Role of chest CT in patients with negative chest x-rays referred for hepatic colorectal metastases.
Povoski SP. Fong Y. Sgouros SC. Kemeny NE. Downey RJ. Blumgart LH.
Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.
BACKGROUND: Hepatic resection is the standard treatment for hepatic colorectal metastases. The lung represents the next most likely site, after the liver, of metastatic disease. Computed tomography (CT) of the chest is more sensitive than is chest x-ray in detecting metastatic lung lesions. However, the usefulness of chest CT in the evaluation of patients before hepatic resection remains uncertain. METHODS: One hundred consecutive patients with negative chest x-rays and potentially resectable hepatic colorectal metastases underwent chest CT. Patients with CT findings suggestive of metastatic disease were subjected to thoracotomy or video-assisted thoracic surgery (VATS) before laparotomy and attempted hepatic resection. The operative findings and clinical course were analyzed. RESULTS: Eleven of 100 patients had a positive chest CT. Four of these 11 patients had malignant lesions of the lung (three metastatic colorectal cancers and one primary lung cancer). There was no difference in median total hospital stay (8.5 days [range 7 to 13 days] vs. 8.0 days [range 3 to 49 days]), number of perioperative deaths (0 vs. 2 deaths), or long-term outcome between those patients with a positive chest CT undergoing thoracotomy/VATS and those patients with a negative chest CT. Overall, chest CT provided a positive yield of 4% and a positive predictive value of 36% for the detection of malignant lesions of the lung. CONCLUSIONS: Chest CT only minimally improved detection of malignant lesions of the lung over chest x-ray. Thoracotomy/VATS and wedge resection of lung nodules did not adversely affect outcome. The low positive yield and low positive predictive value of chest CT in the setting of a negative chest x-ray places in question the usefulness of routinely performing chest CT as part of the extent-of-disease work-up before hepatic resection.
Intraoperative high dose rate brachytherapy in recurrent or metastatic colorectal carcinoma.
Nag S. Martinez-Monge R. Mills J. Bauer C. Grecula J. Nieroda C. Martin E.
Division of Radiation Oncology, Arthur G. James Cancer Hospital and Research Institute, Ohio State University, Columbus 43210, USA.
BACKGROUND: The survival of patients with recurrent or metastatic colorectal cancer usually is less than 12 months. In an attempt to improve this dismal prognosis, we investigated the role of intraoperative high dose rate brachytherapy (IOHDR) in the management of these patients. METHODS: From April 1992 to December 1996, 26 patients with locally recurrent or metastatic colorectal carcinoma were treated with maximal surgical resection and IOHDR. Intraoperative radiation dose ranged from 10 to 20 Gy, prescribed at 0.5 cm depth. The residual tumor irradiated was microscopic in 16 patients (62%) and gross residual in 10 patients (38%). Six patients received postoperative external beam radiation therapy. RESULTS: After a median follow-up of 28 months (range 6 to 54 months), seven of 15 evaluable patients (47%) failed in the area treated with IOHDR. The median time to local failure was 21 months (range 4 to 52 months). The median survival was 23 months (microscopic 24 months; gross 17 months), with a 4-year actuarial survival rate of 36%. Major morbidity was observed in 7 patients (47%) and usually was surgery-related. CONCLUSION: The use of IOHDR in association with radical resection increases local control in patients with recurrent or metastatic colorectal cancer. Patients with microscopic residual disease achieved a better result than do those with gross residual disease. Future strategies include the addition of limited EBRT dose to IOHDR, even for previously irradiated patients.
Radiation and chemotherapy instead of surgery for low infiltrative rectal adenocarcinoma: a prospective trial.
Rossi BM. Nakagawa WT. Novaes PE. Filho WD. Lopes A.
Department of Pelvic Surgery, A.C. Camargo Hospital, Antonio Prudente Foundation, Sao Paulo, Brazil.
