Predicting recurrence in colorectal cancer patients

SELECTED SUMMARIES

April 1993

advantage

of the fact that nearly

greatly.

Obvious

ity would

questions

have

augment

survival

with

respect

to sensitivity

and

clinical

for screening

measures

how

such

and specific-

strategies would

studies

of APC as an actual

such as the reintroduction

could

be of para-

into colon

cancer

phenotype

as well as tumorigenicity

tumor

suppressor

cells and observing

its effects

gene

APC gene

of the normal

on the malignant

in normal cell proliferation and how alterations of it contribute to dysregulated cell growth are areas of intensive and exciting research.

PREDICTING RECURRENCE CANCER PATIENTS

M.D.

General

Surgery

metastatic

tumour

patients.

Lancet

1992;340:685-689

At the time

of diagnosis,

or clinical

this study, presence

the authors

is a significant surgery.

cancer

tumor

prognostic

indicator

bone marrow.

metastases The

confirmed cluded

aspirates

elective

preoperative

tients during chest

the

physical

firsr year

radiography,

measurements, Bone marrow

with

every

ultrasonography,

were initially

tal cancer

showed

computed analyzed

patients (32%). Previous the absence of epithelial

Within

3-year

relapse-free

cells.

relapse

with a

Within

the CKS

of disease recur-

(30%) who were CK-

with

tumor

recurrence,

and the remaining

22 had dis-

the group with distant

survival

whereas

had 12 pa-

metastases,

13 were CK-.

9 The

rates were also calculated

for a

subgroup of 54 patients who underwent surgery at least 36 months earlier. Within the group without tumor cells in the this rate was 71%, whereas

it was 36% in those with

bone marrow. conclude

munocytochemical bone marrow

of tumor

as an independent

radical surgery. Further-

of tumor

histological

the

factor for recur-

value of bone marrow

to be independent

the im-

cells within

prognostic

cancer following

more, the prognostic found

that their work established

demonstration

rence of colorectal

Comment.

Current

mostly

the

upon

tumor

extension,

grading,

Staging

in colorectal

cancer

postoperative

cells was

lymph

node

age, and localization.

prognostic

in-

most

extensive

and

marrow

with

detection

con-

thelial value

tomography. for the presfor CK-

have shown

This paper

with colorecin 28

studies by the authors had shown cells in 102 patients with nonma-

was found

lignant disease. At the time of diagnosis, no statistically significant correlation was found between tumor extension, lymph node involvement, or histological grading and the

cancer

disease

marrow

neuroblastoma

extension

the predictive

(N

recurrence Engl

cancer

in

J

Med

(Int J Cancer

monoclonal

Suppl

antibodies, cell in 200,000

of the authors’

of epithelial

in patients

patients The

for epi-

1988;61:2407-2411).

with

previous

cells in the bone

with

colorectal

nonmalignant

to conventional

of bone marrow of 160 breast Metastases

cancer

patients

were found

histological

techniques

and the authors’

previous

(Cancer studies,

when

(J Clin Oncol staining

histological

micrometastases

work marrow

cancer

disease

use of immunocytochemical

to be superior

biopsies.

ventional

bone

for tumor

has

staining

in colorectal

Nat1 Acad Sci USA 1978;84:8672-8676).

by a study

to the

(J Surg Oncol

confirmed

that as few as one breast

exclusively

the detection

have

immunofluorescent

is a logical

1990;8:831-837).

report

as

(Cancer

with

been shown (Proc

bone

that the presence

compared

of fac-

staining

and small cell lung cancer Using

can be detected showing

for the

marrow

prognostic

micrometastases in breast

studies

well

1991;324:219-226) studies

en-

as

on

performed

Various

cancer

barium

at

therapy.

evidence

cells in the bone

as an independent

work

of micrometastatic

breast

patients

from adjuvant

by immunocytochemical

cells has been

1991;47:32-36).

1988;2:8-10).

level

cancer

surgical-paththose

convincing

tumor

of that

recurrence.

The

3 months

(CK+)

colorectal

subgroups

It is possible

to identify

put forth

importance

in various

likely to benefit

the authors

rely 1979;

that have established

to conventional

clinicians

relapse

cancer

(Cancer

a greater

reports

as effective

in addition

of micrometastatic with

resection

1990;322:352-3580).

will allow

In this report,

for colorectal

have assumed

therapy

J Med

high risk for tumor presence

methods

factors

staging

methods at surgical

since the recent

adjuvant

(N Engl

ological

staging

findings

43:961-968).

