Pancreatic Resection for M1 Pancreatic Ductal Adenocarcinoma

Background Improved safety of pancreatic surgery has led to consideration of more aggressive approaches, such as resection for primary pancreatic ductal adenocarcinoma (PDAC) with metastatic disease (M1). Methods A total of 29 patients who underwent pancreatic resection with resection of associated metastatic disease (interaortocaval lymph node dissection, liver resection, and/or multiorgan resections) were retrospectively identified from a database of 316 R0/R1 pancreatic resections for PDAC. An explorative data analysis of perioperative and clinicopathological parameters, and overall survival was performed by Kaplan-Meier estimation, log rank test, and Fisher’s exact test. Results The overall in-hospital mortality and morbidity of R0/R1 pancreatic resections for M1 disease (n = 29) was 0% and 24.1%, compared with 4.2% and 35.2% of R0/R1 pancreatic resections for M0 disease (n = 287). The median overall survival time was 13.8 months (95% confidence interval [CI], 11.4–20.5), and the estimated 1-year overall survival rate was 58.9% (95% CI, 34.8–76.7) for patients with M1 disease. The median survival in those with metastatic interaortocaval lymph nodes was 27 months (95% CI, 9.6–27.0), whereas it was 11.4 months (95% CI, 7.8–16.5) and 12.9 months (95% CI, 7.2–20.5) for those with liver and peritoneal metastases, respectively. Conclusions Pancreatic resections with M1 disease can be performed with acceptable safety in highly selected patients. The survival after interaortocaval lymph node resection is comparable to that of other lymph nodes that do not constitute M1 disease. Resection of liver and peritoneal metastases, although safe in this series, cannot be generally recommended until further controlled trials can be conducted. S.V.S. and J.K. contributed equally to this article.     

Prognostic Factors Affecting Survival and Recurrence of Patients with pT1 and pT2 Colorectal Cancer

Background Data on the prognostic factors of survival and recurrence in patients with colorectal cancers confined to the bowel wall (T1 and T2) are limited. The aim of the present study was to determine factors that might predict the survival and recurrence of patients who had T1 and T2 colorectal cancers. Patients and Methods All patients with T1 or T2 colorectal cancers who underwent resection in the Department of Surgery, University of Hong Kong Medical Centre, from 1996 to 2004 were included. Analysis was made from the prospectively collected database. Predictive factors for lymph node metastasis and prognostic factors were analyzed. Results A total of 265 patients (144 men) with the median age of 71 years (range: 33–93 years) were included. Seventy-two patients had T1 cancers (rectal cancer n = 44; colon cancer n = 28; p = 0.89) and 193 patients suffered from T2 cancer (rectal n = 120; colon cancer n = 73). The overall incidence of lymph node metastasis was 12.7% (5.6% for T1 cancer and 14.5% for T2 cancer; p = 0.021). The presence of lymphovascular permeation was the only independent factor associated with a higher incidence of lymph node metastasis on multivariate analysis (odds ratio: 1.48, 95% CI: 1.44–13.47, p = 0.009). There were no significant differences in disease-free 5-year survival (T1 = 84.6%; T2 = 81.1%) and 5-year cancer-specific survival in patients with T1 and T2 tumors (T1 = 90.2%; T2 = 90.6%). Patients with lymph node metastasis had a significantly shorter disease-free 5-year survival (p < 0.001) and 5-year cancer-specific survival (p = 0.002) when compared with those having a negative lymph node status. Cox proportional hazards model analysis showed that lymph node status was the only significant independent factor predicting cancer-specific survival (hazard ratio: 3.52, 95% CI: 1.60–7.71, p = 0.002) and disease-free survival (hazard ratio: 3.42, 95% CI: 1.75–6.69, p < 0.001). Conclusions Presence of lymphovascular permeation would have a significant higher chance of lymph node metastasis. Positive lymph node status was predictive of poorer survival in patients with T1 or T2 colorectal cancers. For those cancers with positive lymphovascular permeation, radical surgery is recommended.     

