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Dukes B colorectal cancer: are we harvesting enough lymph nodes?
1168 Introduction: Geriatric patient comprises a large cohort of general surgical emergency workload. Old age associated with multiple co morbidity and physiological changes increases the morbidity and mortality in these patients. We tried to evaluate the mortality and risk factor associated with mortality in these subset of the patients undergoing emergency surgery. Material method: It was a retrospective study of 112 patients over the period of 2.6 (Sep 99-March 03) years all undergoing emergency surgery above the age of 75. Analysis: The mortality remains very high around 40% (45/112) in these patients. Sepsis and MOD remain the leading cause of death 46.6 %(21/45). The type of pathology was also associated with higher mortality as patients with primary peritonitis had 49 %(22/45) and gangrene 20 %(8/45) mortality. Mortality in patients multiple co morbidity were 78% (35/45) against 22% (10/45) with no co morbidity. Increasing ASA Grade was associated with higher mortality in these patients as 68.7% were more than 2 on ASA grade. Conclusion: We concluded that with increasing geriatric population having multiple co morbidity and Higher ASA grade, early risk stratification, planning, preoperative medical emergency team evaluation and optimization of patient condition with adequate resuscitation can potentially decrease mortality associated with these patients. Sepsis control following defined and protocol based pathway can avoid MOD and sepsis related deaths. P8. Combined Resection And Radiofrequency Ablation For Bilobar Liver Metastases Elaine Y.L. Leung, C. Roxburgh, E. Leen, P. Horgan Glasgow Royal Infirmary, University Department of Surgery, Glasgow, G31 2ER Introduction: Surgical resection remains the only potential curative treatment for colorectal cancer liver metastases (CRCLM). Bilobar disease was traditionally considered unresectable. Novel techniques such as radiofrequency-ablation (RFA) have been employed as an adjunct to traditional hepatic resection, however few have reported outcomes using this approach. The present study’s aim is to report our experience of hepatic resection combined with intra-operative RFA in patients with initially unresectable bilobar CRCLM compared with patients who underwent simple resection of unilobar metastases. Patients: 95 patients underwent resection for CRCLM between 20002007. Of these 16 patients had additional RFA for bilobar disease at the time of resection. The majority of the total population were > 75 years (83%), male (57%), had metachronous disease (64%) and a single liver metastasis (57%). Those who had additional RFA had a median number of liver metastases of 3 (2-7). Results: Median follow-up of the survivors was 26.7 months (24.4 months for RFA plus resection and 31.4 months for resection alone); during which 48 died, 44 from recurrent cancer. Median hospital stay was 11 days for both groups. 30-day morbidity rate was 25% for each group. There was no peri-operative mortality. Acturial 3-year survival rates were 50% for liver resection alone and 54% for RFA plus resection. One patient who underwent RFA plus resection is alive at 57 months. Conclusions: In our experience those who undergo RFA plus resection for bilobar liver metastases can achieve perioperative and survival outcomes comparable to patients who have resection alone for unilobar metastases. P9. Has the QUASAR study on Dukes’ B colorectal cancer impacted on rates of post operative adjuvant chemotherapy? Andrew Wigham, S. Irukulla, L. Malhas, S. Essapen, D. Donaldson St Peters Hospital, Guildford Road, Chertsey, Surrey, KT16 0PZ Introduction: The incidence of Dukes’ B colorectal cancer has increased significantly. Surgery remains the mainstay of treatment, however the role of adjuvant chemotherapy remains controversial. In June 2004 the QUASAR trial was presented, which demonstrated a survival benefit of 3-4% was conferred by post-operative chemotherapy. Aim of the study was to evaluate the impact of the QUASAR trial on our practice.
