Anastomotic recurrence of colorectal cancer--a biological phenomenon or an avoidable calamity?

Risk factors and clinical characteristics of rectal cancer recurrence after radical surgical treatment

<b><br>Introduction:</b> Recurrence of rectal cancer affects from 4% to even 50% of patients after surgical treatment. The incidence may be influenced by numerous factors depending on the patient, the characteristics of the tumor and the type and quality of the surgical technique used.</br> <b><br>Aim:</b> The aim of this study was to assess the clinical characteristics of rectal cancer recurrence, identify potential risk factors and role of patient surveillance after primary resection of rectal cancer.</br> <b><br>Materials and methods:</b> The study comprised patients operated on due to recurrence of rectal cancer at the Department of General and Colorectal Surgery of Medical University of Lodz between 2014 and 2020, who were in the follow-up program at the hospital's outpatient clinic after the primary surgery. Risk factors for disease recurrence were sought by analyzing the characteristics of the primary tumor, treatment history and postoperative care.</br> <b><br>Results:</b> Twenty-nine patients were included in the study, the majority (51.7%) of the patients were men. The largest group was represented by patients with stage II and III disease. The most frequently performed primary surgery was low anterior resection (LAR) (62.8%). 35% of patients received neoadjuvant treatment prior to primary surgery. We demonstrated that the lack of neoadjuvant treatment before primary surgery increases the risk of cancer recurrence nine times. Higher stage of disease at the point of primary surgery is associated with nearly seven times the risk of recurrence compared to stage I disease.</br> <b><br>Conclusions:</b> Optimal preoperative staging, reasonable neoadjuvant treatment, proper surgical technique and precise follow-up regimen are essential for further improvement of rectal cancer outcomes.</br>.

Impact of a multidisciplinary training programme on outcome of upper rectal cancer by critical appraisal of the extent of mesorectal excision with postoperative MRI

BACKGROUND

Optimal management of patients with upper rectal cancer remains unclear. Partial mesorectal excision (PME) without neoadjuvant therapy is currently advocated for the majority of patients. Recent studies, however, reported a high risk of local recurrence and suboptimal surgery. The aim of this study was to evaluate the effects of a quality assurance initiative with postoperative MRI to improve outcomes in these patients.

METHODS

Patients who underwent mesorectal excision with curative intent for rectal cancer in 2007-2013 were included. Postoperative MRI of the pelvis was performed 1 year after surgery. In 2011, a multidisciplinary workshop with focus on extent and completeness of surgery was held for training surgeons, pathologists and radiologists involved in treatment planning. Images of residual mesorectum and histopathological reports were reviewed with regard to the distal resection margin. Local recurrence after a minimum of 3 years' follow-up was compared between two cohorts from 2007-2010 and 2011-2013.

RESULTS

A total of 627 patients were included; postoperative MRI of the pelvis was done in 381 patients. The 3-year actuarial local recurrence rate in patients with upper rectal cancer improved from 12·9 to 5·0 per cent (P = 0·012). After the workshop, fewer patients with cancer of the upper rectum were selected to have PME (90·8 per cent in 2007-2010 versus 80·2 per cent in 2011-2013; P = 0·023), and fewer patients who underwent PME had an insufficient distal resection margin (61·7 versus 31 per cent respectively; P < 0·001).

CONCLUSION

Quality assessment of surgical practice may have a major impact on oncological outcome after surgery for upper rectal cancer.

Local recurrences at the anastomotic area are clonally related to the primary tumor in sporadic colorectal carcinoma

PURPOSE

Anastomotic recurrences (AR) occur in 2-10% of colorectal carcinoma cases after resection of primary tumor (PT). Currently, there are no molecular data investigating their genetic profile and multiple theories exist about their pathogenesis. The aim of our study was to compare the genomic profile of AR to that of the patients' corresponding matched PT and, when available, to a distant metastasis (DM).

EXPERIMENTAL DESIGN

Thirty-six tumors from 14 patients were genotyped using a capture-based, next-generation assay to define the mutational status of 341 cancer-associated genes. All patients had R0 resection of their PT and AR occurred 1.1-7.0 years following PT resection. A DM or a second AR was analyzed in 8 patients. All tumors were microsatellite stable except in one patient with Lynch syndrome.

