Elective postoperative radiotherapy after incomplete resection of colorectal cancer

It is known that patients with incompletely resected epithelial cancers are at high risk of local recurrence. A prospective study to determine whether elective postoperative radiotherapy can decrease the incidence of local recurrence and thus improve survival of those patients with an incompletely resected tumor was made of 125 irradiated patients with locally advanced colorectal cancer (B₂ C₁, C₂) 78 patients had rectosigmoid tumors and 47 had colonic cancers. Complete resection (R0) was performed in 94 patients (75 per cent). Thirteen (10 per cent) had microscopic (R1) and 18 (14 per cent) had gross residual disease (R2). Local control and survival (average follow-up, 38 months) of patients with microscopic residual cancer (R1) were 84 per cent (11/13) and 77 per cent (10/13) respectively. These results were identical to those obtained in patients without residual disease (R0). Patients with gross residual disease (R2) had a local control of 50 per cent (9/18) and a survival of 39 per cent (7/18). Radiation complication occurred in seven of 125 patients (6 per cent). One patient died, of radiation enteritis. One patient required a nephrostomy. The remaining five patients were treated conservatively. Elective postoperative radiotherapy given to patients who had incomplete resection of a colorectal cancer prevented local recurrence in the majority and may have increased survival.     

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.     

Malignant retrorectal tumors: 28 years' experience at memorial sloan-kettering cancer center

From 1949 to 1977, 39 patients with localized malignant retrorectal tumors were treated at Memorial Sloan-Kettering Cancer Center. Chordomas were the most frequent histologic type (38 per cent of patients) followed by neurogenic tumors (15 per cent) chondrosarcomas, hemangiopericytomas, and embryonal adenocarcinomas (8 per cent each). Treatment consisted of surgical excision in 28 patients (18 of whom received adjuvant radiotherapy and/or chemotherapy). Ten patients were treated nonsurgically, receiving radiation and/or chemotherapy alone. Large tumors were most successfully managed by a combined surgical approach consisting of exploratory celiotomy, rectal mobilization, and bilateral hypogastric artery (with middle sacral artery and vein) ligation, followed by transsacral tumor excision with incontinuity sacrectomy. For all treated patients, survival at 5, 10, 15 and 20 years was 69 per cent, 50 per cent, 37 per cent and 20 per cent, respectively. Long-term disease-free survival (17 to 25 years post treatment) was noted in six patients Read at the meeting of the American Society of Colon and Rectal Surgeons, Colorado Springs, Colorado, June 7 to 11, 1981.     

Curative local excision in the treatment of carcinoma of the rectum

A safe, simple technique of curative local excision is used for early invasive carcinoma of the rectum. Strict criteria were applied in selecting patients for curative local excision: (1) the tumor was less than 3cm in diameter; (2) there were no clinically involved pelvic lymph nodes; (3) the tumor had a pedicle or pseudopedicle, and (4) subsequent histopathologic examination showed that the tumor was confined to the mucosa and submucosa of the bowel wall and completely excised. Curative local excision in 16 patients had no operative mortality or morbidity. The five-year cancer specific survival was 100 per cent, which compares favorably with the 88 per cent cancer specific survival rate in 268 patients managed by conventional curative resection for Dukes' stage A tumors. When the 7.1 per cent operative mortality of resection was additionally considered, the five-year survival fell to 81 per cent. The probability of lymph-node metastases in primary rectal tumors confined to the mucosa and submucosa was found to be 6.2 per cent irrespective of their diameter,i.e., slightly less than the mortality of resection. Supported by a grant from the Anti-Cancer Council of Victoria.     

Total pelvic exenteration for locally advanced rectal carcinoma

Total pelvic exenteration was performed in 31 patients (30 males and 1 female) who had rectal cancers involving adjoining pelvic structures. Twenty-nine patients had primary tumors and two had recurrent diseases after previous abdominoperineal resection. Preoperative irradiation was used in nine patients with fixed tumors. When performing the surgical procedure, we also actively employed lateral node dissection to make the operation more radical. Three patients (one with primary tumor and two with recurrent) underwent the exenteration with partial sacrectomy because of the sacral involvement and they all died of local failure within 15 months. The overall 5-year survival rate was 52 percent for all patients and 56 percent for those who had primary tumors. The results suggest that total pelvic exenteration with lateral node dissection should be performed for locally advanced rectal cancer if the tumor is not completely fixed to the pelvic wall and preoperative irradiation should be used to convert a fixed tumor to a resectable one.     

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.     

