Clinical predictors of upgrading to Gleason grade 4 or 5 disease at radical prostatectomy: potential implications for patient selection for radiation and androgen suppression therapy

BACKGROUND: To determine the local control, survival, and functional outcome of local excision plus postoperative therapy for patients with rectal cancer. METHODS: A total of 39 patients underwent a local excision (2 with snare excision of a T1 polyp and 37 with full-thickness local excision) followed by postoperative radiation therapy +/- 5-FU-based chemotherapy. The median follow-up was 41 months, and 11 patients had positive margins. RESULTS: The 5-year actuarial colostomy-free survival was 87% and overall survival was 70%. Crude local failure increased with T stage: 0% T1, 24% T2, and 25% T3. Of the 8 patients (21%) who developed local failure, 5 underwent salvage APR and were locally controlled. Actuarial local failure at 5 years was 31% for T2 disease and 27% for the total patient group. In the 32 patients with an intact sphincter, 94% had good to excellent sphincter function. CONCLUSION: Although local failure in patients with T2 tumors has increased since our prior report, the survival, sphincter function, and local salvage rates are acceptable. Local excision and postoperative therapy remains a reasonable alternative to APR in selected patients.     

A Population-Based Comparison of Overall and Disease-Specific Survival Following Local Excision or Abdominoperineal Resection for Stage I Rectal Adenocarcinoma

Purpose

The use of local excision (LE) for early stage rectal adenocarcinoma is increasing due to the associated morbidity of radical resection. To determine if survival in stage I rectal cancer differs following LE or abdominoperineal resection (APR), we analyzed the Surveillance, Epidemiology, and End Results Database.

Material and Methods

We selected patients diagnosed between 1988 and 2002 with T1-2N0M0 rectal adenocarcinoma measuring ≤4 cm who underwent either local excision with (LE + RT) or without adjuvant radiation (LE alone) or APR alone. Overall survival (OS) and disease-specific survival (DSS) curves were calculated using the Kaplan–Meier method. Univariate and multivariate Cox regression was also performed to determine the effect of covariates on OS and DSS.

Results

A total of 2,391 patients were identified including 981 (41 %) treated with APR, 1,018 (43 %) treated with LE alone, and 392 (16 %) treated with LE + RT. With a median follow-up of 69 months, there was no difference in OS or DSS seen between the three groups (p?>?0.05 for all comparisons). When stratifying by T-stage, there was a significant difference in overall survival between LE alone and APR for T2 disease. However, there was no difference in DSS between these two subgroups. There were no other significant survival differences between all comparable subgroups.

Conclusions

In this large population-based study, there was no difference in long-term DSS between patients who underwent an APR compared to selected patients who underwent LE with or without adjuvant radiation. Although these data further reinforce the promising data regarding the selected use of LE, further prospective studies are needed to further elucidate the role of LE in this setting.     

Malignant melanoma of the anorectal region

The charts of 15 patients with malignant melanoma of the anorectal region treated at Roswell Park Cancer Institute in the period 1975–1991 were reviewed. All the lesions except one developed at the pectinate line, in the area of transitional mucosa. Two of the patients at the time of initial presentation had distant metastases. Of the remaining 13, 8 were treated with abdominoperineal resection (APR) and 5 with local excision (LE). The incidence of local recurrence was 50% in the LE group and 22% in the APR group. Patients treated with APR had a 25%, 5-year survival rate compared with 0% for those treated with LE, although one of the latter group died 55 months following LE due to unrelated causes without recurrence. The median survival of those with LE was 15.7 months and of those with APR 13.7 months. © 1995 Wiley-Liss, Inc.     

