Preoperative Chemoradiation Followed by Total Mesorectal Excision for Locally Advanced Rectal Cancer: Oncologic Outcomes According to Pathologic T and N Stage

PURPOSE: Tumor response of patients with locally advanced rectal cancer after chemoradiation showed 60~70% of tumor volume reduction and T and N downstaging. Curative resection with total mesorectal excision should be followed for good oncologic outcomes. This study was designed to analyze the oncologic outcomes in patients who received preoperative chemoradiation followed by total mesorectal excision for locally advanced rectal cancer according to pathologic T and N stage. METHODS: Total 108 patients with locally advanced rectal cancer treated between 1989 and 2000. All patients were analyzed retrospectively and staged as T3, 4 N (+) by transrectal ultrasonography and pelvic MRI. All patients received a 5, 040 cGy of radiation over 5 weeks and systemic intravenous bolus chemotherapy 5 FU 450 mg/m2 and leucovorin 20 mg/m2 for 5 days was given during first and fifth weeks of radiation treatment, followed four to six weeks later by radical surgery. RESULTS: Among 108 patients there were 74 males and 34 females. Mean age was 54.4 years in male and 52.3 years in female. Mean follow up periods was 41.3 months. Complete follow up was in 96.4% of patients. Curative resection was done in 90 patients (83.3%). The most common type of surgery was low anterior resection in 40 (44.4%) and unresectable patients in 10 (9.3%). Postoperative morbidities were wound infection (n=10, 9.2%), anastomostic leakage (n=2, 1.9%), and anastomotic stricture (n=1, 0.9%). After chemoradiation, tumor stage were as follows: pathologic complete remission was in 7 (6.5%), pT1, T2 N0 (stage I) was in 21 (19.4%), T3N0 (stage II) was in 28 (25.9%) and T3 N (+) (stage III) was in 34 (31.5%). The rate of local recurrence was 10.7% in stage II and 20.6% in stage III. Systemic recurrence was 21.4% in stage II and 47.1% in stage III. 5 year survival rate according to T stage was T0 (100%), T1 (100%), T2 (79.5%), T3 (43.7%), T4 (33.3%) (p=0.0088). According to N stage, N (-)(72.0%) and N (+) (35.7%)(p=0.002). Among T3 patients, 5 year survival rate was N (-)(58.2%) vs. N (+)(32.0%)(P=0.0228). CONCLUSION: Preoperative chemoradiation followed by total mesorectal excision downstaged locally advanced rectal cancer and showed high resectability. Clinical outcomes correlated with pathologic T and N downstaging. Patients who did not show pathologic T and N downstaging showed high local and systemic failure and poor prognosis.

Significance of postoperative serum level of carcinoembryonic antigen (CEA) and actual half life of CEA in colorectal cancer patients

The postoperative levels of carcinoembryonic antigen (CEA) and the actual half life (T1/2) of CEA were evaluated to ascertain their potency in predicting the recurrence of colorectal cancer after curative surgery in patients who had an abnormally high level of preoperative carcinoembryonic antigen (CEA, > or = 5 ng/ml). Ninety-four patients who underwent curative surgery were enrolled and 24 patients (25.5%) had recurrence during the follow-up period (median: 30 months, range: 2-69 months). T1/2 of CEA for all patients ranged from 1.2 days to 88.1 days, with a median of 4.4 days. T1/2 of CEA (mean +/- standard deviation) was 11.7 +/- 17.9 days in recurrent patients, whereas it was 6.2 +/- 4.9 days in patients without recurrence (p = 0.0224). The patients' age, gender, size of the tumor, location of the tumor, pre-, and postoperative CEA level, pathologic type of the tumor and Dukes stage had no significance in recurrence. The 1-year, 2-year, and 5-year disease-free survival rates were 95.1%, 81.1%, and 73.8% in patients with postoperative CEA levels less than 5 ng/ml (n = 62), respectively, and 71.4%, 64.8%, and 64.8% in patients with postoperative CEA levels higher than or equal to 5 ng/ml (n = 32), respectively (p = 0.04). Patients were divided into Group S (T1/2 of CEA or = 4.4 days, n = 51). The 1-year, 2-year, and 5-year disease-free survival rates were 95.3%, 85.1%, and 77.7% in Group S, respectively, and 80%, 67.5%, and 64.1% in Group L, respectively (p = 0.0261). In conclusion, the disease-free survival of colorectal cancer patients was prolonged in patients who had a short T1/2 of CEA or a low level of postoperative CEA. In high-risk colorectal cancer patients with an abnormally high level of preoperative CEA, recurrence may be predicted by checking an early postoperative CEA level and/or by a simple calculation of the actual half life of CEA.

