Abdominal Lymphoma - the Place for Surgery

Gastrointestinal lymphoma (GIL) is rare but may be cured by surgery and chemotherapy. Because symptoms frequently mimic common abdominal conditions, presentation is often to a surgeon. Fiftyfive patients with GIL were treated between 1975 and 1984: all underwent operations before the correct diagnosis was made, 22 (40%) as emergencies. Misdiagnosis in 23 (42%) led to a delay in correct treatment of ≥ 6 months from the start of symptoms: in 17 (31%) the delay was ≥ one year. Endoscopy and radiology were inaccurate and suggested peptic ulceration, Crohn's disease or irritable bowel syndrome. The site of disease was usually stomach and duodenum (26, 47%) or ileum and jejunum (29, 53%). The extent of surgical resection was associated with survival at ≥3 years - in 16 (29%) who underwent ‘complete resection’ 14 survived, but only one of 28 survived when the operation was limited to diagnostic biopsy (P < 0.0001). Most deaths occurred within one year of operation, commonlyfrom perforation or haematemesis from residual mural disease during chemotherapy. In 5 of 11 patients who had biopsy only, CT scans suggested localized disease, and ‘complete resection’ was achieved at a second laparotomy. Complete resection should be attempted wherever possible before chemotherapy. The place for surgeons with experience is clearly central to the management of this disease.

Foreign Bodies in the Rectum: A Review

Foreign bodies which lodge above the anal sphincter mechanism may arrive from one of two portals of entry, the mouth or the anal canal. Ingestion of a foreign body is usually unknown to the patient, who presents with symptoms due to impaction and minor injury to the rectal ampulla or anal canal. The patient may have severe anal pain or sepsis associated with the foreign body. The diagnosis is usually obvious on examination under an anaesthetic, but before this there may be a difficult diagnostic problem.

Foreign bodies passed into the rectum through the anal sphincter are more common and show an extreme variety. The reasons for insertion are discussed. Management of the problem includes extraction of the foreign body and the recognition and treatment of any associated injury, both extraperitoneal and intraperitoneal. Minor extraperitoneal injuries may be treated expectantly, but in all intraperitoneal and major extraperitoneal injuries laparotomy and colostomy are required. It is stressed that most foreign bodies can be removed transanally, and laparotomy to remove the foreign body is rarely required.

Bowel Disease after Radiotherapy

The clinical presentation, operative findings and outcome in 40 patients who required surgery for bowel disease after radiotherapy are presented. The type of presentation varied according to the time after radiotherapy. In the first month, many patients had a proctitis but none required surgery. Five patients were operated on within one month, 2 for radiation-induced acute ileitis and 3 for exacerbations of pre-existing disease (diverticular disease 2, ulcerative colitis 1). The commonest time of presentation was between 3 and 18 months after radiotherapy, when 20 patients needed surgery for bowel disease caused by radiation-induced local ischaemia. Twelve of these patients had chronic perforation, 6 had severe rectal bleeding and 2 had painful anorectal ulceration. Fifteen patients presented between 2 and 24 years after radiotherapy, usually with incomplete intestinal obstruction due to a fibrous stricture, but 2 patients had rectal carcinoma.

Wide resection of the involved bowel was the principal method of treatment but any anastomosis was protected by a proximal defunctioning stoma. There was no operative mortality but 10 patients have died subsequently. The danger of dismissing these patients as having incurable malignancy is stressed because, although the condition is infrequent, it is usually amenable to adequate surgery.

Are We Using the Correct Dose of Metronidazole in Colorectal Surgery?

In a series of 20 patients undergoing elective colorectal surgery, 10 received an infusion of metronidazole 500 mg and 10 an infusion of 1500 mg commencing at the induction of anaesthesia. The concentrations of metronidazole in the plasma, rectus muscle and colon of the two groups during the course of the operation were compared. In those patients who received 1500 mg, the plasma and tissue concentrations were all well above the minimum inhibitory concentration (MIC) of metronidazole against Bacteroides fragilis. In those patients who received 500 mg, serum and tissue concentrations were at or only just above the MIC. It may be that 1500 mg would be a more effective dose of metronidazole for prophylactic use in colorectal surgery.