Local excision for rectal cancer

BACKGROUND AND OBJECTIVES: The aim of this retrospective study is to evaluate the results of local excision (LE) for rectal cancer for curative purposes. METHODS: From 1969 to December 1997, a total of 456 operations were performed for surgical treatment of rectal carcinoma (262 males and 194 females, mean age 66 years). Twenty patients (4.1%) underwent LE (7 males and 13 females, median age 65 years). Patients were selected for LE if they met the following criteria during preoperative staging: tumors staged as T1-T2,N0,M0, grading G1 or G2, and accessible location. Types of LE performed were: 13 transanal excisions (Francillon's technique), 2 Mason surgeries, 2 endoscopic excisions, and 3 transanal endoscopic microsurgeries. RESULTS: There was no in-hospital mortality among LE patients. Thirteen tumors were T1 and 7 were T2; all 20 were adenocarcinoma, 14 G1 and 6 G2. There was no specific morbidity, and aspecific morbidity was minimal (5%). There were no local recurrences, but 2 patients (10%) had secondary lesions. Five-year overall survival following LE was 87.4%. Comparing T1 and T2 tumors treated with abdominoperineal resection (APR) and SSR (17 T1 and 42 T2, all adenocarcinoma), in-hospital mortality and specific morbidity were respectively 1.7% (P = 0.55) and 28% (P = 0.007). There were 5 (8.5%) local recurrences (P = 0.17) and 6 (10.2%) metastatic lesions. Five-year overall survival was similar to LE (88.3%; P = 0.76). CONCLUSIONS: LE for rectal carcinoma might only be successfully performed in selected patients with correct preoperative staging. In the LE cases reported five-year overall survival, local recurrence, and in-hospital mortality were similar to APR and SSR, while there was a statistically significant difference following LE in terms of specific morbidity.     

Wide Perineal Dissection and Its Effect on Local Recurrence Following Potentially Curative Abdominoperineal Resection for Rectal Adenocarcinoma

Ninety-three patients underwent a potentially curative abdominoperineal resection (APR) with a wide perineal dissection to the ischial tuberosities and excision of the entire mesorectum. There were 56 males and 37 females. The median follow-up was 67 months (range 7-240 months). The lymph node clearing technique was used and the median number of lymph nodes cleared was 35 (range 6-89). Eighteen of 93 patients (19%) developed a local recurrence, 12 of whom (13%) developed local recurrence only as the first site of recurrence. In 10 of 18 patients (56%) the distal rectum was the site of the primary rectal cancer. Of the 18 patients, 1 patient had stage I disease, 5 stage II, and 12 stage III. Five of the 18 patients (28%) who developed a local recurrence received adjuvant therapy. The median survival from the time of diagnosis of a local recurrence was 12 months. Histological grade (p = .001), patient age (p = .006), and presence of positive lymph nodes (p = .005) had a statistically significant adverse effect on survival. We believe the surgical technique of abdominoperineal resection with wide perineal resection to the ischial tuberosities and total excision of the mesorectum allowed us to achieve a low local recurrence rate (13%) in a high-risk group of patients. Clearly, the best form of prevention for local recurrence from rectal adenocarcinoma is radical surgical therapy of the primary tumor.     

Surgical outcomes after total mesorectal excision for rectal cancer

BACKGROUND AND OBJECTIVES: This study reviewed the results of surgery for distal rectal cancer following the introduction of total mesorectal excision (TME) for rectal cancer. METHODS: Two hundred sixty-four patients who had undergone elective curative surgical resection of rectal cancer within 12 cm of the anal verge were included. Comparisons were made between patients who had different surgical procedures. RESULTS: The overall operative mortality rate was nil, and the morbidity 39.4%. With a mean follow-up of 34 months (range 5-105 months), local recurrence occurred in 21 of the patients. The 3- and 5-year actuarial local recurrence rates were 9% and 12%, respectively for the whole group. Abdominoperineal resection (APR) was necessary in 65 of 264 (24.6%) of the patients, with a very low local recurrence rate in this subgroup (5% at 3 years). On multivariate analysis, only stage was a significant prognosticator of overall survival (P = 0.012). CONCLUSIONS: With the practice of TME, APR was still necessary in 25% of patients with rectal cancer within 12 cm of the anal verge. Type of surgery and tumor distance from the anal verge influenced local recurrence rates, but only initial tumor stage was associated with long-term survival.     

