Prospective Evaluation of Quality of Life and Sexual Functioning After Laparoscopic Total Mesorectal Excision

Purpose This study was designed to investigate how the quality of life of patients with rectal cancer changes with time after laparoscopic total mesorectal excision. Methods Patients completed the Medical Outcomes Study Short Form 36 and the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire and a colorectal-specific European Organisation for Research and Treatment of Cancer quality of life questionnaire before laparoscopic total mesorectal excision, on discharge from the hospital and at 3, 6, and 12 months postoperatively. Patients were treated by laparoscopic low anterior resection or laparoscopic abdominoperineal resection. Results Fifty-one patients (mean age, 64 years; 29 males (57 percent)) participated in this study, of whom 38 (75 percent) underwent laparoscopic low anterior resection and 13 (25 percent) laparoscopic abdominoperineal resection. Compared with preoperative scores on the Medical Outcomes Study Short Form 36, patients reported a deterioration in physical functioning (74 vs. 80; P = 0.009), and improved mental functioning (76 vs. 70; P = 0.007) at three months. Improvement in emotional well-being was reported both on the Medical Outcomes Study Short Form 36 (78 vs. 53; P = 0.006) and the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (84 vs. 69; P < 0.001). At one year, improvements in global quality of life (82 vs. 68; P = 0.001) and symptoms, such as fatigue (18 vs. 32; P < 0.001), pain (5 vs. 12; P = 0.009), and appetite loss (3 vs. 13; P = 0.01), were reported. Sexual functioning was worse from three months onward until one year after surgery (47 vs. 66; P = 0.004). Patients who underwent low anterior resection experienced less sexual dysfunction than patients after abdominoperineal resection (21 vs. 56; P = 0.004). Conclusions One year after laparoscopic total mesorectal excision for rectal cancer, patients reported improvement in some important quality of life outcomes, including global quality of life, despite a decrease in sexual functioning. Presented at the meeting of the European Association for Endoscopic Surgery, Venice, Italy, June 1 to 4, 2005. Presented at the meeting of the Society of American Gastrointestinal and Endoscopic Surgeons, Dallas, Texas, April 26 to 29, 2006. Presented at the meeting of the 10th World Congress of Endoscopic Surgery, Berlin, Germany, September 13 to 19, 2006.     

The Impact of Surgery for Colorectal Cancer on Quality of Life and Functional Status in the Elderly

Purpose Colorectal cancer is a common diagnosis in the elderly. Frequently concerns arise about outcomes after surgery, and little is known about postoperative quality of life in this older group after major bowel surgery. The objective of this study was to compare quality of life and functional status of elderly patients (older than aged 80 years) who have undergone surgery for colorectal cancer with a younger (younger than aged 70 years), procedure-matched control group. Methods Patients in the case (older than aged 80 years) and control groups (younger than aged 70 years) were identified from the colorectal cancer database at Mount Sinai Hospital, Toronto, Canada. All had treatment for colorectal cancer within the last five years. Patients were surveyed by mail using the European Organization for Research and Treatment of Cancer quality of life scales specific to cancer and colorectal cancer (EORTC-C30 and EORTC-CR38) and the Short Form-36. Student’s t-test was used to test differences. Results There were 29 patients in each of the groups. The current average ages were 83.2 (standard deviation = 2.79) years, and 67.7 (standard deviation = 5.1) years, respectively. The two groups scored similarly on the European Organization for Research and Treatment of Cancer quality of life scales in all domains except physical functioning, functional role, micturition, and stoma-related problems. Similarly, the mean scores of the Short Form-36 were similar with the exception of the vitality domain. Most patients did not require special assistance or alternate living arrangements after discharge from the hospital, and most patients seemed to be able to return to their preoperative level of functioning. However, stoma care was a greater concern to the elderly. Conclusions Elderly patients older than aged 80 years who are selected for surgery have a quality of life comparable to younger patients in most respects. Therefore, colorectal cancer surgery may be offered to the highly functioning elderly with the expectation of a good quality of life postoperatively. Reprints are not available.     