Use of bone meal amendments to immobilise Pb, Zn and Cd in soil: A leaching column study

The aim of this study is to test the stabilisation of metals in contaminated soils via the formation of low-solubility metal phosphates. Bone apatite, in the form of commercially available bone meal, was tested as a phosphate source on a mine waste contaminated made-ground with high levels of Pb, Zn and Cd. Triplicate leaching columns were set up at bone meal to soil ratios of 1:25 and 1:10, in addition to unamended controls, and were run for 18 months. The columns were irrigated daily with a synthetic rain solution at pH of 2, 3, and 4.4. After 100 days, the leachate Pb, Zn and Cd concentrations of all amended columns were significantly reduced. For 1:10 treatments, release of these metals was suppressed throughout the trial. For 1:25 treatments, Zn and Cd concentrations in the leachates began to increase after 300 days. DTPA and water extractions showed that Pb and Cd were more strongly held in the amended soils. This study concludes that the complexity of soil processes and the small quantities of metals sequestered precluded determination of a metal immobilisation mechanism.

Patterns of local disease failure and outcome after salvage surgery in patients with anal cancer

Background

Salvage surgery for anal cancer is usually reserved for local disease failure, but issues relating to the prediction of local failure and surgical outcome are ill defined.

Methods

Between 1988 and 2000, 254 patients with non-metastatic anal epidermoid carcinoma were treated at a regional cancer centre with radiotherapy (n = 127) or chemoradiotherapy (n = 127).

Results

There were 99 local disease failures (39·0 per cent), all but five occurring within 3 years of initial treatment. Increasing age (P &lt; 0·001, Cox model), total radiation dose (P = 0·004) and tumour stage (P = 0·010) were independent predictors of local failure. The overall 3- and 5-year survival rates after local disease failure were 46 and 29 per cent; the corresponding rates after salvage surgery (73 patients) were 55 and 40 per cent. A positive resection margin was the strongest negative predictor of survival after salvage surgery (P = 0·008, log rank test). Of 52 patients treated before the routine consideration of primary plastic reconstruction, delayed perineal wound healing occurred in 22 (42 per cent).

Conclusion

In the management of anal cancer, local disease failure is a major clinical problem requiring early detection followed by radical surgery, often accompanied by plastic reconstruction. By implication, these factors favour the centralization of treatment for this uncommon cancer to a multidisciplinary oncology team.

Acute compartment syndrome of the legs after colorectal surgery

This review considers the causes, diagnosis and management of compartment syndrome affecting the legs after colorectal surgery.

Inguinal hernia: medicolegal implications

Repair of an inguinal hernia is one of the commonest operations undertaken by surgeons but the role of trauma in causing inguinal hernia is not well understood. This paper does not attempt to discuss the cause of inguinal hernia but seeks to analyse the cases which may be accepted by the Courts as being due to trauma.

Development of X-ray photoemission electron microscopy (X-PEEM) at the SRS

The use of synchrotron radiation sources for X-ray spectroscopy is a well known and developed field. The majority of applications, however, have been limited to studies of materials containing only a single phase of the element of interest. Owing to limited availability of suitable instrumentation, the study of materials comprising intergrowths of different phases has presented difficulties in analysis. The majority of natural materials, including mineralogical samples, fall into this category. However, by applying the technique of photoemission electron microscopy (PEEM) to view the X-ray stimulated photoemission generated at an absorption edge, micro-area-selectable spectroscopy becomes possible. An instrument for X-ray PEEM (X-PEEM) is being developed at the Daresbury SRS and this paper shows how it can be used to obtain characteristic L-edge XANES spectra from finely intergrown iron oxide minerals.

