Current follow-up strategies after resection of colon cancer

The follow-up of patients after potentially curative resection of colon cancer has important clinical and financial implications for patients and society, yet the ideal surveillance strategy is unknown. PURPOSE: The aim of this study was to determine the current follow-up practice pattern of a large, diverse group of experts. METHODS: The 1,663 members of The American Society of Colon and Rectal Surgeons were asked, via a detailed questionnaire, how often they request nine discrete follow-up evaluations in their patients treated for cure with TNM Stage I, II, or III colon cancer over the first five post-treatment years. These evaluations were clinic visit, complete blood count, liver function tests, serum carcinoembryonic antigen (CEA) level, chest x-ray, bone scan, computerized tomographic scan, colonoscopy, and sigmoidoscopy. RESULTS: Forty-six percent (757/1663) completed the survey and 39 percent (646/1663) provided evaluable data. The results indicate that members of The American Society of Colon and Rectal Surgeons generally conduct follow-up on their patients personally after performing colon cancer surgery (rather than sending them back to their referral source). Routine clinic visits and CEA levels are the most frequently performed items for each of the five years. The large majority (>75 percent) of surgeons see their patients every 3 to 6 months for years 1 and 2, then every 6 to 12 months for years 3, 4, and 5. Approximately 80 percent of respondents obtain CEA levels every 3 to 6 months for years 1,2, and 3, and every 6 to 12 months for years 4 and 5. Colonoscopy is performed annually by 46 to 70 percent of respondents, depending on year. A chest x-ray is obtained yearly by 46 to 56 percent, depending on year. The majority of the members of The American Society of Colon and Rectal Surgeons do not routinely request computerized tomographic scan or bone scan at any time. There is great variation in the pattern of use of complete blood count and liver function tests. Members of The American Society of Colon and Rectal Surgeons from the United States tend to follow their patients more closely than do those living in other countries. The intensity of follow-up does not markedly vary across TNM Stages I to III. CONCLUSION: The surveillance strategies reported here rely most heavily on clinic visits and CEA level determinations, generally reflecting guidelines previously proposed in the current literature.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Chicago, Illinois, May 2 to 7, 1993.     

Outcome of surgery for colorectal cancer in a defined population in Sweden from 1984 to 1986

PURPOSE: This study was designed to investigate incidence, treatment, and outcome for patients with colorectal cancer. METHODS: From 1984 to 1986 in Östergötland, a county in Sweden with a defined population, a prospective registration using a computerized protocol was undertaken. RESULTS: In the surgical departments 596 cases were diagnosed and 31 more cases were diagnosed in other departments, bringing the incidence to 53 cases per 100,000 inhabitants per year. Of the cases, 14 percent presented as emergencies. The resectability rate was 90 percent, and the rate of curative operations was 74 percent. Postoperative mortality within 30 days was 2.9 percent. Crude five-year survival for all patients was 40 percent, and the corrected survival rate was 53 percent. After curative resection the crude five-year survival rate was 53 percent, and the corrected survival rate was 70 percent. Prognosis was better for colon than for rectal cancer, 76 percent vs.59 percent corrected five-year survival rate. For rectal cancer the local recurrence rate was 20 percent after curative resection. CONCLUSIONS: The prognosis was improved compared with a previous study from the same area because of decreased postoperative mortality, increased rate of operations for cure, and an increased five-year corrected survival rate. Local recurrence after rectal cancer was still high but may be reduced with improved surgical technique.Supported by grants from Östergötlands Läns Landsting (Project 52/82, 49/83, and 51/84).     

