Performance of CT in the locoregional staging of colon cancer: detailed radiology-pathology correlation with special emphasis on tumor deposits, extramural venous invasion and T staging

PURPOSE

To investigate the performance of computed tomography (CT) in the local staging of colon cancer in different segments, with emphasis on parameters that have been found to be significant for rectal cancer, namely, extramural venous invasion (EMVI) and tumor deposits (TDs).

METHODS

CT and pathology data from 137 patients were independently reviewed by radiology and pathology teams. The performance of CT in categorizing a given patient into good, versus poor prognostic groups was assessed for each segment, as well as the presence of lymph nodes (LNs), TDs and EMVIs. Discordant cases were re-evaluated to determine potential sources of error. Elastic stain was applied for EMVI discordance.

RESULTS

The T staging accuracy was 80.2%. For T stage stratification, CT performed slightly better in the left colon, and the lowest accuracy was in the transverse colon. Under-staging was more common (in 12.4%), and most of the mis-staged cases were in sigmoid colon. According to the first comprehensive correlative analysis, the sensitivity, specificity, and accuracy of CT for detecting TDs were found to be 57.9%, 92.4%, 87.6%, respectively. These figures were 44.7%, 72.7%, and 63.5% for LN, and 58.5%, 82.1% and 73% for EMVI. The detection rate was better for multifocal EMVI. The detection rate was also comparable (although substantially underestimated) for LNs, with the half of the LNs missed by CT being < 5 mm. Four patients that were classified as TD by CT, disclosed to be LNs by pathology. Correlative analysis led to refinement of the pathology criteria, with subsequent modifications of the initial reports in 13 (9.5%) patients.

CONCLUSION

Overall, CT performed well in the evaluation of colon cancer, as did TD and EMVI. It is advisable to include these parameters in CT-based staging. Radiologists should be aware of the pitfalls that occur more commonly in different segments.

Reliability and validity of the Turkish version of the New Cleveland Clinic Colorectal Cancer Quality of Life Questionnaire

PURPOSE

This study aims to adapt and validate the Cleveland Clinic Colorectal Cancer Quality of Life Questionnaire (CCF-CaQL) in Turkish, addressing the significant need for reliable, language-specific QoL measures for colorectal cancer (CRC) in Turkiye. This effort fills a critical gap in CRC patient care, enhancing both patient-provider communication and disease-specific QoL assessment.

METHODS

The CCF-CaQL was translated into Turkish, verified for accuracy, and reviewed for clarity and relevance. Eligible patients who underwent colorectal surgery for cancer between July 2021 and July 2022 from six hospitals completed the CCF-CaQL and SF-36 questionnaires. For analysis, confirmatory factor analysis using Smart PLS 4 and descriptive statistics were employed. The questionnaire's reliability and validity were assessed using Cronbach alpha, composite reliability, and the heterotrait-monotrait (HTMT) ratio, along with multicollinearity checks and factor loadings. Nonparametric resampling was used for precise error and confidence interval calculations, and the Spearman coefficient and split-half method were applied for reliability testing.

RESULTS

In the study involving 244 colorectal cancer patients, confirmatory factor analysis of the CCF-CaQL indicated effective item performance, with one item removed due to lower factor loading. The questionnaire exhibited high internal consistency, evidenced by a Cronbach alpha value of 0.909. Convergent validity was strong, with all average variance extracted (AVE) values exceeding 0.4. Discriminant validity was confirmed with HTMT coefficients below 0.9, and no significant multicollinearity issues were observed (VIF values < 10). Parallel testing with the SF-36 scale demonstrated moderate to very strong correlations, affirming the CCF-CaQL's comparability in measuring quality of life.

CONCLUSION

The Turkish version of the CCF-CaQL was validated for assessing quality of life in colorectal cancer patients. This validation confirms its reliability and cultural appropriateness for use in Turkiye. The disease-specific nature of the CCF-CaQL makes it a useful tool in clinical and research settings, enhancing patient care by accurately monitoring treatment effects and interventions in the Turkish colorectal cancer patient population.

Factors affecting operative morbidity and long-term outcomes in patients undergoing surgery for presacral tumours: a multicentric cohort study from the Turkish Collaborative Group for Quality Improvement in Colorectal and Pelvic Surgery

AIM

Data regarding the operative management of presacral tumours present various dilemmas due to their rarity and heterogeneous nature. The aim of this study was to evaluate the management strategy, factors associated with operative morbidity and long-term postoperative outcomes in a large group of patients undergoing surgery for presacral tumours.

METHOD

This study was designed as a multicentre retrospective cohort study. Records of patients who underwent surgery for presacral tumours at 10 tertiary colorectal centres between 1996 and 2017 were evaluated.

RESULTS

One hundred and twenty seven patients (44 men) with a mean age of 46 years and body mass index of 27 kg/m2 were included. Fifty eight per cent of the patients had low sacral lesions (below S3). The operative approaches were transabdominal (17%), transsacral (65%) and abdominosacral (17%). The postoperative morbidity was 19%. Thirty per cent of the patients had a malignant tumour. Longer duration of symptoms (p = 0.001), higher American Society of Anesthesiologists score (p = 0.01), abdominosacral operations (p = 0.0001) and presacral tumours located above S3 (p = 0.004) were associated with an increased risk of postoperative morbidity. Overall long-term postoperative recurrence and mortality were 6% and 5%, respectively, within a 3-year mean follow-up period in patients with presacral malignant tumours.

CONCLUSION

Reduced physical condition, omission of symptoms prior to surgery, combined resections and high sacral tumours are the risk factors associated with postoperative complications in patients undergoing surgery for presacral tumours. Meticulous planning of the operation and intensified perioperative care may improve the outcomes in high-risk patients.

A novel scoring system for the early detection of anastomotic leakage: bedside leak score-a pilot study

Background

Anastomotic leakage is a major complication in colorectal surgery, resulting in significant morbidity and mortality rates. Despite substantial progress in surgical technique, anastomotic leakage rates remain stable. An early diagnosis of anastomotic leaks was proven to reduce adverse outcomes and improve survival.

Objective

This study aims to find a novel scoring system for detecting anastomotic leaks using inflammatory and nutritional indicators after colorectal surgery. Our purpose was to analyze the diagnostic accuracy of leak scores ( ( CRP POD 3 ) ( CRP POD 1 ) ∗ preoperative albumin level ) in predicting postoperative complications.

Design

The study included colorectal cancer patients who underwent curative surgery at Koc University Hospital between 2014 and 2018. Patients were categorized into two groups depending on the presence of anastomotic leaks and compared in terms of preoperative albumin levels, CRP levels in postoperative days 1 and 3, anastomotic leakage rates, length of hospital stay, and CRP quotient, which was calculated by dividing POD 3 CRP level to POD 1 CRP level. The bedside leak score is calculated by dividing the CRP quotient by the preoperative albumin level. The predictive value of bedside leak score, CRP quotient, and preoperative albumin levels in estimating anastomotic leakage was analyzed, and a cutoff value for the leak score was calculated.

Results

A total of 184 patients were included in the study. The leak score, CRP POD 3-1 ratio, and preoperative albumin levels were found to successfully detect anastomotic leakage. The area under the curve for the leak score was calculated as 0.78. The optimal cutoff value was found to be 50.3 for the bedside leak score, which shows 90.9% sensitivity and 59.3% specificity.