Effect of anorectal eversion on long-term clinical outcome of restorative proctocolectomy

Eversion of the rectum during restorative proctocolectomy with stapled ileal pouch-anal anastomosis (IPAA) remains a controversial surgical manoeuvre because of concern that it may impair anal sphincter function and adversely affect outcome. We have reviewed the long-term results in 41 patients whose operation included formation of a 20 cm J-pouch with stapled IPAA by the technique of rectal eversion. At median follow-up of 4 years (range 1-6 years), 4 pouches (10%) had been removed (2 for pelvic sepsis, 1 for rectovaginal fistula and 1 for Crohn's disease). In 34 patients with functioning pouches in situ, median stool frequency was 5 per 24 h (range 2-10). 11 patients (33%) regularly had to evacuate their pouch at night and 4 (12%) used antidiarrhoeal medication. No patients reported major incontinence; 2 (6%) had minor leakage, and in another 2 minor leakage had now ceased. 4 patients had had episodes of pouchitis. These favourable results offer no support for the contention that rectal eversion substantially worsens the long-term results of restorative proctocolectomy.

Distortion Characteristics Across the Structural Phase Transition in (Cu1−x Zn x )WO4

Rietveld analysis of neutron powder diffraction data on the sanmartinite (ZnWO4)-cuproscheelite (CuWO4) solid solution has enabled the comparison of microscopic and macroscopic order parameters associated with the P2/c–P\overline 1 structural phase transition. The macroscopic spontaneous strain, calculated from the lattice parameters, conforms well with a second-order Landau model. Furthermore, this is also true of the symmetry-related atomistic M—O order parameter and the quadratic elongation of the MO6 octahedra. It is clear that the Jahn–Teller effect, associated with the divalent Cu cation, is the driving force for the phase transition and the excess elongation evident in the M—O(2) bond giving rise to the non-symmetry predicted strain element e 22. The existence of a large region of order parameter saturation at the copper-rich end of the solid solution is also associated with the MO6 elongation and the breakdown of the homogeneous strain field of the zinc solute atoms.

Transforming growth factor beta 1 expression in human colorectal tumours: an independent prognostic marker in a subgroup of poor prognosis patients

Members of the transforming growth factor beta (TGF-beta family, in particular TGF-beta 1, are some of the most potent inhibitory growth factors in a variety of cell types. Resistance to TGF-beta 1-induced growth inhibition is frequently observed in colorectal carcinomas and is associated with tumour progression. Perturbations of TGF-beta 1 expression and function, therefore, may contribute to the loss of some constraints on tumour cell growth. In this study we have examined the expression of TGF-beta 1 and its precursor latency-associated peptide (LAP)-TGF-beta in human colorectal tumours using immunohistochemical techniques. In 86% of the tumours the LAP-TGF-beta complex was present in both the stromal and epithelial cells, whereas the mature TGF-beta 1 peptide was expressed in the glandular epithelium of 58.3% of these tumours. Intense staining for TGF-beta 1 was positively associated with advanced Dukes' stage. Furthermore, there was a significant correlation between the presence of TGF-beta 1 in the tumours and a shorter post-operative survival. This was most significant in a subgroup of patients who had received only a palliative operation. These results suggest that TGF-beta 1 expression may be useful as an independent prognostic indicator for a subgroup of patients who have a particularly poor prognosis.

Definition of local recurrence after surgery for rectal carcinoma

Local recurrence rates of rectal carcinoma have been analysed among 284 patients in a prospective randomized multicentre trial of adjuvant preoperative radiotherapy for locally advanced rectal carcinoma. Wide variations in local recurrence rates are demonstrated depending on the definition of local recurrence employed and the subgroup studied. Thus after surgical operation alone, rates as high as 43.3 per cent or as low as 12.7 per cent can be calculated. After both adjuvant preoperative radiotherapy and operation the overall local recurrence rate is 12.8 per cent, although the local recurrence rate inside the radiotherapy field (true recurrence) may be as low as 2.3 per cent. It is recommended that local recurrence after operation for rectal carcinoma be defined as any detectable local disease at follow-up, occurring either alone or in conjunction with generalized recurrence, in patients who have undergone resection. A rate should be given both for all patients and for those operated on for cure, but not for the latter group alone as this could introduce bias.

2p X-ray Absorption Spectroscopy in the Earth Sciences

A complete knowledge of 3d transition-metal valencies, site occupancies and site symmetries is essential for a full understanding of mineral/melt energetics and behaviour. Over the last few years, significant advances in both instrumentation and theory associated with synchrotron radiation sources and experiments have enabled the development of 2p X-ray absorption spectroscopy as a sensitive, element-specific site and valency probe. The potential of this technique in the Earth sciences is discussed in this paper with examples reflecting the variety of problems set by 3d transition metals in natural systems.

