Survival in acute obstructing colorectal carcinoma

Acute intestinal obstruction was the presenting feature in 124 (19 per cent) of 646 patients with colorectal carcinoma seen over a six-year period. Forty-two per cent of tumors were incurable at presentation. Obstruction was complicated by perforation in 22 patients (18 per cent). Only 15 per cent of tumors occurred in the rectum. Although the postoperative mortality rate was higher in patients with coincidental perforation than in those without (52 vs. 26 per cent:P=0.03), five-year survival rates were the same: 18 per cent overall, rising to 29 to 34 per cent after “curative” resection. Five-year survival rates were best for right colon tumors and worst for rectal tumors (36 vs. 5 per cent:P=0.01). The overall hospital mortality rates for colostomy and delayed resection, resection with colostomy, and resection with anastomosis were equivalent (18 to 22 per cent), but following “curative” resection the hospital mortality rate was higher for resection with colostomy than with other treatments (29 vs. 15 per cent), since two patients died following early colosure of colostomy. Five-year survival was better following resection with anastomosis (48 per cent) than staged procedures (18 per cent:P=0.01), since two patients died following late closure of colostomy.     

Five-year results of abdominopelvic lymph node dissection for carcinoma of the rectum

Summary and Conclusions A series of 122 patients with adenocarcinoma of the rectum who had abdominopelvic lymph node dissection five or more years ago is presented. Metastases to abdominopelvic extramesenteric lymph nodes which would not have been removed by the standard types of resection of the rectum were found in 11 cases (9 per cent). There was 66 (54 per cent) five-year survivors. The survival rate for those classified according to Dukes’ method as A, B and C was 83, 58 and 40 per cent, respectively. Two patients of 11 having metastases to abdominopelvic extramesenteric lymph nodes which would not have been removed by the usual procedures for cancer of the rectum lived five or more years. Of 35 patients who died of residual or metastatic cancer, 22 (60 per cent) had residual pelvic malignant disease. Read at the meeting of the American Proctologic Society, June 29 to July 3, 1958, Los Angeles, California.     

Radical external beam radiation therapy for adenocarcinoma of the rectum

External beam megavoltage radiation therapy was used as primary treatment for 123 patients with rectal adenocarcinoma. Surgery was undertaken for some patients who had residual tumor. The overall five-year survival rate was 21 per cent. When patients were separated into those who presented with clinically mobile and those with clinically fixed rectal tumor masses, the survival rates were 38 per cent and 2 per cent, respectively. The primary tumor was controlled by radiation alone in 21 of 56 (38 per cent) patients who had mobile tumors but in only six of 67 (9 per cent) patients who had fixed tumors. Further investigation of high-dose primary radiation, with surgery reserved for patients with residual rectal carcinoma, may allow reduction of the number of patients who require abdominoperineal resection. Secretarial and statistical service support was provided by a grant from the Ontario Cancer Treatment and Research Foundation.     

The influence of cell type and lymph node metastases on survival of patients with carcinoma of the lung undergoing thoracotomy.

We studied 202 cases of bronchogenic carcinoma treated surgically between January 1, 1966 and December 31, 1970. Over all, adenocarcinoma was the most common cell type (36.1 per cent). Of 151 patients whose carcinomas were successfully resected, and who lived for at least 30 days postoperatively, 88 had lymph nodes free of cancer. Not surprisingly, 5-year survival was related to lymph node metatases and cell type. The best over-all 5-year survival rate was for large cell carcinoma; it was 52.0 per cent without nodal involvement. Similar figures for epidermoid carcinoma were 29.0 per cent over all, and 26.3 per cent without lymph node involvement; for adenocarcinoma, 19.3 per cent over all, and 32.0 per cent without nodal involvement. For the entire group of 151 patients, the 5-year survival rate was 27.8 per cent over all, and 36.4 per cent without nodal metastases. Among resected patients with mediastinal lymph nodes positive for cancer, the 5-year survival rates were 1 of 10 patients with large cell carcinoma, 1 of 19 patients with adenocarcinoma, and 3 of 12 patients with epidermoid carcinoma. This suggests that in patients with epidermoid carcinoma, the presence of mediastinal lymph node metastases is not, in itself, an absolute contraindication to resectional therapy.     

