Management of Square Carcinoma of the Lower Lip Using Camille-Bernard Flap under Local Anesthesia: When Constraints Dictate Our Attitude

Introduction: Squamous cell carcinomas of the lip essentially pose a therapeutic management problem. In the West, their treatment is done under general anesthesia and follows the classic rules of oncology. In our context of exercise, we sometimes have a different attitude dictated by various constraints. Observation: 55-year-old patient with no notable history, seen in consultation for a very large ulcerative-budding lesion on the right 2/3 of the lower lip with mucocutaneous involvement without lymph node findings found on examination. Faced with this suspicious lesion and the patient’s financial difficulties, we decided to operate under local anesthesia to remove this tumor. The oncological excision was followed by immediate plasty using a Camille-Bernard flap with a good immediate aesthetic and functional result and postoperative day 7. The patient was unable to take his surgical specimen to anatomy-pathology and was lost to follow-up due to lack of financial resources. On anatomo-pathological analysis of the surgical specimen, the margins were healthy with confirmation of squamous cell carcinoma (anapathological reading made for scientific interest). Discussion: The particular mentality of certain patients and their difficult financial conditions push us to have an unconventional therapeutic attitude in oncology, but which nevertheless makes it possible to resolve certain problems that we often face. Local anesthesia is possible and realistic in cases like ours and the results can be acceptable and life-saving.

Myocardial metastasis from ZEB1-and TWIST-positive spindle cell carcinoma of the esophagus:A case report

BACKGROUND Metastatic cardiac tumors are known to occur more frequently than primary cardiac tumors,however,they often remain asymptomatic and are commonly dis-covered on autopsy.Malignant tumors with a relatively high frequency of cardiac metastasis include mesothelioma,melanoma,lung cancer,and breast cancer,whereas reports of esophageal cancer with cardiac metastasis are rare.CASE SUMMARY The case of a 60-year-old man who complained of dysphagia is presented.Upper gastrointestinal endoscopy showed a submucosal tumor-like elevated lesion in the esophagus causing stenosis.Contrast-enhanced computed tomography showed left atrial compression due to the esophageal tumor,multiple liver and lung metastases,and a left pleural effusion.Pathological examination of a biopsy speci-men from the esophageal tumor showed spindle-shaped cells,raising suspicion of esophageal sarcoma.The disease progressed rapidly,and systemic chemotherapy was deemed necessary,however,due to his poor general condition,adminis-tration of cytotoxic agents was considered difficult.Given his high Combined Positive Score,nivolumab was administered,however,the patient soon died from the disease.The autopsy confirmed spindle cell carcinoma(SCC)of the esophagus and cardiac metastasis with similar histological features.Cancer stem cell markers,ZEB1 and TWIST,were positive in both the primary tumor and the cardiac metastasis.CONCLUSION To the best of our knowledge,there have been no prior reports of cardiac metastasis of esophageal SCC.This case highlights our experience with a patient with esophageal SCC who progressed rapidly and died from the disease,with the autopsy examination showing cardiac metastasis.

Systemic treatments for resectable carcinoma of the esophagus

One of the most prevalent malignancies in the world is esophageal cancer(EC).The 5-year survival rate of EC remains pitiful despite treatment advancements.Neoadjuvant chemoradiotherapy in conjunction with esophagectomy is the standard of care for patients with resectable disease.The pathological complete response rate,however,is not acceptable.A distant metastasis or a locoregional recurrence will occur in about half of the patients.To increase the clinical effectiveness of therapy,it is consequently vital to investigate cutting-edge and potent therapeutic modalities.The approach to the management of resectable EC using immunotherapy has been considerably altered by immune checkpoint inhibitors.Systemic immunotherapy has recently been shown to have the potential to increase the survival of patients with resectable EC,according to growing clinical data.A combination of chemotherapy,radiation,and immunotherapy may have a synergistic antitumor impact because,according to mounting evidence,these treatments can stimulate the immune system via a number of different pathways.In light of this,it makes sense to consider the value of neoadjuvant immunotherapy for patients with surgically treatable EC.In this review,we clarify the rationale for neoadjuvant immunotherapy in resectable EC patients,recap the clinical outcomes of these approaches,go through the upcoming and ongoing investigations,and emphasize the difficulties and unmet research requirements.