22例肛管直肠恶性黑色素瘤的临床分析并文献复习

背景与目的：肛管直肠恶性黑色素瘤恶性度高,其治疗方法尚存在争议．本研究旨在总结肛管直肠恶性黑色素瘤的诊断及治疗经验。方法：回顾性分析1977年至2003年江苏省肿瘤医院收治的22例肛管直肠恶性黑色素瘤患者的临床及病理资料．包括临床表现、诊断、手术方式和预后,并复习相关文献。结果：本组22例．占同期收治的大肠恶性肿瘤的0．4％（22／5205）,男性6例,女性16例．中位年龄61岁。主要临床表现为：便血86％（19／22）、肛门疼痛或不适59％（13／22）、肛门口肿物27％（6／22）等。首次就诊误诊率86％（19／22）,术前病理诊断确诊率48％（10／21）。无远处转移16例,伴远处转移6例。行腹会阴联合切除术11例．局部广泛切除术5例（2例复发后补充腹会阴联合切除术）,Park’s术2例．Hartmann’s术1例,乙状结肠双腔造瘘术3例。术后1、3、5年生存率分别为45．4％、18．1％、9．1％,中位生存时间12个月（95％CI：6～18个月）。结论：肛管直肠恶性黑色素瘤少见,易误诊,预后差。腹会阴联合切除术可作为无远处转移的肛管直肠恶性黑色素瘤患者的首选术式。     

直肠系膜全切除术的合理实施

目的 从直肠癌术后局部复发形式探讨直肠系膜全切除(TME)的合理实施及临床意义。方法 分析207例局部复发直肠癌患者的复发形式、治疗情况及治疗效果。结果 吻合口复发71例,直肠系膜复发65例,会阴部复发50例,淋巴结复发59例,多部位复发89例,其他部位少见。第1次行前切除术(AR)的8l例患者中,改行腹会阴联合切除术(APR)者58例;第1次行APR者102例,改行会阴部肿块切除者38例;行全盆及后盆器官切除者15例,补充行淋巴结清除者18例。手术切除率为66．2％(137／207),其中根治性切除率为46．0％(63／137)。172例有完整随访资料的患者中,病灶切除者的5年生存率为23．4％(32／137)．根治切除者的5年生存率为34．9％(22／63)。结论 从局部复发形式来看,TME是中低位直肠癌手术必须遵循的原则,复发患者只要全身条件允许,应再行手术治疗。     

Local excision and chemoradiation for clinical node-negative anal adenocarcinoma

BackgroundGiven the lack of consensus in the surgical treatment of anal adenocarcinoma, practice-patterns demonstrate utilization of organ-preserving techniques. The adequacy of local excision compared to abdominoperineal resection (APR) as a surgical approach for stage II disease is unknown. Our study examines the utilization of local excision in the treatment of stage II anal adenocarcinoma, rates of R0 resection, and differences in overall survival compared to APR.Materials and methodsUsing the National Cancer Database (2004–2016), we retrospectively analyzed patients diagnosed with clinical stage II anal adenocarcinoma who received chemoradiation and surgery. Patient cohorts were assigned based on the surgical procedure they received. Propensity score matching was used to offset selection bias and confounding factors. Treatment approach, pathologic margin status, and overall survival were assessed.ResultsOverall, 359 patients underwent resection of clinical stage II anal adenocarcinoma and received chemoradiation therapy. Of these patients, 87 (24%) underwent local excision, whereas 272 (76%) received an abdominoperineal resection. In a propensity score-matched cohort, patients who underwent local excision were less likely to achieve an R0 resection (40% vs 90%), and more likely to receive adjuvant instead of neoadjuvant chemoradiation. Overall survival was not significantly different between the propensity-matched groups. Surgical approach and pathologic margin status were not independently associated with overall survival.ConclusionsAmong patients with clinical stage II anal adenocarcinoma who received chemotherapy and radiation, complete resection was significantly less likely with local excision compared to abdominoperineal resection, however, overall survival was not affected. Prospective studies of neoadjuvant chemoradiation followed by local excision are warranted.     

Decision analysis as an aid to determining the management of early low rectal cancer for the individual patient.

