Anal canal cancer treatment: practical limitations of routine prescription of concurrent chemotherapy and radiotherapy

This study is an analysis of the criteria considered when prescribing concomitant chemotherapy and radiotherapy, as a routine treatment for patients with anal canal cancer, and related complications. Between 1990 and 1996, 67 patients were treated at Institut Curie for invasive, nonmetastatic cancer of the anal canal. Median age was 65 years (range, 35–90 years). TNM stage distribution was as follows: seven T1, 17 T2, 27 T3, 16 T4, and 22 N+ patients. A total of 29 patients (i.e., five T1/T2, and 24 T3/T4) received concurrent chemotherapy and radiotherapy. Radiotherapy volumes and dose and prescribed dose for chemotherapy were not statistically different from one group of patients to another. Only 55% of T3/T4 patients underwent standard chemoradiation treatment for anal canal cancer. Age was the one of main factor in determining if the patient would undergo concomitant chemotherapy or not. For the T3/T4 patients, concomitant chemotherapy was prescribed to 69% of patients <55 years, 90% of patients between 56 and 64 years, 45% of patients between 65 and 75 years, and 20% of patients over 75 years (P<0.02).Overall survival at 4 years was 66%. The 4 years overall survival rate of T3/T4 patients, who underwent concomitant chemotherapy, was 72%, and that of T3/T4 patient who did not, was 34% (P<0.04). The patients who did not undergo chemotherapy were significantly older. The difference in cause-specific survival rates (72 vs 48%) was not significant. Relapse-free interval without local recurrence at 4 years was 70%. Relapse-free interval of T3/T4 patients was 78% with chemotherapy and 60% without chemotherapy (p=NS). Rates of treatment discontinuation and early toxicity were not statistically different. Late complications occurred in 33 patients, eight of whom had grade 2/3 tumours. At 2 years, complications occurred in 39% of patients who had undergone concomitant chemotherapy, and in 20% of patients who had not (p<0.02). Differences in grade 2/3 complications were not significant. In conclusion, although radiotherapy with concomitant chemotherapy is considered the current ‘gold-standard’ treatment for anal canal cancer, in our daily experience, only 55% of our T3/T4 patients have undergone this treatment. The remainder did not undergo chemotherapy mainly because they were deemed too old. In this series, no increase in local control and cause-specific survival was observed in patients who received concomitant chemotherapy; this may be due to the small number of patients included in the series. The increased rate of late complications observed in patients who received the combined treatment, however, provides evidence that this treatment should be restricted to younger patients without comorbidity and therefore justifies our position. Perhaps reduction of doses of chemotherapy must be discussed for older patients.

Effects of preoperative chemotherapy on liver function tests after hepatectomy

BACKGROUND/AIMS

Surgical resection of liver metastases is performed increasingly frequently after chemotherapy, which can induce fatty degeneration, possibly modifying the postoperative course after hepatectomy. This study evaluated the effect of chemotherapy on postoperative liver function tests according to the use of preoperative chemotherapy or not.

METHODOLOGY

Thirty-two patients were operated on for isolated breast cancer hepatic metastases, after stabilization or complete response to systemic therapy. The first group included 20 patients operated on after chemotherapy (9 major and 11 minor hepatic resections). The second group included 12 patients operated on without chemotherapy (3 major and 9 minor hepatic resections).

RESULTS

Histological examination after chemotherapy confirmed micronodular fatty degeneration in 85% of cases, versus none in the control group (P = 0.05). Fall in prothrombin time on day 1 (D1) was more marked in the chemotherapy group (58%) versus control group (74%) (P = 0.001). gamma-glutamyl transpeptidase did not rise on D7 in the chemotherapy group (1.4 x N), even after major hepatectomy (1.6 x N), in contrast with the control group, in which the mean gamma-glutamyl transpeptidase on D7 was 4.6 x N after major hepatectomy and 2 x N after minor hepatectomy (P = 0.05).

CONCLUSIONS

Chemotherapy induces almost constant fatty degeneration of the liver. Hepatic regeneration in the postchemotherapy liver is delayed, as reflected by a later and lower elevation of gamma-glutamyl transpeptidase. The predictive risk of liver failure, reflected by prothrombin time, following minor hepatectomy on postchemotherapy liver is similar to that of major hepatectomy to healthy liver.