RESULTS

A total of 254 somatic mutations were detected including 138 mutations in the microsatellite stable (MSS) cases. The most commonly mutated genes were APC, KRAS, TP53, PIK3CA, ATM and PIK3R1. In all patients with MSS tumors the AR and PT shared between 50-100% of mutations, including mutations in key driver genes, consistent with these tumors being clonally related. Genetic events private to DM were not detected in AR and phylogenetic analysis showed that ARs were more closely related to PT than DM. In the Lynch syndrome patient the PT and AR showed distinct somatic mutations consistent with independent primaries.

CONCLUSIONS

ARs are clonally related to PT in sporadic colorectal carcinomas and do not appear to represent seeding of the anastomotic site by distant metastases.

Isolated repeated anastomotic recurrence after sigmoidectomy

Repeated anastomotic recurrence (AR) of colonic cancer is uncommon. We report a case of a double-isolated AR after sigmoidectomy. In 2003, a 60-year-old woman underwent stapled sigmoid resection for a moderately differentiated adenocarcinoma. Further rectal bleeding occurred after six months, and colonoscopy detected an AR. Thus, an additional stapled colorectal anastomosis was performed. Ten months later, a colonoscopy detected a circumferential AR that prompted the completion of a second colorectal resection, with a double-stapled colorectal anastomosis. Twenty-four hours after surgery, a massive pulmonary embolism occurred, and the patient died within a few hours. At present, only six cases of repeated isolated AR have been described. Repeated segmental colorectal resections are generally associated with a favourable prognosis, with a median survival rate of 45 mo (range, 13-132 mo). Repeated isolated ARs are rare, and segmental colorectal resections are generally associated with long-term disease-free survival.

The Cause and Prevention of Anastomotic Recurrence following Colectomy: An Immunohistochemical Approach for Detecting Transforming Colonocytes

With the ability to identify the presence of transforming colonocytes in a field adjacent to an existing primary colon cancer, it is now possible to reduce if not eliminate one of the major causes leading to anastomotic tumor recurrence. In a review of those colectomy cases that presented post-surgery with anastomotic recurrence, we noted that mucosal abnormalities could readily be detected adjacent to the primary lesion. Such changes had gone unrecognized at the time of surgery, when standard histologic procedures were employed. By utilizing monoclonal antibodies (mAbs) that defined the presence of tumor immunogenic proteins, we were able to reexamine so-called normal biopsy sites adjacent to the tumor. Here, it was possible to demonstrate the presence of altered cellular activity in existing phenotypically normal appearing colonocytes that were in the process of transforming to malignancy.

Eight consecutive patients that had been admitted for evaluation and resection of an anastomotic recurrence post colectomy, were studied with regard to possible etiologic factors. The original margins incorporated into the anastomosis were re-examined by immunohistochemistry employing those monoclonal antibodies (mAbs) designed to target colon tumor antigen. This antigen had previously been shown to be expressed only in colon cancer and not in adjacent normal tissue. In addition, biopsies from margins of resection in five patients free of recurrence following colectomy were also studied along with colon specimens from 50 normal patients, non-demonstrating expression of tumor antigen in the normal appearing colonocytes.

In each of the patients who had presented with anastomotic recurrence, normal appearing colonocytes defined by light microscopy and found adjacent to the previously resected primary lesion, expressed tumor antigen. The antigen detected in these colonocytes proved to be identical to antigen expressed in the anastomotic recurrence giving credence to the concept that these normal appearing cells in proximity to the tumor were responsible for the regrowth of tumor in the suture line used to establish continuity of the bowel.

Based on the findings of this preliminary retrospective study it is felt that at the time of performing a colectomy for a malignant lesion of the bowel, that it is important that those normal appearing colonocytes adjacent to tumor be evaluated for expression of tumor associated antigen. Excluding such cells from an anastomosis, may help to assure that tumor recurrence will be minimized if not totally eliminated.

Anastomotic Recurrence of Colon Cancer-is it a Local Recurrence, a Second Primary, or a Metastatic Disease (Local Manifestation of Systemic Disease)?