Mortality,morbidity, and patterns of recurrence after abdominoperineal resection for cancer of the rectum

Records of 230 patients who underwent abdominoperineal resection between 1963 and 1976 were reviewed. The median age of the patients was 62 years. The mortality rate was 1.7 per cent, and the morbidity rate was 61 per cent. One hundred eighty patients were followed for five to 13 years to identify patterns of recurence. Ten-year survival for Dukes' A, B, and C lesions was 83 per cent, 57 per cent, and 31 per cent, respectively. Seventy-eight patients (43 per cent) had recurrent cancer; 10 per cent had local lesions, and 33 per cent had distant lesions. Dukes' B lesions had a greater latency for local recurrence than Dukes' C lesions. Dukes' A lesions with distant recurrence had a greater latency than Dukes' B or C lesions. Once recurrence was established, the survival rate was not significantly different, regardless of Dukes' stage or local or distant site. Radiation therapy for established local recurrence or chemotherapy for established distant recurrence did not seem to alter survival rates. Read at the meeting of the American Society of Colon and Rectal Surgeons, Colorado Springs, Colorado, June 7 to 11, 1981. Aided by a grant from the American Cancer Society, Massachusetts Division, Inc.     

Management of carcinoma of the right colon—immediate and remote results: Review of 93 cases

Summary The results of the management of 98 patients with carcinoma of the right colon, treated during the period 1950–1969, are presented. Abdominal pain was the most common presenting symptom. Curative procedures were attempted in 57 per cent of the cases, whereas palliative operations were performed in 31 per cent. The five-year survival rate was 35.7 per cent, being in inverse proportion to the degree of extension of the disease at the time of operation. Thus, for carcinomas of stage A of Dukes' classification the rate was 68.7 per cent. Survival may be improved by earlier diagnosis and consequent radical surgery.     

Surgical results in 657 patients with colorectal cancer

Six hundred fifty-seven patients with colorectal cancer who were operated upon at the Second Department of Surgery, Helsinki University Central Hospital during the period 1966 to 1975 had a 40.5 per cent crude five-year survival rate and 54.2 per cent relative (corrected) rate. The survival rates of patients with Dukes' A lesions were 80.7 per cent, Dukes' B, 61.6 per cent, Dukes' C, 40.4 per cent, and Dukes' D, 2.7 per cent. One hundred two patients (15.5 per cent) underwent emergency operations; 91 were occlusive cancers, eight were perforations and three were cancer bleedings. The operative mortality for the whole series was 6.5 per cent (4.7 per cent in elective and 16.7 per cent in emergency operations). A definite improvement of the five-year survival rates could be seen in both the colonic and rectal cancer series. This was due to earlier detection of the disease, reflecting a decreasing number of palliative operations. Patients at high risk for colorectal cancer (inflammatory bowel disease, inherited intestinal polyposis, cancer family syndrome, multiple colorectal cancers, and neoplastic polyps) might benefit from more effective cancer surveillance and prophylactic surgery to find and treat cancers in earlier stages, to prevent recurrences, and to facilitate follow-up. The controversial findings on postoperative adjuvant therapy presented in this study indicate the need for further controlled studies to define the patients who really benefit from it.     

A further evaluation of the one-stage low-anterior resection

Summary Follow up data have been presented on 424 patients with carcinoma of the rectum or rectosigmoid, or both, who underwent one-stage low-anterior resection. A total of 27 patients died in the immediate postoperative period, giving a hospital mortality of 6.4 per cent. Hospitalization of the remaining 397 patients averaged 19.4 days, and if 128 patients with postoperative complications are excluded, hospitalization of the remaining 269 patients averaged 14.3 days. The most frequent postoperative complication was fecal fistula (13.1%). The sphincteric function was satisfactory eventually in 93.7 per cent of the cases. When the hospital deaths and palliative procedures were excluded, the five-year survival rate was 61.4 per cent, and the ten-year survival rate was 49.7 per cent. Five-year survival rates with and without nodal involvement are presented, and 15-year survivals (statistically insignificant) are discussed. The three-year intraluminal recurrence rate was 9.7 per cent, and the total local recurrence rate during the same period was 14.2 per cent. Read at the meeting of the American Proctologic Society, San Francisco, California, May 20 to 23, 1963.     

