Multimodal Treatment of cT3 Rectal Cancer in a Prospective Multi-Center Observational Study: Can Neoadjuvant Chemoradiation Be Omitted in Patients with an MRI-Assessed, Negative Circumferential Resection Margin?

BACKGROUND/AIM: Neoadjuvant chemoradiation (nCRT) in rectal cancer is associated with significant long-term morbidity. It is unclear whether nCRT in resectable mesorectal fascia circumferential resection margin (mrCRM)-negative rectal cancer treated by adequate total mesorectal excision (TME) is beneficial. The aim was to determine if nCRT can be omitted in patients with MRI-assessed cT3 rectal cancer and a negative mrCRM undergoing good-quality TME. METHODS: By means of a prospective nationwide registry (n = 43.147; prospective multi-center observational study), patients with cT3 rectal cancer <12 cm from the anal verge with a negative (>1 mm) MRI-assessed CRM undergoing radical resection from 2006 to 2008 were selected. Overall, 87 patients were available for the final analysis (TME-alone, n = 25; nCRT+TME, n = 62). Groups were balanced for age, sex, and ASA score, with a nonsignificant predominance of males in the nCRT+TME group. As main outcome measures, local and distant recurrence rates were compared between patients undergoing primary surgery (TME-alone) vs. neoadjuvant chemoradiation + surgery (nCRT+TME). RESULTS: In the TME-alone group, tumors were located closer to the anal verge (p = 0.018) and demonstrated a smaller minimal circumferential distance from the resection margin (p = 0.036). TME quality was comparable, as was median follow-up (48.9 vs. 44.9 months; p = 0.268). Local recurrences occurred at a similar rate in the TME-alone (n = 1; 5.3%) and nCRT+TME groups (n = 3; 5.5%) (p = 0.994) and were diagnosed at 10 months (TME-alone) and at 8, 13, and 18 months (nCRT+TME). Distant recurrences occurred in 28.9 and 17.4% of the cases, respectively (p = 0.626). The analysis was limited to cT3 cancers with a negative mrCRM. In addition, caution is required when appraising these results because of the limited number of evaluable subjects (especially in the TME-alone group), which adds some uncertainty to the statistical analysis. CONCLUSIONS: In this cohort of patients with rectal cancer located <12 cm from the anal verge and a negative mrCRM undergoing adequate TME, omission of nCRT had no impact onto the local recurrence rate.

Implementing complete mesocolic excision for colon cancer - mission completed?

The definition of complete mesocolic excision (CME) for colon carcinomas revolutionized the way of colon surgery. This technique conquered the world starting from Erlangen. Nevertheless, currently new developments especially in minimally invasive surgery challenge CME to become settled as a standard of care. To understand the evolution of CME, anatomical details occurring during embryogenesis and their variations have to be considered. This knowledge is indispensable to transfer CME from an open to a minimally invasive setting. Conventional surgery for colon cancer (non-CME) has a morbidity of 12.1-28.5% and a 3.7% mortality risk vs. 12-36.4% morbidity and 2.1-3% mortality for open CME. The morbidity of laparoscopic CME is between 4 and 31% with a mortality of 0.5-0.9%. In robotic assisted surgery, morbidity between 10 and 25% with a mortality of 1% was published. The cancer-related survival after 3 and 5 years for open CME is respectively 91.3-95% and 90% vs. 87% and 74% for non-CME. For laparoscopic CME the 3- and 5-year cancer-related survival is 87.8-97% and 79.5-80.2%. In stage UICC III the 3- and 5-year cancer-related survival is 83.9% and 80.8% in the Erlangen data of open technique vs. 75.4% and 65.5-71.7% for laparoscopic surgery. For stage UICC III the 3- and 5-year local tumor recurrence is 3.8%. The published data and the results from Erlangen demonstrate that CME is safe in experienced hands with no increased morbidity. It offers an obvious survival benefit for the patients which can be achieved solely by surgery. Teaching programs are needed for minimally invasive CME to facilitate this technique in the same quality compared to open surgery. Passing these challenges CME will become the standard of care for patients with colon carcinomas offering all benefits of minimally invasive surgery and oncological outcome.