The aim of this study is to review the literature to find out the exact etiology of anastomotic cancers of colon post resection and differentiate them between a recurrence, second primary, and metastatic disease (local manifestation of systemic disease). Web-based literature search was done, and datas collected. We searched PubMed for papers using the keywords colon cancer recurrence, anastomotic recurrence, and recurrent colon carcinoma. We also searched for systematic review in the same topic. In addition, we used our personal referrence archive. Anastomotic recurrences of colon are postulated to arise due to inadequate margins, tumor implantation by exfoliated cells, altered biological properties of bowel anastomosis, and missed synchronous lesions. Some tumors are unique with repeated recurrence after repeated resection. Duration after primary surgery plays a major role in differentiating recurrent and second primary lesions. Repeated recurrences after repeated resections have to be considered a manifestation of systemic disease or metastatic disease due to the virulence of the disease. A detailed analysis and study of patients with colonic anastomotic lesion are required to differentiate it between a recurrent, a second primary lesion, and a metastatic disease (local manifestation of a systemic disease). The nomenclature is significant to study the survival of these patients, as a second primary lesion will have different survival compared to that of recurrent lesions.

Cancer seeding contributes to intestinal anastomotic dehiscence

BACKGROUND

Surgical wounds in cancer patients have a relatively high dehiscence rate. Although colon cancer resections are performed so as to include macroscopically non-involved tissues, some cancer cells can be present in the line of transection. The local healing process may facilitate proliferation of these localized cancer cells and the high cytokine concentration within the healing wound may also attract cancer cells from distant sites to migrate into the wound area. The growing tumor cells may then stretch the wound, hampering its contraction process.

METHODS

The aim of the study was to monitor and compare, using immunohistochemical methods, the healing process of intestinal anastomosis in both normal rats and in rats with disseminated cancer (the CC531 colon cancer model).

RESULTS

There was a significantly higher rate of anastomotic dehiscence in the group of rats with disseminated cancer, than in the group of normal rats. There were no significant differences between the two groups in the levels of mononuclear wound infiltration or of formation of connective tissue or new vessels. All anastomotic wounds in animals with disseminated cancer had abundant infiltrates of both migrating and proliferating cancer cells.

CONCLUSIONS

We confirmed that the environment of a healing wound attracts cancer cells. Migration of cancer cells to the wound and centrifugal cancer proliferation may adversely affect the healing process and cause wound disruption.

Operative safety and oncologic outcomes of anal sphincter-preserving surgery with mesorectal excision for rectal cancer: 931 consecutive patients treated at a single institution

BACKGROUND

This study was designed to evaluate the operative safety and long-term oncologic outcomes of sphincter-preserving surgery based on sharp mesorectal excision for rectal cancer.

METHODS

Between January 1989 and June 2004, 931 patients underwent sphincter-preserving surgery based on sharp mesorectal excision. The operative safety and oncologic outcomes were assessed for the periods of 1989-1996 (n = 208) and 1997-2004 (n = 723). Total mesorectal excision (TME)-based sphincter-preserving surgery was performed during the period of 1989-1996. A multidisciplinary team approach and tailored mesorectal excision, which is the differential removal of the mesorectum, were our standard treatment for patients with rectal cancer during the period of 1997-2004.

RESULTS

The use of preoperative chemoradiation (P < 0.001), ultralow anterior resection with coloanal anastomosis (P = 0.01), diverting stoma (P = 0.001), and <2 cm of a distal resection margin (P = 0.01) were more common during the period of 1997-2004. There were no differences between the two periods with regard to perioperative complications (P = 0.2), such as anastomosis leakage (2.4% vs. 3.6%). Cancer-specific survival rates (79.1% vs. 79.6%, P = 0.7) and local recurrence (8.4% vs. 8.6%, P = 0.99) did not differ significantly for the two periods.

CONCLUSIONS

Based on sharp mesorectal excision, operative safety and oncologic outcomes were not compromised by technical advances in sphincter-preserving surgery using tailored mesorectal excision and a shortened distal margin.

Factors associated with anastomotic recurrence after total mesorectal excision in rectal cancer patients

BACKGROUND

In patients undergoing total mesorectal excision (TME), the clinical variables most relevant to anastomotic recurrence have not been identified. We evaluated factors associated with anastomotic recurrence in patients undergoing TME and the impact of a reduced distal margin on anastomotic recurrence.