PURPOSE: Because there are no data available from randomized controlled trials (RCT), a decision analysis was performed to aid in the decision of which option, a local excision with or without radiotherapy or an abdominal perineal resection (APR), should be offered to medically fit patients with early (suspected T1/T2) low (< 5 cm) rectal cancer. METHODS: All clinically relevant outcomes, including complications of surgery and radiotherapy, cure, salvageability after local recurrence, distant disease, and death, were modeled for both options. The probabilities of complications and outcomes after radiotherapy and/or local excision were derived from weighted averages of results from studies conducted between 1969 and 1997. The probabilities for the APR option were extracted from relevant RCTs. Long- and short-term patient-centered utilities for each complication and outcome were extracted from the literature and from expert opinion. RESULTS: The expected utility of local excision (EU = 0.81) for the base case was higher than the expected utility for APR (EU = 0.78). Although the result was sensitive to all variables, local excision was always favored over APR within the plausible ranges of the variables taken one, two, or three at a time. The model illustrated the tension between the patient's perception of a colostomy and the higher recurrence rates with local excision. CONCLUSION: The results of this decision analysis suggest that local therapy for early low rectal cancer is the preferred method of treatment. However, there must be careful preoperative assessment, patient selection, and consideration of patient concerns. In addition, decision analysis may be useful in providing patient information and assisting in decision making.     

Optimizing local control in anorectal melanoma

Background: Wide local excision (WLE) of anorectal melanoma is associated with a high incidence of local recurrence. There is a paucity of literature on adjuvant radiation in this malignancy. Aim: To identify the optimal method of local treatment in anorectal melanoma. Settings and Design: Retrospective study in a tertiary cancer centre. Materials and Methods: Records of 63 patients who presented between 1980 and 2004 were reviewed. Results: Of the 63 patients, 18 were treated by either surgery with or without adjuvant radiation, or by radiation alone. The remaining had advanced disease and were offered only symptomatic treatment. The median overall survival in stage I patients was 12 months, while it was seven and four months in those with stage II and III disease respectively. The median survival in patients treated by WLE with adjuvant radiation (RT), WLE alone or Abdominoperineal resection (APR) was 34, 12 and 10 months respectively. Patients in whom the disease was confined to the mucosa had a better median overall survival than those in whom it had infiltrated beyond the mucosa (102 vs 11 months). The pattern of recurrence following WLE with adjuvant RT or APR was similar. None of the patients who received adjuvant RT after wide excision had a local or nodal recurrence. Conclusion: Local treatment of anorectal melanoma should be individualized. WLE with adjuvant radiation seems to offer good locoregional control without reducing the survival and may be an option of treatment for patients with small, superficial anorectal melanoma. However, APR should be offered for patients with locally advanced disease or as a salvage following recurrence.     

Local excision and postoperative radiotherapy for distal rectal cancer

To assess the outcome following local excision and postoperative radiotherapy (RT) for distal rectal carcinoma.

Seventy-three patients received postoperative radiotherapy following local surgery for primary rectal carcinoma at Princess Margaret Hospital from 1983 to 1998. Selection factors for postoperative RT were patient preference, poor operative risks, and “elective” where conservative therapy was regarded as optimal therapy. Median distance of the primary lesion from the anal verge was 4 cm (range, 1–8 cm). There were 24 T1, 36 T2, and 8 T3 lesions. The T category could not be determined in 5. Of 55 tumor specimens in which margins could be adequately assessed, they were positive in 18. RT was delivered using multiple fields by 6- to 25-MV photons. Median tumor dose was 50 Gy (range, 38–60 Gy), and 62 patients received 50 Gy in 2.5-Gy daily fractions. The tumor volume included the primary with 3–5 cm margins. No patients received adjuvant chemotherapy. Median follow-up was 48 months (range, 10–165 months).

