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Purpose It remains controversial as to whether high ligation of the inferior mesenteric artery (IMA) should be performed during surgical treatment for sigmoid colon or rectal cancer. The purpose of this study is to attempt to clarify the extent of the oncologic benefit of high ligation of the IMA. Materials and methods From January 1995 to July 2001, a total of 1,389 patients underwent high ligation of the IMA; 387 patients featured non-disseminated sigmoid colon cancer and 1,002 patients had rectal cancer. Pathology of the primary tumors, IMA nodes, and clinical outcome were reviewed. Results Forty-three patients (3.1%) revealed IMA node metastasis. Of these 43 patients, 29 (67.4%) featured tumor recurrences/metastases. After a minimum 5-year follow-up, 11 of these 43 patients (25.6%) were alive and disease free. Of these 43 patients, the 5-year disease-free survival rate for patients featuring sigmoid cancer was 50% and for patients with rectal cancer 13.8%. The beneficial rate of high ligation of the IMA for non-disseminated sigmoid colon cancer and rectal cancer was 0.8%, for non-disseminated sigmoid colon cancer 1.8%, and for non-disseminated rectal cancer, the rate was only 0.4%. The rates of IMA metastasis in patients with T stage tumors were 0% (pT1), 1.0% (pT2), 2.6% (pT3), and 4.3% (pT4). Conclusions Although patients afflicted with IMA node metastasis revealed a rather high incidence of tumor recurrence/metastasis, 25.6% of these patients remained disease free following IMA node dissection after a minimum 5-year follow-up. We consider that IMA node dissection is more beneficial in patients with non-disseminated sigmoid pT4 tumor.

Purpose Colon obstruction is suggested to be a predictor of poor outcome in colon cancer. However, the effect of obstruction on outcome in patients with different tumor-nodes-metastases (TNM) stage cancer has not been fully addressed. The aim of this study is to determine whether colon obstruction predicts surgical and long-term oncologic outcomes in patients with proximal colon cancer. Methods A total of 1,492 consecutive patients underwent open resection of primary adenocarcinoma of right colon in a single institution between January 1995 and December 2005. Clinical and follow-up data were extracted from a prospective colorectal cancer database. Univariate and multivariate analyses were performed to identify colon obstruction and other predictors of surgical and oncologic outcomes. Results Among 1,492 patients, 306 (20.5%) patients presented with colon obstruction. The rates of surgical morbidity and mortality were greater in patients with an obstruction as compared to patients without an obstruction (22.2% and 3.9% vs. 14.1% and 1.9%; p = 0.0005 and 0.041, respectively). Obstruction predicted a worse long-term disease-free survival (DFS) among patients with stage II-III disease (log-rank test, p = 0.0003). The data were stratified by TNM stage. Obstruction predicted a worse DFS among patients with TNM stage II cancer (598 patients; log-rank test, p = 0.001; Cox regression, p = 0.012), but it was not a predictor in TNM stage III cancer patients (424 patients; p = 0.116; p = 0.108). Conclusions Colon obstruction was an independent predictor of long-term outcome only in TNM stage II but not in stage III proximal colon cancer. Patients with TNM stage II obstructive colon cancer could be included in future trials of adjuvant therapies.

Purpose We evaluated the effect of neutrophil-to-lymphocyte ratio (NLR) on disease-free survival in patients with stages I to III colorectal cancer (CRC). Methods There were 3857 patients identified from our database. We used receiver operating characteristic (ROC) analysis to identify the best cutoff value of NLR. A 5-year disease-free survival was used as end point. Survival analysis was used to assess the NLR effect, after stratification by several clinopathologic factors. Results In the ROC analysis, NLR = 3 had the highest sensitivity and specificity. Elevated NLR (>3) in colon cancer seemed to accompany larger tumor size (≧5 cm) and more advanced T stage. By multivariate analysis, elevated NLR in colon cancer was associated with an increased risk of disease progression or cancer death [hazard ratio (HR) 1.377, 95  % confidence interval 1.104–1.717, P  = 0.014]. However, elevated NLR in rectal cancer lost its significance in multivariate analysis (HR 1.121, 95  % confidence interval 0.941–1.336, P  = 0.200). Patients with elevated NLR had worse outcome, especially for colon cancer. Conclusions Preoperative NLR influenced the disease-free survival in patients with stages I to III CRC. Elevated NLR (>3) was associated with worse outcome (5-year disease-free survival 66.3  % vs. 78.9  % in colon cancer, P  < 0.001; 60. 5 % vs. 66.2  % in rectal cancer, P  = 0.008). The difference was larger in colon cancer than in rectal cancer. NLR should be considered as a prognostic factor for stages I to III CRC patients after curative surgery.