Prognostic Factors in Patients with Synchronous Peritoneal Carcinomatosis (PC) Caused by a Primary Cancer of the Colon

Background  Peritoneal carcinomatosis (PC) is seen in about 10% of patients with colon cancer during the initial operation and has been considered a preterminal condition. The actual outcome can vary extensively depending on the presence/absence of metastases other than PC. Methods  A total of 975 consecutive patients with colon cancer who underwent resection were included. The extent of PC was determined at laparotomy. Metastases restricted to the adjacent peritoneum or a few metastases to the distant peritoneum were classified as “limited,” whereas numerous metastases to the distant peritoneum were as “extensive” regardless of the sizes of the disseminated nodules. Results  PC group consisted of 75 patients (7.7%). The median survival time (MST) in the PC group was 6.8 months. Survival was significantly better in cases with limited PC (MST, 12.4 months), without lymph node involvement (20.8 months), with preoperative performance status of 0 or 1 (8.5 months), and who received chemotherapy more than 3 months (8.8 months). A multivariate analysis revealed that these four factors were significant predictors of better outcome. Conclusions  The extent of PC and lymph node involvement, even if the distribution is confined around the primary lesion, are more accurate prognostic factors than distant metastasis in patients with colon cancer and synchronous PC.     

Re-study of Gastric Cancer: Analysis of Outcome

Cancer of the stomach (CaS) is a dreaded disease. Fortunately, there is a decreasing incidence, except in the East. The authors did a re-study of CaS, a widely investigated but unresolved gastrointestinal malignancy. The clinicopathologic features were evaluated to identify and measure the prognostic factors that would help the surgeon decide optimal therapy. Among 383 admitted for CaS at the East Avenue Medical Center, Quezon City, Philippines between January 1987 and December 1996, 149 underwent radical resection with curative intent. (As historical control, the experience in 136 cases was reviewed during the immediately preceding 5-year period [1982–1986] when extended lymphadenectomy was not the standard policy.) For staging, the TNM system (tumor-node-metastasis) was used; to describe anatomy and surgery of stomach lymphatics, the "Japanese Rules," as modified, were adapted. Curative radical gastrectomy would include removal of the diseased stomach and regional lymphatics as defined by frozen section, including subtotal (or total) gastrectomy and "extended" D2 (with no. 12) node dissection. The clinicopathologic factors were statistically analyzed, using the accepted methods: Kaplan-Meier for survival, univariate analysis, and multivariate analysis for independent predictors. Of the 12 risk factors assessed by univariate analysis, the following were identified by multivariate analysis as independent prognosticators of survival: (1) wall penetration; (2) node invasion; (3) TNM stage; (4) resection margin; and (5) tumor size. After curative resection, the operative mortality was 5.3% and the complications, 19.4%. The 5-year survival was 60.4%, and recurrence, 15.4%. The results have shown that the pathology-related factors, (1) wall penetration; (2) node invasion; and (3) resection margin, are independent prognosticators of survival, remarkably affecting outcome. In conclusion, the study supports radical gastrectomy with extended D2 lymphadenectomy for CaS as safe and effective. Survival and recurrence are a function of pathology and adequate resection; operative mortality is defined by the patient’s condition.     

Outcomes of Salvage Surgery for Squamous Cell Carcinoma of the Anal Canal

Background For patients with anal canal cancer who fail combined modality treatment (CMT), salvage surgery (SS) offers the potential for long term survival. The literature regarding SS is limited by small patient numbers and/or heterogeneous treatment protocols. We report on a large series of patients initially treated with chemoradiation at a major referral center. Methods We identified 60 patients with persistent or recurrent anal cancer who had undergone SS; 20 were excluded. Overall and disease-free survival (OS, DFS) curves were constructed using the Kaplan Meier method. Univariate analysis was done using the Log-Rank test, and multivariable analysis using Cox proportional hazards. Results The 40 patients (29 women, 11 men, median age 57) underwent curative intent resection. The initial procedure was multivisceral resection (n = 24), abdominoperineal resection alone (n = 14) or local excision (n = 2). Postoperative mortality was 5%. Postoperative complications were seen in 72%. Median follow-up was 18 months overall and 36 months in survivors. Median OS was 41 months; OS and disease free survival at 5 years were 39% and 30%, respectively. Recurrence was present in 21 patients at time of analysis. Failure was locoregional in 86% (18 of 21) and distant in 48% (10 of 21). Independent predictors of poor OS were male gender, Charlson Comorbidity Score and tumor size. Independent predictors of poor disease free survival were positive margins and lymphovascular invasion. Conclusion SS for anal canal cancer was associated with significant morbidity. Long-term survival was achieved in 39% of patients. Comorbidities should guide patient selection, and R0 resection should be the goal. Presented at the 60th Annual Meeting of the Society of Surgical Oncology, Washington, DC, March 17, 2007.     