Overall 5-year survival and disease-free survival were 67% and 55%, respectively. Tumor recurrence was observed in 23 patients. There were 14 isolated local relapses; 6 patients developed local and distant disease; and 3 relapsed distantly only. For patients with T1, T2, and T3 lesions, 5-year local relapse-free rates were 61%, 75%, and 78%, respectively, and 5-year survival rates were 76%, 58%, and 33%, respectively. The 5-year local relapse-free rate was lower in the presence of lymphovascular invasion (LVI) compared to no LVI, 52% vs. 89%, p = 0.03, or where tumor fragmentation occurred during local excision compared to no fragmentation, 51% vs. 76%, p = 0.02. Eleven of 14 patients with local relapse only underwent abdominoperineal resection, 8 achieved local control, and 4 remained cancer free. The ultimate local control, including salvage surgery, was 86% at 5 and 10 years. The 5-year colostomy-free rate was 82%. There were 2 patients who experienced RTOG Grade 3 late complications, and 1 with Grade 4 complication (bowel obstruction requiring surgery).

The local relapse rate for patients with T1 disease was high compared to other series of local excision and postoperative RT. Patients with LVI or tumor fragmentation during excision have high local relapse rates and may not be good candidates for conservative surgery and postoperative RT.     

Sphincter-sparing local excision and adjuvant radiation for anal-rectal melanoma.

PURPOSE: To evaluate the outcome and toxicity of a sphincter-sparing treatment strategy in the management of patients with anal-rectal melanoma. PATIENTS AND METHODS: Between 1989 and 2000, 23 patients with invasive anal-rectal melanoma were managed with sphincter-sparing surgical resection and adjuvant radiation. Surgery consisted of primary local excision, as well as dissection for patients with documented regional nodal disease. Adjuvant radiation was delivered using a hypofractionated regimen of 30 Gy in five fractions over 2.5 weeks. Adjuvant systemic therapy was delivered to nine patients: cytotoxic chemotherapy in seven and immunotherapy in two. RESULTS: After a median follow-up of 32 months, 15 patients had relapsed and 15 patients had died. The actuarial 5-year overall, disease-specific, disease-free, and distant metastasis-free survival rates were 31%, 36%, 37%, and 35%, respectively. The actuarial 5-year local and regional nodal control rates were 74% and 84%, respectively. No patient had locoregional failure as the sole site of failure and no patient required salvage abdominoperineal resection (APR). By univariate analysis, patients with nodal disease at presentation had a decreased actuarial 5-year disease-specific (0% v 45%, P =.004), disease-free (0% v 45%, P <.001), and distant metastasis-free survival (0% v 42%, P <.001). The actuarial complication-free survival rate was 71%. Two patients developed mild scrotal edema (grade 1), and four patients developed moderate proctitis requiring prolonged medical management (grade 2). CONCLUSION: Sphincter-sparing local excision and adjuvant radiation is well tolerated and can effectively control local-regional disease while avoiding the functional morbidity of APR.     

Influence of hospital volume on the frequency of abdominoperineal resection and long-term oncological outcomes in low rectal cancer.

AIM: Studies analysing the outcome after resection of low rectal cancer that has not infiltrated the anal sphincter reveal poorer long-term outcomes after abdominoperineal resections (APR) in comparison with low anterior resections (LAR). Further, a relationship between the frequency of APR and LAR for low rectal cancer and hospital volume is known. Our aim was to investigate the independent impact of hospital volume and type of resection on oncological outcomes after resection of low rectal cancer. METHOD: In a prospective multi-centre observational study of 1557 patients with low rectal cancer undergoing LAR or APR, the long-term oncological outcomes were analysed for their dependence on hospital volume and type of procedure. RESULTS: Univariate analysis revealed that patients undergoing APR had a higher local recurrence rate (p = 0.022) and shorter disease-free survival (p < 0.001) than patients undergoing LAR, while hospital volume showed merely a tendency to impact the local recurrence rate (p = 0.060). With regard to disease-free survival, no dependence on hospital volume was to be found (p = 0.201). The rate of APR was significantly associated with hospital volume (p < 0.001). Multivariate analysis revealed an independent impact of hospital volume on local recurrence rate, while disease-free survival was influenced by the type of surgical procedure performed. CONCLUSION: In the surgical treatment of low rectal cancer the hospital volume has a major impact on outcome. The type of procedure does not affect the local recurrence rate but the disease free survival.     

