Neoadjuvant chemo-radiotherapy for cT3N0 rectal cancer: any benefit over upfront surgery? A propensity score-matched study.

PURPOSE: Benefits of neoadjuvant chemo-radiotherapy (CRT) are well known for locally advanced and/or node-positive rectal cancer, but the best timing for CRT has been less explored for cT3N0 patients. The aim of the present study was to compare the 5-year disease-free survival (DFS) probability between neoadjuvant CRT and upfront surgery in patients affected by cT3N0 rectal cancer. METHODS: A retrospective review of 105 patients affected by cT3N0 rectal cancer, staged by pelvic magnetic resonance imaging and treated at the National Cancer Institute of Milan between 2011 and 2017, was performed: 42 (40.0%) were treated by neoadjuvant CRT and 63 (60.0%) by upfront surgery. Propensity score matching was performed to avoid selection bias, and Cox multivariate regression was used to analyze outcomes. RESULTS: The 5-year DFS probability was 87.5% in neoadjuvant CRT patients vs. 90.0% in upfront surgery cases (Log-rank p = 0.76). The 5-year loco-regional recurrence-free survival probability was respectively 96.8% vs. 96.3% (Log-rank p = 0.954). On multivariate analysis, neoadjuvant CRT had no impact on DFS when compared to upfront surgery (adjusted HR 0.71, 95%CI 0.18-2.70, p = 0.613), but 61.9% of upfront surgery cases were treated by adjuvant chemo-radiation (adjusted HR 0.41, 95%CI 0.11-1.57, p = 0.196). The only independent predictor of improved DFS was age at diagnosis (adjusted HR 0.95, p = 0.017). CONCLUSION: CRT should be considered for cT3N0 patients, but its timing (neoadjuvant vs. adjuvant) seems not to affect the disease-free survival in the present cohort of patients.

Laparoscopic colectomy and restorative proctocolectomy for familial adenomatous polyposis.

BACKGROUND: Familial adenomatous polyposis (FAP) is a dominantly inherited syndrome. Risk of cancer begins to increase after age 20 years if not treated. The purpose of this study was to evaluate the feasibility and short- and long-term outcomes after laparoscopic prophylactic surgery for FAP. METHODS: Fifty-five patients with FAP were identified through the Hereditary Colorectal Tumor Registry from 2003 to 2009. Patients with laparoscopic total colectomy (TC)/IRA or proctocolectomy (TPC)/ileal pouch-anal anastomosis IPAA were included. Patients with previous colon or abdominal major surgery, malignancy, and desmoids before surgery were excluded. Main outcomes were: 30 days anastomotic leak and pouch failure; long-term desmoids and malignant recurrence. RESULTS: Of the 55 patients, 32 were men, median age was 28 years, and mean body mass index was 23. Median follow-up time was 36 (range, 5-77) months. Forty-four patients had laparoscopic TC/IRA and ten had laparoscopic TPC/IPAA. One patient was converted to open surgery and received an open TPC/IPAA. Incision length was 7 (range, 5-14) cm. Anastomotic leak was 3 (5.4%: 2 laparoscopic and 1 open), and pouch failure was 0. Median postsurgical length of stay was 7 (range, 4-24) days. Desmoids occurred in three patients (5.4%), and there was no malignant recurrence within the follow-up period. Pathology revealed severe dysplasia in ten patients and adenocarcinoma in nine (8 laparoscopic and 1 open). Long-term small-bowel obstruction was 2 (3.6%). One mortality due to liver metastases occurred at 24 months. CONCLUSIONS: Laparoscopic prophylactic treatment of FAP appears to be safe and feasible and may be an appealing alternative to open surgery. If the goal of prophylactic FAP surgery is to avoid cancer occurrence, laparoscopic surgery could be an important advancement.

Simultaneous idiopathic segmental infarction of the great omentum and acute appendicitis: a rare association.

Idiopathic segmental infarction of the greater omentum is an uncommon cause of acute abdomen. The etiology is still unclear and the symptoms mimic acute appendicitis. Its presentation simultaneously with acute appendicitis is still more infrequent. We present a case of a 47-year old woman without significant previous medical history, admitted with an acute abdomen, in which the clinical diagnosis was acute appendicitis and in whom an infarcted segment of right side of the greater omentum was also found at laparotomy. As the etiology is unknown, we highlighted some of the possible theories, and emphasize the importance of omental infarction even in the presence of acute appendicitis as a coincident intraperitoneal pathological condition.

The art of decision-making in surgery. To what extent does economics influence choice?

Traditionally most surgeons have paid little attention to the costs of healthcare treatments. With the increase in the number of efficacious surgical alternatives, a distinct scarcity of available resources has emerged. Since the Eighties, the impact of surgical expenditure has been increasing everywhere. The causes are: medical progress, increased life expectancy, escalating costs and decreasing revenues. The surgeon has been increasingly forced to weigh up theories, doctrines and techniques of economics and management. This created new problems of choice. In any event, the surgeon's decision-making could lead to negative consequences if the primary concern is with the financial constraints and he is prompted simply to act rather than to achieve his therapeutic goal. In conclusion, although the impact of economic considerations is inevitable in the choice of surgery, the terms and methods involved in the process are rather ambiguous. In other words, surgeons face with the dilemma of the patient to whom the economist denies treatment. To be aware of this issue is the first step, but there is still much more to do in order to define the terms of action.