Value of carcinoembryonic antigen in the management of colorectal cancer

PURPOSE: The practical value of carcinoembryonic antigen (CEA) assay in the management of colorectal cancer after surgery is controversial. The value of CEA in the management of colorectal cancer was reviewed and discussed to justify the use of CEA assay in the management of colorectal cancer. METHODS: A retrospective study was performed on 318 patients who underwent resection by one surgeon (JYW) between 1981 and 1986 and who were followed for a minimum of 5 years or until death. RESULTS: The incidence of preoperative CEA levels >5 ng/ml in Dukes Stages A, B, C, and D were 0, 32, 48, and 79 percent, respectively. Five-year survival rates for groups with CEA levels 5 ng/ml and >5 ng/ml were 85 percent and 55 percent (P < 0.05), respectively, in Dukes Stage B patients and 64 percent and 37 percent (P < 0.05) in Stage C patients. The sensitivity and specificity of postoperative CEA monitoring in detecting recurrent diseases were 66 percent and 94 percent, respectively, for patients with a preoperative CEA value 5 ng/ml and 97 percent and 88 percent for patients with a higher preoperative CEA value. CONCLUSION: CEA is still the best tumor marker available to be used as an independent prognostic factor and as a monitor for recurrence of disease after primary tumor resection.     

Value of carcinoembryonic antigen monitoring in curative surgery for recurrent colorectal carcinoma

PURPOSE: This study is designed to review a carcinoembryonic antigen (CEA)-driven postoperative protocol designed to identify patients suitable for curative reresection when recurrent colorectal cancer is identified. METHODS: A total of 285 patients who were operated on for colon or rectal carcinoma between 1981 and 1985 were evaluated (with CEA levels) every two months for the first two years, every three months for the third year, every six months for years 4 and 5, and annually thereafter. CEA levels above 5 g were considered abnormal and were evaluated with diagnostic imaging and/or endoscopy. RESULTS: Follow-up was available for 280 patients (98.2 percent). Distribution of patients by Astler-Coller was: A, 14 percent; B₁ 20 percent; B₂, 39 percent; C₁, 5 percent; C₂, 21 percent. There were 62 of 280 patients (22 percent) who developed elevated CEA levels, with 44 patients who demonstrated clinical or radiographic evidence of recurrence. Eleven patients were selected for surgery with curative intent (4 hepatic resections, 1 pulmonary wedge resection, 2 abdominoperineal resections, 2 segmental bowel resections, and 2 cranial metastasectomies). Three of 11 patients (27 percent) benefited and have disease-free survivals greater than 60 months. Of the 223 patients without elevated CEA, 22 (9.9 percent) had recurrent cancer without any survivors. Overall, 3 of 285 patients (1.1 percent) were cured as a result of CEA follow-up. CONCLUSION: CEA-driven surgery is useful in selected patients and can produce long-term survivors.Read at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 9 to 14, 1996.     

Role of CEA,TPA, and Ca 19-9 in the early detection of localized and diffuse recurrent rectal cancer

Sixty-six consecutive patients who underwent curative resection for rectal cancer were studied prospectively to evaluate the roles of sequential carcinoembryonic antigen (CEA), tissue plasminogen activator (TPA), and carcinomatous antigen 19-9 (Ca 19-9) determinations in the early diagnosis of resectable recurrences. Thirty-three recurrences were detected between 6 and 42 months. CEA, TPA, and Ca 19-9 showed a sensitivity of 72.7 percent, 78.8 percent, and 60.1 percent, respectively, and a specificity of 60.6 percent, 60.6 percent, and 87.9 percent, respectively. In 23 cases the rise in the value of CEA and/or TPA and/or Ca 19-9 was the first sign of recurrences, and the diagnosis was established later by clinical methods. In this group, the lead time was two months for liver metastases and four months for disseminated metastases. As far as the relationship between localization of recurrence and marker level increase is concerned, of 16 hepatic metastases CEA, TPA, and Ca 19-9 showed a sensitivity of 94 percent (P <0.05), 69 percent, and 62 percent, respectively. Of six patients with local recurrences, CEA, TPA, and Ca 19-9 showed a sensitivity of 50 percent, 100 percent (P <0.05), and 83.3 percent, respectively. Of three patients with peritoneal carcinomatosis, CEA, TPA (P <0.05), and Ca 19-9 showed a sensitivity of 0 percent, 100 percent, and 0 percent, respectively. No significant differences were reported among the three markers according to multiple metastases and metachronous polyps. Fourteen patients (42.4 percent) underwent surgical treatment for recurrent disease, and eight of them (57 percent) showed a resectable disease, for a total resectability rate of 24.2 percent. The findings of our study indicate that a followup program based on CEA, TPA, and Ca 19-9 assays is related to an early diagnosis and a good resectability rate for both local and metastatic recurrences from rectal cancer.     

