Colorectal cancer. Genetic variants in BMP signaling pathway and ancestry in the Mexican population

INTRODUCTION

Genetic variants related to bone morphogenetic proteins (BMP2, BMP4, GREM1, SMAD7) signaling pathway have been associated with colorectal cancer, mainly in Caucasian populations.

OBJECTIVE

To describe the association of variants in members of the BMP signaling pathway in a Mexican population, characterized by its indigenous American and Caucasian ancestry.

METHODS

Genotyping of 1,000 colorectal cancer cases and 1,043 control individuals recruited in Mexico City, Monterrey, and Torreón was carried out using the Sequenom platform. Associations between colorectal cancer and variants were studied with univariate and multivariate analyses.

RESULTS

Variants rs4444235, rs12953717 and rs4939827 replicated the association with the neoplasm (p ≤ 0.05). Caucasian ancestry showed association with the tumor.

CONCLUSIONS

The study replicated the associations between colorectal cancer and SMAD7 and BMP4 variants, with an association being observed with the Caucasian component of the ethnic mix.

Risk factors for anastomotic leakage after preoperative chemoradiation therapy and low anterior resection with total mesorectal excision for locally advanced rectal cancer

BACKGROUND

Risk factors for anastomotic leakage after preoperative chemoradiation plus low anterior resection and total mesorectal excision remain uncertain.

OBJECTIVE

To analyze, the associated risk factors with colorectal anastomosis leakage following preoperative chemo-radiation therapy and low anterior resection with total mesorectal excision for rectal cancer.

MATERIALS AND METHODS

Between January 1992 and December 2000, 92 patients with rectal cancer were treated with 45 Gy of preoperative radiotherapy and bolus infusion of 5-FU 450 mg/m2 on days 1-5 and 28-32, six weeks later low anterior resection was performed. Univariate analysis was performed as to find the risk factors for colorectal anastomotic leakage.

RESULTS

There were 48 males and 44 females, mean age was 55.8 years. Mean tumor location above the anal verge was 7.4 +/- 2.6 cm. Preoperative mean levels of albumin and lymphocytes were 3.8 g/dL and 1,697/microL, respectively. Mean distal margin was 2.9 +/- 1.4 cm. Multivisceral resection was performed in 11 patients (13.8%), 32 patients (35%) had diverting stoma. Mean preoperative hemorrhage was 577 +/- 381 mL, and 27 patients (24%) received blood transfusion. Ten patients (10.9%) had anastomotic leakage. No operative mortality occurred. Risk factors for anastomotic leakage were: gender (male) and tumor size > 4 cm. Three patients of the group without colostomy required a mean of six days in the unit of intensive care; mean time of hospital stay of patients with and without protective colostomy was 12.4 +/- 4.5 days vs. 18.3 +/- 5.2 days (p = 0.01).

CONCLUSION

In male patients with rectal adenocarcinoma measuring > 4 cm, treated by preoperative chemoradiotherapy + low anterior resection with total mesorectal excision, a diverting stoma should be performed to avoid major morbidity due to anastomotic leak.

Prognostic significance of circumferential margin involvement in rectal adenocarcinoma treated with preoperative chemoradiotherapy and low anterior resection

INTRODUCTION

Histologic examination of circumferential margins is an important predictor of local and distant relapse in non-radiated rectal cancer. However, for patients who received preoperative chemoradiotherapy this role has not yet been addressed.

METHODS

From January 1995 to December 1997, 61 patients with rectal adenocarcinoma located between 0 and 10 cm from anal verge with invasion into perirectal fat assessed by rectal ultrasound were included. All patients received 45 Gy + bolus infusion of 5-FU (450 mg/m(2)/days 1-5, 28-33 of RT); 4-6 weeks later, surgery was performed. Circumferential margin was assessed (<2 mm was considered as positive). Five-year survival was calculated by Kaplan-Meier method and comparison of groups with log-rank test. Multivariate Cox regression analysis was performed to find risk factors affecting local control and survival.

RESULTS

There were 35 males and 26 females, mean age 60.3 years. Twelve patients (19.7%) had circumferential margin involvement. Median follow-up was 44 months. Overall local recurrence was observed in 6 of 61 patients (9.8%); in patients without circumferential margin involvement this was 8%, whereas it was 16% in those with circumferential margin involvement (P = 0.33). Distant recurrence was observed in 22% of patients without circumferential margin involvement; conversely, it was 58.3% in those with involvement (P = 0.02). Five-year survival of patients without circumferential resection involvement margin was 81%, while it was 42% in patients with circumferential involvement (P = 0.006).

CONCLUSIONS

In patients with rectal cancer treated by preoperative chemoradiation plus total mesorectal excision (TME) and sphincter saving surgery, circumferential margin involvement is associated with high incidence of distant recurrence and cancer-related death.

Composite pelvic exenteration: is it worthwhile?

BACKGROUND

In locally advanced pelvic cancer, tumor fixation to the bony pelvis is regarded as unresectable and often inoperable. Few data exist regarding the futility or utility of pelvic exenteration with en bloc resection of involved portions of the bony pelvis.