ABSTRACTS Methods: Retrospective cohort study. Total of 271 patients underwent resection of a Dukes’ B colorectal cancer over a 5-year period (20022006). Data collection was from MDT case notes and hospital computer databases. All patients were discussed at the Colorectal MDT meeting. Primary outcome measure was to identify patients who received adjuvant chemotherapy within the first 3 months. Results: Table 1: showing rates of chemotherapy pre and post QUASAR
Total n ¼ 271 Pre n ¼ 129 Post n ¼ 142
Treated with adjuvant chemotherapy
No adjuvant chemotherapy, seen in oncology clinic
No adjuvant chemotherapy, no oncology OPA
25.8% (70/271) 25.6% (33/129) 26.1% (37/142)
21.8% (59/271) 22.5% (29/129) 21.1% (30/142)
52.4% (142/271) 51.9% (67/129) 52.8% (75/142)
There was no statistical difference between chemotherapy rates preQUASAR (25.6%) and post-QUASAR (26.1%) p-value 0.991(Chi square). There was no statistical significance between referral rates to oncology pre-QUASAR (22.5%) and post-QUASAR (21.1%). Conclusions: We conclude that the publication of QUASAR has yet to have an impact on clinical practice. One of the possible reasons for this is questionable clinical benefit of a ~ 4% increased survival, when the mortality (0.5-1%) and morbidity of adjuvant chemotherapy is considered. P10. Dukes B colorectal cancer: are the right patients getting chemotherapy? Faheez Mohamed, S. Biswas, E. Ahmed, M. Thomas, M. Jha, R. Wilson James Cook University Hospital, Marton Road, Middlesborough, TS4 3BW Introduction: The role of adjuvant chemotherapy for Dukes B (T3 or T4 N0 (Stage II)) patients remains unclear. The Colorectal Multidisciplinary Team (MDT) identifies patients from this group who may benefit from adjuvant chemotherapy. Our aim was to analyze outcome of Dukes B colorectal cancer patients treated at our institution. Methods: All patients with Dukes B histology were selected from a prospectively collected database of all colorectal cancers resected between 1997 and 2007 at our institution. Data including demographics, CEPOD classification, site of tumour, histopathology and adjuvant treatment were analysed. Survival from date of operation was calculated using KaplanMeier estimates and log rank test. Results: Of 1098 patients who underwent colorectal cancer resections, 38 % (414/1098) were staged as Dukes B (238 males and 176 females). Mean age at surgery was 71 years (range 37 to 97 years). Median follow up was 45 months. Resections were elective in 79% (328/414) of patients, and urgent or emergency in 21% (86/414). Tumours were colonic in 66% (275/414) of patients, and rectal in 34% (139/414). 25% (105/414) of patients received adjuvant chemotherapy. Overall median survival was 80 months with a 60% 5-year survival. Patients who received chemotherapy had a median survival of 81 months and 56% five year survival. This was equivalent to patients who received no chemotherapy (80 months median survival, 62% 5-year survival, p ¼ 0.98). Conclusion: Our colorectal MDT selection criteria appear to optimize survival in those Dukes B patients who would benefit while minimizing inappropriate use of chemotherapy. P11. Dukes B colorectal cancer: are we harvesting enough lymph nodes? Faheez Mohamed, S. Biswas, E. Ahmed, M. Thomas, M. Jha, R. Wilson James Cook University Hospital, Marton Road, Middlesborough, TS4 3BW Introduction: Treatment for colorectal cancer depends upon adequate retrieval and reporting of lymph nodes. The Association of Coloproctology of Great Britain and Ireland (ACPGBI) recommend examination of
ABSTRACTS
1169
a median of 12 lymph nodes. Our aim was to assess reporting of lymph node evaluation in Dukes B colorectal cancer patients treated at our institution. Methods: All patients with Dukes B histology were selected from a prospectively collected database of all colorectal cancers resected between 1997 and 2007 at our institution. Data including demographics, histopathology and adjuvant treatment were analysed. Survival from date of operation was calculated using Kaplan-Meier estimates and log rank test. Results: Of 1098 patients who underwent colorectal cancer resections, 37 % (405/1098) were staged as Dukes B (235 males). 25% (103/405) of patients received adjuvant chemotherapy. The median number of lymph nodes evaluated was 9 (range 0-35). 