[How does Diabetes Mellitus Influence Early Postoperative Results and Survival in Rectal Cancer?] / Wie beeinflusst der Diabetes mellitus das frühpostoperative und onkochirurgische Langzeit-"Outcome" beim Rektumkarzinom?

INTRODUCTION: Aim of this study was to investigate the influence of diabetes mellitus (DM) onto the early postoperative and long-term oncosurgical outcome after surgery for rectal cancer using data prospectively obtained in a representative number of patients. METHODS: Data (using a registration form of 68 items) from the ongoing multicenter observational study "rectal cancer (primary tumor) - elective surgery" on Quality Assurance was used including years 2008 to 2011. A voluntary and frequent follow-up was done to gain long-term data. Patients were grouped as non-diabetic and not-/insulin-dependent DM (NIDDM/IDDM). RESULTS: In total, 10 442 patients were enrolled; 11.0 % had NIDDM and 7.2 % IDDM. Average age of patients without DM was 67.3 [95 %-CI: 67,07; 67,55] years (yr) and was lower than in IDDM- (71.7 [95 %-CI: 71,01; 72,35] yr) and NIDDM-patients (70.9 [95 %-CI: 70.41; 71.45] yr) (p < 0.001). Tumor stages according to classification by UICC were comparable (p = 0.547). Patients with DM were more likely to be obese and to have cardiovascular and renal risk factors as well as a more critical ASA-classification (p < 0.001 each). Postoperative morbidity (in the group 65 - 74 yr; p = 0.006) and in-hospital mortality (< 65 yr; p = 0.011) was higher in patients with DM. The 5-year overall survival (OS) was 60.6 % in patients without DM. IDDM (46.4 %) and NIDDM (53.3 %) decreased the OS (p < 0.001 each). The 5-year disease-free survival (DFS) was also worsened by IDDM (p < 0.001) and NIDDM (p = 0.004). No difference was observed concerning 5-year local recurrence rate, neither for IDDM (p = 0.524) nor NIDDM (P = 0.058). DISCUSSION: The metabolic disorder DM has a significant impact onto the outcome after surgery for rectal cancer most likely due to its own risk potential and associated comorbidities. Postoperative morbidity and mortality were increased and the oncological survival was worsened.

Impact of Body Mass Index on Early Postoperative and Long-Term Outcome after Rectal Cancer Surgery.

BACKGROUND: The aim of this study was to investigate the impact of obesity and underweight onto early postoperative and long-term oncological outcome after surgery for rectal cancer. METHODS: Data from 2008 until 2011 was gathered by a German prospective multicenter observational study. 62 items were reported by the physicians in charge, and a consecutive follow-up was performed if the patient had signed a consent form. Patients were subclassified into: underweight, normal weight, overweight, and obese - using the definitions of the World Health Organization. RESULTS: In total, 9,920 patients were included, of whom 2.1% were underweight and 19.4% obese. The mean age was 68 years (range 21-99 years). Postoperative morbidity (mean 38.0%) was significantly increased in underweight and obese patients (p < 0.001). In-hospital mortality was 3.1% on average with no significant differences among patient groups (p = 0.176). The 5-year overall survival ranged between 36.9 and 61.3% and was worse in underweight and prolonged in overweight and obese patients compared to those with normal weight (p < 0.001 each). While the 5-year disease-free survival was increased in overweight and obese patients (p < 0.05 each), the 5-year local recurrence rate showed no correlation (p > 0.05 each). Multivariate analysis revealed that advanced age, higher ASA scoring, postoperative morbidity, and advanced tumor growth worsened the long-term survival independently. CONCLUSIONS: Underweight patients had a worse early and long-term outcome after rectal cancer surgery. Overweight and obesity were associated with a significantly better long-term survival.

Adjuvant treatment for resected rectal cancer: impact of standard and intensified postoperative chemotherapy on disease-free survival in patients undergoing preoperative chemoradiation-a propensity score-matched analysis of an observational database.

