Can Differences in Bowel Function After Surgery for Rectal Cancer Be Identified by the European Organization for Research and Treatment of Cancer Quality of Life Instrument?

BACKGROUND

Bowel function is an important outcome after rectal cancer surgery that affects quality of life (QOL). Postoperative bowel function is often assessed with QOL instruments, but their ability to detect functional differences has not been evaluated. This study evaluated the efficacy of the European Organization for the Research and Treatment of Cancer (EORTC) Core (C)-30 and Colorectal (CR)-38 QOL instruments in identifying functional differences among patients undergoing sphincter-preserving surgery, grouped by clinical and treatment-related factors known to be associated with bowel function.

METHODS

A total of 123 patients who underwent sphincter-preserving surgery for stage I to III rectal cancer completed the EORTC C-30 and CR-38 a median of 22.9 months after restoration of bowel continuity. The global QOL, Social and Physical Function subscales of the EORTC C-30, and Gastrointestinal (GI) Symptom and Defecation subscales of the EORTC CR-38 were hypothesized to be affected by bowel function. Known factors associated with function (age, sex, radiation, procedure, rectal reconstruction) were used to group patients. Differences in the QOL scores between patient groups were evaluated (t-test or analysis of variance).

RESULTS

The global QOL was high, with a mean score of 76.84 +/- 18.6. The Defecation subscale detected differences in patients grouped by age (P = .002), use of radiation (P = .04), and procedure type (P = .05). However, the remaining subscales failed to identify any differences.

CONCLUSIONS

We found neither the EORTC C-30 nor CR-38 to be sensitive instruments in delineating differences in bowel function. The use of a validated instrument designed to assess function in patients with rectal cancer will more effectively and efficiently identify those patients with poor postoperative function.

The role of abdominoperineal resection as surgical therapy for anorectal melanoma

OBJECTIVES

1) Characterize changes in the surgical treatment of anorectal melanoma over time. 2) Determine if the extent of surgical resection is associated with outcome. 3) Identify prognostic factors correlating with survival.

SUMMARY BACKGROUND DATA

Although early data suggested improved survival in patients undergoing abdominoperineal resection (APR) for primary anorectal melanoma, such an aggressive approach may be unwarranted as distant relapse rates are high. We have seen a trend toward less aggressive surgical treatment of the local disease over the past 20 years.

METHODS

A retrospective review was performed of all patients with anorectal melanoma treated at our institution between 1984 and 2003. Extent of primary resection and pathologic factors were studied.

RESULTS

Forty-six patients underwent a curative resection with a median follow-up of 29 months, and 5-year disease-specific survival (DSS) rate of 35%. While patient and tumor characteristics remained similar, there was a dramatic shift in surgical treatment toward less radical procedures. Prior to 1997, the majority of patients (15 of 21, 71%) underwent APR. After 1997, the majority of patients (21 of 25, 84%) underwent local excision (LE) (P < 0.0001). Local recurrence was noted in 11 of 46 (24%) patients: 4 of 19 (21%) who underwent APR and 7 of 27 (26%) who underwent LE (P = not significant). Five-year DSS was similar: 34% following APR and 35% following LE. Tumor perineural invasion (PNI) was the only factor identified as an independent predictor of worse outcome (P = 0.01).

CONCLUSION

The extent of surgical treatment is not associated with outcome in primary anorectal melanoma. Therefore, LE of the primary tumor is recommended when technically feasible. The presence of PNI is an important prognostic factor and should be considered in future clinical trials.

Carcinoid of the rectum risk stratification (CaRRS): a strategy for preoperative outcome assessment

BACKGROUND

Predicting rectal carcinoid behavior exclusively on the basis of tumor size is imprecise. We sought to identify factors associated with outcome and incorporate them into a preoperative risk stratification scheme.

METHODS

Seventy patients with rectal carcinoid evaluated at our institution were identified. Demographic, clinical, and histopathologic data were collected and correlated with recurrence and survival.

