A report on the lymph node recovery in rectal cancer resection specimens

The American Joint Committee on Cancer presently recommends obtaining at least seven to 14 lymph nodes in radical colon and rectum resections. OBJECTIVES: 1.) To determine the number of lymph nodes recovered in our rectal cancer resection specimens, and 2.) to compare the number of our lymph node harvest with current international recommendations.METHODS: Records of patients who underwent resection for adenocarcinoma of the rectum from 2001 to 2002 were reviewed. From the final pathology report, the number of lymph nodes recovered per specimen was described. This was correlated with the depth of tumor penetration (T) and the intra-operative staging of nodal status (N) by the surgeon. RESULTS: Forty-seven patients underwent resection for adenocarcinoma of the rectum. Ages of patients ranged from 21 to 74 years, with a mean of 52 years. The lymph nodes recovered from the specimens ranged from zero to 15, with an average of 3.1 nodes per specimen. T4 tumors had the highest average rate of lymph node recovery at four nodes per specimen. In 16 patients, metastasis to regional lymph nodes were identified (16/47 or 34 percent node positive). The range of nodes recovered in node positive patients ranged from one to 15, with an average of six nodes. Thirty-one patients were node negative (31/47 or 66 percent). The average nodes recovered per specimen in this group was 1.8, ranging from zero to 12. SUMMARY: From our review, almost 90 percent of our reports did not meet the minimum standard of recovering at least seven lymph nodes in rectal cancer resection specimens. In 94 percent of node negative patients, no sound therapeutic plans could be made due to inadequate lymph node harvest.

Tumor height from the anal verge before and after complete mobilization of the rectum

Rectal tumor height has been observed to increase after complete mobilization.OBJECTIVES: 1.) to measure tumor height in resectable rectal cancers before and after complete mobilization, 2.) to describe changes in tumor height measurements at different levels of the rectum, and 3.) to determine the probability of a two centimeter increase in tumor height after mobilization in low rectal cancers. METHODS: Prospective cross-sectional series including all resectable rectal cancer treated at our hospital from January to December, 2003. Proctoscopy measurements of rectal tumor height after induction of anesthesia were compared to measurements done after complete rectal mobilization. Logistic curve fitting was used to calculate the probability of a two centimeter increase in tumor height for low rectal cancers after complete mobilization.RESULTS: In the 12-month period, 37 patients with adenocarcinoma of the rectum were seen. Ages of patients ranged from 26 to 86, with mean age of 57.8 years. Thirty-three patients had resectable rectal cancer. Tumor height ranged from zero to 11 cm, with mean height of 5.7 cm. After complete mobilization, tumor height increased in 50 percent of upper rectal cancers, 92 percent of mid-rectal cancers, and 32 percent of low rectal cancers. Logistic curve fitting showed probability of a two-centimeter increase in tumor height was 52 percent at seven centimeters, 40 percent at six centimeters, 28 percent at five centimeters, and 19 percent at four centimeters. DISCUSSION: The decision to perform APR for low rectal cancers must not be based solely in pre-operative tumor height measurements since pre-operative measurements of rectal tumor height can increase when the rectum is completely mobilized.

Colorectal cancer in the young: A five-year review of cases

OBJECTIVES: The objectives of this paper were: 1) to determine the relative frequency of colorectal cancer in the young, and 2) to compare the clinical features of young patients with colorectal cancer to those patients in the older age group.METHODS: A total of 322 colorectal cancer patients (136 colon, 186 rectum) seen and treated by our section from 1995 to 1999 were reviewed.RESULTS: In the five-year period, 32 colon cancer patients (24 percent) and 41 rectal cancer patients (22 percent) were less than 40 years old. The overall frequency of young patients with colorectal cancer was 23 percent. For colon cancer, there was a predominance of right-sided lesions in young patients (69 percent versus 31 percent in the older group). Both groups of patients had advanced disease (chi square, p=0.38). Aggressive histology of cancers was seen in 63 percent of the younger patients and 24 percent of the older patients (chi square, p=0.007). Most of the rectal cancers seen in both groups were distal third lesions (90 percent in young patients and 86 percent in older patients). Both groups of patients presented with advanced disease at the time of surgery (chi square p=0.71). Pathologic examination showed an aggressive tumor type in 30 percent of the young patients and 25 percent in the older group (chi square p=0.72).CONCLUSION: The clinical features that we observed in young colorectal cancer patients were similar to those of earlier reports.