AIMS: Adjuvant chemotherapy for resected rectal cancer is widely used. However, studies on adjuvant treatment following neoadjuvant chemoradiotherapy (CRT) and total mesorectal excision (TME) have yielded conflicting results. Recent studies have focused on adding oxaliplatin to both preoperative and postoperative therapy, making it difficult to assess the impact of adjuvant oxaliplatin alone. This study was aimed at determining the impact of (i) any adjuvant treatment and (ii) oxaliplatin-containing adjuvant treatment on disease-free survival in CRT-pretreated, R0-resected rectal cancer patients. METHOD: Patients undergoing R0 TME following 5-fluorouracil (5FU)-only-based CRT between January 1, 2008, and December 31, 2010, were selected from a nationwide registry. After propensity score matching (PSM), comparison of disease-free survival (DFS) using Kaplan-Meier analysis and log-rank test was performed in (i) patients receiving no vs. any adjuvant treatment and (ii) patients treated with adjuvant 5FU/capecitabine without vs. with oxaliplatin. RESULTS: Out of 1497 patients, 520 matched pairs were generated for analysis of no vs. any adjuvant treatment. Mean DFS was significantly prolonged with adjuvant treatment (81.8 ± 2.06 vs. 70.1 ± 3.02 months, p < 0.001). One hundred forty-eight matched pairs were available for analysis of adjuvant therapy with or without oxaliplatin, showing no improvement in DFS in patients receiving oxaliplatin (76.9 ± 4.12 vs. 79.3 ± 4.44 months, p = 0.254). Local recurrence rate was not significantly different between groups in either analysis. CONCLUSION: In this cohort of rectal cancer patients treated with neoadjuvant CRT and TME surgery under routine conditions, adjuvant chemotherapy significantly improved DFS. No benefit was observed for the addition of oxaliplatin to adjuvant chemotherapy in this setting.

Ex Vivo Intra-arterial Methylene Blue Injection in Rectal Cancer Specimens Increases the Lymph-Node Harvest, Especially After Preoperative Radiation.

BACKGROUND: The examination of as large a number of lymph nodes as possible in rectal carcinoma resectates is important for exact staging. However, after neoadjuvant radiochemotherapy (RCT), it can be difficult to obtain a sufficient number of lymph nodes. We therefore investigated whether staining with methylene blue via the inferior mesenteric artery can lead to an increase in the yield of lymph nodes in rectal carcinoma tissue after neoadjuvant RCT. METHODS: In a prospective, unicentric study rectal carcinoma resectates from three consecutive groups of patients were examined (Group I, no staining; Group II, staining with methylene blue; Group III, again no staining). The numbers of lymph nodes examined were compared (a) between the groups and (b) between patients who had not, or who had, received neoadjuvant RCT. RESULTS: In all, 75 rectal carcinoma preparations were assessed. The yield of lymph nodes investigated before the use of staining (Group I) increased when staining was introduced (Group II), both for the patients without neoadjuvant RCT (20.9 vs. 31.3, p = 0.018) and for those who did receive this (15.0 vs. 35.1; p = 0.003). After withdrawal of the staining procedure (Group III), the lymph-node yield remained high for the patients without neoadjuvant RCT (31.3 vs. 30.4; p = 0.882), but it reverted to a lower value for those who did receive neoadjuvant RCT (35.1 vs. 24.2; p = 0.029). Before the introduction of staining (Group I), significantly fewer lymph nodes were examined for patients who received neoadjuvant RCT (15.0 vs. 20.9; p = 0.039). However, with staining (Group II), no difference was found associated with the use or non-use of neoadjuvant RCT (31.3 vs. 35.1; p = 0.520). CONCLUSION: The use of methylene blue staining of rectal carcinoma preparations leads to a significant increase in the number of lymph nodes examined after neoadjuvant RCT. This can be expected to improve the accuracy of lymph-node staging of neoadjuvant-treated rectal carcinoma.

Pretherapeutic MRI for decision-making regarding selective neoadjuvant radiochemotherapy for rectal carcinoma: interim analysis of a multicentric prospective observational study.

