Treatment of local recurrence of rectal cancer

We report on 2 infants with Ullrich-Turner syndrome in whom partial anomalous pulmonary venous drainage was diagnosed noninvasively by color-coded Doppler sonography. Several patients with the combination of anomalous drainage of one or more pulmonary veins and Ullrich-Turner syndrome have been described in the literature. However, in the majority of those previously reported cases the diagnosis of partial anomalous pulmonary venous drainage was established by angiography during cardiac catheterization performed for confirmation of other cardiovascular malformations. Our patients show that partial anomalous pulmonary venous drainage can be diagnosed easily in neonates and young infants, as long as this anomaly is taken into consideration.     

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.     

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.     

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.     

Intrahepatic cholangiocarcinoma showing mixed differentiation: a case report

Aspergillosis is a rare infection. It varies considerably in its virulence depending on whether or not the patient affected is immunodepressed. The serious form is characterized by vascular invasion with haematogenic dissemination, tissue infarction and necrosis. The most often affected site is the lung. A laryngeal localization is exceptional and usually results from dissemination from a lower airways portal of entry. Diagnosis is difficult: cultures are only positive in 50 per cent of cases, while in 60 per cent of cases the characteristic histological features reminiscent of sprigs of mistletoe are only found on postmortem examination. In view of the high morbidity and mortality in acquired immunodeficiency syndrome (AIDS) sufferers, this condition must be treated early and aggressively. Treatment is based essentially on amphotericin B and itraconazole.     

Adjuvant radiation therapy in resectable rectal cancer: should local recurrence rates affect the decision?

Adjuvant external beam pelvic radiotherapy (XRT) for resectable rectal cancer has been mandated by the National Cancer Institute because of reported 20 to 50 per cent reductions in local recurrence rates. However, these series' reported local recurrence rates are 18 to 39 per cent in the nonradiated patients, which seems extraordinarily high compared to the 3 to 5 per cent rates reported by surgeons advocating proctectomy with complete mesorectal excision. This fact, coupled with the high cost of XRT ($11,000-$14,000), the risk of radiation injury to small bowel and the neo-rectum, and the failure of XRT to provide any survival advantage, raises questions as to the precise role of XRT for rectal cancer. The purpose of this study was to perform a review of 212 consecutive patients undergoing curative resection via low anterior resection (LAR) or abdominoperineal resection (APR) for rectal cancer between 1989 and 1993, focusing on local and distant recurrence rates and survival. The choice of surgery alone (SUR), preoperative radiation (PRE) (45 Gy), or postoperative radiation (POST) (45-50 Gy) was at the surgeon's discretion. There were no significant differences in male:female ratio (SUR, 83:60; PRE, 14:8; POST, 34:13) or type of procedure (SUR-LAR, 112:APR, 31; PRE-LAR, 5:APR, 17; POST-LAR, 30:APR, 17) between the groups. There were no significant differences in age between the preoperative and postoperative radiation groups (PRE, 64.0 +/- 2.4; POST, 59.2 +/- 1.7); however, age was significantly different (P < 0.05) between the surgery-alone and the postoperative radiation groups (SUR, 68.5 +/- 0.8; POST, 59.2 +/- 1.7). With a median follow-up of 49 months, there were no significant differences in local recurrence (SUR, 4.2%; PRE, 4.5%; POST, 2.1%); however, there was a significantly longer survival for the SUR group compared to the other groups (SUR, 45.9 months; PRE, 36.4 months; POST, 39.3 months; P < 0.05 least significant difference). The PRE group also had shorter survival compared to the other groups when only Stage II and III lesions were studied (S, 40.0 months; PRE, 28.3 months; POST, 39.3 months). Local recurrences based on TNM stage were: T1N0 (S, 0 of 27; PRE, 0 of 3); T2N0 (S, 4 of 4S; PRE, 0 of 7); T2N1 (S, 0 of 9; POST, 1 of 5); T3,4N0 (S, 2 of 37; PRE, 1 of 9; POST, 0 of 10); and T3,4N1,2 (S, 0 of 21; PRE, 0 of 3; POST, 0 of 30). The results of this series support the contention that proctectomy with complete mesorectal excision yields a 4.2 per cent local recurrence rate without the need for adjuvant XRT. In this series, if all the patients had received adjuvant radiation, an additional $2.2 million would have been added to the costs of medical care. Therefore, the potential risks, costs, and benefits of adjuvant pelvic XRT for rectal cancer must be weighed against optimal benchmarks for local recurrence rate for surgery alone.     

