Open low anterior resection (LAR) and abdominoperineal resections (APR) are not easy procedures, esp. in tight male pelvises. The laparoscopic approach gave us a tool dramatically improving the exposure and making the whole mesorectal excision significantly easier. As frequently in situations like that, we were quite hopeful (and meanwhile biased towards believing) that the advantages in the laparoscopic LAR and APR would translate into better oncological outcomes.
Dr. Fleshman (Dallas, Texas) was one of the most vocal proponents of the laparoscopic approach and wanted to prove it. He recently published a very well designed study:
Recently I had an interesting case with a weird behavior of a suspected metastasis after resection of the primary tumor.
Description
A 43 years old gentleman came in July 2008 to the Medical Service with nausea, vomiting and abdominal pain. The workup showed a tumor in the 3rd portion of the duodenum as well as a big mass in the right liver lobe, so the IM guys asked us to take a look. They performed two attempts to biopsy the masses which showed no tumor. This was the reason for the decision to resect the tumor.
This is a somehow old (mid 2004) but nevertheless important multicenter trial which aroused my interest due to the fact that I do laparoscopically (hand)assisted colectomies.
The conclusion is:
...the rates of recurrent cancer were similar after laparoscopically assisted colectomy and open colectomy, suggesting that the laparoscopic approach is an acceptable alternative to open surgery for colon cancer.
Though, "no advantage of laparoscopically assisted surgery was evident with respect to either all stages of cancer or high-risk subgroups".
The collecting of data for the trial began 1994. Therefore the new, hand assisted approach in the laparoscopic surgery, could not be considered.
A recent publication from the laboratory institute in the University Hospital in Hamburg, Germany discusses a new approach to diagnosing colorectal carcinoma: detection of tumor DNA in stool samples. Here is the abstract of the publication in the german "Aerzteblatt":
Detection of tumour DNA in stool is a new screening approach aimed at improving the early diagnosis of colorectal cancer. DNA from colorectal adenomas or carcinomas can be detected using specific mutations or methylation patterns. Altered DNA can in principle be detected in a high excess of normal DNA with high sensitivity, but low cost routine screening assays have yet to be developed. The combination of markers and methods must be refined to detect early stage tumours reliably. Only a test with high sensitivity could replace colonoscopy as the recommended screening method in the future.
The guys at the Mayo Clinic performed an interesting retrospective study about new-onset diabetes as a marker of underlying pancreatic cancer. They found that approxymately 1% of diabetes subjects aged > or =50 years will be diagnosed with pancreatic cancer within 3 years of first meeting criteria for diabetes.
Especially in patients with a positive family history for pancreatic carcinoma and new-onset of DM, a follow up may be a good idea.