Evaluation of Calgranulin B in Stools from the Patients with Colorectal Cancer

Purpose  Calprotectin (heterodimer of calgranulin A and B) has been previously studied as a candidate stool marker for detecting colorectal cancer. We assessed the clinical usefulness of calgranulin B as a stool marker for colorectal cancer in a pilot study of patients with colorectal cancer. Methods  We performed 2-DE-based proteomics to screen stool markers for colorectal cancer. We checked the calgranulin B in stools from 77 colorectal cancer patients and from 75 controls by western blot and enzyme-linked immunosorbent assay. We measured calgranulin A using the same methods, and stool hemoglobin by immunologic fecal occult blood test. Results  Fecal calgranulin A did not show any difference, but stool calgranulin B of colorectal cancer patients was significantly higher than controls [50.6 ng/mg stool protein (SD, 34.8) vs. 20.2 ng/mg stool protein (SD,24.0), respectively, P < 0.001). At the cut off level 24.4 ng/mg stool protein, the sensitivity was somewhat higher than fecal occult blood test (72.0 percent vs. 62.3 percent) but the specificity was much lower than fecal occult blood test (77.1 percent vs. 98.7 percent). Conclusions  Calgranulin B was increased in stools of colorectal cancer patients but our results suggest that colorectal cancer screening by determination of stool calgranulin B would not be better than conventional fecal occult blood test. This work was supported by research grants 0710670–1 (Yoo BC) and 0410063–3 (Lim SB) from the National Cancer Center, Korea. Poster presentation at the meeting of European Biomarkers Summit and Proteomics Europe, Amsterdam, The Netherlands, September 4 to 5, 2007.     

Bacterial Translocation May Influence the Long-Term Survival in Colorectal Cancer Patients

Purpose The purpose of this study was to investigate the association of bacterial translocation with long-term disease-specific and disease-free survival in colorectal cancer patients. Methods This was a prospective cohort study in which 128 and 30 colorectal cancer patients undergoing curative and palliative resections, respectively, were recruited between 1992 and 1997. Samples of mesenteric lymph nodes were harvested for culture before administration of prophylactic antibiotics. Median follow-up for patients without cancer death was 103 (range, 72–147) months. This cohort of patients was internally validated by Dukes staging. Results The cumulative disease-specific survival (time to death) and disease-free survival (time to recurrence) for all patients at five years of follow-up was 55 percent (standard error [SE], 4.4 percent) and 65 percent (SE, 4.8 percent), respectively. Bacteria were isolated from the mesenteric nodes of 23 (15 percent) patients. There was no association between bacterial translocation and nodal metastases, bowel obstruction, and septic complications. Patients with confirmed bacterial translocation had a worse disease-specific survival (n=158, 5-year survivorship estimates±SE, 38 percent±12 percent vs. 58 percent±4.7 percent; P < 0.01) and disease-free survival (n=128, 5-year survivorship estimates±SE, 46 percent±14 percent vs. 66 percent±5 percent; P = 0.004) than those without. Using multivariate Cox regression analysis, bacterial translocation was a predictor of disease-specific survival (P = 0.011) and disease-free survival (P = 0.02) independent of other pathologic prognostic indicators. Conclusion Colorectal cancer patients with bacterial translocation in the mesenteric lymph nodes have a worse outcome. Presented at the meeting of the Society of Academic and Research Surgery, Belfast, Northern Ireland, January 14 to 16, 2004.     

Synchronous gastric cancer in primary sporadic colorectal cancer patients in Korea

Background and aims Colorectal cancer has been reported to be the malignancy most frequently associated with gastric cancer in Korea. The aim of this study was to define the frequency and clinical characteristics of synchronous gastric cancer detected at preoperative esophagogastroduodenoscopy (EGD) in colorectal cancer patients. Materials and methods This prospective study analyzed the EGD results from 1,542 consecutive colorectal cancer patients who underwent surgery from January 2003 to December 2005 at the Center for Colorectal Cancer, National Cancer Center, Korea. Results Of the 1,542 cases, 1,155 (74.9%) underwent EGD at our center and 387 underwent EGD at other hospitals within 6 months before surgery. Of the 1,542 cases, synchronous gastric cancers were detected in 31 cases (2.0%). Of these 31 cases, 26 had early gastric cancer (EGC; 83.9%) and 5 had advanced gastric cancer. Ten (38.5%) of the 26 EGC cases were managed using endoscopic mucosal resection. Compared to colorectal cancer patients without synchronous gastric cancer, the group of patients with synchronous gastric cancer was older (65.5 ± 9.6 vs 58.4 ± 11.3 years, p = 0.001) and had a greater proportion of males (77.4 vs 59.4%, p = 0.043). Conclusion This study found that 2% of Korean sporadic colorectal cancer patients had synchronous gastric cancer. A preoperative EGD for colorectal cancer patients is likely to greatly assist in the diagnosis of synchronous gastric cancer at an early stage and the implementation of appropriate minimally invasive treatment. Presented at the Tenth Congress of Asian Federation of Coloproctology, Singapore, March 24–26, 2005.     