METHODS

Thirty-eight patients with anastomotic recurrence were compared with 876 patients who received curative rectal cancer surgery. Patients were compared according to: (1) the presence of anastomotic recurrence (recurrence vs. recurrence-free), (2) distal margin length (< or =10 mm vs. >10 mm) and (3) additional treatment (none, adjuvant, or neoadjuvant). The risk factors for anastomotic recurrence were analyzed.

RESULTS

In the recurrence group, an advanced T stage (T3 and T4) (P = 0.01) microscopic distal margin involvement (P = 0.002) and an elevated CEA level (>5 ng/ml) (P = 0.04) were more commonly found. The incidence of anastomotic recurrence was not higher in the distal margin < or =10 mm group and did not differ according to additional treatment. The multivariate analysis showed that an advanced T stage (T3 and T4) and microscopic distal margin involvement were risk factors for anastomotic recurrence.

CONCLUSION

A distal margin < or =10 mm appears to be acceptable in terms of anastomotic recurrence. Patients with a positive distal margin, on the postoperative pathology, should be considered at high risk for anastomotic recurrence.

Differing coping mechanisms, stress level and anorectal physiology in patients with functional constipation

AIM: To investigate coping mechanisms, constipation symptoms and anorectal physiology in 80 constipated subjects and 18 controls.

METHODS: Constipation was diagnosed by Rome II criteria. Coping ability and anxiety/depression were assessed by validated questionnaires. Transit time and balloon distension test were performed.

RESULTS: 34.5% patients were classified as slow transit type of constipation. The total colonic transit time (56 h vs 10 h, P < 0.0001) and rectal sensation including urge sensation (79 mL vs 63 mL, P = 0.019) and maximum tolerable volume (110 mL vs 95 mL, P = 0.03) differed in patients and controls. Constipated subjects had significantly higher anxiety and depression scores and lower SF-36 scores in all categories. They also demonstrated higher scores of ‘monitoring’ coping strategy (14 ± 6 vs 9 ± 3, P = 0.001), which correlated with the rectal distension sensation (P = 0.005), urge sensation (P=0.002), and maximum tolerable volume (P = 0.035). The less use of blunting strategy predicted slow transit constipation in both univariate (P = 0.01) and multivariate analysis (P = 0.03).

CONCLUSION: Defective or ineffective use of coping strategies may be an important etiology in functional constipation and subsequently reflected in abnormal anorectal physiology.

A novel indicator for surveillance colonoscopy following colorectal cancer resection

INTRODUCTION

Current surveillance for recurrent intraluminal or metachronous colorectal cancer following resection is largely undertaken by colonoscopic examination of the remaining colon. The burden on colonoscopic services is high and the procedure is expensive. Immunological faecal occult blood testing (FOBT) is a sensitive and specific test for detecting colorectal cancer, and may fine tune the need for timely surveillance colonoscopy.

METHODS

Consecutive patients due for surveillance colonoscopy following colonic resection for cancer were prospectively studied. Each patient had a single faecal sample obtained at per rectal examination on a gloved examining finger. This was subjected to immunological FOBT in the clinic, and patients were categorized as FOBT positive or negative, according to the result. Colonoscopy as well as ultrasound or CT of the liver were performed within eight weeks of FOBT.

RESULTS

Six hundred and eleven patients had both FOBT and colonoscopy. Fifty-nine (13.6%) were categorized as FOBT-positive. Of these, nine had biopsy-proven recurrent or metachronous cancer, 12 patients had one, or more adenomatous polyps, one patient had radiation proctitis and two patients had pan-colonic mucositis following chemotherapy. In the remaining 552 FOBT-negative patients, no cancers were found. Thirty-eight patients had polyps that were removed. The sensitivity and specificity for detecting cancer by immunological FOBT was 100% sensitivity for detecting adenomatous polyps was 24% but specificity was 93%.

CONCLUSION

The immunological faecal occult blood test provides sensitive detection of metachronous and recurrent cancer in postoperative surveillance. Routine application may be used to reduce the frequency of colonoscopic surveillance, as a negative FOBT may be taken as a sign that colonoscopy may be deferred safely.

Does laparoscopic vs. conventional surgery increase exfoliated cancer cells in the peritoneal cavity during resection of colorectal cancer?