BACKGROUND: The objective of this prospective study was to determine the possibility of treatment based exclusively on chemotherapy and radiotherapy for patients with low infiltrative rectal tumors in an attempt to preserve sphincter function. METHODS: Sixteen patients with rectal adenocarcinoma up to 3 cm above the pectineal line with initial indications for abdominoperineal resection (APR) were submitted to a 5040-cGy (28 x 180 cGy) radiotherapy dose and chemotherapy during the first 3 and last 3 days of radiotherapy, using 425 mg/m2/day of 5-fluorouracil (5FU) and 20 mg/m2/day of folinic acid. Levamisole was used at 150 mg/day for 3 consecutive days at 2-week intervals throughout the period of therapy. Patients with a complete response were not submitted to APR, but received additional brachytherapy for curative purposes with doses from 2000 to 3000 cGy. Patients with recurrence after a complete response, with partial response, or with no response were submitted to APR. RESULTS: Six patients (37.5%) presented a complete response, five (31.25%) presented a partial response, and five (31.35%) did not respond. The disease-free interval ranged from 1 to 34 months (mean = 11 months) among the six patients with complete response, and only one patient not submitted to APR is currently asymptomatic. Among the 15 patients with an indication for APR, three refused surgery because of full improvement of clinical symptoms and currently have tumor activity in the rectum. Mean patient follow-up was 23.8 months (8 to 43 months), and ten patients (62.5%) showed no evidence of active disease at last follow-up. CONCLUSIONS: The therapeutic schedule used was not effective in preserving sphincter function in patients with low infiltrative rectal adenocarcinoma, because responses, although very frequent, were only temporary.
Absence of frequent involvement of modifier of Min(APC) in sporadic colorectal cancer.
Kahlenberg MS. Stoler DL. Petrelli NJ. Rodriguez-Bigas M. Weber TK. Anderson GR.
Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, New York 14263, USA.
BACKGROUND: Mutations in the multiple intestinal neoplasia (Min) gene, the mouse homologue of the APC gene, result in the development of intestinal tumors. The degree of tumor expression is suppressed by the modifier of Min (MOM). Alterations in the MOM gene result in markedly increased tumor expression in the mouse. The human homologue of the MOM gene has been mapped to a locus on chromosome 1p35-36, but the role of the MOM gene in the development of human sporadic colorectal cancers has not been defined. METHODS: The microsatellite marker D1S199 has been previously mapped to the region of the MOM gene and was used as a primer for PCR amplification. The PCR products were subjected to denaturing electrophoresis and analyzed for loss of heterozygosity (LOH) and the mismatch repair phenomenon (RER) of each tumor compared to its mucosal control. RESULTS: 48 consecutive sporadic colorectal cancers and normal adjacent mucosa were analyzed. LOH was noted in 2 of 48 tumors and the RER phenomenon was noted in 6 of 48 tumors. Thus, 8 of 48 tumors (16.7%) showed alterations in the region of the locus of the MOM gene. There was no association between alterations in this region and TNM stage, disease-free survival, overall survival, or p53 mutation. CONCLUSIONS: Although mutation of the APC gene is an integral component of sporadic colorectal carcinogenesis, alteration in the region including the MOM gene does not appear to play a significant role in the development or clinicopathologic behavior of human sporadic colorectal tumors.
p53 protein overexpression and response to induction chemoradiation therapy in patients with locally advanced rectal adenocarcinoma.
Luna-Perez P. Arriola EL. Cuadra Y. Alvarado I. Quintero A.
Surgical Oncology Department, Hospital de Oncologia, Centro Medico Nacional, IMSS, Mexico DF, Mexico.