The Comparison of the Risk Factors and Clinical Manifestations of Proximal and Distal Colorectal Cancer

Purpose Colorectal cancers in the proximal or distal site have distinct clinical characteristics. In this study, the authors compared the risk factors of proximal and distal colorectal cancer. Methods A 16-page questionnaire was administered to 529 patients with colorectal cancer before operation. Cancers were classified as proximal or distal relative to the splenic flexure. Of these 529 patients, 6 patients were excluded because of the presence of synchronous colorectal cancers. Data of the 523 patients were analyzed. Results Total numbers of proximal and distal cancers were 123 and 400. The proportion of patients with Type 2 diabetes was significantly higher for distal cancer (P = 0.034), whereas a greater proportion of patients with proximal cancer had a gallstone history (P = 0.005). Multivariate analysis revealed Type 2 diabetes to be a risk factor for distal colorectal cancer (P = 0.027) and cholelithiasis to be a risk factor for proximal cancer (P = 0.049). The odds ratio for distal colorectal cancer among males with Type 2 diabetes was 4.1 (95 percent confidence interval, 1.4–12.1). On the other hand, a gallstone history was more associated with proximal colon cancer, especially in females (odds ratio = 5.5; 95 percent confidence interval, 1.4–20.9). Conclusions A comparison of the risk factors of proximal and distal colorectal cancer showed that Type 2 diabetes is associated with distal colorectal cancer in males and that cholelithiasis is associated with proximal colon cancer in females. Poster presentation at the United European Gastroenterology Week (UEGW), Berlin, German, October 21 to 25, 2006.     

Colorectal Surgery in Cirrhotic Patients: Assessment of Operative Morbidity and Mortality

Purpose  The morbidity from colorectal surgery can be high and increases for patients with cirrhosis of the liver. This study was designed to assess morbidity, mortality, and prognostic factors for patients with cirrhosis undergoing colorectal surgery. Methods  From 1993 to 2006, 41 cirrhotic patients underwent 43 colorectal procedures and were included. Both univariate and multivariate analyses were performed to identify variables influencing morbidity and mortality. Results  Postoperative morbidity was 77 percent (33/43). Postoperative mortality was 26 percent (11/43) among whom six patients (54 percent) underwent emergency surgery. Four factors influenced mortality on univariate analysis: presence of peritonitis (P < 0.05), postoperative complications (P < 0.04), postoperative infections (P < 0.01), and total colectomy procedures (P < 0.02). On multivariate analysis, the only factor influencing mortality was postoperative infection (P < 0.04). The only factor influencing morbidity was the existence of preoperative ascites (P < 0.04). Conclusions  Colorectal surgery for cirrhotic patients has a high risk of morbidity and mortality. This risk is associated with the presence of infection, ascitic decompensation, and the urgent or extensive nature of the procedure. The optimization of patients through selection and preparation reduces operative risk.     