Assessment of management for thyroid carcinoma invading the trachea / 대한암학회지

No abstract available.

Use of the stomach as an esophageal substitute after esophagectomy

No abstract available.

Primary appendiceal adenocarcinoma

No abstract available.

The Result of Surgical Treatment for Esophageal Cancer

This study is to evaluate the clinicopathologic characteristics of esophageal cancer and to assess its surgical outcome according to these clinicopathologic features. A retrospective analysis was performed for 90 esophageal cancer patients who had undergone a radical esophagectomy or a palliative operation by the one surgeon at the Department of Surgery, Yonsei University, College of Medicine, from Jan. 1990 to Aug. 1996. The survival rates were calculated by the Kaplan-Meier method. The middle one-third of the esophagus was the most frequent site with 48 cases. T3 depth of invasion was present in 53 cases (57%) at the time of operation and a superficial depth in 18 cases (20%). The rates of lymph-node metastasis was 25% in T1; 47% in T2; 66% in T3 or more. 40 patients were in stage I, 23 in IIa, 13 in IIb, 33 in III, and 7 in IV. A transhiatal esophagectomy(THE) was performed in 28 cases, and a 3-staged radical esophagectomy (transthoracic radical esophagectomy; TTRE) was done in 56 cases. The most common early postoperative complication was hoarseness, but it disappeared within 6 months. The commonly noted late complication was esophageal stricture, and it was corrected by Savary-Guillard dilatation. The leading cause of death during the follow-up period was recurrence; it was about 30 cases(33%). The survival rates according to lymph-node metastasis were 50.1% for lymph-node negative cases and 16.3% for, lymph-node positive cases. The survival rates according to depth of invasion were 83.3% in mucosa confined cases, 46.7% in submucosa invasion cases, 30.3% in muscularis propria invasion cases, and 36.5% in adventitia invasion cases. The five-year survival rates according to stage were 56.4% in stage I, 51% in stage IIa, 48% in IIb, and 33.1% in III. From this study, it can be concluded that the frequent numbers of early esophageal lesions in our study may have been a major factor in the relatively high survival rate; also the low operative mortality rate encourages us to use surgical resection for the treatment of esophageal cancer.

Gastroduodenal artery-duodenal fistula complicated during intraartrial chemotherapy for metastatic hepatic tumor / 대한암학회지

No abstract available.

Gastric Remnant Cancer Following a Partial Gastrectomy for Benign Gastroduodenal Disease