Adjuvant preoperative radiotherapy for locally advanced rectal carcinoma. Results of a prospective, randomized trial

PURPOSE

A prospective, randomized clinical trial was conducted by the Northwest Rectal Cancer Group to study the effects of preoperative radiotherapy given one week before surgery in locally advanced (tethered or fixed) rectal carcinoma.

METHODS

A total of 284 patients were entered into the trial between 1982 and 1986; 141 were allocated to receive surgical treatment alone, and 143 were allocated to receive preoperative radiotherapy. A 10 x 10 x 10 cm volume in the posterior pelvis, centered on the tumor, was irradiated at a dose of 20 Gy, divided into four daily fractions of 5 Gy each.

RESULTS

No differences were observed in any of the clinicopathologic variables in the two arms of the trial; there were no striking down-staging effects in the irradiated tumors. After a minimum follow-up period of 96 months, the overall and cancer-related mortality rates were similar in both arms of the study (P = 0.21 and P = 0.09, respectively). There was a highly significant reduction in local recurrences in the irradiated group (12.8 percent x-ray therapy vs. 36.5 percent surgery; P = 0.0001). The majority of local recurrences after preoperative radiotherapy occurred inside the radiotherapy field (10 cases; 7 percent), with only six cases (5 percent) outside the field. No significant difference was observed in the rates of distant metastasis between the two treatment groups (P = 0.73).

CONCLUSIONS

Although there is no statistically significant survival benefit in the whole series, there is a survival benefit for the subset of patients considered by the surgeon to have undergone a curative operation. We recommend that this form of adjuvant therapy should be offered to all patients with locally advanced rectal cancer who are to undergo radical surgery.

An evaluation of five different methods for estimating proliferation in human colorectal adenocarcinomas

Five different methods of determining cell proliferation have been compared in samples taken from a group of 125 human colorectal tumours labelled in vivo with iododeoxy-uridine (IUdR). The labelling index (LI) was obtained immunocytochemically using monoclonal antibodies against proliferating cell nuclear antigen (PCNA), the Ki67 antigen and IUdR (IUdRimm). Incorporation of IUdR was also determined flow cytometrically (IUdRfcm) and PCNA expression was measured in both formalin- and methanol-fixed tissue (PCNAf and PCNAm respectively). There was significant variation in the results obtained both within and between the different assays. Paired analysis of the data showed that the correlation between the different methods of determining the LI was poor. However, the IUdRfcm LI was significantly correlated with both IUdRimm (r = 0.39; n = 78; P < 0.001 by Spearman's test) and Ki67 LIs (r = 0.32; n = 87; P < 0.001). The IUdRimm LI was also significantly related to the Ki67 LI (r = 0.44; n = 60; P < 0.001). The median IUdRfcm and IUdRimm LIs were significantly higher in the aneuploid vs. the diploid tumours (17.4% vs. 6.2% for IUdRfcm; 23.2% vs. 18.9 for the IUdRimm; P < 0.001 and P = 0.014 respectively by Mann-Whitney U-test) but none of the other proliferative indices showed this relationship. Finally, none of the LIs showed a significant association with the clinical characteristics of the tumours such as stage, grade, age, sex or fixity. The findings of this investigation highlight the need for carefully controlled studies when assessing the value of proliferation markers in solid human tumours.