67% of patients had less than 12 lymph nodes evaluated (73/102 who received chemotherapy, 196/300 who received no chemotherapy). In patients who received chemotherapy, 5 year survival was equivalent in those with less than 12, or 12 or more lymph nodes harvested (p ¼ 0.89).When no chemotherapy was given there was a trend towards improved survival in patients with more than 12 lymph nodes harvested (70% 5 year survival, median survival not reached vs 59% 5 year survival, median survival 78 months, p ¼ 0.13). Conclusion: Understaging of Dukes B colorectal cancer may occur if insufficient lymph nodes are evaluated. The impact of this on overall survival needs further investigation. P12. Changing Trends In Rectal Cancer - The Nineties To Now A. Ben Sassi, S. Eccles, A. Woodward, J. Shannon, M. Foster Royal Glamorgan Hospital, Surgical Department, Glamorgan, CF72 8XR Introduction: The investigation and management of rectal cancer has evolved over the past two decades. The present study looked at trends in rectal cancer in 2003e2007, and compared the results with two previously published studies from the same institution on cases from 1991 onwards. Methods: Histologically-proven cases of rectal adenocarcinoma resected with curative intent between 2003e2007 at the Royal Glamorgan Hospital were identified and analysed from pathology reports. Data was compared with results from two previous studies conducted between 1996-2000 and 1991-97 respectively. Results: Eighty-six cases of rectal cancer excision with curative intent were identified from 2003-07. The key results are summarised in the table below. 20032007
19962000
19911997
Median age (yrs)
65
70
M - 69, F - 74
% % % % %
30.2 29.1 25.6 45.3 15.1
31.5 22.2 26.9 50.9 13.4
48.0 16.3 35.8 47.9 -
-
1991 - 0% 1997 - 85%
underwent AP resection Dukes A Dukes B Dukes C with tumour within 1mm of circumferential excision margin % with circumferential resection margin (CRM) reported in mm
Discussion: The present study highlights interesting trends in rectal cancer presentation and management over the past two decades. Patients undergoing rectal cancer resection now have a younger median age, and the percentage of patients with Dukes A disease has almost doubled. These findings may be due to increased awareness of colorectal cancer amongst the general population. The move away from AP resection has been maintained, whilst CRM reporting has continued to increase. These trends are consistent with best practice and comparable to national standards.
P13. Management of Retroperitoneal Tumours: A Single Institution Experience Bobby V. M. Dasari, B. Lee, D. Carey Belfast City Hospital, Level 5, Belfast Health and Social Care Trust, Lisburn Road, Belfast , BT9 7AB Introduction: Retroperitoneal tumours (RPT) account for 0.2% of all tumor types and 10-25% of all soft tissue tumors. Complete resection is the treatment of choice; however, this is often challenging due to the location of tumour, delay in clinical presentation, and frequent involvement of surrounding structures. Objectives of this study are to review the immediate and long-term postoperative outcomes of the RPTs. Methods: Patients who underwent laparotomy for the management of RPTs between 1998 and 2008 are included in the study. Operative details, postoperative morbidity, 30-day mortality and recurrence rates are assessed by retrospective review of the notes. Surgical team comprised of a general and a vascular surgeon with special interest in RPTs. Results: Twelve patients underwent surgery for primary RPTs. Median age at surgery is 46 years (range 18-81 years). Liposarcoma (2/12) and leiomyosarcoma (2/12) are the most common tumours. 11/12 tumours were completely resected; adjacent structures were resected in 5 patients. Repair of the inferior vena cava (2/13) is the most common additional intraoperative procedure. Two patients died in the immediate postoperative period (respiratory failure in 1 patient, small bowel ischemia and renal failure in 1 patient). None of the patients had local recurrence; one patient had distant bony metastases. Overall mortality rate at a median follow up period of 17 months (range of 6 - 58 months) is 33%. Conclusions: Long-term prognosis of RPTs remains poor. Complete en bloc resection (including the surrounding structures involved) at the initial operation is important in preventing the recurrence of RPTs.