Alternative genetic pathways in colorectal carcinogenesis

The comparative typing of matched tumor and blood DNAs at dinucleotide repeat (microsatellite) loci has revealed in tumor DNA the presence of alleles that are not observed in normal DNA. The occurrence of these additional alleles is possibly due to replication errors (RERs). Although this observation has led to the recognition of a subtype of colorectal cancer with a high incidence of RERs (caused by a deficiency in DNA mismatch repair), a thorough analysis of the RER frequency in a consecutive series of colorectal cancers had not been reported. It is shown here that the extensive typing of 88 colorectal tumors reveals a bimodal distribution for the frequency of RER at microsatellite loci. Within the major mode (75 tumors, RER- subtype), the probability that a locus exhibited instability did not differ significantly among loci and tumors, being 0.02. The subsequent development of a statistical test for an operational discrimination between the RER- and RER+ subtypes indicated that the probability of misclassification did not exceed 0.001 in this series. The frequency of K-ras mutation was found to be equivalent in the two subtypes. However, in the RER+ tumors, the p53 gene mutation was less frequently detected, the adenomatous polyposis coli (APC) mutation was rare, and the biallelic inactivation of either of these genes was not observed. Furthermore, the concomitant occurrence of APC and tumor growth factor beta receptor type II gene alterations was found only once. These data suggest that the repertoires of genes that are frequently altered in RER+ and RER- tumors may be more different than previously thought.

[Genetic anomalies of colorectal cancers]

The prognosis of colorectal cancer has been based essentially on pathological data for many years. The analysis of genetic anomalies has led to fundamental progress and clinical advances. Genetic anomalies are routinely studied. 1--Flowcytometry evaluates the quantity of DNA in the nucleus during the cell cycle. 2--Cytogentics is the study of karyotype anomalies by loss or gain of chromosome material and structural changes. 3--Molecular biology gives a means of recognizing chromosome losses and especially to study oncogenic or antioncogenic mutations. These analyses allow: 1--an evaluation of their value as a prognosis factor and thus their use for indicating adjuvant medical and/or surgical treatments. 2--an understanding of cancerogenic processes. 3--the development of future therapeutic techniques based on a better understanding of the mechanisms involved. 4--familial counselling in high risk families and an examination of responsible or favouring genes in certain familial cancers. Research into familial forms has recently led led to the demonstration of genetic alterations located on chromosomes 1 and 2. These anomalies called RER correspond to alterations found on tumors. Studying these alterations will allow better prediction of high risk subjects in cancer families without polyposis.

Cytogenetic study of 30 colorectal adenomas

The cytogenetic analysis of 30 colorectal adenomas obtained from 24 patients is reported. Only normal karyotypes were observed in eight cases. Among the 22 adenomas with abnormal karyotypes, 15 showed clonal anomalies. Chromosome gains involving chromosomes 13, 20, 7, 9, and 12 were recurrently observed. Chromosome 18 was frequently lost or involved in translocations at bands q21-q22. More chromosome alterations were observed in the cases in which histologic examination revealed severe dysplasia or a carcinomatous component. These anomalies are discussed in relation to those described in colorectal adenocarcinoma.

[Genetic anomalies of colorectal cancers. Their role in guiding therapeutic indications]

Progress in detecting genetic anomalies with proven prognostic value in colorectal cancers offers a means of selecting adjuvant therapy with the best probability of success. Several methods are currently used. With flow cytometry, a significant correlation between primary tumour ploidy and hepatic metastasis has been demonstrated. Caryotypes of tumour cells provides a means of exposing segmental or total chromosome loss and subsequent classification leads to a better understanding of tumour heterogeneity. New techniques in molecular biology are used to describe mutations. Monoclonal antibodies can then be developed against the epitopes involved. Based on these different methods clinicians and fundamentalists can analyse treatment results with more precision and thus adopt the most effective treatment protocol.

Association of p53 mutations with short survival in colorectal cancer

BACKGROUND/AIMS

Mutations in p53, a tumor suppressor gene located on chromosome 17p, are the most frequent genetic alterations found in human cancers. Increased intracellular concentration of p53, which is frequently but not systematically related to p53 mutation, has been proposed to be associated with poor prognosis in some tumor types. In colorectal cancer, this significance is still a matter of debate. To directly investigate the relationship between prognosis and p53 mutation, this study screened a series of 85 colorectal carcinomas for mutations in exons 5-8 of this gene.