Adenocarcinoma of the appendix

Twenty-two cases of appendiceal adenocarcinoma are reviewed. Correct diagnosis was not made preoperatively in any case, and in only 38 per cent of the cases was it made intraoperatively. Thirty-two per cent of the patients had second primary neoplasm, and in more than half of these cases, the neoplasms were most likely concurrent with the appendiceal tumors. The overall five-year survival rate of the 22 patients was 18.7 per cent, with a 43.4 per cent survival rate in the curative resection group. The grade of tumor differentiation was the only significant factor in determining curative resectability and prognosis.     

Resectability of rectal cancers still fixed after radio-chemotherapy: evaluation by digital rectal examination, MRI, and intraoperative examination

Eighteen patients with primary fixed rectal cancer as judged by digital rectal examination (DRE) were included. They all had radiation therapy with 60 Gy in 30 fractions combined with oral UFT and Isovorin. All patients were evaluated by DRE and magnetic resonance imaging (MRI) before and after treatment. After 5–7 weeks, eight tumors were mobile on DRE. All eight patients had an R0 resection. Of the remaining ten patients with fixed rectal cancer, eight had an R0 resection. One patient had an R1 resection and one patient was not operated. Intraoperative bimanual rectal examination was performed with one finger through the anus and one hand in the rectovaginal/rectovesical fossa before resection was performed. After chemo-radiation DRE correctly predicted the tumor to be advanced or not in 12/17 patients, MRI in 14/17, and bimanual rectal examination in 17/17 patients.     

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.     

Colorectal carcinoma in patients less than 40 years of age

Between 1960 and 1979, 37 patients, ranging in age from 18 to 40 years, were treated for colorectal cancer. Symptoms typical of colorectal malignancy had been present for an average of 10.4 months; a positive family history, previous colonic disease, or immunosuppression was present in 22 patients (59 per cent). Distribution of lesions was unusual in that only 40 per cent were within reach of the sigmoidoscope, and only 7.5 per cent could be palpated on rectal examination. Dukes' staging at diagnosis was improved in distribution to that reported in the adult population (51 per cent localized vs. 40.1 per cent). Histologic characteristics of the tumors were not unusual; however, incidence of poorly differentiated (18.9 per cent) and mucin-producing (10.8 per cent) cancers was increased. Perineural invasion was associated with disseminated disease. Vascular invasion was associated with disseminated disease and poor prognosis. Overall fiver-year survival was 56.8 per cent. Five-year survival in 24 patients undergoing potentially curative resection increased to 70.8 per cent. Colorectal carcinoma in patients under 40 years of age is unusual, and delay in diagnosis is common. The distribution of lesions is more homogeneous than that seen in older patients, and high-grade malignancies are more frequent. Survival data in this series are more favorable than those generally reported. Improved five-year survival following potentially curative resection (70.8 per cent) stresses the need for early diagnosis and treatment Read at the meeting of the American Society of Colon and Rectal Surgeons, Hollywood, Florida, May 11 to 16, 1980. Supported in part by the Roessler Foundation and the American Cancer Society.     

Influence of surgical techniques on survival in patients with colorectal cancer

This review was undertaken in an attempt to accumulate and critically evaluate all evidence that suggests that special techniques may alter survival rates of patients undergoing surgery for large-bowel cancer. Data suggesting reduced survival with a distal margin of resection less than 5 cm in patients undergoing anterior resection were found to be inconsistent.En bloc removal of the primary tumor and an adhesed adjacent structure seemed important, for 30 to 60 per cent survival has been reported using this approach, and adhesions were found to contain malignant cells at the interface of the primary tumor and adjacent structure in 40 to 100 per cent of patients. No statistically significant differences in survival rates were found in studies comparing conservative segmental bowel resection with radical hemicolectomy. This was true for colonic as well as rectal resections; while patient morbidity was not markedly increased for radical colectomy, it was found to be much greater with radical rectal resections. No data to support the use of “no-touch techniques” could be uncovered. Data to support the use of techniques for control of intraluminal tumor cells were sparse; however, because these maneuvers cost the patient little in terms of added morbidity, they should be used. Important aspects of the techniques for large-bowel surgery need to be investigated by prospective controlled clinical trials.     

Palliative resection for colorectal carinoma

In an attempt to identify those patients who would benefit from palliative resection of the colon or rectum and those who would not, an analysis of ten years of resections was undertaken. For the 81 patients who underwent palliative resection, the operative mortality was 10 per cent and the postoperative morbidity was 50 per cent. The mean survival was 11.4 months and the median survival nine months. Poor prognostic factors deduced were patients with extensive liver metastases, those over the age of 75 years, and a previous history of cardiovascular disease. It is believed that patients with a combination of these factors may not benefit from palliative resection. Otherwise, resections satisfactorily relieve patients of the symptoms of impending obstruction and rectal bleeding and are, therefore, believed to be worthwhile. Read at the meeting of the american Society of Colon and Rectal Surgeons, Hollywood, Florida, May 11 to 16, 1980.     

