Prognostic value of neural invasion in rectal carcinoma: a multivariate analysis on 339 patients with curative resection.

To determine whether neural invasion or other clinico-pathological factors are prognostic, we performed a retrospective study on 339 rectal carcinomas. The overall 5-year survival was 62%. In the multivariate analysis, age over 60 years, a distance from the anal verge of less than 6 cm, the number of positive lymph nodes, neural invasion and tumour penetration were found to be prognostic. A scoring system identified five prognostic groups of patients. Neural invasion is an independent prognostic factor in our scoring system and it is suggested that this parameter should be taken into consideration for postsurgical treatment.

[Surgical approaches to segment I for malignant tumors (20 cases)]. / Approches chirurgicales du segment I pour tumeurs malignes (20 cas).

Seven complete and 13 partial resections of segment I (caudate lobe) were performed for malignant tumors. In all except one instance, removal of segment I was combined with other types of hepatic resection for technical or carcinologic reasons. Six were iterative hepatic resections for recurrent hepatic metastases. In two, the future remaining left lobe was hypertrophied by right portal venous embolization preoperatively. Hepatectomies were performed with intermittent portal triad clamping (mean total duration of 63 minutes, range of 20 to 120 minutes) and after preparation for total vascular exclusion. Associated partial resection of the inferior vena cava was necessary in three instances. Mean duration of operation was 285 minutes (range of 60 to 540 minutes) and mean blood loss was 1,749 milliliters (range of 200 to 5,200 milliliters). There was no postoperative mortality and the morbidity rate was low. Surprisingly, we discovered retrospectively that free margins were small (less than 5 millimeters) in 83 percent of the patients. Regardless of limited free margins and six iterative hepatectomies, eight patients were free of disease with a mean follow-up examination period of 19.2 months. Technical problems were different for each patient and a patient by patient adaptation was necessary. Left, right and central approaches were used accordingly. If resection of segment I associated with a right of left hepatectomy can currently considered as a standard hepatic resection, isolated complete resection of segment I remains a real technical challenge.

[Resectable liver metastases and synchronous extra-hepatic sites of colorectal origin. Surgical indications]. / Métastases hépatiques et localisations extra-hépatiques synchrones et résécables d'origine colo-rectale. Indications opératoires.

Twenty-two patients with liver metastases and synchronous extra-hepatic localizations or colorectal cancer underwent complete resection of all their cancerous lesion. Their survival was not significantly different from that of 87 patients in whom single or multiple metastases involving only the liver had been resected. Analysis of our 22 patients showed that they fell into two subgroups: those with lung metastases (n = 5) and those with pediculate colonic nodes (n = 6), who benefited from the double resection since their disease-free survival rate at 5 years was 35 percent. In contrast, patients who had a few peritoneal nodules (n = 8) relapsed during the first 13 postoperative months. The presence of one or a few extra-hepatic lesions does not necessarily preclude resection of the liver metastases, provided they can be resected during the same operation in case of intra-abdominal lesions and during a later operation in case of lung metastases. A single peritoneal nodule may be the first manifestation of peritoneal dissemination and contra-indicates the resection of liver metastases.

[Single and multifactorial prognostic study of 400 operated rectal adenocarcinomas]. / Etude pronostique uni et multi-factorielle de 400 adénocarcinomes rectaux réséqués.

From 1976 to 1988, 496 patients with rectal adenocarcinoma have been treated at Gustave-Roussy Institute. There were 258 men (52%) and 238 women (48) with a median age of 61 years. Sixty pts (12%) had local treatment (contact-therapy or electro-resection). Thirty six pts (8.25%) had a simple exploration with colostomy. Four hundred pts had a resection: 202 abdomino-perineal resection, 7 perineal resection, 167 anterior resection, and 24 Hartmann's technique. Post-operative mortality was 1% (4 pts). Among these 400 pts, 208 had no complementary treatment, 134 had pre +/- post-operative radiotherapy and 58 had post-operative radiotherapy. Sixty one pts had palliative resection. The actuarial survival of the 400 pts at 3, 5 and 10 years are respectively 65%, 51% and 37.5%. The number of lost to follow-up patients was 11 (2.5%) at 5 years and 24 (5.5%) at 10 years. A retrospective uni and multifactorial analysis of the clinical, biological and histopathological data of the 400 pts was done, 18 factors were studied. Our judgement criterion was 5 year survival. The uni-factorial analysis showed 7 variables which had great influence on survival: age > 60 (p = 0.001), signs of severe illness (p < 0.0001), curative or palliative criterion of the surgery (p = 0.0001), depth of invasion (p = 0.0001), lymph node invasion (p = 0.0001), neural invasion (p = 0.0001) and positive emboli (p = 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

[Desmoid tumors or intra-abdominal fibromatoses]. / Tumeurs desmoïdes ou fibromatoses intra-abdominales.

Intraabdominal desmoid tumour or fibromatosis, recurrent but non-metastatic, invasive, fibroblastic proliferations, are rare tumours. From 1968 to 1989, 16 patients were treated at Gustave Roussy Institute. They were associated with familial adenomatous polyposis in 10% of cases. These tumours, observed mainly in young women (70 to 85% of cases), are aggravated by pregnancy, and spontaneous regression can occur at menopause, proving their hormonal dependence. Although histologically benign, they are serious lesions due to their invasive character; their excision is complete in only 50% of cases. They recur in 30% to 75% of cases and cause death of the patient in 30% of cases. Treatment is surgical but due to their often very slow course, and their spontaneous stabilisation in some cases, a mutilating surgical treatment (extensive small intestine resection) does not seem to be justified. Radiotherapy is effective only at doses incompatible with the site of these tumours (35 to 60 Gy). Chemotherapy has never been shown to be effective.