PURPOSE: To study the accuracy of different cutoffs for an involved circumferential resection margin (CRM) compared with T and N categories measured by MRI as basis for selective application of neoadjuvant radiochemotherapy (nRCT) in rectal carcinoma. MATERIALS AND METHODS: In a prospective multicenter observational study involving 153 primarily operated patients, the preoperative results of MRI with pathohistological findings of resected specimens were compared. RESULTS: For a cutoff of ≤1 mm for involvement of the CRM, the accuracy of preoperative MRI was 90.9% (139/153). The negative predictive value was 98.5% (134/136). The four participating departments did not differ significantly. For a cutoff of >2 mm and >5 mm, the rates of false-positive findings increased significantly from 5% to 12% and 35% with a decrease in accuracy to 82% and 62%, respectively. In contrast, the accuracy in predicting T (69.3%) and N categories (61.4%) was much lower. CONCLUSION: The indication for nRCT should be based on the determination of the minimal distance of the tumor from mesorectal fascia with a cutoff point of >1 mm as measured by MRI.

Impact of fast-track concept elements in the classical pancreatic head resection (Kausch-Whipple procedure).

UNLABELLED: The aim of the study was to determine statistically significant factors with an impact on the early postoperative surgical outcome. MATERIAL AND METHODS: The influence of applied fast-track components on surgical results and early postoperative outcome in 143 consecutive Kausch-Whipple procedure patients was evaluated in a single-center retrospective analysis of a prospective collection of patient-associated pre-, peri- and postoperative data from 1997-2006. RESULTS: The in-hospital mortality rate was 2.8% (n=4). Fast-track measures were shown to have no effect on the morbidity rate in the multi-variate analysis. Over the study period, a decrease of intraoperative infusion volume from 14.2 mL/kg body weight/h in the first year to 10.7 mL/kg body weight/h in the last year was accompanied by an increase in patients requiring intraoperative catecholamines, up from 17% to 95%. The administration of ropivacain/sufentanil via thoracic peri-dural catheter injection initiated in 2000 and now considered the leading analgesic method, was used in 95% of the cases in 2006. Early extubation rate rose from 16.6% to 57.9%. CONCLUSIONS: Fast-track aspects in the perioperative management have become more important in several surgical procedure even in those with a greater invasiveness such as Kausch-Whipple. However, such techniques used in peri-operative management of Kausch-Whipple pancreatic-head resections had no impact on the morbidity rate. In addition, the low in-hospital mortality rate was particularly attributed to surgical competence.

MRI-based indications for neoadjuvant radiochemotherapy in rectal carcinoma: interim results of a prospective multicenter observational study.

BACKGROUND: This study evaluated use of circumferential resection margin status in preoperative MRI (mrCRM) as an indication for neoadjuvant radiochemotherapy (nRCT) in rectal carcinoma patients. MATERIALS AND METHODS: In a multicenter prospective study, nRCT was given to patients with carcinoma of the middle rectum with positive mrCRM (≤1 mm), with cT3 low rectal carcinoma, and all patients with cT4 tumors. The short-term endpoints were pathologic pCRM (≤1 mm) as a strong predictor of local recurrence rate and the quality of total mesorectal excision according to the plane of surgery. These endpoints were compared in patients with and without nRCT. RESULTS: Of 230 patients that met the inclusion criteria, 96 (41.7%) received a long course of nRCT and 134 (58.3%) were primarily operated on. The pCRM was positive in 13 of 230 (5.7%) (primarily operated on, 2 of 134 [1.5%]; after nRCT, 11 of 96 [11%]). In 1 of 134 (0.7%) case, the mrCRM was falsely negative. Patients at participating centers varied in terms of preoperative stage but not in pCRM positivity (0%-13%, P = .340). The plane of surgery was mesorectal (good) in 209 of 230 (90.9%), intramesorectal (moderate) in 16 of 230 (7%), and the muscularis propria plane (poor) in 2.2% (5 of 230). CONCLUSIONS: Low pCRM positivity and the high quality of mesorectal excision support use of MRI-based nRCT in rectal carcinoma. nRCT was avoidable in 45% of patients with stage II and III disease without significant risk of undertreatment. Preoperative MRI thus allows identification of patients with high risk of local recurrence and use of selective nRCT.

The care of patients with colon cancer: current treatment, and evaluation of new surgical approaches.

