[Resection time and number of detected colorectal lymph nodes in resection specimens with carcinoma]

INTRODUCTION

The number of identified lymph nodes (LNs) is an essential element in the pathologist's rapport on colorectal resection specimens with carcinoma (CRSC). A considerable number of papers discuss the acceptable minimum number of identified LNs to secure a correct LN status (LNS). Details as to the most appropriate grossing technique for LN detection are, however, largely lacking. In this paper the influence of the time invested by the pathologist in the pursuit of LN is investigated.

MATERIAL AND METHODS

The material comprised 150 CRSCs. The usual gross examination was extended by 15 minutes in an effort to identify additional LNs. Provided this careful analysis failed to produce 12 LNs and all detected LNs were benign (pNx), the specimen was re-sampled for an additional 15-minute period. Data were correlated with a baseline material comprising 100 CRSCs.

RESULTS

The intensified search for LNs increased the average number of LNs pr. specimen from 9.1 to 14.9. The number of cases with pNx was reduced from 54% to 18%. Re-sampling performed on 25 specimens resulted in the detection of another 61 LNs in 21 cases, ranging from 1 to 8 LN pr. specimen (median 2), whereby pNx was converted to pN0 in eight cases. In another four cases, additional LNs were not detected. Re-sampling did not uncover metastatic disease.

CONCLUSION

This intensified effort in the Department of Pathology resulted in a more reliable LNS.

[Magnetic Resonance Imaging in the preoperative staging of rectum cancer]

INTRODUCTION

The treatment of rectum cancer depends on the tumour stage, and until 2005 treatment included preoperative radiation therapy for the T3 and T4 cancer stages. An exact preoperative assessment of the cancer stage is therefore essential. In Denmark rectal Magnetic Resonance Imaging (MRI) is used as a standard procedure in preoperative evaluation, sometimes supplemented by transrectal ultrasound (TRUS). The purpose of this study was to determine the accuracy of preoperative MRI in tumour stage evaluation in order to correctly select the patients who will benefit from preoperative radiation therapy.

MATERIAL AND METHODS

The MRI reports from 173 patients (98 male, 75 female, mean age 71 years) who underwent surgery for rectum cancer at Hvidovre Hospital, Copenhagen during the 2002-2005-period were evaluated. The T-stage of the MRI report was compared to the histological T-stage of the resected tumour.

RESULTS

The overall accuracy of T-staging was 58% (n = 100) of which 41% T2 tumours (n = 18), 78% T3 tumours (n = 78) and 33% T4 tumours (n = 4) were correctly staged. In all, 29% of cancers were overstaged (n = 50) (100% of T1 tumours, 59% of T2 tumours, 7% of T3 tumours). A total of 13% of the cancers were understaged (15% of T3 tumours, 67% of T4 tumours). The selection of patients for preoperative radiation therapy had a sensitivity and specificity of 83% and 48%, respectively.

CONCLUSION

The overall accuracy of 58% indicates that MR imaging in the early learning phases was not an optimal method for the preoperative T-staging of rectal cancer. In particular, the low specificity of MRI in selecting the patients who will benefit from preoperative radiation can result in overtreatment and increased morbidity.

[Lymph node identification in colorectal cancer specimens cases]

Colorectal carcinoma is one of the most prevalent malignancies in Western countries. Lymph node status is a significant prognosticator. The chance of identifying node-positivity is positively correlated with the number of lymph nodes (LN) identified. The present paper discusses various variables that may influence the detection of LNs, including patient- as well as surgeon- and pathologist-related issues. The pathologist-related variable most probably shapes the yield the most. Introduction of guidelines focusing on the most appropriate technique may secure better and more consistent results, and the pathologist's commitment is crucial in this respect.

Genotype predicting phenotype in familial adenomatous polyposis: a practical application to the choice of surgery

PURPOSE

Genetic information may help preoperatively select patients with familial adenomatous polyposis for either colectomy with ileorectal anastomosis or proctocolectomy with ileal pouch-anal anastomosis. Although complicated, the latter procedure has a low long-term risk of rectal cancer.

METHODS

Data were obtained from four national polyposis registries. On the basis of previously described genotype-phenotype correlations, patients were divided into three genotype groups predicting attenuated, intermediate, and severe polyposis phenotypes. Cumulative risks of secondary proctectomy and rectal cancer after primary colectomy were calculated using the Kaplan-Meier method.