RESULTS

The mean age of our cohort was 53.6 years. Fifty-seven percent of patients were women. The mean tumor size was 1.3 cm (range, .1-5 cm). Twenty-five percent of patients had deeply invasive tumors (into the muscularis propria or deeper); an equal percentage had tumors with lymphovascular invasion (LVI) or an increased mitotic rate (two or more mitoses per 50 high-power fields). Eleven patients (17%) had distant metastases at presentation. Sixty-one patients were followed for a median of 22 months (range, 2-308 months), during which seven patients developed recurrence and seven died of disease (including two of seven whose disease recurred). Poor outcome was associated with large tumor size, deep invasion, presence of LVI, and increased mitotic rate. These factors were incorporated into a Carcinoid of the Rectum Risk Stratification (CaRRS) score. CaRRS predicted recurrence-free and disease-specific survival better than any single factor alone.

CONCLUSIONS

Poor prognostic features of rectal carcinoids include large size, deep invasion, LVI, and increased mitotic rate. The CaRRS score incorporates these features and accurately predicts outcome. Because the CaRRS score is based on values available by preoperative biopsy, it can identify patients with favorable prognosis and those with poor prognosis who may benefit from additional staging or surveillance.

Predictors of recurrence in patients with T2 and early T3, N0 adenocarcinoma of the rectum treated by surgery alone

PURPOSE

Treatment of rectal cancer with neoadjuvant radiotherapy has been shown to reduce local recurrence and improve overall survival. The role of chemoradiotherapy in patients with T2, N0 and early T3, N0 rectal cancer, treated by radical surgery with total mesorectal excision, remains controversial. The aim of this study was to identify predictors of recurrence in this group of patients to enhance treatment selection.

PATIENTS AND METHODS

One hundred patients with primary T2-3, N0 adenocarcinoma of the rectum, uniformly treated by surgery alone, were studied. The pathology slides available for 97 patients were rereviewed. Three patients with incomplete data sets were excluded. Clinical and survival data were obtained from a prospective computerized database and updated from hospital and office charts. The study end points were disease-free survival, disease-specific survival (DSS), time to pelvic recurrence (PR), and distant recurrence.

RESULTS

Complete follow-up was available for all study patients. Median follow-up was 79.5 months (range, 57.7 to 105.9 months). During this time period 30 patients (31.9%) died as a result of disease and 64 patients (68.1%) remained alive and disease free. Five-year DSS was 73%. The cumulative risk for PR was 8% at 5 years and 10% at 8 years. Lymphovascular invasion, preoperative serum carcinoembryonic antigen (CEA > 5 ng/mL) level, and age older than 70 years were all associated with adverse outcome. CONCLUSION Patients with T2-3, N0 rectal cancers and either lymphovascular invasion or elevated CEA levels have reduced survival and a higher incidence of PR, and should be considered for future randomized trials.

A pathologic complete response of rectal cancer to preoperative combined-modality therapy results in improved oncological outcome compared with those who achieve no downstaging on the basis of preoperative endorectal ultrasonography

BACKGROUND

Preoperative combined-modality therapy (CMT) is the preferred treatment for locally advanced rectal cancer (endorectal ultrasonography [ERUS] T3-4, N1, or clinically bulky) and achieves a pathologic complete response (pCR) in 4% to 33% of patients. However, the prognostic significance of pCR remains unclear.

METHODS

A prospectively collected database was queried to identify 200 patients with locally advanced disease treated from 1992 to 2002. The pCR group was defined as having no evidence of viable tumor on pathologic analysis. The no-downstaging group was defined as no difference between the pre-CMT ERUS stage and the pathologic stage. Those achieving some downstaging but not pCR were excluded. Patients were treated with CMT (5040 cGy of radiation and 5-fluorouracil-based chemotherapy) followed by surgery, and 51 (85%) in the pCR group and 129 (92%) in the no-downstaging group (P = .1) received postoperative chemotherapy. Recurrence-free survival (RFS) and overall survival (OS) were determined by using the Kaplan-Meier method.

