatostatin. In conclusion, bile is a new, less invasive, source for patient-derived cholangiocyte organoids and makes their regenerative medicine applications more safe and feasible.

Transanal endoscopic microsurgery is feasible for adenomas throughout the entire rectum: a prospective study.

INTRODUCTION: Transanal endoscopic microsurgery for rectal adenomas is safe and has low recurrence rates. However, the feasibility of the procedure for all rectal adenomas is unclear. This issue was investigated prospectively. METHODS: From 1996 to 2007, 353 consecutive rectal adenomas were evaluated according to a standard protocol. Transanal endoscopic microsurgery was intended in all rectal adenomas. RESULTS: The median diameter was 3 cm and median distance was 8 cm. The peritoneum was opened peroperatively without any adverse effects in 8.7 percent. The conversion rate was 9.6 percent, with an alternative local procedure performed in 4.2 percent and a transabdominal procedure performed in 5.4 percent. Conversion rate correlated with the distance of the tumor (P = 0.007) and the operating surgeon's level of experience (P = 0.004). The median operation time was 45 minutes. Operation time correlated with specimen area, experience, and operating surgeon (all P < 0.001). All rectal adenomas were excised in one piece. Complete margins were observed in 85 percent. Rectal adenomas with incomplete margins were larger (P < 0.001) and were located more proximally (P < 0.001). Morbidity was 7.8 percent and mortality 0.6 percent. The median hospital stay was four days. The median follow-up was 27 months. The recurrence rate at three years was 9.1 percent. The median time from operation to recurrence was 12 (range, 4-54) months. Resection margin status was a predictor of recurrence, with 6.1 percent recurrence in cases of complete margins and 25.2 percent in cases of incomplete margins (P < 0.001). CONCLUSIONS: For nearly all rectal adenomas, transanal endoscopic microsurgery is safe, feasible, and has excellent results.

Total mesorectal excision for rectal cancer in an unselected population: quality assessment in a low volume center.

OBJECTIVE: The aim of this study was to review the results and long-term outcome after total mesorectal excision (TME) for adenocarcinoma of the rectum in an unselected population in a community teaching hospital. MATERIALS AND METHODS: Between 1996 and 2003, 210 patients with rectal cancer were identified in our prospective database, containing patient characteristics, radiotherapy plans, operation notes, histopathological reports, and follow-up details. An evaluation of prognostic factors for local recurrence, distant metastases, and overall survival was performed. RESULTS: The mean age at diagnosis was 69 years (range 40-91 years). A total of 145 patients were treated by anterior rectal resection; 65 patients had to undergo an abdominoperineal resection (APR). Anastomotic leakage rate was 5%. Postoperative mortality was 3%. After a median follow-up of 3.6 years, the local recurrence-free rate in patients with microscopically complete resections was 91%. The 5-year overall survival rate was 58%. An increased serum carcinoembryonic antigen, an APR, positive lymph nodes, and an incomplete resection all significantly influenced the 5-year overall survival and local recurrence rate. In a multivariate analysis, age was the most important prognostic factor for overall survival. CONCLUSIONS: Patients with rectal cancer can safely be treated with TME in a community teaching hospital and leads to a good overall survival and an excellent local control. In patients aged above 80, treatment-related mortality is an important competitive risk factor, which obscures the positive effect of modern rectal cancer treatment.

Harmonic long shears further reduce operation time in transanal endoscopic microsurgery.