Conclusion

The leak score may represent a valuable diagnostic tool for detecting patients at risk for anastomotic leakage after colorectal surgery and planning a better strategy to reduce morbidity and mortality rates and associated costs. However, further multicenter studies with large cohorts are necessary to confirm these results.

Is there no need to discuss adjuvant chemotherapy in stage II colon cancer patients with high tumor budding and lymphovascular invasion?

PURPOSE

The aim of this study is to evaluate the clinicopathologic associations of tumor budding (Bd) as well as other potential prognosticators including lymphovascular invasion (LVI) in T3/4aN0 colon cancer patients and to investigate their impact on the outcome.

METHODS

The patients were enrolled in three groups according to the number of budding as Bd1 (0-4 buds), Bd2 (5-9 buds), and Bd3 (> 10 buds). These groups were retrospectively compared in terms of demographic features, other tumor characteristics, operative outcomes, recurrences, and survival. The mean follow-up time was 58 ± 22 months.

RESULTS

A total of 194 patients were divided as follows: 97 in Bd1, 41 in Bd2, and 56 in Bd3 groups. The Bd3 group was associated with significantly higher LVI and larger tumor size. The rate of recurrence increased progressively from 5.2% in Bd1 to 9.8% in Bd2 and to 17.9% in Bd3 group (p = 0.03). More importantly, the 5-year overall survival (OS: Bd1 = 92.3% vs. Bd2 = 88% vs. Bd3 = 69.5%, p = 0.03) and disease-free survival (DFS: Bd1 = 87.9% vs. Bd2 = 75.3% vs. Bd3 = 66%, p = 0.02) were significantly worse in Bd3 group. In addition, in the subgroup of patients with the presence of Bd3 and LVI together, the 5-year OS (60% vs. 92%, p = 0.001) and DFS (56.1% vs. 85.4%, p = 0.001) were significantly worse. In multivariate analysis, Bd3+LVI was significantly associated with poor OS and DFS (p < 0.001).

CONCLUSION

In patients with T3/4aN0 colon cancer, high tumor budding negatively affects long-term oncological outcomes. These findings strongly suggest that adjuvant chemotherapy be considered for the patients with Bd3 and LVI together.

Comparison of neoadjuvant versus upfront surgery for treatment of locally advanced gastric cancer

OBJECTIVE

In this study, we aimed to compare long term oncological outcomes of upfront surgery versus neoadjuvant treatment in patients with locally advanced gastric cancer.

METHODS

A total of 183 patients who were operated for gastric cancer were retrospectively analyzed. The patients received either standard gastrectomy or preoperative NACT + gastrectomy. Neoadjuvant therapy was administered with FLOT regimen (docetaxel, oxaliplatin, fluorouracil, and leucovorin) or DCF regimen (docetaxel, cisplatin, and 5-fluorouracil).

RESULTS

Of the patients receiving NACT, 33 received FLOT regimen and 14 received DCF regimen. The number of male patients was higher in both standard gastrectomy and NACT + gastrectomy groups (p=0.385). Leukopenia and neutropenia were the most common hematological toxicities, while anemia and nausea were the most frequent non-hematological side effects in the both of NACT group. The outcomes of the grades of postoperative complications according to the Clavien-Dindo classification is similar between groups. There was no statistically significant difference in the length of hospital stay after surgery between the groups (p=0,001). According to the disease stage, it was found no statistically significant difference in the OS and DFS between the NACT and standard gastrectomy groups.

CONCLUSION

Although we found no significant difference between the patients undergoing standard gastrectomy and those undergoing NACT before gastrectomy, we believe that NACT may contribute to the favorable prognosis of patients with locally advanced disease with improved OS and DFS and this should be examined in future studies.

KEY WORDS

FLOT, Gastric Cancer, Neoadjuvant Treatment.

Extramural venous invasion (EMVI) revisited: a detailed analysis of various characteristics of EMVI and their role as a predictive imaging biomarker in the neoadjuvant treatment response in rectal cancer

PURPOSE

To assess whether size, diameter, and large vein involvement of MR-detected extramural venous invasion (MR-EMVI) have an impact on neoadjuvant therapy response in rectal adenocarcinoma.

METHODS

57 patients with locally advanced rectal adenocarcinoma scanned with MRI before and after neoadjuvant therapy were included. Two abdominal radiologists evaluated the images with special emphasis on EMVI, on initial staging and after neoadjuvant treatment. The sensitivity and specificity of MRI for detection of rest EMVI were determined. The association of various MR-EMVI characteristics including number, size, and main vein involvement with treatment response was investigated. In subjects with discordance of radiology and pathology, elastin stain was performed, and images and slides were re-evaluated on site with a multidisciplinary approach.

RESULTS

At initial evaluation, 17 patients were MR-EMVI negative (29.8%) and 40 were MR-EMVI positive (70.2%). Complete/near-complete responders had less number (mean 1.45) and smaller diameter of MR-EMVI (mean 1.8 mm), when compared with partial responders (2.54 and 3.3 mm; p < 0.005). The sensitivity of MRI for rest EMVI detection was high, specificity was moderate, and in one patient elastin stain changed the final decision. In five patients with rest MR-EMVI positivity, carcinoma histopathologically had a distinctive serpiginous perivascular spread, growing along the track of vascular bundle, although it did not appear in intravascular spaces.

CONCLUSION

This study demonstrates that not only the presence, but also size and number of EMVI that may be significant clinically and thus these parameters also ought to be incorporated to the MRI evaluation and prognostication of treatment response. From pathology perspective, tumors growing alongside major vessels may also reflect EMVI even if they are not demonstrably "intravascular."

Different uses of the breast implant to prevent empty pelvic complications following pelvic exenteration

Pelvic exenteration surgery is used as a standard procedure in recurrent pelvic cancers. Total pelvic exenteration (TPE) includes resection of the uterus, prostate, ureters, bladder and rectosigmoid colon from pelvic space. Empty pelvis syndrome is a complication of the TPE procedure. Following TPE, complications such as haematoma, abscess leading to permanent pus discharge and chronic infections can occur. Herein, we present the case of a man in his 50s who was referred for pelvic pain, foul-smelling discharge and non-functioning colostomy, and operated for distal rectal cancer 1.5 years ago and underwent low anterior resection. In this case, we performed TPE for the recurrent tumour. To prevent TPE complications, we used a breast implant for filling the pelvic cavity. The early and late postoperative course was uneventful.

Is elective cancer surgery feasible during the lock-down period of the COVID-19 pandemic? Analysis of a single institutional experience of 404 consecutive patients

Background

We aimed to assess the feasibility and short‐term clinical outcomes of surgical procedures for cancer at an institution using a coronavirus disease 2019 (COVID‐19)‐free surgical pathway during the peak phase of the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) pandemic.

Materials and Methods

This was a single‐center study, including cancer patients from all surgical departments, who underwent elective surgical procedures during the first peak phase between March 10 and June 30, 2020. The primary outcomes were the rate of postoperative SARS‐CoV‐2 infection and 30‐day pulmonary or non‐pulmonary related morbidity and mortality associated with SARS‐CoV‐2 disease.