RESULTS

The median follow-up was 38.6 months (range, 18.2-124.9 months). The pCR (n = 60) and control (n = 140) groups were similar in age (P = .6), sex (P = .4), distance of the tumor from the anal verge (P = .3), pre-CMT ERUS stage (P = .2), and comorbidities (P = .2). The 5-year RFS was 96% and 54% in the pCR and control groups, respectively (P < .00001); the 5-year OS was 90% and 68% (P = .009). Sphincter-preservation rates were higher in the pCR group (P = .01).

CONCLUSIONS

Rectal cancer patients with pCR after preoperative CMT have improved RFS, OS, and sphincter preservation compared with patients without downstaging. Because pCR seems to be associated with better outcome, an understanding of the factors governing the response to CMT should be pursued.

Ten-year results of preoperative radiation followed by sphincter preservation for rectal cancer: increased local failure rate in nonresponders

BACKGROUND

The primary objective of this study was to determine the long-term outcome of sphincter preservation with preoperative radiation therapy (RT) and surgical resection in the treatment of distal rectal adenocarcinoma.

PATIENTS AND METHODS

Between April 1988 and December 1996, 36 (cT2, n=9; cT3, n=27) patients with rectal adenocarcinoma were enrolled on a phase I/II trial of preoperative RT followed by surgical resection. All patients had distal tumors that were clinically judged to require an abdominoperineal resection and received preoperative RT (50.4 Gy) followed by surgery. The median follow-up was 94.5 months (range, 4-187 months).

RESULTS

Of the 35 patients in this study who underwent resection, 77% were able to undergo sphincter preservation after preoperative RT. The pathologic complete response rate for these patients was 14%. The 10-year rates of overall survival and local failure for patients undergoing sphincter preservation were 54% and 21%, respectively. The 10-year local failure was 26% in patients with cT3 disease who underwent sphincter preservation. All local failures in this study occurred in patients with cT3 disease undergoing sphincter preservation; however, none of the patients with cT3 disease that was downstaged by preoperative RT experienced local failure. In contrast, 10-year local failure was 67% in the patients with cT3 disease that was not downstaged by RT. Sphincter function was good or excellent in 85% of patients at the time of last follow-up.

CONCLUSION

This approach provides excellent long-term results in all patients with cT2 disease and those with cT3 disease that is downstaged by RT. However, patients with cT3 disease that is not downstaged by RT have an increased risk of local failure. These data underscore the impact of tumor response to radiation on long-term oncologic outcome.

Extranodal follicular dendritic cell sarcoma: clinical, pathologic, and histogenetic characteristics of an underrecognized disease entity

It has been more than 10 years since follicular dendritic cell (FDC) sarcoma was first reported to occur in extranodal sites, yet extranodal FDC sarcoma still appears underrecognized, and its clinical and pathological characteristics remain to be defined. This study analyzed the clinical and pathological findings of three such cases that the authors encountered recently and 43 previously reported cases identified in the literature. Assessment of all 46 cases showed a slight female predominance (1.2:1) with a median age of 41.5 years. One-third of the cases were misdiagnosed at initial evaluation mainly because the possibility of FDC sarcoma was not considered. When considered, this disease had distinct pathological characteristics that allowed an accurate diagnosis. Staining for FDC markers, CD21, CD35, and clusterin was particularly helpful. The pathogenesis of the disease appeared heterogeneous, and associated factors included Epstein-Barr virus infection (in hepatic cases) and inflammatory pseudotumor-like conditions. Treatment modality varied widely although surgical resection was often included. With a median follow-up of 18 months, 43% of the cases recurred and 7% died of disease. The 5-year recurrence-free survival was 27.4%. From data available at the current time, we were not able to identify prognostically significant pathologic factors.

Surgical treatment of rectal cancer: radical resection

Currently, surgery is the only potentially curative treatment modality for rectal cancer. The major goals of surgery for rectal cancer are to optimize oncologic outcome and maintain anorectal and genitourinary function. This article reviews the surgical management of primary rectal cancer and discusses major surgical considerations in the treatment of this disease.