Distal Bile Duct Carcinoma: Prognostic Factors After Curative Surgery. A Series of 112 Cases

Background The identification of independent prognostic indicators in distal bile duct carcinomas (DBDCs) has been limited by the small number of tumors and a lack of molecular prognostic markers. Markers assessed in combination may perform better than those considered individually. We conducted this study to identify prognostic predictors of patients with DBDC with special focus on combination of expression of p53 protein and clinicopathological predictors. Methods Between December 1996 and 2002, 112 consecutive patients undergoing pancreaticoduodenectomy in the Eastern Hepatobiliary Surgery Hospital for distal bile duct carcinomas were identified in a prospectively collected database. The survival of patients was comparable with respect to patient characteristics, clinicopathological factors and degree of p53 protein expression followed by a univariate and multivariate analysis. Results Actual 1, 3, and 5-year survival rates were 85.7, 50.9, and 25.0%, respectively. By Cox proportional hazards survival analysis, the most powerful predictors of survival rate were p53 expression [relative risk (RR) 5.2, 95% CI 4.8–5.6], pancreatic invasion (RR 5.6, 95% CI 4.3–6.9), lymph nodes metastasis (RR 3.9, 95% CI 3.3–4.5), and operative time (RR 1.8, 95% CI 1.5–2.1). Conclusions Overexpression of p53 in DBDC is strongly associated with significantly reduced survival, independently of clinicopathological prognostic factors. The resection margin status provides little independent prognostic information. Longer operative time may have unfavorable effect on prognosis of patients with DBDC. Qingbao Cheng and Xiangji Luo contributed equally to this work.     

Results of Surgical Salvage after Failed Chemoradiation Therapy for Epidermoid Carcinoma of the Anal Canal

Background The standard treatment for epidermoid carcinoma of the anal canal consists of combined radiation and chemotherapy. For patients who present with persistent or locally recurrent disease, salvage abdominoperineal resection is the treatment of choice. The purpose of this study is to review our experience with salvage surgery in this group of patients. Methods From 1990–2002, 31 patients underwent radical salvage surgery with curative intent after failure of initial sphincter-conserving therapy, and the medical records of these patients were retrospectively reviewed. Clinicopathologic variables were determined and comparisons performed with the Cox proportional hazards model. Survival was calculated by the Kaplan–Meier method. Results Eleven patients underwent radical salvage surgery for persistent disease and 20 patients for recurrent disease. The median follow-up time was 29 months. The actuarial 5-year overall survival was 64%. Twelve patients developed recurrent disease after radical salvage surgery. Patients who received an initial radiation dose of less than 55 Gy had a significantly worse survival than those who received at least 55 Gy as part of their initial treatment (5-year overall survival 37.5% vs. 75%; age-adjusted hazard ratio 8.2 [95% CI: 1.1–59.8], P = .037). The presence of positive lymph nodes at presentation also adversely affected survival (P < .05). Factors that were not found to have an impact on survival included the presence of persistent versus recurrent disease, tumor (T) stage, and margin status of resection. Conclusions Long-term survival following salvage surgery for persistent or locally recurrent epidermoid carcinoma of the anal canal can be achieved in the majority of patients. However, patients who initially present with node-positive disease and patients who receive a radiation dose of less than 55 Gy as part of their initial chemoradiation therapy regimen have a worse prognosis after radical salvage surgery.     

胃癌患者N2淋巴结转移和腹膜扩散的相关因素和预后分析

目的 分析淋巴结转移和腹膜扩散胃癌发病相关临床病理因素及其近远期预后,并探讨姑息性手术对预后的影响.方法 查近11年间中山大学附属第一医院胃癌数据库,对其临床病理和随访结果进行分析.结果 T4、淋巴结转移、肝转移、全胃癌、未分化癌、Borrmann Ⅳ型、女性性别与腹膜扩散有关;全胃癌、Borrmann Ⅲ型,T2,T3,T4,肝转移及腹膜扩散与淋巴结转移有关（P＜0.05）.腹膜扩散P3组1年内生存率总体低于P1组和P2组（P＜0.05）;N2淋巴结转移组（N2组）术后1,3,5年内生存率总体低于N1组.胃癌腹膜扩散并N2淋巴结转移（PN2）组术后1,3,5年内生存率总体低于N2组.腹膜扩散患者姑息性切除术（PR）组1年内及N2患者PR组术后1,3年内生存率总体上高于旁路手术或喂食性造口术组和剖腹探查组（P＜0.05）.结论 PN2患者近远期预后比N2差;P3患者预后比P1,P2差;N2患者预后差于N1;PR可改善腹膜扩散胃癌患者的近期生存率,还可改善N2患者近、远期预后.     