Distribution of gelatinase B (MMP-9) and type IV collagen in colorectal carcinoma

Gelatinase B (92 kD, matrix metalloproteinase-9, MMP-9), an enzyme capable of degrading several connective tissue components, was demonstrated by immunolocalization in all specimens of colorectal carcinoma (n = 40), but its distribution between specimens was variable. MMP-9 expression was more frequently observed in advanced tumour stages and was especially prevalent at the side and deep margins of the tumours, and ulceration sites. MMP-9 staining was observed for transformed epithelial cells, macrophages and neutrophils, but seldom for vascular or stromal cells. By contrast, the enzyme was absent from epithelial cells of normal mucosal tissue. Immunostaining of type IV collagen, the major structural component of basement membranes, revealed a general depletion or loss of these structures both within the tumours and at the tumour margins. Dual immunolocalization of MMP-9 and type IV collagen demonstrated that MMP-9 expression at specific sites in the tumour was often inversely related to the distribution of type IV collagen. MMP-9 expression was most pronounced at the invasive tumour margins and in microfoci where tumour cells were in close proximity to inflammatory cells. Such observations support the concept that localized proteolytic and collagenolytic activities contribute to the invasive properties of colorectal tumours.

Prognostic significance of 5T4 oncofetal antigen expression in colorectal carcinoma

The 5T4 oncofetal antigen is a 72 kDa glycoprotein defined by a monoclonal antibody raised against human placental trophoblast and is expressed in many different carcinomas but detected only at low levels in some normal epithelia. Immunohistochemical analysis of the patterns of expression in colorectal carcinomas has indicated a significant association between the presence of the antigen in tumour cells and metastatic spread. The 5T4 antigen phenotype of 72 colorectal cancers has been compared with the clinical outcome of the patients in order to assess its relationship with prognosis. Forty per cent of tumours were 5T4 positive; the remainder were either unlabelled or exhibited stroma-associated labelling only. There was a significant correlation between 5T4 expression in the malignant cells and unfavourable course of disease (P < 0.001). The 5 year survival with 5T4-positive tumours was 22% compared with 75% for patients with 5T4-negative tumours; median survival was 24 versus > 90 months respectively. Stratified analysis showed that 5T4 antigen tumour positivity was acting independently of each of stage, site of tumour, age or sex. There were significant differences in survival for patients with Dukes' B and C stage carcinomas (P = 0.001 and P = 0.034). The results suggest that in colorectal cancer immunohistochemical assessment of 5T4 expression may be useful in identifying patients at high risk for tumour recurrence and for whom additional treatment strategies might be most appropriate.

Intra-tumoral heterogeneity of tumour potential doubling times (Tpot) in colorectal cancer

Intra-tumoural heterogeneity of proliferation has been assessed by taking multiple biopsies from 30 colorectal cancers. Following in vivo IUDR labelling, dual parameter flow cytometry was used to measure tumour DNA index (DI) and labelling index (LI) and to derive DNA synthesis time (Ts) and potential doubling time (Tpot). Heterogeneity was seen for all parameters under investigation. Overall coefficients of variation (CV) and logarithmic transformation of Ts and Tpot (due to their non-gaussian distributions) indicate that LI (CV 25%) was the most variable parameter. Intra-tumoral heterogeneity in Tpot (lnTpot CV = 22%) was less than inter-individual variation (CV = 63%), suggesting that this variation should not be a limitation to the possible usefulness of this technique as an independent prognostic indicator. Correlations of Tpot values were examined between the shortest, the median and the value for a pooled homogenate sample from a single tumour. Using an homogenate, it was possible to accurately predict classification of tumour Tpot values as being below the median ('fast tumours') in 15 of 19 cases (79%). The data suggest that assaying an homogenate may allow a more rapid analysis of a multiply sampled tumour.

The value of exfoliative cytology in the diagnosis of rectal malignancy

This study has assessed the feasibility and reliability of cytology smears taken from patients with known rectal carcinomas without the use of any special instruments. In a pilot study of 23 patients who all had proved rectal cancer, 19 patients had satisfactory smears, one of which produced a false negative result. The remaining 18 displayed varying degrees of dysplasia (10) or frank malignancy (8). One of the patients with a smear containing severely dysplastic cells had a negative biopsy but had clear clinical and radiological evidence of a rectal tumour. Subsequently, a blind controlled study was undertaken on 29 patients with either carcinoma, proctitis or a normal rectum. All 29 sets of smears were of diagnostic quality and were correctly diagnosed as benign or malignant by the cytologist who had no knowledge of the clinical diagnosis. This is a rapid and simple diagnostic test which, if positive for malignancy, allows treatment to be planned at the first consultation. In combination with a forceps biopsy, the rate of positive diagnosis may be increased. A dysplastic smear adds to the level of clinical suspicion and confirms the need for biopsy of a lesion.