6 months),

antibody

origin

patients

had CK+ bone marrow

tor for tumor

for these pa-

antigen

from the 88 patients

cells of epithelial

tumor criteria

(every

subsequently

and in rectal cancer,

aspirates

of micro-

criteria

Follow-up

ence of epithelial cells using a monoclonal 18 (cytokeratin no. 18). Bone marrow

is

of surgery second-

serum carcinoembryonic

aspirates

patients

other

as-

histologically-

Exclusion

2 months

of 35 months.

initial

of tumor

had tumor

(57%) had evidence

had local recurrence,

patients

of this protein

Inclusion

examinations

and

abdominal

ema or colonoscopy,

the

following

as evidence

of the primary

complications.

included

tients

the presence

18 of 60 patients

Of those

tant metastases.

patients

aspirates.

of death within

ary to perioperative

Presence

cancer.

resection

bone marrow

sisted primarily

whether

no. 18), which

88 patients

colorectal

radical

In

cancer.

recruited

primary

metastases.

for relapse

was taken

from colorectal

authors

and

used an immunocytochemical

not found

in normal

relied

histology,

of the bone marrow

(cytokeratin

period

Disease-free

in which

of the prog-

to determine seeding

protein

marrow

cancer

has primarily

of distant

say for an epithelial in bone

rence, whereas

involvement,

stage, tumor

attempt

The investigators

of colorectal

the determination

evidence

of microscopic

of Muof micro-

(Sept).

with colorectal

the surgical-pathological

radiological

University

significance

cells in bone marrow

nosis for patients upon

Clinic,

Prognostic

showed

16 of 28 patients

marrow.

in patients

of all patients

follow-up

group

shorter

aspirates

The authors

and II Medical

Germany).

median

CK+

of

cells in the bone

four percent

marrow,

IN COLORECTAL

Lindemann F, Schlimok G, Dirscbedl P, et al. (Department nich, Munich,

Thirty

relapsed.

in nude mice. The role of APC

h. K. RUSTGI,

of CK+

was significantly

bone marrow

importance.

The demonstration awaits

presence

in the coding

to be addressed,

known

mount

region

protein will facilitate screening

all alterations

of the APC gene lead to truncated

1225

in

cancer

This is supported who

underwent

in only 2 patients

bone by con-

1988;60:96-98). none of the patients

In this with

1226

SELECTED

CK+

bone

SUMMARIES

marrow

had clinically

presence

of tumor

increased

risk of developing

kept in mind

prognostic

low investigators Further marker

of CK-

indicators

implications.

conventional

day be augmented

patients

specific

The

to predict

cancer.

for cancer

more

metastases.

seems

colorectal

need to be performed

and its clinical

lar biology,

percent

bone

marrow

recurrent

to design

studies

evident

cells in the bone

that a smaller

Additional

GASTROENTEROLOGY

Given

recurrent

It must be

two or more episodes

of abdominal

also recurred. may al-

therapy

the advances

trials.

should

one

M.D.

In addition

value

to the comment

we want

to point

of our proposed

was investigated

analysis

by the Cox proportional-hazards

patients

bone

marrow

predictive

variable

P = 0.022,

and lymph

gated variables cannot after

tool allowing

The readers the findings Cancer tients

precise

frequency

in metastatic In a follow-up

cancer

resection,

shorter

relapse-free

marrow

tumor

criminative

disease

interval

approach

subgroups

DC (organized

by

of micrometastasis)

cells,

with

(50%) or lymph comprising

cancer

a

with

Especially

seems to be clinically in larger

after

gastric

a significantly

disseminated

in NO stages,

most

pa-

higher

node involvement

showed

for patients

(Eur J

cancer

an even

38 patients

analysis

cells (P = 0.002).

sults need to be confirmed variate

an important

with gastric

CK-positive

study

But

may also take note from

of patients

a univariate

power

staging.