BACKGROUND: Multi-center observational studies in surgery can yield important findings, as long as they are appropriately designed and monitored and employ modern methods of statistical analysis. METHODS: In a multi-center quality assurance study carried out in 346 German hospitals from 2000 to 2004, data were collected from a total of 31 055 patients who underwent surgery for colon carcinoma. The current, overall state of medical care for this disease was analyzed, with particular attention to aspects of quality assurance. RESULTS: 46.7% of the patients were in the advanced, prognostically unfavorable stages UICC III and IV and had an overall 5-year survival of 53.8% in stage III and 9.8% in stage IV. Laparoscopic intention-to-treat procedures were performed on 1401 patients (4.7%), of whom 20.6% required conversion to laparotomy. The patients who required conversion to laparotomy had a worse overall outcome. 28 271 patients were treated with tumor resection and primary anastomosis; in this group, 3% (n = 844) developed an anastomotic leak. Logistic regression analysis identified the following risk factors for anastomotic leakage: duration of surgery, ileus, tumor localization in the left colon, and single-layer suturing. CONCLUSION: This multi-center observational study yields valid findings about the epidemiology and overall quality of medical care for colon carcinoma in Germany.

Risk adjustment as basis for rational benchmarking: the example of colon carcinoma.

BACKGROUND: The results of resection of colorectal carcinoma can vary greatly from one hospital to another. However, this does not necessarily reflect differences in the quality of treatment. The purpose of this study was to compare various tools for the risk-adjusted assessment of treatment results after resection of colorectal carcinoma within the context of hospital benchmarking. METHODS: On the basis of a data pool provided by a multicentric observation study of patients with colon cancer, the postoperative in-hospital mortality rates at two high-volume hospitals ("A" and "B") were compared. After univariate comparison, risk-adjusted comparison of postoperative mortality was performed by logistic regression analysis (LReA), propensity-score analysis (PScA), and the CR-POSSUM score. Postoperative complications were compared by LReA and PScA. RESULTS: Although postoperative mortality differed significantly (P = 0.041) in univariate comparison of hospitals A and B (2.9% vs. 6.4%), no significant difference was found by LReA or PScA. Similarly, the observed mortality at these did not differ significantly from the mortality estimated by the CR-POSSUM score (hospital A, 2.9%/4.9%, P = 0.298; hospital B, 6.4%/6.5%, P = 1.000). Significant differences were seen in risk-adjusted comparison of most postoperative complications (by both LReA and PScA), but there were no differences in the rates of relaparotomy or anastomotic leakage that required surgery. CONCLUSIONS: For the hard outcome variable "postoperative mortality," none of the three risk adjustment procedures showed any difference between the hospitals. The CR-POSSUM score can be regarded as the most practicable tool for risk-adjusted comparison of the outcome of colon-carcinoma resection in clinical benchmarking.

Neoadjuvant chemoradiotherapy for rectal carcinoma: effects on anastomotic leak rate and postoperative bladder dysfunction after non-emergency sphincter-preserving anterior rectal resection. Results of the Quality Assurance in Rectal Cancer Surgery multicenter observational trial.

INTRODUCTION: Randomized trials have demonstrated a reduction in local recurrence rate in rectal cancer patients treated with preoperative chemoradiotherapy and total mesorectal excision (TME) compared to patients undergoing TME alone. Accordingly, preoperative chemoradiotherapy in all UICC stages II and III rectal cancers has been recommended in the German treatment guidelines as of 2004. However, this policy has been questioned in recent years, partly due to concern regarding an increase in postoperative complications through preoperative therapy. Studies on this issue are sparse; most have been conducted in specialized centers, included relatively few patients, and yielded partly contradicting results. It was the aim of our analysis to investigate the influence of preoperative chemoradiotherapy on anastomotic leak rate and postoperative bladder dysfunction in rectal cancer patients using a representative data set from the Quality Assurance in Rectal Cancer Surgery multicenter observational trial. METHOD: This is a retrospective analysis of data from the Quality Assurance in Rectal Cancer Surgery prospective multicenter observational trial. Data of all patients undergoing curatively intended sphincter-preserving resection for UICC stage I through III rectal carcinoma between 01 Jan 2005 and 31 Dec 2007 with or without preoperative chemoradiotherapy (groups A and B, respectively) were included. Multivariate statistical analysis using propensity score analysis was carried out regarding outcome parameters total anastomotic leak rate, rate of anastomotic leaks requiring reoperation, and postoperative bladder dysfunction. RESULTS: A total of 2,085 patients were included (group A, n = 676, group B, n = 1,409). Significant differences were present between groups regarding age, sex, distance of the tumor from the anal verge, pT-stage, UICC stage, hepatic risk factors, and use of protective enterostomy by univariate analysis. Multivariate logistic regression including these parameters was used to calculate the propensity score (likelihood to be assigned to group A or B as a consequence of the individual profile of these factors) for each patient. When outcome parameters were compared between groups A and B after stratification for propensity score, no significant differences regarding postoperative bladder dysfunction (p = 0.12), total anastomotic leak rate (p = 0.56), and anastomotic leaks requiring reoperation (p = 0.56) could be demonstrated. CONCLUSION: Neoadjuvant chemoradiotherapy for rectal carcinoma does not increase the risk for anastomotic leakage or postoperative bladder dysfunction after curatively intended sphincter-preserving rectal resection.