An assessment of the reliability and reproducibility of measurement of potential doubling times (Tpot) in human colorectal cancers

An assessment has been made of the reproducibility of measuring tumour proliferation using in vivo iododeoxyuridine (IUdR) labelling and flow cytometry. The variation that occurs between different institutions (Paterson Institute for Cancer Research, Manchester and the Gray Laboratory, Northwood), different observers and different runs on the same flow cytometer have been measured on 139 samples from 53 patients with colorectal cancer. The results demonstrate that the IUdR technique for measuring tumour proliferation is reproducible. Correlations were seen between measurements of Tpot obtained by different individuals and on separate machines. However, direct comparisons of the measured parameters showed that there were highly significant differences in the values obtained between institutes and observers (P < 0.001). Despite these variations, there were still significant detectable differences in Tpot measurements between individual tumours (P < 0.001). Analysis of the results obtained by running the same samples on two separate occasions on the same machine showed that the technique was highly reproducible and that the staining procedure was stable. Eighty per cent of the samples were similarly assigned to either above or below the median Tpot value, regardless which observer/laboratory combination was utilised. These data suggest that large clinical trials using Tpot should employ a single centre and a single individual to prepare, run and analyse samples.

An improved means of faecal diversion: the trephine stoma

Twenty-four patients in whom trephine stoma formation was performed over a 4-year period are described. This procedure permits the formation of an end ileostomy or colostomy without laparotomy. It is simple, rapid, safe and allows speedy recovery. It is widely applicable and previous abdominal surgery is no contraindication. The procedure was impossible in two patients who required laparotomy and in a third in whom a loop colostomy was created. Operation time was shorter and postoperative opiate requirements less than when laparotomy was undertaken for stoma formation. Follow-up (median 1 year) of 17 patients confirmed a low incidence of complications (two prolapses, one parastomal hernia) after trephine stoma formation. This procedure is recommended as the preferred method of ileostomy or colostomy formation when laparotomy is not otherwise indicated.

ABC of colorectal diseases. Tropical colonic diseases

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Flow cytometric DNA characteristics of radiation colitis--a preliminary study

The DNA status of 12 rectal biopsies, taken during the investigation of radiation proctitis, was investigated. Of these six were in the acute phase and six in the chronic phase. All of the acute biopsies had diploid DNA, despite bizarre histological epithelial cell appearances. Two of the chronic phase biopsies were to have aneuploid DNA profiles. This finding may be relevant to the increased risk of malignancy in irradiated tissues.

K-ras gene mutation in colorectal adenomas and carcinomas from familial adenomatous polyposis patients

Colorectal adenomas and carcinomas from familial adenomatous polyposis (FAP) patients were screened for the presence of K-ras gene mutations at codon 12 using an in vitro amplification step (polymerase chain reaction) followed by dot blot analysis using oligonucleotide probes specific for different mutations at codon 12. We examined 28 colorectal adenomas and two colorectal carcinomas from 12 FAP patients and observed a mutation at codon 12 in seven adenomas and in both carcinomas. The frequency of K-ras gene mutations in colorectal tumours from FAP patients is similar to those in cases of sporadic adenomas and sporadic colorectal carcinomas indicating that the mechanisms involved in their development may be similar.

K-ras gene mutations in adenomas and carcinomas of the colon

DNA extracted from 29 colorectal carcinomas and 40 sporadic adenomas was amplified by the polymerase chain reaction (PCR) and analysed for the presence of K-ras gene mutations at codon 12 using a panel of synthetic oligonucleotide probes specific for normal and mutated sequences. The presence of mutations was correlated with various histopathological and clinical data. Ten carcinomas (34.5%) and 14 sporadic adenomas (35%) showed K-ras mutations at codon 12. In the carcinoma group, no apparent correlation was found between the presence of mutant oncogenes and the degree of histological differentiation, Dukes' staging or the development of distant metastasis. In the adenoma group, the frequency of mutations increased with the size of the adenoma and the severity of the dysplastic changes. This study confirms that ras gene mutations are common and early events in colon carcinogenesis. They appear to give a selective growth advantage to those polyps with mutations which leads to their increase in size and thus possibly prepare the ground for malignant transformation.