Metastatic basaloid-squamous cell carcinoma of the esophagus treated by 5-fluorouracil and cisplatin

Basaloid squamous cell carcinoma （BSC） of the esophagus is a rare malignant disease. We report here a patient with recurrent esophageal BSC, who was successfully treated by systemic chemotherapy containing 5-fluorouracil （5-FU） and cisplatin （CDDP）. A 57-year-old woman was diagnosed as having SCluamous cell carcinoma of the esophagus upon endoscopic examination. Curative esophagectomy with lymph node dissection was performed under the thoracoscope. The pathological diagnosis of the surgical specimen was BSC. Five months after operation, the patient was diagnosed as having a recurrence of the BSC with metastases to the liver and spleen, and a right paraclavicular lymph node. She was given systemic chemotherapy consisting of continuous infusion of 800 mg/d of 5-FU and 3 h infusion of 20 mg/d of CDDP for 5 consecutive days every 4 wk. The metastatic lesions in the spleen and right paraclavicular lymph node disappeared, and the liver metastasis was apparently reduced in size after 2 courses of chemotherapy. The tumor regression was seen over 6 courses, with progression afterwards. Although subsequent treatment with CPT-11 and CDDP was not effective, docetaxel and vinorelbine temporarily controlled the tumor growth for 2 mo. 5-FU and CDDP combination may be useful for the patients with advanced BSC.

Effect of bilateral supraclavicular postoperative radiotherapy in middle and lower thoracic esophageal carcinoma

AIM: To evaluate whether postoperative radiotherapy is an alternative to neck lymph node surgery and if it provides a survival benefit for those receiving two-field, chest and abdomen, lymphadenectomy.

Multiple carcinosarcomas of the esophagus with adenocarcinomatous components: A case report

BACKGROUND Carcinosarcoma(spindle cell carcinoma) of the esophagus is an extremely rare event;the etiology and origins of this neoplasm have not yet been determined.Epithelial-mesenchymal transition(EMT) has been associated with invasion and metastasis, and may be related to the generation of a stem cell population within this tumor.CASE SUMMARY We present the case of a 61-year-old male with nausea and fever. Upper gastrointestinal endoscopy revealed the presence of type 1 and 0-Ⅱc lesions located 35 cm from the incisors toward the esophago-gastric junction.Thoracoscopic esophagectomy was performed. Macroscopic analysis revealed three polypoid lesions in the abdominal esophagus that accompanied the main lesion in the lower thoracic esophagus and 0-Ⅱc lesions that spread continuously with them. Histologically, the lesions included proliferating spindle cells. Adenocarcinomatous components were detected in a section near the foot, and squamous cell carcinoma was identified in the mucosa at the base of the tumor.The patient was diagnosed with multiple carcinosarcomas, staged at pT1b(SM3),pN1(#110, #7), cM0, Stage Ⅱ(sarcomatous metastasis to the lymph nodes).Spindle cells did not express E-cadherin but were positive for EMT markers,including zinc finger E-box-binding homeobox 1, TWIST, and snail family transcriptional repressor 2. The patient has experienced no recurrence at 5 years and 2 mo after surgery.CONCLUSION This report suggests that multiple sarcomatous tumors may be generated from primary squamous cell carcinoma via mechanisms related to EMT.