METHODS

Thirty-four of 625 patients undergoing radical pelvic procedures had an en bloc resection of pelvic organs with portions of the bony pelvis. There were 19 female and 15 male patients, and the median age was 59 years. Primary neoplasms included 19 rectal, 6 cervicouterine, 4 anal, 3 vaginal, 1 sarcoma, and 1 penile. All but three patients underwent preoperative pelvic irradiation. Pelvic exenterations were posterior in 7 patients, anterior in 3, supralevator in 3, and total in 21 patients. Pelvic bony resections included portions of the sacrum-coccyx in 18 patients, ischium in 5, pubic symphysis in 4, and ischial pubic rami in 4, and hemipelvectomy was performed in 3.

RESULTS

Surgical morbidity occurred in 67.6% (23) of 24 patients. Median follow-up was 37 months. Pelvic or perineal tumor recurrence was concurrent with distant metastases in 9 patients (26.4%); 6 (17.6%) had only distant relapse, and 2 (5.8%) died with local recurrence alone. Overall cancer-related mortality rate was 50%. Five-year overall and cancer-specific survival rates were 44% and 52%, respectively.

CONCLUSIONS

Substantial survival can be accomplished for patients whose tumors are fixed to limited portions of the bony pelvis. These procedures are still associated with substantial morbidity, but operative mortality is infrequent.

Prognostic significance of retrieved lymph nodes per specimen in resected rectal adenocarcinoma after preoperative chemoradiation therapy

BACKGROUND

Histologic examination of a regional lymphadenectomy specimen ordinarily should include 12 or more lymph nodes. However, in specimens from patients who received preoperative chemoradiotherapy this number has not yet been established.

METHODS

From January 1990 to December 2000, 210 patients with rectal adenocarcinoma located between 0 and 10 cm from anal verge with invasion into perirectal fat, tethered or fixed to the pelvis, diagnosed by computed tomography (CT) scan and/or rectal ultrasound were included. All patients received 45 Gy+bolus infusion of 5-FU (450 mg/m2/days 1-5, 28-33 of RT) 4-8 weeks after surgery was performed. Specimens were mapped and sliced. Lymph nodes were studied under clearing or manual techniques. Five-year survival was calculated by Kaplan-Meier method and comparison of groups with log-rank test. Multivariate Cox regression analysis was performed to find risk factors affecting local control and survival.

RESULTS

There were 126 males and 84 females; mean age was 55.2 years. Low anterior resection was performed in 112 patients, abdominoperineal resection in 85, and pelvic exenteration in 13. Total retrieved lymph nodes numbered 2,554, of which 252 contained metastasis. The group was divided into patients with 1-10 retrieved lymph nodes (n=119) and patients with > or = 11 retrieved lymph nodes (n=91). Median follow-up was 49 months. Local recurrence was as follows: 15% in patients with specimens containing 1-10 lymph nodes and conversely 7.4% in those with > or = 11 (p=0.01). Five-year survival of patients with 1-10 lymph nodes was 48%, whereas for those with > or = 11 lymph nodes it was 69% (p=0.02).

CONCLUSIONS

Retrieval of at least 11 lymph nodes in the surgical specimen is not only a powerful tool to properly stage patients with rectal adenocarcinoma treated with preoperative chemoradiotherapy and surgery, but it is also of prognostic relevance in that 5-year survival and local recurrence were better in this group of patients.

Anal sphincter preservation in locally advanced low rectal adenocarcinoma after preoperative chemoradiation therapy and coloanal anastomosis

BACKGROUND AND OBJECTIVES

Standard treatment of rectal adenocarcinoma located 3-6 cm above anal verge is abdominoperineal resection. The objective was to evaluate feasibility, morbidity, and functional results of anal sphincter preservation after preoperative chemoradiation therapy and coloanal anastomosis in patients with rectal adenocarcinoma located between 3 and 6 cm above the anal verge.

METHODS

This study included 17 males and 15 females with a mean age of 54.8 +/- 15.4 years. Tumors were located at a mean of 4.7 +/- 1.1 cm above the anal verge. The mean tumor size was 4.6 +/- 1.5 cm. All patients received the scheduled treatment. Twenty-two patients underwent coloanal anastomosis with the J pouch; 10 underwent straight anastomosis. Average surgical time was 328.7 +/- 43.8 min, and the average intraoperative hemorrhage was 471.5 +/- 363.6 ml. The mean distal surgical margin was 1.3 +/- 0.6 cm. Five patients (15.6%) received a blood transfusion.

RESULTS

Major complications included coloanal anastomotic leakage (three); pelvic abscess (three), and coloanal stenosis (two). Tumor stages were as follows: T0-2,N0,M0 = 12; T3,N0,M0 = 9; T1-3,N+,M0 = 9, and T1-3,N0-3,M+ = 2. Diverting stomas were closed in 30 patients. Median follow-up was 25 months. Recurrences occurred in four patients and were local and distant (n = 1) and distant (n = 3). Anal sphincter function was perfect (n = 20), incontinent to gas (n = 3), occasional minor leak (n = 2), frequent major soiling (n = 3), and colostomy (n = 2).

CONCLUSIONS

In patients with locally advanced rectal cancer located 3-6 cm from anal verge who are traditionally treated with abdominoperineal resection, preservation of anal sphincter after preoperative chemoradiation therapy plus complete rectal excision with coloanal anastomosis is feasible and is associated with acceptable morbidity and no mortality.

[Multivariate analysis of risk factors associated with dehiscence of colorectal anastomosis after anterior or lower anterior resection for sigmoid or rectal cancer]

INTRODUCTION

Clinical anastomotic leakage remains a major problem after anterior or low anterior resection for rectal or sigmoid cancer.

