Are we overtreating some patients with rectal cancer?

The definition of overtreatment of rectal cancer is controversial, and thus it is difficult to accurately quantitate its prevalence. All components of rectal cancer treatment are associated with significant potential for morbidity and dysfunction that may have a negative impact on the patient's quality of life. No one would disagree with the tenet that overtreatment should be avoided whenever possible. Despite that consensus, little attention is given in the literature to the issues of overtreatment of rectal cancer. This review article presents a variety of clinical scenarios and summarizes available data demonstrating that overtreatment of some patients with rectal cancer is occurring on a regular basis. It is hoped that this will stimulate clinicians to critically review their own practices to eliminate such overtreatment. Development of new clinical trials to determine whether current practice guidelines are promoting overtreatment of selected rectal cancer patients is proposed.

Use of laser for rectal lesions in poor-risk patients

BACKGROUND

This study evaluates laser ablation of large polyps and cancer of the rectum in poor-risk surgical patients.

METHODS

We performed a retrospective review of treatment of rectal lesions with the neodymium yttrium aluminium garnet (Nd:YAG) laser. Biopsy was performed before the first and subsequent therapies. Large lesions were initially debulked by diathermy snare. Biopsies were performed on suspicious areas at follow-up after completion of therapy.

RESULTS

Three patients with unresectable rectal cancer had symptom control over a mean period of 15.7 months and 12 patients with large polyps over 60.6 months since the start of therapy. Indications in polyps were carpeting of the rectum (n = 3), proximity to sphincter (n = 1), or comorbidity (n = 8). No complication occurred; however, there was 1 treatment failure. None of the patients with polyps developed cancer during a mean follow-up interval of 14 months after final treatment.

CONCLUSIONS

Outpatient laser therapy is safe, repeatable, and effective in the local control of rectal lesions.

Plasma basic fibroblast growth factor levels in colorectal cancer: a clinically useful assay?

Angiogenic cytokines in the plasma and serum of cancer patients may serve as 'surrogate' markers of tumour neoangiogenesis. Serum VEGF correlates with disease stage in colorectal cancer (CRC), but the role of bFGF in CRC is uncertain. This study aimed to assess plasma bFGF levels in CRC patients before treatment, during chemoradiotherapy and at one-year follow-up. Plasma samples were taken from 124 CRC patients, 26 polyp patients and 55 controls, and bFGF levels were measured by ELISA. 19 patients underwent pre-operative chemoradiotherapy. One-year follow-up samples were available from 48 disease-free patients and 18 patients with progressive disease. There were no detectable differences between plasma bFGF levels in polyp, Dukes' A or B patients (4.55, 5.77, 4.25 pg/ml, respectively), but there was a significant increase in metastatic CRC patients [Dukes' C and D (7.42 and 6.6 pg/ml; P = 0.004 and 0.048, respectively)], relative to median control levels of 4.14 pg/ml. At follow-up, there was a significant fall in plasma bFGF levels in disease-free patients (pre-op 6.09 and follow-up 3.45 pg/ml, P = 0.0004), but a non-significant rise in 18 patients with progressive disease (pre-treatment 5.90 and follow-up 9.99 pg/ml, P = 0.33). Pre-treatment plasma bFGF in patients receiving chemo-radiotherapy was similar in those with responsive and non-responsive tumours. There were no detectable changes in plasma bFGF through the adenoma-carcinoma sequence or patient groups with non-metastatic cancers. Elevated plasma bFGF was, however, associated with metastatic spread. The significant fall in bFGF in disease-free patients following therapy suggests that bFGF may be useful in clinical practice.

