Stuart H. Q. Quan

Patterns of pelvic recurrence following definitive resections of rectal cancer

Patterns of local and distant recurrences following resections for rectal cancer provide clinical perspective for multidisciplinary prevention and follow‐up programs. From 1968 to 1976 at Memorial Hospital, 412 patients with potentially curable rectal cancer were treated by anterior (AR) or abdominoperineal (APR) resections. First sites of recurrences were categorized as pelvis, liver, distant viscera, and intraabdominal/ retroperitoneal sites. Pelvic recurrences were further evaluated according to the location of the tumor, type of resection, and stage of disease. Among the 412 cases, 182 (44.2%) patients developed recurrence, of which 105 (57.6%) were pelvic. Pelvic recurrence was the predominating site either alone (55 of 103) or with concomitant extra‐pelvic sites (50/79). In instances of single‐site first recurrence, pelvic failure was recognized earliest at 19.1 months, which was significantly earlier than single‐distant visceral sites at 34.9 months. Pelvic recurrence was selectively related to various categories of the Dukes and modified Dukes staging systems. Dukes stage significantly predicted pelvic recurrence rates for Dukes A versus B. Astler‐Coller stages of B2 and C1 were associated with significantly lower rates of pelvic recurrence (29.7% and 22.1%, respectively) than C2 cancers. The incidence of pelvic recurrence was significantly increased for low and mid rectal cancers as compared with cancers at or above 12 cm. The type of resection utilized (APR versus AR) was associated with no difference in the rate of pelvic recurrence, except for the few patients in whom AR was performed for low rectal Dukes C cancers. Patients with pelvic recurrence had an ultimate disease‐free survival of only 3.8% as compared with patients with no pelvic recurrence of whom 77% remained alive without disease or went on to die of other causes. The timing and predominance of pelvic failure in rectal cancer with its own treatment‐related morbidity and overall dismal survival outcome justifies organized multidisciplinary efforts to prevent such failure and prospective trials of comprehensive follow‐up programs to evaluate improved cure rates or palliation. Cancer 53:1354‐1362, 1984.

Anorectal melanoma. A 64-year experience at Memorial Sloan-Kettering Cancer Center.

PURPOSE: Operative management of patients with anorectal melanoma is controversial. To formulate a rational approach to patients with this disease, we reviewed our experience from 1929 to 1993. METHODS: Records of all patients treated at our center with anorectal melanoma from 1929 to the present were reviewed. Survival analyses were graphically displayed using the Kaplan-Meier productlimit method, and distributions were compared using the log-rank test. Fishers exact test was used to compare groups with small sample sizes. RESULTS: Survival for the entire group (n = 85) was poor, 17 percent at 5 years (median, 19 months). Among the 71 patients with resectable disease, the five-year, disease-free survival distribution of patients who underwent abdominoperineal resection (APR) was more favorable than that of patients who underwent local procedures only, although this was not statistically significant (27 percentvs.5 percent, APRvs. local procedures, respectively;P=0.11). However, those who had an APR were more likely to survive long term than those who did not (P<0.05). All ten long-term survivors were women. Nine had undergone APR, and one had a wide local excision. Of the nine survivors following APR, eight had negative and one had positive mesenteric nodes. Median size of the primary tumor in survivors following APR was 2.5 cm, compared with 4.0 cm for patients who did not survive long term following APR. CONCLUSIONS: APR should be considered in patients with localized anorectal melanoma, particularly those with smaller tumors and no evidence of nodal metastases.

T3N0 rectal cancer: results following sharp mesorectal excision and no adjuvant therapy☆

Adjuvant chemoradiation therapy following resection of T3N0 rectal cancer is recommended in order to reduce the incidence of local recurrence and improve survival. However, recent experience with rectal cancer resection utilizing sharp dissection and total mesorectal excision has resulted in a reduction in local recurrence rates to as low as 5% without adjuvant treatment. The purpose of this study was to determine if rectal cancer resection utilizing sharp mesorectal excision alone is adequate treatment for local control of T3N0 rectal cancer. Between July 1986 and December 1993, 95 patients with T3N0M0 rectal cancer underwent resection with sharp mesorectal excision and did not receive any adjuvant therapy. Various prognostic factors were analyzed for their association with local recurrence and survival. Seventy-nine patients had a low anterior resection, 10 of whom had a coloanal anastomosis, and 16 had an abdominoperineal resection. The median follow-up was 53.3 months. Six patients had local recurrence, 12 had distant recurrence, and three had local and distant recurrences. The overall local recurrence rate was 9% crude and 12% 5-year actuarial. The overall crude recurrence rate was 22%. The 5-year disease-specific survival rate was 86.6% with an overall survival of 75%. Postoperative complications occurred in 18 patients (19%). Five patients (6%) had a documented anastomotic leak. Perioperative mortality was 3%. No technical factors, including type of resection (low anterior vs. abdominoperineal), location of tumor, or extent of resection margin, were significant for determining local recurrence. The only histopathologic marker significant for determining local recurrence was lymphatic invasion (P <0.04). Sharp mesorectal excision with low anterior resection or abdominoperineal resection for T3N0M0 rectal cancer results in a local recurrence rate of less than 10% without the use of adjuvant therapy. Therefore, in select patients with T3N0M0 rectal cancer, the standard use of adjuvant therapy for local control may not be justified.