OBJECTIVE

To analyze risk factors associated with this complication.

MATERIAL AND METHODS

From January 1992 to December 2000, 232 anterior or low anterior resections were performed. An univariate and multivariate analysis were performed as to find the risk factors.

RESULTS

There were 122 females and 110 males, mean age was 58.5 +/- 14.1. Tumors were located as follows: low third (n = 10), middle third (n = 104), upper third (n = 52) and sigmoid (n = 66). Ninety-two patients received preoperative radiotherapy +/- chemotherapy. Twenty-six (11.6%) had diabetes mellitus, 52 (22.4%) hypertension and 31 (13.4%) mixed cardiopathy. Forty-six patients (19.8%) had > 90% of tumor obstruction. Mean levels of serum albumin and lymphocytes were 3.7 +/- .62 g/L y de 2,026 +/- 1,576/mm3, respectively. Tumors mean distance from the anal verge was 10.2 +/- 6.7 cm. Colorectal anastomoses were performed with the following techniques: double stapled (n = 92), single stapled (n = 85) and manual (n = 55). Multivisceral resection was performed in 29 patients (12.5%); a diverting colostomy was performed in 54 patients (23.2%). Mean intraoperative haemorrhage was 505.3 +/- 393.5 mL. Mean operative time was 267.4 +/- 83 min. Sixty patients (27.2%) received blood transfusion. Mean tumor size was 4.8 +/- 2.6 cm. Tumor stage was as follows: T0-, T2, N0 (n = 60), T3, T4, N0 (n = 103), any T, N+ (n = 55) y T3-4, N+, M+ (n = 14). Nineteen patients (8.1%) developed clinical anastomotic leakage. No operative mortality was observed. Adverse risk factors for clinical anastomotic leakage were: gender (male), preoperative albumin levels < 3 g/L, preoperative tumor obstruction (> 90%) and distance of the anastomosis from the anal verge (< 7 cm).

CONCLUSIONS

In patients with these adverse risk factors a diverting colostomy or ileostomy should be performed, as to avoid fecal peritonitis.

Multivisceral resection for colon cancer

BACKGROUND

There is a lack of appropriate information in regard to the optimal treatment for colon cancer infiltrating neighboring organs.

OBJECTIVES

The objective of this study is to analyze treatment results and to identify the risk factors of death by cancer in these patients.

METHODS

A retrospective analysis of 40 patients with colon cancer infiltrating neighboring organs without distant metastases was carried out. Patterns of recurrence and 5-year survival were analyzed.

RESULTS

The study included 20 males and 20 females with a median age of 51.5 years. Primary tumor location was as follows: right colon (n = 15); transverse colon (n = 5); left colon (n = 7), and sigmoid (n = 13). In 17 patients, the colon tumor infiltrated the abdominal wall alone or together with neighboring organs and in 23 patients, one or more neighboring organs were infiltrated. Eleven patients (27.5%) developed postoperative complications. Two patients (5%) died during the postoperative period. Microscopic tumor infiltration was demonstrated in 29 patients (72.5%). Tumor stage was as follows: T3,N0 (n = 8); T3,N+ (n = 3); T4,N0 (n = 16), and T4,N+ (n = 13). Overall 5-year survival was 45%. Multivariate analysis shows that the unfavorable risk factors for 5-year survival were neoplastic cell infiltration to neighboring organs, age > 50 years, and lymph node metastases.

CONCLUSIONS

The main risk factors for cancer-related failure are neoplastic infiltration to neighboring organs, age > 50 years, and lymph node metastases. In T4 colon cancer, the recurrence pattern was found at local, peritoneal, and distant sites.

Formalin instillation for refractory radiation-induced hemorrhagic proctitis

BACKGROUND AND OBJECTIVES

Radiation proctitis is a common complication after pelvic irradiation. One to five percent of these patients will develop intractable or massive hemorrhagic radiation proctitis that will require repeated hospital admissions and blood transfusions. We evaluated the benefits of instillation of 4% formalin in the management of refractory hemorrhagic radiation-induced proctitis.

METHODS

From January 1998 to May 1999, 20 female patients who failed with administration of topical steroids and/or mesalazine were treated with 500 ml of 4% formalin instilled into the rectum in 50-ml aliquots.

RESULTS

Median age was 58 years. Eighteen patients had cervical cancer and two, endometrial cancer. These patients received a mean of 7,500 rads to the pelvis. The symptoms began at a mean of 8 months after termination of radiotherapy. Median time of symptomatic rectal hemorrhage was 8 months. Median of blood units previously transfused was six (range: 2-11). Hemorrhage immediately ceased after the 4% formalin instillation in 17 patients. Three patients required formalin instillation repetition with success in one. Overall success was 90%. Median follow-up was 20 months. Five patients had moderate pelvic pain after instillation and one developed rectosigmoideal necrosis that required resection plus Hartmann procedure. Two patients developed rectovaginal fistula and required colostomy, and one thereafter, required abdominoperineal resection en bloc with the posterior wall of the vagina due to pelvis sepsis.

CONCLUSIONS

Rectal instillation of 4% formalin is a simple, inexpensive, and efficient treatment for refractory hemorrhagic radiation proctitis.