Pylorus-preserving pancreatoduodenectomy is applicable to patients with carcinoma of the head of the pancreas: Studies of lymph node metastasis and quality of life

Metastases to the regional lymph nodes of the stomach were studied in patients in whom carcinoma of the head of the pancreas had been resected (51 standard pancreatoduodenectomy and 26 total pancreatectomy). Involvement of gastric lymph nodes was rare (1.3%–3.9%), except of the subpyloric lymph nodes (9.1%). Carcinoma in the five patients with positive gastric lymph nodes, with the exception of the subpyloric nodes, was clinically far advanced: four of the five had liver metastasis or peritoneal dissemination. This suggests that, in terms of preservation of the regional gastric lymph nodes, only subpyloric node involvement has any significance with respect to surgical treatment of carcinoma of the head of the pancreas. There was no significant difference in survival rates after curative resection between standard pancreatoduodenectomy (n=44) and pylorus-preserving pancreatoduodenectomy (n=17). In the patients who underwent the pylorus-preserving pancreatoduodenectomy for various kinds of periampullary diseases (n=47), postoperative recovery of gastric and small bowel function was temporarily prolonged compared to that after shandard pancreatoduodenectomy (n=44). However, the former group were able to take significantly more calories 6 weeks after the operation. Our study indicates that the pylorus-preserving pancreatoduodenectomy with subpyloric lymph node dissection is applicable to the treatment of patients with carcinoma of the head of the pancreas from the viewpoints of both extent of operation and quality of life.     

Ethnicity Influences Lymph Node Resection in Colon Cancer

The purpose of this study is to determine the association between ethnicity and lymph node retrieval after colon cancer resection. Using the Surveillance Epidemiology and End Results (SEER)–Medicare database, patients who underwent colon cancer resection from 2000–2003 were evaluated. Subjects were classified as having <12 (N = 20,605) or ≥12 (N = 12,358) lymph nodes examined. Multivariate models were used to analyze the relationship between lymph nodes resected and independent variables. Out of a total of 32,936 patients, 62.5% had fewer than 12 lymph nodes resected. In multivariate analysis, Hispanic ethnicity was associated with a significantly lower chance of having ≥12 lymph nodes than the Caucasian population (OR = 0.61; CI, 0.50–0.74). Despite this, there was no understaging: the proportion of stage II and III diagnoses was the same. Both groups received the same rate of cancer-directed surgery and survival was equivalent. During this study period, a majority of colon cancer resections were inadequate based on the current standard of ≥12 nodes. Hispanic patients were less likely to have an adequate node resection when compared to Caucasians. Despite fewer lymph nodes harvested, they had equivalent staging and survival. These results suggest that ethnicity influences the lymph node count.     

肛管腺癌49例的临床特点及其治疗

目的 探讨肛管腺癌的临床特点和治疗方法。方法 回顾性分析我院1965年1月至2002年3月间收治的肛管腺癌共49例的临床资料。结果 男女比例1．3：1，平均年龄52岁，中位年龄56岁。肛门出血、便条变细和肛门肿物是最常见的症状。36．7％伴有慢性肛周疾病史。治疗后中位随访时间66个月。局部复发和腹股沟淋巴结转移各7例，肺转移2例，锁骨上淋巴结转移和纵隔转移各1例。单纯手术组、单纯放化疗组、综合治疗组（腹会阴联合切除加术后辅助放化疗）和无局部治疗组患者的3年总生存率分别是41，3％、20．0％、56．3％和15．0％，5年总生存率分别是34．4％、0、37．5％和0。结论 早期诊断是改善肛管腺癌预后的最基本保证，综合治疗是目前疗效较好的治疗手段。     

