Assessment of pathologic response after preoperative chemoradiotherapy and surgery in pancreatic adenocarcinoma.

PURPOSE: The benefits provided by preoperative chemoradiotherapy (CRT) in pancreatic ductular adenocarcinoma (PDA) are still controversial. However, in most reports from referral centers, improvement in local control and survival appears to be provided in selected patients. The aim of this retrospective study was to analyze the radiation-induced pathologic effects of preoperative CRT in patients with resectable PDA and determine the precise long-term outcome of the responding patients. METHODS AND MATERIALS: Between November 1996 and October 2003, 61 patients underwent preoperative CRT for resectable PDA. The tumor location was the pancreatic head in 49 patients and pancreatic body in 12 patients. Of the 61 patients, 21 (34.5%) did not undergo surgery because of disease progression and 40 (65.5%) underwent pancreatic resection, including pancreaticoduodenectomy in 32 (80%) and distal pancreatectomy in 8 (20%). RESULTS: A major pathologic response was noted in 9 patients, including three complete responses, and was found only in patients with tumor of the pancreatic head. The local control rate was similar in patients with and without a major pathologic response. Survival in patients with a major response was significantly greater than in those without a response or with a minor response. CONCLUSION: Major tumor downstaging can be provided by preoperative CRT in patients with resectable cephalic PDA. Survival appears to be significantly improved in selected patients.

Emergency subtotal/total colectomy in the management of obstructed left colon carcinoma.

PURPOSE: The treatment of acutely obstructed carcinoma of the left colon still represents a matter of controversy. The aim of the study was to evaluate the results of its management by emergency subtotal or total colectomy with immediate anastomosis without diversion. METHODS: An emergency subtotal/total colectomy was performed in 72 patients (mean age 74.9 years). Inclusion criteria were reasonable operative risk, resectable acutely obstructed carcinoma, massively distended colon of dubious viability, and likely to contain ischemic lesions, signs of impending cecal perforation, and masses suggesting synchronous colonic cancers. RESULTS: Postoperative mortality was 9.7% (7 patients). An 83-year-old woman died as a result of an anastomotic dehiscence; the six other deaths resulted of cardiopulmonary complications. Postoperative morbidity was 15% (11 patients) including two fistulas, which recovered without surgery. There were eight synchronous colon carcinomas. Six months after surgery, the mean daily stool frequency was two following subtotal colectomy and three after total colectomy. CONCLUSION: Emergency subtotal colectomy achieves in one-stage relief of bowel obstruction and tumor resection by encompassing a massively distended and fecal-loaded colon with ischemic lesions and serous tears on the cecum. It ensures restoration of gut contiguity via a "safe" ileocolonic anastomosis and removes occasional lesions proximal to the index cancer.