Objective:To evaluate CT and or MRI imaging in the diagnosis of lateral lymph node metastasis in patients of middle and low rectal cancer.Methods:In this study, 112 lateral lymph nodes were harvested in 79 patients with middle and low rectal cancer. The relationship between the preoperative imaging features of the lateral lymph nodes and the postoperative pathology was evaluated.Result:Thirty-eight cases (48%) were pathologically confirmed to have lateral lymph node metastasis. The diameter of metastasis-positive lateral lymph nodes was significantly larger than that of metastasis-negative lateral lymph nodes ( P<0.01). Multivariate analysis of clinical features and imaging features found that, tumors poorly differentiated, mucinous adenocarcinoma, signet ring cell carcinoma ( P=0.006), and the largest short diameter of the lateral lymph node ≥7 mm ( P=0.024), uneven density or signal ( P=0.022) were independent risk factors for lateral lymph node metastasis. Conclusion:Poor tumor differentiation, lateral lymph node maximum short diameter ≥7 mm, density or signal unevenness are independent risk factors for lateral lymph node metastasis in middle and low rectal carcinoma.

Objective:To evaluate the factors affecting the degree of radical resection and the prognosis of patients with locally recurrent rectal cancer (LRRC).Methods:A retrospective case-control study was performed. Clinical data of 111 patients with LRRC undergoing operation at the General Surgery Department of Peking University First Hospital from January 2009 to August 2019 were analyzed retrospectively. The "Peking University First Hospital F typing" was performed according to the preoperative images of the pelvic involvement. The pelvis was assigned into four directions: the front wall, lateral sides of the pelvic wall and the sacrum. According to the degree of pelvic wall involvement, F typing included F0 type (no involvement of the pelvic wall, the cancer only involved the adjacent organs or invaded conteriorly the urinary tract, genital organs or small intestine), F1 type (cancer involved the pelvic wall in one direction, such as the sacrum, or one side of the pelvic wall), F2 type (cancer involved the pelvic wall in two directions) and F3 type (cancer involved the pelvic wall in three directions). Case inclusion criteria: (1) LRRC was confirmed by imaging and pathological examination of samples (puncture or endoscopic biopsy); (2) complete clinical and follow-up data; (3) informed consent of patient. Those with dysfunction of heart, lung, etc., intolerance of operation, F3 type indicated by image, and distant metastasis were excluded. The degree of radical resection was evaluated according to the postoperative pathological results. Patients were followed up every 12 months and related examinations were arranged. The univariate analysis of radical resection was performed by χ 2 test, and the multivariate analysis was performed by logistic methods. The survival rate was calculated by Kaplan-Meier method and the survival curve was drawn. The survival rate was compared by log-rank test. Cox proportional hazards model was used to analyze the factors affecting the prognosis of patients with LRRC. Results:A total of 111 patients were included in this study. Of 111 patients, 59 were male and 52 were female; recurrent age of 36 cases was ≥ 65 years old; CEA level of 48 cases was ≥15 μg/L. According to the "Peking University First Hospital F typing", 70 cases were F0 type, 38 F1 type and 3 F2 type. Surgical procedures were abdominoperineal resection ( n=28), posterior pelvic exenteration ( n=32), and total pelvic exenteration ( n=51, including 1 case of TPE combined with sacrectomy). According to the postoperative pathological results, R0, R1 and R2 resections were 83, 20 and 8 cases, respectively. Univariate analysis showed that the degree of radical resection was associated with the secondary surgical procedure, F typing and lymph node metastasis (all P<0.05). Multivariate analysis showed that F typing (F1-F2) was an independent risk factor for non- R0 resection (OR=37.256, 95%CI:8.572 to 161.912, P<0.001). The morbidity of operative complications was 22.5% (25/111); the perioperative mortality was 1.8% (2/111); the local recurrence rate after the second operation was 37.8% (42/111). The 3- and 5-year overall survival rates were 41.2% and 21.9% respectively. The 3-year survival rates of patients with and without postoperative chemotherapy were 52.7% and 32.4% respectively ( P=0.005). The 3-year survival rates of patients with lower (<15 μg/L) and higher CEA level (≥15 μg/L) were 52.9% and 24.3% respectively ( P<0.001). The 3-year survival rates of patients with R0, R1 and R2 resection were 49.8%, 21.3% and 8.5% respectively ( P=0.002). The 3-year survival rates of patients with F0, F1 and F2 type were 52.7%, 22.0% and 0 respectively ( P<0.001). Cox analysis confirmed that the degree of radical resection (HR=2.088, 95%CI:1.095 to 3.979, P=0.025), the CEA level before the secondary operation (HR=1.857, 95%CI:1.157 to 2.980, P=0.010) and postoperative chemotherapy (HR=1.826, 95%CI:1.137 to 2.934, P=0.013) were independent factors affecting the prognosis. Conclusions:The indication of LRRC surgical treatments must be strictly limited. Evaluation of the fixation site to the pelvic wall is helpful for improving the rate of R0 resection. Lower preoperative CEA level, radical resection and postoperative chemotherapy are protective factors of prolonged overall survival time of patients with LRRC.