Prognostic factors for advanced diffuse histiocytic lymphoma following treatment with combination chemotherapy.

Combination chemotherapy can dramatically improve the survival of those patients with advanced diffuse histiocytic lymphoma who enter complete remission. The age, sex, stage, constitutional symptoms, sites of disease and tumor mass of 56 consecutive patients with advanced diffuse histiocytic lymphoma were analyzed as prognostic factors. Twenty-four patients received cytoxan, vincristine, procarbazine and prednisone (C-MOPP) and 32 patients received bleomycin, adriamycin, cytoxan, vincristine and prednisone (BACOP). In 26 of 56 (46 per cent) a complete remission was achieved, in 21 of 56 (38 per cent) a partial remission and in nine of 56 (16 per cent) no response. Median survival with a complete remission was not reached at three years with 82 per cent still alive, but was significantly greater than with a partial remission (7.6 months median) or no response (3.2 months median). Survival of those with a partial remission and no response did not differ statistically. Stage IV disease, bone marrow involvement, gastrointestinal involvement and a tumor mass greater than 10 cm in diameter in a single location were all poor prognostic factors. No other analyzed factor significantly affected survival in this study. Complete response rates and survival curves for patients treated with C-MOPP were similar to those treated with BACOP.     

Multimodality therapy for malignant mesothelioma based on a study of natural history

Forty patients with malignant mesothelioma were studied to assess the efficacy of current treatment concepts and to examine clinical features at diagnosis which correlate with prognosis. Sixty-three per cent had been exposed to asbestos. Women, patients who presented with limited disease and those who had had symptoms for more than six months before diagnosis survived significantly longer (p < 0.02). Patients who presented with dyspnea had a median survival of 14.2 months, twice the survival (7.8 months) of patients whose first complaint was of chest pain (p < 0.32). No prognostic significance could be found for a history of smoking or asbestos exposure, pathologic subtype or pleural versus peritoneal presentation.Thirty of the 40 patients underwent open thoracotomy or laparotomy for diagnosis. The median survival of the 10 patients in whom a subtotal resection was attempted was 15 months, contrasted to 8.5 months for the 24 patients who underwent only an open biopsy.Five patients received aggressive radiotherapy, four immediately following subtotal surgical resection and one after biopsy alone. These patients survived a median of 9.21 months, with one patient disease-free at 52 months after diagnosis.Twenty-nine patients received chemotherapy. A partial response occurred in nine of 22 (40 per cent) previously untreated patients given Adriamycin^TM-containing regimens. Patients who received chemotherapy survived a median of 15 months.In contrast, five patients (four who presented with limited disease) who accepted only supportive care survived a median of only 4.2 months after diagnosis.The treatment of mesothelioma is often based on protocols designed for sarcomas. Unlike patients with sarcoma, who generally die of metastatic disease, 78 per cent of our patients who could be evaluated died of complications of their local primary disease.We conclude that mesothelioma is sufficiently different from sarcoma to justify its treatment as a separate disease entity. Otherwise healthy patients with disease limited to a single hemithorax should be offered maximal tumor resection, followed by postoperative radiation therapy to areas of residual disease, followed by chemotherapy with a regimen containing Adriamycin.     

Role of p53 and p21/WAF1 detection in patient selection for preoperative radiotherapy in rectal cancer patients

BACKGROUND: Recent studies showed that p53 and p21 may play major roles in determining tumor radiosensitivity through the apoptosis pathway. The aim of this study was to investigate the predicting value of radiosensitivity in human rectal carcinoma. METHODS: p53 and p21/WAF1 expressions in formalin fixed, paraffin-embedded, preradiation biopsy samples from 49 patients with primary rectal carcinoma were analyzed immunohistochemically. p53 and p21 expressions and their relationships with histopathologic changes after radiation and other clinical features were evaluated. RESULTS: Expressions of p53 and p21/WAF1 were 49 and 28.6 percent, respectively. In 36.7 percent of total tumors, significant histopathologic effect can be observed. There was a significant inverse expression of p53 and p21. Most of the p53(+) or p21(–) tumors were radioresistant, and the majority of p53(–) or p21(+) tumors were radiosensitive. Tumors size in the radiosensitive, p53(–), or p21(+) group decreased more significantly than in radioresistant, p53(+), or p21(–) group (P<0.01), and patients with radioresistant, p53(+), or p21(–) tumors had more local recurrence, more distant metastasis, and a shorter five-year survival rate than those with radiosensitive, p53(–), or p21(+) tumors, but without statistic significance. No statistically significant correlation can be observed between other tumor clinical features and radiosensitivity, p53, or p21 expressions. CONCLUSION: Immunohistochemistry detection of p53 and p21 expressions may be useful parameters for more radiosensitive patients selected for preoperative radiotherapy.Supported by a Grant-in-aid for Scientific Research from the Ministry of Education, Science and Culture of Japan.Presented at the meeting of the Asian-Pacific Congress of Gastroenterology, Yokohama, Japan, September 19 to 23, 1996.     