BACKGROUND: Previous research indicates that application of 5-mm harmonic shears rather than diathermia significantly reduces operation time in transanal endoscopic microsurgery (TEM). Frequently, however, additional instruments were required to complete resection. We investigated whether the new 5-mm harmonic long shears (H-LS) are better equipped for TEM compared with regular harmonic shears (HS). METHODS: Between 2001 and 2006, 162 tumors (117 adenomas, 42 carcinomas, and 3 other tumors; mean distance 6.6 cm, mean area 40 cm(2)) were excised in 161 patients (82 men, 79 women; mean age 66 years). RESULTS: Eighty-eight resections were performed with HS and 74 with H-LS. Tumor and patient characteristics were similar except for specimen area. Tumors resected by H-LS were on average smaller than those resected by HS (34.4 versus 44.1 cm(2); Mann-Whitney U-test: p = 0.027). Mean operation time was 48 min and proportional to area in both groups (univariate analysis of variance p < 0.001). Mean operation time was 54 min using HS and 41 min using H-LS (t-test: p < 0.001). After correction for area, operation time for H-LS was reduced by 14% compared with HS (t-test: p < 0.001). H-LS is singly capable of completing resection in 88% compared with 26% for HS (Mann-Whitney U-test: p < 0.001). Mean blood loss was 16 cc for HS and 3 cc for H-LS (p < 0.001). Morbidity (11%) and mortality (0.6%) were not different between the two groups (Fisher's exact test). CONCLUSION: Performing transanal endoscopic microsurgery with 5-mm harmonic long shears reduces operation time compared with regular shears, and completing resection seldom requires other instruments.

Preoperative radiotherapy has no value for patients with T2-3, N0 adenocarcinomas of the rectum.

BACKGROUND: Treatment of rectal cancer with preoperative radiotherapy followed by total mesorectal excision is nowadays the standard treatment. It reduces local recurrences and improves overall survival. However, in patients with T2-3, N0 rectal cancer, the role of preoperative radiotherapy remains controversial. The aim of this study was to review the benefit of radiotherapy in T2 and T3, N0 rectal cancer patients. METHODS: Between 1996 and 2003, 103 patients with T2-3, N0 rectal cancer were identified in our prospective database. This study evaluated time to local recurrence, distant metastases and overall survival. RESULTS: Median follow-up was 4.3 years. The 5-year local control rate was 94%. The 5-year overall survival was 65%. The 5-year disease-free survival rate was 82%. Preoperative radiotherapy did not show any statistical differences. Abdominal perineal resection and T3 tumors negatively influenced overall survival (p = 0.02). Advanced age was of significant importance in overall survival. CONCLUSIONS: Preoperative radiotherapy does not seem to be of significant importance in patients with T2-3, N0 rectal cancer regarding local recurrence and survival. Since preoperative radiotherapy is associated with short- and long-term morbidity, patients with T2-3, N0 tumors should be identified and treated with surgery alone.

Malignant fibrous histiocytoma of the sigmoid: a case report and review of the literature.

BACKGROUND: Malignant fibrous histiocytoma (MFH) in the large bowel, which is composed of spindle-shaped cells arranged in a pleiomorphic and storiform pattern, is an extremely rare tumor. METHODS: We in this study report on a case of a 73-year-old man with a sarcoma arising from a diverticular sigmoid without any signs of involvement of regional lymph nodes or metastasis to liver or the abdomen. RESULTS: A sigmoid resection was performed with an uneventful postoperative course. Microscopically, the tumor consisted of bundles of spindle-shaped and pleiomorphic multinucleated cells without differentiation characteristics for other tumors than MFH. SUMMARY: Since the late 1970s, only 22 case reports of colorectal MFH have been documented, and little is known about its histogenesis and optimal treatment. A review of the cases and the world literature on immunohistochemistry and treatment is given.

Curative resection of rectal carcinoid tumors with transanal endoscopic microsurgery.

BACKGROUND: Transanal endoscopic microsurgery is a minimally invasive technique for local resection of rectal tumors. Its place needs to be defined for resection of carcinoid tumors of the rectum. MATERIALS AND METHODS: From 1998 to 2004, rectal carcinoid tumors were diagnosed in 5 patients. The diagnosis was suggested at biopsy in all patients. All tumors were resected full thickness with transanal endoscopic microsurgery. Data were obtained retrospectively from a review of hospital charts. RESULTS: At the time of operation all tumors were small without clinical or biochemical signs of metastasis. All resected tumors were highly differentiated and had free margins without invasion into the submucosa. Operative times ranged from 15 to 35 minutes. Hospital stays ranged from 2 to 4 days. No morbidity or mortality was observed. Follow-up ranged from 3 to 75 months. No recurrences were observed. CONCLUSION: Transanal endoscopic microsurgery is an excellent technique for removal of carcinoid tumors of the rectum and even the distal part of the sigmoid, if the diameter is <1 cm without invasion of the rectal wall.