METHODS

Polymerase chain reaction-amplified products from tumor DNA were analyzed by denaturing gradient gel electrophoresis and direct DNA sequencing.

RESULTS

Forty-four tumors were found to be mutated (52%). A strong correlation between the presence of a mutation and short survival was observed (P = 0.003). When tumors were classified according to their histological stage, a multivariate Cox model analysis showed that p53 mutation, rather than 17p allelic loss (previously proposed to convey prognostic information), was retained as the only independent prognostic factor (relative risk, 2.25; 95% confidence interval, 1.06-4.80; P < 0.029).

CONCLUSIONS

Combined with staging, direct monitoring of p53 mutation improves prognostic accuracy for colorectal cancer.

[Perineal hernia after abdominoperineal amputation. Role of epiploplasty and/or irradiation]

Healing of the perineal wound after abdominoperineal amputation is a difficult technical problem for surgeons to resolve. The majority of current therapeutic protocols include pre- or post-operative radiotherapy, and most study results show a reduction in perineal relapses when compared with a control group, but at the price of delayed healing of the perineal wound. This delayed healing reaction varies with the radiation dose. The use of epiploplasty shortens the healing period, but when performed after pre-operative radiotherapy it can predispose to the development of a perineal hernia. Four cases of this complication are described. No standard procedure for treatment of these hernias exists, and although it is possible to use the uterus to fill the perineal cavity, the most effective method appears to be a double perineal and abdominal pathway using a plate.

Survival and acquired genetic alterations in colorectal cancer

To set the basis for a precise assessment of new therapeutic approaches, the prognosis of patients with colorectal cancer should be evaluated with the highest precision. The recent discovery, in tumor cells, of somatically acquired genetic alterations believed to be instrumental in tumor behavior may provide new independent prognostic factors. In the present study, the usual prognostic factors and a set of genetic alterations, i.e., Ki-ras mutations, DNA content, and allelic losses on chromosome 17p, 18q, 5q, and 1p, were investigated in 109 colorectal carcinomas. Univariate analysis for correlation with 5-year survival showed the following significant associations: histological staging (P less than 0.00001), preoperative serum carcinoembryonic antigen concentration (P less than 0.002), DNA content (P less than 0.009), and allelic loss on the short arm of chromosome 17 (P less than 0.002) and 1 (P less than 0.03). In multivariate analysis, only histological staging and allelic loss on the short arm of chromosome 17 were found to be independently associated with shorter survival (P less than 0.0001 and P less than 0.004, respectively). Loss of 17p alleles in colorectal carcinoma thus appears to be a marker of tumor aggressiveness. Its monitoring may lead to an improved classification of patients when adjuvant chemotherapy is considered.

[Prognostic value of the Lauren and Ming classifications in gastric adenocarcinoma. Multidimensional analysis]

Of the various pathology classifications for gastric carcinoma, those of Lauren and of Ming have been claimed to be of prognostic value. We therefore reviewed the charts of 101 patients (mean age 64 +/- 11 years) treated for gastric carcinoma between 1960 and 1983 at the Institut Curie. We excluded the following patients: 1) those with distant metastases; 2) those who were not operated on; 3) those who underwent laparotomy only, and 4) those who had a palliative procedure. The type of surgery performed was partial gastrectomy in 73 cases and total gastrectomy in 28. Pathology was reviewed according to the WHO, Lauren, and Ming classifications. Were taken into consideration: 1) whether the surgeon believed that removal of tumor was grossly complete or not, 2) the degree of parietal involvement according the pTNM classification system, and 3) the number of positive lymph nodes. Survival was analyzed by the Kaplan Meier method after exclusion of all postoperative deaths. Mean overall survival was 30 months, while that for patients undergoing grossly complete removal of tumor was 34 months. In univariate analysis, no correlation was found between survival and pathology according to Lauren's or Ming's classifications, sex, parietal involvement, or age. Survival was statistically correlated with the size of the tumor (p = 0.015), the gross completeness of surgery (p = 0.008), the type of surgery performed (prognosis was better after partial gastrectomy than after total gastrectomy) and the number of positive lymph nodes (p = 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