Site,emergency, and duration of symptoms in the prognosis of colorectal cancer

Four prognostic factors,i.e., site of the tumors, mode of presentation, duration of symptoms, and pathologic staging, were correlated to the results of surgical treatment,i.e., curative resectability, postoperative complications and mortality, and five-year survival, in 161 patients operated upon for colorectal cancer. Only 31 (19 per cent) of the growths were right-sided; 71 patients (44 per cent) had symptoms less than six months. Fifty-four of them had a localized cancer; a radical procedure was performed in 114 (71 per cent), and postoperative complications occurred in 42 cases (26 per cent). The overall crude five-year survival was 38 per cent (53 of the 140 followed-up patients). The length of the clinical history did not correlate with the pathologic staging, which greatly influenced curability and survival. A statistically significant poorer prognosis was observed in patients with left-sided tumors, with an emergency presentation and with a duration of symptoms shorter than six months. A better prognosis can be achieved by means of a presymptomatic diagnosis. Supported by CNR.     

Full-thickness excision using transanal endoscopic microsurgery for treatment of rectal neuroendocrine tumors

AIM:To assess the efficacy of full-thickness excision using transanal endoscopic microsurgery(TEM) in the treatment of rectal neuroendocrine tumors.METHODS:We analyzed the data of all rectal neuroendocrine tumor patients who underwent local full-thickness excision using TEM between December 2006 and December 2014 at our department. Data collected included patient demographics,tumor characteristics,operative details,postoperative outcomes,pathologic findings,and follow-ups. RESULTS:Full-thickness excision using TEM was performed as a primary excision(n = 38) or as complete surgery after incomplete resection by endoscopic polypectomy(n = 21). The mean size of a primary tumor was 0.96 ± 0.21 cm,and the mean distance of the tumor from the anal verge was 8.4 ± 1.4 cm. The mean duration of the operation was 57.6 ± 13.7 min,and the mean blood loss was 13.5 ± 6.6 m L. No minor morbidities,transient fecal incontinence,or wound dehiscence was found. Histopathologically,all tumors showed typical histology without lymphatic or vessel infiltration,and both deep and lateral surgical margins were completely free of tumors. Among 21 cases of complete surgery after endoscopic polypectomy,9 were histologically shown to have a residual tumor in the specimens obtained by TEM. No additional radical surgery was performed. Norecurrence was noted during the median of 3 years' follow-up.CONCLUSION:Full-thickness excision using TEM could be a first surgical option for complete removal of upper small rectal neuroendocrine tumors.     

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.     

The risk of rectal carcinoma following colectomy in ulcerative colitis

In a series of 1439 patients with ulcerative colitis, managed by one of the authors (E.S.R.H.), surgical resection was performed on 374 patients (26 per cent): colectomy, 273 (subtotal colectomy and mucous fistula, 172, colectomy and primary ileorectal anastomosis, 101); proctocolectomy, 61; and miscellaneous procedures, 40. Of the 172 patients undergoing subtotal colectomy and mucous fistula, 93 (54 per cent) subsequently required rectal excision, 33 (19 per cent) had ileorectal anastomosis performed as a second procedure, and in 46 (27 per cent) subsequently developed as a mucous fistula. Two hundred seventy-three patients were at risk for the development of rectal, cancer after subtotal colectomy; ten patients (3.6 per cent) subsequently developed rectal cancer. The cumulative probability of developing rectal cancer after subtotal colectomy reached 17 per cent at 27 years from disease onset. The tumors were more advanced in stage and of higher grade malignancy than those of a parallel general series of patients with rectal cancer uncomplicated by inflammatory bowel disease. Colectomy and ileorectal anastomosis has been successful for most patients. However, the experience of this series highlights the danger of carcinomatous transformation in the retained rectum, the requirement for regular long-term follow-up, the need for markers of precancerous change, and the value, where relevant, of prophylactic proctectomy.