Development and validation of a prognostic nomogram model for Chinese patients with primary small cell carcinoma of the esophagus

BACKGROUND Primary small cell carcinoma of the esophagus(PSCE)is a highly invasive malignant tumor with a poor prognosis compared with esophageal squamous cell carcinoma.Due to the limited samples size and the short follow-up time,there are few reports on elucidating the prognosis of PSCE,especially on the establishment and validation of a survival prediction nomogram model covering general information,pathological factors and specific biological proteins of PSCE patients.AIM To establish an effective nomogram to predict the overall survival(OS)probability for PSCE patients in China.METHODS The nomogram was based on a retrospective study of 256 PSCE patients.Univariate analysis and multivariate Cox proportional hazards regression analysis were used to examine the prognostic factors associated with PSCE,and establish the model for predicting 1-,3-,and 5-year OS based on the Akaike information criterion.Discrimination and validation were assessed by the concordance index(C-index)and calibration curve and decision curve analysis(DCA).Histology type,age,tumor invasion depth,lymph node invasion,detectable metastasis,chromogranin A,and neuronal cell adhesion molecule 56 were integrated into the model.RESULTS The C-index was prognostically superior to the 7th tumor node metastasis(TNM)staging in the primary cohort[0.659(95%CI:0.607-0.712)vs 0.591(95%CI:0.517-0.666),P=0.033]and in the validation cohort[0.700(95%CI:0.622-0.778)vs 0.605(95%CI:0.490-0.721),P=0.041].Good calibration curves were observed for the prediction probabilities of 1-,3-,and 5-year OS in both cohorts.DCA analysis showed that our nomogram model had a higher overall net benefit compared to the 7th TNM staging.CONCLUSION Our nomogram can be used to predict the survival probability of PSCE patients,which can help clinicians to make individualized survival predictions.

Neuroendocrine carcinoma of the esophagus: Report of a case and review of the literature

Esophageal neuroendocrine carcinomas are rare, aggressive and have a poor prognosis. Combined therapy using chemotherapy, radiotherapy and/or surgery appear effective for them. Upper gastrointestinal endoscope of a 65-year-old male revealed a localized ulcerative lesion in the middle esophagus. Histology of biopsy specimens indicated a neuroendocrine carcinoma. A computed tomography showed an esophageal tumor with enlarged mediastinal lymph nodes. The patient was administered neoadjuvant chemo-therapy consisting of 5-fluorouracil and cisplatin, which led to partial response. Subtotal esophagectomy with three-field lymphadenectomy was performed. Pathologically, the tumor was 25 mm and infiltrated the proper muscle layer. The tumor cells were arranged in microtubular structures, with small and round cells containing scanty cytoplasm, and exhibited intense mitosis 51/10 HPF. They were positive for synaptophysin and chromogranin A, and Ki-67 labeling index was 70% - 80%. These findings led to the diagnosis of neuroendocrine carcinoma of small cell type. The patient was administered adjuvant chemotherapy using cisplatin and CPT-11, and he is now alive disease-free at the time of this writing.

Determination of esophageal squamous cell carcinoma and gastric adenocarcinoma on raw tissue using Raman spectroscopy

BACKGROUND Cancer detection is a global research focus,and novel,rapid,and label-free techniques are being developed for routine clinical practice.This has led to the development of new tools and techniques from the bench side to routine clinical practice.In this study,we present a method that uses Raman spectroscopy(RS)to detect cancer in unstained formalin-fixed,resected specimens of the esophagus and stomach.Our method can record a clear Raman-scattered light spectrum in these specimens,confirming that the Raman-scattered light spectrum changes because of the histological differences in the mucosal tissue.AIM To evaluate the use of Raman-scattered light spectrum for detecting endoscopically resected specimens of esophageal squamous cell carcinoma(SCC)and gastric adenocarcinoma(AC).METHODS We created a Raman device that is suitable for observing living tissues,and attempted to acquire Raman-scattered light spectra in endoscopically resected specimens of six esophageal tissues and 12 gastric tissues.We evaluated formalin-fixed tissues using this technique and captured shifts at multiple locations based on feasibility,ranging from six to 19 locations 200 microns apart in the vertical and horizontal directions.Furthermore,a correlation between the obtained Raman scattered light spectra and histopathological diagnosis was performed.RESULTS We successfully obtained Raman scattered light spectra from all six esophageal and 12 gastric specimens.After data capture,the tissue specimens were sent for histopathological analysis for further processing because RS is a label-free methodology that does not cause tissue destruction or alterations.Based on data analysis of molecular-level substrates,we established cut-off values for the diagnosis of esophageal SCC and gastric AC.By analyzing specific Raman shifts,we developed an algorithm to identify the range of esophageal SCC and gastric AC with an accuracy close to that of histopathological diagnoses.CONCLUSION Our technique provides qualitative information for real-time morphological diagnosis.However,further in vivo evaluations require an excitation light source with low human toxicity and large amounts of data for validation.