A Prospective Evaluation of Sexual Function and Quality of Life After Ileal Pouch-Anal Anastomosis

Purpose  This study was designed to assess the effect of ileal pouch-anal anastomosis on sexual function and quality of life in men and women. Methods  Sexual function of patients undergoing ileal pouch-anal anastomosis from February 2005 to June 2006 was prospectively evaluated using the International Index of Erectile Function in men and Female Sexual Function Index in women. Quality of life was assessed using the Short Inflammatory Bowel Disease Questionnaire. Preoperative scores were compared with scores at 6 and 12 months postoperatively. Results  Of 110 patients eligible for inclusion, 59 (53.6 percent) agreed to participate. Male sexual function and erectile function scores remained high 12 months after surgery (mean International Index of Erectile Function score 51.7 preoperative vs. 58.3 at 12 months postoperative; P = not significant (NS)). Abnormal sexual function decreased from 33.3 percent before surgery to 22.7 percent 12 months after surgery (P = NS). Female sexual function improved 12 months after surgery (mean Female Sexual Function Index score 19.2 preoperative vs. 27 at 12 months postoperative; P = 0.031). Abnormal sexual function decreased from 73.1 percent before surgery to 25 percent 12 months after surgery (P = 0.001). Quality of life significantly improved after ileal pouch-anal anastomosis in both sexes. Conclusions  In men, ileal pouch-anal anastomosis does not have an adverse effect on sexual function, whereas sexual function in women seems to improve 12 months after surgery. Read at meeting of The Association of Coloproctology of Great Britain and Ireland, Glasgow, Scotland, July 2 to 5, 2007. Published in abstract form in Colorectal Disease 2007;9(Suppl 1):20.     

Multicentre review of lymph node harvest in colorectal cancer

Background  Lymph node examination in colorectal cancer is of vital importance for accurate staging. Patients who have fewer nodes examined may be understaged and not offered adjuvant chemotherapy. The national institute of clinical excellence and the association of coloproctology of Great Britain and Ireland both recommend that 12 nodes should be examined for accurate staging. The aim of this study was to assess lymph node harvest at five hospitals in the northwest of England in respect to these guidelines. Materials and methods  This study is a retrospective review of all colorectal cancer resections over a 1-year period at five hospitals. Results  Two hospitals met the national guidelines of a median of 12 or more nodes. Overall, over 50% of colorectal cancers contained fewer than 12 nodes. Fifty-three point seven percent (53.7%) of Dukes B patients did not have 12 nodes in their specimens and may therefore be understaged. There was a significant variation between hospitals in terms of the number of cancers with 12 or more nodes (P < 0.0001) and the number of Dukes B cancers with 12 or more nodes (P < 0.008). Conclusion  Over 50% of all colorectal cancer specimens contain fewer than 12 lymph nodes despite clear national guidelines. This is of particular importance to Dukes B cancers where over 53% of cases may be understaged and not offered adjuvant therapy. Significant variation exists between hospitals within the same region. Paper presented as oral presentation:  At the Association of Surgeons of Great Britain and Ireland International Surgical Congress, Bournemouth 2008. Date of oral presentation: 16th May 2008     

Robotic Colorectal Surgery: First 50 Cases Experience

Purpose  Laparoscopic colorectal surgery is believed to be technically and oncologically feasible. However, some limitation of traditional laparoscopic surgery may cause difficulties. Robotic-assisted surgery may overcome these pitfalls. Methods  From December 2005 to July 2007, 50 patients were selected for robotic-assisted colorectal resection mainly for cancer. Results  Of the 50 patients enrolled, 32 (64 percent) were men and 18 (36 percent) were women. Their mean age was 66.7 (range, 37–92) years. The American Society of Anesthesiologists’ (ASA) class distribution was 13 (26 percent) ASA I, 24 (48 percent) ASA II, 12 (24 percent) ASA III, and 1 (2 percent) ASA IV. Forty-four patients suffered from cancer and six patients from benign disease. Amongst the cancer patients, 3 percent were at UICC (International Union Against Cancer) Stage 0, 36 percent at UICC Stage I, 24 percent at Stage II, 28 percent at Stage III, and 9 percent at Stage IV. The global conversion rate was 4 percent. The mean operative time was 338.8 minutes. It decreased as the experience increased (419 minutes in the first 20 cases vs. 346 minutes in the last 30 cases; P = 0.036). As a gross comparison, the results of a coeval standard laparoscopy group of patients were shown. Conclusions  Robotic laparoscopic colon surgery is feasible and safe. A longer operating time is needed.     