The influence of total mesorectal excision on local recurrence and survival in rectal cancer patients: a population-based study in Greater Amsterdam

BACKGROUND AND OBJECTIVES: To determine retrospectively in a population-based setting, the influence of the introduction of total mesorectal excision (TME) on local recurrence and survival in patients with rectal carcinoma. METHODS: All rectal carcinomas diagnosed during 1988-1991 (979 patients, conventional surgery with blunt dissection of the rectum) and 1998-2000 (890 patients, TME resection) were selected from the Amsterdam Cancer Registry. For all patients who underwent a macroscopically radical resection in the absence of distant dissemination, information on the occurrence of local recurrent disease and distant metastasis was collected. RESULTS: The cumulative 5-year recurrence rate decreased significantly from 20% for patients diagnosed in 1988-1991 to 11% in 1998-2000. Stage (T-category, nodal status), period of diagnosis (conventional surgery vs. TME resection), radiotherapy, and chemotherapy were independent variables of local recurrence in multivariate analysis. There was a non-significant trend for improved 5-year relative survival for all rectal carcinoma cases from 52% (95% CI 48-55) for patients diagnosed in 1988-1991 to 59% (95% CI 55-63) in 1998-2000. CONCLUSIONS: A significant decrease in local recurrence and a trend for improved relative survival were observed. The broad introduction of TME and the shift towards preoperative radiotherapy are the most plausible explanations for these observations.     

Comparison of abdominoperineal resection and low anterior resection in lower and middle rectal cancer

IntroductionThis study aimed to investigate local control and survival rates following abdominoperineal resection (APR) compared with low anterior resection (LAR) in lower and middle rectal cancer.MethodsIn this retrospective study, 153 patients with newly histologically proven rectal adenocarcinoma located at low and middle third that were treated between 2004 and 2010 at a tertiary hospital. The tumors were pathologically staged according to the 7th edition of the American Joint Committee on Cancer (AJCC) staging system. Surgery was applied for 138 (90%) of the patients, of which 96 (70%) underwent LAR and 42 were (30%) treated with APR. Total mesorectal excision was performed for all patients. In addition, 125 patients (82%) received concurrent (neoadjuvant, adjuvant or palliative) pelvic chemoradiation, and 134 patients (88%) received neoadjuvant, adjuvant or concurrent chemotherapy. Patients’ follow-up ranged from 4 to 156 (median 37) months.ResultsOf 153 patients, 89 were men and 64 were women with a median age of 57 years. One patient (0.7%) was stage 0, 15 (9.8%) stage I, 63 (41.2%) stage II, 51 (33.3%) stage III and 23 (15%) stage IV. There was a significant difference between LAR and APR in terms of tumor distance from anal verge, disease stage and combined modality therapy used. However, there was no significant difference regarding 5-year local control, disease free and overall survival rates between LAR and APR.ConclusionLAR can provide comparable local control, disease free and overall survival rates compared with APR in eligible patients with lower and middle rectal cancer.     

Comparison of three-year oncological results after restorative low anterior resection,non-restorative low anterior resection and abdominoperineal resection for rectal cancer

IntroductionOncological outcome might be influenced by the type of resection in total mesorectal excision (TME) for rectal cancer. The aim was to see if non-restorative LAR would have worse oncological outcome. A comparison was made between non-restorative low anterior resection (NRLAR), restorative low anterior resection (RLAR) and abdominoperineal resection (APR).Materials and methodsThis retrospective cohort included data from patients undergoing TME for rectal cancer between 2015 and 2017 in eleven Dutch hospitals. A comparison was made for each different type of procedure (APR, NRLAR or RLAR). Primary outcome was 3-year overall survival (OS). Secondary outcomes included 3-year disease-free survival (DFS) and 3-year local recurrence (LR) rate.ResultsOf 998 patients 363 underwent APR, 132 NRLAR and 503 RLAR. Three-year OS was worse after NRLAR (78.2%) compared to APR (86.3%) and RLAR (92.2%, p < 0.001). This was confirmed in a multivariable Cox regression analysis (HR 1.85 (1.07, 3.19), p = 0.03). The 3-year DFS was also worse after NRLAR (60.3%), compared to APR (70.5%) and RLAR (80.1%, p < 0.001), HR 2.05 (1.42, 2.97), p < 0.001. The LR rate was 14.6% after NRLAR, 5.2% after APR and 4.8% after RLAR (p = 0.005), HR 3.22 (1.61, 6.47), p < 0.001.ConclusionNRLAR might be associated with worse 3-year OS, DFS and LR rate compared to RLAR and APR.     