Second-look operation for recurrent colorectal cancer based on carcinoembryonic antigen and imaging techniques

PURPOSE: The usefulness of postoperative carcinoembryonic antigen (CEA) monitoring and improvements in imaging techniques have renewed enthusiasm for second-look operations (SLO) as the most effective treatment for recurrent colorectal cancer by reresection following early detection. The aim of our study is to evaluate the role of CEA and imaging techniques-directed SLO. METHODS: Seven hundred fifty-six patients with Dukes Stages B and C, who had undergone curative resection, were monitored postoperatively using CEA and imaging techniques. An SLO was performed on any potentially resectable recurrence, and in addition, an SLO was done when a persistently rising CEA value was detected. RESULTS: Recurrence developed in 18.8 percent (142/756) of patients, and 90.8 percent (129/ 142) of the recurrences were detected within the first three years following curative resection. When comparing carcinomas of the colon with that of the rectum, the former were associated with significantly more hepatic and intra-abdominal recurrences, whereas the latter had significantly more locoregional and pulmonary recurrences. Seventy-two patients underwent SLO. Of these patients, 54.2 percent (39/72) had all of their disease resected, and 1.4 percent (1/72) had no detectable disease at the SLO. Among the 142 patients with recurrence, 71 (50 percent) patients underwent SLO. The resectable group at SLO carried a significantly better survival than the unresectable recurrence group (41.3 vs. 5.2 percent;P <0.01). CONCLUSIONS: Complete removal of colorectal cancer recurrences by SLO, on the basis of postoperative, follow-up CEA and imaging technique findings, results in improved survival.Supported, in part, by a grant-in-aid for Cancer Research from the Japanese Ministry of Health and Welfare and Scientific Research from the Japanese Ministry of Education, Culture and Science.     

Sensitivity of monoclonal antibodies to carcinoembryonic antigen,tissue polypeptide antigen,alpha-fetoprotein,carbohydrate antigen 50, and carbohydrate antigen 19-9 in the diagnosis of colorectal adenocarcinoma

PURPOSE: This study was designed to establish the sensitivity of monoclonal antibodies to carcinoembryonic antigen (CEA), alpha-fetoprotein (AFP), tissue polypeptide antigen (TPA), carbohydrate antigen 50 (CA 50), and carbohydrate antigen 19-9 (CA 19-9) and the efficacy of the joint determination of several tumor markers, as well as the dynamics of postoperative normalization of each marker in the absence of recurrence. MATERIALS AND METHODS: A prospective study was carried out in 100 patients subjected to surgical resection of colon adenocarcinoma. Serum concentrations of these markers were determined the day before surgery and seven days, two months, and six months after surgery. RESULTS: The results demonstrate that sensitivity increased as the disease spread and that CA 19-9 was the most sensitive tumor marker. The rate of false negatives was 40 percent for Dukes Stage A lesions, 19 percent for Dukes Stage B, 7 percent for Dukes Stage C, and 0 percent for Dukes Stage D. Determination of two markers (CA 19-9 and CEA) provided the greatest sensitivity in Stages A and D tumors (60 percent and 100 percent, respectively); the incidence did not change when measurements of other antigens were associated. For Stages B and C, determination of at least three markers was necessary, the association of CEA, TPA, and CA 19-9 being that which showed the greatest sensitivity, 78 percent and 91 percent, respectively. CONCLUSIONS: It would be advisable to include monoclonal antibody determination of CEA, TPA, and CA 19-9 in the diagnosis of adenocarcinoma, despite the fact that ultimate sensitivity will depend on the degree of tumor extension or on the presence of metastasis.     