Endoscopic treatment of Barrett's esophagus:From metaplasia to intramucosal carcinoma

The annual incidence of adenocarcinoma arising from Barrett’s esophagus (BE) is approximately 0.5%. Through a process of gradual transformation from lowgrade dysplasia to high-grade dysplasia (HGD), adenocarcinoma can develop in the setting of BE. The clinical importance of appropriate identifi cation and treatment of BE in its various stages, from intestinal metaplasia to intramucosal carcinoma (IMC) hinges on the dramatically different prognostic status between early neoplasia and more advanced stages. Once a patient has symptoms of adenocarcinoma, there is usually locally advanced disease with an approximate 5-year survival rate of about 20%. Esophagectomy has been the gold standard treatment for BE with HGD, due to the suspected risk of harboring occult invasive carcinoma, which was traditionally estimated to be as high as 40%. In recent years, the paradigm of BE early neoplasia management has recently evolved, and endoscopic therapies (endoscopic mucosal resection, radiofrequency ablation, and cryotherapy) have entered the clinical forefront as acceptable non-surgical alternatives for HGD and IMC. The goal of endoscopic therapy for HGD or IMC is to ablateall BE epithelium (both dysplastic and non-dysplastic) due to risk of synchronous/metachronous lesion development in the remaining BE segment.

Human papillomavirus in squamous cell carcinoma of esophagus in a high-risk population

AIM: To investigate the relation of human papillomavirus (HPV) and esophageal squamous cell carcinoma (ESCC) in Iranian patients as compared to normal controls. METHODS: Using MY09/MY11 consensus primers, we compared the prevalence of a HPV L1 gene in tumor tissues from 38 ESCC cases and biopsied tissues from 38 endoscopically normal Iranian individuals. We also compared the presence of HPV16 and HPVA18 in the same samples using type-specific E6/E7 primers. RESULTS: Fourteen (36.8%) of the 38 ESCC samples but only 5 (13.2%) of the 38 control samples were positive for the HPV L1 gene (P= 0.02). Five (13.2%) of the ESCC samples but none of the control samples were positive for the HPV16 E6/E7 gene (P= 0.05). Three (7.9%) of the ESCC samples and 5 (13.2%) of the control samples were positive for the HPV18 E6/E7 gene (P= 0.71). CONCLUSION: Our data are consistent with HPV DNA studies conducted in other high-risk areas for ESCC. HPV should be considered as a potential factor contributing to the high incidence of ESCC in Iran and other high-incidence areas of the world.