Results

Four hundred and four cancer patients fulfilling inclusion criteria were analyzed. The rate of patients who underwent open and minimally invasive procedures was 61.9% and 38.1%, respectively. Only one (0.2%) patient died during the study period due to postoperative SARS‐CoV2 infection because of acute respiratory distress syndrome. The overall non‐SARS‐CoV2 related 30‐day morbidity and mortality rates were 19.3% and 1.7%, respectively; whereas the overall SARS‐CoV2 related 30‐day morbidity and mortality rates were 0.2% and 0.2%, respectively.

Conclusions

Under strict institutional policies and measures to establish a COVID‐19‐free surgical pathway, elective and emergency cancer operations can be performed with acceptable perioperative and postoperative morbidity and mortality.

Comparative study between ghost ileostomy and defunctioning ileostomy in terms of morbidity and cost-effectiveness in low anterior resection for rectal cancer

PURPOSE

The aim of this study was to compare ghost ileostomy (GI) and defunctioning ileostomy (DI) in patients who underwent low anterior resection (LAR) for rectal cancer in terms of postoperative morbidity, rehospitalization rates, and total costs.

METHODS

Patients with an anastomosis level between 5 and 10 cm from the anal verge after LAR were analyzed retrospectively. Clinical characteristics, operative outcomes, postoperative morbidity, rehospitalization rates, and total costs were compared.

RESULTS

A total of 123 patients were enrolled as follows: 42 patients in the GI group and 81 patients in the DI group. Anastomotic leakage (AL) was identified in three patients who underwent GI, and in all of them, GI was easily converted to DI. There were 96.3% of the patients with DI rehospitalized at least one time because of surgery-related and/or stoma-related complications or stoma closure. When we did not take into account the patients who were rehospitalized for stoma closure, the rates of rehospitalization were 4.7% and 22.2% in the GI and DI groups, respectively (P= 0.01). The mean total costs calculated by removing additional surgical procedures and adding all of the rehospitalization costs were 25,767 USD and 41,875 USD in the GI and DI groups, respectively (P= 0.0001).

CONCLUSION

GI may be a safe and cost-effective method in patients who underwent LAR with low or medium risk factors for AL. It is possible to avoid unnecessary ileostomy and reduce unwanted outcomes due to it, such as postoperative complications, rehospitalizations, and increased total costs by performing GI.

COVID-19 and the Global Impact on Colorectal Practice and Surgery

BACKGROUND

The novel severe acute respiratory syndrome coronavirus 2 virus that emerged in December 2019 causing coronavirus disease 2019 (COVID-19) has led to the sudden national reorganization of health care systems and changes in the delivery of health care globally. The purpose of our study was to use a survey to assess the global effects of COVID-19 on colorectal practice and surgery.

MATERIALS AND METHODS

A panel of International Society of University Colon and Rectal Surgeons (ISUCRS) selected 22 questions, which were included in the questionnaire. The questionnaire was distributed electronically to ISUCRS fellows and other surgeons included in the ISUCRS database and was advertised on social media sites. The questionnaire remained open from April 16 to 28, 2020.

RESULTS

A total of 287 surgeons completed the survey. Of the 287 respondents, 90% were colorectal specialists or general surgeons with an interest in colorectal disease. COVID-19 had affected the practice of 96% of the surgeons, and 52% were now using telemedicine. Also, 66% reported that elective colorectal cancer surgery could proceed but with perioperative precautions. Of the 287 respondents, 19.5% reported that the use of personal protective equipment was the most important perioperative precaution. However, personal protective equipment was only provided by 9.1% of hospitals. In addition, 64% of surgeons were offering minimally invasive surgery. However, 44% reported that enough information was not available regarding the safety of the loss of intra-abdominal carbon dioxide gas during the COVID-19 pandemic. Finally, 61% of the surgeons were prepared to defer elective colorectal cancer surgery, with 29% willing to defer for ≤ 8 weeks.

CONCLUSION

The results from our survey have demonstrated that, globally, COVID-19 has affected the ability of colorectal surgeons to offer care to their patients. We have also discussed suggestions for various practical adaptation strategies for use during the recovery period.

Clinicopathologic features and prognosis of histologic subtypes in the right-sided colon cancer

PURPOSE

Differentiation of the histopathologic subtypes can be clinically important as it can affect the course of treatment and the prognosis. The aim of this study was to investigate both the clinicopathological features and prognosis of histologic subtypes in right-sided colon cancer.

METHODS

This study included 138 patients who underwent surgery for right-sided colon cancer. The patients were divided into three groups according to histopathological subtypes as follows: medullary carcinoma (MC, n=11), mucinous adenocarcinoma (MAC, n=29), and classic adenocarcinoma (AC, n=98). The groups were compared in terms of demographic characteristics, type of surgery, pathological outcomes and survival.

RESULTS

The rate of laparoscopic surgery was significantly lower in the MC group compared with MAC and AC groups (45.4% vs 54.5% vs 35.7%, respectively, p=0.001). In MC group, T4 stage was significantly higher than in other groups (90.0% vs 34.5% vs 35.7%, respectively, p=0.001). While patients with MAC had no distant metastasis, 18.2% and 15.3% of patients with MC and AC respectively, had distant metastasis (p=0.07). MAC vs MC, p=0.01, MAC vs AC, p=0.03). Tumor size, tumor volume, and the rate of microsatellite instability were found significantly higher in the MC group (p<0.05). The 5-year overall (OS) and disease-free survival (DFS) were better in the MAC group compared with MC and AC groups, but these differences did not reach statistical significance (OS: 92.8% vs 72.7% and 68.7%, p=0.16 and DFS 87.3% vs 58.2% and 64%, p=0.10, respectively).

CONCLUSION

MC is associated with more advanced tumor size and T stages, and therefore entails reduced rate of minimally invasive procedures. In our series, the absence of distant metastasis in the patients of MAC also had a positive effect on survival.

Impact of Prolonged Neoadjuvant Treatment-surgery Interval on Histopathologic and Operative Outcomes in Patients Undergoing Total Mesorectal Excision for Locally Advanced Rectal Cancer

BACKGROUND

This study primarily aimed to assess the impact of prolonged neoadjuvant treatment-surgery interval (PNSI) on histopathologic and postoperative outcomes. Impacts of the mode of neoadjuvant treatment (NT) and surgery on the outcomes were also evaluated in the same patient population.

PATIENTS AND METHODS

Between February 2011 and December 2017, patients who underwent NT and total mesorectal excision for locally advanced rectal cancer were included. PNSI was defined as >4 and >8 weeks after short-course and long-course NT modalities, respectively.

RESULTS

A total of 44 (27%) patients received short-course NT (standard interval: n=28; PNSI: n=16) and 122 (73%) patients received long-course NT (standard interval: n=39; PNSI: n=83). Postoperative morbidity was similar between the standard interval and PNSI in patients undergoing short-course [n=3 (11%) vs. n=3 (19%), P=0.455] and long-course [n=6 (15%) vs. n=16 (19%), P=0.602] NT. PNSI was associated with increased complete pathologic response in patients receiving short-course NT [0 vs. n=5 (31%), P=0.002]. Compared with short-course NT, long-course NT was superior in terms of tumor response based on the Mandard [Mandard 1 to 2: n=6 (21%) vs. 6 (38%), P=0.012] and the College of American Pathologists (CAP) [CAP 0 to 1: n=13 (46%) vs. n=8 (50%), P=0.009] scores. Postoperative morbidity was similar after open, laparoscopic, and robotic total mesorectal excision [n=1 (14.2%) vs. n=21 (21%) vs. n=6 (12.5%), P=0.455] irrespective of the interval time to surgery and the type of NT.