Purpose Pathologic examination of at least 12 lymph nodes (LNs) is widely accepted as a standard for colon cancer surgery. We sought to address its association with patient source, other clinicopathological factors, and survival by comparing information from two branches in a large single institution. Methods Patients with stages I-III adenocarcinoma of the colon between 1998 and 2003 were identified from the Chang Gung Colorectal Tumor Registry in two branches (Linkou and Kaohsiung branches) of same institution. We used multivariate analysis to adjust for variables with P < 0.1 in univariate analyses. Results A minimum of 12 examined nodes were observed in 80% of patients in Linkou branch versus 25% in Kaohsiung branch (P < 0.0001). Younger age, right hemicolectomy, larger tumor, higher tumor stage, higher caseload of surgeons, and patients at Linkou branch with an odds ratio (OR) as high as 23 (95% CI, 17-31) were independently associated with a higher frequency of ≥12 examined nodes. Patients with examined node number of <12 had a greater risk of recurrence within stages II and III (stage II: adjusted OR 1.88, 95% CI 1.27-2.79; stage III: adjusted OR 1.58, 95% CI 1.15-2.17) but not within stage I (OR 0.73, 95% CI 0.23-2.24). Conclusions The results confirm that factors influencing nodal harvest are multifactorial and the examined LN number of 12 or more is associated with an increased long-term survival in stages II-III colon cancer. It is possible to adequately sample and examine a sufficient number of nodes in the majority of colon cancer specimens by standardized conventional methods.

Background and aims Selection of appropriate stage II colon cancer patients for adjuvant chemotherapy is critical for improving survival outcome. With the aim of identifying more high risk factors for stage II colon cancer, this study aimed to determine whether the neutrophil–lymphocyte ratio (NLR) is a predictor of surgical outcomes in patients with stage II colon cancer who do not receive adjuvant chemotherapy. Materials and methods We enrolled 1,040 stage II colon cancer patients who had undergone colectomy at a single institution between January 1995 and December 2005 and did not receive adjuvant chemotherapy. Results Of these 1,040 patients, 785 (75.5%) patients had a normal NLR and 255 (24.5%) had an elevated NLR. Those with an elevated NLR included patients ≥65 years, T4b cancer, carcinoembryonic antigen ≥5 ng/mL, and tumor obstruction or perforation. Patients with an elevated NLR had a significantly worse overall survival (OS) and worse disease-free survival (DFS) than did patients with a normal NLR. Cox regression analysis revealed that elevated NLR was an independent predictor of OS ( P =0.012) but not DFS ( P =0.255). Conclusion An elevated NLR is an independent predictor of OS but not DFS in stage II colon cancer patients who did not receive adjuvant chemotherapy. Preoperative NLR measurement in stage II colon cancer patients may be a simple method for identifying patients with a poor prognosis who can be enrolled in further trials of adjuvant chemotherapy.

Background This retrospective study evaluated the prognostic factors of chemotherapy in stage III colorectal cancer after curative resection. Methods From 1996 to 2001, 1,054 patients with primary single colorectal cancer underwent curative resection. Seven hundred sixteen patients received various 5-fluorouracil (FU)-based adjuvant chemotherapy regimens, including oral and intravenous treatments. The chemotherapy-related parameters examined included therapeutic duration, frequency, route of administration, composition of combination therapies, and postoperative time interval from the operation to the start of chemotherapy. Results The therapeutic duration and postoperative time interval of starting therapy were independent prognostic factors, in addition to clinicopathological factors. The 8-year cancer-specific/overall survival rates in patients who received chemotherapy for >4 months (63.0/58.6%) were significantly higher than the rates in patients who received no chemotherapy (56.7/37.7%, P  < 0.01) and those who remained on chemotherapy for 1–4 months (49.4/41.9%, P  < 0.05). The 8-year cancer-specific/overall survival rates in patients who waited 1–5 weeks after surgery to receive chemotherapy (62.9/58.5%) were significantly higher versus rates in those who did not receive chemotherapy (56.7/37.7%) and those who did not receive chemotherapy until >5 weeks after surgery (52.3/45.9%) (both P  < 0.05). Survival rates did not differ between patients who did not undergo chemotherapy, those for whom chemotherapy lasted 1–4 months, and patients who did not receive chemotherapy until >5 weeks after surgery. Conclusions The appropriate duration of therapy and early chemotherapy after surgery were 2 of the most important factors in eradicating occult cancer and effecting long-term survival benefits in patients with stage III colorectal cancer.