RESULTS

Four hundred and seventy-five polyposis patients with a previous colectomy were included. Cumulative risks of secondary proctectomy 20 years after primary colectomy were 10%, 39%, and 61% in the attenuated, intermediate, and severe genotype groups, respectively (P < 0.05, groups compared separately). Cumulative risks of rectal cancer after primary colectomy were 3.7%, 9.3%, and 8.3%, respectively, in the three groups (P > 0.05, groups compared separately).

CONCLUSION

Mutation analysis may be used to predict the risk of secondary proctectomy after primary colectomy in familial adenomatous polyposis. Patients with severe genotypes have a high risk of reoperation after primary colectomy and will benefit from primary proctocolectomy with ileal pouch-anal anastomosis. The risk of rectal cancer after primary colectomy was not significantly different between the three groups.

Colectomy and ileorectal anastomosis is still an option for selected patients with familial adenomatous polyposis

PURPOSE

The risk of rectal cancer after colectomy and ileorectal anastomosis may be reduced in the last decades, as patients with severe polyposis now have an ileoanal pouch. We have reevaluated the risk of rectal cancer and proctectomy for all causes according to the year of operation.

METHODS

On the basis of the year of operation in 776 patients with ileorectal anastomosis and 471 pouch patients in Denmark, Finland, Holland, and Sweden, the "pouch period" was defined to start in 1990. Ileorectal anastomosis follow-up data was captured by May 31, 2006. The cumulative risk of rectal cancer and proctectomy was compared before and after 1990 by Kaplan-Meier analysis.

RESULTS

In the prepouch period 56/576 patients (10 percent) developed rectal cancer, vs. 4/200 (2 percent) in the pouch period. Neither the cumulative risk of rectal cancer (p = 0.07) nor the cumulative risk of proctectomy (p = 0.17) changed. However, in females the cumulative risk of rectal cancer (p = 0.04) and of proctectomy (p = 0.03) were lower in the pouch period.

CONCLUSIONS

Since the introduction of the ileoanal pouch rectal cancer has decreased after ileorectal anastomosis, but only statistically significant in females. This indicates that ileorectal anastomosis may still be justified in selected patients with mild adenomatosis, especially in young females.

Postoperative medical complications are the main cause of early death after emergency surgery for colonic cancer

BACKGROUND

Only a few small studies have evaluated risk factors related to early death following emergency surgery for colonic cancer. The aim of this study was to identify risk factors for death within 30 days after such surgery.

METHODS

Some 2157 patients who underwent emergency treatment for colonic cancer from May 2001 to December 2005 were identified from the national colorectal cancer registry. Thirty-day mortality rates were calculated and risk factors for early death were identified using logistic regression analysis.

RESULTS

The overall 30-day mortality rate was 22.1 per cent. The strongest risk factor for early death was postoperative medical complications (cardiopulmonary, renal, thromboembolic and infectious), with an odds ratio of 11.7 (95 per cent confidence interval 8.8 to 15.5). Such complications occurred in 24.4 per cent of patients, of whom 57.8 per cent died. Other independent risk factors were age at least 71 years, male sex, American Society of Anesthesiologists grade III or more, palliative outcome, tumour perforation, splenectomy and adverse intraoperative surgical events. Postoperative surgical complications were noted in 20.4 per cent of the patients but had no statistically significant influence on mortality.

CONCLUSION

Emergency surgery for colonic cancer is still associated with an increased risk of death. There is a need for a system providing increased safety in the perioperative period.

[Restorative proctocolectomy with an ileoanal pouch. Postoperative course and long-term functional results]

INTRODUCTION

Over the last 25 years restorative proctocolectomy with an ileoanal pouch has been the gold standard in the surgical treatment of ulcerative colitis and in selected patients with familial adenomatous polyposis. We present a study of the course, complications and long-term functional results.

MATERIALS AND METHODS

A prospective cohort analysis and a questionnaire in 178 consecutive patients operated since 1987 in Hvidovre Hospital.

RESULTS

Postoperative complications were seen in 38 patients (21%), but only few were serious: anastomotic leakage in 2 (1%), pelvic abscess in 4 (2%) and complications after ileostomy closure in 2 (1%). The late complications comprised reoperation for intestinal bowel obstruction in 10 (6%), pouch fistula in 6 (3%), pouchitis in 22 (12%), and anastomotic stricture in 8 (5%). Three patients (2%) had the pouch removed. After a median observation period of 7 years (range 1-19) the patients had a median of 7 bowel movements per 24 hours (range 3-15), and 2/3 were totally continent day and night. 88% were satisfied with the results.