T1 adenocarcinoma of the rectum: transanal excision or radical surgery?

BACKGROUND

Recent studies suggest local excision may be acceptable treatment of T1 adenocarcinoma of the rectum, but there is little comparative data with radical surgery to assess outcomes and quantify risk. We performed a retrospective evaluation of patients with T1 rectal cancers treated by either transanal excision or radical resection at our institution to assess patient selection, cancer recurrence, and survival.

METHODS

All patients who underwent surgery for T1 adenocarcinomas of the rectum (0-15 cm from anal verge) by either transanal excision (TAE) or radical resection (RAD) between January 1987 and January 2004 were identified from a prospective database. Data were analyzed using Fisher exact test, Kaplan-Meier method, and log-rank test.

RESULTS

Three hundred nineteen consecutive patients with T1 lesions were treated by transanal excision (n = 151) or radical surgery (n = 168) over the 17-year period. RAD surgery was associated with higher tumor location in the rectum, slightly larger tumor size, a similar rate of adverse histology, and a lymph node metastasis rate of 18%. Despite these features, patients who underwent RAD surgery had fewer local recurrences, fewer distant recurrences, and significantly better recurrence-free survival (P = 0.0001). Overall and disease-specific survival was similar for RAD and TAE groups.

CONCLUSION

Despite a similar risk profile in the 2 surgical groups, patients with T1 rectal cancer treated by local excision were observed to have a 3- to 5-fold higher risk of tumor recurrence compared with patients treated by radical surgery. Local excision should be reserved for low-risk cancers in patients who will accept an increased risk of tumor recurrence, prolonged surveillance, and possible need for aggressive salvage surgery. Radical resection is the more definitive surgical treatment of T1 rectal cancers.

Contemporary Applications of Transanal Endoscopic Microsurgery: Technical Innovations and Limitations

PURPOSE

Transanal endoscopic microsurgery (TEM) is a minimally invasive procedure used to transanally excise select benign and malignant tumors of the rectum. In properly selected patients, TEM can provide for decreased postoperative morbidity without compromising oncologic outcome. This report summarizes the recent literature concerning TEM, comprehensively analyzes the authors' experience with TEM, and describes recent technical innovations and indications.

PATIENTS AND METHODS

Thirty-two consecutive patients scheduled for TEM were identified from our prospectively maintained colorectal service database. Clinicopathologic factors, postoperative complications, and oncologic outcomes were analyzed for all patients. In addition, a PubMed literature search was performed with use of the key words "transanal endoscopic microsurgery," "TEM," "rectal tumor," and "rectal cancer."

RESULTS

Transanal endoscopic microsurgery was performed for rectal adenocarcinoma (n = 17; 53%), adenoma (n = 12; 38%), and carcinoid tumors (n = 3; 9%). Median tumor location was 9 cm from the anal verge (range, 3-15 cm). Of the 32 attempted TEM procedures, 27 (84%) were completed. Reasons for inability to complete TEM included narrow rectal lumen or contour of bony pelvis prohibiting passage of the operating proctoscope into the upper rectum and inability to maintain the proctoscope in the rectal lumen with carbon dioxide insufflation because of the distal location of the tumor. Innovations used in the excision of rectal tumors via TEM included the use of the harmonic scalpel, closure of the rectal defect with an extracorporeal slip knot, and a hybrid approach incorporating TEM and traditional transanal techniques.

CONCLUSION

Transanal endoscopic microsurgery provides for low morbidity and does not appear to impair oncologic outcome in properly selected patients.