BACKGROUND: Gastric cancer that occurs 5 or more years after a partial gastric resection for benign disease is defined as gastric remnant cancer. The purpose of this study was to examine the clinicopathologic features and the treatment results of sixteen cases of gastric remnant cancer following partial gastrectomies for benign gastroduodenal diseases. METHODS: Sixteen patients who underwent operations for gastric cancer in the remnant stomach from January 1980 to December 1996 were evaluated retrospectively. RESULTS: The mean age was 51.5 years, and 15 patients were male. All of them had undergone surgical treatment for benign disorders, including gastric ulcers (14 cases) and duodenal ulcers (2 cases), and the mean time interval between the primary operation and the diagnosis of gastric cancer was 24.5 years. Most patients presented vague, nonspecific symptoms, except two cases of early diagnosis without symptom. Surgical resection of the remnant stomach was performed in 13 patients of which 11 patients underwent a curative resection with curative intent. Of these 13 patients, a combined resection of adjacent organs was performed in 10 cases. Fifteen patients had advanced gastric cancer, most of which involved depth of invasions to seromuscular layers, and lymph-node metastases were found in 8 patients. Most of patients who underwent bypass surgery or palliative resection died within 1 year of the operation. Among the 11 patients who underwent a curative resection, 3 patients died within 1 month of the operation due to postoperative complications, 2 patients died of recurrent cancer, and another 6 patients are alive without evidence of recurrence. CONCLUSIONS: Eearly detection of gastric cancer in the remnant stomach by periodic follow up is important, especially in high-risk groups, and the application of aggressive surgical treatment will provide for better patient survival.

Laparoscopy-assisted radical subtotal gastrectomy for early gastric carcinoma

In order to evaluate whether it is possible to perform a minimal invasive operation without compromising to the radicality, we analyzed six patients who had been performed laparoscopy-assisted radical subtotal gastrectomy at Yongdong Severance Hospital, Yonsei University College of Medicine between September 1995 and February 1996. All patients were diagnosed easearly gastric carcinoma without lymph node metastases preoperatively by upper gastrointestinal barium study (UGI), esophagogastroduodenoscopy(EGD) with biopsy and computed tomography scan (CT-scan). Postoperative pathologic reports revealed that we could obtain the resection margin and regional lymph nodes sufficient enough by laparoscopy-assisted radical subtotal gastrectomy. All patients had a good postoperative course. Flatus was present on the 2nd in a patient and 3rd postoperative day in five patients respectively. Nasogastric tube was removed and oral feeding was started on the day after flatus was present. Minor bile leak was noted in one patient postoperatively and managed conservatively. The postoperative scar was in excellent condition and measured about 2 approximately 3 inches in length. And postoperative courses were uneventful in all except a patient with bile leakage. Further technical experience and development could shorten the operation time. Popular acceptance of this procedure in the management of early gastric carcinoma (EGC) may give great help to the patients.

Transrectal ultrasonography in preoperative staging of rectal cancer

A precise knowledge of the depth of invasion of tumor is essential for the planning of treatment of rectal cancer. Transrectal ultrasonography is a new diagnostic modality that has become useful in determining the depth of invasion preoperatively and the presence or absence of metastatic lymph nodes. Transrectal ultrasonography was used in preoperative staging of 36 patients with rectal cancer. Thirty three patients had a radical resection (17 low anterior resection, 15 abdominoperineal resection and 1 pelvic exenteration), one patient had a local excision. Two among these thirty four patients had preoperative radiotherapy. Preoperative transrectal ultrasonographic staging was compared with pathologic findings. In staging depth of invasion, the overall accuracy was 88.8 percent, overstaged in 5.8 percent, understaged in 5.8 percent. Transrectal ultrasonography is the more accurate method than CT in staging of depth of tumor invasion (61.8% vs 88.8%). In staging of lymph nodes, the overall accuracy of transrectal ultrasonography was 85.3 percent, sensitivity was 71.7 percent and specificity was 88.8 percent. Transrectal ultrasonography is a safe, inexpensive and accurate staging method in the assessment of both depth of invasion and nodal status.

Pharyngo;aryngoesophagectomy with pharyngogastric anastomosis / 대한암학회지

No abstract available.

