Preoperative versus postoperative 5 FU-based chemoradiation in the management of resectable rectal carcinoma

Forty-eight patients with resectable rectal carcinoma [stages II and III] were randomized to receive either preoperative concomitant 2 cycles of 5-FU/LV and pelvic radiation followed 4-6 weeks later by surgery then additional 4 cycles of the same chemotherapy [group A = 23 patients] or the standard surgical procedure to be followed by 6 cycles of 5-FU/LV and concomitant pelvic irradiation during cycle 3 and 4 [group B = 25 patients]. In preoperative group, objective response was seen in 47.8% of patients 4 weeks after chemoradiation. The remaining patients had stable disease. Ten patients [43.5%] and 16 patients [64%] in preoperative group and postoperative group, respectively, underwent abdominoperineal resection [APR]; while 13 patients [56.5%] in preoperative group and 9 patients [36%] in postoperative group underwent sphincter saving surgery. Seven out of 17 patients [41%] in preoperative group who were initially candidates for APR saved their anal sphincter after preoperative chemoradiation, 85.7% of these patients had excellent to good sphincter function. No pathologic complete response had been recorded. Hematologic grade 3+ toxicity was recorded in 17.4% of patients in preoperative group and in 28% in postoperative group. Grade 3+ diarrhea was recorded in 17.4% in preoperative group and in 20% of patients in postoperative group. The differences were not statistically significant. Eight patients [34.8%] in preoperative group and 9 patients [36%] in postoperative group had one or more components of failure. The difference was not statistically significant. The 2-year overall survival was 69.6% in preoperative group and 72% in postoperative group. The 2-year disease free survival was 65.2% in preoperative group and 64% in postoperative group. The differences in survival and disease free survival between the two groups were not statistically significant. The study concluded that treatment with preoperative combined modality therapy, followed by surgery and postoperative chemotherapy in resectable rectal carcinoma is an attractive alternative to the standard postoperative combined modality therapy. The local control, survival rates and toxicity are comparable to postoperative combined modality therapy. Preoperative chemoradiation offers an additional potential advantage of sphincter preservation. This work needs to be confirmed on a larger number of patients with longer follow up

Occult malignancy in patients with idiopathic deep venous thrombosis

The relationship between deep venous thrombosis [DVT] and malignancy has long been recognized and documented, patients diagnosed with malignancy are clearly at risk for the development of venous thromboembolism and conversely some patients with deep venous thrombosis have subsequently been discovered to harbor an occult malignancy. This is a prospective study of 51 DVT patients who presented to Ain Shams University Hospitals between January 1997 and December 2000. These patients were chosen out of 188 DVT cases because of absence of any major thrombotic risk factor, their ages were over 40 years, and non were previously diagnosed with any form of malignancy. All patients were screened for any signs of occult cancer, which included careful history taking, thorough physical examination, laboratory screening including tumor markers, and abdominal ultrasonographic examinations. After the first level of screening; suspicious cases were subjected to the second level of specific laboratory, radiological, or endoscopic tests to reach a final diagnosis. Malignant neoplasms were detected in 11 cases [21.5%]. Carcino-embryonic antigen [CEA] and endoscopy were key in diagnosing 2 cases of early colon cancer and 2 cases of adenomatous colonic polypi. Cystoscopy followed by biopsy detected 2 cases of early urinary bladder cancer, and high levels prostate specific antigen, transrectal ultrasound and biopsy were used to diagnose cancer prostate in one patient. Biopsy of palpable axillary and cervical lymph nodes attracted our attention to one case of cancer breast, and one case of non-Hodgkin lymphoma. Oncofeotal proteins and scrotal ultrasound led to diagnosing one case of early testicular tumor. Computerized tomography scans of the abdomen discovered one case of cancer body of the pancreas. The most striking finding was that most of these cases were in the early stages of malignancy. These findings underscore the importance of screening for occult malignancy in idiopathic DVT patients especially in the elderly population and regardless of the cost, since we are sometimes rewarded by finding cancer at an early stage, giving the patient the best chance for survival