Characteristic chromosomal imbalances in 18 near-diploid colorectal tumors

The cytogenetic study of 18 near-diploid colorectal tumors shows that the observed numerical and structural abnormalities resulted in recurrent chromosomal losses and gains. By order of decreasing frequencies, they are: monosomy 17p (16/18), partial or more frequently complete monosomy 18 (14/18), trisomy 20q (11/18), trisomy or tetrasomy 13 (10/18), monosomy lp and trisomies X and 8q (9/18). The absence of recurrent breakpoints in euchromatin contrasts with the high preponderance of breakage at various places of heterochromatic region. Because these tumors are characterized by very recurrent chromosomal imbalances, it is assumed that the observed chromosomal changes may be related to a recessive genetic determinism and to gene dosage imbalances.

[Ploidy in colorectal cancer]

For several authors, DNA tumoral cell content represents an important prognostic factor in colorectal cancer. Samples obtained from 65 human colorectal cancers operated on between 1983 and 1986 were studied. Of 52 cases studied by flow cytometry 60 p. 100 were aneuploid tumors. The proliferative index was calculated in slightly over 50 p. 100 of the cases by DNA histogram analysis. During the same period 30 tumoral karyotypes were established by cytogenetic analysis. In 17 cases a comparison was possible between flow cytometry and cytogenetic results. In all cases a significant correlation was seen between the DNA histogram modal value and the mean number of chromosomes counted by cytogenic analysis. In this study, there was no statistical correlation between flow cytometry results and Dukes classification. Because of the short follow-up in our series, no prognostic value may be attributed to the DNA index.

Recurrent deletions of chromosomes 11q and 3p in anal canal carcinoma

A cytogenetic study of 8 cases of anal canal cancer, including 1 cloacogenic and 7 squamous-cell carcinomas, was performed. All tumors exhibited chromosomal abnormalities. A rearrangement involving the long arm of chromosome 11 was seen in all instances, and, with the exception of the i (11q) found in one tumor, all the observed rearrangements resulted in a deletion of the distal segment. Rearrangements of chromosome 3, detected in 6 tumors, led to a deletion of the short arm in 5 cases. The association of these 2 deletions may characterize the anal canal carcinoma, the smallest common deleted segments being distal to 11q22 or q23 and 3p22.

Prognosis of cloacogenic and squamous cancers of the anal canal

From 1968 to 1982, 195 patients with invasive cancer of the anal canal were treated (average age, 67 +/- 11 years; range, 38 to 85 years; sex ratio [women/men]: 5/1). Histology revealed: cloacogenic cancer, 20 cases; squamous cancer, poorly differentiated, 30; moderately differentiated, 68; well differentiated, 77. The initial size of the cloacogenic cancers was smaller than the squamous cancers. Invasion less than half the circumference of the canal was 90 and 74 percent, respectively. No patients with cloacogenic cancer presented with positive inguinal nodes; however, there were 22 unilateral and five bilateral positive nodes in the squamous cancers. All 195 patients received radiotherapy as the first treatment. There were no differences among the patients operated on with respect to sterilized operative specimens, postradiotherapy sequelae, perineal recurrences, and/or visceral metastases in the cloacogenic and squamous cancers. Five-year survival was better in cloacogenic (62 percent) than in squamous cancers (56 percent); this difference was not significant, and was related to the initial size of the tumor. The number of patients with no evidence of disease and good anal function was significantly related to the initial size of the tumor, and was independent of the histologic findings.

[Cancer of the anal canal. Results of the treatment of a series of 195 cases]

Between 1968 and 1982, 195 patients with invasive anal canal carcinoma were treated at Institut Curie (Paris, France). There were 168 females and 27 males --sex-ratio: 5.7/1, mean age: 67 +/- 11 yrs. (range: 38-85 yrs.). The initial size of the tumors was analyzed according to the circumferential invasion of the anal canal. The tumor involved 1/4 of the circumference in 49 cases, 1/2 of the circumference in 108 cases, 3/4 of the circumference in 22 cases and the whole circumference in 16 cases. Pathological examination revealed 20 cloacogenic carcinomas and 175 squamous carcinomas. All patients received radiotherapy as initial treatment and none received chemotherapy as a curative procedure. Eight patients received only palliative treatment. Twenty-seven patients were operated on because the response of the tumor to irradiation was partial or incomplete. One hundred and sixty patients received the full course of irradiation with a complete response. Among the latter, 100 patients were alive NED with a normal anal function with at least a 2-year follow-up. Local recurrences (n = 42) underwent salvage surgery in 50 p. 100 of the cases with a 3-year survival over 50 p. 100. Actuarial survival of the 195 patients was 68.5 p. 100 at 3 years and 58 p. 100 at 5 years. Survival was highly related to the initial size of the tumor and to the presence of positive inguinal nodes (p less than 0.0002). The histologic type was not related to the response to radiotherapy, nor to local recurrence or to survival.(ABSTRACT TRUNCATED AT 250 WORDS)