Lectin staining of neoplastic and normal background colorectal mucosa in nonpolyposis and polyposis patients

A lectin histochemistry approach was adopted for comparative assessment of a colon cancer risk. Binding of Ulex europaeus agglutinin-I (UEA-I), peanut agglutinin (PNA), Griffonia simplicifolia agglutinin-II (GSA-II), and Dolichos biflorus agglutinin (DBA) was investigated in tumor and background tissue from a total of 34 adenoma and 44 cancer patients and compared with reaction patterns in control and familial adenomatous pplyposis (FAP) patients. Adenoma patients with UEA-I positive rectal mucosa were found to have a 33.3 percent familial history of large bowel cancer, which was significantly higher (P <0.05) than the respective 4.0 percent figure for patients with negative rectal mucosa. In the cancer patients, an even stronger correlation was noted, with a 63.2 percent UEA-I positive family history association being recorded, as opposed to 4.0 percent in the negative rectal mucosa patients (P <0.01). Thus, the results suggest that, apparently, normal rectal background mucosa of individuals genetically at high risk for colon and rectal cancer demonstrates a specific lectin binding ability similar to that of FAP patients and that the simple method using UEA-I staining of rectal biopsy specimens can be of practical use in identification of high-risk colorectal cancer.     

Comparison of tumor marker CA 242 with CA 19-9 and carcinoembryonic antigen (CEA) in pancreatic cancer

BACKGROUND/AIMS: Although there are a variety of tumor markers used for diagnosis of pancreatic carcinoma, the sensitivity and specificity of those markers have not yet reached an ideal level. The aim of this study was to compare the diagnostic value of CA 242 with CA 19-9 and CEA in the patients with pancreatic cancer. METHODOLOGY: Serum CA 242, CA 19-9 and CEA levels were determined in 135 subjects in the following groups: Pancreatic cancer (n = 40), cholangiocellular carcinoma (n = 15), hepatocellular carcinoma (n = 10), cirrhosis (n = 7), chronic active hepatitis (n = 7), choledochal stone (n = 12), chronic pancreatitis (n = 9), acute pancreatitis (n = 6), and healthy controls (n = 29). RESULTS: An elevated serum CA 242 concentration (> 20 U/mL) was found in 30 out of 40 (70%) (mean; 2163 +/- 838 U/mL) patients with pancreas cancer, in 11 out of 15 patients with cholangiocellular carcinoma (93.3%) (mean 916 +/- 529 U/mL), in none of patients with hepatocellular carcinoma and healthy controls. Slightly elevated CA 242 concentration was found in 6 out of 41 patients with benign hepatobiliary and pancreatic disease (range 0.4-97.8 U/mL) (1 acute pancreatitis, 2 chronic pancreatitis, 1 cirrhosis, 2 choledochal stone). Mean serum CA 242, CA 19-9 and CEA levels of the pancreas cancer group were significantly higher than those of the other groups except the cholangiocellular carcinoma group. There was no significant difference between the stage of pancreas cancer regarding mean serum CA 242, CA 19-9 and CEA level. There was positive correlation between serum CA 242 and CA 19-9 level. In the pancreas cancer, the sensitivity of CA 242, CA 19-9 and CEA was 75%, 80%, 40%, respectively and the specificity of those markers was 85.5%, 67.5% and 73%, respectively. CONCLUSIONS: In conclusion, the advantage of CA 242 compared to CA 19-9 is that its specificity is higher than that of CA 19-9 in the diagnosis of pancreas cancer.     