CONCLUSION

Our results are similar to those in the literature, probably because the preoperative evaluation, operation, postoperative course and long-term follow-up were managed by few specialists in ileoanal pouch surgery. In our opinion restorative proctocolectomy with an ileoanal pouch is still the gold standard for patients with ulcerative colitis and for selected patients with familial adenomatous polyposis.

Guidelines for the clinical management of familial adenomatous polyposis (FAP)

Familial adenomatous polyposis (FAP) is a well-described inherited syndrome, which is responsible for <1% of all colorectal cancer (CRC) cases. The syndrome is characterised by the development of hundreds to thousands of adenomas in the colorectum. Almost all patients will develop CRC if they are not identified and treated at an early stage. The syndrome is inherited as an autosomal dominant trait and caused by mutations in the APC gene. Recently, a second gene has been identified that also gives rise to colonic adenomatous polyposis, although the phenotype is less severe than typical FAP. The gene is the MUTYH gene and the inheritance is autosomal recessive. In April 2006 and February 2007, a workshop was organised in Mallorca by European experts on hereditary gastrointestinal cancer aiming to establish guidelines for the clinical management of FAP and to initiate collaborative studies. Thirty-one experts from nine European countries participated in these workshops. Prior to the meeting, various participants examined the most important management issues according to the latest publications. A systematic literature search using Pubmed and reference lists of retrieved articles, and manual searches of relevant articles, was performed. During the workshop, all recommendations were discussed in detail. Because most of the studies that form the basis for the recommendations were descriptive and/or retrospective in nature, many of them were based on expert opinion. The guidelines described herein may be helpful in the appropriate management of FAP families. In order to improve the care of these families further, prospective controlled studies should be undertaken.

[Anastomotic leakage after anterior resection for rectal cancer]

On the basis of the literature about anastomotic leakage after anterior resection for rectal cancer a review is presented of the frequency, potential risk factors and consequences of leakage. The risk factors are evaluated according to the level of scientific evidence of the individual background articles, and based upon the best documented risk factors recommendations are proposed for prophylactic measures against anastomotic leakage. Furthermore, proposals for future research in the area are presented.

Transanal stent in anterior resection does not prevent anastomotic leakage

OBJECTIVE

A defunctioning transanal stent may theoretically reduce the leakage rate after anterior rectal resection. We present a randomized open study with the aim of comparing the leakage rate after anterior resection with a loop ileostomy, a transanal stent, both or neither.

PATIENTS AND METHODS

Randomized open trial of 194 patients operated in 11 hospitals during September 2000 to September 2003 with anterior resection for a mobile rectal tumour, 115 men and 79 women, median age 68 years (range 37-90 years). The surgeon decided upon the use of a protective ileostomy, and after completion of the operation the patients were randomized in two groups with and without a transanal stent.

RESULTS

A clinically significant leakage was diagnosed in 25 patients (13%). No significant difference was found 17 of 98 patients with a stent and 8 of 96 without (P = 0.09), or in 9 of 44 ileostomy patients with a stent and in 3 of 45 without (P = 0.07). Several leaks over a short time led to an interim analysis after inclusion of 194 of 448 planned patients. The analysis showed no significant protective effect of the stent, and more leakages in the stent group, although not statistically significant. On this basis it was decided to discontinue the study prematurely for ethical reasons.

CONCLUSION

Decompression of the anastomosis with a transanal stent does not reduce the risk of anastomotic leakage after anterior resection.

[Familial colorectal cancer]

The most frequent monogenic predisposition to CRC is hereditary non-polyposis colorectal cancer (HNPCC). Less frequent are syndromes with polyposis. In some families the occurrence of CRC indicates a familial risk of CRC without the diagnostic criteria for the above syndromes being fulfilled. In families where causative mutations are identified, predictive genetic testing is offered. When no mutation is identified in a family, the risk of individual members of the family is evaluated according to the family history. Individuals with a high risk of CRC are offered surveillance.