[Usefulness of scintigraphy images with 111In-CYT-103 in the diagnosis of colonic and rectal recurrence]

OBJECTIVE

To determine the effectiveness of radioimmunoscintigraphy (RIC) with 111In-CYT-103 in detecting the extension of malignant disease in patients surgically treated for colorectal adenocarcinoma under suspicion of recurrence in comparison to CT scan (computed tomography) and exploratory laparotomy.

DESIGN

Prospective and observational study.

MATERIAL AND METHODS

A total of 26 patients under suspicion of recurrence, with a total of 31 lesions. All the patients had performed the following studies with GT, RIC with 111In-CYT-103, exploratory laparotomy and histopathology.

RESULTS

A sensitivity of 96.8%, and specificity of 77.8%, and accuracy of 92% were found for the RIC. CT scan had a sensitivity, specificity and accuracy of 71.5%, 88.8%, and 75.7%, respectively in extrahepatic lesions. When both methods are combined, results shows an increment in sensitivity. Hepatic lesions were present in 50% of the patients; a sensitivity of 85%, a specificity of 92%, and accuracy of 89% for RIC and sensitivity, specificity and accuracy of 92% for the CT.

CONCLUSION

The results of clinical studies with 111In-CYT-103 in detecting the occurrence of colorectal carcinoma provided additional information, making this method a valuable complementary test that contributes to patient management.

Morbidity and mortality following abdominoperineal resection for low rectal adenocarcinoma

BACKGROUND

Abdominoperineal resection (APR) has been the standard treatment of low rectal cancer, but it is associated with significant morbidity and mortality.

AIM

To analyze the morbidity and mortality rates associated with this surgical procedure performed at a tertiary-level cancer center.

MATERIALS AND METHODS

From 1995-1999, 137 patients with rectal cancer located between 0 and 8 cm from the anal verge underwent APR. Covariates were analyzed mean chi 2 and those favorable or adverse covariates affecting the perineal infection and recurrences were analyzed by logistic regression analysis.

RESULTS

There were 78 males and 59 females, with a mean age of 57.4 +/- 14.6 years. Mean intraoperative hemorrhage was 739 +/- 547 mL; 51 (37.2%) patients received blood transfusion. Seventy-two patients received preoperative radiotherapy (PRT): 22, postoperative chemo-radiation therapy; 21, PRT + chemotherapy, and 22, APR only. Seventeen patients (12.4%) had major complications and 47 (34.3%) had minor complications. Twenty patients (14.6%) developed perineal wound infection. The main factors influencing these complications were administration of PRT +/- chemotherapy and age over 55 years. Operative mortality was 0.7%. Median follow-up was 32 months. Twelve patients (8.8%) had local recurrence and 35 (25.7%) had distant recurrence. Overall five-year survival was 75%.

CONCLUSIONS

APR is a surgical procedure associated with significant morbidity but low postoperative surgical mortality. The main cause of morbidity was perineal would infection influenced by administration of PRT +/- chemotherapy and age over 55 years. However, this treatment association is linked with low rate of local recurrence.

Preoperative chemoradiation therapy and anal sphincter preservation with locally advanced rectal adenocarcinoma

Preoperative irradiation has been used to produce tumor regression and allow complete resection of rectal cancer with a sphincter-saving procedure. To evaluate the associated toxicity, the response in the primary tumor, and the postsurgical morbidity in a group of patients with locally advanced rectal cancer treated with preoperative chemoradiation therapy and low anterior resection, 120 patients were treated with 45 Gy of preoperative radiotherapy and a bolus infusion of 5-fluorouracil 450 mg/m2 on days 1 to 5 and 28 to 32 of radiotherapy. Four to six weeks later, 16 lesions were found unresectable; 36 patients underwent abdominoperineal resection or pelvic exenteration, and in the remaining 68 a low anterior resection was performed. For the purpose of this study only the latter group was included. There were 38 men and 30 women, with a mean age of 54.7 +/- 13.1 years. Gastrointestinal and hematologic acute toxicity grade 3 to 4 occurred in 12 and 7 patients, respectively. The mean distance of the tumor above the anal verge was 8.2 +/- 2.6 cm. In 10 patients the surgical resection included neighboring pelvic organs; 16 patients (23.5%) required a temporary diverting colostomy. The main causes of surgical morbidity were clinical anastomotic leakage in seven (10%), abdominal wall infection in five (7.4%), anastomotic stenosis in three (4.5%), and intraabdominal abscess in one (1.5%). No operative deaths occurred. The postsurgical stages were as follows: no tumor in the specimen, 17 (25%); T1, 4 (6%); T2, 12 (17%); T3, 17 (25%); T4, 5 (7%); any T with N+, 9 (13%); and any T, N with M+, 4 (6%). The median and mean follow-ups were 30.0 months and 37.4 +/- 25.0 months, respectively. The local recurrence rate was 2.9%, and the distant recurrence rate was 17%. The administration of preoperative chemoradiation therapy for locally advanced rectal cancer is associated with tolerable toxicity, a high rate of response in the primary tumor that allowed anal sphincter preservation, and a low rate of local recurrence.

Specific c-K-ras gene mutations as a tumor-response marker in locally advanced rectal cancer treated with preoperative chemoradiotherapy

BACKGROUND

Forty percent of patients with colorectal cancer develop mutations in the K-ras gene.