Primary adenosquamous carcinoma of the esophagus

AIM:To investigate the clinical characteristics,diagnosis,treatment,and prognosis of primary adenosquamous carcinoma(ASC)of the esophagus.METHODS:A total of 4015 patients with esophageal carcinoma underwent surgical resection between January 1995 and June 2012 at the Cancer Hospital of Shantou University Medical College.In 37 cases,the histological diagnosis was primary ASC.Clinical data were retrospectively analyzed from these 37 patients,who underwent transthoracic esophagectomy with lymphadenectomy.Theχ2or Fisher’s exact test was used to compare the clinicopathological features between patients with ASC and those with squamous cell carcinoma(SCC).The Kaplan-Meier and Log-Rank methods were used to estimate and compare survival rates.A Cox proportional hazard regression model was used to identify independent prognostic factors.RESULTS:Primary esophageal ASC accounted for0.92%of all primary esophageal carcinoma cases(37/4015).The clinical manifestations were identical to those of other types of esophageal cancer.All of the 24patients who underwent preoperative endoscopic biopsy were misdiagnosed with SCC.The median survival time(MST)was 21.0 mo(95%CI:12.6-29.4),and the1-,3-,and 5-year overall survival rates were 67.5%,29.4%,and 22.9%,respectively.In multivariate analysis,only adjuvant radiotherapy(HR=0.317,95%CI:0.114-0.885,P=0.028)was found to be an independent prognostic factor.The MST for ASC patients was significantly lower than that for SCC patients[21.0 mo(95%CI:12.6-29.4)vs 46.0 mo(95%CI:40.8-51.2),P=0.001].In subgroup analyses,the MST for ASC patients was similar to that for poorly differentiated SCC patients.CONCLUSION:Primary esophageal ASC is a rare disease that is prone to be misdiagnosed by endoscopic biopsy.The prognosis is poorer than esophageal SCC but similar to that for poorly differentiated SCC patients.

Squamous Cell Carcinoma and Adenocarcinoma of the Esophagus–Di?erences in Etiology, Epidemiology and Prevention

In Germany, esophageal carcinoma is one of the ten most frequent causes of death. Normally the disease is found in men over the age of 50. Although squamous cell carcinoma (SCC) of the esophagus has been more commonly diagnosed over the past 30 years, there is increasing incidence of esophageal adenocarcinoma (AC) in Western industrialized countries. For SCC the known etiological risk factors are nicotine and alcohol abuse. For AC, they are moderate nicotine and alcohol consumption as well as gastro-esophageal re?ux and obesity.

Thoracoscopic resection of a large lower esophageal schwannoma:A case report and review of the literature

BACKGROUND Esophageal schwannomas originating from Schwann cells are extremely rare esophageal tumors.They commonly occur in the upper and middle esophagus but less frequently in the lower esophagus.Herein,we report a rare case of a large lower esophageal schwannoma misdiagnosed as a leiomyoma.We also present a brief literature review on lower esophageal schwannomas.CASE SUMMARY A 62-year-old man presented with severe dysphagia lasting 6 mo.A barium esophagogram showed that the lower esophagus was compressed within approximately 5.5 cm.Endoscopy revealed the presence of a large submucosal protuberant lesion in the esophagus at a distance of 32-38 cm from the incisors.Endoscopic ultrasound findings demonstrated a 4.5 cm×5.0 cm hypoechoic lesion.Chest computed tomography revealed a mass of size approximately 53 mm×39 mm×50 mm.Initial tests revealed features indicative of leiomyoma.After multidisciplinary discussions,the patient underwent a video-assisted thoracoscopic partial esophagectomy.Further investigation involving immunohistochemical examination confirming palisading spindle cells as positive for S100 and Sox10 led to the final diagnosis of a lower esophageal schwannoma.There was no tumor recurrence or metastasis during follow-up.CONCLUSION The final diagnosis of esophageal schwannoma requires histopathological and immunohistochemical examination.The early appropriate surgery favors a remarkable prognosis.