Spleen Preservation in Radical Surgery for Gastric Cardia Cancer

Background In gastric cardia cancer (GCC), the spleen is usually removed when the tumor is resected. This allows thorough lymph node dissection in the splenic hilus. However, the long-term effect of splenectomy on patient survival is controversial. The purpose of this study was to investigate the effect of spleen preservation on survival following radical resection for gastric cardia cancer. Methods We reviewed the records of 116 GCC patients (Siewert types II and III) who underwent radical resection with D2 or D3 lymphadenectomy between July 1994 and December 2003. Survival status was ascertained in December 2004 and data from 108 patients were analysed. Of these 108 patients, 38 underwent splenectomy and 70 had splenic preservation. Clinicopathological features and prognostic data of the splenectomy(+) and splenectomy(−) groups were compared. Results Seventy-four patients (68.5%) had lymph node involvement; 18 (16.7%) had involvement of nodes in the splenic hilus. Postoperative morbidity in the two groups was similar. Overall 5-year survival was higher in the splenectomy(−) group than the splenectomy(+) group (38.7% versus 16.9%, P =.008). Multivariate regression indicated that tumor invasion (P =.009) and lymph node metastasis (P = .001) were independent prognostic factors – they predicted decreased survival – with or without splenectomy. Although splenectomy was be associated with lower survival, it was not an independent prognostic factor (P =.085). Conclusions Splenectomy does not improve survival of patients who undergo curative resection for gastric cardia cancer. Thus, the spleen should be preserved in patients without direct cancer invasion of the spleen. Supported by the Project of 211 from Chinese Education Ministry, No.98087.     

The Lymph Node Ratio is the Strongest Prognostic Factor after Resection of Pancreatic Cancer

Introduction  Survival after surgery of pancreatic cancer is still poor, even after curative resection. Some prognostic factors like the status of the resection margin, lymph node (LN) status, or tumor grading have been identified. However, only few data have been published regarding the prognostic influence of the LN ratio (number of LN involved to number of examined LN). We, therefore, evaluated potential prognostic factors in 182 patients after resection of pancreatic cancer including assessment of LN ratio. Methods  Since 1994, 204 patients underwent pancreatic resection for ductal pancreatic adenocarcinoma. Survival was evaluated in 182 patients with complete follow-up evaluations. Of those 182 patients, 88% had cancer of the pancreatic head, 5% of the body, and 7% of the pancreatic tail. Patients underwent pancreatoduodenectomy (85%), distal resection (12%), or total pancreatectomy (3%). Survival was analyzed by the Kaplan–Meier and Cox methods. Results  In all 204 resected patients, operative mortality was 3.9% (n = 8). In the 182 patients with follow-up, 70% had free resection margins, 62% had G1- or G2-classified tumors, and 70% positive LN. Median tumor size was 30 (7–80) mm. The median number of examined LN was 16 and median number of involved LN 1 (range 0–22). Median LN ratio was 0.1 (0–0.79). Cumulative 5-year survival (5-year SV) in all patients was 15%. In univariate analysis, a LN ratio ≥ 0.2 (5-year SV 6% vs. 19% with LN ratio < 0.2; p = 0.003), LN ratio ≥ 0.3 (5-year SV 0% vs. 18% with LN ratio < 0.3; p < 0.001), a positive resection margin (p < 0.01) and poor differentiation (G3/G4; p < 0.03) were associated with poorer survival. In multivariate analysis, a LN ratio ≥ 0.2 (p < 0.02; relative risk RR 1.6), LN ratio ≥ 0.3 (p < 0.001; RR 2.2), positive margins (p < 0.02; RR 1.7), and poor differentiation (p < 0.03; RR 1.5) were independent factors predicting a poorer outcome. The conventional nodal status or the number of examined nodes (in all patients and in the subgroups of node positive or negative patients) had no significant influence on survival. Patients with one metastatic LN had the same outcome as patients with negative nodes, but prognosis decreased significantly in patients with two or more LN involved. Conclusions  Not the lymph node involvement per se but especially the LN ratio is an independent prognostic factor after resection of pancreatic cancers. In our series, the LN ratio was even the strongest predictor of survival. The routine estimation of the LN ratio may be helpful not only for the individual prediction of prognosis but also for the indication of adjuvant therapy and herein related outcome and therapy studies. Presented in part at the 49th Annual Meeting of the Society for Surgery of the Alimentary Tract, May 2008 in San Diego and at the Annual Meeting of the German Cancer Society, February 2008 in Berlin, Germany     

