Who profits from neoadjuvant radiochemotherapy for locally advanced esophageal carcinoma?

BACKGROUND: Patients suffering from locally advanced esophageal carcinoma are generally treated using multimodal therapies. This prospective, non-randomized trial was performed to evaluate the survival benefit of neoadjuvant radiochemotherapy prior to surgery in comparison with surgery only. PATIENTS & METHODS: Histopathological outcomes and survival were compared between 61 patients who underwent neoadjuvant radiochemotherapy and 64 comparable control patients who had been under-staged. After neoadjuvant therapy, tumor regression was assessed using the method described by Mandard in 1994. Survival curves for the two groups were estimated using the Kaplan-Meier method, and compared with the log-rank test. RESULTS: Median and 3-year recurrence-free survival for the entire group were 26 months and 39.7%, respectively. The median and 3-year overall survival reached 34 months and 48.1%. Patients who showed complete response to neoadjuvant therapy had significantly improved survival (35 months) compared to patients with residual tumor cells (28 months), patients with tumors unresponsive to radiochemotherapy (22 months), or patients who received surgery only (control group, 29 months). Patients with nodal-negative carcinomas showed significantly longer survival after surgery only and after neoadjuvant therapy compared to patients with lymph node-positive cancers. CONCLUSIONS: Complete response after neoadjuvant radiochemotherapy is associated with significantly improved survival. Negative nodal status is a major determinant of outcomes following primary operation or neoadjuvant treatment.

Colorectal liver metastasis surgery: analysis of risk factors predicting postoperative complications in relation to the extent of resection.

BACKGROUND/AIMS: Despite advances in diagnosis and treatment, the rate of complications after resection for colorectal liver metastases remains high. An awareness of risk factors is essential for the rates of morbidity and mortality to fall to optimal levels. MATERIALS AND METHODS: Of the 240 patients who underwent resection for the first manifestation of colorectal liver metastases, 49 patients with lobectomy or extended hepatectomy (major resections) and 58 with wedge resections within only one liver segment (minor resections) form the basis of this report. A total of 16 variables were analyzed to find the risk factors linked to postoperative morbidity and mortality. RESULTS/FINDINGS: Thirty-four patients (31.8%) suffered postoperative complications, and one patient died during the hospital stay (0.9%). In the major resection group, multivariate analysis showed that neoadjuvant chemotherapy [odds ratio (OR): 2.4; p = 0.005], vascular clamping (OR: 1.4; p = 0.008), and intraoperative blood loss with transfusion of three to six packed red cell units (OR: 1.2; p = 0.029) were significantly associated with postoperative morbidity. Vascular clamping was an independent predictor for biliary fistula (OR: 1.2; p = 0.029). Postoperative temporary liver failure was influenced by neoadjuvant chemotherapy (OR: 3.4; p = 0.010), vascular clamping (OR: 1.5; p = 0.015), and requirement of blood transfusion (OR: 2.1; p = 0.016). After minor resections, only a decreased postoperative serum cholinesterase B level was an independent predictor for complications (OR: 2.2; p = 0.001), as well as for hemorrhage (OR: 1.6; p = 0.023). Postoperative mortality was not predicted by any of the factors that were analyzed. INTERPRETATION/CONCLUSION: Factors for complications differ depending on the extent of colorectal liver metastasis resection. Only knowledge and particular consideration of these factors may provide for an optimal postoperative outcome for the individual patient.

Prognostic factors and evaluation of a clinical score for predicting survival after resection of colorectal liver metastases.

BACKGROUND: Patient outcome after resection of colorectal liver metastases can be predicted by various prognostic factors. AIMS: Development of a model for risk stratification based on analysis of prognostic factors. METHODS: Data of 201 patients were collected prospectively and included in a single-centre trial. A total of 20 factors were analysed as to their influence on recurrence-free and overall survival. Independent prognostic factors were entered into a model of a clinical risk score. RESULTS: Median recurrence-free survival reached 24 months for all patients; median overall survival was 50 months. Only a synchronous manifestation of primary colorectal carcinoma and liver metastases, the presence of four or more metastases and a carcino-embryonic antigen level of 200 ng/ml or more significantly influenced recurrence-free and overall survival in the multivariate analysis. The derived risk stratification grouped the patients according to the following criteria: low risk, zero prognostic factors (n=112); intermediate risk, one factor (n=74); high risk, two or more factors (n=15). The median recurrence-free survival for low, intermediate and high risk were 30.0, 23.0 and 11.0 months, respectively; the median overall survival was 94.0, 40.0 and 33.0 months. Compared with the low-risk group, patients with intermediate risk demonstrated an increased hazard ratio (HR) of 1.57-fold for recurrence (P=0.018) and 1.91-fold for mortality (P=0.007). For the high-risk group, the HR rose significantly to 3.26 for recurrence (P<0.0005) and to 3.10 for mortality (P=0.001). CONCLUSIONS: The presented clinical score may allow for patients with colorectal liver metastases to be stratified appropriately and for optimization of their subsequent therapeutic management.

Impact of age on the short-term postoperative outcome of patients undergoing surgery for colorectal carcinoma.

BACKGROUND: Patient age has a decisive impact on the short-term postoperative results in surgery for carcinoma. PATIENTS AND METHODS: This prospective multicenter study involved 75 German hospitals and 3756 patients undergoing treatment in 1999: 1447 aged under 65 years, 1847 aged 65-79 years, and 458 aged over 80 years. RESULTS: In the oldest patient group, there was a significantly higher proportion of extensive, localized tumors (UICC stage II: 25.9%, 28.4%, and 36.1%, respectively) and significant differences were found among the three groups in operation rates (98.8%, 98.6%, and 96.5%), resection rate (94.2%, 93.2%, and 83.9%), general postoperative complications (21.5%, 28.6%, and 41.2%), morbidity (36.5%, 42.6%, and 50.0%) and mortality (2.7%, 6.6%, and 11.8%). CONCLUSION: In the elderly, locally advanced tumors, but not metastasizing tumors, are to be expected. The increase in postoperative morbidity and mortality rates with increasing age was due to the increase in general postoperative complications. Surgery for colorectal carcinoma in patients of advanced age is not associated with any increase in intraoperative or specific postoperative complications.