Objective:To evaluate the factors affecting the degree of radical resection and the prognosis of patients with locally recurrent rectal cancer (LRRC).Methods:A retrospective case-control study was performed. Clinical data of 111 patients with LRRC undergoing operation at the General Surgery Department of Peking University First Hospital from January 2009 to August 2019 were analyzed retrospectively. The "Peking University First Hospital F typing" was performed according to the preoperative images of the pelvic involvement. The pelvis was assigned into four directions: the front wall, lateral sides of the pelvic wall and the sacrum. According to the degree of pelvic wall involvement, F typing included F0 type (no involvement of the pelvic wall, the cancer only involved the adjacent organs or invaded conteriorly the urinary tract, genital organs or small intestine), F1 type (cancer involved the pelvic wall in one direction, such as the sacrum, or one side of the pelvic wall), F2 type (cancer involved the pelvic wall in two directions) and F3 type (cancer involved the pelvic wall in three directions). Case inclusion criteria: (1) LRRC was confirmed by imaging and pathological examination of samples (puncture or endoscopic biopsy); (2) complete clinical and follow-up data; (3) informed consent of patient. Those with dysfunction of heart, lung, etc., intolerance of operation, F3 type indicated by image, and distant metastasis were excluded. The degree of radical resection was evaluated according to the postoperative pathological results. Patients were followed up every 12 months and related examinations were arranged. The univariate analysis of radical resection was performed by χ 2 test, and the multivariate analysis was performed by logistic methods. The survival rate was calculated by Kaplan-Meier method and the survival curve was drawn. The survival rate was compared by log-rank test. Cox proportional hazards model was used to analyze the factors affecting the prognosis of patients with LRRC. Results:A total of 111 patients were included in this study. Of 111 patients, 59 were male and 52 were female; recurrent age of 36 cases was ≥ 65 years old; CEA level of 48 cases was ≥15 μg/L. According to the "Peking University First Hospital F typing", 70 cases were F0 type, 38 F1 type and 3 F2 type. Surgical procedures were abdominoperineal resection ( n=28), posterior pelvic exenteration ( n=32), and total pelvic exenteration ( n=51, including 1 case of TPE combined with sacrectomy). According to the postoperative pathological results, R0, R1 and R2 resections were 83, 20 and 8 cases, respectively. Univariate analysis showed that the degree of radical resection was associated with the secondary surgical procedure, F typing and lymph node metastasis (all P<0.05). Multivariate analysis showed that F typing (F1-F2) was an independent risk factor for non- R0 resection (OR=37.256, 95%CI:8.572 to 161.912, P<0.001). The morbidity of operative complications was 22.5% (25/111); the perioperative mortality was 1.8% (2/111); the local recurrence rate after the second operation was 37.8% (42/111). The 3- and 5-year overall survival rates were 41.2% and 21.9% respectively. The 3-year survival rates of patients with and without postoperative chemotherapy were 52.7% and 32.4% respectively ( P=0.005). The 3-year survival rates of patients with lower (<15 μg/L) and higher CEA level (≥15 μg/L) were 52.9% and 24.3% respectively ( P<0.001). The 3-year survival rates of patients with R0, R1 and R2 resection were 49.8%, 21.3% and 8.5% respectively ( P=0.002). The 3-year survival rates of patients with F0, F1 and F2 type were 52.7%, 22.0% and 0 respectively ( P<0.001). Cox analysis confirmed that the degree of radical resection (HR=2.088, 95%CI:1.095 to 3.979, P=0.025), the CEA level before the secondary operation (HR=1.857, 95%CI:1.157 to 2.980, P=0.010) and postoperative chemotherapy (HR=1.826, 95%CI:1.137 to 2.934, P=0.013) were independent factors affecting the prognosis. Conclusions:The indication of LRRC surgical treatments must be strictly limited. Evaluation of the fixation site to the pelvic wall is helpful for improving the rate of R0 resection. Lower preoperative CEA level, radical resection and postoperative chemotherapy are protective factors of prolonged overall survival time of patients with LRRC.