Local recurrence following curative resection for carcinoma of the rectum

One hundred ninety-three patients had curative resections for carcinoma of the rectum between January 1971 and December 1979. Nineteen patients developed local recurrence (9.8 per cent): 5/95 after abdominoperineal excision (5.2 per cent) and 14/98 after anterior resection (14.3 per cent). There was no difference in the overall survival rate between the two operations, but there was a trend toward decreased survival for patients who developed local recurrence. Metastatic spread to the lymph nodes increased the risk of local recurrence.     

Primary radiation therapy in the treatment of anal canal carcinoma

A retrospective analysis was undertaken of 51 patients with primary anal canal carcinoma who were treated by radiation therapy, with surgery being reserved for those with residual carcinoma. The five-year uncorrected survival rate was 59 per cent, and the corrected survival rate was 71 per cent. The primary tumor was controlled by radiation alone in 29 of 51 patients (57 per cent) and by subsequent radical surgery in eight of ten patients. Abnormal lymph nodes were controlled by radiation alone in eight of 11 patients. Only three of 29 patients required surgery for complications associated with radiation in the absence of persistent tumor. Seventy-seven per cent (23 of 30) of long-term survivors did not require colostomy and retained anal continence. It is concluded that modern radiation therapy techniques are well tolerated and are an effective method of treating carcinoma of the anal canal.     

Complete prolapse of the rectum treated by modified Orr operation

During a 25-year period 24 patients were treated for complete rectal prolapse with a modification of the operation described by Orr in 1947. After a median follow-up of five years two recurrences occurred (8 per cent). Of 11 patients who were incontinent for fluid feces or flatus preoperatively, five gained continence after the operation. An actuarial analysis of the data revealed a cure rate after five years of 91 per cent (95 per cent confidence limits: 76–100 per cent).     

Prognosis in synchronous colorectal carcinomas

The prognosis of synchronous colorectal carcinomas is a matter of controversy. 5-year survival rates are reported to be either better or worse in comparison with single carcinomas. In this study 736 cases with histologically proven malignancies oft the large intestine were reviewed. 22 patients (3 per cent) showed multiple primary tumors. Patients with multiple tumors had associated adenomas in 72 per cent vs 14 per cent of the patients with single cancers (P < 0.01). 77 per cent of the synchronous tumors were located in the left colon. Only in 5 patients (23 per cent) two different lymphatic drainage areas were involved. 15 patients (68 per cent) presented without lymph node or distant metastases. A radical procedure was performed in 82 per cent. The overall 5-year survival rate was 54.5 per cent for multiple and 44.5 per cent for single carcinomas. The better survival rate seems to be due to the higher rate of early detection because of rectal bleeding in patients with synchronous tumors.     

Prognosis in patients rejected for coronary revascularization surgery

The clinical course, catheterization data, and coronary and left ventricular angiograms of 231 patients rejected for coronary revascularization surgery between 1971 and 1974 and treated conservatively were evaluated. Based upon analysis of available data, patients were classified into one of eight groups as follows: 66 patients with poor left ventricular function, 43 with atherosclerotic distal coronary vessels, one with advanced age, 13 with isolated stenosis of the left circumflex coronary artery, 14 with nonjeopardized collaterals to myocardium beyond the critical coronary stenosis, 25 with akinetic or dyskinetic myocardium beyond the critical coronary stenosis, and 19 with coronary lesions of 50 to 74 per cent of the luminal diameter were rejected; 50 patients were considered acceptable surgical candidates at the time of this review. At three years the actuarial survival rate for all patients was 77.6 per cent. However, those considered operable had a 36 month survival rate of 97.9 per cent. Ejection fraction was the only hemodynamic or clinical feature which had significant prognostic value. The probability of survival for three years was 89.7 per cent for those with ejection fractions greater than 34 per cent, whereas in others the survival rate was only 59.0 per cent (p < 0.001). Patients with poor distal vessels but adequate left ventricular function and those in the other five patient groups had three year survival rates exceeding 82 per cent. Patients with one, two and three vessel disease had three year survival rates of 88.3, 74.7 and 61.3 per cent, respectively. However, when subdivided according to left ventricular function, there was little difference in survival rates for patients with ejection fractions in excess of 34 per cent and one, two or three vessel disease. In patients with poor ventricular function survival rates were similarly low irrespective of the extent of coronary obstructive disease. Fifty-six per cent of patients returned to work, and 42 per cent had no or minimal symptoms. Only nine patients were housebound.Thus, (1) ejection fraction is confirmed as an important prognostic tool, (2) the extent and severity of coronary artery disease, and the condition of the myocardium are important chiefly as they affect the ejection fraction, (3) distal vessel disease does not affect survival adversely, and (4) extensive vascular and myocardial damage can be compatible with a long survival and productive life.     

