Sphincter preservation with chemoradiation in anal canal carcinoma: abdominoperineal resection in selected cases?

PURPOSE: This study contained herein assessed long-term results, toxicity, and prognostic variables following combined modality therapy of patients with International Union Against (Cancer Classification T1-4, N0-3, M0 squamous-cell carcinoma of the anal canal. PATIENTS AND METHODS: Between 1985 and 1996, 62 patients completed treatment with combined modality therapy. A median total dose of 50 Gy was given to the primary, perirectal, presacral, and inguinal nodes followed by a local boost in selected cases. 5-Fluorouracil was scheduled as a continuous infusion of 1,000 mg/m2 per 24 hours on days 1 to 5 and 29 to 33 and mitomycin C as a bolus of 10 mg/m2 on days 1 and 29. Routinely processed paraffin-embedded sections were stained using monoclonal antibodies for detection of proliferating cell nuclear antigen and MIB1 (Ki-67) antigen to determine the labeling index. In addition, DNA ploidy was assessed after Feulgen staining. RESULTS: Actuarial cancer-related survival, no evidence of disease survival, and colostomy-free survival rates at five years were 81, 76, and 86 percent, respectively. In univariate analysis, T category (T1/2 vs. T3/4) was predictive for no evidence of disease survival (87 vs. 59 percent; P = 0.03) and colostomy-free survival (94 vs. 73 percent; P = 0.05). N category (N0 vs. N1-3) influenced actuarial cancer-related survival (85 vs. 58 percent; P = 0.002) and no evidence of disease survival (80 vs. 53 percent; P = 0.02). A higher proliferative potential as measured by the MIB1 labeling index was associated with a better colostomy-free survival (90 vs. 50 percent; P = 0.04). In multivariate analysis, actuarial cancer-related survival was only influenced by the N category (P = 0.03) and no evidence of disease survival by N category (P = 0.03) and mitomycin C dose (P = 0.04). Salvage abdominoperineal resection achieved long-term control in only four of seven patients with local failures. CONCLUSION: Treatment with a combination of radiotherapy and chemotherapy is safe and effective for patients with anal canal carcinoma. Abdominoperineal resection is indicated as a salvage procedure in nonresponding and recurrent lesions and may be of benefit in a small subgroup of patients with poor prognostic factors.

[Intraperitoneal colon anastomosis with laparoscopic purse string suture clamp and Valtrac ring]. / Intrakorporale Kolonanastomose mit laparoskopischer Tabaksbeutelnahtklemme und Valtrac-Ring.

In combination with the biofragmentable Valtrac ring a newly developed purse-string suture clamp offers the possibility of performing intraperitoneal anastomoses of the small and large bowel without the need for stapling devices. During this experimental study end-to-end anastomoses of the descending colon were constructed in five pigs. One animal was re-examined on day 1 after the operation and the others were all sacrificed on day 21 after. None of the animals showed any signs of an anastomotic leakage. Little scar tissue was seen macroscopically or histologically in the anastomotic region of the animals sacrificed 3 weeks after the operation. The operative technique presented in this paper might render the so-called assisted laparoscopic procedures for the right hemicolon unnecessary in the future.

Treatment of pilonidal sinuses by phenol injections.

Six female and 39 male outpatients, who suffered from acutely inflamed pilonidal sinus were treated by sclerotherapy between January 1985 and December 1988. Under local anaesthesia, 1-2 ml 80% phenol was injected into the sinus. The phenol, which was allowed to act for a minute, was washed out by irrigating the sinus with physiological common-salt solution. Of the questionnaire sent to all 45 patients, 37 proved suitable for evaluation. Complete healing occurred in 22 cases (59.8%). The healing time was 6.2 weeks on average. Besides a rather frequently observed transient reddening as a result of the local inflammation caused by the phenol, 5 patients developed an abcess which needed operative treatment. This study does not support the encouraging results of previous series.

Epidermoid carcinoma of the anal canal: treatment by combined radiation and chemotherapy.

From June 1985 to September 1991, 44 patients with epidermoid carcinoma of the anal canal were treated prospectively by a protocol of combined radiation and chemotherapy (RCT) with 5-fluorouracil (5-FU) and mitomycin C (MTC). External radiation was delivered with 10 MV photons and single daily fractions between 1.8 and 2 Gy in an uninterrupted course up to a median total dose of 50 Gy. 5-FU was given by a continuous intravenous infusion (1 g/m2/day) for 96 h on days 1-4 and 29-32, MTC by a single bolus intravenous injection of 10 mg/m2 on days 1 and 29. The actuarial survival rate, no evidence of disease (NED) survival rate and local tumour control rate were 84%, 71% and 83% at 5 years. Anorectal function was retained in 33 of 41 patients (80%). Severe acute toxicity including three fatal outcomes was observed and there was an acceptable late morbidity. The only marginally significant prognostic factor (p = 0.06) for local tumour control was T-stage. RCT can provide good local control and preserve anal function with acceptable morbidity.

Combined radiation and chemotherapy for epidermoid carcinoma of the anal canal.

Between 1985 and 1992, 46 patients with epidermoid carcinoma of the anal canal were treated prospectively by a protocol of combined radiation and chemotherapy with 5-Fluorouracil and Mitomycin C. The survival rate, NED-survival rate and local tumour control rate were 84%, 71% and 83% at 5 years. Anorectal function was retained in 33 of 41 patients (80%). We observed severe acute toxicity including three deaths, but very little late morbidity. The only marginally significant prognostic factor (P = 0.06) for local tumour control was T-stage. NED-survival was significantly affected (P = 0.02) by reduction of chemotherapy during the second course.