Surgical treatment of adenocarcinoma of the rectum

OBJECTIVE: The authors' aim was to determine survival and recurrence rates in patients undergoing resection of rectal cancer achieved by abdominoperineal resection (APR), coloanal anastomosis (CAA), and anterior resection (AR) without adjuvant therapy. SUMMARY BACKGROUND DATA: The surgery of rectal cancer is controversial; so, too, is its adjuvant management. Questions such as preoperative versus postoperative radiation versus no radiation are key. An approach in which the entire mesorectum is excised has been proposed as yielding low recurrence rates. METHODS: Of 1423 patients with resected rectal cancers, 491 patients were excluded, leaving 932 with a primary adenocarcinoma of the rectum treated at Mayo. Eighty-six percent were resected for cure. Surgery plus adjuvant treatment was performed in 418, surgery alone in 514. These 514 patients are the subject of this review. Among the 514 patients who underwent surgery alone, APR was performed in 169, CAA in 19, AR in 272, and other procedures in 54. Eighty-seven percent of patients were operated on with curative intent. The mean follow-up was 5.6 years; follow-up was complete in 92%. APR and CAA were performed excising the envelope of rectal mesentery posteriorly and the supporting tissues laterally from the sacral promontory to the pelvic floor. AR was performed using an appropriately wide rectal mesentery resection technique if the tumor was high; if the tumor was in the middle or low rectum, all mesentery was resected. The mean distal margin achieved by AR was 3 +/- 2 cm. RESULTS: Mortality was 2% (12 of 514). Anastomotic leaks after AR occurred in 5% (16 of 291) and overall transient urinary retention in 15%. Eleven percent of patients had a wound infection (abdominal and perineal wound, 30-day, purulence, or cellulitis). The local recurrence and 5-year disease-free survival rates were 7% and 78%, respectively, after AR; 6% and 83%, respectively, after CAA; and 4% and 80%, respectively, after APR. Patients with stage III disease, had a 60% disease-free survival rate. CONCLUSIONS: Complete resection of the envelope of supporting tissues about the rectum during APR, CAA, and AR when tumors were low in the rectum is associated with low mortality, low morbidity, low local recurrence, and good 5-year survival rates. Appropriate "tumor-specific" mesorectal excision during AR when the tumor is high in the rectum is likewise consistent with a low rate of local recurrence and good long-term survival. However, the overall failure rate of 40% in stage III disease (which is independent of surgical technique) means that surgical approaches alone are not sufficient to achieve better long-term survival rates.     

A case of solitary metastatic pancreatic cancer from rectal carcinoma: a case report

A 79 year-old male who had undergone resection of the rectum for rectal cancer was shown to have metastasis to the pancreas 11 years after surgery. The metastatic lesion was located at the tail and body of the pancreas, and was resected with distal pancreatectomy. The same patient also had metastasis to the lung 8 years after initial rectal surgery. Therefore, the course of metastasis to the pancreas was suggested to be from the metastatic lung tumor to the pancreas by hematogenous spread. The patient was considered disease-free 8 months after the pancreatectomy. Recent advances in the technology of diagnostic imaging have facilitated the selection of surgical therapy for metastasis to the pancreas in rectal cancer patients after follow-up by imaging diagnosis.     

Complete remission after radiotherapy for recurrent rectal cancer

Although the efficacy of radiotherapy for the palliation of recurrent or inoperable cancer has been proven, it results in complete tumor remission only rarely. We report a case of pelvic recurrence in which complete histological remission followed radiotherapy. A 68-year-old man developed a small pelvic recurrence near the rectal stump 8 months after a Hartmann procedure for rectal cancer. Histologic examination of the biopsy specimens revealed adenocarcinoma consistent with the primary tumor. He received radiotherapy to the whole pelvis, with a total dose of 39.4 Gy administered in 22 fractions over 4 weeks, with a continuous infusion of 5-fluorouracil as a radiosensitizer. After regression of the tumor was confirmed, resection of the pelvic recurrence was performed. Histologic examination of the resected specimen revealed no tumor. Thirty-six months after the second operation, the patient was alive with no evidence of disease. The experience of our case and a review of the literature suggests that small pelvic recurrences may be more responsive to radiotherapy than larger ones.     

Circumferential margin involvement after mesorectal excision of rectal cancer with curative intent. Predictor of survival but not local recurrence?