OBJECTIVE: To investigate the value of neoadjuvant chemoradiotherapy (nCRT) combined with total pelvic exenteration (TPE) in the treatment of primary T4b rectal cancer. METHODS: A retrospective cohort study was conducted to analyze the clinicopathological data of 31 patients with primary T4b rectal cancer who underwent TPE from January 2008 to December 2015 at Peking University First Hospital. INCLUSION CRITERIA: preoperative clinical stage (cTNM) was defined as cT4b primary rectal cancer with only front wall Invasion; the lower edge of tumor was within 10 cm from the anal margin; TPE was performed; R0 resection was confirmed by pathology. Patients with recurrent rectal cancer, distant metastasis, and undergoing TPE for non-rectal tumors were excluded. Patients were divided into nCRT group and non-nCRT group according to whether receiving nCRT before surgery. The nCRT group received long course radiotherapy (total dose 50 Gy in 25 daily fractions) with concomitant chemotherapy (Capecitabine), and the surgery was performed 6-8 weeks after the neoadjuvant chemoradiation, while the non-nCRT group received surgery directly. The intraoperative, postoperative and pathological conditions and local recurrence were compared between the two groups. The survival curves were drawn by Kaplan-Meier method and the survival of two groups were compared. RESULTS: A total of 31 patients were enrolled, including 13 patients in the nCRT group and 18 patients in the non-nCRT group. The baseline data, such as age, duration of disease, preoperative basic disease, body mass index, smoking rate, and tumor distance from the anal margin, were not significantly different between the two groups (all P>0.05). In the nCRT group and non-nCRT group respectively, the ratio of anal preservation was 30.8%(4/13) and 38.9%(7/18) (P=0.468), the median intraoperative blood loss was 1 000 ml and 800 ml (P=0.644), the operation time was (531.7±137.2) minutes and (498.0±90.1) minutes (P=0.703), the median hospital stay was 18 days and 14 days (P=0.400), the morbidity of complications within 30 days after surgery was 23.1%(3/13) and 38.9%(7/18)(P=0.452), the incidence of postoperative abdominal abscess was 15.4%(2/13) and 0 (P=0.168), the proportion of secondary surgery was 7.7%(1/13) and 11.1%(2/18)(P=1.000), whose differences were not significantly different. The proportion of postoperative pathological pT4b in whole group was 58.1%(18/31), including 53.8%(7/13) in nCRT group and 61.1%(11/18) in non-nCRT group, which was not significantly different between the two groups (P=0.691). The number of harvested lymph node in nCRT group was 13.5±5.9, which was significantly less than 23.0±11.8 in non-nCRT group (P=0.013). There was no pathological complete remission (ypCR) case in nCRT group, and among 13 patients, tumor regression grade (TRG) of 2, 3, 4, and 5 was in 1 case (7.7%), 6 cases (46.2%), 5 cases(38.5%), and 1 case (7.7%), respectively. The median follow-up time was 33 (2 to 115) months, and the follow-up rate was 93.5%(29/31). One case was lost in both the nCRT group and non-nCRT group. The 3-year disease-free survival rate was 43.5% in pooled data, and was 43.6% and 43.3% in nCRT group and non-CRT group respectively without significant difference (P=0.833). The 3-year overall survival rate was 51.1% in pooled data, and was 45.7% and 54.7% in nCRT group and non-nCRT group respectively without significant difference (P=0.653).The local recurrence rate of nCRT and non-nCRT groups was 8.3%(1/12) and 5.9%(1/17) respectively, and the distant metastasis rate was 50.0%(6/12) and 41.2%(7/17) respectively, whose differences were not statistically significant as well (P=1.000 and P=0.865, respectively). CONCLUSION For primary T4b rectal cancer which can achieve R0 resection through total pelvic exenteration, neoadjuvant chemoradiotherapy has not been demonstrated any advantage in tumor regression, reducing local recurrence, or improving survival, and may increase postoperative complications.
Adenocarcinoma ; pathology ; therapy ; Antineoplastic Agents ; administration & dosage ; Chemoradiotherapy ; Combined Modality Therapy ; Humans ; Neoadjuvant Therapy ; Neoplasm Staging ; Pelvic Exenteration ; Rectal Neoplasms ; pathology ; therapy ; Retrospective Studies ; Treatment Outcome