The importance of combining xylene clearance and immunohistochemistry in the accurate staging of colorectal carcinoma

The prognosis of colorectal carcinoma relies heavily on pathological staging which includes the metastatic state of lymph nodes. Colorectal resectates from 47 patients (41 with colorectal carcinoma and six with non-malignant disease) were entered into a study to assess the best method for detecting metastases in lymph nodes. The maximum number of lymph nodes was harvested at an initial careful examination of the specimen. Subsequently, the pericolic and perirectal fat was dissected out, dehydrated in alcohol, cleared in xylene and further lymph nodes were recovered. Both sets of lymph nodes were examined by the standard histological method and subsequently stained immunohistochemically for cytokeratins (CK). The mean number of lymph nodes recovered at the initial dissection from all 47 cases was 6.7, this was raised to 58.2 after xylene clearance, ie an average of 51.5 lymph nodes were not recovered by traditional methods. At the initial dissection no epithelial cells were detected in any of the lymph nodes from the nonmalignant cases or 25 of the malignant cases. In the other 16 cases, epithelial cells were detected by H&E in 38 lymph nodes. Thus the initial staging was 3 Dukes A, 22 Dukes B and 16 Dukes C. After immunohistochemistry, eight additional cases (originally staged Dukes B) showed epithelial cells in the lymph nodes, these were chiefly occult invasion, raising the involved lymph nodes number to 70. After xylene clearance and applying the CK staining, an additional 135 lymph nodes were found to be involved, thus the overall number of involved lymph nodes was increased to 205. The combined technique changed the Dukes staging in 12 out of 41 cases of colorectal carcinoma, resulting finally in 3 Dukes A, 10 Dukes B and 28 Dukes C, ie 55% of Dukes B become Dukes C.

ABC of colorectal diseases. Colorectal neoplasia--III: Treatment and prevention

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ABC of colorectal diseases. Colorectal neoplasia--II: Large bowel cancer

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ABC of colorectal diseases. Colorectal neoplasia--I: Benign colonic tumours

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Management of neutropenic colitis

Neutropenic colitis is recognized as a rare complication of chemotherapy in haematological malignancies. By contrast, the complication is less well known in relationship to chemotherapy for solid malignancies. There are very few examples reported and this paper adds three further cases and reviews the literature. We emphasize that although some cases of neutropenic colitis may be managed medically, full thickness involvement of the bowel wall may lead to perforation and require surgery. The pathogenesis of this progression is discussed and it is concluded that clinical awareness is important in the diagnosis. The signs of peritonitis or septicaemia are indications for excisional surgery with the formation of a temporary ileostomy.

Prognostic factors in colorectal carcinoma treated by preoperative radiotherapy and immediate surgery

The clinicopathologic staging of colorectal cancer is the subject of recent debate. We studied morphologic variables in a series of tumors resected from 284 patients. Half had been prospectively, randomly allocated to receive a 4-day schedule of preoperative pelvic radiotherapy followed by immediate surgery. There was a significant (P less than 0.01) difference in the distribution of tumors of various histopathologic grades between irradiated (XS) and unirradiated (S) patients and borderline differences in the predictive values of venous spread, tumor grading, and local spread. However, these differences were less marked in 180 tumors examined by one review pathologist. They were thought to be due to misinterpretation of changes induced by radiotherapy. No differences were detected in the distribution of tumors of various sizes and Dukes' stage in the XS and S groups. The review pathologist recorded a borderline (P = 0.049) difference in the distribution of tumors of various CEA staining patterns between the XS and S groups. In a Cox regression model. Dukes' staging remained the most important predictive variable for survival and pelvic recurrence in the XS and S groups. Dukes' staging was apparently unchanged by this schedule of preoperative radiotherapy, but Broders' grading may be unreliable. Any new clinicopathologic staging system for colorectal cancer should record when preoperative radiotherapy is delivered. More studies of radiotherapy effects are required.