PURPOSE: This study examines the prognostic significance of circumferential margin involvement by tumor in resected specimens after potentially curative rectal cancer surgery. METHODS: During an eight-year period, all patients with rectal cancer were prospectively audited. For tumors of the middle and lower thirds of the rectum, a total mesorectal excision was performed; for tumor of the upper third, mesorectal excision proceeded at least 5 cm distal to the primary tumor. Resected specimens were subjected to careful histologic assessment, and patients undergoing curative procedures were entered into a surveillance program to detect both local and distant recurrence. RESULTS: Of 218 patients in the cohort, 9 had no resection, 14 underwent local excision, 1 had pre-operative radiotherapy, and 42 patients (20 percent) had palliative resections and were excluded from further analysis. This left 152 patients having a curative resection, of whom 20 (13 percent) had tumor within 1 mm of the circumferential margin. After follow-up until death or a median period of 41 months, recurrent disease was seen in 24 percent of patients with a negative margin and 50 percent with a positive margin. Both disease-free survival and mortality were significantly related to margin involvement (log-rank, P = 0.01 and P = 0.005, respectively). Local recurrence, however, was not significantly different in the two groups (11 and 15 percent, respectively; log-rank, P = 0.38). CONCLUSIONS: When mesorectal excision is performed, circumferential margin involvement is more an indicator of advance disease than inadequate local surgery. Patients with an involved margin may die from distant disease before local recurrence becomes apparent.     

Tumors originating in the muscularis mucosae of the recto-sigma

Tumours arising from the muscular layer of the bowel are uncommon and extremely rare when localized in colon and rectum. Most of them arise from the external muscular layer or muscularis propria. Tumours originating in muscularis mucosae or in the vascular system are uncommon. Two hundred rectal leiomyomas and leiomyosarcomas have been described. Tumours originated in the muscularis mucosae are polypoid, pedunculated, benign and most of them will be treated by a polypectomy without recurrence. However leiomyomas arising from the muscularis propia have a 60% of recurrence after local treatment and in some cases the recurrence will be a metastatic leiomyosarcoma. Three tumours arising from muscularis mucosae of the rectum and sigma are presented. All three were diagnosed and removed by colonoscopy. Two were diagnosed as leiomyomas. The third was a low grade leiomyosarcoma and an anterior resection was performed as definitive treatment.     

Post-traumatic hormonal disturbances: prolactin as a link between head injury and enhanced osteogenesis

The local recurrence rate after rectal cancer surgery is discussed as related to conventional and total mesorectal excision (TME) techniques. Studies now show that the wide variation in results between centers and among surgeons depends, at least in part, on differences in surgical technique. We conclude that local tumor recurrence rate is lower after TME than after conventional surgery and emphasize the importance of a standardized macroscopic evaluation of the resected specimen. Population-based registration to evaluate the quality of surgery is recommended. It is also suggested that randomized studies on adjuvant treatment for rectal cancer should include a "surgery only" arm when a local tumor recurrence rate of 10% or less is being studied. Until such investigations are performed, we conclude that the role for adjuvant treatment is questionable and that TME surgery is preferred as the treatment option for Stage T1-T3 rectal cancers.     

Brief preoperative radiotherapy in surgical therapy of rectal carcinoma. Long-term results of a prospective randomized study

To ascertain whether preoperative short-term radiotherapy can improve local tumor control and the long-term survival of patients with operable rectal cancer, a prospective randomised trial was performed from 1988 to 1993. Ninety-three patients with rectal cancer were either directly treated with surgery (n = 46) or underwent preoperative radiotherapy with 5 x 3.3 Gy irradiation and operation within 48 h (n = 47). If indicated (T4, UICC stage III) patients also received postoperative irradiation. Comparison of the methods of operation (abdominoperineal amputation versus anterior resection) revealed no significant difference in 5-year survival rate (P = 0.393). Local control of R0-resected tumors was improved after preoperative irradiation (P = 0.08). The 5-year survival rate was significantly higher after preoperative short-term radiotherapy (P = 0.027). Preoperative radiotherapy is not an independent factor according to overall survival (P = 0.078) and local recurrence (P = 0.07). In agreement with the results of other authors the present study indicates improved local tumor control of rectal cancer after preoperative radiation therapy. The 5-year survival rate was significantly better after preoperative radiotherapy than after surgery alone.     