DNA Stool Test for Colorectal Cancer: Hypermethylation of the Secreted Frizzled-Related Protein-1 Gene

Purpose To investigate a potential mode of noninvasive screening for colorectal cancer, we evaluated the hypermethylation of the secreted frizzled-related protein-1 gene promoter in human stool DNA. Methods In stool samples from 36 patients with colorectal neoplasia (7 adenoma, 29 colorectal cancer) and 17 healthy control subjects, isolated DNA was treated with sodium bisulfite and analyzed by methylation-specific polymerase chain reaction with primers specific for methylated or unmethylated promoter sequences of the secreted frizzled-related protein-1 gene. Results Hypermethylation of the secreted frizzled-related protein-1 promoter was present in the stool DNA of patients with adenoma and colorectal cancer. A sensitivity of 89 percent and specificity of 86 percent were achieved in the detection of colorectal neoplasia. The difference in hypermethylation status of the secreted frizzled-related protein-1 promoter between the patients with colorectal neoplasia and the control group was statistically highly significant (P < 0.001). Adenoma and early tumor Stage I (International Union Against Cancer) displayed both unmethylated and methylated secreted frizzled-related protein-1 promoter sequences, whereas advanced tumor stages showed only methylated secreted frizzled-related protein-1 (P = 0.05). Conclusions The results indicate that this DNA stool test of hypermethylation of the secreted frizzled-related protein-1 promoter is a sensitive and specific method. It has the potential of a clinically useful test for the early detection of colorectal cancer. Supported by grants of the Funds for Research and Teaching (Elan-Fonds to W. Zhang) and by the Interdisciplinary Centre of Clinical Research (IZKF, Project A1 to M. Stürzl) of the University of Erlangen-Nuremberg, Germany. Presented at the Research Forum of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 3 to 7, 2006.     

Hereditary Nonpolyposis Colorectal Cancer (Lynch Syndrome) in Argentina: Report from a Referral Hospital Register

Purpose The first Argentine experience with epidemiologic, molecular, and genetic counseling data is reported. Methods We analyzed 43 families fulfilling Amsterdam criteria identified from a prospective database with data from 779 relatives. Results Eleven families (25.6 percent) presented as Lynch I, 29 (67.4 percent) as Lynch II, and 3 (7 percent) as Muir-Torre syndrome. Among the 306 affected members, 197 cases of colorectal cancer were identified (mean age at diagnosis, 52.1 (range, 21–90) years). The most frequent extracolonic tumors were gastric adenocarcinoma in males and endometrium adenocarcinoma in females. A high incidence of breast cancer was observed (16 cases among 155 females, crude rate: 11,594.20/100,000). Twenty-seven patients (8.8 percent) developed more than one tumor. These patients were younger than those with only one tumor (45 vs. 51 years; P = 0.001). In 5 of 11 patients who underwent molecular sequencing, a pathologic mutation was found. A novel C deletion at 1910 nucleotide, codon 637, exon 12 of MSH2 gene was identified in a family with a strong aggregation of breast cancer with lack of MSH2 immunohistochemical staining. For 78.2 percent of counseled individuals, this session represented the first time they received information, and 73.9 percent stated that their physicians were unaware of their family background. Conclusions Argentine families presented a high incidence of stomach cancer. The elevated incidence of breast cancer and its association with a novel hMSH2 mutation bring to consideration the inclusion of this malignancy as part of the syndrome. A lack of awareness by both physicians and persons at risk was observed. Poster presentation at the meeting of the Collaborative Group of the Americas on Inherited Colorectal Cancer (CGA-ICC), Salt Lake City, Utah, October 23-24, 2005.     

DNA Ploidy Status and Prognosis in Colorectal Cancer: A Meta-Analysis of Published Data