Esophageal squamous cell carcinoma: the specific limited place of surgery defined by a prospective multivariate study of prognostic factors after surgical approach.

From 1982 to 1990, 181 patients underwent surgery for esophageal squamous cell carcinoma, for which 14 prognostic parameters were prospectively recorded in order to perform a multivariate study. A squamous cell head and neck cancer was associated with the esophageal tumor in 40% of the cases (synchronous 18% and metachronous 22%). Resection was curative (i.e. macroscopically complete) in 128 cases, palliative (i.e. with residual tumor) in 24 cases and not possible in 29 cases. There were 21 deaths in hospital (hospital mortality was 11.7%). One hundred and twenty-two patients received preoperative chemotherapy and 77 received postoperative radiotherapy according to different phase II prospective studies. The 5-year survival rate according to the Kaplan-Meier method was 15.8% (+/- 3.4) for all patients and 23.5% (+/- 4.8) for the patients who had a curative resection. A palliative resection or the invasion of a neighbouring organ was synonymous with incurability, but positive lymph nodes were not considered proof of incurability. The multifactorial study concerning all the patients highlighted two main prognostic parameters: the histological staging according to the Japanese classification (P = 0.0006) and the type of resection (curative or not) (P = 0.006). An objective response to preoperative chemotherapy was the third and last parameter revealed by Cox's model. The multivariate study, which was limited to the 112 patients who were alive after a curative resection, showed that only the stage was an important prognostic factor (P = 0.003), with stages 2 and 3 carrying a worse prognosis. We propose a therapeutic scheme, based on these prognostic data and on the usual pre-therapeutic workup with three additional exams: CT scan measurement of tumor diameter, ultrasound examination +/- fine needle aspiration cytology of supra-clavicular lymph nodes and echo-endoscopy. The aim of this scheme is to limit surgery to the subgroup of patients for whom this modality is really beneficial.

Surgical approach to segment I for malignant tumors of the liver.

Seven complete and 13 partial resections of segment I (caudate lobe) were performed for malignant tumors. In all except one instance, removal of segment I was combined with other types of hepatic resection for technical or carcinologic reasons. Six were iterative hepatic resections for recurrent hepatic metastases. In two, the future remaining left lobe was hypertrophied by right portal venous embolization preoperatively. Hepatectomies were performed with intermittent portal triad clamping (mean total duration of 63 minutes, range of 20 to 120 minutes) and after preparation for total vascular exclusion. Associated partial resection of the inferior vena cava was necessary in three instances. Mean duration of operation was 285 minutes (range of 60 to 540 minutes) and mean blood loss was 1,749 milliliters (range of 200 to 5,200 milliliters). There was no postoperative mortality and the morbidity rate was low. Surprisingly, we discovered retrospectively that free margins were small (less than 5 millimeters) in 83 percent of the patients. Regardless of limited free margins and six iterative hepatectomies, eight patients were free of disease with a mean follow-up examination period of 19.2 months. Technical problems were different for each patient and a patient by patient adaptation was necessary. Left, right and central approaches were used accordingly. If resection of segment I associated with a right or left hepatectomy can be currently considered as a standard hepatic resection, isolated complete resection of segment I remains a real technical challenge.

[Epidermoid cancers of the operated esophagus. High incidence of associated neoplasia]. / Cancers épidermoïdes de l'oesophage opéré. Incidence élevée des néoplasies associées.

In a retrospective study we counted the number of neoplasias associated with oesophageal epidermoid cancer, as we thought that their frequency and influence on treatment had been underestimated. Between 1982 and 1990, 181 patients underwent surgery of oesophageal epidermoid cancer. The global actuarial 5-year survival rate was 20.7 percent (28.8 percent after complete excision of the tumour). The mean follow-up period was 4.2 +/- 2.6 years. These 181 patients had a total of 324 cancers, 97 percent of which were cancers of the upper respiratory and digestive tracts. The frequency of associated cancers was 56 percent (102 out of 181), and 50 percent of the patients presented with at least one associated head and neck cancer. Twenty-two percent of the patients had been treated for another cancer before the oesophageal epidermoid cancer, and in 19 percent of the cases this was a head and neck cancer. Thirty-five percent had a malignancy that was contemporary with the oesophageal cancer (this malignancy affected the head and neck in 18 percent of the cases and consisted of multiple lesions in 25 percent). During the short period under study, in only 10 percent of the patients did a cancer develop after the oesophageal one, and 6 percent of these affected the head and neck. This high incidence of associated neoplasia was due to tobacco and alcohol abuse. The presence of multiple cancers should alter as least as possible the treatment required by each associated cancer in order to optimize the chances of complete cure. Close surveillance of the high-risk population may result in the early discovery of a 2nd cancer at a curable stage. For the time being, the prevention of such associated cancers relies more on daily administration of retinoids than on alcohol and tobacco abstinence which is difficult to obtain.