Transverse colostomy in the management of cancer of the colon

Summary The indications, time factors, results and complications of the transverse colostomy when used at some time in the course of management of 45 patients with cancer of the large bowel are reviewed. The transverse colostomy is safe and effective for decompression, but when it was needed to alleviate acute obstruction only approximately half of the patients subsequently completed the three staged procedures. An average of 94 days was required for completion of the staged operations. Significant complications are associated with closure of the transverse colostomy. The survival rate in 45 patients with cancer of the colon who had transverse colostomies was extremely poor—8.8 per cent survived five years. Colostomy closure was not achieved in 42 per cent of the patients. It is suggested that when possible, reconsideration be given to Mikulicz resection for management of obstructing lesions of the proximal colon. When a transverse colostomy has been established to alleviate obstruction closure at the time of resection would be desirable, in view of the poor prognosis for these patients and in order to decrease hospitalization and the need for a further major surgical procedure, with its attendant risks and expense.     

Protein-calorie undernutrition in hospitalized cancer patients

A survey of the nutritional status of hospitalized cancer patients was conducted in two phases. In phase 1, protein-calorie nutrition was evaluated in 54 ward patients by anthropometries, creatinine excretion and serum albumin. In phase two, 30 cancer patients with protein-calorie undernutrition were transferred to the Clinical Research Unit for study of the underlying mechanisms. Evaluation in this group included anthropometries, serum albumin, creatinine excretion, vitamin levels, caloric intake, basal metabolic rate and stool fat content. Duration of survival from study was recorded in both phases.We found a nearly universal prevalence of protein-calorie undernutrition in advanced cancer, with loss of adipose tissue, visceral protein and skeletal muscle varying unpredictably from patient to patient. The creatinine to height ratio was the most sensitive indicator of protein-calorie undernutrition; 88 per cent of the patients in both phases had a creatinine to height ratio less than 80 per cent of standard, whereas only 42 per cent and 23 per cent of these patients had values less than 80 per cent of standard for triceps skin fold and mid-arm muscle area, respectively. In phase 2, plasma folate, ascorbic acid and vitamin A levels were low in 20 to 45 per cent. Steatorrhea was rare. Neither the basal metabolic rate nor caloric intake differed from expected values for normal sedentary subjects of comparable size.The degree of malnutrition significantly correlated with survival. Patients who died within 70 days of study generally had a creatinine to height ratio <60 per cent of standard (18 of 19 patients), albumin <3.5 g/dl (16 of 23 patients) and/or triceps skin fold thickness <60 per cent of standard (12 of 19 patients).We conclude that protein-calorie undernutrition is present in most hospitalized cancer patients but that it varies widely in degree between subjects and is often obscured at the bedside by residual obesity. The creatinine to height ratio, however, is a sensitive quantitative indicator of this condition. There appear to be nutritional thresholds below which survival is decreased. Survival might be enhanced if nutrition could be maintained above these critical levels.     

Results of aortocoronary bypass operations. Follow-up in 343 patients.

Three hundred and forty-three patients who had aortocoronary bypass graft operations for disabling angina were followed up for from 6 months to 5 years (average 2 years). 80 per cent had multiple grafts and 20 per cent had additional endarterectomy. The overall mortality within one month of operation was 5 per cent, and in those who had vein graft procedures only was 4 per cent. 11 per cent had a postoperative myocardial infarction (6% perioperative) and there were 3 per cent late deaths. At 3 years 90 per cent are surviving. 80 per cent are asymptomatic without treatment. The mean angina grade was 0.3 at the latest follow-up, compared with 2.5 before operation; maximum exercise tolerance was also significantly improved (P less than 0.001). When angina recurred, it did so in 80 per cent of the cases within 12 months of operation and was usually attributable to inadequate revascularisation. Ventricular function as assessed by preoperative ventriculography was the factor most clearly related to survival rate and the early excellent results of coronary bypass operations seem to be maintained up to 5 years. It is, therefore, reasonable to continue to advise operation if only for relief of angina.     