The 2002 AJCC TNM classification is a better predictor of primary small cell esophageal carcinoma outcome than the VALSG staging system

Small cell carcinoma of the esophagus (SCCE) is a rare and aggressive malignant tumor with a poor prognosis. The optimal disease staging system and treatment approaches have not yet been defined. This study aimed to evaluate the prediction of different staging systems for prognosis and treatment options of SCCE. We retrospectively accessed the clinicopathologic characteristics, treatment strategy, and prognosis of 76 patients diagnosed with primary SCCE between 2001 and 2011. The 1-, 2-, 3-, and 5-year overall survival rates were 58%, 31%, 19%, and 13%, respectively. Univariate analysis showed that the 2002 American Joint Committee on Cancer (AJCC) tumor-node-metastasis (TNM) classification (P=0.002), Veterans Administration Lung Study Group (VALSG) stage (P=0.001), predisposing factors (P<0.001), T category (P=0.023), and M category (P<0.001) were prognostic factors for overall survival. Multivariate analysis showed that the 2002 AJCC TNM stage (P<0.001) was the only independent prognostic factor for survival. The value of the area under the receiver operator characteristic (ROC) curve (AUC) of the 2002 AJCC TNM staging system was larger than that of VALSG staging system with regard to predicting overall survival (0.774 vs. 0.620). None of the single treatment regimens showed any benefit for survival by Cox regression analysis. Thus, the 2002 AJCC TMN staging system improved the prediction of SCCE prognosis; however, the optimal treatment regimen for SCCE remains unclear.

A case of EMRC for basaloid squamous carcinoma of the cervical esophagus

Basaloid squamous carcinoma (BSC) of the esophagus is a rare esophageal tumor. A 79-year-old man with a history of proximal gastrectomy for gastric adenocarcinoma in 2000 was followed-up by esophagogastroduodenoscopy (EGD) annually. In June 2010, EGD revealed a new protruding lesion in the cervical esophagus. The small lesion was approximately 5 mm in size. A biopsy specimen showed poorly differentiated squamous cell carcinoma. We performed endoscopic mucosal resection using a cap-fi tted endoscope (EMRC). The histological diagnosis of the endoscopically resected specimen was BSC and the invasion depth was limited to the muscularis mucosae. Horizontal and vertical margins were negative. We report the case of superfi cial BSC in the cervical esophagus successfully resected by EMRC.

Endoscopic submucosal dissection combined with adjuvant chemotherapy for early-stage neuroendocrine carcinoma of the esophagus:A case report

BACKGROUND Neuroendocrine carcinoma(NEC)of the esophagus is rare and highly aggressive,and lacks biological features.Currently,there are no established standard treatments for this cancer.In this report,we describe a patient with large-cell NEC of the esophagus who was successfully treated using endoscopic submucosal dissection(ESD)combined with adjuvant chemotherapy.CASE SUMMARY A 55-year-old woman presented with intermittent mild dysphagia for 2 mo.Gastroscopy revealed a disc-shaped protruding lesion about 18 mm×18 mm in size on the upper esophagus.Endoscopic ultrasonography demonstrated that the bulged lesion originated from the muscularis mucosa.We assessed en bloc resections using ESD for therapeutic diagnosis to devise a safe and appropriate treatment.Histopathological examination revealed a poorly differentiated neoplasm comprising of large cells with marked nuclear atypia and multifocal necrosis.In addition,the specimens had a negative horizontal margin and vertical margins.Depth of invasion was classified as submucosa 2(SM2)without lymphovascular invasion.These histopathological results were consistent with a diagnosis of esophageal NEC,large cell type.Adjuvant therapy has been considered for ESD patients with SM2/SM3 lesions and patients with poorly differentiated lesions.After comprehensive consideration,we initiated combination treatment,i.e.,ESD plus adjuvant chemotherapy.The patient remained disease-free at the 2-year follow-up.CONCLUSION En bloc resection approach using ESD may play a vital role as a diagnostic and therapeutic modality for esophageal NEC.