Familial adenomatous polyposis and mental retardation caused by a de novo chromosomal deletion at 5q15-q22: report of a case

Familial adenomatous polyposis, caused by mutations in the adenomatous polyposis coli gene located at chromosome 5q21, is an autosomal dominant syndrome characterized by polyposis of the colon and rectum and nearly 100 percent progression to colorectal cancer. We report a case of familial adenomatous polyposis and mental retardation caused by a chromosomal deletion at 5q15-q22. Chromosomal analysis is considered part of the evaluation of children with mental retardation and developmental delay. The resulting karyotypes from high-resolution chromosomal analysis can help characterize large deletions, some of which involve known tumor suppressor genes. Because familial adenomatous polyposis may arise from de novo chromosomal deletions involving the adenomatous polyposis coli gene locus, individuals with chromosomal deletions involving 5q21 should be considered at-risk for familial adenomatous polyposis and offered standard screening with flexible sigmoidoscopy by 10 to 12 years of age.

Association of statin use with a pathologic complete response to neoadjuvant chemoradiation for rectal cancer

PURPOSE

To assess whether 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, or statins, might enhance the efficacy of neoadjuvant chemoradiation in rectal cancer.

METHODS AND MATERIALS

Between 1996 and 2001, 358 patients with clinically resectable, nonmetastatic rectal cancer underwent surgery at Memorial Sloan-Kettering Cancer Center after neoadjuvant chemoradiation for either locally advanced tumors or low-lying tumors that would require abdominoperineal resection. We excluded 9 patients for radiation therapy dose <45 Gy or if statin use was unknown, leaving 349 evaluable patients. Median radiation therapy dose was 50.4 Gy (range, 45-55.8 Gy), and 308 patients (88%) received 5-fluorouracil-based chemotherapy. Medication use, comorbid illnesses, clinical stage as assessed by digital rectal examination and ultrasound, and type of chemotherapy were analyzed for associations with pathologic complete response (pCR), defined as no microscopic evidence of tumor. Fisher's exact test was used for categoric variables, Mantel-Haenszel test for ordered categoric variables, and logistic regression for multivariate analysis.

RESULTS

Thirty-three patients (9%) used a statin, with no differences in clinical stage according to digital rectal examination or ultrasound compared with the other 324 patients. At the time of surgery, 23 nonstatin patients (7%) were found to have metastatic disease, compared with 0% for statin patients. The unadjusted pCR rates with and without statin use were 30% and 17%, respectively (p = 0.10). Variables significant univariately at the p = 0.15 level were entered into a multivariate model, as were nonsteroidal anti-inflammatory drugs (NSAIDs), which were strongly associated with statin use. The odds ratio for statin use on pCR was 4.2 (95% confidence interval, 1.7-12.1; p = 0.003) after adjusting for NSAID use, clinical stage, and type of chemotherapy.

CONCLUSION

In multivariate analysis, statin use is associated with an improved pCR rate after neoadjuvant chemoradiation for rectal cancer. The low prevalence of statin use limits the power to detect a significant difference at a type I error threshold of p = 0.05 in this analysis. Although no definitive conclusions can be drawn on the basis of this retrospective study, the unusually high incidence of pCR after chemoradiation suggests that the use of statins in the treatment of rectal cancer warrants further evaluation.

Clinical examination following preoperative chemoradiation for rectal cancer is not a reliable surrogate end point

PURPOSE

Clinical assessment of rectal cancer response to preoperative combined-modality therapy (CMT) using digital rectal examination (DRE) has been proposed as a means of assessing efficacy of therapy. However, because the accuracy of this approach has not been established, we conducted a prospective analysis to determine the operating surgeon's ability to assess response using DRE.

PATIENTS AND METHODS

Ninety-four prospectively accrued patients with locally advanced rectal cancer (T3/4 or N1) were evaluated with DRE and sigmoidoscopy in order to determine the following tumor characteristics: size, location, mobility, morphology, and circumference. Following preoperative CMT (50.40 Gy with fluorouracil-based chemotherapy) and under general anesthesia, the same surgeon estimated tumor response based on changes in these tumor characteristics, assessed via DRE. Percent pathologic tumor response was determined prospectively by a single pathologist using whole mount sections of the resected cancer.