BACKGROUNDColorectal carcinoma is one of the most common malignant tumors. Despite advances in therapy, mortality is still very high. The aim of this study was to evaluate the expression of paxillin in the human colon adenocarcinoma cell line SW480 and its role in cell cycle and apoptosis. We also investigated the expression of paxillin in colorectal carcinoma tissues and its relationship to clinicopathological features and survival.

METHODSPaxillin short hairpin RNA (shRNA) was constructed and transfected into the colon adenocarcinoma cell line SW480. The influence of paxillin shRNA on the cell cycle and cell apoptosis was analyzed by flow cytometry. Immunohistochemistry staining was used to assess the expression of paxillin and its association with the expression of carcinoembryonic antigen (CEA), carbohydrate antigen (CA) 19-9, p53 and Bcl-2 in 102 patients with primary colorectal carcinoma. Western blotting was also used to investigate the expression of paxillin. Medical records were reviewed and a clinicopathological analysis was performed.

RESULTSIn vitro, the percentage of cells in S phase was (45.23±1.05)%, (43.53±1.23)%, and (36.13±0.57)% in the blank control group, negative control group, and paxillin shRNA group respectively. It was significantly decreased in the paxillin shRNA group (P = 0.000). The early apoptosis index of the paxillin shRNA group (17.2±1.18%) was significantly increased compared to the control shRNA group ((13.17±1.15)%, P = 0.013). Paxillin was positive in 71 (69.6%) patients, and it was found to be overexpressed in tumor tissues compared with normal adjacent tissues. Paxillin positive rate was higher in patients who are less than 50-years old (100.0% vs. 65.6%, P = 0.016). Paxillin expression was associated with a high histologic grade of carcinoma (81.4% vs. 61.0%, P = 0.031), a high rate of regional lymph node metastasis (22.5% vs. 13.0%, P = 0.031), mesenteric artery lymph node metastasis (100.0% vs. 64.8%, P = 0.008), distant metastasis (94.1% vs. 64.7%, P = 0.016) and a high Tumor Node Metastasis (TNM) stage (94.1%, 73.2%, 60.0%, and 50%, P = 0.030). Multivariate analyses revealed that recurrence was associated with the rate of regional lymph node metastasis (P = 0.001) and paxillin expression (P = 0.024). Multivariate analysis indicated that the overall survival is related to the TNM stage (P = 0.000).

CONCLUSIONSIn vitro, paxillin may promote cell proliferation and inhibit apoptosis in SW480 cells. Paxillin may be a potential metastasis predictor, and an independent prognosis factor of recurrence. It may also be related to poor patient outcomes, but was not an independent predictor of survival.

Apoptosis ; genetics ; physiology ; Biomarkers, Tumor ; genetics ; metabolism ; Carcinoembryonic Antigen ; metabolism ; Cell Cycle ; genetics ; physiology ; Cell Line, Tumor ; Cell Proliferation ; Colorectal Neoplasms ; genetics ; metabolism ; Female ; Humans ; Immunohistochemistry ; In Vitro Techniques ; Male ; Paxillin ; genetics ; metabolism ; RNA, Small Interfering ; genetics