[Colonoscopy detection of polyps in patients operated on for colorectal cancer. Prospective study]

Subjects operated upon for colorectal carcinoma seem to constitute a population at high risk of a second colorectal malignancy and/or colonic adenoma (polyp). Ninety-four such patients were examined by colonoscopy. Their distribution by age and sex and the location of cancers in the colon were comparable to those reported in the literature. Colonoscopy was performed 12 +/- 6 months after surgery in 52 patients and was complete in 90% of them. Twenty-seven patients (52%) were found to have one or several polyps distributed throughout the colonic frame and varying in size from 2 to 75 mm (75% were less than 10 mm long). The larger the polyp, the more severe the dysplasia. Three malignant polyps were discovered; they were more than 10 mm in diameter. The colonoscopic examination was repeated annually over more than 3 years in 30 patients: at first repeat examination 54% had polyps which were still present in more than 30% at subsequent examinations. It is concluded that patients operated upon for colorectal carcinoma are at high risk of polyps and/or a second colorectal carcinoma and must therefore be followed-up by repeated colonoscopy.

Treatment of epidermoid anal canal cancer

Between 1968 and 1979, 183 patients with invasive epidermoid cancer of the anal canal were treated at Institut Curie. There was 156 women, 27 men with a mean age of 67 +/- 11 years (range 40 to 85 years). The initial height of the tumor was less than 4 cm (65 patients), 4 to 6 cm (98 patients), and more than 6 cm (20 patients). All the patients received radiotherapy, either preoperatively or as curative procedure. Twenty-five patients received preoperative radiotherapy, and there was no residual tumor in 9 biopsies obtained at operation. Four local recurrences were observed. One hundred fifty-eight patients received curative radiotherapy, 115 of whom did not undergo operation. Eighty were alive with no evidence of disease and good anal function with a minimum of 3 years follow-up. We observed 15 local recurrences, 4 inguinal recurrences, and 8 visceral metastases. In addition, eight patients initially had such a big tumor that radiotherapy was only a palliative procedure. Forty-three patients required a surgical procedure after this curative radiotherapy. Colostomy (12 patients) or abdominoperineal amputation (25 patients) was required for local recurrence and colostomy was required for necrosis related to radiotherapy. Five year survival was 59 percent. The survival was related to the size of the tumor (p less than 0.0001). The likelihood of retaining normal anal function with local control of the tumor was also closely related to the initial size of the tumor.

[Cimetidine treatment of anastomotic ulcers (author's transl)]

Fifteen patients with anastomotic ulcer were treated with cimetidine for 30 days. Endoscopy showed healing or marked regression of the ulcer in 53% of the cases. Neither the type of operation previously performed nor the amount of gastric secretion prior to entering the trial gave any indication as to which patients would respond to treatment. Other authors using the same therapeutic regimen have obtained similar results, but some have reported that extending treatment up to 8 weeks seems to produce considerably better results. The present authors conclude that cimetidine may constitute a suitable alternative to a second surgical operation.

Acute spontaneously recovering ulcerating colitis (ARUC). Report of 6 cases

Six patients each with an extensive ulcerating colitis are reported. Common features were a febrile nonbloody diarrhea; radiological involvement of the whole colon with superficial ulcerations and preservation of haustra, and integrity of the terminal ileum and rectum; the absence of any specific pathological finding; and, most important, the spontaneous recovery of the lesions in the absence of any treatment except sympatomatic measures. The present follow up after recovery range from 18 months to 5 years. Four cases were young women taking oral contraceptives and two patients were older. These patients with colitis could represent a new entity or could be a particular form of Crohn's disease of the colon, with delayed diagnostic pathological features.