Tumor size as a prognostic factor in patients with advanced gastric cancer in the lower third of the stomach

AIM: To explore the impact of tumor size on outcomes in patients with advanced gastric cancer in the lower third of the stomach. METHODS: We retrospectively analyzed the clinical records of 430 patients with advanced gastric cancer in the lower third of the stomach who underwent distal subtotal gastrectomy and D2 lymphadenectomy in our hospital from January 1998 to June 2004. Receiver-operating characteristic (ROC) curve analysis was used to determine the appropriate cutoff value for tumor size, which was measured as maximum tumor diameter. Based on this cutoff value, patients were divided into two groups: those with large-sized tumors (LSTs) and those with small-sized tumors (SSTs). The correlations between other clinicopathologic factors and tumor size were investigated, and the 5-year overall survival (OS) rate was compared between the two groups. Potential prognostic factors were evaluated by univariate KaplanMeier survival analysis and multivariate Cox's propor-tional hazard model analysis. The 5-year OS rates in the two groups were compared according to pT stage and pN stage. RESULTS: The 5-year OS rate in the 430 patients with advanced gastric cancer in the lower third of the stomach was 53.7%. The mean ± SD tumor size was 4.9 ± 1.9 cm, and the median tumor size was 5.0 cm. ROC analysis indicated that the sensitivity and specificity results for the appropriate tumor size cutoff value of 4.8 cm were 80.0% and 68.2%, respectively (AUC=0.795, 95%CI: 0.751-0.839, P=0.000). Using this cutoff value, 222 patients (51.6%) had LSTs (tumor size ≥ 4.8 cm) and 208 (48.4%) had SSTs (tumor size<4.8 cm). Tumor size was significantly correlated with histological type (P=0.039), Borrmann type (P=0.000), depth of tumor invasion (P=0.000), lymph node metastasis (P=0.000), tumor-nodes metastasis stage (P=0.000), mean number of metastatic lymph nodes (P=0.000) and metastatic lymph node ratio (P=0.000). Patients with LSTs had a significantly lower 5-year OS rate than those with SSTs (37.1% vs 63.3%, P=0.000). Univariate analysis showed that depth of tumor invasion (c 2=69.581, P=0.000), lymph node metastasis (c 2=138.815, P=0.000), tumor size (c 2=78.184, P=0.000) and metastatic lymph node ratio (c 2=139.034, P=0.000) were significantly associated with 5-year OS rate. Multivariate analysis revealed that depth of tumor invasion (P=0.000), lymph node metastasis (P=0.019) and tumor size (P=0.000) were independent prognostic factors. Gastric cancers were divided into 12 subgroups: pT2N0; pT2N1; pT2N2; pT2N3; pT3N0; pT3N1; pT3N2; pT3N3; pT4aN0; pT4aN1; pT4aN2; and pT4aN3. In patients with pT2-3N3 stage tumors and patients with pT4a stage tumors, 5-year OS rates were significantly lower for LSTs than for SSTs (P<0.05 each), but there were no significant differences in the 5-year OS rates in LST and SST patients with pT23N0-2 stage tumors (P > 0.05). CONCLUSION: Using a tumor size cutoff value of 4.8cm, tumor size is a prognostic factor in patients with pN3 stage or pT4a stage advanced gastric cancer located in the lower third of the stomach.

Study of circumferential resection margin in patients with middle and lower rectal carcinoma