CONCLUSIONS

PNSI can be considered in patients undergoing short-course NT due to its potential oncological benefits. The mode of surgery performed at tertiary centers has no impact on postoperative morbidity after both NT modalities.

Robotic Complete Mesocolic Excision Versus Conventional Laparoscopic Hemicolectomy for Right-Sided Colon Cancer

Background: Robotic technique has been proposed to overcome the limitations of laparoscopic surgery. In this study, we aimed at determining whether robotic complete mesocolic excision (CME) for right-sided colon cancer can be safe and effective as conventional laparoscopic right hemicolectomy (CLRH). Materials and Methods: Between February 2015 and September 2017, patients undergoing robotic right CME and CLRH with curative intent for right-sided colon cancer were included. Patient characteristics, short-term and histopathological outcomes were compared between the groups. Results: Ninety-six patients (robotic, n = 35) were included in this study. The operative time (286 ± 77 versus 132 ± 40 minutes, P = .0001) was significantly longer in the robotic group. There were no conversions in either group. No significant differences existed between the groups regarding the mean estimated blood loss, time to first flatus, length of hospital stay (6 ± 3 versus 6 ± 3 days, P = .64), and follow-up times (robotic 15 ± 8 versus laparoscopic 16 ± 10 months P = .11). Overall complication rates (n = 10 [29%] versus n = 15 [25%], P = .67) were similar. In the robotic group, vascular injury occurred in 2 patients, and both were repaired robotically. The mean number of harvested lymph nodes was significantly higher (41 ± 12 versus 33 ± 10, P = .04) and length between the vascular tie and colonic wall was longer (13 ± 3.5 versus 11 ± 3, P = .02) in the robotic group. Conclusion: Although robotic right CME seems equally safe to CLRH in terms of short-term morbidity, future prospective randomized trials are needed to define its role for treatment of right colectomy.

Hyperthermic intraperitonal chemotherapy is an independent risk factor for development of acute kidney injury

PURPOSE

Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) or hyperthermic intrapleural chemotherapy (HIC) has been established as the new treatment modality for selected patients with peritoneal and pleural malignancies. The purpose of the study was to compare the development of acute kidney injury (AKI) in patients who received intravenous cisplatin alone, HIPEC and underwent surgery.

METHODS

This retrospective study included 104 patients who underwent different therapeutic procedures including systemic cisplatin, surgery and HIPEC or HIC using cisplatin for the treatment of peritoneal carcinomatosis from a variety of primary tumors at Koc University Hospital and American Hospital between January 2015 to December 2017.

RESULTS

AKI developed in 18 (17.3%) patients. Baseline creatinine was significantly increased in 3 groups after therapies. The development of AKI was highest in patients treated with HIPEC compared to patients treated with intravenous cisplatin and patients who underwent surgery. AKI developed 31.2% in the HIPEC group (10 of 32 patients), 11.7% in the surgery group (4 of 34 patients) and 10.5% in intravenous cisplatin group (4 of 38 patients), respectively (p 0.04).

CONCLUSION

HIPEC may not be so safe with regard to kidney function. Every attempt should be taken to decrease kidney damage during this procedure.

Laparoscopic colon resection in patients with situs inversus totalis: Is it the same operation as in patients without situs inversus totalis?

Situs inversus totalis (SIT) is a rare condition. In this case, a patient who underwent laparoscopic anterior resection for repeated sigmoid colon diverticulitis with SIT was presented. Laparoscopy surgery in patients with this condition has some important technical differences than standard laparoscopic procedures. Therefore, it may be more appropriate to request surgical experience to perform safe laparoscopic surgery in patients with SIT.

GSTT1 is deregulated in left colon tumors

Our aim was to determine GSTT1 expression levels in left colon tumors and paired normal tissue in order to identify specific alterations in GSTT1 mRNA levels. Alterations in GSTT1 expression in twenty-four left- sided colon tumors and paired cancer free tissue were determined by qRT-PCR. Significant fold changes were determined with t-test. When compared with cancer free tissue, left colon cancers showed a significant decrease in GSTT1 expression. However, GSTT1 mRNA levels among different grades increased gradually in correlation with tumor grade. Our results suggest that downregulation of GSTT1 in left-sided colon cancers is an early event and is reversed with cancer progression, probably due to cellular defense mechanisms as a response to changes in the microenvironment.

Fourth versus eighth week surgery after neoadjuvant radiochemotherapy in T3-4/N0+ rectal cancer: Istanbul R-01 study

BACKGROUND AND PURPOSE

The optimum duration between neoadjuvant radiochemotherapy and transmesorectal excision in locally advanced rectal cancer has not been defined yet. This randomized study was designed to compare the efficacy of four-week versus eight-week delay before surgery.

METHODS

One-hundred and fifty-three patients with locally advanced low- or mid-rectum rectal adenocarcinoma were included in this single center prospective randomized trial. Patients were assigned to receive surgical treatment after either four weeks or eight weeks of delay after chemoradiotherapy. Patients were followed for local recurrence and survival, and surgical specimens were examined for pathological staging and circumferential margin positivity.

RESULTS

4-week and 8-week groups did not differ with regard to lateral surgical margin positivity (9.2% vs. 5.1%, P=0.33, respectively), pathological tumor regression rate (P=0.90), overall survival (5-year, 76.5% vs. 74.2%, P=0.60) and local recurrence rate (11.8% vs. 10.3%, 0.77). Overall survival was better in patients with negative surgical margins (78.8% vs. 53.0%, P=0.04). Local recurrence rate was significantly higher among patients with positive surgical margin (28.5% vs. 9.3%, P=0.02).

CONCLUSIONS

Intentional prolongation of the chemoradiotherapy-surgery interval does not seem to improve clinical outcomes of patients with locally advanced rectal cancer. Surgical margin positivity seems to be more important with this regard.

Abstract A08: Analysis of MRGBP and PPIL1 genes in colon cancer

Colorectal cancer is one of the most common causes of cancer death throughout the world. Colorectal carcinogenesis is a multi-step process and in addition to genetic changes significant changes in DNA methylation and epigenetic events such as histone modifications can also lead to deregulation of gene expression. The histone proteins play a dynamic role in the chromatin structure and transcription. Aberrant protein acetylation, particularly on histones, has been related to cancer while abnormal expression of histone deacetlytransferases (HDACs) are observed in a broad range of cancer types. Therefore, HDACs have emerged as promising targets in cancer therapeutics.

The MRG-binding protein (MRGBP / C20orf20) is a component of the NuA4 histone acetyltransferase (HAT) complex and is involved in the transcriptional activation of specific genes. The MRGBP gene is frequently upregulated in tumors and is thought to play a role in cancer development. On the other hand removal of introns from pre-mRNA is carried out by a large macromolecular spliceosome complex. PPIL1 (Peptidyl-prolylisomerase-like 1) is a component of the human spliceosome and plays a primary role in pre-mRNA splicing for catalyzing isomerization of the peptide bonds. Overexpression of the PPIL1 protein in cancer suggest a potential role of PPIL1 in the in the development and promotion of colon cancer. In the present study we analyzed MRGBP and PPIL1 gene expression levels in matched tumor and normal tissue samples from patients with colorectal cancer.

