Clinical Impact of Tumor Regression Grade after Preoperative Chemoradiation for Locally Advanced Rectal Cancer: Subset Analyses in Lymph Node Negative Patients

BACKGROUND: We investigated the prognostic significance of tumor regression grade (TRG) after preoperative chemoradiation therapy (preop-CRT) for locally advanced rectal cancer especially in the patients without lymph node metastasis. METHODS: One-hundred seventy-eight patients who had cT3/4 tumors were given 5,040 cGy preoperative radiation with 5-fluorouracil/leucovorin chemotherapy. A total mesorectal excision was performed 4-6 weeks after preop-CRT. TRG was defined as follows: grade 1 as no cancer cells remaining; grade 2 as cancer cells outgrown by fibrosis; grade 3 as a minimal presence or absence of regression. The prognostic significance of TRG in comparison with histopathologic staging was analyzed. RESULTS: Seventeen patients (9.6%) showed TRG1. TRG was found to be significantly associated with cancer-specific survival (CSS; P = 0.001) and local recurrence (P = 0.039) in the univariate study, but not in the multivariate analysis. The ypN stage was the strongest prognostic factor in the multivariate analysis. Subgroup analysis revealed TRG to be an independent prognostic factor for the CSS of ypN0 patients (P = 0.031). TRG had a stronger impact on the CSS of ypN (-) patients (P = 0.002) than on that of ypN (+) patients (P = 0.521). In ypT2N0 and ypT3N0, CSS was better for TRG2 than for TRG3 (P = 0.041, P = 0.048), and in ypN (-) and TRG2 tumors, CSS was better for ypT1-2 than for ypT3-4 (P = 0.034). CONCLUSION: TRG was found to be the strongest prognostic factor in patients without lymph node metastasis (ypN0), and different survival was observed according to TRG among patients with a specific histopathologic stage. Thus, TRG may provide an accurate prediction of prognosis and may be used for f tailoring treatment for patients without lymph node metastasis.

Mucinous Histology as a Predictive Marker of 5-Fluorouracil-based Adjuvant Chemotherapy for Colon Cancer

PURPOSE: The aim of this study was to evaluate the value of mucinous histology as a predictive marker of 5-Fluorouracil (FU)-based adjuvant chemotherapy in stage II, III colon cancer. METHODS: Between January 1995 and December 2004, 987 patients who underwent curative resections for stage II, III sporadic colon cancer were classified into two groups, a mucinous carcinoma (MC) group and a non-mucinous carcinoma (NMC) group, based on the histology of the primary tumor. The differences in their clinicopathological characteristics and the prognostic impact of 5-FU-based adjuvant chemotherapy for various tumor histologies were analyzed. RESULTS: Of the 987 patients, MCs accounted for 6.8% (68 patients). MCs were more frequently located in the Rt. Colon (P<0.001) and were more frequently seen in young patients (less than 40 yr old) (P=0.028). The 5-yr survival rates between MC and NMC did not show any statistically significant difference. Patients, including both MC and NMC patients, who received 5-FU-based chemotherapy, revealed a better overall survival rate than patients with no adjuvant chemotherapy. In the multivariate analysis for the prognosis in NMC patients, 5-FU-based adjuvant chemotherapy, initial negative nodal status, and preoperative CEA <5 ng/mL were statistically significant prognostic factors (P values: <0.001, <0.001, and <0.001, respectively). In contrast, there was no statistically independent significance of 5-FU-based adjuvant chemotherapy in MC patients. CONCLUSION: In stage II and stage III sporadic colon cancer patients, response to 5-FU-based adjuvant chemotherapy in MC patients might be poor than it is in NMC patients.