Sphincter-saving surgery for low rectal cancer. The experience of the National Cancer Institute, Milano.

The treatment of tumors of the distal rectum continues to be a matter of great controversy among oncologic surgeons. There are increasingly promising indications that functionally conservative surgery may be a valid therapeutic alternative to conventional therapy in patients with tumours of the lower rectum, traditionally treated by abdomino-perineal resection and definitive colostomy. Many points are presently under evaluation and we want to discuss some of the most relevant topics that are now permitting to change the guide lines of therapy of this disease. Our view of the problem is based on a personal experience cumulated in fourteen years of activity in a specialized unit and this paper reports the main results of a complex and diversified study carried out during this period at the National Cancer Institute of Milan.

Correlation between radiotherapy and suture fistulas following colo-anal anastomosis for carcinoma of the rectum evaluation of 152 consecutive patients.

INTRODUCTION: The aim of this study was to evaluate the prevalence of suture fistulas and their possible correlation with adjuvant therapy in patients who underwent colo-anal anastomosis and J pouch reconstruction with a protective colostomy. The reliability of the radiological screening and monitoring program was also verified. METHODS: One hundred and fifty-two consecutive patients were evaluated radiologically with water-soluble radio-opaque contrast enema before surgery for closure of the protective colostomy. Fifty-seven patients were treated with surgery alone (group A) and 95 patients received adjuvant treatment (group B). RESULTS: A total of 54 fistulas were seen: 17 in group A (28.9% of patients in group A) and 37 in group B (38.9% of patients in group B). Six fistulas involved the rectovaginal septum. All fistulas were managed medically. The time to resolution was 30 days in 76.4% of patients in group A and about 50 days in 82% of patients in group B. Rectovaginal fistulas always took much longer to heal in both groups and failed to heal in two of the four cases in group B. CONCLUSIONS: Two factors appear to contribute to the high prevalence of fistulas in this series: extension of radiological screening to all operated patients and adjuvant radiotherapy. However, the postoperative course was not compromised by radiotherapy in that these fistulas resolved with medical treatment alone, although healing took longer. The incidence of rectovaginal fistulas was substantially the same in the two groups, but two of the four occurring in group B did not heal. Postoperative monitoring with water-soluble contrast enema appears to be the diagnostic procedure of choice because it is well tolerated, non-invasive and a reliable aid in planning surgical bowel recanalization since no false negative cases were detected clinically after closure of the colostomy.

Lymphadenectomy in gastric cancer: prognostic role and therapeutic implications.

AIMS: Surgeons involved in the treatment of gastric cancer are interested in the extent of lymphadenectomy as the latter may not only influence the reliability of the tumour, node and metastasis classification but also be relevant for the long-term oncological outcome. The purpose of the study was to evaluate the prognostic role of the number of resected lymph nodes (as an indicator of the scope of lymphadenectomy) and of the number of metastatic lymph nodes on the long-term mortality for all causes and to provide clinicians with estimates of predictive survival probabilities. METHODS: The study involved 615 cancer patients subjected to a curative (R0) subtotal or total gastrectomy in a randomized Italian trial. According to the trial protocol, a D2 lymphadenectomy had been advised. The number of resected and metastatic lymph nodes was analysed as a continuous variable in multiple Cox models. RESULTS: There was no difference in operative mortality (about 1.8%) according to the number of lymph nodes in the specimen (< or =15, 16-25, >25). The risk of long-term death for all causes tended to decrease with increasing number of resected lymph nodes up to about 25, and then could be considered stable for wider lymphadenectomies. An increasing risk of death for all causes was associated with an increasing number of metastatic lymph nodes; the risk could be considered stable for more than 20 metastatic lymph nodes. CONCLUSIONS: A lymphadenectomy including more than 25 lymph nodes is suggested, provided that there is a low risk of operative mortality.

Risk of second malignancies after surgical treatment for early gastric cancer.

We evaluated the follow-up of 105 patients who received surgical treatment at our Institute for early gastric cancer (EGC). Median follow-up was 71 months. Operative mortality was 5.7% and the 5-year survival rate was 82.8%, approximately that of an age- and sex- matched Italian population. Overall mortality was assessed with regard to mortality from gastric cancer or other causes. Ten second primary malignancies were identified, and the standardized mortality ratio (1.12; 90% confidence interval [CI] 0.77-1.64) and standardized morbidity ratio (1.50; 90% CI 0.89-2.50) were determined using data from the Tumor Registry of Lombardy. To our knowledge, this is the biggest Western series to measure the risk EGC patients face of developing a second primary tumor. In conclusion, oncologists who follow-up patients surgically treated for EGC, a disease that is much less frequent in Western countries than in Eastern ones, should be aware of the possible occurrence of extragastric primary tumors so that they may plan the appropriate diagnostic investigation when necessary.