Tissue samples were collected from 51 patients with colorectal cancer who underwent surgery for tumor resection. The normal tissue specimens used in the study were histologically confirmed to be free of cancer. The HPRT (hypoxanthine-Guanine phosphoribosyltransferase) gene was used as reference. The target and reference genes were amplified in the same multiplex PCR using the LightCycler 480 System. 8-9 nucleotide long UPL probes were labeled with fluorescein (FAM) and TAMRA at the 5′ and 3′ ends, respectively. Expression levels were determined using the Basic Relative Quantification analysis software and the results were evaluated by the Mann-Whitney U test.

Although the median MRGBP expression levels in the tumor tissue were higher than normal tissue (1,72 vs.1,41) the difference was not significant. The median expression levels of PPIL1 in the tumors and normal tissue samples (1,97 vs 1,86) were also similar. Our results indicate that neither MRGBP nor PPIL1 gene expression levels are upregulated in colon cancer cells indicating that these are not directly associated with colorectal cancer.

Citation Format: Ebru Akisik, Nejat Dalay, Sumer Yamaner, Dursun Bugra. Analysis of MRGBP and PPIL1 genes in colon cancer. [abstract]. In: Proceedings of the Third AACR International Conference on Frontiers in Basic Cancer Research; Sep 18-22, 2013; National Harbor, MD. Philadelphia (PA): AACR; Cancer Res 2013;73(19 Suppl):Abstract nr A08.

Laparoscopic surgery for rectal cancer: outcomes in 513 patients

BACKGROUND

Few reports have demonstrated the feasibility and efficacy of laparoscopic resection in patients with rectal cancer (RC). The objective of the present study was to assess the effectiveness of laparoscopic resection for RC, with an emphasis on perioperative variables and long-term oncological outcomes.

METHODS

This prospective study was carried out between January 2005 and September 2010 and included 513 patients diagnosed with RC who underwent laparoscopic surgery. Patients with locally advanced RC (cT3/cT4 or N+) received neoadjuvant treatment. Adjuvant treatment was applied to patients with stage II/III disease or according to the neoadjuvant protocol. All patients were followed-up prospectively for the evaluation of complications and oncological outcome. Survival rate analysis was performed using the Kaplan-Meier method.

RESULTS

Sphincter-preserving surgery was performed on 389 patients, and the remaining 124 patients underwent abdominoperineal resection. Perioperative mortality occurred in only one patient (0.2 %), and 27 (5.3 %) intraoperative complications were recorded. The most common postoperative complication was anastomotic leakage (5.5 %). The conversion rate was 6.4 %. The mean number of harvested lymph nodes was 23.6 ± 13. The mean distance to the distal margin was 2.6 ± 1.9 (0-7) cm. Distal margin positivity was detected in 9 (1.7 %) patients. The circumferential margin was positive in 39 (7.6 %) cases. After a median follow-up period of 30 (1-78) months, recurrence occurred in a total of 59 patients (11.5 %). Local recurrence was detected in 16 patients (3.1 %), and both local and distant recurrence was found in 7 patients (1.4 %). Distant recurrence only was detected in 43 patients (8.4 %). The overall 5-year survival rate was 84 %, and the 5-year disease-free survival rate was 77.4 %. The local recurrence-free survival rate was 98.4 % at 2 years, 95.7 % at 3 years, and 94.3 % at 5 years.

CONCLUSIONS

Our results, together with the review of the literature, clearly demonstrate that laparoscopic resection for RC is a feasible method at specialized high-volume centers. The long-term outcomes are at least as good as those from open surgery as long as the principles of oncologic surgery are respected and faithfully performed.

PPAR-gamma Pro12Ala polymorphism and gastric cancer risk in a Turkish population

BACKGROUND

Peroxisome proliferator-activated receptor gamma (PPARγ) is a ligand dependent transcription factor involved in various processes, including carcinogenesis. We aimed to investigate any possible association of the PPARγPro12Ala (rs1801282) polymorphism with risk of developing gastric cancer (GC).

PATIENTS AND METHODS

A hospital based case control study was designed covering 50 patients with GC and 120 healthy controls. The frequencies of PPARγPro12Ala (rs1801282) were determined using a polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) assay.

RESULTS

The Ala12 allele of the PPARγPro12Ala G gene was associated with a 1.95 fold increased risk of GC development (p: 0.022; 95% CI: 1.58-2.40). Subgroup analyses showed that the same allele was also associated with metastasis (p: 0.000; OR:4.09; 95%CI:2.273-7.368) and differentiation (p: 0.004; OR:1.95; 95%CI:1.335-2.875) in patients with GC.

CONCLUSION

This study suggests that the PPARγPro12Ala G (Ala12) allele might be associated with development, differentiation and metastatic process of GC in the Turkish population. Further studies conducted in larger study groups and in different ethnic populations will be needed to clarify the exact role of the PPARγPro12Ala polymorphism in GC.

Increased gastric cancer risk with PTEN IVS4 polymorphism in a Turkish population

We aimed to investigate the association of the phosphatase and tensin homolog (PTEN) IVS4 polymorphism with a gastric cancer (GC) risk in the Turkish population. A hospital-based case-control study was conducted in 93 patients with GC, and 113 healthy controls. The PTEN IVS4 (rs no: 3830675) polymorphism was determined by using polymerase chain reaction-restriction fragment length polymorphism analysis. The PTEN IVS4 (-/-) genotype exhibited a significantly elevated risk for GC compared to controls (p<0.005; odds ratio: 1.6, 95% confidence interval: 1.19-2.14). Analyses on clinicopathological parameters showed that PTEN IVS4 genotypes were not associated with any of the variables of patients with GC (p>0.05). In conclusion, the PTEN IVS4 polymorphism might contribute to the development of GC in a Turkish population. Further studies, including comparison of the PTEN IVS4 polymorphism with plasma and tissue expressions of PTEN in larger study size groups will provide a further assessment of the PTEN IVS4 polymorphism in GC patients.

Low Mmp 9 and VEGF levels predict good oncologic outcome in mid and low rectal cancer patients with neoadjuvant chemoradiation

Background

The aim of this study was to evaluate apoptotic (Bcl-2, Bax expression, caspase-3 activity, and cytochrome-c) and angiogenic (MMP-9 levels and VEGF expression) markers in operable rectal cancer patients who were treated with preoperative chemoradiotherapy (CRT) followed by total mesorectal excision (TME). Understanding these factors will facilitate the identification of potential pathological responders before treatment, leading to better local control and survival rates.

Methods

Between March 2006 and March 2008, 29 patients withTNM Stage III (cT3 N+) mid or low rectal cancer were included in this study. Our sample consisted of 17 males (58.6%) and 12 females (41.4%). The median age was 60 years (range 24-88 years). Biopsy samples were taken from different portions of the tumors using flexible endoscopy before neoadjuvant CRT. Preoperatively, all patients received radiation (45-50.4 gray (Gy) in 25 cycles with concurrent 5-florouracil (5-FU) chemotherapy.