Familial adenomatous polyposis (FAP): genotype correlation to FAP phenotype with osteomas and sebaceous cysts

Gardner syndrome is characterized by the triad of colorectal adenomas, soft and hard tissue tumors. This disorder was regarded as a separate disease until the identification of the APC gene when it was recognized that mutations in the APC gene were the underlying cause of both Gardner syndrome and familial adenomatous polyposis (FAP). The present study aimed at examining whether a particular APC genotype could be delineated in FAP patients with benign extracolonic manifestations: sebaceous cysts and/or osteomas. A questionnaire was sent to all Danish FAP patients (N = 234) asking for occurrence of sebaceous cysts and palpable osteomas. Medical records later verified positive findings, when possible. The results for each patient were correlated to the position of his or her mutation in the APC gene. Positive participation compliance was 77% (N = 180), and in 105 of these patients the pathogenic APC mutation was known. Palpable osteomas were reported in 17 of the patients in whom a pathogenic mutation had been identified. Osteomas were only identified in patients with mutations between codon 767 and 1513, a gene area also associated with congenital hypertrophy of the retinal-pigmented epithelium (CHRPE) and hepatoblastoma. Sebaceous cysts were reported in 51% of the patients, and their APC mutations were evenly distributed in the gene with no particular hotspot. Osteomas appeared most frequently in patients with sebaceous cysts, odds ratio 6.6, P < 0.001. The study provides molecular evidence that Gardner syndrome is a variant of FAP and essentially obsolete in clinical practice.

[Treatment of rectal cancer]

Patients with rectal cancer are evaluated with digital examination, endoscopy and imaging of the liver and lungs, including biopsies of the primary tumour and suspected secondary spread. On the basis of a precise tumour staging by MRI scan and/or transrectal ultrasound scan, the combined surgical-oncological treatment is discussed at a multidisciplinary treatment conference. Preoperative oncological treatment is offered depending on the tumour stage and for selected patients may include radiotherapy and chemotherapy. Radiotherapy may be offered as a short-term adjuvant treatment or a long-term course with the aim of downstaging. The surgical treatment for selected patients includes total mesorectal excision or local tumour resection. The prognosis has improved over the last decade.

[Future organisation of colorectal cancer surgery in Denmark]

We recommend that in the future, surgery for colorectal cancer (CRC) in Denmark should be done in 10 to 15 colorectal units with an uptake zone of 350,000-500,000 citizens each. These units should perform both acute and elective CRC surgery and acute surgical treatment of other intestinal diseases. In each unit, a senior colorectal surgeon should be available on a 24-hour shift, and there should be sufficient diagnostic and theatre capacity to ensure optimal treatment levels. A stoma clinic should be available Monday to Friday. The units should perform research according to international standards. Each senior surgeon should document his or her relevant continuing surgical education. A national postgraduate education should be ensured to all members of the multidisciplinary team according to the standards in force in Great Britain. The treatment of primary advanced T4 tumors and local recurrence should be done in only one to two colorectal units in Denmark, and the treatment of local recurrence with spread to the pelvis should be done in only one unit in Denmark.

[Hereditary colorectal cancer]

HNPCC and FAP are inherited diseases with a lifetime risk of colorectal cancer (CRC) of 80-100% in gene carriers. Disease-causing mutations have been identified in the APC gene at FAP and in MMR genes at HNPCC. In FAP-patients, screening has reduced the prevalence of CRC by 55%, and the survival rate has improved considerably. For HNPCC-patients, 77% of CRCs found by screening were Duke' A or B, and survival after CRC has improved significantly since 1990. Continuous central registration in the HNPCC and Polyposis registers is recommended to ensure identification of high-risk families and evaluate the effect of screening.

Hospital volume and outcome of rectal cancer surgery in Denmark 1994-99

OBJECTIVE

The association between hospital volumen and outcome of major cancer surgery is being debated at present. We analysed the outcome of rectal cancer surgery in Denmark during the period 1994-99.

METHODS

All patients with a first-time rectal cancer were registered in a national database during the 5-year period. In this observational cohort study, the influence of hospital case volume on resectional procedure, complications, 30-day mortality and 5-year mortality was analysed.

RESULTS

The register comprised 5021 patients. Surgery was performed in 27 hospitals with <15 operations per year, 15 hospitals with 15-30 operations per year and 11 hospitals with >30 operations per year. In a multivariate model, the risk of permanent colostomy was significantly increased in the group of low-volume hospitals. On the contrary, volume did not influence the risk of anastomotic leakage, 30-day mortality and 5-year mortality. However, a large variation in 5-year mortality was observed particularly within the low-volume group of hospitals.

CONCLUSIONS

In this study, only risk of having a permanent colostomy during surgery for rectal cancer was significantly related to hospital case volume. When individual hospitals were analysed, a large variation in 5-year mortality was observed within the low-volume group of hospitals.