Histopathologic support of the 2 cm distal resection margin for rectal carcinoma

Recent evidence has shown that a five-centimeter distal margin is not required for cancers of the rectum. These findings proved significant in that selected patients with low rectal lesions can be offered curative operations that can preserve normal sphincter function, an intact route of defecation, and have a better quality of life. From August 2000 to July 2001, we began our series of examining specimens after rectal resection to determine the negative distal margin. The specimens for pathologic examination were cut at 0.5 cm intervals up to 2.0 cm from the raised distal edge of the tumor. The objective of this paper is to determine the distance of intramural tumor spread of rectal cancer from the macroscopic tumor edge. During the one-year period, a total of 11 specimens from rectal cancer patients were examined, ages of the patients ranged from 29 to 77 years. Eighty-two percent of patients had locally advanced (T3 and T4) lesions. Lymph node involvement was seen in 72 percent. Analysis of distal margins showed the following: five of 11 (45 percent) were positive for malignant cells at 0.5 cm from the tumor edge, four of 11 (36 percent) positive at 1.0 cm, one of 11 (nine percent) positive at 1.5 cm, and no malignant cells were seen at 2.0 cm distal margin. Our early results support the adequacy of a 2 cm distal resection margin for rectal cancer surgery. (Author)

Application of the TRISS method to evaluate trauma care

The TRISS (Revised Trauma Score and Injury Severity Score) method of trauma care evaluation was applied to 476 consecutive trauma patients admitted to our medical center over a 6-month period. Male to female ratio was 8:1, with a mean age of 24.7 years. Penetrating injury was the most common mechanism of injury (62%), with the chest as the most common region injured (36%). Mean probability of survival of 476 patients was 0.9802 and a predicted mortality of 9.4 patients. The overall mortality was 5.4 per cent with 26 actual deaths. As 93 per cent of patients had injuries to isolated anatomic regions, using the TRISS method, assigning numerical values to noninjured anatomic regions mathematically increased their probability of survival, even though the isolated injury was life-threatening. Consideration should be taken before adapting the TRISS method as the gold standard in evaluating trauma care in the local setting

Injuries to the rectum and anus following radiation therapy in patients with cervical cancer: 5-year experience at the Philippine General Hospital

A five-year review of anorectal complications seen following radiotherapy for cervical carcinoma was done with the following objectives: 1) to present the profile of patients presenting with anorectal complications following radiation treatment for cervical cancer; 2) to describe the manifestations of these complications and findings on proctosigmoidoscopy with biopsy; and 3) to present the approaches in their management. A total of 116 patients, all with confirmed diagnosis of cervical cancer, were seen over this period. Mean age was 49.5 years. All received external beam cobalt and intracavitary radium. Complications were observed from 10 days to 20 months after treatment. Anal bleeding was the most common complaint (62%), followed by rectovaginal fistula (14%). Residual/recurrent malignancy was noted in seven patients (6%). Treatment modalities varied considerably, ranging from conservative and symptomatic treatment for bleeding, pain, constipation, and diarrhea, to major abdominal procedures for rectovaginal fistula

Management of foreign body ingestion beyond the gastroesophageal junction

During a two-year period, the clinical courses of 33 patients with foreign body ingestion beyond the gastroesophageal (GE) junction were reviewed. Mean age was 12.7 years with a male predominance (5:1). Twenty five patients ingested blunt foreign bodies and 8 patients ingested sharp foreign bodies. All of the patients who ingested blunt foreign bodies were managed expectantly, and spontaneous passage of the foreign bodies were noted after an average of 3.8 days. Three of the eight patients who ingested sharp foreign bodies were operated on to extract the foreign bodies: an open safety pin, and a nail and a sewing pin. The decision to operate on the latter two patients were made after repeat x-rays failed to show progression of the location of the foreign bodies. The remaining five patients had spontaneous passage of the ingested sharp foreign bodies. Ingested sharp foreign bodies can be initially managed expectantly with little morbidity and mortality but only in the absence of signs of bowel perforation either presenting initially or during the course of observation. (Author)