PURPOSE

Traumatic manipulation of cancer specimens during laparoscopic colectomy may increase exfoliation of malignant cells into the peritoneal cavity, causing an early occurrence of peritoneal carcinomatosis or port-sites recurrence. Because of this concern, the routine use of intraperitoneal chemotherapy after laparoscopic colectomy for cancer was suggested recently. We assessed if laparoscopic vs. conventional surgery increases exfoliated malignant cells in the peritoneal cavity during resection of colorectal cancer.

METHODS

In a prospective, randomized fashion, 38 colorectal cancer patients undergoing an elective, curative operation were assigned to either a conventional or laparoscopic procedure between June 1996 and May 1997. In either group (n = 19), after the abdominal cavity was entered, saline was instilled into the peritoneal cavity, and the fluid was collected (Specimen 1). During surgery, all irrigating fluids were collected (Specimen 2). Both specimens were assessed for malignancy using four techniques: filtration process (ThinPrep), smear, cell block, and immunochemistry using Ber-EP4. The change in the amount of tumor cells in both specimens was compared between surgical groups. A pilot study was performed to validate the proposed cytologic method.

RESULTS

In the pilot study of 20 consecutive patients with colorectal cancer, postresectional peritoneal cytology was positive in six patients, including two Stage II (T3, N0, M0) patients. The pilot study also validated that our semiquantitative scoring system can be reliably used to assess the amount of free peritoneal cancer cells. In the main study, 16 right colectomies, 3 extended right colectomies, 17 proctosigmoidectomies, and 1 left colectomy were performed. The T and N stages were T1 (n = 13, T2 (n = 5), T3 (n = 8), T4 (n = 11); N0 (n =22), N1 (n = 8), N2 (n = 7). Malignant cells were not detected in any Specimens 1 or, more importantly, in Specimens 2 in either surgical group.

CONCLUSION

When performed according to strict oncologic surgical principles, laparoscopic techniques in curative colorectal cancer surgery did not have an increased risk of intraperitoneal cancer cell spillage, compared with conventional techniques. We hope that these results can decrease some of the concerns about tumor cell spillage and seeding during laparoscopy.

Routine compared with nonscheduled follow-up of patients with "curative" surgery for colorectal cancer

BACKGROUND

The main rationale for follow-up of colorectal cancer patients resected for "cure" is that early detection and treatment of recurrence and metachronous disease should result in improved survival. Our purpose was to assess in a prospective fashion the impact on survival of a follow-up program versus that of undergoing nonscheduled visits.

METHODS

Within the 14-year period from 1975 through 1988, a prospective study was carried out on 800 patients with colorectal adenocarcinoma radically resected with no evidence of synchronous cancers of the colon and rectum or in other organs, of whom 322 patients were to attend a 5-year follow-up, and 478 patients were free to make nonscheduled visits on account of symptoms.

RESULTS

Asymptomatic recurrence was found at follow-up in 92 (28%) of 322 patients, whereas 175 (36%) of 478 patients had a symptomatic recurrence detected at a nonscheduled visit. Diagnosis of resectable recurrence was established within a median time of 21.5 months. Surgical resection of recurrence was performed in 30 (32%) of 92 and in 13 (7%) of 175 patients (32 vs. 7%; p < 0.001). Resection was curative in 13 (14%) of 92 and in two (1%) of 175. Five-year survival of resected recurrence was 10% in 30 of 92 patients and 0.8% in 13 of 175 (10 vs. 0.8%; p < 0.01). Two patients are alive with no evidence of disease or two (2%) of 92. Metachronous colorectal lesions were treated for cure in 63 (19.5%) of 322 patients. The effectiveness of scheduled follow-up was 4% (13 of 322 patients).

CONCLUSIONS

These results underline the rationale for a follow-up program in early detection and surgical treatment of recurrent disease in patients operated on for colorectal cancer.