Results

A complete response was observed in 7 of 29 patients (24%). Bax staining was negative in 1 of the 7 patients (14%) in the pathological complete response (PCR) group and in 18 of the 22 patients (82%) in the no pathological complete response (noPCR) group (p = 0.001). MMP-9 and VEGF levels were higher in the noPCR group than the PCR group (p = 0.04, p = 0.05 respectively). No statistically significant differences were found between VEGF and MMP-9 levels in nodal downstaging. No statistically significant relationships were found between the other apoptotic factors (Bcl 2, cytochrome-c, and caspase-3 activity) and pathological response rate (p > 0.05).

Conclusion

In neoadjuvant CRT patients, high levels of Bax expression and low levels of VEGF and MMP-9 expression on preoperative biopsies indicate that the patient will potentially be a good pathological responder.

Plasma Kisspeptin-54 levels in gastric cancer patients

BACKGROUND

Kisspeptin (Kisspeptin-54; KP-54) is a 54-amino acid peptide was originally known as metastin that was implicated in suppression of tumor metastasis and circulating kisspeptin has been proposed as a tumor marker for numerous cancers in humans. However, the plasma level of KP-54 in gastric cancer (GC) remains undetermined.

AIM

We aimed to investigate the plasma levels of KP-54 in patients with GC.

METHODS

Plasma KP-54 levels were quantified with enzyme-immunoassay from blood samples of 40 patients with GC at their initial staging and 59 age-matched controls.

RESULTS

Plasma KP-54 levels were significantly higher in GC patients (63.3±17.9) than in controls (49.0±12.7) (p=0.000). Cut-off value for KP-54 was determined as 44 ng/ml and sensitivity, specificity, positive predictive value and negative predictive value, were 60%, 78%, 63%, and 74% respectively. Plasma KP-54 levels were not correlated with any clinicopathological features of GC patients (p>0.05).

CONCLUSIONS

Result of our preliminary study suggest that plasma KP-54 levels might be a useful parameter in diagnosis of GC.

Promoter and histone methylation and p16(INK4A) gene expression in colon cancer

The inactivation of the cyclin-dependent kinase inhibitor p16^INK4A gene by hypermethylation is observed in numerous types of cancer. New findings indicate that DNA and histone methylation act in concert in gene silencing. In this study, we investigated the methylation status of the p16^INK4A gene promoter and the histone 3 lysine 9 residue in the tumors and matched normal tissue samples from patients with colorectal cancer and analyzed their association with gene expression. The methylation and expression of the p16^INK4A gene were analyzed by real-time PCR, and histone methylation was analyzed by chromatin immunoprecipitation followed by real-time PCR. p16^INK4A expression was significantly higher in the tumors compared to normal tissue. Mono-, di- and trimethylation levels of the H3K9 residue were similar in the tumor and normal tissue samples. We did not observe any significant correlation between p16^INK4A methylation or expression and clinical parameters. Our results suggest that epigenetic modifications of the p16^INK4A gene and histone lysine methylation do not play a major role in colon carcinogenesis.

Association of APE1 and hOGG1 polymorphisms with colorectal cancer risk in a Turkish population

BACKGROUND

There is growing evidence describing DNA repair genes polymorphisms are related to increased cancer risk including colorectal cancer (CRC). The aim of this study was to investigate the associations between the APE1 Asp148Glu, hOGG1 Ser326Cys, XRCC1 Arg399Gln, XRCC3 Thr241Met, XPD Lys751Gln, XPG Asp1104His polymorphisms and CRC risk in Turkish population.

PATIENTS AND METHODS

Polymorphisms of APE1 Asp148Glu (rs3136820), hOGG1 Ser326Cys (rs1052133), XRCC1 Arg399Gln(rs25487), XRCC3 Thr241Met (rs861539), XPD Lys751Gln (rs13181), and XPG Asp1104His (rs17655) were determined by polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP) methods in blood samples of 79 CRC patients at their initial staging and 247 healthy controls. Of the CRC patients, 26 out of 40 were diagnosed with rectal cancer and received neoadjuvant chemoradiotherapy following diagnosis; 39 others were diagnosed as colon cancer.

RESULTS

Our preliminary results showed that frequencies of Glu allele of APE1 Asp148Glu and Cys allele of hOGG1 Ser326Cys were higher in CRC patients than in controls (p = 0.006, OR: 3.43; 95% CI: 1.76-6.70; p = 0.000, OR: 2.77; 95% CI: 1.40-5.48, respectively). Higher frequency of Met allele of XRCC3 Thr241Met was detected in patients treated with neoadjuvant chemoradiotherapy (p = 0.024, OR: 5.25; 95% CI: 1.23-23.39) and with proximal colon tumors (p = 0.04, OR: 2; 95% CI: 1.18-3.34). Increased frequency of Ser/Ser genotype of hOGG1 Ser326Cys was found to be associated both with higher grade (p = 0.001, OR: 6.4; 95% CI: 2.69-62.69) and liver metastasis (p = 0.005, OR: 7.5; 95% CI: 0.7-68.36).

CONCLUSION

APE1 Asp148Glu and hOGG1 Ser326Cys polymorphisms might be associated with increasing risk of CRC in a Turkish population. Future studies with larger-sized samples, as well as detecting the association of DNA repair genes with other confounding factors will help elucidate the exact roles of DNA repair genes polymorphisms in development and progression of CRC.

Revisiting stapled and handsewn loop ileostomy closures: a large retrospective series

OBJECTIVE

To compare the surgical outcomes of stapled and handsewn closures in loop ileostomies.

METHODS

The data of 225 patients requiring loop ileostomies from 2002 to 2007 were retrospectively evaluated. The patients underwent partial small-bowel resections and either handsewn or stapled anastomoses for the ileostomy closures. They were followed up postoperatively with routine surgical examinations.

RESULTS

The study group consisted of 124 men and 101 women with a mean age of 49.12 years. The ileostomy closure was performed with handsewn in 129 patients and with stapled in 96 patients. The mean time to the first postoperative flatus was 2.426 days in the handsewn group and 2.052 days in the stapled group (p <0.05). The mean time to the first postoperative defecation was 3.202 days in the handsewn group and 2.667 days in the stapled group (p <0.05). The mean duration of patient hospital stay was 8.581 days for the handsewn group and 6.063 days for the stapled group (p <0.05).

CONCLUSIONS

Patients who underwent ileostomy closure with stapled recovered faster in the postoperative period and required shorter hospital stays than those whose closures were performed with handsewn. In our opinion, stapled should be considered the gold standard for loop ileostomy closures.

Phosphorylation and novel mutations of β-catenin in colon tumors

A significant proportion of colon tumors have defects in the Wnt signaling pathway indicating that wnt signaling plays a major role in carcinogenesis. Mutations and aberrations in this pathway may result in constitutive activation. The β-catenin molecule is a key component of this pathway and in absence of wnt signaling the cellular β—catenin level is kept low through degradation of the protein. Disruption of the β-catenin regulation plays a critical rol ein tumor development. Four critical serine/threonine residues on the protein form the recognition site for the proteasomic degradation complex. Sequential phosphorylation of β —catenin at these sites regulates the degradation rate of the protein. Mutations in this region may block phosphorylation and the mutant protein can escape from destruction. In the present study we investigated β—catenin expression and phosphorylation of the protein at the Ser33, Ser37, Thr 41 and Ser45 sites in tumors and matched normal tissue samples from 77 patients with colon cancer. β—catenin protein expression and and phosphorylation were analyzed by Western Blotting. The phospho-β—catenin expressing SW 480 cell line was used as the normal control. β—catenin protein expression was higher in tumor tissue in % 57.1 of the patients but the difference was not significant. Likewise, no significant difference was observed between phosphorylation levels of the different sites in the tumor and normal tissue. However, phosphorylation of the Ser 33/37/Thr41 and the Ser45 sites were significantly correlated.