P14. Are obesity (expressed as body mass index [BMI] [ 25kg/m2) and hepatic steatosis contraindications to patients undergoing hepatectomy for colorectal liver metastases (CRLM)? Joseph Tang, S. Pathak, M. Terlizzo, M. Haqqani, A. Wu, G. Poston University Hospital Aintree, Lower Lane, Liverpool, L9 7AL Background: Neoadjuvant chemotherapy is now employed in treating patients with CRLM. Chemotherapy increases the risk of steatohepatitis, thus increasing post-operative mortality. Furthermore, our society is getting larger, with increasing BMIs also predisposing to ‘‘fatty’’ liver, possibly also affecting post-operative outcome. We examined the relationship between BMI, degree of steatosis and post-operative survival. Methods: Retrospective analysis of a prospective consecutive cohort of 102 CRLM patients undergoing hepatectomy with 60 months followup. Resection specimens were examined to determine the degree of steatosis in the ‘normal’ liver. Data compared to BMIs and other relevant history. Statistical analyses by log rank and Fisher’s Exact Test. Results: 27(26.5%) had no detectable fatty change; 1(1.0%) cirrhotic, 17(16.7%) were indeterminate. 57 were steatotic(55.9%): 26(25.5%) graded mild; 10(9.8%) graded moderate; 21 (20.6%) graded severe. 1 patient (BMI 29.5 kg/m2) had steatohepatitis but survived surgery. No steatosis in patients with BMI < 25. No significant difference in median survival between patients with and without steatosis(28.6 vs 32.3 months, log rank p ¼ 0.340). Survival outcomes similar between patients with BMI < 25 and BMI ¼ 25 (30.3 vs. 36.9 months, log rank p ¼ 0.361) and between patients with BMI < 30 and BMI ¼ 30 (34.4 vs. 27.2 months, log rank p ¼ 0.381). Significant correlation between BMI ¼25 and presence of steatosis (p ¼ 0.0097) but lost between BMI < 30 vs. ¼30(p ¼ 0.0612). Conclusion: Raised BMI ( ¼ 25 kg/m2) is associated with increased risk of steatosis however, neither raised BMI, nor the presence of steatosis influence long-term survival. We conclude that obesity and the presence of steatosis are not contraindications when considering patients with CRLM for hepatectomy.
ABSTRACTS Methods: Retrospective cohort study. Total of 271 patients underwent resection of a Dukes’ B colorectal cancer over a 5-year period (20022006). Data collection was from MDT case notes and hospital computer databases. All patients were discussed at the Colorectal MDT meeting. Primary outcome measure was to identify patients who received adjuvant chemotherapy within the first 3 months. Results: Table 1: showing rates of chemotherapy pre and post QUASAR
Total n ¼ 271 Pre n ¼ 129 Post n ¼ 142
Treated with adjuvant chemotherapy
No adjuvant chemotherapy, seen in oncology clinic
No adjuvant chemotherapy, no oncology OPA
25.8% (70/271) 25.6% (33/129) 26.1% (37/142)
21.8% (59/271) 22.5% (29/129) 21.1% (30/142)
52.4% (142/271) 51.9% (67/129) 52.8% (75/142)
There was no statistical difference between chemotherapy rates preQUASAR (25.6%) and post-QUASAR (26.1%) p-value 0.991(Chi square). There was no statistical significance between referral rates to oncology pre-QUASAR (22.5%) and post-QUASAR (21.1%). Conclusions: We conclude that the publication of QUASAR has yet to have an impact on clinical practice. One of the possible reasons for this is questionable clinical benefit of a ~ 4% increased survival, when the mortality (0.5-1%) and morbidity of adjuvant chemotherapy is considered. P10. Dukes B colorectal cancer: are the right patients getting chemotherapy? Faheez Mohamed, S. Biswas, E. Ahmed, M. Thomas, M. Jha, R. Wilson James Cook University Hospital, Marton Road, Middlesborough, TS4 3BW Introduction: The role of adjuvant chemotherapy for Dukes B (T3 or T4 N0 (Stage II)) patients remains unclear. The Colorectal Multidisciplinary Team (MDT) identifies patients from this group who may benefit from adjuvant chemotherapy. Our aim was to analyze outcome of Dukes B colorectal cancer patients treated at our institution. Methods: All patients with Dukes B histology were selected from a prospectively collected database of all colorectal cancers resected between 1997 and 2007 at our institution. Data including demographics, CEPOD classification, site of tumour, histopathology and adjuvant treatment were analysed. Survival from date of operation was calculated using KaplanMeier estimates and log rank test. Results: Of 1098 patients who underwent colorectal cancer resections, 38 % (414/1098) were staged as Dukes B (238 males and 176 females). Mean age at surgery was 71 years (range 37 to 97 years). Median follow up was 45 months. Resections were elective in 79% (328/414) of patients, and urgent or emergency in 21% (86/414). Tumours were colonic in 66% (275/414) of patients, and rectal in 34% (139/414). 