OBJECTIVE

Our objective was to evaluate whether the presence of c-K-ras gene mutations is a useful tumor-response marker in patients with locally advanced rectal cancer treated with preoperative chemoradiotherapy.

MATERIAL AND METHODS

Thirty seven patients with locally advanced rectal cancer were treated with preoperative chemoradiotherapy. Four to six weeks later, surgery was performed. Specimens were classified according to the UICC-AJC classification. A segment of the tumor was obtained to analyze specific c-K-ras gene mutations. Restriction fragment length polymorphism (RFLP) and single strand confirmation polymorphism (SSCP) techniques were used with a set of probes to detect specific c-K-ras mutations in codons 12, 13, and 61. The 37 patients were divided into Group A (with mutations) and Group B (without mutations).

RESULTS

All 37 patients completed the scheduled treatment. Group A consisted of 12 patients, whose tumors were classified and specific c-K-ras mutations were located as follows: eight in codon 12, two in codon 13, and one in codon 61. Group B consisted of 25 patients. The tumors were classified and there were more early-stage tumors in Group A, whereas in Group B there were more advanced-stage tumors (P = .05, respectively). The mean follow-up was 36.2+/-18.3 months. All Group A patients survived, whereas 8 of the 25 patients in Group B died due to progressive metastatic disease. Survival in Group A was 100%, whereas in Group B it was 59% (P = .03).

CONCLUSIONS

The presence of specific c-K-ras mutations is an indicator of tumor response in patients with locally advanced rectal cancer treated with preoperative chemoradiotherapy and surgery. Therefore, responding patients may be more amenable to less radical surgical procedures based on c-K-ras mutations.

[Cystic lymphangioma of the mesentery. Clinical, radiological, and morphological analysis]

BACKGROUND

The cystic mesenteric lymphangioma is a rare benign neoplasia, that can be misdiagnosed with others cystic intra-abdominal tumors.

AIM

To shown the clinical and histopathological features of a cystic mesenteric lymphangioma.

MATERIAL AND METHODS

A 17-year old male with a past history of 17 days of right lower abdominal pain, palpable mass, fever, nausea and vomitus. The initial clinical diagnosis was appendicitis, during the appendectomy a mesenteric tumor was found. The patient was then sent to a third level cancer center for further diagnosis and treatment. In an abdominal CT scan a multicystic retroperitoneal tumor was found and diagnosed as a cystic pancreatic tumor. At midline exploratory celiotomy a cystic tumor infiltrating the right colon mesenterium, duodenum, proximal jejunum, and pancreas head was found. A pancreatoduodenectomy in bloc with right hemicolectomy was performed. During the postoperative period the patient developed cholestasis due to endovenous parenteral nutritional support that improved when it was suspended. The patient was discharged without complications at the 15th postoperative day. The histopathologic diagnosis was cystic mesenteric lymphangioma. At 12 months of follow-up the patient is healthy.

CONCLUSION

The cystic mesenteric lymphangioma is a rare benign tumor and its diagnosis should be included in the differential diagnosis of cystic intra-abdominal neoplasias. Due to the tumor's location, as in the current patient, the surgeon should plan the appropriate surgery as to avoid morbidity, since the objective of such treatment is curative.

Prognostic factors in patients with locally advanced rectal adenocarcinoma treated with preoperative radiotherapy and surgery

Preoperative radiation therapy (PRT) prior to potential curative resection for rectal adenocarcinoma is not widely accepted. This report evaluates the prognostic factors affecting local recurrence and 5-year survival. This is a retrospective study of 214 patients with primary rectal adenocarcinoma treated from January 1986 to December 1994. A PRT dosage of 45 Gy in 20 fractions was administered to patients with clinically tethered or fixed tumors, and 4 to 8 weeks later surgery was performed (group I). Patients with clinically mobile tumors were treated by surgery alone (group II). There were 130 men and 84 women. The median age was 58 years (range 19-85 years). There were 111 patients in group I: 7 patients had no microscopic residual tumor, 80 had Dukes' A and B, and 24 had Dukes' C. There were 103 patients in group II: 70 patients were classified as Dukes' A and B and 33 as Dukes' C. The mean follow-up of the entire cohort was 62 months (range 2-132 months). Local recurrence was seen in 17% of patients in group I and 35% in group II (p = 0.002). Distant recurrence in patients with metastatic lymph nodes was seen in 79% of group I and in 34% of group II (p = 0.001). The favorable prognostic factors for local control were the administration of PRT and well differentiated cancer. The favorable prognostic factors for survival were age < 50 years and the absence of lymph node metastasis. The administration of PRT diminishes the risk of local recurrence. The presence of metastatic lymph nodes in the postirradiated specimen is an ominous prognostic factor for survival. Therefore such patients should be considered for adjuvant chemotherapy.

The influence of pre-operative radiation therapy on the patterns of recurrence in rectal adenocarcinoma

From January 1976 to December 1994, we evaluated the institutional experience of local recurrence and survival in patients with rectal adenocarcinoma treated with pre-operative radiation therapy (PRT) as compared to those treated with radical surgery alone. There were 412 patients, divided into two groups: 259 patients (142 males and 117 females) in Group I and 153 patients (88 males and 65 females) in Group II. The median age was 56 years. Group I patients with locally advanced tumors, either tethered or fixed, received PRT at doses of 45 Gy delivered to the pelvis in two fields; 4 to 8 weeks later, radical surgery was performed. Patients with mobile tumors underwent radical surgery only (Group II). The operative mortality was 4.6% in Group I as compared to 1.9% in Group II (P = 0.18). At median follow-up of 89 months, there were local recurrences in 12.9% of Group I as compared to 36.2% in Group II (P = 0.0000001). The administration of PRT was associated with a low rate of local recurrence, but this improvement corresponded with a high morbidity rate, especially in patients who underwent abdominoperineal resection or pelvic exenteration.