Local recurrence after low anterior resection of rectal cancer

Among 75 consecutive patients operated upon with anterior resection for rectal adenocarcinoma during a five year period, 29 (39%) developed local cancer recurrence. The total cumulative five-year survival was 49%, but only 17% in those with a local cancer recurrence. The most important risk factors for development of local recurrence were tumour fixation, intraoperative blood transfusion and surgical routine. Local recurrence was seen in 4/23 (17%) after operation performed by a consultant, 1/5 (20%) after a consultant-supervised operation and 24/47 (51%) after operation by a senior registrar (p < 0.02). As a consequence we recommend that operation for rectal cancer should only be performed or supervised by a few specialists in colorectal surgery.     

Viruses and atherosclerosis: do they play a pathogenic role?

PURPOSE: To evaluate the results of interstitial radiotherapy of anorectal tumors. PATIENTS AND METHODS: From 1972 to 1993, one of the authors treated 45 patients by an interstitial implant for anorectal tumors. Of these, 33 patients suffered from primary tumors, 19 from squamous carcinoma, 2 from basaloid carcinoma of the anus and the other 12 from primary adenocarcinoma of the rectum. Of 12 patients treated for local recurrence, 10 had adenocarcinoma and 2 squamous cell carcinoma. Of the 33 patients with primary tumors, 27 received a course of external-beam radiotherapy before the implant. The median follow-up was 35 months. RESULTS: Local response depended on the tumor volume treated. All 21 anal tumors showed complete response, 5 patients developed local recurrence and 4 distant metastases: 3 died from their disease. Of 12 rectal adenocarcinomas, 9 responded completely, 4 patients developed local recurrence and 4 distant metastases; 6 died from active disease. In the last group of 12 patients who were treated for recurrent tumors, 7 responded completely. One patient developed local recurrence and 9 distant metastases, only 4 are alive. CONCLUSIONS: A combination of external-beam and interstitial radiotherapy is a relatively simple, non-mutilating, but well-tolerated and very effective method of treatment for early carcinoma of the lower rectum and anus.     

Adjuvant and neoadjuvant therapy of rectal carcinoma. The current status

BACKGROUND: The Consensus Conference of the German Cancer Society (CAO/AIO/ARO, 1.7.1998) has recently updated recommendations for patients with rectal cancer. Instead of a former reservation regarding the indication of adjuvant therapy for rectal cancer the actual version of the consensus particularly emphasizes the role of postoperative radiochemotherapy for stage-II/III tumors. This article reviews the most recent and ongoing trials of adjuvant and neoadjuvant therapy of rectal cancer. RESULTS: To avoid local recurrence is the most important aspect in the primary treatment of rectal cancer. In some series, e.g. the results of the Surgical Department of the University of Erlangen, a significant correlation between local control and survival was noted. The final results of the Swedish Rectal Cancer Trial with 1168 randomized patients not only confirmed the potential of radiotherapy to reduce local recurrence rate, but also demonstrated a significant survival advantage for patients receiving short-course preoperative radiation therapy. Postoperative combination therapy is usual in the United States and in most European countries since the publication of two randomized trials of the Gastrointestinal Tumor Study Group (GITSG) and the North Central Cancer Treatment Group (NCCTG). The survival advantage resulting from an adjuvant radiotherapy with conventional doses and concurrent fluorouracil-based chemotherapy as compared to surgery alone was recently confirmed in a Norwegian trial. Protracted venous 5-fluorouracil infusion should further improve treatment results. Numerous phase-II studies have demonstrated the efficacy of preoperative radiochemotherapy with high rates of pathological response. Thus, neoadjuvant radiochemotherapy is recommended for patients with locally advanced tumor primarily not amenable to curative surgery. Prospective randomized trials are ongoing to clarify the role of preoperative versus postoperative combined treatment for patients with resectable rectal cancer. CONCLUSION: Radiochemotherapy for rectal cancer is recommended as standard treatment outside clinical trials for stage II/III patients after curative treatment and for patients with T4-tumor prior to surgery. The optimal use of chemotherapy and the sequence of treatment modalities remains to be elucidated.     

Microcystic adnexal carcinoma. First reported case in a black patient

BACKGROUND: Microcystic adnexal carcinoma is an uncommon malignancy of the skin with a propensity for local aggressive growth and high rates of recurrence. To date, this neoplasm has been described mainly in the Caucasian population. We describe here the first reported case in a black patient. OBJECTIVE: To discuss the successful identification and management of this aggressive neoplasm in the non-Caucasian population. METHODS: Mohs micrographic surgery was performed on this tumor. RESULTS: The tumor was successfully excised without evidence of recurrence at 6 months. CONCLUSIONS: We present the first reported case of microcystic adnexal carcinoma in a black patient. This tumor was identified in its early stages and removed by Mohs micrographic surgery without sequelae.     

