Preoperative chemoradiation therapy and anal sphincter preservation with locally advanced rectal adenocarcinoma.

Preoperative irradiation has been used to produce tumor regression and allow complete resection of rectal cancer with a sphincter-saving procedure. To evaluate the associated toxicity, the response in the primary tumor, and the postsurgical morbidity in a group of patients with locally advanced rectal cancer treated with preoperative chemoradiation therapy and low anterior resection, 120 patients were treated with 45 Gy of preoperative radiotherapy and a bolus infusion of 5-fluorouracil 450 mg/m2 on days 1 to 5 and 28 to 32 of radiotherapy. Four to six weeks later, 16 lesions were found unresectable; 36 patients underwent abdominoperineal resection or pelvic exenteration, and in the remaining 68 a low anterior resection was performed. For the purpose of this study only the latter group was included. There were 38 men and 30 women, with a mean age of 54.7 +/- 13.1 years. Gastrointestinal and hematologic acute toxicity grade 3 to 4 occurred in 12 and 7 patients, respectively. The mean distance of the tumor above the anal verge was 8.2 +/- 2.6 cm. In 10 patients the surgical resection included neighboring pelvic organs; 16 patients (23.5%) required a temporary diverting colostomy. The main causes of surgical morbidity were clinical anastomotic leakage in seven (10%), abdominal wall infection in five (7.4%), anastomotic stenosis in three (4.5%), and intraabdominal abscess in one (1.5%). No operative deaths occurred. The postsurgical stages were as follows: no tumor in the specimen, 17 (25%); T1, 4 (6%); T2, 12 (17%); T3, 17 (25%); T4, 5 (7%); any T with N+, 9 (13%); and any T, N with M+, 4 (6%). The median and mean follow-ups were 30.0 months and 37.4 +/- 25.0 months, respectively. The local recurrence rate was 2.9%, and the distant recurrence rate was 17%. The administration of preoperative chemoradiation therapy for locally advanced rectal cancer is associated with tolerable toxicity, a high rate of response in the primary tumor that allowed anal sphincter preservation, and a low rate of local recurrence.

The surgeon as prognostic factor for local recurrence and survival in the anal sphincter preservation for mid-rectal cancer.

BACKGROUND: The prognostic factors in rectal adenocarcinoma are influenced by the tumor stage. However, it is important to evaluate the role of the surgeon as part of the prognostic factors affecting local recurrence and survival rates in a group of patients with mid-rectal cancer treated with low anterior resection at a cancer referral center, and those treated at general hospitals. MATERIALS AND METHODS: Eighty-two patients with mid rectal adenocarcinoma stage II and III who underwent low anterior resection from January 1980 to December 1995, were retrospectively analyzed. Forty-two patients were treated at a cancer center (Group I) and 40 patients were treated at general hospitals (Group II). Cox regression analysis for local recurrence and survival was performed. RESULTS: There were 42 males and 40 females with a mean age of 55.8 +/- 14.9 years. No differences were found between both groups in terms of the following: age; gender; stage; grade of differentiation; number of positive lymph nodes; infiltration of neighboring organs, and administration of adjuvant chemoradiation therapy (POST RT). However, significant differences in the number of studied lymph nodes per specimen and follow-up were found. The median follow-up for the entire group was 49 months. Local recurrence occurred in 9.5% of patients in Group I vs. 50% in Group II (p = 0.0001). The 5-year survival in Group I was 63% vs. 54% in Group II (p = 0.04). The favorable prognostic factors for local recurrence and survival were: surgical treatment at a cancer center, and no lymph node metastases. CONCLUSION: The prognostic factors for local recurrence and survival depends mainly on the surgeon and on the post-surgical tumor stage.

The influence of pre-operative radiation therapy on the patterns of recurrence in rectal adenocarcinoma.

From January 1976 to December 1994, we evaluated the institutional experience of local recurrence and survival in patients with rectal adenocarcinoma treated with pre-operative radiation therapy (PRT) as compared to those treated with radical surgery alone. There were 412 patients, divided into two groups: 259 patients (142 males and 117 females) in Group I and 153 patients (88 males and 65 females) in Group II. The median age was 56 years. Group I patients with locally advanced tumors, either tethered or fixed, received PRT at doses of 45 Gy delivered to the pelvis in two fields; 4 to 8 weeks later, radical surgery was performed. Patients with mobile tumors underwent radical surgery only (Group II). The operative mortality was 4.6% in Group I as compared to 1.9% in Group II (P = 0.18). At median follow-up of 89 months, there were local recurrences in 12.9% of Group I as compared to 36.2% in Group II (P = 0.0000001). The administration of PRT was associated with a low rate of local recurrence, but this improvement corresponded with a high morbidity rate, especially in patients who underwent abdominoperineal resection or pelvic exenteration.