RESULTS

Clinical assessment using DRE underestimated pathologic response in 73 cases (78%). In addition, DRE was able to identify only 3 of 14 cases (21%) with a pathologic complete response. There were no clinical overestimates of response. None of the clinicopathologic tumor characteristics examined had a significant impact on DRE estimation of response.

CONCLUSION

Clinical examination underestimates the extent of rectal cancer response to preoperative CMT. Given the inaccuracy of DRE following preoperative CMT, it should not be used as a sole means of assessing efficacy of therapy nor for selecting patients following CMT for local surgical therapies.

Complications after Preoperative Combined Modality Therapy and Radical Resection of Locally Advanced Rectal Cancer: A 14-Year Experience from a Specialty Service

BACKGROUND

Preoperative combined modality therapy followed by total mesorectal excision has emerged as the optimal treatment paradigm for locally advanced rectal cancer (T3 to 4, N1, or both). But its impact on postoperative complications has not been adequately evaluated. Our aims were to evaluate our comprehensive experience and identify factors predictive of complications in this patient population.

STUDY DESIGN

The study group consisted of 297 consecutive patients with locally advanced rectal adenocarcinoma treated with preoperative combined modality therapy (radiation: 5,040 cGy; chemotherapy: 5-FU-based) and then operation. Major complications were defined as those requiring medical or surgical treatment. A prospectively collected database was queried to determine the incidence of postoperative complications and associated clinicopathologic factors.

RESULTS

Median followup was 43.9 months (range 0.8 to 128.6 months). There were no postoperative mortalities (within 30 days of operation). But there were 145 major complications in 98 patients (33% of study population). The most common complications were small bowel obstruction (n = 32 [11%]) and wound infection (n = 31 [10%]). There were eight anastomotic leaks (4%) and nine pelvic abscesses (4%) in patients treated with low anterior resection (n = 210). Preoperative comorbidity was the only clinicopathologic factor associated with postoperative complications (p = 0.02). Postoperative complications had no significant impact on oncologic outcomes.

CONCLUSIONS

Although postoperative mortalities are rare, complications requiring treatment can be anticipated in one-third of patients undergoing preoperative combined modality therapy and total mesorectal excision. A policy of selective fecal diversion after preoperative combined modality therapy and total mesorectal excision for locally advanced rectal cancer can achieve low rates of pelvic sepsis, but may lead to an increased incidence of small bowel obstruction.

Long-term oncologic outcome following preoperative combined modality therapy and total mesorectal excision of locally advanced rectal cancer

OBJECTIVE

Our aims were to (1) determine the long-term oncologic outcome for patients with rectal cancer treated with preoperative combined modality therapy (CMT) followed by total mesorectal excision (TME), (2) identify factors predictive of oncologic outcome, and (3) determine the oncologic significance of the extent of pathologic tumor response.

SUMMARY BACKGROUND DATA

Locally advanced (T3-4 and/or N1) rectal adenocarcinoma is commonly treated with preoperative CMT and TME. However, the long-term oncologic results of this approach and factors predictive of a durable outcome remain largely unknown.

METHODS

Two hundred ninety-seven consecutive patients with locally advanced rectal adenocarcinoma at a median distance of 6 cm from the anal verge (range 0-15 cm) were treated with preoperative CMT (radiation: 5040 centi-Gray (cGy) and 5-fluorouracil (5-FU)-based chemotherapy) followed by TME from 1988 to 2002. A prospectively collected database was queried for long-term oncologic outcome and predictive clinicopathologic factors.

RESULTS

With a median follow-up of 44 months, the estimated 10-year overall survival (OS) was 58% and 10 year recurrence-free survival (RFS) was 62%. On multivariate analysis, pathologic response >95%, lymphovascular invasion and/or perineural invasion (PNI), and positive lymph nodes were significantly associated with OS and RFS. Patients with a >95% pathologic response had a significantly improved OS (P = 0.003) and RFS (P = 0.002).