Analysis of Risk Factors of Predictive Local Tumor Control in Oral Cavity Cancer

Background Survival in oral cavity squamous cell carcinoma (OSCC) depends heavily on locoregional control. In this study, we sought to determine the independent prognosticators for local tumor control, disease-specific survival (DSS), and overall survival (OS) rates in a series of OSCC patients undergoing radical surgery. Methods We retrospectively reviewed 827 consecutive OSCC patients undergoing radical surgery from January 1998 to March 2005. Postoperative radiotherapy was performed in patients with pT4 tumors, positive lymph node(s), or close margins (≤4 mm). Local control rates and survivals were plotted using the Kaplan–Meier method. Results On multivariate analysis (MVA), unfavorable prognostic factors for local control were pathological margins ≤7 mm (P < 0.001), pathological tumor depth ≥10 mm (P < 0.001), pathological positive lymph node(s) (P = 0.001), and the presence of betel quid chewing (P = 0.012). The same predictors, with the exception of betel quid chewing and pathological positive lymph node(s), were independently associated with DSS and OS in MVA. A prognostic scoring system was formulated by summing up the four significant local control covariates from MVA. Patients with scores of 3–4 had a significantly poorer local control rate compared to patients with scores of 0–2 (score 3 versus score 0–2: P < 0.001; score 4 versus score 0–2: P < 0.001) Conclusions Taken together, our data suggest that pathological margins and pathological tumor depth are major independent prognosticators not only for local tumor control, but also for DSS and OS.     

Impact of Total Lymph Node Count and Lymph Node Ratio on Staging and Survival after Pancreatectomy for Pancreatic Adenocarcinoma: A Large, Population-Based Analysis

Background Based on data from other malignancies, the number of lymph nodes evaluated and the ratio of metastatic to examined lymph nodes (LNR) may be important predictors of survival. LNR has never been investigated in a large population-based study of patients with pancreatic adenocarcinoma. Methods The Surveillance, Epidemiology, and End Results (SEER) database was used to identify 4005 patients who underwent resection for pancreatic adenocarcinoma from 1988 to 2003. The effect of total lymph node count and LNR on survival was examined using univariate and multivariate analyses. Results The median number of lymph nodes examined was seven; 390 (10.1%) patients had no lymph nodes examined. Of those patients who had at least one lymph node examined, 1507 (43.3%) had no lymph node metastases (N0) and 1971 (56.7%) had metastatic nodal disease (N1). Overall median survival was 13 months, and 5-year survival was 6.8%. N1 disease was associated with a worse 5-year survival compared with N0 disease (4.3 vs 11.3%, respectively, P < .001). Patients with N0 disease could be further stratified based on the number of lymph nodes evaluated (median survival: 1–11 nodes, 16 months vs 12 or more nodes, 23 months; P < .001). For N1 patients, LNR was one of the most powerful factors associated with survival (LNR > 0–0.2, 15 months; LNR > 0.2–0.4, 12 months; LNR > 0.4, 10 months) (P < .001). Conclusions Most patients have an inadequate number of lymph nodes evaluated following pancreatic surgery. N0 patients who have fewer than 12 lymph nodes examined may be understaged. In patients with N1 disease, LNR may better substratify patients with regard to prognosis. Presented at the 60th Annual Cancer Symposium, The Society of Surgical Oncology, March 17, 2007.     

Significant Prognostic Factors for Completely Resected pN2 Non-small Cell Lung Cancer without Neoadjuvant Therapy

Purpose: To identify prognostic factors for pathologic N2 (pN2) non-small cell lung cancer (NSCLC) treated by surgical resection.Methods: Between 1990 and 2009, 287 patients with pN2 NSCLC underwent curative resection at the Cancer Institute Hospital without preoperative treatment.Results: The 5-year overall survival (OS), cancer-specific survival (CSS), and recurrence-free survival (RFS) rates were 46%, 55% and 24%, respectively. The median follow-up time was 80 months. Multivariate analysis identified four independent predictors for poor OS: multiple-zone mediastinal lymph node metastasis (hazard ratio [HR], 1.616; p = 0.003); ipsilateral intrapulmonary metastasis (HR, 1.042; p = 0.002); tumor size >30 mm (HR, 1.013; p = 0.002); and clinical stage N1 or N2 (HR, 1.051; p = 0.030). Multivariate analysis identified three independent predictors for poor RFS: multiple-zone mediastinal lymph node metastasis (HR, 1.457; p = 0.011); ipsilateral intrapulmonary metastasis (HR, 1.040; p = 0.002); and tumor size >30 mm (HR, 1.008; p = 0.032).Conclusion: Multiple-zone mediastinal lymph node metastasis, ipsilateral intrapulmonary metastasis, and tumor size >30 mm were common independent prognostic factors of OS, CSS, and RFS in pN2 NSCLC.     