BACKGROUND: The association between mutations in the p53 gene and prognosis in colorectal cancer remains controversial. This report evaluates the role of p53 protein to predict the response of neoadjuvant chemoradiation therapy in patients with primary locally advanced rectal adenocarcinoma. METHODS: Between January 1993 and December 1994, 26 patients were seen with locally advanced primary rectal adenocarcinoma, located between 0 and 10 cm from the anal verge, demonstrated clinically and by CT scan. Each received 45 Gy of preoperative radiation therapy (RT) concomitantly with bolus infusion of 5-fluorouracil (5-Fu) (450/mg/m2 on days 1 to 5 and 28 to 33 of RT). Surgery was performed between 4 and 8 weeks later. All the primary tumors were mapped and sliced. The response rate was divided according to the percentage of malignant cells in the rectal wall and perirectal fat. Lymph nodes were studied with the manual or modified clearing technique. p53 mutant status was assessed immunohistochemically from sections of the formalin-fixed, paraffin-embedded pretreatment biopsy and the resected specimen. RESULTS: There were 14 females and 12 males, with a mean age of 54 years. All received the scheduled treatment. An abdominoperineal resection (n = 10), low anterior resection (n = 10), and pelvic exenteration (n = 6) were performed. The stages of tumors were as follows: no residual tumor (n = 4); T2 (n = 6); T3-4 (N = 9); and T3-4, N1,2 (n = 7). Fourteen specimens (54%) had mutated p53, and 10 (71%) had >50% of residual tumor, whereas only two (17%) of the specimens with normal p53 had >50% of residual tumor (P = .018). Eight of the 10 low anterior resections were performed in patients whose specimens expressed normal p53. CONCLUSION: Our results suggest that the determination of p53 is a factor in predicting tumor response in patients who undergo preoperative chemoradiation therapy for rectal adenocarcinoma.
T-cell evaluation in patients with colon cancer: dinitrochlorobenzene skin testing versus plasma levels of sIL-2r and sCD8.
Bleeker WA. de Ley L. Oeseburg HB. Martens A. Mulder NH. Hermans J. Plukker JT.
Department of Surgery, University Hospital, Groningen, The Netherlands.
BACKGROUND: Developing reliable methods to test the T-cell system may be important in the treatment of colon cancer patients with 5-fluorouracil/levamisole. In a pilot study we explored whether DNCB (dinitrochlorobenzene) skin testing correlated with plasma levels of soluble interleukin-2 receptor (sIL-2r) and soluble CD8 (sCD8) and, secondly, whether the application of DNCB had any influence on the production of sIL-2r and sCD8. METHODS: In 10 patients with advanced colon cancer and in 10 healthy volunteers, plasma levels of sIL-2r and sCD8 were measured before and 10 days after the application of 2 mg DNCB on the inner side of the forearm. RESULTS: As expected, colon cancer patients showed a depressed immune system compared to healthy volunteers (DNCB skin test: P = .005, sIL2r [medians 700 vs 295, P = .002], sCD8 [medians 158 vs 90, P = .03], M-W test). The plasma levels for sIL-2r and sCD8 were significantly lower in the skin-positive cases (P = .01 and P = .03, M-W test). However, a large overlap in plasma levels could be observed between the two skin categories. DNCB had no influence on the production of sIL-2r and sCD8; median change skin-negative and skin-positive -10 vs +25, P = .14, respectively; 48 vs 0, P = .32 (M-W test). CONCLUSIONS: DNCB skin testing and plasma levels of sIL-2r and sCD8 seem to be equally useful in evaluating the T-cell system and can be used simultaneously.
Wilms tumor presenting with abdominal pain: a special subgroup of patients.
Davidoff AM. Soutter AD. Shochat SJ.
Department of Surgery, Children's Hospital of Philadelphia, Pennsylvania, USA.
BACKGROUND: Although significant progress has been made in the management of children with Wilms tumor, two major controversies still exist: the extent of radiographic evaluation necessary before surgery and the role of preoperative chemotherapy. This study sought to determine whether patients with Wilms tumor who presented with abdominal pain defined a special subset of patients who might require a more extensive preoperative work-up and neoadjuvant chemotherapy. METHODS: From 1970 to 1995, 250 children were treated for Wilms tumor at a single pediatric institution. A retrospective chart review determined presenting signs and symptoms for each patient. RESULTS: Thirty-four (14%) patients (mean age 5.5 years) sought medical attention with a chief complaint of abdominal pain. The stage distribution for these patients tended to be higher and was significantly different (P