Endoscopic abnormalities of the anastomosis following resection of colonic neoplasm

When 321 patients with resections for colonic neoplasms were prospectively evaluated for changes occurring at the anastomosis, eight different kinds were found (118 abnormalities seen in total). Inflammatory polyps, the most commonly observed abnormality (14.5%), may be misinterpreted as recurrent neoplasia by endoscopy. The majority of inflammatory polyps were discrete, 5- to 15-mm lesions, although diffuse nodularity was occasionally seen. Staples or sutures were visible at 11.3% of the anastomoses. Benign strictures, which developed in 7.1%, occurred primarily after left colonic resection with end-to-end anastomosis. Prominent vessels were occasionally seen at the anastomotic site (3.9%). Recurrent carcinoma at the anastomosis was found in 6 of 116 patients with Dukes B and C tumors (5.2%) and occurred 0.4 to 2.0 years after surgery (mean, 1.2 years). Recurrent carcinoma appeared as ulcerated submucosal lesions, bulky luminal masses, and polypoid lesions. In two patients, mucosal erythema, edema, and friability at the anastomosis were the only endoscopic evidence of underlying carcinoma.

Benefits of colonoscopic surveillance after curative resection of colorectal cancer

OBJECTIVE

The authors determined the usefulness of routine colonoscopy after colorectal cancer surgery.

SUMMARY BACKGROUND DATA

Some studies suggest benefit to colonoscopy in the routine follow-up of patients with colorectal cancer who are resected for cure, whereas other studies show no benefit.

METHODS

Chart review was conducted for 290 patients who underwent curative resection for colorectal cancer between 1967 and 1991 at a colorectal surgeon's practice. Colonoscopy was performed every 6 months during the first year, then every 1 to 2 years, or when intercurrent symptoms appeared.

RESULTS

Overall, 31 patients (10.7%) developed recurrent disease, which increased as a function of stage (C2 > B2 > A), with a median time to diagnosis of 20 months. Of these 31 recurrences, 14 (45.2%) were solely local (of whom 12 were asymptomatic); 17 (54.8%) involved distant disease. Nine locally recurrent patients were able to undergo curative resection. Of 19 symptomatic patients, only 3 (15.8%) were amenable to curative resection. Six patients (2.1%) developed a metachronous second primary colorectal cancer, of whom four (66.7%) were asymptomatic, and five (83.3%) were able to undergo curative resection. Overall, because of surveillance colonoscopies, 13 asymptomatic patients (4.5%) had curative resection for localized recurrent disease or a metachronous second primary cancer.

CONCLUSIONS

Colonoscopy is a useful modality in the early detection of recurrent and metachronous disease after colorectal cancer, increasing the potential for curative resection and improved survival.

Proliferative activity at colonic anastomoses as determined by statin. A nonproliferation-specific nuclear protein

PURPOSE

One theory of anastomotic recurrence in large bowel carcinoma is that epithelial hyperplasia at the suture line causes metachronous carcinoma.

METHODS

S44, a monoclonal antibody directed against statin, a nuclear protein expressed in quiescent cells, was used to determine whether the anastomosis represents an area with a high proliferation rate. During follow-up colonoscopic examination of patients who had undergone previous resection for colorectal carcinoma, biopsies were taken from the anastomotic site and from the mucosa 10 to 15 cm from the anastomosis. One side of 10 well-oriented crypts was counted for each patient with the number of nuclei positive for statin being determined by the presence of dark brown reaction product.

RESULTS

The average percentages of statin-positive cells varied between 19.4 and 44.4 (average, 31.3 +/- 6.5) for the normal mucosa and 22.8 to 35.1 (average, 29.98 +/- 3.67) for the anastomotic mucosa. The differences were not significant. There were no differences between those patients in whom the postoperative time elapsed was two years or less and those greater than two years.

CONCLUSION

This study is unique in that the proliferative activity at the site of colonic anastomosis was determined in a clinical setting, and patients in which the anastomoses were created anywhere from 1 to 14 years earlier were included. Using S44 as a marker, this study does not support the theory that suture line recurrence is a result of an enhanced proliferation rate.

Principles of surgical resection. Influence of surgical technique on treatment outcome

In the absence of curative medical therapy, surgical resection remains the cornerstone of treatment for patients with colorectal carcinoma. A thorough knowledge of colon and rectal anatomy is crucial for the formulation of an effective operative strategy. There are certain technical factors under the control of the surgeon that may have prognostic significance for the patient. These include the length of the distal margin of resection, the use of intraluminal cytotoxic solutions to reduce the viability of exfoliated cancer cells, and the technique of colon anastomosis. Curative resections should include removal of the lymphatic drainage of the tumor-bearing segment of colon. When there is adjacent organ invasion by the colonic primary, en block resection of the entire tumor mass with adequate margins is the procedure of choice. Prophylactic oophorectomy in women with colon carcinoma remains controversial. The effects of perioperative transfusion on tumor behavior remain unclear. Blood transfusions should be administered only when there is a specific medical necessity.