Clinical significance of tumor marker NCC-ST 439 in large bowel cancers

We examined serum NCC-ST 439 for its significance as a tumor marker of large bowel cancer in 121 patients with primary and 36 with recurrent large bowel cancer. Serum NCC-ST 439 was positive in 27.3 percent of the former and 66.7 percent of the latter. It was false-positive in only 5.6 percent of patients with benign diseases. Positive serum NCC-ST 439 correlated with lymph node and liver metastases. The combination assay for NCC-ST 439, CEA, and CA19-9 was positive in 49.6 percent of the patients with primary tumors and 88.9 percent of those with recurrent tumors; in other words, the diagnostic accuracy improved. The results demonstrated that the determination of serum NCC-ST 439 in large bowel cancer might be useful in cancer staging and that NCC-ST 439, if used in combination with CEA, is particularly useful in diagnosing recurrences because of its improved diagnostic accuracy.     

新辅助化疗对直肠癌患者肿瘤标记物及免疫功能的影响

目的探讨II、III期直肠癌单纯新辅助化疗对肿瘤标记物及免疫功能的影响。 方法分析我院31例II、III期直肠癌单纯新辅助化疗患者数据,并在化疗前后给予监测肿瘤标记物及免疫功能。 结果本组31例患者前后对比肿瘤标志物CEA(P＝0.049)、CA242(P＝0.048)有显著性差异;而CA199未见显著性差异(P＝0.252)。免疫功能中仅B细胞有显著性差异(P＝0.044),其余总T细胞、辅助T细胞、细胞毒性T细胞、CD4/CD8、自然杀伤细胞、调节性T细胞均未见显著性差异。 结论新辅助化疗可以显著降低II、III期直肠癌患者肿瘤标志物CEA、CA242;而对细胞免疫功能无影响,仅降低B细胞功能。     

血清肿瘤标志物和肝功能指标联合检测在胰腺癌肝转移诊断中的价值

目的探讨肿瘤标志物和肝功能指标联合检测在胰腺癌肝转移早期诊断中的临床价值。方法选取125例胰腺癌患者,其中肝转移58例,无肝转移67例。检测患者血清肿瘤标志物和肝功能指标水平,并对结果进行分析。结果胰腺癌肝转移者血清中癌胚抗原（CEA）、糖类抗原19-9（CA19-9）、糖类抗原242（CA242）和乳酸脱氢酶（LDH）水平显著高于无肝转移者（P〈0.05）。ROC曲线分析显示CEA、CA19-9、CA242与LDH诊断肝转移的最佳上限为6.0μg/L、842 U/m l、64.48 U/L与220 U/L。CEA和LDH单独检测肝转移的敏感性为64.2%和51.9%,特异性为71.4%和74.2%。而CEA与LDH联合检测的敏感性和特异性为77.6%和93.5%。结论肿瘤标志物和肝功能指标联合检测特异性高,有助于胰腺癌肝转移的早期诊断。     

Colorectal adenocarcinoma in patients less than 40 years of age

From 1973 to 1985, 105 patients under 40 years of age were treated for colorectal adenocarcinoma at Roswell Park Cancer Institute. There were 51 males and 54 females. The mean age was 32 years. The majority of patients were treated for left colon or rectal carcinomas. Ninety-seven of 105 patients underwent surgical resection of their primary cancer, 70 (67 percent) of which were potentially curative. Twenty-seven patients underwent palliative resections. Dukes' A or B lesions were not seen in patients less than 20 years old, whereas these early lesions were seen in 11 percent of patients 20 to 29 years old and in 26 percent of patients greater than 30 years of age. The mean survival for patients between 20 and 29 years was 39 months and 46 months for patients 30 years and older.     