In 34 out of 97 gastric

we detected

investi-

relevant.

series and analyzed

bone the dis-

These

re-

by a multi-

FRITZ

LINDEMANN

&INTER

SCHLIMOK

PETER

DIRSCHEDL JENS WITTE

GERT

RIETHMtiLLER

DIVISUM:

TO STENT

St. Luke’s Hospital,

Racine

eta/. (Digestive Wisconsin;

of Gastroenterology,

Medical

waukee,

Endoscopic

Wisconsin).

and the Department

College

of Wisconsin,

therapy

in patients

Milwith

pancreas divisum and acute pancreatitis: a prospective, randomized, controlled clinical trial. Gastrointest Endosc 1992;38:430-434 (July-August). This study reports the use of endoscopic (stent) placement across the minor papilla of acute recurrent

pancreatitis

in patients

endoprosthesis in the treatment with pancreas

di-

freely

at endo-

(ERCP)

or to

duct. by grading

room

visits,

visits. Narcotic

hospitalizations,

fice visits related to recurrent were recorded.

dorsal

divisum

pancreatic

pancreatic

duct,

was shown

a patient

In the patients

minor

papilla

ated dilating

catheter,

at ERCP

papilla

ofpain

and a guide-

to the tail of the to dorsal

or to no endoscopic

randomized

was dilated

use,

or abdominal

was randomized

duct stent placement

ment.

analgesic

and physician

pancreatitis

across the accessory

to stent

from 4 to 7 French

the

with a gradupancreatic

stent

at each end was placed

across

the minor

of the stent varied from 3 to 7

papilla.

and a 5 or 7 French

treat-

placement,

with dual side barbs located The length

cm so as to avoid “repetitious

contact

by the tip of the stent.”

Subsequently,

change

every

was performed

which

the stent was removed.

ERCP

was repeated

Nineteen

communicating) creatitis

with

4 months In control

divisum

to

follow-up

for the stent group

dorsal

pancreatic

for

1 year,

patients,

of complete

(non-

and acute recurrent stent

pan-

were ran-

placement.

Mean

and for the

(P > 0.05, NS). In two treated

31.5 months

migrated

into the pancreatic

the stent migrated

num; all were successfully

after

however,

recurred.

was 28.6 months

the stent subsequently

duct, and in one patient

duct

and stent ex-

into the study. Ten patients

domized

group,

ERCP

the diagnosis

pancreas

were entered

patients,

to the pancreatic

only if pancreatitis

patients

restented.

into the duode-

No inflammatory

tures of the dorsal duct were noted during

stric-

or following

stent

therapy. or emergency

ing or following

Disease Center,

papilla

10 = worst

before

replacement

group,

5 patients

no patients

required

of an occluded required

stent.

hospitalization

period

in the control

epi-

immediately

In the control

and 2 patients

room (P < 0.05). Seven episodes

were documented

study and follow-up

hospi-

pain dur-

The single documented

in the stent group occurred

ited the emergency creatitis

group,

room visits for abdominal

stent therapy.

sode of pancreatitis

ImzsJI, GeenenJE,]ohmnJF

pan-

sphincteroplasty,

was followed

talization

OR NOT

retrograde chronic

pancreatic

symptomatology

In the stent treatment

PANCREAS TO STENT

prior

the minor

into the dorsal

Each patient’s

control

in the future.

included

pain based on a visual analog scale (0 = no pain,

wire advanced

was made.

of GASTROENTEROLOGY

(39%).

other

criteria

cholangiopancreatography

place a guidewire

as

range, and

by endoscopic

resection,

to cannulate

Once pancreas

extension,

in certain

in Washington,

to the diagnosis

marrow

in our

and age), we feel our test

risk assessment

meeting

1991;27:1461-1465). (35%),

P = 0.017;

it may become

standardization

in bone

tumor

surgical-pathological

standardization,

and devoted

Although

pancreatic

retrograde

emergency

to be the strongest

with

localization,

conventional

a more

first step towards

compared

node involvement,

At a recent

the NCI/NIH

model.

twice the normal

pain) at initial and subsequent

and

prognostic

in a multivariate

cells were found

(P = 0.0035

still necessary

of patients.

tumor

were grading,

yet replace

made by Horsby-Lewis

out that the independent

method

M.D.

prior

from

was defined

pain with documented

was documented Exclusion

No. 4

Wisconsin,

pancreatitis

level elevations

divisum

and failure scopic

N. HERBSMAN,

Herbsman,

pancreas creatitis,

by these techniques. L. HORNSBY-LEWIS,

Reply.

serum amylase pancreatography.

of molecu-

staging

Racine,

1985 to 1990. Acute

to assess this cytochemical

surgical-pathological

seen at St. Luke’s Hospital,

an

recurrence

adjuvant

visum

Vol. 104,

group

(P < 0.05). On patient

vis-

of pan-

during

the

question-

naires, 9 patients in the stent therapy group rated their improvement greater than or equal to 50% during the study, whereas only 1 patient in the control group rated an improvement greater than or equal to 50%. After completion of the study, 4 patients in the control group who continued to have episodes of acute pancreatitis or abdominal pain