Purpose In colorectal cancer, the negative effect of aneuploidy has been a controversy for more than 20 years. Studies to determine a survival-deoxyribonucleic acid content relationship have conflicting results. A systematic literature search followed by a meta-analysis of published studies addressing prognostic effect of aneuploidy for patients who underwent surgical treatment of colon and rectal cancer was conducted. Methods The main outcome measure was the five-year overall mortality rate after surgical resection. For the selected studies, we estimated this outcome for three subsets of patients through separate meta-analyses: 1) for all patients with colorectal cancer; 2) only between patients with Stage II colon cancer; and 3) only for studies in which follow-up losses were declared. The presence of publication bias was assessed with a funnel plot for asymmetry. Results A total of 5,478 patients with colorectal cancer were represented in 32 studies (Group 1), we estimated a reduction in the five-year overall mortality from 43.2 percent for aneuploid tumors to 29.2 percent for diploid tumors (combined relative risk = 1.44; 95 percent confidence interval = 1.34–1.55; P < 0.001). In addition, 357 patients with Stage II colon cancer (Group 2) extracted from three studies had an absolute reduction of 14.3 percent in five-year overall mortality favoring diploid tumors (combined relative risk = 1.93; 95 percent confidence interval = 1.29–2.89; P = 0.001). Lastly, of 14 studies in which follow-up losses were declared (Group 3), 2,221 patients were represented and a 15.7 percent mortality reduction was measured favoring patients with diploid tumors (combined relative risk = 1.44; 95 percent confidence interval = 1.3–1.61; P < 0.001). Conclusions Patients who undergo an aneuploid colorectal cancer surgical resection have a higher risk of death after five years. This finding may ultimately impact survival of patients with node-negative colon cancer through adjuvant therapy. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 3 to 7, 2006.     

Hand-Assisted Laparoscopic vs. Laparoscopic Colorectal Surgery: A Multicenter, Prospective, Randomized Trial

Purpose  This study was designed to compare short-term outcomes after hand-assisted laparoscopic vs. straight laparoscopic colorectal surgery. Methods  Eleven surgeons at five centers participated in a prospective, randomized trial of patients undergoing elective laparoscopic sigmoid/left colectomy and total colectomy. The study was powered to detect a 30-minute reduction in operative time between hand-assisted laparoscopic and straight laparoscopic groups. Results  There were 47 hand-assisted patients (33 sigmoid/left colectomy, 14 total colectomy) and 48 straight laparoscopic patients (33 sigmoid/left colectomy, 15 total colectomy). There were no differences in the patient age, sex, body mass index, previous surgery, diagnosis, and procedures performed between the hand-assisted and straight laparoscopic groups. Resident participation in the procedures was similar for all groups. The mean operative time (in minutes) was significantly less in the hand-assisted laparoscopic group for both the sigmoid colectomy (175 ± 58 vs. 208 ± 55; P = 0.021) and total colectomy groups (time to colectomy completion, 127 ± 31 vs. 184 ± 72; P = 0.015). There were no apparent differences in the time to return of bowel function, tolerance of diet, length of stay, postoperative pain scores, or narcotic usage between the hand-assisted laparoscopic and straight laparoscopic groups. There was one (2 percent) conversion in the hand-assisted laparoscopic group and six (12.5 percent) in the straight laparoscopic group (P = 0.11). Complications were similar in both groups (hand-assisted, 21 percent vs. straight laparoscopic, 19 percent; P = 0.68). Conclusions  In this prospective, randomized study, hand-assisted laparoscopic colorectal surgery resulted in significantly shorter operative times while maintaining similar clinical outcomes as straight laparoscopic techniques for patients undergoing left-sided colectomy and total abdominal colectomy. Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, June 2 to 6, 2007. Reprints are not available Drs. Marcello, Read, and Mutch are consultants for Applied Medical and have received honoraria and potential stock options. Drs. Milsom and Whelan have received honoraria for speaking on behalf of Applied Medical. Applied Medical provided financial support to the institutions for the project.     