CONCLUSIONS

Treatment of locally advanced rectal cancer with preoperative CMT followed by TME can provide for a durable 10-year OS of 58% and RFS of 62%. Patients who achieve a >95% response to preoperative CMT have an improved long-term oncologic outcome, a novel finding that deserves further study.

Operative salvage for locoregional recurrent colon cancer after curative resection: an analysis of 100 cases

PURPOSE

Locoregional recurrence after resection of colon carcinoma is an uncommon and difficult clinical problem. Outcome data to guide surgical management are limited. This investigation was undertaken to review our experience with surgical resection for patients with locoregional recurrence colon cancer, determine predictors of respectability, and define prognostic factors associated with survival.

PATIENTS AND METHODS

A prospective database was queried for patients who had recurrent colon cancer between January 1991 and October 2002. Patients were selected for analysis if they had either isolated resectable locoregional recurrence or concomitant resectable distant disease. Disease-specific survival analysis was performed with the Kaplan-Meier actuarial method, and factors associated with outcome were determined by the log-rank test and Cox regression.

RESULTS

During this period of time, 744 patients with recurrent colon cancer were identified and 100 (13.4 percent) underwent exploration with curative intent for potentially resectable locoregional recurrence: 75 with isolated locoregional recurrence, and 25 with locoregional recurrence and resectable distant disease. The median follow-up for survivors was 27 months. Locoregional recurrence was classified into four categories: anastomotic; mesenteric/nodal; retroperitoneal; and peritoneal. Median survival for all patients was 30 months. Fifty-six patients had an R0 resection (including distant sites). Factors associated with prolonged disease-specific survival included R0 resection (P < 0.001); age <60 years (P < 0.01); early stage of primary disease (P = 0.05); and no associated distant disease (P = 0.03). Poor prognostic factors included more than one site of recurrence (P = 0.05) and involvement of the mesentery/nodal basin (P = 0.03). The ability to obtain an R0 resection was the strongest predictor of outcome, and these patients had a median survival of 66 months.

CONCLUSION

Salvage surgery for locoregional recurrence colon cancer is appropriate for select patients. Complete resection is critical to long-term survival and is associated with a single site of recurrence, perianastomotic disease, low presalvage carcinembryonic antigen level, and absence of distant disease.

A636P testing in Ashkenazi Jews

Hereditary nonpolyposis colorectal cancer (HNPCC) is an autosomal dominantly inherited colorectal cancer syndrome attributable to mutations in one of several DNA mismatch repair genes, most commonly MLH1 and MSH2 . In certain populations, founder mutations account for a substantial portion of HNPCC. In this report we summarize the literature and our personal experience testing for a specific founder mutation in the Ashkenazi Jewish population, MSH2*1906G > C , also known as A636P. Although rare in the general population, the A636P mutation is detected in up to 7% of Ashkenazi Jewish patients with early age-of-onset colorectal cancer, and may account for up to one third of HNPCC in the Ashkenazi Jewish population. In addition, we summarize our initial experience with a prospective A636P testing protocol aimed at Ashkenazi Jewish patients at high or intermediate risk for harboring the A636P mutation.

Value of immunohistochemical detection of DNA mismatch repair proteins in predicting germline mutation in hereditary colorectal neoplasms

