Increasing crude and adjusted mortality rates for colorectal cancer in a developing South American country.

AIM: Colorectal cancer (CRC) is a major cause of cancer death worldwide. We examined temporal trends in death rates from colorectal cancer in Chile from 1983 to 2008. METHOD: We analysed the mortality database in Chile from 1983 to 2008. Cases were selected using ICD-9/10 codes. We calculated mortality rates per 100,000 inhabitants according to sex, age group and type of cancer - colon (CC) or rectal (RC). The rates were adjusted by a direct method using the WHO-2000 standard population. Time trends were assessed with Prais-Winsten regression models. RESULTS: There were 26,250 deaths from CRC (75.7% for CC). There was a higher frequency of deaths from CC (57.6%) in women than in men, who had a higher frequency of deaths from RC (51.3%). The crude CC mortality rate increased by 116% (from 3.6 to 7.8), while the overall RC rate increased by 71% (from 1.4 to 2.4). After adjusting for age, a significant increase in mortality rate was found for CC (coefficient 0.09, 95% CI 0.08-0.11, P < 0.001) and RC (coefficient 0.02, 95% CI 0.009-0.04, P = 0.002) in men. In women, this increase was significant for CC (coefficient 0.03, 95% CI 0.005-0.05; P = 0.02), but not for RC (coefficient -0.007, 95% CI -0.02 to 0.005, P = 0.23). CONCLUSION: The crude mortality rate from CRC has doubled in Chile in this period. After adjustment of mortality rates, it appears that much of this increase is due to the aging population. However, part of this increase could be explained by other factors.

Large deletions and splicing-site mutations in the STK11 gene in Peutz-Jeghers Chilean families.

Peutz-Jeghers syndrome (PJS) is an autosomal dominant disorder characterized by mucocutaneous melanocytic macules, gastrointestinal hamartomatous polyposis and an increased risk of various neoplasms. Germline mutations in the serine/threonine kinase 11 (STK11) gene have been identified as a cause for PJS. The aim of this study was to characterize the genotype of Chilean PJS patients. Mutation screening of 13 patients from eight PJS families was performed using a single strand conformation polymorphism analysis, DNA sequencing and multiplex ligation-dependent probe amplification assay. The breakpoints of the genomic rearrangements were assessed by a long-range polymerase chain reaction and sequencing. The results revealed the existence of seven different pathogenic mutations in STK11 gene in seven unrelated families, including three point mutations and four large genomic deletions. Three of these point mutations (43%, 3/7) may be considered as novel. Our results showed that a germline mutation is present in STK11 in 88% of probands fulfilling the diagnostic criteria of PJS. In this study, the combination of two different experimental approaches in the screening of the STK11 in PJS, led to a higher percentage of mutation detection.

Locally recurrent rectal cancer: predictors and success of salvage surgery.

PURPOSE: After curative surgery for rectal cancer, patients with pelvic recurrence may undergo curative surgical resection. We determined whether salvage surgery in appropriately selected patients could significantly lengthen disease-free survival time and if so what factors predicted this outcome. METHOD: We reviewed the records of all patients treated for rectal cancer at our institution between 1980 and 1993. Of 937 patients who underwent surgery with curative intent after proctectomy or transanal local excision, 81 (8.6 percent) experienced local recurrence. During the same period 36 patients with locally recurrent rectal cancer were referred from other institutions. Logistic regression analysis was used to identify predictors of salvage surgery. The Kaplan-Meier method was used to estimate cancer-specific and disease-free survival times in 43 patients who underwent salvage surgery. The Cox proportional hazard model was used to identify factors associated with these outcomes. RESULTS: Of 117 patients with locally recurrent rectal cancer, 43 (36.7 percent) underwent salvage surgery. Factors associated with higher chance of receiving salvage surgery were female gender, the first operation performed at outside institutions, and transanal local excision as the initial operation. For 43 patients who underwent salvage surgery, five-year cancer-specific and disease-free survival rates were 49.7 and 32.2 percent, respectively. No factors were significantly associated with death caused by cancer. However, a trend for poor prognosis was observed in patients with recurrence diameter >3 cm and tumor fixation Degree 2. CONCLUSION: Salvage surgery for properly selected patients with locally recurrent rectal cancer allows long-term palliation and significantly lengthens disease-free survival.