Usefulness of carcinoembryonic antigen monitoring despite normal preoperative values in node-positive colon cancer patients

PURPOSE: The aim of our study was to determine to what extent serial carcinoembryonic antigen (CEA) monitoring is helpful in detecting colorectal cancer recurrence in patients if their preoperative serum CEA is normal. Additional major objectives of this study were to correlate CEA immunohistochemical features of the primary tumor with serum CEA levels at the time of tumor recurrence in node-positive colorectal cancer patients with low preoperative CEA values. METHODS: One hundred fourteen node-positive colorectal cancer patients with preoperative serum CEA levels of <5.0 ng/ml undergoing clinically curative operations were studied. Primary tumors were evaluated for tissue CEA using the same monoclonal antibody as used for serum CEA determinations utilizing the avidin-biotin-peroxidase immunohistochemical technique. RESULTS: The exact preoperative serum CEA value did not correlate with tumor grade, immunohistochemical CEA intensity or pattern. In the 32 patients who developed recurrent cancer, the serum CEA at recurrence was greater than 5 ng/ml in 44 percent. All such patients had CEA present in their primary tumor. There was no correlation with the exact preoperative serum CEA, the intensity of the primary tissue CEA, or the localization of such CEA and subsequent serum elevation at recurrence. CONCLUSION: Serum CEA is a useful marker in the detection of recurrent colorectal cancer despite normal preoperative values.     

Combined detection tumor markers for diagnosis and prognosis of gallbladder cancer

AIM:To clarify the value of combined use of markers for the diagnosis of gallbladder cancer and prediction of its prognosis.METHODS:Serum cancer antigens(CA)199,CA242,carcinoembryonic antigen(CEA),and CA125 levels were measured in 78 patients with gallbladder cancer(GBC),78 patients with benign gallbladder diseases,and 78 healthy controls using electrochemiluminescence.CA199,CA242,CEA,and CA125 levels and positive rates were analyzed and evaluated pre-and postoperatively.Receiver operator characteristic curves were used to determine diagnostic sensitivity and specificity of GBC.Survival time analysis,including survival curves,and multivariate survival analysis of a Cox proportional hazards model was performed to evaluate independent prognostic factors.RESULTS:Serum CA242,CA125,and CA199 levels in the GBC group were significantly higher when compared with those in the benign gallbladder disease and healthy control groups(P<0.01).With a single tumor marker for GBC diagnosis,the sensitivity of CA199 was the highest(71.7%),with the highest specificity being in CA242(98.7%).Diagnostic accuracy was highest with a combination of CA199,CA242,and CA125(69.2%).CA242 could be regarded as a tumor marker of GBC infiltration in the early stage.The sensitivity of CA199 and CA242 increased with progression of GBC and advanced lymph node metastasis(P<0.05).The78 GBC patients were followed up for 6-12 mo(mean:8 mo),during which time serum CA199,CA125,and CA242 levels in the recurrence group were significantly higher than in patients without recurrence(P<0.01).The post-operative serum CA199,CA125,and CA242levels in the non-recurrence group were significantly lower than those in the GBC group(P<0.01).Multivariate survival analysis using a Cox proportional hazards model showed that cancer of the gallbladder neck and CA199 expression level were independent prognostic factors.CONCLUSION:CA242 is a marker of GBC infiltration in the early stage.CA199 and cancer of the gallbladder neck are therapeutic and prognostic markers.     

Colorectal cancers of rare histologic types compared with adenocarcinomas

PURPOSE: To examine clinical characteristics of colorectal cancers of rare histologic types compared with adenocarcinomas. METHODS: Review of a population-based registry with complete ascertainment. RESULTS: There were 7,422 colorectal cancers, 4,900 (66 percent) colonic and 2,522 (34 percent) rectal. Two hundred fifty-five cancers (3 percent) were of nonadenocarcinoma varieties including 75 (33 percent) squamous, 74 (33 percent) malignant carcinoids, 37 (16 percent) transitional cell-like, 25 (11 percent) lymphomas, 9 (4 percent) sarcomas, and 2 (0.9 percent) melanomas. Sixty (1.2 percent) of the colon cancers occurred in the appendix, and proportionately more carcinoids accounted for these tumors. Compared with adeno-carcinomas, colonic and rectal carcinoids and colonic lymphomas accounted for a larger proportion of cancers in the younger age groups. The elderly had proportionately fewer colonic carcinoids. Colonic carcinoids, rectal squamous-cell cancers, and rectal transitional cell-like cancers were more common in women. Colonic lymphomas had a worse prognosis than adenocarcinomas. Survival was better with colonic and rectal carcinoids and rectal transitional cell-like cancers than with adenocarcinomas. CONCLUSIONS: Colorectal cancers of histologic varieties other than adenocarcinoma have distinctive epidemiologic and clinical traits.Supported in part by National Institutes of Health Grants N01-CN-05222 and CA 40641.     