The surgeon as prognostic factor for local recurrence and survival in the anal sphincter preservation for mid-rectal cancer

BACKGROUND

The prognostic factors in rectal adenocarcinoma are influenced by the tumor stage. However, it is important to evaluate the role of the surgeon as part of the prognostic factors affecting local recurrence and survival rates in a group of patients with mid-rectal cancer treated with low anterior resection at a cancer referral center, and those treated at general hospitals.

MATERIALS AND METHODS

Eighty-two patients with mid rectal adenocarcinoma stage II and III who underwent low anterior resection from January 1980 to December 1995, were retrospectively analyzed. Forty-two patients were treated at a cancer center (Group I) and 40 patients were treated at general hospitals (Group II). Cox regression analysis for local recurrence and survival was performed.

RESULTS

There were 42 males and 40 females with a mean age of 55.8 +/- 14.9 years. No differences were found between both groups in terms of the following: age; gender; stage; grade of differentiation; number of positive lymph nodes; infiltration of neighboring organs, and administration of adjuvant chemoradiation therapy (POST RT). However, significant differences in the number of studied lymph nodes per specimen and follow-up were found. The median follow-up for the entire group was 49 months. Local recurrence occurred in 9.5% of patients in Group I vs. 50% in Group II (p = 0.0001). The 5-year survival in Group I was 63% vs. 54% in Group II (p = 0.04). The favorable prognostic factors for local recurrence and survival were: surgical treatment at a cancer center, and no lymph node metastases.

CONCLUSION

The prognostic factors for local recurrence and survival depends mainly on the surgeon and on the post-surgical tumor stage.

Inguinal lymph node metastases from rectal adenocarcinoma

BACKGROUND AND OBJECTIVES

The prognosis of patients with inguinal lymph node metastases from rectal adenocarcinoma is poor. The purpose of this study is to analyze the clinical behavior and response to different therapies in a group of these patients.

MATERIALS AND METHODS

The medical records of 32 patients with inguinal lymph node metastases from rectal adenocarcinoma, diagnosed between January 1985 and December 1996, were retrospectively analyzed. The cohort was divided into: Group A (synchronous), and Group B (metachronous), according to the time of diagnosis.

RESULTS

There were 17 males and 15 females, with a mean age of 53.5+/-13.8 years. Bilateral inguinal lymph node metastases were diagnosed in 17 patients, and unilateral in 15 patients. Fourteen of 18 patients in Group A (78%) and 13 of 14 patients (93%) in group B, respectively, had concomitantly extrapelvic metastatic disease. Seventeen patients in Group A treated with colostomy + chemoradiotherapy (45 Gy/20 fractions to the pelvis and groin area + 5-fluorouracil 450 mg/m2/weekly) had a progressive metastatic disease; the remaining patient was lost to follow-up after an abdominoperineal resection plus superficial groin dissection. Median survival was 8 months (range, 4-30 months). Overall 5-year survival was 0%. Ten patients in Group B were treated with chemoradiotherapy (50 Gy/25 fractions + 5-fluorouracil 450 mg/m2 + leucovorin 30 mg/m2); three patients received supportive care only, and one patient was treated with a groin dissection. All of them died of disseminated metastatic disease at a median of 13 months (range, 6-57 months). Overall 5-year survival was 0%.

CONCLUSION

The presence of inguinal metastases in patients with rectal cancer heralds systemic disease and, due to a poor response to the different therapies, only palliative treatment should be indicated.

[Treatment of anastomotic leakage following low anterior resection for rectal adenocarcinoma]

BACKGROUND

The most important complication after low anterior resection for rectal cancer is the anastomotic leakage. Its frequency ranges between 0%-17% and, it's associated mortality ranges between 0%-25%.

OBJECTIVE

To analyze the treatment results of the above mentioned complication.

MATERIAL AND METHODS

Between January 1990 and July 1998, 176 patients with rectal cancer underwent low anterior resection. 13 (7.3%) of them developed anastomotic leakage. The results of the treatment due to, this surgical complication were analyzed.

RESULTS

There were 9 males and 4 females with a mean age of 64.3 years. Seven of these patients received preoperative radiotherapy. The tumor mean size was 5.5 cm. The tumor and distance of the anastomoses were located at a mean distance of 8 cm and 5 cm respectively, above the anal verge. All patients presented one or more of the following symptoms: increase of drainage (n = 10); prolonged ileus and abdominal pain (n = 9), fever and leucocytosis (n = 8). The surgical treatments were: drainage of abdominal or pelvic cavity (n = 11); loop transversostomy (n = 9); end colostomy, and Hartmann's procedure (n = 3). One patient received only enteral nutrition. In eight patients, the surgical treatment was performed during the first 24 hours of the initial symptoms and in four after 24 hours. The mean hospital stay in the former groups was 9.2 days vs 26.8 days of the later group (p = 0.02). No mortality was observed.