Carcinome ��pidermo?de du canal anal: indications op��ratoires, suivi apr��s radiochimioth��rapie

Combined treatment of epidermoid carcinoma of the anal canal by radiochemotherapy allows a 5-year overall survival of 70?C80%. Immediate abdominoperineal resection (APR) is justified only for radiotherapy contraindications. Pre-radiochemotherapy surgical resection is an independent factor of worse prognosis. Complete response of bulky T4 tumors is rare, with weak carcinologic and functional results leading to systematic APR discussion. Only small Tis or T1 tumors with no lymph node extension, located in the lower anal canal with little transmural spread, are accessible to local resection. Salvage surgery indications are local failure by recurrence persistent tumors, and severe complications of radiotherapy. Systematic deep biopsy samples of doubtful anal lesions are dangerous. Persistent suspicious anal lesions can lead to radical surgery, especially if they are responsible for chronic pain or fecal incontinence. There is no consensus on the appropriate follow-up of patients after treatment particularly because of morphologic distortion of the post-radiotherapy anal canal. Endoanal ultrasound is of little value in the follow-up, even if compared with clinical examination. The role of pelvis MRI are not well defined. Pet-scan seems to have a high negative predictive value in the prediction of the tumoral status of a clinically suspicious anal lesion.     

Improved Outcome of Resection of Hilar Cholangiocarcinoma (Klatskin Tumor)

Background Treatment of hilar cholangiocarcinoma (Klatskin tumors) has changed in many aspects. A more extensive surgical approach, as proposed by Japanese surgeons, has been applied in our center over the last 5 years; it combines hilar resection with partial hepatectomy for most tumors. The aim of this study was to assess the outcome of a 15-year evolution in the surgical treatment of Klatskin tumors. Methods A total of 99 consecutive patients underwent resection for hilar cholangiocarcinoma in three 5-year time periods: periods 1 (1988–1993; n = 45), 2 (1993–1998; n = 25), and 3 (1998–2003; n = 29). Outcome was evaluated by assessment of completeness of resection, postoperative morbidity and mortality, and survival. Results The proportion of margin negative resections increased significantly from 13% in period 1 to 59% in period 3 (P < .05). Two-year survival increased significantly from 33% ± 7% and 39% ± 10% in periods 1 and 2 to 60% ± 11% in period 3 (P < .05). Postoperative morbidity and mortality were considerable but did not increase with this changed surgical strategy (68% and 10%, respectively, in period 3). Lymph node metastasis was, next to period of resection, also associated with survival in univariate analysis. Conclusions Mainly in the last 5-year period (1998–2003), when the Japanese surgical approach was followed, more hilar resections were combined with partial liver resections that included segments 1 and 4, thus leading to more R0 resections. This, together with a decrease in lymph node metastases, resulted in improved survival without significantly affecting postoperative morbidity or mortality.     

进展期胃底贲门癌淋巴结清扫数目对预后的影响

目的探讨D2根治术中淋巴结清扫数目对进展期胃底贲门癌患者的预后和术后并发症发生率的影响。方法总结施行D2根治术的236例进展期胃底贲门癌患者的临床资料，将其清扫淋巴结的数目与术后5年患者的生存率及术后并发症发生率的关系进行分析。结果236例进展期胃底贲门癌患者术后5年生存率为37．5％。相同病期患者的术后5年生存率随着淋巴结清扫数目的增加而增高（P=0．0013）。Ⅱ期患者淋巴结清扫数目超过或等于20枚（P=0．0136）、Ⅲ期超过或等于25枚（P〈0．0001）、Ⅳ期超过或等于30枚（P=0．0002）、整组病例超过或等于15枚（P=0．0024）时生存率高，且差异具有统计学意义。本组术后并发症发生率为15．7％，淋巴结清扫的数目与术后并发症发生率的相关性无统计学意义（P=0．101）。结论进展期胃底贲门癌患者在施行D：根治术时，淋巴结清扫数目与患者预后呈正相关；合理的淋巴结清扫数目并不增加患者术后并发症发生率。