Complication and Relevant Factors after an Ileostomy for Fecal Diversion in a Patient with Rectal Cancer

PURPOSE: The proportion of sphincter-saving operations for lower rectal cancer is increasing with improved surgical techniques and additional concurrent preoperative chemo-radiation therapy. A defunctioning ileostomy or colostomy is performed after a sphincter-saving operation in the belief that diverting the fecal stream will prevent anastomotic leakage. This study was undertaken to assess all morbidity and combined problems associated with a temporary loop ileostomy. METHODS: A total of 167 patients who had undergone an ileostomy after a proctectomy between July 1997 and May 2007 were enrolled in this study. All patients were analyzed retrospectively, and the enrolled patients were registered in the Colorectal Cancer Database and were followed prospectively. Three patients did not receive an ileostomy take-down operation because of tumor recurrence. RESULTS: Complications of ileostomy formation developed in 20 (11.9%) cases. There were no significant relevant factors influencing the complications of ileostomy formation. Complications related with ileostomy take-down developed in 33 (17.9%) cases. Longer operation time, perioperative transfusion, and postoperative radiotherapy were statistically significant factors related to the complications of ileostomy take-down (P=0.047, P=0.019, P=0.042). After ileostomy take-down, six patients were identified with complications, such as a rectovaginal fistula or an anastomotic stenosis, related with rectal cancer surgery. CONCLUSIONS: The useful ileostomy sometimes carries certain morbidity; therefore, an ileostomy should be performed selectively, and the decision should be made with care. Also, a careful evaluation of the distal part of an ileostomy is necessary before and after an ileostomy take-down.

The Influence of Age on Survival and Recurrence after a Curative Surgical Resection for Colon Cancer Patients

PURPOSE: This study was performed to evaluate whether age was a factor associated with oncological outcome for colon cancer patients who underwent a curative surgical resection. METHODS: A retrospective study of 2,125 colon cancer patients who underwent surgery between January 1989 to December 2004 was conducted. RESULTS: Of the 2,125 patients, 1,724 patients underwent a curative resection (R0). The patients with R0 were classified into three groups: group I (n=142) under 40 yr of age, group II (n=1,462) between 40 and 75 yr of age, and group III (n=120) over 75 yr of age. There were no significant differences in gender, tumor diameter, or postoperative complications among the groups. A history of hereditary colon cancer, advanced TNM stage (III, IV), and poorly- differentiated histology were more commonly found in group I. Adjuvant chemotherapy was administered less frequently in group III. In the survival analysis, the cancer-specific survival (CSS) and the disease-free survival (DFS) rates were not different between groups I and II. The CSS and the DFS rates of group III were significantly unfavorable compared with those of groups I and II. On the multivariate analysis, old age (group III), TNM stage, and preoperative CEA level were independent risk factors for CSS and DFS. CONCLUSION: In colon cancer patients, tailored approaches according to age, such as early screening in young adults with family history and proper patients selection for adjuvant treatment in old patients, could be needed.

Intestinal Endometriosis Mimicking Carcinoma of Rectum and Sigmoid Colon: A Report of Five Cases

Among women with intestinal endometriosis, the sigmoid colon and rectum are the most commonly involved areas. Sometimes, the differential diagnosis of colorectal endometriosis from carcinoma of the colon and rectum is difficult due to similar colonoscopic and radiologic findings. From October 2002 to September 2007, we performed five operations with curative intent for rectal and sigmoid colon cancer that revealed intestinal endometriosis. Colonoscopic and radiologic findings were suggestive of carcinoma of rectum and sigmoid colon, such as rectal cancer, sigmoid colon cancer and gastrointestinal stromal tumor (GIST). Anterior resection was performed in two patients, low anterior resection was performed in one patient and laparoscopic low anterior resection was done in two patients. We suggest to consider also intestinal endometriosis in reproductive women presenting with gastrointestinal symptoms and an intestinal mass of unknown origin.