CONCLUSION

The early diagnosis of the following symptoms: drainage increase; prolonged ileus; postoperative abdominal pain; fever, and leucocytosis after low anterior resection, should guide us to the diagnosis of anastomotic leakage and therefore, to initiate surgical treatment during the first 24 hours as to avoid major morbidity and mortality.

Colorectal sarcoma: analysis of failure patterns

BACKGROUND AND OBJECTIVES

Colorectal sarcomas (CRS) are rare and their treatment remains controversial, especially for those located in the rectum. The aim of this paper is to evaluate our experience, with special emphasis on the failure pattern after surgical therapy alone or combined with postoperative radiotherapy.

MATERIALS AND METHODS

The medical records and histological slides of 13 CRS patients treated between 1986 and 1996 were reviewed retrospectively.

RESULTS

The patients included eight males and five females, with a median age of 54 years; nine of their primary tumors were located in the rectum, and four in the colon. The histologies were leiomyosarcoma in nine cases and malignant fibrous histiocytoma in four cases. Surgical treatment consisted of anatomical colectomy (four); local excision (three); abdominoperineal resection (APR)(two); low anterior resection (LAR)(two); LAR en bloc with the prostate (one), and total pelvic exenteration (one). One operative death occurred. The median size of the tumors was 8 cm (range, 5-40). The tumors were graded as low, three, and high, ten. The median follow-up was 24 months. Eight patients in the overall group developed recurrences as follows: local, three; local and distant, three, and distant, two. Five out of nine patients with rectal sarcoma received adjuvant postoperative radiotherapy (PRT). Local recurrence occurred in 20% (1/5) of those who received PRT, and in 100% (3/3) of those who did not. The overall 5-year survival was 40%, and the 5-year survival for patients with low-grade tumors was 66%, as compared with 22% for those with high-grade tumors.

CONCLUSIONS

The patterns of failure in CRS are combined in both local and distant sites. However, our results suggest that in rectal sarcoma, the use of surgery + PRT may reduce the local recurrence rate; in selected patients, it may allow for anal sphincter preservation.

[Rapunzel's syndrome (trichobezoar)]

The Rapunzel syndrome is uncommon, only 6 cases have been previously reported. Its characteristics are: 1) the body of a trichobezoar located in the stomach, and its tail in the small bowel and/or in the right colon, 2) small or large bowel obstruction, 3) occurring in psychiatric patients and, 4) trichophagia. We have added an additional patient, who was submitted to our hospital with diagnosis of abdominal mass, who, during his work-up was found with the above mentioned characteristics. The patient underwent a exploratory celiotomy, gastrotomy, and the trichobezoar was removed. The pathogenesis and current treatment are reviewed.

[Colorectal cancer]

OBJECTIVE

To describe the multistep carcinogenesis of the colon and rectum, and updated in the screening diagnosis and treatment of colorectal cancer.

BACKGROUND

Colorectal cancer is one of the most frequent malignant neoplasia in developing countries. In Mexico, is the second malignant neoplasia of the gastrointestinal tract.

MATERIAL AND METHODS

A literature search was performed to known the usefulness of screening, diagnosis and treatment procedures. Also, some of our actual proceedings are described.

RESULTS

No impact in decreasing the mortality rate for colorectal cancer, has been observed with the contemporary screening programs in low risk population. The recommended treatment for colorectal cancer in early stages (Dukes A and B1) is the surgical resection alone. In those patients with colon metastasizing to the lymph nodes (Dukes C), a combination of surgery + chemotherapy is recommended. In patients with rectal cancer with full penetration until the perirectal fat or with lymph node metastasis (Dukes B2 and C) a combination of surgery, chemotherapy and radiotherapy is the elective treatment. Until today, is controversial if radiotherapy should be used pre- or postoperatively.

CONCLUSION

The colorectal carcinogenesis included a multistep where are involved a tumor suppressor genes and oncogenes. Surgery is the accepted treatment for early colorectal cancer. A combination of surgery + chemotherapy +/- radiotherapy is the elective treatment for locally advanced colorectal cancer.

[Associated clinical features in 41 patients with anal epidermoid carcinoma, studied at a cancer center]

OBJECTIVE

To investigate the main associated clinical characteristics in a group of patients with squamous cell carcinoma of the anus.

BACKGROUND

Anal carcinoma is associated with sexually transmitted viral carcinogenesis.

MATERIAL AND METHODS

We analyzed the charts of patients with squamous cell carcinoma of the anus treated during 1994 and 1995. Demographic characteristics, presence of HIV-1, sexual behavior and the presence of anal warts were analyzed.

RESULTS

There were 41 patients, 26 females and 15 males with a mean age of 61 and 45 years respectively. Twenty-three patients (56%) had history of anal intercourse, 17 (41%) had anal warts and 12 (29%) were HIV-1 (+). This factors were observed more frequently in the male population (p < 0.001). The patients who had anal intercourse had more frequently anal warts and HIV-1(+) compared with those who did not (p < 0.001 in both). The HIV-1 (+) patients had more frequently anal intercourse and anal warts than those HIV-1(-) (p < 0.001 in both).

CONCLUSION

1) male population develop squamous cell carcinoma of the anus earlier than female population, 2) there is a high incidence of homosexuality, anal warts and HIV-1(+) in the male population; these findings suggest different mechanism of carcinogenesis in both gender.