Patient Preferences Between Surgical and Medical Treatment in Crohn’s Disease

Purpose Crohn’s disease poses difficult choices in which the most appropriate treatment option is not always obvious. When this state of uncertainty exists, patients’ preferences should have an increasingly important part of clinical decision making. The purpose of this study was to compare patients’ preferences for surgical intervention in Crohn’s disease with the preferences of surgeons and gastroenterologists. Methods Outpatients with Crohn’s disease were interviewed to quantify their preferences for six scenarios by using the prospective preference measure. An identical questionnaire was mailed to all Australian and New Zealand colorectal surgeons and a random sample of 300 Australian gastroenterologists. Results Forty-one of 123 patients with Crohn’s disease (33 percent), 92 of 127 colorectal surgeons (72 percent), and 74 of 272 gastroenterologists (27 percent) participated. There were significant differences between patients and gastroenterologists for three of six scenarios and between surgeons and gastroenterologists in four of six scenarios. Seventy-six percent of gastroenterologists were willing to gamble to avoid an ileocolic resection compared with 37 percent of surgeons (chi-squared = 25.44; P < 0.0001) and 39 percent of patients (chi-squared = 15.44; P < 0.001). Conclusions Patients and clinicians were able to trade and gamble life expectancy as a measure of preference for varying hypothetical surgical treatments, even though these treatment options impacted on quality of life rather than survival. Patients’ preferences did not align with clinicians. For most scenarios, colorectal surgeons’ preferences were significantly different to those of gastroenterologists. Dr. Byrne was supported by the Notaras Fellowship from the University of Sydney, the Section of Colon and Rectal Surgery of the Royal Australasian College of Surgeons, and the Training Board of the Colorectal Surgical Society of Australasia. Presented at the Tripartite Colorectal Meeting, Dublin, Ireland, July 5 to 7 2005. Reprints are not available.     

The Prognostic Significance of RON and MET Receptor Coexpression in Patients with Colorectal Cancer

Purpose  Although Recepteur d’Origine Nantais (RON), a member of the MET receptor tyrosine kinase family, is overexpressed and constitutively active in some primary tumors and tumor cell lines, its expression pattern and clinical significance in colorectal cancer are not well documented. Methods  By using immunohistochemical staining, we examined RON and MET expression in 135 colorectal cancer specimens and investigated the association of the immunoreactivity of both receptors with colorectal cancer clinical parameters and prognosis. Results  We found moderate to strong expression in 99 cases (73 percent) for RON and 97 cases (72 percent) for MET. Univariate analysis showed that increased immunoreactivity of RON or MET was associated with shorter patient survival and that moderate to strong coexpression of both receptors was associated with a significantly worse prognosis. Multivariate Cox analysis showed that the risk of tumor recurrence for patients with high-RON/high-MET expression was approximately 11 times greater than for patients with low-RON/low-MET expression (P = 0.001). In addition, RON and MET expression levels were positively correlated (P ≤ 0.001; τ = 0.306). Conclusions  The crosstalk between RON and MET in colorectal cancer seems important. Evaluating the expression patterns of RON and MET was predictive of clinical outcome for patients with colorectal cancer. Supported by grants NSC94–2314-B-006–058 from the National Science Council and DOH-TD-B-111–004 from the Department of Health, Executive Yuan, Taiwan. Poster presentation at the 11th Congress of Asian Federation of Coloproctology, Tokyo, Japan, September 20 to 22, 2007.     

Postoperative Radiotherapy for Stage IIIA Rectal Cancer: Is It Justified?

Purpose  Adjuvant radiotherapy is currently recommended for all node-positive rectal cancers to reduce local recurrence. This study evaluated if an adequate mesorectal excision can obviate the need for radiotherapy in early node-positive cancer. Methods  Stage IIIA rectal cancer patients were identified in a prospectively maintained database. Patients who received postoperative radiotherapy (radiotherapy) and those who did not (no radiotherapy) were compared for recurrence, survival, bowel function, and quality of life. Quality of life was assessed using the Short Form-36 Medical Outcomes Survey. Results  Eighty-six patients underwent proctectomy for T1-T2,N1 rectal cancers from 1978 to 2004. Patients receiving radiotherapy (n = 34) were younger and had a higher percentage of T1 tumors than patients who did not receive radiotherapy (n = 52). Other tumor characteristics, type of surgery, and number of involved lymph nodes were comparable. Estimated 5-year local recurrence was radiotherapy 3.4 percent and no radiotherapy 4.7 percent; distant recurrence was radiotherapy 13.5 percent and no radiotherapy 16.5 percent; and disease-specific mortality rates were similar 13.5 vs. 11.3 percent, for radiotherapy and no radiotherapy (all P > .05). Patients receiving radiotherapy had higher frequency of daytime bowel movements, urgency, and usage of pads and antidiarrheal medications. Age adjusted quality of life parameters were comparable between treatments. Conclusion  Postoperative radiotherapy did not reduce recurrence or mortality. Function but not quality of life was adversely affected. Routine postoperative radiotherapy for Stage IIIA rectal cancer should be reconsidered. Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, June 2 to 6, 2007.     