Oncologic Outcomes and Safety after Tumor-specific Mesorectal Excision for Resectable Rectal Cancer: A Single Institution's Experience with 1,276 Patients with Rectal Cancer

PURPOSE: The purpose of this work was to review the oncologic outcomes and the operative safety of a tumor- specific mesorectal excision (TSME) for resectable rectal cancer. The risk factors for recurrence and survival were analyzed, and the changes in the sphincter-preserving rate with time were analyzed. METHODS: A total of 1,276 patients with rectal cancer who underwent curative surgery between 1989 and 2003 were analyzed retrospectively. The enrolled patients were registered in the Colorectal Cancer Database and were followed prospectively. RESULTS: The pathologic stages were stage I in 330 (25.9%), II in 403 (31.6%), and III in 543 (42.6%). Postoperative complications developed in 263 patients (20.6%). The rates of anal sphincter preservation were 32.6% between 1989 and 1993, 56.8% between 1994 and 1998, and 69.4 % between 1999 and 2003. With a mean follow-up of 69.4 months, the overall local recurrence (LR) rate was 5.4%. The 5-year LR rates were 3.8% in stage I, 4.7% in stage II, and 8.4% in stage III (P=0.016). A multivariate analysis revealed that the risk factors affecting LR were pN (0.005) and preoperatively increased serum CEA (P=0.008). The 5-year cancer-specific survival rates were 93.8% in stage I, 84.5% in stage II, and 64.5% in stage III (P=0.021). A multivariate analysis revealed that the factors affecting cancer-specific survival were pN (P=0.012) and circumferential resection margin (P<0.001). CONCLUSIONS: TSME for resectable rectal cancer showed acceptable operative morbidity and excellent oncologic outcomes. The trend toward sphincter preservation was obvious, and the shortening of the distal resection margin without deteriorating the oncologic outcomes was one of the major enabling factors.

Patterns of Recurrence and Prognosis in Patients with Intestinal Behcet's Disease Who Underwent a Bowel Resection

PURPOSE: We aim to analyze the clinical course and the recurrence patterns after surgical treatment in patients with intestinal Behcet's disease and to determine the prognostic factors. METHODS: Thirty-eight patients with intestinal Behcet's disease who had undergone operations between 1979 and 2007 were analyzed. Clinical characteristics between the recurrent group (n=24) and the non-recurrent group (n=14) were compared. The cumulative recurrence rates were calculated by using the Kaplan-Meier method, and the results were compared by using the log-rank test. RESULTS: The median follow-up was 120 months. The median age of the 38 patients was 36.5 years, and the patients included 26 males and 12 females. Recurrences after surgical treatment were observed in 24 patients, and reoperations were performed in 21 patients. The mean age at operation was 35.7 years in the recurrent group and was less than 43.4 years in the non-recurrent group (P=0.030). Clinical subtypes of Behcet's disease (complete or incomplete vs. suspicious) and the cause of operation (presence vs. absence of a perforation or fistula) were different between the recurrent and the non-recurrent groups (P=0.048, P=0.014, respectively). The 5-year cumulative recurrence rate and reoperation rate for all patients with intestinal Behcet's disease who underwent operations were 52.7% and 36.0%, respectively the clinical subtypes and the cause of the operation were significant factors affecting the cumulative recurrence and the reoperation rates. CONCLUSIONS: Intestinal Behcet's disease demonstrates high recurrence and reoperation rates after surgical treatment. More careful follow up is needed to these surgical patients with high risk of recurrence and reoperation.

Curative Resection Following Neoadjuvant Chemotherapy Including a Molecularly Targeted Agent in Patients with Unresectable Colorectal Distant Metastases

PURPOSE: A colorectal carcinoma is the fourth most common malignancy in the world. Unfortunately, only approximately 20% of the liver metastases are resectable at the initial presentation. Neoadjuvant chemotherapy has been used for downsizing in unresectable disease. In addition, the use of newer biologic agents, such as cetuximab and bevacizumab, has much improved responses in patients with unresectable colorectal liver metastases. The aim of this study was to report on patients who had received a curative resection following neoadjuvant chemotherapy including a molecularly targeted agent for unresectable colorectal liver metastases. METHODS: Following the neoadjuvant chemotherapy using cetuximab plus FOLFIRI (irinotecan and infused fluorouracil plus leucovorin) or bevacizumab plus FOLFOX (oxaliplatin and infused fluorouracil plus leucovorin), 10 patients with initially unresectable colorectal liver metastases underwent a curative surgical resection between September 2005 and June 2007. RESULTS: One patient underwent a right lobectomy, three patients a segmentectomy and five a wedge resection with or without radiofrequency ablation. With a median postoperative follow-up of 14 months (range, 1 to 22 months), five recurrences (50%) occurred. The common toxic effects were grade 2/3 skin toxicity (60%), grade 4 hematologic toxicity (20%), grade 3 gastrointestinal toxicity (10%), and grade 3 neurologic toxicity (10%). CONCLUSIONS: Our preliminary data suggests that neoadjuvant chemotherapy including a molecularly targeted agent may improve resectability in patients with initially unresectable colorectal liver metastases although a high recurrence rate exists. Randomized prospective studies comparing neoadjuvant chemotherapy including a targeted agent in cases of unresectable colorectal liver metastases are warranted.