Local recurrence after breast conservation therapy for early stage breast carcinoma: detection, treatment, and outcome in 266 patients. Dutch Study Group on Local Recurrence after Breast Conservation (BORST)

BACKGROUND: Controversy exists concerning the roles of mammography and physical examination in the detection of local recurrence after conservation therapy for breast carcinoma. In addition, the prognostic factors for and optimal treatment of patients with local recurrence are uncertain. METHODS: At eight radiotherapy institutes, two cancer institutes, and one surgical clinic in the Netherlands, regular follow-up of patients who underwent breast conservation therapy between 1980 and 1992 identified 266 patients with local recurrence in the breast. These patients exhibited no clinical signs of distant metastases at the time of diagnosis of the local recurrence. Data on the method of detection were available for 189 patients (72%). Local recurrence was diagnosed by mammography alone in 47 cases (25%). Of all patients, 85% underwent salvage mastectomy, 8% underwent local excision, 4% received systemic treatment only, and 3% remained untreated. Specimens of the primary tumor were available for review from 238 of the 266 patients (89%). RESULTS: Local recurrences detected by mammography alone were smaller than those detected by physical examination (P = 0.04). At 5 years from the date of salvage treatment, the overall survival rate for all 266 patients was 61% (95% confidence interval [CI], 55-67%), and the distant recurrence free survival rate was 47% (95% CI, 40-53%). For the 25 patients with noninvasive recurrence, these figures were 95% and 94%, respectively. Skin involvement, the extent of recurrence (< or = 10 mm vs. >10 mm), and both lymph node status and histologic grade of the primary disease were strong predictors for distant metastases in patients with invasive recurrence. CONCLUSIONS: Patients with invasive local recurrence more than 1 cm in size are at a substantial risk for distant disease. The better distant disease free survival for patients with recurrence measuring 1 cm or less may indicate that early detection can improve the treatment outcome. Recurrence with skin involvement should be considered generalized disease.     

Role of local excision in the treatment of rectal cancer

Local excision (LE) of properly selected rectal cancers can provide long-term survival, with minimal morbidity, negligible mortality, and excellent functional results. The role of LE has evolved over the past century. Initially, to avoid the excessive mortality of abdominal surgery, aggressive LE was performed to control the symptoms of rectal cancer. As abdominal surgery became safer, LE was restricted for use in palliation or high-risk patients. Better preoperative tumor staging resulted in an expanded role for LE, including curative-intent treatment of selected T(1-2) rectal cancers. Techniques for LE include snare polypectomy, transanal excision, transanal endoscopic microsurgery, and posterior approaches. The high local recurrence rate and compromised survival reported in modern series, despite efforts to properly select patients with cancers suitable for LE, have convinced the authors to restrict the use of curative-intent LE in good-risk patients only to the most favorable rectal cancers. Close follow-up after LE is critical, because radical surgical salvage is usually possible if recurrence is identified promptly. Whether adjuvant chemoradiation can expand the role of curative intent LE remains controversial.     

A comparison of wide local excision with abdominoperineal resection in anorectal melanoma

Anorectal melanoma is a rare condition and its surgical management is controversial. Seventeen large case series from over the past 10 years were reviewed. The survival of patients treated by either abdominoperineal resection (APR) or wide local excision (WLE) was analysed according to the stage of the disease. Comparison of the survival of patients who underwent APR with those who underwent WLE showed no statistically significant advantage for either procedure in patients at all disease stages. APR should therefore only be performed when local excision is not possible or for palliative purposes.