[Treatment of anastomotic leakage following low anterior resection for rectal adenocarcinoma]. / Tratamiento de la dehiscencia anastomótica secundaria a resección anterior baja por adenocarcinoma de recto.

BACKGROUND: The most important complication after low anterior resection for rectal cancer is the anastomotic leakage. Its frequency ranges between 0%-17% and, it's associated mortality ranges between 0%-25%. OBJECTIVE: To analyze the treatment results of the above mentioned complication. MATERIAL AND METHODS: Between January 1990 and July 1998, 176 patients with rectal cancer underwent low anterior resection. 13 (7.3%) of them developed anastomotic leakage. The results of the treatment due to, this surgical complication were analyzed. RESULTS: There were 9 males and 4 females with a mean age of 64.3 years. Seven of these patients received preoperative radiotherapy. The tumor mean size was 5.5 cm. The tumor and distance of the anastomoses were located at a mean distance of 8 cm and 5 cm respectively, above the anal verge. All patients presented one or more of the following symptoms: increase of drainage (n = 10); prolonged ileus and abdominal pain (n = 9), fever and leucocytosis (n = 8). The surgical treatments were: drainage of abdominal or pelvic cavity (n = 11); loop transversostomy (n = 9); end colostomy, and Hartmann's procedure (n = 3). One patient received only enteral nutrition. In eight patients, the surgical treatment was performed during the first 24 hours of the initial symptoms and in four after 24 hours. The mean hospital stay in the former groups was 9.2 days vs 26.8 days of the later group (p = 0.02). No mortality was observed. CONCLUSION: The early diagnosis of the following symptoms: drainage increase; prolonged ileus; postoperative abdominal pain; fever, and leucocytosis after low anterior resection, should guide us to the diagnosis of anastomotic leakage and therefore, to initiate surgical treatment during the first 24 hours as to avoid major morbidity and mortality.

The natural history of liver metastases from colorectal cancer.

BACKGROUND: The optimal treatment for patients with liver metastases from colorectal cancer is surgical resection. However, fewer than 10% of these patients will be amenable to this surgery. The aim of this study is to ascertain the natural history of a group of untreated patients, and to evaluate simultaneously in another group whether or not the administration of systemic chemotherapy modifies this natural history. METHODS: From January 1986 to September 1996, 77 patients with liver metastases from colorectal cancer biopsy proven or documented by means of a CT scan or a liver ultrasound were retrospectively analyzed. The group was divided according to treatment as follows: Group A, untreated patients, and Group B, those patients who received chemotherapy (5-FU 450 mg/m2/days 1-5 of the first week and thereafter weekly) + leucovorin 20 mg/m2 on the same days as 5-FU. The end points were patterns of recurrence and survival evaluated by means of the Mann-Whitney test and the Kaplan-Meier method. RESULTS: There were 41 females and 36 males in the study. Their median age was 59 years (range, 30-80). The primary tumor was located in the rectum in 44, in the sigmoid, 20, cecum, 9, descending colon, 2, hepatic flexure, 1, and transverse colon, 1. Forty-nine patients had metachronous and 28 had synchronous liver metastases. In group A, which was made up of 45 patients, 41 developed extrahepatic metastatic disease, and their median survival rate was 13 months (range, 3-57). In group B, including 32 patients, 29 developed extrahepatic metastatic disease, and their median survival rate was 15 months (range, 4-60). There were no differences in overall survival in both groups (p = 1.00). All patients in both groups died of the metastatic disease. CONCLUSION: The natural history of patients with liver metastases from colorectal cancer is towards progressive hepatic and extrahepatic metastatic disease. The administration of systemic chemotherapy did not modify the natural course of the disease.

[Colorectal cancer]. / Cáncer colorrectal.

OBJECTIVE: To describe the multistep carcinogenesis of the colon and rectum, and updated in the screening diagnosis and treatment of colorectal cancer. BACKGROUND: Colorectal cancer is one of the most frequent malignant neoplasia in developing countries. In Mexico, is the second malignant neoplasia of the gastrointestinal tract. MATERIAL AND METHODS: A literature search was performed to known the usefulness of screening, diagnosis and treatment procedures. Also, some of our actual proceedings are described. RESULTS: No impact in decreasing the mortality rate for colorectal cancer, has been observed with the contemporary screening programs in low risk population. The recommended treatment for colorectal cancer in early stages (Dukes A and B1) is the surgical resection alone. In those patients with colon metastasizing to the lymph nodes (Dukes C), a combination of surgery + chemotherapy is recommended. In patients with rectal cancer with full penetration until the perirectal fat or with lymph node metastasis (Dukes B2 and C) a combination of surgery, chemotherapy and radiotherapy is the elective treatment. Until today, is controversial if radiotherapy should be used pre- or postoperatively. CONCLUSION: The colorectal carcinogenesis included a multistep where are involved a tumor suppressor genes and oncogenes. Surgery is the accepted treatment for early colorectal cancer. A combination of surgery + chemotherapy +/- radiotherapy is the elective treatment for locally advanced colorectal cancer.