Clinicopathological Features of Retrorectal Tumors in an Adult: A Case Report and Review of the Literatures

Retrorectal tumors are particularly rare among the adult population, occurring in 1 of 40,000 hospital admissions. Clinical diagnosis is difficult and is often delayed because of vague symptoms. This study aimed to investigate the clinicopathological features of retrorectal tumors. Between January 1999 and March 2005, 10 patients were diagnosed with retrorectal tumors at the Department of Surgery, Yonsei University Medical Center, and their medical records were reviewed. We analyzed chief complaints, imaging studies, surgical approaches and pathologic examinations. Out of 10 patients, 8 were female and 2 were male. The mean age was 42.8 years. Four patients had no symptoms. Perianal and abdominal pain were the most common presentations. CT and MRI were the most frequently performed imaging studies. Surgery was performed in 9 patients. Postoperative pathologic diagnosis was possible in 9 patients. An epidermal cyst was the most common tumor (4 patients); others included a mature teratoma, an adenocarcinoma from a tail gut cyst, a duplication cyst, a neurogenic tumor, and a smooth muscle cell tumor. Imaging techniques like CT scans, MRI and TRUS are helpful to determine the size and the extent of a tumor and its relationship to the surrounding anatomical structures for the operative approach. A surgical resection is the standard of treatment and demonstrates good results and a good prognosis.

Clinical Significance of E-cadherin and beta-catenin Complex Expression in T2 Colorectal Cancer

PURPOSE: Expression of adhesion molecules is significantly correlated with the invasion and the metastasis of colorectal cancer. The aim of this study is to identify the importance of the expressions of E-cadherin and beta-catenin as a prognostic factor in T2 colorectal cancer. METHODS: Forty-five cases of primary T2 colorectal cancers were selected between February 1997 and February 2000. We evaluated the membranous expressions of E-cadherin and beta-catenin by using immunohistochemisty and analyzed the relationship with various clinicopathologic parameters. RESULTS: Loss of membranous E-cadherin was significantly associated with histologic differentiation (P=0.023), vascular invasion (P<0.001), lymphatic invasion (P<0.001), and lymph-node metastases (P=0.001). Similar patterns were observed in the expression of beta-catenin. The correlation between the E-cadherin and the beta-catenin expressions was statistically significant (P<0.001). In the multivariate analysis, neither the loss of expression of E-cadherin nor beta-catenin is a risk factor affecting lymph-node metastasis in T2 colorectal cancers. However, there were significant differences in the 5-year disease-free survival rates between the positive (+/-, +) and the negative (-) expression groups of E-cadherin and beta-catenin (P=0.015, 0.03). CONCLUSIONS: This study suggests that loss of membranous expression of E-cadherin and beta-catenin molecules correlates with poor prognostic factors and indicates invasion and metastasis in T2 colorectal cancer, which, therefore, might be predictive of short survival in these patients.

