Colon and rectal carcinoma. Forty years and 1400 cases

One thousand four hundred cases of colorectal carcinoma were treated primarily at the Wake Forest University Medical Center between 1945 and 1985. The surgical approach was constant in all patients without obvious stage IV disease: wide resection, including at least the primary-level and intermediate-level lymph nodes. There were 812 women and 588 men in the series. Sixty-eight per cent of the 1400 cancers occurred in the rectosigmoid, but only 53 per cent of the last 300 cases were in this region. Initial staging showed 560 cases (40%) of local disease, 504 cases (36%) of regional disease, and 336 cases (24%) of distant disease. Cecal, ascending, hepatic, and transverse lesions were most often associated with stage IV disease. Among the 1115 patients with long-term follow-up, 44 per cent with stage I disease, 37 per cent with stage II disease, 24 per cent with stage III disease, and 6 per cent with stage IV disease had survived for 5 years or longer. There were no differences when 5-year survival was correlated with site. This review provided no evidence that wide resection leads to increased long-term survival.     

青年人大肠癌的临床特点及外科治疗

笔者对1990年1月—2004年12月间收治的30岁以下大肠癌56例的临床资料进行回顾性分析。 全组误诊率达67.1％，癌肿以直肠癌和右半结肠癌为主，病理分期Dukes C，D期占87.5％，分化不良型占75.0％。根治性手术率占57.1％，淋巴结转移率62.0％，根治性手术5年生存率为23.0％，姑息性手术3年生存率为10％，无5年生存。 提示 青年人大肠癌的发病率在增高，以直肠癌和右半结肠癌多见，而且恶性程度和误诊率高，手术根治率和5年生存率低。提高对本病的认识，早期诊断，及时合理的治疗，是提高生存率的关键。     

青年与老年直肠癌临床对比分析

目的探讨青年与老年直肠癌的临床、病理及预后差异。方法中国医学科学院肿瘤医院自1990年1月至2000年1月收治40岁以下直肠癌患者138例（青年组），65岁以上者163例（老年组），对这组患者的病例资料进行生存分析和预后的多因素分析。结果青年组Ⅲ期直肠癌患者比例（53．6％，74／138）明显高于老年组（34.3％，55／163）；P=0．001；青年组中黏液腺癌和低分化腺癌患者比例（28．2％，39／138）也高于老年组（10．4％，17／163）P〈0．001。青年组和老年组5年生存率分别为50．4％和64．1％．两组比较差异有统计学意义（P〈0．05）；而按照TNM分期进一步分析显示．同期别两组的生存率差异均无统计学意义（P〉0．05）。多因素分析结果显示，肿瘤T分期（P=-0．001）和淋巴结转移（P〈0．05）是影响两组患者预后的独立因素。结论与老年直肠癌相比，青年直肠癌患者的病期较晚、肿瘤分化程度较低，影响其预后；但相同病期者生存率相似。早期诊疗是提高直肠癌总体生存率的关键。     

An evaluation of the role of rectal endosonography in rectal cancer.

The applications of rectal endosonography (ES) in the preoperative staging and follow-up of patients with rectal cancer have been investigated. Endosonography is an accurate method of staging local invasion (93%) preoperatively and is superior to digital examination (58%) and computed tomography (CT) (74%). In addition, ES can predict mesorectal lymph node involvement with an accuracy of 83% which compares favourably with CT (57%). Extrarectal, locally recurrent cancer can be detected using ES and established recurrence assessed more objectively.     

Colon and rectal complications after heart and lung transplantation

BACKGROUND: Gastrointestinal complications of solid organ transplantation have been well described, but little attention has been paid to colorectal disorders in particular. The purpose of this study was to identify the incidence and severity of colorectal complications among a large cohort of heart and lung transplant recipients. STUDY DESIGN: We reviewed the medical records of heart, lung, and heart-lung transplant recipients at a single institution between 1978 and 2004. Complications were identified based on need for consultation, endoscopy, or operation by a colorectal surgeon after transplantation. RESULTS: Of 1,012 patients who received transplantations (530 heart, 435 lung, 47 heart-lung), 56 patients (6%) required evaluation for 84 colorectal problems. Incidence of complications was 7% in lung transplant recipients, 6% in heart-lung transplant recipients, and 4% in heart transplant recipients. Forty-four events (52%) were considered major (diverticulitis, perforation, malignancy, and other) and 40 (48%) were minor (polyps, pseudo-obstruction treated medically or endoscopically, benign anorectal disease, and other). Twenty-three (27%) required colectomy and 9 (10%) necessitated anal operation. Thirty-six (43%) required less-invasive interventions (endoscopy, minor anorectal procedures, and other). Eighteen (21%) were treated with medical therapy alone. Six patients died from colorectal disease (7%). CONCLUSIONS: Colorectal complications are a considerable source of morbidity and mortality after heart and lung transplantation. These complications occur more frequently in patients who undergo lung and heart-lung transplantation as compared with heart transplantation alone.     