Anastomotic leakage: impact on local recurrence and survival in surgery of colorectal cancer

Anastomotic leakage is a serious complication in colorectal surgery, especially in the treatment of adenocarcinoma located in the left-sided colon and rectum. It is controversial whether anastomotic leakage is a prognostic factor for local recurrence and/or survival in this disease. To evaluate the impact of anastomotic dehiscence on the outcome of surgery we reviewed data on 467 consecutive patients with adenocarcinoma of the left colon and rectum treated between 1985 and 1995 in our Department. Of these, 41 (8.8%) developed anastomotic leakage. The overall-survival differed nonsignificantly (P = 0.57) between leakage and nonleakage groups. Of 331 patients with curative resection 29 showed an anastomotic leakage. There were 46 R0-resected patients who died under disease-related conditions: 7 patients in the leakage group (24.1%) and 39 in the nonleakage group (12.9%; P = 0.045). In the curatively resected group 5 of 29 patients developed local recurrence in the leakage group (17.2%) but only 26 of 302 patients in the nonleakage group (8.6%; P = 0.0357). Multivariate analysis showed only the factors of age, stage of resection, staging of lymph nodes, and tumor staging as independent prognostic factors for overall survival. For local recurrence the multivariate analysis revealed tumor staging and anastomotic leakage as independently significant. Anastomotic leakage thus appears to be a prognostic factor for local tumor recurrence of colorectal cancer. In addition, disease-related survival is considerably decreased under leakage conditions. Anastomotic leakage was not shown in this study to be an independent prognostic factor for overall survival due to the lack of statistical significance.     

Urethral recurrence of bladder cancer 16 years after total cystectomy. A case report]

A 74-year-old man was admitted to our hospital. Diagnosis of invasive bladder cancer was made and a total cystectomy was performed on January, 30, 1980. Histological examination showed transitional cell carcinoma, grade 2, pT1 is N0M0. After 16 years, when he suffered left femur, he had right inguinal lymphnode swelling. On the biopsy of the inguinal mass, histology was transitional cell carcinoma. The urethral washing cytology was positive. Lung CT scan dem onstrated multiple lesions. He was diagnosed of the urethral recurrence, right inguinal lymphnode metastasis and lung metastasis of bladder cancer. This case is the 5th case of urethral recurrence of bladder cancer following cystectomy in our hospital.     

Prostatic adenocarcinoma showing features of endometrioid and mucinous carcinomas: a case report

A 77-year-old male was admitted for the examination of post renal acute renal failure. Blood examination revealed renal dysfunction and elevation of carcinoembryonic antigen (CEA). Computed tomography and retrograde pyelography showed bilateral hydronephrosis due to ureteral stenosis. He died of renal failure and autopsy was done. Histologic findings showed moderately differentiated adenocarcinoma of the prostate associated with endometrioid and mucinous carcinoma, and metastases of retroperitoneal lymph nodes and multiple bones. Immunohistochemically, endometrioid carcinoma was positive for prostatic acid phosphate (PAP) and prostatic specific antigen (PSA), and negative for CEA. Mucinous carcinoma was negative for PAP and PSA, and positive for CEA. Including our case, 29 cases of endometrioid and 32 of mucinous carcinoma of the prostate reported in the Japanese literature are reviewed.     

Preoperative irradiation affects functional results after surgery for rectal cancer: results from a randomized study