Background Local excision has become an alternative for radical resection in rectal cancer for selected patients. The purpose of this study was to assess the clinicopathologic factors determining lymph node metastasis (LNM) in patients with T1–2 rectal cancer. Methods Between January 1995 and December 2009, a total of 943 patients with pT1 or pT2 rectal adenocarcinoma received radical resection at a single institution. Clinicopathologic factors were evaluated by univariate and multivariate analyses to identify risk factors for LNM. Results A total of 943 patients (544 men and 399 women) treated for T1–2 rectal cancer were included in this study. LNM was found in 188 patients (19.9%). In multivariate analysis, lymphovascular invasion (LVI; P  < 0.001, hazard ratio 11.472), poor differentiation (PD; P  = 0.007, hazard ratio 3.218), and depth of invasion (presence of pT2; P  = 0.032, hazard ratio 1.694) were significantly related to nodal involvement. The incidence for LNM lesions in the presence of LVI, PD, and pT2 was 68.8, 50.0, and 23.1%, respectively, while that for pT1 carcinomas with no LVI or PD was 7.5%. Conclusions LVI, PD, and pT2 are independent risk factors predicting LNM in pT1–2 rectal carcinoma.

Treatment of liver metastases from colorectal cancer include surgical resection, radiation, hepatic chemoembolization, immunotherapy and intravenous chemotherapy. Complete surgical resection of liver metastases is feasible only for solitary or unilobar metastasis. Unresectable hepatic metastases of colorectal origin are resistant to radiation and immunotherapy, and the unsatisfactory results of systemic chemotherapy and chemoembolization have led to more aggressive treatment. A new method that combines systemic chemotherapy and chemoembolization is proposed. In this study, data from a total of 40 patients with unresectable hepatic metastasis from colorectal cancer were collected. All of these patients received combined chemoembolization and systemic chemotherapy. Embolization was performed by the selective cannulation of right and left hepatic artery. Equal amounts of a mixture of 10 ml lipiodol, 1,500 mg 5-fluorouracil (5-FU) and 15 mg leucovorin was deployed selectively in equal parts into the main right and left hepatic artery. Two weeks following chemoembolization, patients underwent systemic chemotherapy with 2,600 mg/m2 5-FU continuous infusion for 24 h and received 150 mg leucovorin intravenous bolus. The course of chemotherapy was repeated weekly for 24 weeks. The median follow-up period was 27 months (range 10-36 months). Following the intention-to-treat principle, the objective tumor response rate was 47.5%. The median disease-free interval was 12 months and the median survival time was 16 months. Most of the patients (73%) died of hepatic failure, while the second largest group died of abdominal carcinomatosis. In conclusion, the results of this study are of sufficient interest to justify future randomized trials.

Signet ring cell carcinoma of the rectum (SCCR) is a rare type of rectal carcinoma. This study examined the clinical significance of SCCR. From our medical records we retrospectively identified 61 SCCR patients and compared their clinical data and outcomes to those of 144 consecutive patients with non-SCCR mucinous rectal adenocarcinomas (NSMR) and 2,414 consecutive patients with nonmucinous rectal adenocarcinomas (NMR). . The incidence of SCCR was 1.39% of rectal cancers. Mean patient age at onset of SCCR (48.1years, range 15-80) was significantly lower than that for NSMR (57.4 years, 9-88) and NMR (62.6 years, 12-94). The proportion of late stage (TNM III+IV) tumors was significantly higher in SCCR (90%) than in NSMR (69%) and NMR (48%). There were more tumors located in the lower rectum in SCCR (46%) than in NSMR (34%) and NMR (29%). SCCR tumors were significantly larger (5.68+/-3.84 cm) than NSMR (4.27+/-1.78 cm) and NMR tumors (3.76+/-1.71 cm). A higher percentage of patients with SCCR (42.6%) received abdominoperineal resection for treatment. In tumors with TNM stage IV the rate of tumor spread via the hematogenous route was significantly lower in SCCR (18.5%) than in NSMR (43.5%) and in NMR (69%). The rate of tumor spread via seeding to the peritoneum was lower in SCCR (22.2%) than in NSMR (43.5%) but higher than in NMR (2.7%). The rate of tumor spread via the lymphatic route was higher in SCCR (44.4%) than in NSMR (26.1%) and significantly higher than in NMR (12.3%). The 1-, 2-, and 5-year overall SCCR survival rates were 73.9%, 36.3%, and 23.3% respectively, which were significantly poorer than those of NSMR and NMR. For the 28 stage III and R0 SCCR tumors the 1-, 2-, and 5-year disease-free survival rates of SCCR were 84.0%, 44.2%, and 30.3%, respectively, which are comparable with general data of stage III rectal cancer in the world. Diffuse infiltration of signet ring cells enhances the tendency of mucinous carcinomas of the rectum in more local extension and easier lymphatic spreading but not at peritoneal seeding. Although SCCR had the poorest prognosis, this outcome may be due to the advanced tumor stage rather than histology itself.

Although the clinicopathologic features of solitary rectal ulcer syndrome (SRUS) are well documented, the heterogeneous endoscopic appearance of lesions that the syndrome produces and its rare incidence may make for clinical confusion. Together with a literature review, we describe the variety of lesions experienced in our hospital with a series of endoscopic and histological illustrations and emphasize the diagnostic dilemma both clinically and histologically. With comparison of different macroscopic presentations of SRUS, more correct diagnoses will be achieved and more successful treatments will be reported.