Analysis of regional lymph node metastases from rectal carcinoma by the clearing method

PURPOSE: It has been reported that functional outcome following low anterior resection of rectal cancer is improved by construction of a colonic J-pouch compared with straight anastomosis. Hence, we tried to justify use of the sigmoid colon in the construction of a J-pouch by the analysis of regional lymph node metastases. METHODS: A total of 182 patients underwent resection for rectal cancer. Node metastases were examined by the clearing method. According to Japanese General Rules for Clinical and Pathological Studies on Cancer of the Colon, Rectum and Anus (JGR), nodes were classified into the perirectal nodes (PR-N), pericolic nodes (PC-N), central intermediate nodes (C-IM-N), central main nodes (C-M-N), lateral intermediate nodes (L-IM-N), and lateral main nodes (L-M-N). RESULTS: Metastatic rate (number of patients with node metastases/ total number of patients) of PR-N was 57.1 percent. Metastatic rate of C-IM-N was 18.7 percent and that of C-M-N was 7.1 percent. Metastatic rates of L-IM-N and L-M-N were 8.8 and 3.3 percent, respectively, and both were highest in the case of lower rectal cancer. Metastatic rate of PC-N was only 1.1 percent. The number of cases without node metastases (n(–) cases) was 78, that with only PR-N metastases (PR-N cases) was 63, that with intermediate but not main node metastases (IM-N cases) was 29, and that with main node metastases (M-N cases) was 12. Five-year survival rate after curative resection was 88.5 percent for n(–) cases, 70.9 percent for PR-N cases, 65.9 percent for IM-N cases, and 41.7 percent for M-N cases. CONCLUSIONS: In low anterior resection, high ligation of the inferior mesenteric artery and dissection of C-M-N, C-IM-N and PR-N are necessary, with the addition of the L-IM-N and L-M-N in the case of lower rectal cancer. Resection of sigmoid colon is not required, and therefore, a J-pouch can be constructed using the sigmoid colon. Nodal classification according to the JGR was predictive of case distribution and five-year survival rate.Supported, in part, by a Grant-in-Aid for Cancer Research from the Japanese Ministry of Health and Welfare and Scientific Research from the Japanese Ministry of Education, Culture and Science.     

Factors affecting the risk of rectal cancer following rectum-preserving surgery in patients with familial adenomatous polyposis

PURPOSE: Rectum-preserving surgery is one of the most common surgeries for familial adenomatous polyposis (FAP). It is appropriate to analyze factors influencing risk of rectal cancer after rectum-preserving surgery in FAP patients. METHODS: Three hundred twenty-two patients with FAP (169 males, 153 females) who had undergone rectum-preserving surgery and were part of 1050 FAP patients registered at our FAP registry were included in the study. Postoperative survival was investigated and cause of death was elucidated from the death certificate or by inquiry to the hospitals that registered the patients. For risk analysis, log-rank tests were used. RESULTS: Forty-four cases developed invasive cancer within a mean interval of 119 months after surgery. Cumulative risk of rectal cancer was 24.2±7 percent (mean±limit of 95 percent confidence interval) at 15 years. Influencing risk factors for rectal cancer were a postoperative period over ten years or age over 44 years, a rectum longer than 7 cm, and dense polyposis. Other factors such as sex and cancer in the colon at initial surgery were not correlated with risk. CONCLUSION: The rectum may be reasonably preserved in patients with FAP when polyps in the rectum are sparse, ileorectal anastomosis is made on or below the peritoneal reflection, and patients continue having rectal examinations for life.     