In the samples displaying differences in phosphorylation between the tumor and the corresponding normal tissue samples the β—catenin gene was analyzed for mutations. We observed a single nucleotide change which has not been described previously in three (5.8 %) patients. This mutation results from a A G transition and leads to the substitution of glutamic acid by lysine. DNA from matched normal colon tissue and peripheral blood of the patients was also analyzed. In none of the patients the mutation was present in the somatic cells.

Our data indicate that among the molecular alterations affecting the β—catenin molecule mutations rather than phosphorylation of the protein play a major role. Although not described so far, the mutation presented in this study may constitute a more common variant than some of the previously reported alterations.

Dual Inhibition of Wound Healing and Oxidative Process by Montelukast in Experimental Colon Anastomoses

Background. The authors aimed to investigate the effects of montelukast (ML) on the experimental rat colon anastomosis. Methods. A total of 80 Wistar albino rats were divided into 4 groups: sham-operated, colon anastomosis, and colon anastomosis with oral administration (OAML) and rectal administration of 10 mg/kg/d ML (RAML). Anastomotic bursting pressure, anastomotic hydroxyproline contents, malondialdehyde (MDA), glutathione (GSH), glutathione peroxidase (GPX), and superoxide dismutase (SOD) levels, and the expressions of Ki-67, vascular endothelial growth factor (VEGF), and basic fibroblast growth factor (bFGF) with immunohistochemistry were assessed on postoperative day 5. Results . Anastomotic bursting pressures and bFGF expressions were not changed, whereas tissue hydroxyproline concentrations and MDA levels and the expressions of Ki-67 and VEGF were significantly decreased, and GSH, GPX, and SOD levels were significantly increased in the OAML and RAML groups. Conclusion. ML causes impairment of wound healing without altering the anastomosis bursting pressure and reverses the oxidative damage of the colon anastomoses in rats.

Do different abdominal incision techniques play a role in wound complications in patients operated on for gastrointestinal malignancies ? "Scalpel vs. electrocautery"

BACKGROUND

Despite the studies of animals that demonstrate better wound healing after abdominal incisions with the use of a scalpel rather than electocautery, clinical experience does not confirm these findings. The purpose of this study was to compare the early postoperative and late-term wound complication rates between the scalpel and electrocautery in patients with gastrointestinal malignancies undergoing midline abdominal incisions.

METHODS

Patients undergoing midline abdominal incisions for gastrointestinal malignancies were randomly divided into two groups according to the method used to perform the incisions: scalpel or electrocautery. Complications were investigated, diagnosed and compared in the early postoperative and late-term follow-up periods. The independent samples, chi-square, and Student's t tests were used for statistical analysis.

RESULTS

Two hundred and eighteen patients were included to this study, of whom 97 (44.5%) were in the scalpel group and 121 (55.5%) in the electrocautery group. Both groups were similar with respect to their demographic, operative and postoperative characteristics. The analysis revealed no significant statistical differences in consideration of the incidences of either wound infection in the early postoperative period or incisional hernia in the late-term follow-up period between these two study groups (p > 0.05).

CONCLUSIONS

Scalpel and electrocautery are similar in terms of early postoperative and late-term wound complications when used to perform midline abdominal incisions. Therefore, the choice of method remains a matter of the surgeon's preference.

Possible associations of APE1 polymorphism with susceptibility and HOGG1 polymorphism with prognosis in gastric cancer

BACKGROUND

Multiple genetic and epigenetic alterations in several genes are implicated in the multistep process of human gastric carcinogenesis. In this study, we examined the polymorphisms of six DNA repair genes: APE1, HOGG1, XRCC1, XRCC3, XPD, and XPG in patients with gastric cancer (GC).

PATIENTS AND METHODS

Forty patients with GC and 247 controls were included in this study. DNA polymorphisms were determined by polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP) method.

RESULTS

The frequency of the Asp/Glu genotype and Glu allele of APE1 in patients with GC was significantly higher than in the control group (p=0.05). We also observed a higher frequency of the Ser/Ser genotype of HOGG1 in grade III tumors, and in tumors with metastasis to adjacent tissue and solid organs (p<0.05).

CONCLUSION

Our results suggest that (i) APE1 gene polymorphism may be associated with GC risk and (ii) HOGG1 gene polymorphism may be informative in the prognosis of GC.

Surgical approach to extensive hidradenitis suppurativa in the perineal/perianal and gluteal regions

BACKGROUND

Verneuil's disease, or hidradenitis suppurativa, is a chronic suppurative disease with a tendency to sinus formation, fibrosis, and sclerosis. It is a disease of the apocrine sweat glands and may arise from each of the localizations where apocrine glands are prominent: axilla, nipples, umbilicus, perineum, groin, and buttocks. Extensive hidradenitis suppurativa of the perineal/perianal and the gluteal regions constitute a serious social problem. In this study, we present our experience with stage III extensive hidradenitis suppurativa cases, including our treatment methods and patient outcomes.

METHODS

A retrospective review of the medical records from January 1990 to July 2003 of 15 patients was performed.

RESULTS

Fifteen patients underwent treatment for extensive hidradenitis suppurativa in the gluteal, perineal/perianal, and inguinal areas with total surgical excision. All patients were men (100%) and their mean age was 42.5 (range, 23-66) years. The patients underwent a total number of 21 operations. In 11 patients wounds were left open for secondary healing, and the mean time for complete wound healing in this group was 12.2 (range, 9.5-22) weeks. Two patients underwent primary wound closure by the application of rotation flaps, and their complete healing times were observed to be approximately 2 weeks. Delayed skin grafting was used for the remaining two patients in whom the wounds had been left open after the initial operation. In this group, complete wound healing took a total of 8 weeks. Only one diverting colostomy was needed in a patient in the delayed skin-grafting group. Squamous cell carcinoma was diagnosed in the specimens of one patient treated with total excision followed by the application of a rotation flap. This patient had had complaints of gluteal discharge for approximately 30 years. The cancer recurred after 6 months in the perianal region and immediate abdominoperineal resection was performed. He died during the second postoperative month due to systemic spread of the malignancy. At the end of a 5-year mean follow-up period, all remaining patients had no evidence of disease.

CONCLUSIONS

Conservative treatment methods have little or no effect on extensive perineal/perianal hidradenitis suppurativa. Therefore, total surgical excision must be considered for these patients to prevent further complications, such as abscess, sinus tract formation, fistulization, and scarring. A temporary stoma may be needed in some cases. Because wound management after total excision is performed via different methods according to each individual patient, multidisciplinary team work is necessary and the patients often require a long hospital stay. If the treatment is not performed in an appropriate manner or if the patients are not followed closely until definitive healing, recurrence is almost inevitable. Despite the low incidence of accompanying squamous cell carcinoma, it is the most serious complication. We evaluated 15 patients to present our experience with extensive perineal/perianal and gluteal hidradenitis suppurativa.