Objective To investigate the relationship between the expression level of deleted in liver cancer-1 (DLC-1) gene and colon cancer staging or lymph nodes metastatic ratio.Methods Total 60 resection specimens were collected from colon cancer patients between September 2009 and September 2011,and 10 resection specimens from patients with trauma,colonic diverticulitis and colitis were used as the control.The DLC-1 mRNA level was measured with real time quantitative RT-PCR in colon cancer patients and the control group.TNM system was used for colon cancer staging.The linear correlation analysis was performed to determine the relationship between DLC-1 expression level and colon cancer staging or lymph nodes metastatic ratio.Results The mRNA level of DLC-1 was significantly reduced in colon cancer tissues in comparison to that in adjacent normal tissues,while adjacent tissues showed significantly lower DLC-1 level than normal clone tissues.The expression of DLC-1 was negatively correlated with both colon cancer stage and the lymph nodes metastatic ratio (r =0.46,P ＜ 0.05).Conclusions DLC-1 expression was negatively correlated with pathological stage and lymph node metastasis ratio,indicating a critical role of DLC-1 gene in colon cancer genesis,which provide a possible new direction for colon cancer research.

Objective To investigate factors affecting the metastasis of lymph nodes around the root of inferior mesenteric artery(IMA) in rectal cancer,and the significance of root lymph nodes dissection of IMA in radical surgery for rectal cancer.Methods Clinicopathological data of 105 rectal cancer patients undergoing root lymph node dissection of IMA during radical resection in Peking University First Hospital from January 2005 to December 2008 were analyzed retrospectively.Rectal cancer patients without root lymph node dissection of IMA during the same period served as control.Results were compared between these two groups for survival and local recurrence rates.Results The rate of lymph node metastasis around the origin of IMA was 9.5％ (10/105).The five-year survival rate in patients with IMA root nodal dissection was 71.3％,and that without was 70.6％ (P =0.995),while the local recurrence was respectively 1.9％ and 7.4％ (P ＜ 0.05).In multivariate analyses,IMA root nodal metastasis occurred more frequently in patients with pT3 and pT4 tumor(Wald =5.764,P ＜ 0.05) and poorly differentiated tumor(Wald =7.818,P ＜ 0.05).Conclusions Root lymph nodes dissection of IMA could not increase five-year survival rate,but it could reduce local recurrence rate in patients with rectal cancer.In radical surgery of rectal cancer,lymphadenectomy of IMA root should be performed in patients with T3 and T4 tumor with poorly differentiated tumor,so as to reduce local recurrence rate.

Objective To investigate the surgical treatment strategies and prognostic factors of cT4bM0 primary rectal cancer.Methods The clinical data of 53 patients with cT4bM0 primary rectal cancer who were admitted to the First Hospital of Peking University from January 2000 to December 2010 were retrospectively analyzed.All the patients received en-bloc multivisceral resection and postoperative chemotherapy.The survival and prognostic factors were analyzed.The patients were followed up via out-patient examination,phone call or mail,and the follow-up was ended till December 2012.The survival curve was drawn using the Kaplan-Meier method,and the survival was analyzed using the Log-rank test.Uni-and multivariate analysis were done using chisquare test and COX's proportional hazard model.Results Of all the 53 patients,20 received posterior pelvic exenteration (PPE),20 received total pelvic exenteration (TPE),3 received low anterior resection (LAR) +local resection of ballder,2 received LAR + ovariectomy,2 received LAR + local resection of ureter,1 received LAR + local resection of posterior vaginal wall,1 received LAR + vesiculectomy and vesectomy,3 received abdominoperineal resection (APR) + local resection of posterior vaginal wall,1 received APR + sacrectomy.R0 resection was achieved in all the patients.No intraoperative death was observed,and the incidence of postoperative complication was 9.4％ (5/53).The results of postoperative pathological examination showed that 2 patients were with well-differentiated adenocarcinoma,41 with moderate-differentiated adenocarcinoma,and 10 with poorly differentiated adenocarcinoma.Twenty-four patients were with lymph node metastasis.Four patients were in TNM stage Ⅰ,25 in TNM stage Ⅱ and 24 in TNM stage Ⅲ.Fifty-three patients were followed up postoperatively,and the median time for follow-up was 33 months (range,4-116 months).The overall 5-year survival rates was 57.3％.The 5-year survival rate for patients with or without lymph node metastasis were 77.1％ and 30.4％,respectively,with significant difference between the 2 groups (x2 =7.374,P ＜ 0.05).The 5-year survival rates of patients with malignant infiltration and inflammatory adhesion mere 51.0％ and 68.5％,with no significant difference (x2=1.148,P ＞0.05).The 5-year survival rates of patients with malignant infiltration and inflammatory adhesion in stage Ⅱ were 74.6％ and 85.7％,with no significant difference between the 2 groups (x2=0.118,P ＞ 0.05).The 5-year survival rates of patients with malignant infiltration and inflammatory adhesion in stage Ⅲ were 28.8％ and 37.5％,with no significant difference between the 2 groups (x2 =0.959,P ＞ 0.05).The results of univariate analysis showed that lymph node metastasis and TNM stage were the risk factors influencing the prognosis of patients with cT4bM0 primary rectal cancer (x2=6.468,6.596,P ＜ 0.05).The results of multivariate analysis showed that lymph node metastasis was the independent risk factor (RR =3.797,P ＜ 0.05).Conclusions En-bloc multivisceral resection should be the first surgical treatment choice for patients with cT4bM0 primary rectal cancer,and lymph node metastasis is the independent risk factor.Under the same N stage,the prognosis of patients with malignant infiltration or inflammatory adhesion is similar if R0 resection is achieved.