25% (105/414) of patients received adjuvant chemotherapy. Overall median survival was 80 months with a 60% 5-year survival. Patients who received chemotherapy had a median survival of 81 months and 56% five year survival. This was equivalent to patients who received no chemotherapy (80 months median survival, 62% 5-year survival, p ¼ 0.98). Conclusion: Our colorectal MDT selection criteria appear to optimize survival in those Dukes B patients who would benefit while minimizing inappropriate use of chemotherapy. P11. Dukes B colorectal cancer: are we harvesting enough lymph nodes? Faheez Mohamed, S. Biswas, E. Ahmed, M. Thomas, M. Jha, R. Wilson James Cook University Hospital, Marton Road, Middlesborough, TS4 3BW Introduction: Treatment for colorectal cancer depends upon adequate retrieval and reporting of lymph nodes. The Association of Coloproctology of Great Britain and Ireland (ACPGBI) recommend examination of
ABSTRACTS
1169
a median of 12 lymph nodes. Our aim was to assess reporting of lymph node evaluation in Dukes B colorectal cancer patients treated at our institution. Methods: All patients with Dukes B histology were selected from a prospectively collected database of all colorectal cancers resected between 1997 and 2007 at our institution. Data including demographics, histopathology and adjuvant treatment were analysed. Survival from date of operation was calculated using Kaplan-Meier estimates and log rank test. Results: Of 1098 patients who underwent colorectal cancer resections, 37 % (405/1098) were staged as Dukes B (235 males). 25% (103/405) of patients received adjuvant chemotherapy. The median number of lymph nodes evaluated was 9 (range 0-35). 67% of patients had less than 12 lymph nodes evaluated (73/102 who received chemotherapy, 196/300 who received no chemotherapy). In patients who received chemotherapy, 5 year survival was equivalent in those with less than 12, or 12 or more lymph nodes harvested (p ¼ 0.89).When no chemotherapy was given there was a trend towards improved survival in patients with more than 12 lymph nodes harvested (70% 5 year survival, median survival not reached vs 59% 5 year survival, median survival 78 months, p ¼ 0.13). Conclusion: Understaging of Dukes B colorectal cancer may occur if insufficient lymph nodes are evaluated. The impact of this on overall survival needs further investigation. P12. Changing Trends In Rectal Cancer - The Nineties To Now A. Ben Sassi, S. Eccles, A. Woodward, J. Shannon, M. Foster Royal Glamorgan Hospital, Surgical Department, Glamorgan, CF72 8XR Introduction: The investigation and management of rectal cancer has evolved over the past two decades. The present study looked at trends in rectal cancer in 2003e2007, and compared the results with two previously published studies from the same institution on cases from 1991 onwards. Methods: Histologically-proven cases of rectal adenocarcinoma resected with curative intent between 2003e2007 at the Royal Glamorgan Hospital were identified and analysed from pathology reports. Data was compared with results from two previous studies conducted between 1996-2000 and 1991-97 respectively. Results: Eighty-six cases of rectal cancer excision with curative intent were identified from 2003-07. The key results are summarised in the table below. 20032007
19962000
19911997
Median age (yrs)
65
70
M - 69, F - 74
% % % % %
30.2 29.1 25.6 45.3 15.1
31.5 22.2 26.9 50.9 13.4
48.0 16.3 35.8 47.9 -
-
1991 - 0% 1997 - 85%
underwent AP resection Dukes A Dukes B Dukes C with tumour within 1mm of circumferential excision margin % with circumferential resection margin (CRM) reported in mm
Discussion: The present study highlights interesting trends in rectal cancer presentation and management over the past two decades. Patients undergoing rectal cancer resection now have a younger median age, and the percentage of patients with Dukes A disease has almost doubled. These findings may be due to increased awareness of colorectal cancer amongst the general population. The move away from AP resection has been maintained, whilst CRM reporting has continued to increase. These trends are consistent with best practice and comparable to national standards.