A surgical approach to anogenital Buschke Loewenstein tumours (giant condyloma acuminata)

BACKGROUND

Condyloma acuminata are anogenital warts caused by human papillomavirus (HPV). Neglected giant peri-anal condyloma acuminata (Buschke Loewenstein Tumours) require major surgical procedures. This report reflects our experience concerning the aggressive surgical approach to this rarely presented type of condyloma acuminata.

METHODS

The medical records of five patients, who had been surgically treated following the diagnosis of giant perianal condyloma acuminata between April, 1996 and September, 2003 were reviewed and evaluated retrospectively. Full thickness tumour and skin excisions were performed followed by delayed split thickness skin graftings in all patients.

RESULTS

Five patients (3 men, 2 women) who suffered from giant condyloma acuminata lesions obliterating the anal canal were evaluated. The mean age was 36.5 years (range: 24-52). All patients underwent total surgical excisions. The wounds were left open for secondary healing, and following a mean time period of 35 days, split thickness skin graftings were performed. The histopathologic examinations of the specimens of these five patients did not reveal any malignant transformations. No recurrences were detected at the end of a mean follow-up period of 22 months and all patients were considered to be disease-free at the end of their long-term 5-year follow-up periods.

CONCLUSIONS

Peri-anal condyloma acuminatum is usually a benign disease, but may grow locally to an excessive extent, developing into a Buschke Loewenstein Tumour, and may cause serious peri-anal hygiene problems. Even though the incidence of malignant transformation is rare, there is always a risk of this complication occurring. Transmission of the disease to other sexual partners is another point of concern. Therefore, this disease must be treated aggressively with total surgical excision. The results of our surgical treatment methods are satisfactory.

Prospective randomized study comparing fourth-week surgery versus eighth- week surgery after neoadjuvant concomitant radiotherapy and infusional 5-FU in T3–4/N0+ rectal cancer: Istanbul R-01 Study

4131

Background: Prospective randomized study has been designed to compare the efficacy of fourth week surgery (4WS) versus eighth week surgery (8WS) after concomitant neoadjuvant chemoradiotherapy (NeoadjCTRT) on local recurrence and overall survival (OS) in cT3–4/N0+, mid and distal localized (intraperitoneal) rectal cancers. Pathological regression grades (PRG;Dworak) were evaluated after neoadjCTRT. Methods: During Jan 2002- Nov 2007; 170 pts were randomized to the study in Istanbul University Oncology Institute and Medical Faculty. All rectal cancer pts are T3–4/N0+; distal and mid rectum and received 45 Gy conventionally fractionated RT in 25 daily fractions of 1.8 Gy combined with 225 mg/m2/day continous infusion 5-FU. Preoperative staging was performed by endorectal USG and /or MRI and abdominal CT.4cycles FUFA is standard as adjuvant treatment after surgery. Results: 17 pts have been removed (M1, frozen pelvis, refuse surgery, disease progression). Clinical T3N+ was 60.8% before surgery. 76 pts were operated at 4WS and 77 pts at 8WS. Median follow-up was 30 (2–71) months. APR was 31.4%. LAR was 68.6%. Surgical margin positiveness (SMP) and <2mm were detected in 14 pts. R0 resection rate was 90.8%. Median harvested lymph node number were 13. PRG were PRG 0 (1.3%); PRGI in (24.2%); PRGII in (40.5%); PRGIII (17%); PRGIV in (17%). There is no statistical significance between 4WS vs 8WS on pathological regression scores. Local recurrence developed in 8 pts (PRGI:3pts; PRGII:4; PRGrIV:1). There is no statistical difference 4WS v 8WS on local recurrence (5 pts/3). Local recurrence rate was 8.4% in distal rectum (7 pts) and 1.2% in mid rectum (1pts) (p=0.023). SMP and <2mm was statistically significant in local recurrence (p=0.003). 5 years OS were similar in 4WS 75.2% and 8WS 73.9%. Distant metastasis is significant (liver, lung, bone) in distal rectal tumors (p=0,007). SMP or < 2mm is significantly poor in OS (p<0.0001). Conclusions: There is no difference 4WS vs 8WS on local recurrence, OS and PRGs. Important factors for local recurrence and (OS) are having distal rectal tumor and SMP and <2mm. Distal rectal tumors have prone to distant metastases.

No significant financial relationships to disclose.

MR colonography after oral administration of polyethylene glycol-electrolyte solution

This prospective study was approved by the local institutional ethics committee, and written informed consent was obtained from all patients. The aim of this study was to determine whether the oral administration of a polyethylene glycol (PEG)-electrolyte solution induces adequate luminal distention for magnetic resonance (MR) colonography to be performed and to assess patient acceptance of this procedure. Fifty-five patients (26 women, 29 men; mean age, 60.5 years +/- 14 [standard deviation]; age range, 40-75 years) who were referred for optical colonoscopy (OC) owing to symptoms and findings that included rectal bleeding, altered bowel habits, and positive fecal occult blood test results participated in this study. Standard bowel preparation was performed 1 day before the procedure. MR colonography was performed and followed by OC on the same day. Before undergoing MR colonography, the patients received 2.0-2.5 L of the PEG-electrolyte solution orally. Adequate distention of all colonic segments was achieved in 50-53 (91%-96%) of patients imaged in the supine position and in 51-53 (93%-96%) of patients imaged in the prone position. Oral administration of the solution yielded uniform luminal darkening and sufficient colonic distention for MR colonography in 91%-96% of patients.

Diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in children and adolescents: experience in a single institution

INTRODUCTION

Experience in the use of endoscopic retrograde cholangiopancreatography (ERCP) for the investigation and treatment of pancreaticobiliary disorders is relatively limited in children. This report reviews the experience in a single institution with pediatric ERCPs and documents the indications, success rate, diagnostic and therapeutic yields, complications, and the impact on patient management.

PATIENTS AND METHODS

The data of all consecutive patients aged < or = 18 years who underwent ERCP procedures between the years 1997 and 2007 were retrospectively identified through a computer database search. The database prospectively recorded the indications, findings, therapies, and complications.

RESULTS

During the study period, 32 ERCP procedures were performed in 28 children with a median age of 13 (range 8 - 18) years. ERCPs were performed for biliary pathology in 21 (75 %) and for pancreatic pathology in 7 (25 %) patients. The most common biliary indications were suspected choledocholithiasis and postoperative bile leaks. Hydatid disease was the most common diagnosis that yielded bile leaks. The pancreatic indications were recurrent pancreatitis and traumatic pancreatic duct disruption. Cannulation of the desired duct was successful in all procedures. An endoscopic sphincterotomy, stone/sludge removal or a stent placement was performed in 20 (63 %) procedures. According to the long-term follow-up, avoidance from any further surgical interventions was achieved in 11 (65 %) children, in whom ERCP was undertaken as a therapeutic intervention. The complication rate was 6 % with the development of mild self-resolving pancreatitis in one patient and stent occlusion in another.

CONCLUSIONS

ERCP in the pediatric population has a high success rate, both as a diagnostic tool and for therapeutic interventions, provided it is performed by experienced endoscopists. The delicate delineation of the anatomy by ERCP and its therapeutic potential make it absolutely superior to other less invasive tools such as magnetic resonance cholangiopancreatography.