Colon and rectal carcinoma in the west of Scotland. Symptoms, histologic characteristics, and outcome

Multiple clinical and pathologic factors have been analyzed retrospectively for a group of 456 patients with colon and rectal cancer treated in Glasgow over a span of 4 years. Sixty-five percent of these patients underwent curative resection, and another 16 percent had palliative resection. Obstruction and perforation (present in 19 and 5 percent, respectively) were associated with the highest operative mortality (17 percent for both) of any presenting symptom. However, when only patients who survived curative resection were considered, obstruction carried only a slightly lower 5 year survival than did other common symptoms, whereas perforation still led to only a 10 percent 5 year survival. Neither mucin production nor degree of differentiation influenced survival significantly. Adherence of the primary tumor to an adjacent organ was associated with a very poor prognosis (9 percent 5 year survival), but curative resection of the involved organs with the primary tumor increased the 5 year survival to 34 percent. Patterns of recurrence were noted to be markedly different for each primary site and for different stages. Dukes' stage was the most important overall determinant of prognosis.     

Prostate cancer in a young adult : a case report

We report a case of prostate cancer in a 41-year-old male. The patient initially visited another institution with a chief complaint of left breech pain. He was referred to our hospital for further investigation. Serum level of PSA was 267ng/ml and multiple bone metastases were found on bone scintigram. Digital rectal examination revealed a stony-hard prostate. Computed tomography showed multiple lung and lymph node metastases. Transperineal needle biopsy of the prostate revealed moderately differentiated adenocarcinoma (Gleason score 4＋5) frombilateral lobes (the 3th Edition). The patient was diagnosed with cT4N1M1c prostate cancer and maximal androgen blockade therapy was commenced.     

Surgeon-related factors and outcome in rectal cancer.

OBJECTIVE: To determine whether surgical subspecialty training in colorectal surgery or frequency of rectal cancer resection by the surgeon are independent prognostic factors for local recurrence (LR) and survival. SUMMARY BACKGROUND DATA: Variation in patient outcome in rectal cancer has been shown among centers and among individual surgeons. However, the prognostic importance of surgeon-related factors is largely unknown. METHODS: All patients undergoing potentially curative low anterior resection or abdominoperineal resection for primary adenocarcinoma of the rectum between 1983 and 1990 at the five Edmonton general hospitals were reviewed in a historic-prospective study design. Preoperative, intraoperative, pathologic, adjuvant therapy, and outcome variables were obtained. Outcomes of interest included LR and disease-specific survival (DSS). To determine survival rates and to control both confounding and interaction, multivariate analysis was performed using Cox proportional hazards regression. RESULTS: The study included 683 patients involving 52 surgeons, with > 5-year follow-up obtained on 663 (97%) patients. There were five colorectal-trained surgeons who performed 109 (16%) of the operations. Independent of surgeon training, 323 operations (47%) were done by surgeons performing < 21 rectal cancer resections over the study period. Multivariate analysis showed that the risk of LR was increased in patients of both noncolorectal trained surgeons (hazard ratio (HR) = 2.5, p = 0.001) and those of surgeons performing < 21 resections (HR = 1.8, p < 0.001). Stage (p < 0.001), use of adjuvant therapy (p = 0.002), rectal perforation or tumor spill (p < 0.001), and vascular/neural invasion (p = 0.002) also were significant prognostic factors for LR. Similarly, decreased disease-specific survival was found to be independently associated with noncolorectal-trained surgeons (HR = 1.5, p = 0.03) and surgeons performing < 21 resections (HR = 1.4, p = 0.005). Stage (p < 0.001), grade (p = 0.02), age (p = 0.02), rectal perforation or tumor spill (p < 0.001), and vascular or neural invasion (p < 0.001) were other significant prognostic factors for DSS. CONCLUSION: Outcome is improved with both colorectal surgical subspecialty training and a higher frequency of rectal cancer surgery. Therefore, the surgical treatment of rectal cancer patients should rely exclusively on surgeons with such training or surgeons with more experience.     