Colorectal carcinoma: analysis of management in two medical eras

Trends in presentation, diagnosis, management, and outcome were analyzed for 503 patients with colorectal cancer seen at the UCLA Medical Center between 1960 and 1970 (Group A; n = 210) and 1980 and 1985 (Group B; n = 293). Patients in the latter group exhibited a shift in site to the right side of the colon (18% in Group A vs. 31% in Group B; P < .01), an increase in the number of primary resections without colostomy (38% vs. 61%; P < .01), a lower overall complication rate (28% vs. 18%; P = .01), and a decline in 30-day mortality (6.2% vs. 2%; P = .01). Although little difference was seen in detection of asymptomatic tumors, earlier lesions were treated in the latter group, accounting for substantially reduced rate of recurrence (69% in Group A vs. 44% in Group B; P < .01). Future management should include an emphasis on earlier detection in order to continue the trend toward enhanced survival.

Prognostic significance of anastomotic recurrence from colorectal adenocarcinoma

A retrospective analysis of the prognostic significance of anastomotic recurrence in 50 patients with colorectal adenocarcinoma was conducted from 1970 to 1987. All primary cancers were located above 10 cm from the anal verge. Forty anastomotic recurrences (80 percent) followed resection of sigmoid or proximal rectal tumors. The overall disease-free interval was 13 months, with 90 percent of recurrences diagnosed within 24 months of the primary resection. Forty-five recurrences (90 percent) were associated with synchronous or metachronous metastases. Overall median survival following the recurrence was 16 months--37 months if the anastomosis was the only recurrence site. Of five patients alive without evidence of disease, all were asymptomatic, and recurrence was confined to the anastomosis. In conclusion, anastomotic recurrence following resection of colorectal adenocarcinoma frequently heralds disseminated disease but can be potentially resected for cure if it is the only site in an otherwise asymptomatic patient.

Early postoperative contrast radiology in the assessment of colorectal anastomotic integrity

The predictive value and safety of early postoperative radiological assessment of colorectal anastomotic integrity is controversial. In this study, 233 patients with colorectal or left sided colonic anastomoses had water soluble contrast enemas performed in the early postoperative period (mean: day 7 postoperatively, range: days 4-14). A total of 40 radiological leaks were recorded but only 12 of these patients had clinical signs of anastomotic dehiscence. Furthermore, 11 patients who had normal contrast enemas subsequently developed a clinical anastomotic leak. There were therefore 28 (12.0%) false positive and 11 (4.7%) false negative results giving values for the specificity and sensitivity of the radiological investigation of 86.7% and 52.2% respectively. Only 3 patients (1.3%) developed a clinically apparent anastomotic complication following a contrast enema. We conclude that while radiological assessment of distal large bowel anastomoses in the early postoperative period appears to be a safe procedure, it provides little useful clinical information with regard to early postoperative morbidity. Recent work has, however, suggested that radiological anastomotic integrity may be relevant to long term outcome following surgery for colorectal cancer.

Low anterior resection versus abdominoperineal excision: a comparison of local recurrence after curative surgery for "very low" rectal cancer

In the controversy regarding whether sphincter-saving resection (SSR) or abdominoperineal resection (APER) is more appropriate for the treatment of very low rectal cancer, local recurrence rates seem to play a fundamental role in patient outcome. In order to operate an effective patient selection, very low rectal cancer is defined herein as being located within 4.5 to 7.5 cm from the anal verge. This retrospective report investigates the incidence of local recurrence after curative surgery for very low rectal carcinoma in 24 consecutive patients treated by the same surgical team over a 15-year period using the above surgical procedures. In the APER group, the local recurrence rate was 45.5%, occurring in 5 of 11 cases; and in the SSR group 46.1%, occurring in 6 of 13 cases, with no significant difference between the two groups. Recurrence was found within one year of surgical treatment in all except one case. Despite the strict follow-up program, it was only possible to perform reoperation in two recurrent cases, both previously submitted to SSR and diagnosed by means of transanal ultrasonography and macrobiopsy. The high incidence of local recurrence in this series is explained by the advanced stage of disease in the majority of cases. Thus, as the choice between APER and SSR does not seem to affect the incidence of local recurrence, which is related more to tumor size, site, stage, and grading, preservation of the sphincters and restoration of digestive continuity should be achieved whenever technically possible.