Role of carcinoembryonic antigen in predicting resectability of recurrent colorectal cancer

The reported low resectability rate for patients with recurrent colorectal cancer who have carcinoembryonic antigen (CEA) levels >11 has led us to perform this study. One hundred twenty-four patients who underwent Radioimmunoguided Surgery ^® (RIGS ^®)procedures for recurrent colorectal cancer from 1986 to the present were studied. In surgery, all patients underwent a traditional exploration followed by survey with a hand-held, gamma-detecting probe to detect preinjected radiolabeled monoclonal antibodies attached to cancer cells. Sites of metastases included: 72 liver (58.1 percent), 23 pelvis (18.5 percent), 15 distant lymph nodes (12.1 percent), 2 anastomotic (1.6 percent), and 12 other sites (9.7 percent). The resectability rate was 43.5 percent (54 patients). The mean preoperative CEA level for patients with resectable disease was significantly lower than for patients with unresectable disease (P=0.017): unresectable—mean, 87.1; SD, 141.0; minimum, 0.3; maximum, 501; resectable—mean, 36.6; SD, 59.3; minimum, 0.3; maximum, 329. The CEA level for patients with liver metastasis did not vary significantly from those patients without metastasis: 70 vs. 58.2 (P=0.58). Those patients with resectable liver tumors had lower mean CEA levels than those with unresectable liver, approaching significance: 41.6 vs. 91.9 (P=0.065). Other metastatic sites had a mean CEA level of: pelvic, 72.6; distant lymph nodes, 47.8; anastomotic, 2.7; and other sites, 53.8. These data suggest that there is a significant difference between the preoperative CEA level of the resectable and unresectable recurrent colorectal cancer patients, but the large standard deviation does not justify abandonment of exploration for any CEA level.Read at the meeting of The American Society of Colon and Rectal Surgeons, San Francisco, California, June 7 to 12, 1992.     

Nerve-sparing surgery in 302 resectable rectosigmoid cancer patients: Genitourinary morbidity and 10-year survival

PURPOSE: The aim of this study was to evaluate 5-year and 10-year disease-free survival, urinary dysfunction, and sexual activity after nerve-sparing radical surgery, including lumboaortic lymphadenectomy for rectosigmoid cancer. METHODS: Since 1980 to 1992, 302 consecutive patients affected with rectal (188) or sigmoid (114) resectable cancer underwent radical surgery. Lumboaortic lymphadenectomy was routinely performed and total mesorectal dissection was always accomplished in rectal cancer. Splanchnic nerves, superior hypogastric plexus, hypogastric nerves, and sacral parasympathetic nerves were sought, identified, and preserved or, when necessary, unilaterally sacrificed. Fifty-three (17.6 percent) patients were classified Dukes A, 145 (48.0 percent) B, 46 (15.2 percent) C1, and 17 (5.6 percent) C2. Thirtynine (12.9 percent) patients were Dukes D. In 85 rectal cancer patients, tumor was located at the lower third. Eighty-six of 210 Dukes B and C patients were submitted to systemic chemotherapy and/or high-dose pelvic radiotherapy. RESULTS: The actuarial 5-year disease-free survival was 58.5 percent in rectal and 65.7 percent in sigmoid cancer patients, median follow-up time was 47 months. During the follow-up, each patient was interviewed about sexual activity and urinary dysfunction and a questionnaire was filled out. Urinary dysfunction was not frequently observed, while a definitive sexual impotence was reported in 27.6 percent of the patients. The age under 60 years and sphincter-saving surgery were demonstrated as significantly contributing to retaining a satisfactory sexual activity. CONCLUSIONS: Unexpectedly high disease-free survival was observed in the Dukes C2 subgroup. It allows us to hypothesize that lumboaortic lymphadenectomy could remove neoplastic microfoci present at this level in those patients, enhancing surgical chances of cure. The majority of male patients under 60 years old can retain a satisfactory sexual activity after undergoing a nerve-sparing sphincter-saving cancer surgery.