The development of an efficient rat hepatic cirrhosis model

INTRODUCTION: Applying clinical conditions to on experimental animals forto verifverifyingy the mechanism of disease and drug effects is crucial. Cirrhotic livers induced by Hepatitis B virus are frequent, and eEspecially in Korea where a great deal of more liver-related diseases occurs, cirrhotic livers induced by Hepatitis B virus are frequent, and, such viral-induced cirrhosis, and this often impedes other medical treatments. Therefore, creating a proper elucidating properly deriveding cirrhosis method in animal model to simulate the actual pathophysiology of cirrhosis can benefit future researches. AIMS: We wanted toTe testing various hypotheticalsized methods of inducing cirrhosis in animal models, and we wanted the model to have a with higher rate of reproducibility. METHOD: To induce cirrhotic liver, thioacetamide (Sigma, St. Louis, USA) wasis given either freely via oral intaken or it wasand injected into the peritoneal space ofn Sprague-Dawley(SD) rats. The SD rats wereare divided into four groups: the oOral intake gGroup 1 ((N=10, 0.03%, 13 weeks), the oOral intake gGroup 2 (N=20, 0.04%, 30 weeks), the iIntraperitoneal Injected gGroup 1 (N=10, 300mg/kg, 12 weeks (3 times per week for first 2 weeks, 2 times per week for next 10 weeks) and the iIntraperitoneal Injected gGroup 2 (N=20, 300mg/kg, 2 times per week for 16 weeks). The mMortality rate of the tested subjects is recorded, and a visual test of the livers is performed at the end of the experiment, a visual test of the livers is performed. Also, the extracted liver cells that were dyed with Trichrome are compared to evaluate the extent of the liver cirrhosis. RESULT: For theIn oral intake group 1, no loss of occurred until wWeek 13, and 5 of the SD rats (50%) showed signs of liver cirrhosis by the Trichrome dye test. However, the extent of cirrhosis greatly differed betweenfrom each of the subjects. ForIn the oral intakae group 2, no loss occurred until wWeek 30. 20 of the SD rat (100%) in this group possessed a cirrhotic liver. However, the weight of the cirrhoscirrhotic liversis differed from a minimum of 231g to a maximum of 770g. For theIn Injected Group 1, 4 tested subjects (40%) died between wWeeks 3 and 4; however, the rest of them survived and they all revealed a signs of cirrhosis. ForIn the iInjected Group 2, only 3 tested subjects (15%) died, and after wWeek 16, 17 survivors (100%) showed a signs of cirrhosis. CONCLUSION: The short-term oral administration of thioacetamide only induced a minimal amount of cirrhosis;, thus, a longer period of consumption is suggested. Injection of thioacetamide into the peritoneum resulted in higher death rate when thoacetamide wasis injected frequently. Therefore, selecting a proper method to create a cirrhotic liver, with considering the reproducibility, on cirrhotic liver, the survival rate of the experimental animals, and the length of the experiment, isare strongly suggested for creating an animal model of cirrhotic liverfor further experiments.

Factors Influencing Survival after Curative Resection of Pulmonary Metastasis from Colorectal Cancer

PURPOSE: About 10 percent of patients with colorectal cancer develop pulmonary metastases, but selection of patients for resection of lung metastases is difficult problem. This study was performed to identify prognostic factors after resection of pulmonary metastases from colorectal cancer. METHODS: We reviewed retrospectively the clinical course of 64 patients who underwent surgical resection of primary colorectal cancer and metastatic lung disease at the Yonsei University College of Medicine between November 1994 and January 2005. We analyzed the prognostic factors with special reference of the clinicopathologic factors of primary tumors. Univariate and multivariate analyses of survival were used to identify significant prognostic factors. RESULTS: Overall five-year survival rate after resection of lung metastases was 38.4 %. The mean size of the largest metastatic nodules is 2.73 cm. The median interval between colorectal resection and lung resection (disease free interval) was 28.7 months. The disease free interval, number and size of the pulmonary metastases were not significant prognostic factor. The negative hilar lymph node metastasis, colon cancer rather than rectal cancer, normal serum CEA were significant prognostic factors in multivariate analysis. CONCLUSION: Pulmonary resection for metastases from colorectal cancer may help prolong survival in selected patients. In this study, we found that if patients had negative pulmonary hilar lymph node metastases, normal range of serum CEA, and colon cancer rather than rectal cancer, the prognosis preferable than others.