The utility of immunohistochemistry (IHC) as a screening method for the identification of persons with mutations in the DNA mismatch repair (MMR) genes in hereditary nonpolyposis colorectal cancer (HNPCC) remains to be defined. In this study, we analyzed the value of IHC versus that of microsatellite instability (MSI) testing in predicting mutation status of the MLH1, MSH2, and MSH6 genes in colorectal carcinomas and adenomas, and explored the frequency and significance of immunohistochemical staining variability. The study samples included 83 carcinomas and 29 adenomas derived from 110 patients who had strong family histories of colorectal cancer. Our results showed that IHC correctly predicted MSI status in 76% of the cases with a specificity of 100%. The overall sensitivity of IHC in predicting a germline mutation was 79% (30 of 38) with a specificity of 89% (48 of 54), whereas that of MSI testing was 97% (30 of 31) with a specificity of 83% (35 of 42). Six of 31 analyzable cases that had a disease-causing mutation and exhibited MSI showed normal IHC. The lower sensitivity of IHC was caused mainly by its low sensitivity in detecting MLH1 gene mutation (4 of 9). Coexisting adenomas and carcinomas observed in the same slide (n=12) showed a similar or identical staining pattern for all three proteins. No significant difference was detected in the sensitivity of IHC or MSI in detecting a germline mutation between isolated adenomas and carcinomas. In IHC-positive cases, heterogeneous staining was noted in 30% to 40% of the cases with the three different antibodies, and cytoplasmic staining in 5% to 13%. Weak IHC (defined as positive staining in <10% of the tumor with weak intensity) was noted in 14 tumors: 5 for the MLH1 antibody, 1 for MSH2, and 8 for MSH6. One of the 5 MLH1 cases exhibited MSI and had an MLH1 germline mutation. Five of the 8 MSH6 cases exhibited MSI and had MSH2 germline mutations. In conclusion, our study shows that 1) IHC identifies a significant portion of colorectal tumors derived from MMR gene germline mutation carriers and can be used as an adjunct measure in the identification of HNPCC families, but IHC cannot replace MSI testing; 2) adenomas have similar MMR protein expression patterns as carcinomas and may serve as an adequate sample for screening purposes in the identification of patients with MMR mutations; 3) not all IHC-positive cases show uniform positivity throughout the tumor; and 4) weak and focal staining of an MMR protein may be associated with MSI or gene mutation or both, suggesting the need to incorporate staining intensity in further IHC studies.

Rectus flap reconstruction decreases perineal wound complications after pelvic chemoradiation and surgery: a cohort study

BACKGROUND

A major source of morbidity after abdominoperineal resection (APR) after external beam pelvic radiation is perineal wound complications, seen in up to 66% of cases. Our purpose was to determine the effect of rectus abdominus myocutaneous (RAM) flap reconstruction on perineal wound morbidity in this population.

METHODS

The study group consisted of 19 patients with anorectal cancer treated with external beam pelvic radiation followed by APR and RAM flap reconstruction of the perineum. A prospectively collected database was queried to identify a control group (n = 59) with anorectal cancer treated with similar radiation doses that subsequently underwent an APR without a RAM flap during the same time period. Comparison of percentages was performed with a two-sided Fisher's exact test, and comparison of means was performed with Wilcoxon's test.

RESULTS

Perineal wound complications occurred in 3 (15.8%) of the RAM flap patients and 26 (44.1%) of the control patients (P = .03). The incidence of other complications was not different between groups (42.1% vs. 42.4%; P = .8). Despite an increased number of anal squamous tumors, an increased vaginectomy rate, increased use of intraoperative radiotherapy, and an increased proportion of cases with recurrent disease, the flap group had a significantly lower rate of perineal wound complications relative to the control group.

CONCLUSIONS

Perineal closure with a RAM flap significantly decreases the incidence of perineal wound complications in patients undergoing external beam pelvic radiation and APR for anorectal neoplasia. Because other complications are not increased, RAM flap closure of the perineal wound should be strongly considered in this patient population.

Surgical Issues in Rectal Cancer: A 2004 Update

Rectal cancer is a major health concern in the United States, with an estimated 40,570 new cases diagnosed in 2004. There are 4 major goals in the treatment of a patient with rectal cancer: local control; long-term survival; preservation of anal sphincter, bladder, and sexual function; and maintenance or improvement in quality of life. Recent advances have been made in preoperative staging, local and radical surgical therapy, the importance of distal and circumferential resection margins, postoperative preservation of the anal sphincter mechanism and genitourinary function, and the role of laparoscopy in the treatment of these patients. Our aim is to outline some of the important surgical issues surrounding the management of patients with early-stage (T1/T2 N0) or locally advanced (T3/T4 and/or N1) rectal cancer.