The Effect of Intraoperative Anal Sphincter Injection of Ketorolac Tromethamine for Pain Control after Hemorrhoidectomy

PURPOSE: An adequate pain control is one of important factors for obtaining good outcomes in the ambulatory basis of hemorrhoidectomy. There have been many methods for pain control after hemorrhoidectomy such as narcotics, various kinds of analgesics, etc. The aim of this study is to compare intraoperative internal anal sphincter injection of Ketorolac tromethamine and other two conventional methods for pain control. METHODS: A total of 56 patients with hemorrhoid grade III or IV underwent surgery between May and October 1999, and prospectively assigned to three groups in the consecutive order. The group was divided in Group 1: [Ketorolac tromethamine (Tarasyn) 60 mg intrasphincteric injection intraoperatively and 30 mg IM/prn?10 mg po/6hrs], Group 2: [No intraoperative injection and maintain pain control with Tarasyn 30 mg IM/prn/10 mg po/6hrs], and Group 3: [No intraoperative injection and maintain pain control with Pethidine (Demerol) 50 mg IM/prn and Ibuprofen 400 mg/Paracetamol 500 mg/Codeine 20 mg (Myprodol) po/8hrs]. The post operative data and pain scoring was performed on the questionnaire with Point box scale (BS-11) and Behavioral rating scale (BRS-6) each 24 hours during 5 days after surgery. RESULTS: There are 22 patients in the Group 1, 16 in the Group 2 and 18 patients in the Group 3. The median age of the Group 1 is 42.5, Group 2, 44.5 and Group 3, 45 years. The pain score on the first day after surgery in group 1 was significantly lower than group 2 (p0.05). CONCLUSIONS: Intraoperative internal anal sphincter injection of Ketorolac tromethamine shows a better pain control than conventional methods in early postoperative period. Therefore it might be helpful for patients to go home on the day after surgery, and strong pain killer to control pain after discharge will be needed.

Combined Resection in Advanced Gastric Cancer / 대한암학회지

PURPOSE: Prognosis of primary gastric cancer invading neighboring organs is very poor. However, with en bloc resection, a relatively favorable prognosis can be expected even in patients with such advanced cancer. But there has been controversy on the effectiveness of gastrectomy combined with en bloc resection of the invaded organs, and we conducted this study to evaluate the prognostic effects as well as the outcome of the combined resection. MATERIALS AND METHODS: Among 2,603 who underwent gastrectomy due to gastric carcinoma from January 1987 to December 1994 at the Department of Surgery, Yonsei University College of Medicine, 157 patients (6.0%) in whom curative combined resections of grossly invaded adjacent organs (cT4) were perfonned entered this study. Any case with distant metastasis was excluded. Comparisons and multivariate analysis between the invasion (pT3) group and the non-invasion (pT4) group were made for age, sex, tumor size, location, Borrmann type, depth of invasion, lymph node metastasis, histologic type and 5-year survival rate. RESULTS: One-organ combined resection was done in 60 (38.2%) patients; Two-organ, in 80 (51.0%) patients; and three-organ, in 17 (10.8%) patients. Most commonly combined organ was distal pancreas and transverse colon was the next. Histologic confirmation of invasion was made in 40.9%. 157 patients with T4 were divided into pT3 or pT4. Significant differences were found in type of operation, location of tumor, and TNM staging. Postoperative complications of combined resection were observed in 48 cases (30.6%) and the wound infection was the most frequent one. There were only 2 cases (1.3%) of immediate postoperative mortality in the combined group, and the causes of death were pulmonary complication and acute renal failure. Five-year survival rate (5-YSR) of pT3 group was 43.0% and that of pT4 was 26.2%. In comparison of 5-YSR according to TNM stages, no significant difference was found between pT3 and pT4 (45.0% vs. 66.7% in IIIa; 25.4% vs. 18.4% in IV). No difference of 5-YSR was observed in the groups categorized according to the number of resected organs. The comparison of 5-YSR between the 157 curatively-combined cases and the 63 palliatively-combined cases showed a significant difference (35.6% vs. 4.2%, p=0.000). Multivariate analysis showed that lymph node metastasis and microscopic tumor invasion served as significant parametets. CONCLUSION: En bloc combined resection of adjacent invaded organs along with systematic lymph node dissection would be beneficial to gastric cancer patients with neighboring organ invasion.