Arteriovenous malformation of the rectum: report of a case

We report herein the case of a 38-year-old man found to have a rectal arteriovenous malformation (AVM). The patient was admitted to our hospital for investigation of fresh anal bleeding and general malaise. Barium-enema examination showed a slightly elevated lesion in the rectum, and a selective superior rectal angiogram subsequently revealed an AVM in the peripheral region of the superior rectal artery, which was presumed to be the cause of the anal bleeding. Colonoscopic examination disclosed a submucosal tumor-like lesion in the left posterior wall of the rectum, 3cm above the anal verge. After marking the boundaries by clipping, transanal resection of the lesion was performed. Histological examination revealed an irregularly expanded arteriovenous aggregation in the submucosal layer. The patient had a favorable postoperative course, and no residual AVM was seen on a postoperative selective inferior mesenteric arteriogram. There have been no signs of recurrence in the 2 years since his operation.     

Influence of surgery on metachronous distant metastases and survival in rectal cancer

PURPOSE: Total mesorectal excision (TME) and other technical surgical factors reduce local recurrence rate in rectal cancer. Scientific evidence of the positive effect of optimal surgery on survival is locking. Whether a reduction in the incidence of distant metastases can be achieved with optimal surgery is uncertain. We examine the effects of the quality of surgery, as reflected by local recurrence rate, on survival and the incidence of initial distant metastases. PATIENTS AND METHODS: Between 1974 and 1991, 1,581 consecutive patients who underwent curative resection (RO) for rectal carcinoma were monitored for recurrence and survival. TME was introduced in 1985. No patient received adjuvant radiotherapy or chemotherapy. The median follow-up time was greater than 13 years. RESULTS: The local recurrence rate decreased from 39.4% to 9.8% during the study period (P < .0001). The observed 5-year survival rate improved from 50% to 71% (P < .0001). Three hundred six patients with local recurrence had a significantly lower observed 5-year survival rate (P < .0001). A total of 1,285 patients had no local recurrence, but 275 of them developed distant metastases (International Union Against Cancer [UICC] stage I, 8%; stage II, 16%; stage III, 40%). Better-quality surgery had no effect on the incidence of initial distant metastases, which remained constant (P = .44). CONCLUSION: Quality of surgery is an independent prognostic factor for survival in rectal cancer, but has no influence on initial occurrence of distant metastases. Local recurrence cannot be considered an outcome criterion of adjuvant treatment without consideration of the surgeon as a risk factor.     

Blastomatous tumors of the respiratory tract

Two cases of blastomatous tumors of the respiratory tract are presented. The first is a pulmonary blastoma of an 81-year-old man, diagnosed as adenocarcinoma by cytologic examination, the cells being exfoliated from the large carcinomatous component. The patient died 1 year after manifestation of the symptoms. The second case is a tumor that developed in the nasopharynx of a 62-year-old man. This is the first reported case of a nasopharyngeal blastoma that presented a histology comparable to that seen in the pulmonary tumor. The presence of a hamartomatous benign mesenchymal component raises histogenetic considerations as to whether this was an independent part of an otherwise malignant tumor or whether it was induced by the malignant growth. Following incomplete surgical treatment and postoperative radiation, no recurrence was observed during the next 8 months.     

Bile duct cancer associated with extramammary Paget's disease

We report a case of bile duct cancer associated with anogenital Paget's disease. The patient was a 80-yr-old Japanese woman whose chief complaint was exanthema from the left vulva to the anus for the previous 4 yr. Histological examination of the skin biopsy of the vulva showed numerous Paget's cells. Resection of the lesion and the rectum were performed, and a permanent colostomy was created. More than 1 month after the operation, the patient suddenly developed obstructive jaundice. Percutaneous transhepatic cholangiography performed simultaneously with endoscopic retrograde cholangiography showed complete obstruction of the middle part of the bile duct. Bile cytology was class V. On the basis of these results, bile duct cancer associated with extramammary Paget's disease (EMPD) was diagnosed. About 5 months after the operation, the patient died of liver failure. Microscopically the tumor in the bile duct was poorly differentiated adenocarcinoma. Although EMPD has a tendency to be associated with underlying internal malignancies, this is the first reported case, to our knowledge, of bile duct cancer associated with EMPD.     