ObjectiveTo explore the clinical diagnosis and surgical treatment of primary retroperitonealneurilemoma(schwannoma). MethodsClinicaldataof 47patientsof primary retroperitoneal schwannoma admitted and surgically treated from January 1995 to December 2009 were retrospectivelly reviewed.ResultsAs diagnosed by pathology there were 36 cases of Benign schwannoma,with a median age at onset of 41years, among those 11 patients were symptomatic, and 25 were asymptomatic. There were 11 malignant 11 cases, the median age was 38 years, among those 6 patients were symptomatic, and 5 were asymptomatic. The positive diagnostic rate of preoperative CT and MRI were 36. 2％ ( 17/47 ) and 58. 3％ ( 7/12 ) respectively. Immunohistochemically positive rates of S-100 were 100％ and 81.8％(9/11) in benign and malignant group respectively.All cases underwent surgical treatment. Surgical resection rates for benign and malignant groups were 100％ and 90. 9％(10/11)respectively. There was no perioperative death, Overall 5-year survival rates were 100％ and 45.5％ for benign and malignant tumors groups respectively. In benign group 2 cases recurred, in malignant group 4 cases recurred, and 3 had distant metastasis.ConclusionsPrimary retroperitoneal schwannomas are less common. It is difficult to make an accurate preoperative diagnosis. Surgery is the most effective therapy.Prognosis is good for benign and poor for malignant retroperitoneal neurilemomas.

Objective To explore the association between perioperative glycemic control and the post-operative complications of patients undergoing pancreatic surgery. Method The clinical data of 412 patients who underwent pancreatoduodenectomy between January 1995 and April 2010 were retrospectively analyzed. Results The average fasting glycemic level was significantly higher than normal postoperatively, and the post-operative application of insulin effectively controlled glycemic levels. The rates of postoperative mortality, pancreatic fistula,hemorrhage, and infections among patients with glucose level > 8. 3 mmol/L (7.0% , 23.7% , 9.7% , and 15. 1 % ) were significantly higher than those with glucose level ≤8. 3 mmol/L (2. 7% , 11. 9% , 4. 0% , and 6.6%) (P=0.037, P=0.002, P = 0.020, and P=0.005). On the contrary, the rates of postoperative mortality and hemorrhage among patients with glucose level≤6. 1 mmol/L (6. 2% and 8. 6% ) were significantly higher than those with glucose level between 6. 1 and 8. 3 mmol/L (0. 7% and 1.4% ) (P = 0. 023 and P = 0. 011).The rate of hypoglycemia was significantly higher in patients with glucose level ≤6. 1 mmol/L (7. 4% vs. 0. 7% ,P = 0. 009). Conclusions Postoperative glucose level can be stably controlled by continuous intravenous glucose infusion plus regular insulin therapy. A target perioperative glucose level between 6. 1 and 8. 3 mmol/L can effectively and safely reduce postoperative mortality and complications.