P13. Management of Retroperitoneal Tumours: A Single Institution Experience Bobby V. M. Dasari, B. Lee, D. Carey Belfast City Hospital, Level 5, Belfast Health and Social Care Trust, Lisburn Road, Belfast , BT9 7AB Introduction: Retroperitoneal tumours (RPT) account for 0.2% of all tumor types and 10-25% of all soft tissue tumors. Complete resection is the treatment of choice; however, this is often challenging due to the location of tumour, delay in clinical presentation, and frequent involvement of surrounding structures. Objectives of this study are to review the immediate and long-term postoperative outcomes of the RPTs. Methods: Patients who underwent laparotomy for the management of RPTs between 1998 and 2008 are included in the study. Operative details, postoperative morbidity, 30-day mortality and recurrence rates are assessed by retrospective review of the notes. Surgical team comprised of a general and a vascular surgeon with special interest in RPTs. Results: Twelve patients underwent surgery for primary RPTs. Median age at surgery is 46 years (range 18-81 years). Liposarcoma (2/12) and leiomyosarcoma (2/12) are the most common tumours. 11/12 tumours were completely resected; adjacent structures were resected in 5 patients. Repair of the inferior vena cava (2/13) is the most common additional intraoperative procedure. Two patients died in the immediate postoperative period (respiratory failure in 1 patient, small bowel ischemia and renal failure in 1 patient). None of the patients had local recurrence; one patient had distant bony metastases. Overall mortality rate at a median follow up period of 17 months (range of 6 - 58 months) is 33%. Conclusions: Long-term prognosis of RPTs remains poor. Complete en bloc resection (including the surrounding structures involved) at the initial operation is important in preventing the recurrence of RPTs.
P14. Are obesity (expressed as body mass index [BMI] [ 25kg/m2) and hepatic steatosis contraindications to patients undergoing hepatectomy for colorectal liver metastases (CRLM)? Joseph Tang, S. Pathak, M. Terlizzo, M. Haqqani, A. Wu, G. Poston University Hospital Aintree, Lower Lane, Liverpool, L9 7AL Background: Neoadjuvant chemotherapy is now employed in treating patients with CRLM. Chemotherapy increases the risk of steatohepatitis, thus increasing post-operative mortality. Furthermore, our society is getting larger, with increasing BMIs also predisposing to ‘‘fatty’’ liver, possibly also affecting post-operative outcome. We examined the relationship between BMI, degree of steatosis and post-operative survival. Methods: Retrospective analysis of a prospective consecutive cohort of 102 CRLM patients undergoing hepatectomy with 60 months followup. Resection specimens were examined to determine the degree of steatosis in the ‘normal’ liver. Data compared to BMIs and other relevant history. Statistical analyses by log rank and Fisher’s Exact Test. Results: 27(26.5%) had no detectable fatty change; 1(1.0%) cirrhotic, 17(16.7%) were indeterminate. 57 were steatotic(55.9%): 26(25.5%) graded mild; 10(9.8%) graded moderate; 21 (20.6%) graded severe. 1 patient (BMI 29.5 kg/m2) had steatohepatitis but survived surgery. No steatosis in patients with BMI < 25. No significant difference in median survival between patients with and without steatosis(28.6 vs 32.3 months, log rank p ¼ 0.340). Survival outcomes similar between patients with BMI < 25 and BMI ¼ 25 (30.3 vs. 36.9 months, log rank p ¼ 0.361) and between patients with BMI < 30 and BMI ¼ 30 (34.4 vs. 27.2 months, log rank p ¼ 0.381). Significant correlation between BMI ¼25 and presence of steatosis (p ¼ 0.0097) but lost between BMI < 30 vs. ¼30(p ¼ 0.0612). Conclusion: Raised BMI ( ¼ 25 kg/m2) is associated with increased risk of steatosis however, neither raised BMI, nor the presence of steatosis influence long-term survival. We conclude that obesity and the presence of steatosis are not contraindications when considering patients with CRLM for hepatectomy.