PURPOSE: The Swedish Rectal Cancer Trial has unequivocally demonstrated that preoperative high-dose (5 x 5 Gy) radiotherapy reduces local failure rates and improves overall survival. This will have an impact on the primary treatment of rectal cancer. This study investigates the effect of preoperative high-dose radiotherapy on long-term bowel function in patients treated with anterior resection. METHODS: A questionnaire was answered by 92 percent (203/220) of patients who were included in the Swedish Rectal Cancer Trial and who were alive after a minimum of five years. Thirty-two patients were excluded, mainly because of postoperative stomas and dementia, which left 171 for analysis. RESULTS: Median bowel frequency per week was 20 in the irradiated group (n = 84) and 10 in the surgery-alone group (n = 87; P < 0.001). Incontinence for loose stools (P < 0.001), urgency (P < 0.001), and emptying difficulties (P < 0.05) were all more common after irradiation. Sensory functions such as "discrimination between gas and stool" and "ability to safely release flatus" did not, however, differ between groups. Thirty percent of the irradiated group stated that they had an impaired social life because of bowel dysfunction, compared with 10 percent of the surgery-alone group (P < 0.01). CONCLUSIONS: The study indicates that high-dose radiotherapy influences long-term bowel function, thus emphasizing the need for finding predictive factors for local recurrence to exclude patients with a very high probability for cure with surgery alone and to use optimized radiation techniques.     

Causes of death and recurrence after surgery for early gastric cancer

The analysis of generalized tonic clonic seizures is usually difficult with scalp EEG due to muscle artifact. We applied Gabor Transform to evaluate 20 seizures from 8 consecutive patients admitted for video-EEG monitoring. We studied the relative intensity ratios of alpha, theta and delta bands over time. In 14/20 events we found a significant decremental activity in the delta band at the onset of the seizure indicating that this is dominated by theta and alpha bands. We conclude that GT is a useful auxiliary tool in the analysis of ictal activity that sheds light on the underlying pathophysiological mechanisms.     

Perforated rectal lymphoma in a renal transplant recipient: report of a case

PURPOSE: We report the case of a renal transplant recipient with rectal lymphoma manifested by sudden onset of abdominal pain from a perforated rectum who was treated successfully with prompt surgical resection and reduction of immunosuppressants. METHODS: An emergent anterior resection with Hartmann's procedure was done. Immunosuppressants were drastically reduced by discontinuation of cyclosporine. RESULTS: Pathologic examination showed diffusely infiltrated large-cell malignant lymphoma with an immunoblastic feature. The patient has been followed-up for four years, with no tumor recurrence or graft rejection. CONCLUSION: Rectal lymphoma, although rare, should be kept in the list of differential diagnoses for transplant recipients who exhibit lower gastrointestinal bleeding, intestinal obstruction, or abdominal pain.     

Long-term survival after bilateral adrenalectomy for metastatic lung cancer: a case report

Selected patients with solitary metastases from non-small cell lung cancer can benefit from an aggressive treatment approach that includes resection of the metastases. This approach has been used for solitary adrenal metastases, but successful long-term treatment of bilateral adrenal metastases has not been previously reported. This is the report of a patient with bilateral adrenal metastases from lung cancer who is disease-free 9 years after bilateral adrenalectomy and chemotherapy. From this evidence, one may hypothesize that adrenal metastases are occasionally lymphatic in origin and that metastases with this route of spread are more amenable to aggressive curative treatment than adrenal metastases of hematogenous origin.     

Subcutaneous emphysema, pneumoretroperitoneum, and pneumomediastinum following rectal surgery: report of a case and review of the literature

A case of retroperitoneal, mediastinal, and subcutaneous emphysema following rectal surgery is described. This complication has not been reported in medical literature. Treatment was based on the fear of a more extensive and irreversible situation, because on the basis of the single case, it could not be demonstrated that the intestinal gas was not associated with infection.     

Extrapontine myelinolysis and behavioral change after transsphenoidal pituitary surgery: case report

OBJECTIVE AND IMPORTANCE: Rapid correction of hyponatremia is considered the usual cause of central pontine myelinolysis and extrapontine myelinolysis. Little has been reported about mental changes associated with this disorder or its occurrence after transsphenoidal surgery. CLINICAL PRESENTATION: A 24-year-old woman suddenly developed markedly abnormal behavior associated with rapid correction of hyponatremia 11 days after undergoing transsphenoidal surgery for a prolactin-secreting pituitary adenoma. INTERVENTION: Magnetic resonance imaging and positron emission tomography with 18F-fluorodeoxyglucose showed bilateral caudate nuclei and putaminal lesions. Gradual, complete clinical resolution preceded the resolution that was revealed by magnetic resonance imaging. CONCLUSION: We emphasize the importance of cautious correction with frequent electrolyte determinations and attention to behavioral changes in the management of delayed hyponatremia after pituitary tumor surgery.