The clinical and biological significance of the transitional mucosa adjacent to colorectal cancer

The underlying nature of the transitional mucosa adjacent to colorectal cancer is defined and the evidence for and against the statement that this transitional mucosa involves primary premalignant change presented in this article. An association between mucin histochemical changes at the margins of resection and a poorer clinical outcome of patients has been recognized in patients with colorectal cancer after surgery. The retained transitional mucosa at the margins of resection appears to correlate with tumor recurrence and a poorer survival in patients who have undergone radical resection. It is considered that the transitional mucosa adjacent to colorectal cancer and its presence at the margins of resection may be an important prognostic marker for patients with large bowel cancer following radical resection.

Reoperation for colorectal carcinoma

In the management of the patient with intra-abdominal recurrence of colorectal carcinoma, surgery remains the primary mode of therapy when cure or significant palliation is anticipated. Appreciation of the importance of close follow-up after primary resection coupled with improved diagnostic modalities has allowed the surgeon not only to detect earlier recurrence but also to select the patients most likely to benefit from resection of recurrent disease. Improved surgical techniques with resultant decreases in the rates of morbidity and mortality have allowed safe hepatic resection of metastatic disease. In selected patients, this procedure produces 5-year survival rates approaching 50%. Although a clear consensus has not been reached, most studies agree that positive prognostic indicators include absence of extrahepatic disease, a small number of intrahepatic lesions, a low CEA level, and a better Dukes stage of the primary. Likewise, in the patient with recurrent disease locally, surgery provides the only means of cure and also plays a significant role in palliation. Aggressive resection with generous surgical margins in patients with contained disease may yield 5-year survival rates approaching 35%. In patients with unresectable disease and even in those with carcinomatosis, palliation can be obtained by surgical therapy. Judgment is necessary in treating these patients both preoperatively and intraoperatively. Surgical intervention for obstruction, perforation, or other anatomic or physiological compromise is often indicated and can improve the quality of life of the patient with intra-abdominal recurrence.

Local recurrence after curative resection for colorectal cancer: frequency, risk factors and treatment

Analysis of 498 patients with colorectal carcinoma was retrospectively reviewed to evaluate the incidence, risk factors and therapy of local recurrent carcinoma following curative resection. Complete follow-up information was obtained in all but four patients (99.2%). After a median follow up of 42 months, 64 out of 469 (13.6%) patients developed local recurrence (LR). The incidence of LR was higher in rectal than in colon cancer patients (18.3% vs 8.9%) (P less than 0.005). Separate univariate and Cox analyses for rectal patients showed tumor site (P less than 0.02). Dukes stage (P less than 0.002), and adjuvant radiotherapy (P = 0.05) determined risk of LR. For colon cancer patients risk of LR was determined by histological tumor grade (P less than 0.01). Out of 64 patients, 5 (7.8%) underwent radical excision of LR. Forty percent of these survived at 5-year (P less than 0.08). Palliative treatment (radio-chemotherapy) obtained a 5-year survival of 15.3%, with no survivors in no-treatment group. These results suggest that local recurrent colorectal carcinoma remain a difficult treatment problem. More effective combinations of surgery and adjuvant therapy are therefore mandatory to reduce the incidence of local failure in high risk colorectal patients.

Effect of indomethacin in autotransplanted colonic tumors

Seventy-five male Sprague-Dawley rats received weekly injections of dimethylhydrazine (DMH) for six months. Indomethacin was given orally to 40 of the rats. At the end of the allotted period, colonic tumors were autotransplanted into the subcapsular space of the left kidney. The autopsy demonstrated colonic tumors in 32 of 34 rats treated with DMH (94.1 percent), but only in 15 of 40 rats (37.5 percent) treated with DMH-indomethacin. Successful kidney autotransplantation was accomplished in 20 of 32 DMH-treated rats (63 percent) and in 5 of 15 DMH-indomethacin-treated rats (33.3 percent). Thus, the induction of colonic tumors by DMH and successful kidney autotransplants can be substantially abrogated by synchronous treatment with indomethacin.