Urologic complications of composite resection following combined modality treatment of colorectal cancer.

BACKGROUND: It is a common perception that preoperative radiation increases the incidence of urologic complications following composite resection, but there is little evidence to support or refute this claim. METHODS: Patients who underwent ureteric reconstruction as a component of en bloc resection for locally advanced or recurrent colorectal cancer were identified from a multicenter institutional database (1982-2007). Charts were reviewed to determine the incidence, nature, management, and predictors of serious urologic complications. RESULTS: 126 patients (34 female, 92 male) met the inclusion criteria: (1) division of one or both ureters; and (2) ureteric reconstruction involving anastomosis to ureter, bladder, small bowel or colon. Urologic complications requiring intervention occurred in 30 (24%) patients, including: anastomotic leak (n = 11), anastomotic stricture (n = 10), fistula (n = 5), conduit/stoma problem (n = 5), and other (n = 3). Eight patients required surgical revision. The rate of urologic complications was similar in patients who had received radiation at some time prior to the index surgery and those who had not (25% and 19%, respectively, P = 0.61). There was a trend towards a higher complication rate with more complex compared with simpler reconstructive procedures (38% versus 20%, P = 0.069). CONCLUSION: 24% of patients who underwent ureteric reconstruction following composite resection developed a urologic complication that required intervention. Preoperative radiotherapy did not appear to predispose patients to urologic complications. Optimization of surgical technique at the time of en bloc resection may obviate the need for subsequent revision.

Anorectal malignant melanoma: treatment with surgery or radiation therapy, or both.

INTRODUCTION: Anorectal malignant tumours are increasing in frequency for unknown reasons. Surgery is the principal treatment, and the role of adjuvant therapy has not been defined. We therefore decided to review the experience of the Princess Margaret Hospital in Toronto, a large tertiary care cancer hospital, with respect to the surgical management of anorectal melanoma. METHODS: We reviewed the charts of all registered patients with anorectal malignant melanoma (AMM) treated with surgery or radiotherapy, or both, at the hospital between 1980 and 1999, paying particular attention to survival, and local and distant recurrences. RESULTS: There were 14 patients, all of whom were followed up to the time of death or for a minimum of 28 months for surviving patients. The mean ages at diagnosis were 56 years for men and 68 years for women. Clinical staging was as follows: local, 10 patients; locoregional, 3 patients and metastatic disease, 1 patient. Local therapy included local resection alone in 7 cases and abdominoperineal resection in 7. Seven patients received pelvic irradiation at some time during their disease, using different doses and fractionation schemes. Three of them had concomitant chemotherapy and radiotherapy with no tumour regression. In all 3 patients the lesions was reclassified as AMM and the patient underwent surgery. The other 4 patients had a short course of radiotherapy for palliation after the original lesion recurred. The overall median survival was 12 (range from 3-51) months. Two patients remained alive at last follow-up. Patients managed by local excision had a median survival of 12 (range from 3-51) months, and those managed by abdominoperineal resection had a median survival of 7 (range 5-51) months. Of the 10 patients treated initially with local excision, 6 required reoperation. Three underwent salvage abdominoperineal resection. Six patients were alive 1 year after treatment (median survival 32.5 mo [range from 21-51 mo]). Eight patients had a rapid evolution of their disease with a median survival of 5.5 (range from 3-12) months. Eleven of the 12 patients who died had metastatic disease. CONCLUSIONS: Systemic dissemination is almost universal in patients with AMM. The overall survival was poor regardless of local treatment. There was a 60% failure rate of local excision, which necessitated further surgery. Improving local control is important since some patients will survive up to 3 years.

Slow progression of periampullary neoplasia in familial adenomatous polyposis.

Variable endoscopic surveillance protocols and treatment strategies have been proposed for periampullary neoplasia in familial adenomatous polyposis (FAP), primarily because of the lack of long-term, prospective natural history data. A total of 115 patients with FAP were followed prospectively for 10 years with periodic side-viewing upper gastrointestinal endoscopy by a single surgeon. The appearance of the duodenum was classified as stages 1 to 5. Statistical analysis included one-way analysis of variance for age comparisons between stage groupings and Kaplan-Meier analysis for the lifetime risks of having a particular stage of duodenal polyposis. Eighty-seven patients had multiple endoscopies over an average of 6.6 years. Thirty-three subjects had a change in stage, within an average time of 3.9 years at an average age of 41 years. The risk of having stage 3 or 4 duodenal neoplasia increased exponentially after the age of 40. The degree of dysplasia did not correlate with stage at initial classification. Progression of neoplasia in the duodenum of patients with FAP is slow. The severity of duodenal polyposis increases with age and is not influenced by the initial stage. The average time for progression of adenoma to carcinoma is likely long.