Selection criteria for complete cytoreduction after cytoreductive surgery for peritoneal surface malignancy: lessons learned from our first series of patients.

The appropriate selection criteria for complete cytoreduction in patients with peritoneal surface malignancies have not been determined. We performed a retrospective analysis of all patients receiving cytoreductive surgery (CRS) during the study period of 2004 to 2008 to determine appropriate selection criteria for successful complete cytoreduction. During the study period, 38 patients underwent attempted CRS. Cytoreduction was scored complete, incomplete, or not reported in 53 per cent (n = 20), 37 per cent (n = 14), and 11 per cent (n = 4), respectively. Median overall survival for compete and incomplete cytoreduction was 56 months versus 5 months (P = 0.011), respectively. Compared with incomplete cytoreduction, patients receiving complete cytoreduction were more likely to have a lower Peritoneal Cancer Index (PCI) and not have received preoperative systemic chemotherapy (CT). Univariate analysis verified PCI greater than 20 (hazard ratio [HR], 0.048; CI, 0.004 to 0.515; P = 0.01) and CT (HR, 0.17; 0.004 to 0.77; P = 0.021) as predictors of incomplete cytoreduction. Small bowel (100%), periportal region (33%), and mesentery (27%) were the most common sites of residual disease. In conclusion, PCI less than 20 and the need for preoperative chemotherapy should be strongly considered when selecting patients with peritoneal surface malignancy for attempted cytoreduction. Early evaluation of the small bowel, mesentery, and periportal region for resectability prevents unnecessary surgery.

Disparities in reconstruction rates after mastectomy: patterns of care and factors associated with the use of breast reconstruction in Southern California.

BACKGROUND: Many factors influence whether breast cancer patients undergo reconstruction after mastectomy. We sought to determine the patterns of care and variables associated with the use of breast reconstruction in Southern California. MATERIALS AND METHODS: Postmastectomy reconstruction rates were determined from the California Office of Statewide Health Planning and Development (OSHPD) inpatient database from 2003 to 2007. International Classification of Disease-9 codes were used to identify patients undergoing reconstruction after mastectomy. Changes in reconstruction rates were examined by calendar year, age, race, type of insurance, and type of hospital using a chi-square test. Univariate and multivariate odds ratios (OR) with 95% confidence intervals (95% CI) were estimated for relative odds of immediate reconstruction versus mastectomy only. RESULTS: In multivariate analysis, calendar year, age, race, type of insurance, and type of hospital were statistically significantly associated with use of reconstruction. The proportion of patients undergoing reconstruction rose from 24.8% in 2003 to 29.2% in 2007. Patients with private insurance were 10 times more likely to undergo reconstruction than patients with Medi-Cal insurance (OR 9.95, 95% CI 8.46-11.70). African American patients were less likely (OR 0.58, 95% CI 0.46-0.73) and Asian patients one-third as likely (OR 0.37, 95% CI 0.29-0.47) to undergo reconstruction as Caucasians patients Most reconstructive procedures were performed at teaching hospitals and designated cancer centers. CONCLUSIONS: Although the rate of postmastectomy reconstruction is increasing, only a minority of patients undergo reconstruction. Age, race, type of insurance, and type of hospital appear to be significant factors limiting the use of reconstruction.

Transarterial radioembolization with Yttrium-90 for regional management of hepatocellular cancer: the early results of a nontransplant center.