Gastric Adenosquamous Carcinoma / 대한암학회지

PURPOSE: Adenosquamous carcinoma, a rare malignant tumor of the stomach, is characterized by two different cell components, one adenomatous and the other squamous component. Its clinicopathologic feature and prognosis are quite different from the ordinary adenocarcinomas. We report our experience of 9 such cases. MATERIALS AND METHODS: Clinical and pathologic features were reviewed for the 9 patients who undenwent gastrectomies and were confirmed as adenosquamous carcinoma by pathologists during the 10-year period of from 1987 to 1998. Postoperative adjuvant therapy and prognosis were also reviewed. RESULTS: The ages of 6 male and 3 female patients ranged from 30 to 59, with the median age of 48. Total gastrectomy was done in 4 cases, while other underwent subtotal gastrectomy. Curative resection was done in four cases. Fourteeen additional organs were resected concomitantly due to suspicious tumor invasion and among them 9 organs were histologically confirmed for tumor invasion. The mean tumor size was 7.4 cm (2.5-27 cm) and all cases were pathologically advanced. One case showed peritoneal seeding and 3 cases showed hepatic metastases. There were 7 cases of stage IV disease by the UICC TNM classification (5th ed.) and the other two were stage II and stage IIlb respectively. Eight cases received postoperative adjuvant chemotherapy comprising S-FU, DDP, adriamycin, picibanil or VP-16. Of 9 patients, 6 died and the overall 5-year survival rate was 15.3%. CONCLUSION: Adenosquamous cancer of stomach is regarded as a disease of unfavorable prognosis, which was confirmed by this study. The treatments were not quite different from those for other stomach cancers. Although more cases and further investigations are essential for complete understanding of the clinical prognosis and proper treatment of the gastric adenosquamous cancer, early diagnosis, curative resection and close postoperative follow-ups are currently available options for better outcome of this disease.

Congenital absence of gallbladder

Nine surgically proven congenital absence of gallbladder (CAGB) cases were reviewed. All of them had one or more kinds of biliary symptom. Tests such as abdominal ultrasonography, intravenous or oral cholecystography and even endoscopic retrograde cholangiography not only failed to predict CAGB but misleadingly indicated other similar conditions. Only the abdominal computed tomography (CT), performed on one patient, enabled the accurate diagnosis of CAGB. All the patients underwent abdominal exploration, and CAGB was confirmed by the meticulous dissection of the entire extrahepatic biliary tree and the operative cholangiography. Five patients had concomitant biliary pathologies responsible for their symptoms, but four patients had isolated CAGB. CAGB is a rarely encountered condition for a clinician, but extensive diagnostic work-ups including abdominal CT should be performed in all situations where CAGB is suspected. Thus unnecessary exploration can be avoided in the isolated CAGB case.

Prognostic effect of peritumoral vascular, lymphatic and neural invasion in colorectal carcinoma

No abstract available.

Nodal metastasis in the distal mesorectum: need for total mesorectal excision of rectal cancer

Locoregional failure of rectal cancer is a troublesome problem and a major cause of morbidity and mortality following curative surgery. The mesorectum has been regarded as an important site in local failure after surgery of rectal cancer. Total mesorectal excision (TME) has been raised by some colorectal surgeons to prevent early local recurrence. This study was performed to ascertain the incidence of metastatic lymph nodes in the distal mesorectum (DMR) of the colorectal cancer patient. We also examined the clinicopathologic risk factors of distal mesorectal metastasis. Eight of 53 patients had positive metastatic lymph nodes in DMR. Twenty-seven patients were Dukes B and 26 patients were Dukes C stage. Out of 26 Dukes C patients, 8 patients (30.8%) had metastatic lymph nodes in the DMR. However, there was no significant difference in risk factors between DMR positive and DMR negative patients with Dukes C stage. In conclusion, the incidence of metastatic lymph nodes in DMR was about 30.8%, therefore the mesorectum especially the DMR should be removed completely by total mesorectal excision to eradicate the metastatic lymph nodes which may cause local recurrence.