[Associated clinical features in 41 patients with anal epidermoid carcinoma, studied at a cancer center]. / Características clínicas asociadas de 41 pacientes con carcinoma epidermoide del ano, estudiados en un centro de cáncer.

OBJECTIVE: To investigate the main associated clinical characteristics in a group of patients with squamous cell carcinoma of the anus. BACKGROUND: Anal carcinoma is associated with sexually transmitted viral carcinogenesis. MATERIAL AND METHODS: We analyzed the charts of patients with squamous cell carcinoma of the anus treated during 1994 and 1995. Demographic characteristics, presence of HIV-1, sexual behavior and the presence of anal warts were analyzed. RESULTS: There were 41 patients, 26 females and 15 males with a mean age of 61 and 45 years respectively. Twenty-three patients (56%) had history of anal intercourse, 17 (41%) had anal warts and 12 (29%) were HIV-1 (+). This factors were observed more frequently in the male population (p < 0.001). The patients who had anal intercourse had more frequently anal warts and HIV-1(+) compared with those who did not (p < 0.001 in both). The HIV-1 (+) patients had more frequently anal intercourse and anal warts than those HIV-1(-) (p < 0.001 in both). CONCLUSION: 1) male population develop squamous cell carcinoma of the anus earlier than female population, 2) there is a high incidence of homosexuality, anal warts and HIV-1(+) in the male population; these findings suggest different mechanism of carcinogenesis in both gender.

[Rapunzel's syndrome (trichobezoar)]. / Síndrome de Rapunzel (tricobezoar).

The Rapunzel syndrome is uncommon, only 6 cases have been previously reported. Its characteristics are: 1) the body of a trichobezoar located in the stomach, and its tail in the small bowel and/or in the right colon, 2) small or large bowel obstruction, 3) occurring in psychiatric patients and, 4) trichophagia. We have added an additional patient, who was submitted to our hospital with diagnosis of abdominal mass, who, during his work-up was found with the above mentioned characteristics. The patient underwent a exploratory celiotomy, gastrotomy, and the trichobezoar was removed. The pathogenesis and current treatment are reviewed.

[Proctocolectomy with ileoanal anastomosis: morbidity and functional results in patients with and without colorectal cancer]. / Protocolectomía con ileoanoanastomosis: morbilidad y resultados funcionales en pacientes con y sin cáncer colorrectal.

BACKGROUND: The elective prophylaxis for colorectal cancer in patients with familial adenomatous polyposis (FAP) or with ulcerative colitis (UC) is the RPIPAA. AIMS: To evaluate the functional results and the morbidity rate in patients who underwent restorative proctocolectomy with ileal-pouch anal anastomosis (RPIPAA). METHODS: All patient underwent a proctocolectomy with a J reservoir, ileal pouch-anal anastomosis. RESULTS: There were 8 males and 3 females with a mean age of 31 years; the diagnoses were: FAP (n = 4); FAP + colorectal cancer (n = 3); metachronous colorectal cancer (n = 3) and UC + right colon cancer (n = 1). The average surgical time and the intraoperative bleeding were 5.6 h and 600 ml respectively. There were no operative deaths. The surgical complications were: section of left urether (n = 1); hemoperitoneum of 1,200 ml (n = 1); minor pelvic sepsis (n = 1); ileoanal stenosis (n = 1) and pouchitis (n = 1). Tumor staging was: Dukes A (n = 2), B1 (n = 1), B2 (n = 4). The mean follow-up was 22 months. Average of stools at the 3rd, 6th and 12th month was: 7.4, 5.6 and 3.8 respectively. Sexual function was: normal (n = 8), retrograde ejaculation (n = 2) and impotence (n = 1). The use of antidiarrheal agents in 24 hours at the third, sixth and twelfth month was 3, 2 and .8 respectively. CONCLUSIONS: The RPIPAA is associated with a low rate of morbidity and good functional results, similar to previously published results. However, these results should be taken with caution due to the small, selected and retrospective nature of the study.