Clinical Analysis of 40 Patients with Familial Adenomatous Polyposis (FAP)

PURPOSE: This study was carried to find the clinical characteristics of incidence and the phenotype of familial adenomatous polyposis (FAP). METHODS: This retrospective analysis was performed on 40 patients who were diagnosed as having FAP and who underwent surgery due to FAP from June 1985 to April 2005. The operative method, extra-colonic symptoms, and number of polyps were analyzed. RESULTS: From June 1985 to April 2005, 0.65% (40 patients) of all surgically treated colon-cancer patients were diagnosed as having FAP. Seventeen patients had familial history, and 23 patients were neither aware of any familial history nor had taken any tests. The primary symptoms were hematochezia, diarrhea, mucous discharge, constipation, and abdominal pain, but 5 patients had no specific symptoms. The mean age was 38.0 years. A total colectomy with ileostomy was performed in 19 cases, a total colectomy with ileorectal anastomosis in 2 case, and a total proctocolectomy with ileal J pouch anal anastomosis in 17 cases. One case was only diagnosed as having a FAP without surgical treatment, and one cases had palliative surgery due to carcinomatosis. Thirty-five cases had more than one hundred polyps, and 5 cases had less than one hundred polyps with a higher mean age of 62.2 (50~74) years and having no familial history. Extracolonic manifestations, were congenital hypertrophy of the retinal pigment epithelium, submandibular tumor, thyroid cancer, and intraabdominal desmoid tumor. The polyps could develop in other organs, such as the stomach or the duodenum. Because they can progress to cancer, a gastroduodenoscopy needs to be done. As for result, 17 cases underwent endoscopic gastroduodenoscopy, and among them, 9 cases had multiple adenomas. CONCLUSIONS: FAP has been considered as a rare disease. Because of its association with early development of colorectal cancer, measures for early detection of the disease and for identification of other family members at risk should be performed. Furthermore, early prophylactic treatment should be undertaken to reduce the incidence of cancer in these conditions. For early detection and better outcome, clinical and radiological examination and treatment for extracolonic manifestations and extracolonic tumor (thyroid cancer, desmoid tumor, medulloblastoma, hepatoblastoma) are necessary.

Accuracy of Magnetic Resonance Imaging in Predicting TNM Staging and Circumferential Resection Margin Compared with Pathologic Assessment on Whole-mount Section in Rectal Cancer

PURPOSE: Recently, magnetic resonance imaging (MRI) has become the preferred diagnostic tool for preoperative assessment of TNM staging and circumferential resection margin (CRM) in patients with rectal cancer. The aim of this study is to evaluate the accuracy of preoperative MR imaging in the prediction of T, N stage and CRM compared with pathologic results on whole- mount sections. METHODS: Thirty-five consecutive patients with rectal cancer were enrolled between Dec. 2005 and Apr. 2006. 1.5-T MR imaging, was performed, and pathologic results were investigated on whole-mount sections. The agreement between MR imaging and pathologic examination for the assessment of T, N stage and status of CRM were analyzed using kappa statistics. RESULTS: The accuracy of MR imaging compared with pathologic assessment of T stage was 82.9% (kappa=0.56), and that of N stage was 74.3% (kappa= 0.31). Of the MR imaging planes, the oblique axial plane showed the most accurate prediction of CRM, regardless of tumor position within the circumference of the rectum. The accuracy of MR imaging in the oblique axial plane for predicting the CRM was 81.0% (kappa=0.62) in anterior and posterior rectal tumors and 71.4% (kappa=0.43) in laterally located rectal tumors. With a different CRM criteria for the measured distance in MR imaging, the accuracy of the 2-mm CRM criterion was 77.1% (kappa=0.53). CONCLUSIONS: MR imaging in predicting T stage showed fair agreement according to kappa statistics. Of the MR imaging planes, the oblique axial plane provided the most accurate CRM information compared with pathologic examination. The actual measured distance of the CRM in MR imaging can be applied to the pathologic CRM.