Spectral Slope from the Endoscopically-Normal Mucosa Predicts Concurrent Colonic Neoplasia: A Pilot Ex-Vivo Clinical Study

Purpose  We previously reported that analysis of histologically normal intestinal epithelium for spectral slope, a marker for aberrations in nanoscale tissue architecture, had outstanding accuracy in identifying field carcinogenesis in preclinical colorectal cancer models. In this study, we assessed the translatability of spectral slope analysis to human colorectal cancer screening. Methods  Subjects (n = 127) undergoing colonoscopy had spectral slope determined from two endoscopically normal midtransverse colonic biopsies using four-dimensional elastic light-scattering fingerprinting and correlated with clinical findings. Results  Four-dimensional elastic light-scattering fingerprinting analysis showed the submicron particles size progressively shifted toward larger sizes in subjects harboring neoplasia. There was a corresponding decrease in spectral slope values from the endoscopically normal mucosa in subjects harboring adenomas (n = 41) and advanced adenomas (n = 10), compared to neoplasia-free subjects (P ≤ 0.00001). These factors did not appear to be confounded by either age or adenoma location. For detecting advanced adenomas, spectral slope had a negative and positive predictive value of 95 percent and 50 percent respectively. Conclusions  We demonstrate, for the first time, that spectral slope in “normal” mucosa can accurately risk-stratify patients for colonic neoplasia. This proof of concept study serves to underscore the promise of four-dimensional elastic light-scattering fingerprinting analysis for colorectal cancer screening. Drs. Roy, Goldberg, and Backman are cofounders and stock holders in American BioOptics. This work was supported by research grants from the National Institutes of Health (U01CA111257, R01CA112315, R01CA128641, R01CA109861, R42CA130508 and R01EB003682), National Science Foundation (CBET-0733868), and Coulter Foundation. Read meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 3 to 7, 2006.     

Adjuvant perioperative portal vein or peripheral intravenous chemotherapy for potentially curative colorectal cancer: long-term results of a randomized controlled trial

Background and aims  The perioperative use of a single course adjuvant portal vein infusion chemotherapy in patients with potentially curable colorectal cancer has been shown to significantly improve overall survival but did not reduce the occurrence of liver metastases (SAKK 40/81) [Swiss Group for Clinical Cancer Research (SAKK) Lancet 345(8946):349–353, 1995]. The objective of the present prospective, three-arm randomized multicenter trial was to assess whether peripheral venous administration of adjuvant chemotherapy regimen based on 5-fluorouracil (5-FU) and mitomycin C decreases the occurrence of liver metastases as well as prolongs disease-free and overall survival. Materials and methods  Stages I–III colorectal cancer patients (n = 753) were randomized to receive either surgery alone (control arm), surgery plus postoperative portal venous infusion of 5-FU 500 mg/m² plus heparin given for 24 hours for seven consecutive days plus mitomycin C 10 mg/m² given on the first day (arm 2), or surgery and the same chemotherapy regimen administered by peripheral venous route (arm 3). Results  The 5-year disease-free survival for the three treatment groups were 65% (control group), 60% (portal vein infusion, hazard ratio 1.18, p = 0.23), and 64% (intravenous infusion, hazard ratio 1.04, p = 0.76); the 5-year overall survival was 72% (control group), 69% (portal vein infusion, hazard ratio 1.21, p = 0.2), and 74% (intravenous infusion, hazard ratio 1.03, p = 0.86), respectively. A significant accumulation of early deaths were observed in the portal vein infusion group (p = 0.015). Conclusions  The present prospective randomized multicenter trial provides compelling evidence that short-term perioperative chemotherapy does not improve disease-free and overall survival in patients with potentially curative colorectal cancer. In contrary, the chemotherapy regimen administered in the present investigation seems to have potentially harmful effects, a finding which should be carefully considered in the planning of future trials. Postoperative short-term administration of 5-FU plus mitomycin C either through portal infusion or a central venous catheter is not recommended for routine use in patients with potentially curable colorectal cancer. M. Lorenz deceased.