Extravesical tumor implantation caused by perforation during transurethral resection of a bladder tumor: a case report

We report a case of invasive bladder cancer in which cancer dissemination occurred through a perforation of the vesical wall during transurethral resection of the tumor. A radical cystectomy was performed 1 month later and several clusters of viable cancer cells were histologically identified in a fibrous foreign body granuloma in the paravesicular adipose tissue of the lymphadenectomy specimen. The patient received adjuvant chemotherapy, but developed right inguinal lymph node metastasis 21 months after cystectomy.     

Effects of heredity, age, weight, puberty, activity, and calcium intake on bone mineral density in children

Anastomotic dehiscence after colon resection is the most frequent complication in colon surgery and the main cause of post-operative death. In the light of anatomical peculiarities of the blood supply to the rectum, it would appear that in atherosclerotic patients with impairment of hypogastric arteries (80% in authors' series out of 200 atherosclerotic subjects) inferior mesenteric artery ligature, determining vascularization of the rectal ampulla by the distal vessels alone, results in an insufficient supply in case of colo-rectal anastomosis. A series of 15 cases of cancer of the left and sigmoid colon, treated with left hemicolectomy, preservation and peeling of the inferior mesenteric artery, is reported. In the follow-up ranging from 6 months to 5 years, no anastomotic dehiscence was observed and only one case (7.5%) presented hepatic recurrence after two years. The other patients are all alive and disease free.     

Weight-bearing effects on skeletal muscle during and after simulated bed rest

The authors present two case studies of giant cell tumor of tendon sheath. This uncommon lesion of the lower extremity is presented in these two cases in correlation with clinical, radiographic, and intraoperative findings. After the pathologic diagnosis was made, the patient in the first case decided not to have the tumor resected. This patient's postoperative course continues uneventfully without expansion of the tumor. In the second case, a local recurrence was noted 13 months after en bloc resection. A review of the literature shows that treatment modalities for such lesions range from marginal excision to radiation therapy. The authors wish to emphasize the high risk of local recurrence of these tumors. Early marginal resection is the treatment of choice.     

Usefulness of ultrasound-guided prostate biopsy in the diagnosis and treatment of localized prostate cancer

OBJECTIVE: To evaluate the safety and efficacy of stapled anastomosis in left sided colorectal reconstructions. DESIGN: Prospective study. SETTING: District hospital, UK. SUBJECTS: 218 Consecutive patients who underwent elective colorectal reconstructions with stapled anastomoses between July 1980 and July 1994. INTERVENTIONS: 154 Anterior resections of the rectum using single or double stapled anastomoses, 37 rejoining after Hartmann's operations, and 28 restorative proctocolectomies with formation of J pouch ileoanal anastomoses. MAIN OUTCOME MEASURES: Morbidity and mortality. RESULTS: There were 5/154 clinical anastomotic leaks after anterior resection of the rectum and 1/28 after stapled J pouch ileoanal anastomoses. There were no leaks after rejoining of Hartmann's. The overall clinical leak rate was therefore 3%. 11/154 tumours recurred locally after anterior resection of the rectum (7%) during a mean follow up of 18 months, and 8 (73%) developed within 2 years of operation. All but one recurrence developed after single stapled anastomosis. Dukes' staging remains the most reliable prognostic indicator of the local recurrence of the tumour. There were five postoperative deaths after anterior resection but none after Hartmann's procedure or J pouch ileoanal anastomosis, giving an overall postoperative mortality of 2.3%. CONCLUSION: The use of stapling instruments in left sided colorectal anastomosis is safe and technically easy, with a low clinical anastomotic leak rate and an acceptable rate of local recurrence after anterior resection of the rectum.     

Neuroticism and extraversion as predictors of health outcomes in depressed primary care patients

A case with an alpha-fetoprotein (AFP)-producing carcinoma originating from the rectum is described. A 71-year-old male patient, who underwent a rectectomy for rectal carcinoma, developed space occupying lesions in the liver and a remarkable AFP elevation (220,000 ng/ml) in the 6th month postoperatively, and then expired one year later. Histologically, the rectal carcinoma consisted of well-differentiated adenocarcinomas, and contiguous cancerous cells proliferating in either a medullary or trabecular pattern. In the "trabecular" areas, localization of AFP was confirmed immunohistochemically. Results of concanavalin A or lens culinaris agglutinin affinity chromatography demonstrated that it was between a hepatic type and a yolk sac type, and was considered to be an intestinal type. This could have been an AFP-producing rectal carcinoma, in which the patient experienced liver metastasis at a relatively early postoperative period and died. This shows that AFP-producing rectal carcinomas are highly malignant, biologically, similar to AFP-producing gastric cancers.