Role of laparoscopic surgery for treatment of early colorectal carcinoma.

The first laparoscopic colorectal surgery was performed in 1991. Several reports have showed some advantages for the laparoscopic technique compared to open procedures, but the lack of well designed trials has produced doubts about the real advantage of laparoscopy for colorectal cancer. To date, retrospective and prospective evidence suggests that laparoscopy is as safe as conventional colorectal surgery. Two recent prospective, randomized trials have showed that the short-term outcome is not compromised after laparoscopy for colorectal cancer. Furthermore, less pain, faster recovery of respiratory parameters, and better preservation of cell-mediated immune function have been associated with the laparoscopic technique. Laparoscopic surgery for early colorectal cancer may have a role in a well selected group of patients.

Treatment of colon and rectal cancer.

This article discusses multimodal treatment of noncomplicated colon and rectal cancer, considerations for specific types of colon cancer, considerations that may modify the extent and technique of surgery, the role of adjuvant chemotherapy for colon adenocarcinoma and rectal cancer, and surgical treatment of complicated colorectal cancer.

Total mesorectal excision is not necessary for cancers of the upper rectum.

BACKGROUND: The technical aspects of surgery of the upper rectum (10 to 15 cm from the anal verge) and sigmoid colon are similar, but a change in technique is required for surgery of the lower rectum (< 10 cm). The aim of this study was to compare the outcomes of the treatment of upper rectal cancer (UR), in which total mesorectal excision (TME) was not performed, with outcomes of sigmoid colon cancers (S) and lower rectal cancers (LR). METHODS: Between 1980 and 1990, 891 patients were treated with curative intent for sigmoid (n = 225) and rectal cancer (UR = 229; LR = 437). The Kaplan-Meier and Cox proportional hazards analyses were used to compare outcomes. RESULTS: The risk of local recurrence alone, local and distant recurrence, death as a result of cancer, or any recurrence or death as a result of cancer was 3.5, 2.7, 2.1, and 1.9 times higher for patients with LR than for patients with UR, but the risk was not increased for UR relative to S. CONCLUSIONS: The outcome of treatment for UR is the same as for S and differs favorably from that for LR. UR should be treated by the same technique as S.

Chances of cure are not compromised with sphincter-saving procedures for cancer of the lower third of the rectum.

BACKGROUND: The goal of this study was to compare patterns of recurrence and long-term outcome after sphincter-saving procedures (SSPs) and abdominoperineal resection (APR) in patients with tumors located in the lower third of the rectum. METHODS: We reviewed the charts of 1001 patients operated on for primary rectal adenocarcinoma between 1980 and 1991. All patients with tumors located between 5 and 7 cm from the anal verge and treated with curative intent were included. RESULTS: Of the 261 patients who met our criteria, 162 had undergone SSP and 99 had undergone APR. The local recurrence rates for SSP and APR were 8% and 11%, respectively (p = 0.41), and the distant metastases rates were 23% and 28%, respectively (p = 0.35). Recurrence and distant metastases rates for SSP and APR, respectively, did not differ by TNM classification: state I, 10% versus 9% (p = 0.9); stage II, 25% versus 43% (p = 0.13); and stage III, 56% versus 57% (p = 0.92). Five-year disease-free survival rates for SSP and APR patients were 70.5% and 62.3%, respectively (p = 0.2). CONCLUSIONS: Tumors in the lower third of the rectum can be treated with sphincter-saving procedures without compromising the chance of cure.

Management and causes of acute large-bowel obstruction.

Acute LBO has many possible causes. In the United States, the most common cause is colorectal carcinoma. Mechanical obstruction should be differentiated from pseudo-obstruction by contrast enema or colonoscopy because the treatments differ. The high postoperative mortality and morbidity of LBO compared with elective resection are explained by the multiple associated pathophysiologic changes of obstruction. Management of this condition requires careful assessment, awareness, and expertise in the current modalities of treatment. Gangrene and perforation should be avoided because they limit treatment options and are associated with an increase in mortality. We prefer, in most instances, to perform a single-stage procedure, which has the advantages of reduced hospital stay (and cost) and avoidance of a stoma. However, the appropriate treatment needs to be tailored to the individual situation. Recent developments in nonoperative decompressing procedures may demonstrate advantages in the future.