Granulocytopenia in hospitalized patients: II. A prospective comparison of two antibiotic regimens in the empiric therapy of febrile patients

The results of empiric antibiotic therapy in 126 hospitalized patients with fever during 192 episodes of granulocytopenia were studied. Febrile granulocytopenic patients were randomly allocated to receive either carbenicillin, methicillin and gentamicin, or carbenicillin and cephalothin. The response rate for the two antibiotic regimens was similar, 49 (60 per cent) of 81 responded to the former and 42 (54 per cent) of 78 to the latter. The response rate in patients receiving other antibiotics because of specific indications or counterindications was 19 (58 per cent) of 33. Thirty-nine (35 per cent) of 110 patients who responded to initial antibiotic therapy had an increase in circulating granulocytes of one log₁₀ or more compared to only 10 (12 per cent) of 79 nonresponders with such an increase. The mortality rate in adult patients receiving carbenicillin, methicillin and gentamicin was eight (16 per cent) of 51, compared to 18 (37 per cent) of 49 in those receiving cephalothin and carbenicillin (P < 0.05). The significance of this difference in mortality rate is uncertain, as there was no difference in the initial response rate or mortality rate between patients treated with the two antibiotic regimens when only patients with documented bacterial infection were considered. Patients who responded to their initial antibiotic regimen, and patients for whose fever no explanation was found, had the best prognosis.     

Cancer of the rectum ten to twenty years after treatment

Summary and Conclusions The case records of 369 patients (of an original 1,786) who lived more than ten years following initial treatment for cancer of the rectum have been analyzed: 265 patients were alive and well after 15 years, 147 after 20 years, and 47 after 25 years. Very few died of recurrent rectal cancer beyond the first decade following initial treatment. Metachronous polyps developed in only 6.3 per cent of the 309 patients who could be followed for this long period. However, subsequent new colonic cancers developed in 17 (5.4 per cent) of these patients; 13 developed the second cancers during the second decade after the original treatment. Noncolonic cancers also appeared in 9.5 per cent of these 309 patients, an incidence far greater than that in the general population. Nine per cent of the 309 patients required surgical repair of paracolostomy hernias. The overall survival rates for 551 patients at the 5-, 10,- 15-, and 20-year levels, tabulated from the stand-point of Dukes’ classification, are presented, and reconfirm a mortality attrition due more to other causes than to recurrent rectal cancer. Read at the meeting of the American Proctologic Society, Boston, Massachusetts, June 16 to 18, 1969.     

Colorectal carcinoma—Trends and results over a 30-year period

The experience of Karolinska Hospital with colorectal carcinoma over a 30-year period, 1950 through 1979, was reviewed and analyzed. Altogether, 1061 patients were seen; 69 per cent were resected with the intention of cure. The proportion of curative resections did not change with time. Operative mortality decreased from 12 to slightly over 1 per cent. Five-year survival rates were 34 per cent overall and 47 per cent in curable cases. After correction for operative mortality, the latter rate increased from 47 to 58 per cent over the study period (no significance). Sex and age were not correlated with survival. Of tumors resected for cure, 28 per cent were Dukes' A, 39 per cent Dukes' B, and 33 per cent Dukes' C. Corresponding five-year survival rates were 82, 44, and 21 per cent. Though the proportion of Dukes' A tumors increased from 23 to 33 per cent over the 30-year interval, the impact on overall prognosis was insignificant. A possible overdiagnosis of Dukes' A is discussed. The proportion of sphinctersaving procedures for rectal carcinoma increased moderately; excisional and restorative procedures were equal with respect to mortality and survival. Some patients underwent local excisions for Dukes' A rectal carcinomas with a close to 90 per cent five-year survival.     

Squamous-cell carcinoma of the anus

Summary Seventy-six cases of squamous-cell carcinoma of the anus are reviewed—11 of these were classified as anal-margin tumors and 65 as anal-canal carcinomas. Fifty-nine of these were available for five-year follow-up, ten having been treated within the last five years, and seven were lost to follow-up. The five-year survival rate for nine patients with neoplasms arising at the anal margin was 67 per cent (six survivors) and for 50 patients with anal-canal neoplasms, 32 per cent (16 survivors). Radiotherapy proved unsatisfactory, and radical excision was the only method of treatment which carried reasonable prospects of cure. Read at the meeting of the American Proctologic Society, New York, New York, June 11 to 14, 1972.