Isolated Splenic Metastasis from Colorectal Carcinoma

Most splenic metastasis occurs in patients with the widespread visceral metastasis. However, isolated splenic metastasis is very rare. Here we report an isolated splenic metastasis in a patient with colon cancer without any other metastasis and a review of the literature are presented. A 57-year female underwent right hemicolectomy for adenocarcinoma of ascending colon on February, 2004 and the stage of carcinoma was T3N2M0. On August 2004, she hospitalized due to isolated splenic metastasis. The serum carcinoembryonic antigen level was 1.69 ng/ml. An abdominal CT scan revealed a 1 cm sized metastatic mass at the hilum of the spleen. The same finding was shown on MRI and PET. There was no other recurrence or metastatic evidence in radiologic study. Splenectomy was performed and pathologic result of the splenic tumor was metastatic adenocarcinoma from colon cancer. After operation, she was treated with adjuvant chemotherapy. It may be necessary to attend the splenic metatasis in patients who underwent curative resection for colorectal cancer even though splenic metastasis is very rare.

Analysis of Factors Affecting the Degree of Difficulty in Total Mesorectal Excision for Rectal Cancer: Investigation of the Factors Affecting Incomplete Resection and the Resection Time

PURPOSE: The aim of this study was to estimate the degree of difficulty in total mesorectal excisions (TMEs) for rectal cancer by using statistical methods after analysis of factors affecting the resection time and incomplete resection. METHODS: A total of 63 patients who underwent a total mesorectal excision for rectal cancer were evaluated. MRI pelvimetry data {(transverse diameter (TD), obstetric conjugate (OC), interspinous distance (ID), sacrum length (SL), sacrum depth (SD)}, tumor size (TS), T stage, and body mass index (BMI) were prospectively analyzed. A stepwise multiple regression analysis was performed to determine the operating time prediction equation by using these variables, and the differences in the mean operating time hased on gross evaluations of each specimen were analyzed. RESULTS: A stepwise multiple regression with the operating time as a dependent variable led to the following equation: Operation time (min)=35.726-2.162xTD (cm)-2.324 x OC (cm) + 2.671 x SL (cm) + 1.274 x TS (cm), with r2=0.533 and SEE=5.438. The mean operating time according to a gross evaluation of the TME specimen was 20.0 +/- 7.3 min in complete TME cases (n=42) and 27.9 +/- 7.2 min in incomplete TME cases (n=21) (P<0.001). CONCLUSIONS: MRI pelvimetry data (TD, OC, SL) and tumor size were factors affecting the operation time in TMEs for rectal cancer, and the operating time could be predicted by using the equation of the present study. Also, the mean operating time in incomplete TME cases was longer than that in complete TME cases. Thus, the degree of difficulty of an operation for rectal cancer can be predicted by using these factors.

Adenocarcinoma Arising from Tailgut Cyst

Retrorectal cystic harmatoma; Tailgut cyst, is a rare congenital disease typically presented as presacral mass, and malignant change of this disease is extremely rare. Frequently, This disease is misdiagnosed or confused at initial time. So, we have a case of tailgut cyst and report the clinical symptom and the result. A 40-year-old woman has admitted at Severance hospital for the anal pain. About 6cm sized irregular cystic and solid mass in the retrorectal area involving coccygeal bone and right gluteal muscle tendon were detected in magnetic resonance image. Under the impression of malignant tailgut cyst, the patient underwent Hartmann's operation (abdomino-sacral approach) under the sacral resection (S4, 5). The pathology was adenocarcinoma (poorly differentiated) arising from a tailgut cyst involving rectal adventitia, gluteus muscle and sacral bone. For the following 4 months after the operation, The patient is doing well with no evidence of recurrence.