AIM: To clarify the relationship between circumferential resection margin status and local and distant recurrence as well as survival of patients with middle and lower rectal carcinoma. The relationship between circumferential resection margin status and clinicopathologic characteristics of middle and lower rectal carcinoma was also evaluated. METHODS: Cancer specimens from 56 patients with middle and lower rectal carcinoma who received total mesorectal excision at the Department of General Surgery of Guangdong Provincial People's Hospital were studied. A large slice technique was used to detect mesorectal metastasis and evaluate circumferential resection margin status. RESULTS: Local recurrence occurred in 12.5% (7 of 56 cases) of patients with middle and lower rectal carcinoma. Distant recurrence occurred in 25% (14 of 56 cases) of patients with middle and lower rectal carcinoma. Twelve patients (21.4%) had positive circumferential resection margin. Local recurrence rate of patients with positive circumferential resection margin was 33.3% (4/12), whereas it was 6.8% (3/44) in those with negative circumferential resection margin (P = 0.014). Distant recurrence was observed in 50% (6/12) of patients with positive circumferential resection margin; conversely, it was 18.2% (8/44) in those with negative circumferential resection margin (P = 0.024). Kaplan-Meier survival analysis showed significant improvements in median survival (32.2 ± 4.1 mo, 95% CI: 24.1-40.4mo vs 23.0 ± 3.5 mo, 95% CI: 16.2-29.8 mo) for circumferential resection margin-negative patients over circumferential resection margin-positive patients (log-rank, P < 0.05). 37% T3 tumors examined were positive for circumferential resection margin, while only 0% T1 tumors and 8.7% T2 tumors were examined as circumferential resection margin. The difference between these three groups was statistically significant (P = 0.021). In 18 cancer specimens with tumor diameter ≥ 5 cm 7 (38.9%) were detected as positive circumferential resection margin, while in 38 cancer specimens with a tumor diameter of < 5 cm only 5 (13.2%) were positive for circumferential resection margin (P = 0.028). CONCLUSION: Our findings indicate that circumferential resection margin involvement is significantly associated with depth of tumor invasion and tumor diameter. The circumferential resection margin status is an important predictor of local and distant recurrence as well as survival of patients with middle and lower rectal carcinoma.

Risk factors for local recurrence of middle and lower rectal carcinoma after curative resection

AIM： To explore the risk factors for local recurrence of middle and lower rectal carcinoma after curative resection. METHODS： Specimens of middle and lower rectal carcinoma from 56 patients who received curative resection at the Department of General Surgery of Guangdong Provincial People＇s Hospital were studied. A large slice technique was used to detect mesorectal metastasis and evaluate circumferential resection margin status. The relations between clinicopathologic characteristics, mesorectal metastasis and circumferential resection margin status were identified in patients with local recurrence of middle and lower rectal carcinoma. RESULTS： Local recurrence of middle and lower rectal carcinoma after curative resection occurred in 7 of the 56 patients （12.5%）, and was significantly associated with family history （Х^2= 3.929, P = 0.047）, high CEA level （Х^2 = 4.964, P = 0.026）, cancerous perforation （Х^2 = 8.503, P = 0.004）, tumor differentiation （Х^2 = 9.315, P = 0.009） and vessel cancerous emboli （Х^2 = 11.879, P = 0.001）. In contrast, no significant correlation was found between local recurrence of rectal carcinoma and other variables such as age （Х^2 = 0.506, P = 0.477）, gender （Х^2 = 0.102, Z2 = 0.749）, tumor diameter （Х^2 = 0.421, P = 0.516）,tumor infiltration （Х^2 = 5.052, P = 0.168）, depth of tumor invasion （Х^2 = 4.588, P = 0.101）, lymph node metastases （Х^2 = 3.688, P = 0.055） and TNM staging system （Х^2 = 3.765, P = 0.152）. The local recurrence rate of middle and lower rectal carcinoma was 33.3% （4/12） in patients with positive circumferential resection margin and 6.8% （3/44） in those with negative circumferential resection margin. There was a significant difference between the two groups （Х^2 = 6.061, P = 0.014）. Local recurrence of rectal carcinoma occurred in 6 of 36 patients （16.7%） with mesorectal metastasis, and in 1 of 20 patients （5.0%） without mesorectal metastasis. However, there was no significant difference between the two groups （Х^2 = 1.600, P = 0.206）. CONCLUSION： Family history, high CEA level, cancerous perforation, tumor differentiation, vessel cancerous emboli and circumferential resection margin status are the significant risk factors for local recurrence of middle and lower rectal carcinoma after curative resection. Local recurrence may be more frequent in patients with mesorectal metastasis than in patients without mesorectal metastasis.