Selective arterial radioembolization with Yttrium-90 (Y-90) microspheres has shown promise for regional management of hepatocellular cancer (HCC). Our objective was to report our early experience with this treatment modality from a nontransplant center. Treatment of patients with HCC was discussed in a multidisciplinary tumor board. Patients with unresectable disease resulting from high lesion number, ill location of the tumor, poor hepatic reserve, or medical comorbidities were offered Y-90 treatment. Liver treatment was either lobar or tumor-targeted. Response to therapy was assessed by CT scan obtained within 3 months using Response Evaluation Criteria in Solid Tumors criteria. During 2007 to 2009, 40 Y-90 radioembolizations were performed in 20 patients with age that ranged from 16 to 87 years; four patients were 80 years old or older. After the first therapy, CT assessment of the treated area showed stable disease (n=15), partial response (n=3), and progression (n=2). Of the two patients who progressed, one was retreated with a subsequent complete response. The other patient died of progressive disease. The most common side effects were mild fatigue, anorexia, and nausea. In summary, our nontransplant center experience shows that Y-90 radioembolization is a well-tolerated treatment in select patients with unresectable HCC with an associated high rate of local tumor control.

Surveillance with serial serum carcinoembryonic levels detect colorectal cancer recurrences in patients who are initial nonsecretors.

Serum carcinoembryonic antigen (CEA) levels, elevated in a subgroup of patients with colorectal cancer (CRC) at presentation, are serially followed as part of recommended surveillance after initial resection. The value of following serial CEA levels in patients who initially present with less than or normal levels of CEA (nonsecretors) is controversial. This study sought to determine the use of follow-up CEA levels in nonsecretors. A retrospective review was performed of patients with resected Stage I, II, and III CRC. We excluded patients who did not have a pretreatment CEA level, at least two follow-up CEA levels, or in whom CEA levels did not normalize after resection. The patients were grouped by initial CEA values: CEA 5 ng/mL or less (nonsecretors) and CEA 5 + ng/mL: (secretors). We identified 186 patients with CRC; 146 were initial nonsecretors. We identified 22 patients with recurrent colorectal cancer; 6 were secretors and 16 patients were nonsecretors. In the secretors group, CEA was elevated with recurrence in four (66%) of the patients. In the nonsecretors, CEA was elevated with recurrence in eight (50%) of the patients. In summary, many recurrences of CRC are marked by an elevation of CEA regardless of whether the patients initially presented as secretors or nonsecretors.

Optimal management of small rectal cancers: TAE, TEM, or TME?

Total mesorectal excision (TME) remains the gold standard for rectal cancer because it provides superior oncologic outcomes compared with local excision (LE). LE can be offered as an alternative for carefully selected patients; however, it must be emphasized that even in ideal patients, LE does not achieve equivalent results regarding oncologic outcomes compared with TME. With LE, patients trade a higher cancer cure rate for a lower risk of mortality and lower morbidity. The role of chemoradiation and LE in the treatment of rectal cancer is still under study.

Prevalence of left-sided colorectal cancer and benefit of flexible sigmoidoscopy: a county hospital experience.

The best way to evaluate the colon for both diagnosis of symptoms and surveillance is colonoscopy. However, access to colonoscopy is often restricted. Our objective was to assess the anatomic distribution and stage at presentation of colorectal cancer (CRC) in a county hospital population, the prevalence and distribution of CRC in younger patients, and the utility of flexible sigmoidoscopy for early diagnosis of left-sided cancers in this population. We performed a retrospective chart review of 151 patients who underwent colorectal resection from 2001 to 2003. Overall, 66.9 per cent of patients underwent resection for left-sided CRC. Forty-two (27.8%) of 151 were under age 50. In patients over 50, 66.1 per cent were found to have left-sided CRC compared with 69 per cent of patients under 50. Fifty per cent (50.3%) of patients had stage III or IV (advanced) disease. Forty-nine and a half per cent of patients over 50 and 52.3 per cent under 50 had advanced disease. Forty-eight and a half per cent of patients with left-sided CRC had advanced stage disease compared with 54% of patients with right-sided CRC. In patients under 50, the rates were 55.2 per cent and 46.1 per cent respectively. Two-thirds of the CRC occurred in the left side of the colon in both older and younger population. Flexible sigmoidoscopy should be considered as an early tool in the diagnosis of CRC.

Selective treatment of rectal cancer with single-stage coloanal or ultralow colorectal anastomosis does not adversely affect morbidity and mortality.