Modified neoadjuvant short-course radiation therapy in uT3 rectal carcinoma: low local recurrence rate with unchanged overall survival and frequent morbidity.

PURPOSE: The purpose of this study is to investigate the value of a modified neoadjuvant short-course radiation therapy (SCRT) in uT3 rectal carcinoma, which, despite local R0 resectability, carries a greater risk of local recurrence than less invasive carcinomas. METHODS: Sixty-three patients with uT3 rectal carcinoma < or =10 cm above the anal verge received a modified 8 x 3 Gy pre-operative SCRT. Radiation-associated and peri-operative complications were recorded, and the patients were followed up for long-term oncological outcome and morbidity. RESULTS: In the study group, there were no severe adverse radiation-associated effects; the rate of peri-operative morbidity was 54.0% and that of in-hospital mortality is 4.8%. The probability (Kaplan-Meier estimate) of local recurrence was 3.9% with a probability of metachronic distant metastases of 26.8% (5-year rates). We found the probability of 5-year disease-free survival to be 70.5% and that of 5-year overall survival, 59.5%. Long-term complications were reported for 31.7% of patients. CONCLUSIONS: Compared to the literature-modified 8 x 3 Gy neoadjuvant SCRT and surgery in uT3, rectal carcinoma was associated with low local recurrence but frequent peri-operative complications. The decisive prognostic factor, distant metastasis, was unaffected. Difficulties included overestimation of tumour invasion depth by endosonography. Possible clinical consequences of the results are discussed.

Quality of medical care in colorectal cancer in Germany.

BACKGROUND: To investigate recent developments in therapeutic approaches, we examine the quality of and discuss current trends in the routine treatment of colorectal cancer in Germany. MATERIAL AND METHODS: We conducted a prospective, multicentre, country-wide observational study in Germany at a representative number of hospitals providing care at all levels. RESULTS: The perioperative morbidity and mortality rates were found not to have changed for a given risk profile of patient and tumour characteristics. The resection rates and long-term oncological results achieved in clinical routine are comparable with those reported in the current literature for colorectal cancer. The quality of care of rectal carcinoma patients has improved significantly, as measured by perioperative oncosurgical criteria (abdominoperineal resection rate, total mesorectal excision rate and quality, and proportion of neoadjuvant procedures). CONCLUSION: At present, it remains to be seen whether these factors will lead to a further improvement in long-term results (e.g. rates of local recurrence), and this will require further critical analysis.

Oncological outcome of local vs radical resection of low-risk pT1 rectal cancer.