Local Pelvic Recurrence after Curative Resection of the Rectal Cancer: Classification and Prognosis

PURPOSE: The management of local recurrence after curative surgery of the rectal cancer remains difficult clinical problems to surgeons. This study was performed to analyze the outcomes of patients with local pelvic recurrence according to its recurrence type. METHODS: A total 109 patients with local recurrence were evaluated. Among the 109 patients 62 were local recurrence alone and 47 were both local and systemic recurrence. The recurrence type was classified as Central, Anterior, Posterior, Lateral and Perineal recurrence according to the relation of the tumor location and either intra pelvic organ and/or fixed pelvic structure. RESULTS: Only 26 (23.9%) of the 109 patients had curative resection and the remaining 83 (76.1%) patients had palliative exploration or nonsurgical procedure. The resectability according to the recurrence type showed that the Central and Anterior type was higher than other type of recurrences (P=0.001). When the primary operation was Abdominoperineal Resection (APR) the resectability was poorer than Low Anterior Resection (LAR) (P=0.0001). When comparing the patients with local recurrence alone, the 5 year survival rate was significantly higher patients treated by curative resection than palliative or non-resection group (P=0.002). Mean follow up period was 44.2+/-30.0 months and mean recurrence time between primary operation and recurrence was 26.0+/-22.7 months. CONCLUSIONS: Resection for central type of the recurrent is potentially curative, however treatment failure was common when the recurrence invaded fixed pelvic structure. Our data suggest that local pelvic recurrence should be treated with radical resection as can as possible.

Prognostic Significance of Circumferential Resection Margin following a Total Mesorectal Excision in Rectal Cancer

PURPOSE: Studies of the circumferential resection margin (CRM) in rectal cancer surgery have revealed that inadequate surgical excision correlates with a high risk of recurrence. This study was designed to evaluate the prognostic value of the CRM in rectal cancer. METHODS: All 504 patients who underwent a total mesorectal excision for rectal cancer between 1997 and 2001 were studied. The distance between the CRM and the tumor on pathology slides (HE stain, x 20 times) was measured. The CRM was stained by using the Davidson marking system(R) (Bradley Product, Inc. USA), and a micrometer was used for the measurement. We divided the patients into a negative CRM group (CRM >3 mm), an abutting CRM group (CRM 3 mm), 5.6%, 38.9%, and 5.6% in the abutting CRM group, and 8.8%, 44.1%, and 8.8% in the positive CRM group. The five-year survival rates for the negative CRM, the abutted CRM and the positive CRM groups were 73.3%, 48.4%, and 25.5% (P<0.001), respectively, and the disease-free 5-year survival rates were 63.1%, 30.6%, 24.0% (P<0.001). The CRM was shown to be an independent prognostic factor by multivariate analyses adjusted for known predictors of outcome (P<0.001). CONCLUSIONS: The prognosis for a member of the abutting or the positive CRM group was more unfavorable than it was for a member of the negative CRM group; therefore, measurement of the CRM should be reported in the pathologic report. For patients with an abutting or a positive CRM, neoadjuvant or adjuvant chemoradiotherapy should be considered for better oncologic outcomes.

Gastrointestinal Stromal Tumor of Rectum: A Reoport of 7 Cases

PURPOSE: Gastrointestinal stromal tumors (GISTs) are rare. The aim of this study is to investigate and describe the clinicopathologic characteristics of rectal GISTs. METHODS: We retrospectively analyzed the medical records of seven patients who underwent surgery for GIST of the rectum from 1998 to 2003. RESULTS: Male and female patients were two and five respectively. The mean age was 55 years (range, 41~72 years) at the time of diagnosis. The median follow-up period was 23 months (range, 7~75 months). The chief complaints were hematochezia, constipation and anal pain. Curative resections were done in all cases. Abdominoperineal resection was done in five cases and transanal excision was done in one case. In one case, Hartmann's operation with prostatectomy was done. The mean size of tumor was 6.6 cm (1~12 cm). The pathologic feature of all cases were spindle cell type. The mitotic count shown > or =5 in 50 high power field was identified in four cases and that shown < or =5 in 50 high power field in three cases. Adjuvant radiation therapy was done in four cases. Two local recurrences occurred on 54 month and 23 month later after surgery, respectively. CONCLUSION: In cases of GIST of the rectum, the common symptom was same as other rectal tumors. Immuonhistiochemical staning of c-kit is helpful for differential diagnosis. Curative surgical resection should be done for treatment.