BACKGROUND AND AIMS: The surgical treatment of low rectal cancer commonly includes low pelvic anastomoses with coloanal or ultralow colorectal anastomoses. Anastomotic leak rates in low pelvic anastomoses range from 4 to 26%. Many surgeons opt to routinely create a diverting ostomy to reduce the extent of morbidity should an anastomotic leak occur. The intent of our study was to determine if our policy of selected diversion is safe. MATERIALS AND METHODS: A retrospective chart review of 66 rectal cancer patients who underwent proctectomy and low pelvic anastomoses -- less than 6 cm from anal verge, with or without a diverting ostomy -- was undertaken. Temporary diverting stomas were utilized at the discretion of the attending surgeon primarily based on subjective criteria. The main outcome was postoperative complications. RESULTS/FINDINGS: Forty-nine patients (78% preoperatively irradiated) were treated with a one-stage operation, whereas 17 (53% preoperatively irradiated) underwent reconstruction with proximal diversion. The mean anastomotic height for patients with a single stage procedure was 3.8 cm above the anal verge versus 2.6 for patients with a two-stage procedure (p = 0.076). Complication rates were lower in patients who did not undergo diversion (29% vs 47%, p = 16). With regard to anastomotic-associated complications for single stage versus two stage, complication rates were 8% versus 18%, respectively (p = 0.27). INTERPRETATION/CONCLUSION: Low pelvic anastomoses in rectal cancer patients can be safely performed as a single-stage procedure, reserving the use of diversion for select cases.

Evaluation of safety of increased time interval between chemoradiation and resection for rectal cancer.

BACKGROUND: Neoadjuvant chemoradiation is increasingly used for rectal cancer, with resection typically performed 6 weeks after completion of radiotherapy. We observed in our practice that further delay after radiotherapy led to increased downsizing. We performed this retrospective analysis to evaluate the safety of this approach. METHODS: A retrospective review was performed of 48 patients with distal or mid-rectal cancer who were operated on 8 weeks or less after chemoradiation ended (group 1, n = 16), and more than 8 weeks later (group 2, n = 32). We looked at the effect of delaying surgery on intraoperative blood loss, operative and hospital duration, postoperative complications, readmissions, and mortality. RESULTS: The median interval between radiation and operation was 7 weeks in group 1 and 11 weeks in group 2. There was no significant difference between the 2 groups in terms of intraoperative blood loss, postoperative complications, or readmissions. Length of operation and length of stay were slightly longer for group 2. CONCLUSIONS: Delaying surgery after neoadjuvant treatment appears safe, with morbidity and mortality similar to that seen with surgery performed less than 8 weeks after chemoradiation.

The role of carcinoembryonic antigen as a predictor of the need for preoperative computed tomography in colon cancer patients.

A retrospective study of 117 patients with the diagnosis of colon cancer was performed to evaluate the clinical utility of the preoperative computed tomography (CT) scan and to assess the role of carcinoembryonic antigen (CEA) as a predictor of the need for CT scan in colon cancer patients. Forty-nine patients had a CT scan that altered their treatment. One hundred per cent of stage IV patients versus only 26.5 per cent of stage I, II, and III patients had their operative and/or treatment planning altered by the preoperative CT. The sensitivity of CT scan in predicting metastatic disease was 90.3 per cent. All patients with stage IV disease had an abnormal CEA (>3 ng/mL). There was 89.7 per cent of stage IV patients who had a CEA twice that of normal or above. By using a CEA level of 3.1 ng/mL or above as a prerequisite for preoperative tomography, 34 nonmetastatic patients would not have had preoperative CT scans. Using a prerequisite of 6.1 ng/mL or above, 49 nonmetastatic patients would not have had a preoperative CT scan, and 90 per cent of the stage IV patients would have been imaged. We recommend obtaining a preoperative CT scan on those patients with a CEA value twice that of normal or greater.