HYPOTHESIS: Despite the noninclusion of locally draining lymph nodes, limited resection of low-risk pT1 rectal cancer can achieve an adequate oncological outcome with lower morbidity and mortality compared with radical resection. DESIGN: Based on the data of a prospective multicenter observational study performed from January 1, 2000, through December 31, 2001, patients with low-risk pT1 rectal cancer underwent analysis with regard to the early postoperative outcome and the oncological long-term results achieved after limited vs radical resection with curative intent. SETTING: Two hundred eighty-two hospitals of all categories. PATIENTS: Four hundred seventy-nine patients with low-risk pT1 rectal cancer treated for cure. INTERVENTIONS: Eighty-five patients (17.7%) underwent limited excision using a conventional transanal approach and 35 (7.3%) using transanal endoscopic microsurgery. The remaining 359 (74.9%) underwent radical resection. MAIN OUTCOME MEASURES: Postoperative morbidity and mortality, local recurrence rate, and tumor-free and overall survival. RESULTS: In comparison with radical resection, limited resection was associated with fewer general (25.1% vs 7.5%; P<.001) and specific (22.8% vs 9.2%; P<.001) postoperative complications. After a mean follow-up of 44 months, patients who underwent limited resection had a significantly higher 5-year local tumor recurrence rate than did those who underwent radical resection (6.0% vs 2.0%; P = .049), but tumor-free survival did not differ. CONCLUSION: Limited resection of pT1 low-risk rectal cancer can result in an oncologically acceptable outcome but must nevertheless be considered an oncological compromise compared with radical resection.

No prognostic impact of isolated lymphovascular invasion after radical resection of rectal cancer--results of a multicenter observational study.

BACKGROUND: The prognostic impact of isolated lymphovascular invasion (LVI) after radical resection of rectal cancer is controversially discussed. However, it could be relevant to decide for an adjuvant treatment. AIM: The aim of the analysis was, based on the data of an observational study, to determine the prognostic relevance of the isolated LVI. MATERIALS AND METHODS: Patients after radical resection of rectal cancer with no hemangioinvasion were subdivided in three groups: I-no LVI, no lymph node metastases (LNM); II-positive LVI, no LNM; III-positive LNM. Five-year local recurrence rate, distant metastases-free and disease-free survival were determined uni- and multivariate. RESULTS: Patients, n = 846, were studied (I, n = 471; II, n = 75; III, n = 300). The univariate comparison between the groups revealed the following 5-year results: local recurrence rate: 9.4 vs 10.0 vs 14.0%; distant metastases-free survival: 84.1 vs 82.5 vs 49.3%; disease-free survival: 83.2 vs 80.7 vs 45.5%. The differences between groups I and III were significant, but not between groups I and II. The determined higher disease-free survival rate in group II vs group III was significant (P = 0.041), but the differences in local recurrence rate and rate of distant metastases did not reach statistical significance. The multivariate analysis revealed no impact of the isolated LVI on the oncological outcome. CONCLUSION: The isolated LVI has no independent prognostic impact on the local recurrence rate and long-term survival after radical resection of rectal cancer. Based on this finding, no indication for an adjuvant treatment in these patients can be derived.

Incurable stenosing colorectal carcinoma: endoscopic stent implantation or palliative surgery?

BACKGROUND: Palliative surgery for the treatment of incurable obstructive colorectal carcinoma is associated with a considerable perioperative morbidity and mortality but no substantial improvement of the prognosis. The aim of the present study was to study the effectiveness of colorectal stenting compared with palliative surgery in incurable obstructive colorectal carcinoma. PATIENTS AND METHODS: From April 1999 to April 2005, data of consecutive patients with incurable stenosing colorectal carcinoma, either treated with stent implantation or palliative surgical intervention, were prospectively recorded with respect to age, sex, tumor location (including metastases), ASA-score, peri-interventional morbidity, mortality, rates of complications, and re-interventions as well as survival. RESULTS: Of 40 patients, 38 (95%) were successfully treated with a stent. Two patients (5%) underwent surgical intervention after stent dislocation. In contrast, 38 patients primarily underwent palliative surgical intervention. Stent patients were significantly older (P=0.020), had a higher ASA-score (P=0.012), and had more frequently distant metastases (P=0.011). After successful stent implantation, no early complications were observed, but late complications occurred in 11 subjects (29%). Following palliative surgical intervention, postoperative complications occurred in 12 individuals (32%) . Postoperative mortality was 5% in the surgery group, whereas no patient died following stent implantation. There was no significant differences in the survival of both groups (9.9 vs. 7.8 months, respectively; log rank: 0.506). CONCLUSIONS: Palliative treatment of incurable obstructive colorectal carcinoma using stents is an effective and suitable alternative to palliative surgery with no negative impact on the survival but less peri-interventional morbidity and mortality as well as comparable overall morbidity.