Locally recurrent rectal cancer.

Local recurrence (LR) varies from less than 4% to greater than 50%; several tumor factors and operative techniques may influence rate of LR. Of greatest interest has been the considerable inter-surgeon variation, even within the same institution. An LR rate of less than 10% has been consistently reported by those who use total mesorectal excision even without any form of adjuvant therapy, either preoperatively or postoperatively. These findings raise important questions about surgical technique, subspecialty teaching, place of adjuvant therapy and quality assurance. The management of LR by a multispecialty team and multimodality treatment including preoperative chemoradiation, surgical resection and intraoperative radiotherapy provides encouraging results in terms of better local control and prolonged survivorship in carefully selected patients. These uncontrolled results justify further evaluation of these salvage operations in a more controlled manner that should include repercussions on the quality of life of the patients.     

Colon cancer and apoptosis

BACKGROUND: The implementation of new therapeutic options for the management of metastatic colon cancer mandates a revisit to apoptosis and its role in colon cancer tumorigenesis with an emphasis on the mechanisms leading to chemotherapeutic resistance and immune system evasion of colon cancer cells. DATA SOURCES: Literature regarding molecular apoptosis mechanisms and the role of apoptosis in colon cancer progression are reviewed by this article. CONCLUSION: Programmed cell death has rapidly emerged as a potential target for cancer treatment at various stages of tumor progression. Chemoprevention, immuno-regulation, and metastasis are prospective targets by which apoptotic mechanisms could be utilized in the prevention and management of tumorigenesis. Understanding how defects in the death receptor pathway of apoptosis permit colon cancer cells to escape the immune system would allow for treatment options whereby the body's immune system could again recognize and eliminate unwanted cells.     

Colon cancer in pregnancy

Colon cancers arise only rarely in the course of a pregnancy. Yet colon obstruction, perforation and metastatic spread seem to occur more frequently in this setting than with the average colon cancer. Perhaps this is due to the immunotolerance which accompanies pregnancy. No case of epidermoid (squamous cell) cancer of the colon has been previously described in a pregnant woman. This conjunction has a catastrophic prognosis: the diagnosis of colon tumor is delayed since symptoms are masked by the pregnancy, and epidermoid colon cancer is a particularly aggressive lesion. A major sub-diaphragmatic surgical procedure can be performed with reasonable safety to mother and fetus.Radiotherapy is contraindicated. Neo-adjuvant chemotherapy can be administered although the risks to the fetus are not well known. During the first trimester, a therapeutic abortion can be proposed to optimise the treatment of the mother. During the second and third trimesters, treatment of the mother exposes the fetus to the risk of malformations or premature delivery; delay in maternal treatment in hopes of prolonging the pregnancy in order to obtain a viable neonate diminish the chances of maternal survival.     

Asymptomatic renal neoplasms in the rectal cancer patient.

Although cancers of the rectum and kidney are common malignancies the incidence of coexistent rectal and renal primary tumors is unclear. Our objective was to determine the true incidence of synchronous neoplasms of the rectum and kidney. The computed tumor registry database at the City of Hope National Medical Center was queried for patients with synchronous rectal cancer and renal neoplasms presenting between August 1990 and August 2000. During the 10-year period there were 182 patients presenting for treatment of rectal carcinoma. Of these seven (3.8%) were found to have an asymptomatic renal neoplasm. Four patients underwent synchronous resection. Three patients underwent staged renal and rectal resections. The pathology of the renal lesions included renal cell carcinoma in six and an oncocytoma in one patient. Rectal lesions were all adenocarcinomas and all were within 10 cm of the dentate line. Three patients required abdominoperineal resections and four were treated with low anterior resections. Two patients presented with hepatic metastasis at the time of diagnosis. Five patients remain free of disease. Two patients died of persistent and recurrent disease 6 months and 40 months after operation. With the exception of one patient who required prolonged intubation because of severe Parkinson's disease there were no major complications after simultaneous resection of both renal and rectal disease. Simultaneous asymptomatic renal neoplasms may be found in up to 3.8 per cent of patients with rectal cancer. Synchronous lesions may be treated simultaneously without significant morbidity.