[Laser in gastroenterologic endoscopic therapy]

Endoscopic gastrointestinal laser therapy was originally inspired by the haemostatic properties of the laser beam and was subsequently used to destroy tumours. In endoscopic gastroenterology, the most commonly used type of laser is the neodyme+-doped yttrium aluminium garnet (Nd:YAG) laser. Endoscopic Nd:YAG laser therapy of obstructive cancers of the oesophagus and cardia rapidly reduces dysphagia in 70 to 100% of the patients. In the treatment of colorectal cancers, the intestinal transit returns to normal in 57 to 83% of the cases, and rectal haemorrhages are controlled in 38 to 92% of the cases. However, sustained results can only be obtained by a maintenance treatment with at least one application every 4 weeks. The Nd:YAG laser makes it possible to destroy villose tumours in patients who cannot, or will not, be operated upon; the number of applications depends on the size of the tumour. Finally, the Nd:YAG laser seems to be able to control bleeding due to gastrointestinal angiodysplasia and to stabilize the course of Rendu-Osler-Weber disease.

Nd:YAG laser photocoagulation in colorectal adenoma. Evaluation of its safety, usefulness, and efficacy

The usefulness, efficacy, safety, and tissue effects of Nd:YAG laser photocoagulation were investigated prospectively in 100 patients. Sixty-seven elderly patients with colorectal adenoma and 21 patients with rectal stump polyps after colectomy and ileorectal anastomosis in familial polyposis were evaluated. We subdivided our patients into those with extensive, intermediate, and small lesions, and we assessed completeness of tumor ablation, recurrence, and complications in all three groups. In the extensive group only 8 patients achieved complete (i.e., gross endoscopic and histologic) tumor ablation, whereas in 18 patients adenomatous tissue persisted or recurred after a tumor-free interval. In the intermediate group complete tumor ablation was achieved in 10 of 22 patients. Small adenomas were completely ablated in 18 of 19 patients. Five instances of carcinoma were detected in each subgroup of nonresponding extensive (18 patients) and intermediate (12 patients) lesions at follow-up. Prior to laser photocoagulation, symptoms such as watery diarrhea, excessive mucous discharge, hypokalemia, dehydration, and hematochezia and iron-deficiency anemia were present in 16 of 26 patients with extensive adenoma and in 13 of 22 patients with intermediate adenoma. Symptoms subsided during the course of treatment in all but 1 patient, even with the absence of complete ablation. Major complications, consisting of bleeding, symptomatic stenosis, or perforation occurred in 11.6% with extensive adenomas, in 9.1% with intermediate adenomas, and in none with small adenomas. Minor complications such as transient asymptomatic stenosis, minor posttreatment hemorrhage, pain, and "serositis" occurred in 30.9% with extensive lesions, in 27.3% with intermediate lesions, and in 10.6% with small lesions. There was no mortality. Treatment of multiple tiny polyps in 21 patients with familial polyposis was easy and efficient, without retraction and scarring, and without complications. We have concluded that laser photocoagulation is safe and uniformly effective in the ablation of small colorectal adenoma and in recurrent polyps in patients with familial polyposis. In patients with intermediate or large adenomas, symptoms are highly responsive to treatment, but complete tumor ablation--as documented upon repeated endoscopy and multiple biopsies--can only be expected in approximately 40%-50% in long-term follow-up. The high incidence of cancers in these two groups (21%) underscores the need for continued surveillance and frequent biopsy. Major and minor complications will occur in 40% in these sizeable lesions, being of clinical importance in only 10%.(ABSTRACT TRUNCATED AT 400 WORDS)

Desmoid tumors and their management

Nineteen cases of desmoid tumors were reviewed, being intraabdominal. Five of the 7 were associated with polyposis coli. The remaining 12 cases were distributed in different anatomic locations. Sixteen patients were treated with resection either alone or in combination with radiation or hormonal treatment. There were two deaths due to unrelated causes, and the rest of the patients (89 percent) are alive. At present, 16 of the surviving 17 patients are disease-free with a mean follow-up of 6 years. In two of eight patients who were initially treated with wide excision at our center, local recurrence developed, and five patients treated with resection elsewhere were referred because of recurrence. Six patients treated with simple resection and adjuvant radiation remain free of disease with a mean follow-up of 5 1/2 years.