Alpha-Fetoprotein Producing Rectal Cancer: A case report

We experienced a case of a 38 year old women in whom an alpha-fetoprotein producing carcinoma originated in the rectum. The patient had symptoms of hematochezia and bowel habit change, and a rectal examination revealed an ulcerative mass at the midrectum. The mass size was 6.5 cm 6 cm. The serum alpha-fetoprotein measured preoperatively was 9336 ng/ml, and the serum (carcinoembryonic antigen) was 6.4 ng/ml. The serum level of alpha-fetoprotein decreased to 830 ng/ml thirteen days after a low anterior resection. The tumor mass was a poorly differentiated adenocarcinoma. Using an immunohistochemical staining method, we detected alpha-fetoprotein producing cells in the tumor mass. During the follow up, the serum alpha-fetoprotein level began to increase continuously, and an abdomin opelvic CT scan showed a systemic, local tumor recurrence. Based on our experience with this patient and a review of the literature on the few cases previously reported, it seems that alpha-fetoprotein producing colorectal carcinamas have a tendency to produce frequent blood-borne metastasis and are associated with a poor prognosis.

Risk Factors for Recurrence after Curative Surgery for Early Gastric Cancer

PURPOSE: Even with excellent surgical outcome, recurrence of early gastric cancer (EGC) after a curative resection is not declining because the incidence of EGC is increasing. The aim of this study was to propose an appropriate treatment strategy by assessing the risk factors for recurrence of curatively resected early gastric cancer. MATENRIALS AND METHODS: Of 3662 patients who had undergone gastric resections for gastric cancer from 1987 to 1996, the cases of 1050 curatively resected EGC patients were reviewed retrospectively. Among those 1050 patients, 50 patients (4.8%) were diagnosed as having recurrent cancer, which was confirmed by clinico-radiological examination or re-operation. The risk factors that determined the recurrence patterns were investigated by using univariate and multivariate analyses. RESULTS: The mean time to recurrence was 30.9 months, and hematogenous recurrence was the most frequent type (32.0%). Among the 50 recurred patients, peritoneal recurrence showed the shortest mean time to recurrence (18.5+/-17.7 months). Between the recurred and the non-recurred patients, there was no statistically significant difference with respect to age, sex, operation type, tumor size, tumor location, gross appearance, or histological differentiation. However, depth of invasion (submucosal invasion) and nodal involvement were significantly different (P<0.001) between the two groups. Using logistic regression analyses, nodal involvement was the only significant risk factor for recurrence in early gastric cancer (P<0.001). The median survival after the recurrence had been diagnosed was 4 months. CONCLUSION: Although the prognosis for EGC patients is excellent and recurrence of EGC after a curative resection is rare, the time to recurrence and the patterns of recurrence in EGC patients were diverse and unpredictable, and the result after recurrence is dismal. Considering the impact of lymph node metastasis on recurrence of EGC, a systematic lymphadenectomy, rather than limited surgery, should be performed if lymph node involvement is confirmed pre- or intraoperatively. Also if the postoperative pathologic findings reveal lymph node involvement, adjuvant chemotherapy is recommended.

The Prognosis of Patients with Stage IV Gastric Carcinoma without Distant Metastasis

PURPOSE: In the UICC staging system, stage IV contains not only those patients with distant metastasis but also patients with far advanced T and N status but without distant metastasis. We investigated the prognostic factors of stage IV gastric carcinoma patients without distant metastasis after curative resection. MATENRIALS AND METHODS: 190 stage IV gastric carcinoma patients without distant metastasis were reviewed after curative resection. RESULTS: Male sex, distal third location, Borrmann type III, IV and histologically undifferentiated type were common. 5 year survival rate of the 190 patients was 22.2%. Depth of invasion and lymph node metastasis did not influence survival. The lymph node ratio (positive lymph node / retrieved lymph node) and combined resection affected survival by univariate and multivariate analysis. CONCLUSION: Combined resection and positive lymph node ratio were the independent prognostic factors in the patients with stage IV gastric carcinoma who underwent curative resection.