[Proctocolectomy with ileoanal anastomosis: morbidity and functional results in patients with and without colorectal cancer]

BACKGROUND

The elective prophylaxis for colorectal cancer in patients with familial adenomatous polyposis (FAP) or with ulcerative colitis (UC) is the RPIPAA.

AIMS

To evaluate the functional results and the morbidity rate in patients who underwent restorative proctocolectomy with ileal-pouch anal anastomosis (RPIPAA).

METHODS

All patient underwent a proctocolectomy with a J reservoir, ileal pouch-anal anastomosis.

RESULTS

There were 8 males and 3 females with a mean age of 31 years; the diagnoses were: FAP (n = 4); FAP + colorectal cancer (n = 3); metachronous colorectal cancer (n = 3) and UC + right colon cancer (n = 1). The average surgical time and the intraoperative bleeding were 5.6 h and 600 ml respectively. There were no operative deaths. The surgical complications were: section of left urether (n = 1); hemoperitoneum of 1,200 ml (n = 1); minor pelvic sepsis (n = 1); ileoanal stenosis (n = 1) and pouchitis (n = 1). Tumor staging was: Dukes A (n = 2), B1 (n = 1), B2 (n = 4). The mean follow-up was 22 months. Average of stools at the 3rd, 6th and 12th month was: 7.4, 5.6 and 3.8 respectively. Sexual function was: normal (n = 8), retrograde ejaculation (n = 2) and impotence (n = 1). The use of antidiarrheal agents in 24 hours at the third, sixth and twelfth month was 3, 2 and .8 respectively.

CONCLUSIONS

The RPIPAA is associated with a low rate of morbidity and good functional results, similar to previously published results. However, these results should be taken with caution due to the small, selected and retrospective nature of the study.

[The mechanisms of the dissemination and the treatment of ovarian metastases in colonic adenocarcinoma]

OBJECTIVE

The aims of this study are: 1) To known the frequency of ovarian metastasis, 2) to define the role of the surgical therapy and 3) to establish the mechanism of spread of colorectal cancer to the ovaries.

MATERIAL AND METHODS

Between 1989 and 1993 624 patients with colorectal adenocarcinoma; were treated, 19 (7.7%) had ovarian metastasis; they were divided in 2 groups according to the diagnostic time: A) synchronous; B) metachronous. In most patients a peritoneal lavage were performed; the primary tumor was resected.

RESULTS

The median age was 41.4 years. In group A: there were 9 patients; in 3 of them underwent elective surgery and in 6 an exploratory celiotomy due to colonic obstruction or perforation. The primary tumor was located in the sigmoid in 8 patients and in cecum in 1; the stage of the primary tumor was follows: B1, 2; B2, 3; C2, 4. The ovarian metastasis were located in the left ovary in 6; right, 2, and bilateral 1. The peritoneal lavage was positive in 6, and negative in 3. In group B: there were 10 patients; one underwent elective surgery and 9 exploratory celiotomy. The primary tumor was located in the sigmoid in 9, caecum in 1. The stage of the primary tumors were: B2, 4; C2 4; D, 2. The ovarian metastasis were located: left, 5; right, 1; bilateral, 4. The peritoneal lavage was positive in 6, negative in 2. The 5-year survival in group A was 16% in group B, 0%.

CONCLUSION

Ovarian metastasis were associated with advanced metastatic diseases. The treatment of synchronous ovarian metastasis is the resection of primary tumor plus bilateral oophorectomy, and in metachronous metastasis it is palliative. The mechanism of spread to the ovaries is by direct implantation and hematogenous.

[The role of radical surgery in the treatment of epidermoid carcinoma of the anal canal]

In order to define the role of radical surgery in the actual treatment of epidermoid carcinoma of the anal canal (ECAC), we retrospectively reviewed the charts of patients with primary ECAC, treated with radical surgery in the Hospital de Oncología, National Medical Center IMSS. We analyzed the recurrence pattern, its treatment and the contemporary literature was reviewed. From 1975 to 1990, we treated 16 patients; 13 females, 3 males, mean age was 64 years. The presurgical stage was T2, 6; T3 7; T4, 3. An abdominoperineal resection was performed in 12 patients; a posterior pelvic exenteration in 3; a total pelvic exenteration in 1. Ten patients developed surgical complications, 4 of them were major, 2 required surgical reintervention. There was no operative mortality. We obtained local tumor control in 5/16 patients (32%); the local recurrence by stage were T2, 3/6 (50%); T3, 5/7 (71%); T4, 3/3 (100%) p = 0.04. Ten of them were located at the pelvis brim and 1 was located to the central pelvis (vagina, perineum), 9 were treated with radiation therapy (RT) a mean dose of 45 Gy, only the patient with central local recurrence obtained local tumor control. Regional recurrences were as follows: T2 patients, 1/6 (16%); T3, 2/7 (28%); T4, 2/3 (66%). The 2 patients with metachronous inguinal lymph node metastases were treated with a radical groin dissection, with tumor control. In conclusion, the radical surgical treatment is associated with a low loco-regional tumor control; the pelvic tumor relapses were located at the pelvis brim and with no response to RT. With the results herein obtained and the results with other treatment modalities such as RT and its associations with chemotherapy (C) in regard to local tumor control, the actual role of the radical surgical treatment in the salvage of central pelvic relapses to primary treatment with RT or C-RT.