Epidermoid cancer of the anal margin: Pathologic features, treatment, and clinical results*

Summary Epidermoid cancer of the anal margin should be distinguished from that in the canal because of its different clinical and pathologic characteristics, the suitability of local excision for its treatment, and its better overall prognosis. In addition, margin cancer rarely metastasises to visceral sites. Forty-eight patients with epidermoid cancer of the anal margin were reviewed. Two refused treatment, 4 had palliative therapy for advanced, inoperable disease, 31 had local excision, and 11 were treated by abdominoperineal resection. Local excision provided satisfactory results with a corrected 5 year survival of 88 percent, although locoregional recurrence developed in 46 percent of these patients during follow-up. A second local excision or inguinal lymphadenectomy provided good results in the patients with recurrence. Abdominoperineal resection did not provide better overall survival figures.

Preoperative chemotherapy and radiation therapy in the management of anal epidermoid carcinoma

Management of epidermoid carcinoma of the anus has been primarily surgical in the past. Since it is a relatively rare entity, meaningful survival statistics are difficult to obtain. Five‐year survival rates fall between 35 and 68% in patients treated with surgery and/or radiotherapy. Based on preliminary studies indicating promising results with the use of mitomycin C and 5‐fluorouracil (5‐FU) chemotherapy combined preoperatively with radiation therapy, these authors initiated a protocol in 1973 utilizing this multimodality approach. The preoperative treatment consisted of mitomycin C 15 mg/m2 IV bolus on day 1 and 5‐FU 750 mg/m2/24 hours continuous infusion for five days. Radiation followed chemotherapy and consisted of 3000 rad given at 200 rad per day for 15 fractions. Of 37 patients entered on the protocol, 30 had primary disease and seven had been previously treated and had local recurrences. Median follow‐up has been 28 months (range, 5‐74 months). Of 31 patients with measurable lesions, 29 (94%) had major clinical responses (CR + PR) to the combined chemotherapy and radiation. Pathologic responses were also impressive with 53% (17/32) showing no evidence of residual tumor in the subsequently resected surgical specimen. Of the 37 patients treated, seven (19%) have had recurrences. The recurrence rate was 4/17 (24%) for those who had local excision following complete response to therapy as opposed to 3/18 (17%) for those treated by abdominoperineal resection. Thus it appears that the combination of preoperative mitomycin C and 5‐FU with radiotherapy is effective at least in significantly downstaging this uncommon malignancy. Its ultimate effect on recurrence rate and overall patient survival awaits longer follow‐up.

Stage I Rectal Cancer: Identification of High-Risk Patients

BACKGROUND Stage I rectal cancer (T1, T2 N0) is currently treated by surgical resection alone. Despite adequate surgical resection, approximately 10-15% of patients will develop recurrence. Identification of patients at high risk for recurrence could potentially lead to an improvement in outcome by selection of these patients for adjuvant therapy. METHODS Between June 1986 and September 1996, 211 patients with primary rectal cancer (stage I) were treated by radical surgical resection alone. The medical data of all patients were entered into a database and prospectively followed. The following 10 prognostic factors were correlated with recurrence and tumor-related mortality: patient factors: age, gender, and preoperative carcinoembryonic antigen level; tumor factors: location from the anal verge (< 6 cm vs. > or = 6 cm), T stage (T1 vs. T2), intratumoral blood vessel invasion (BVI), intratumoral lymphatic vessel invasion, presence of tumor ulceration, and histologic differentiation; and treatment-related factors: extent of surgical resection--abdominal perineal resection versus low anterior resection. Univariate analysis of the effect of the prognostic factors on recurrence and tumor-related mortality were performed by the method of Kaplan-Meier and log rank test. Independent prognostic factors were determined by a multivariate analysis performed using the Cox proportional hazards model. RESULTS The overall 5-year actuarial recurrence was 12% and tumor-related mortality was 10%. Independent predictors of recurrence were male gender and BVI. Independent predictors of tumor-related mortality were male gender, BVI, and poorly differentiated tumors. CONCLUSIONS Despite radical resection, patients with stage I rectal cancer with male gender, BVI, and poorly differentiated tumors should be considered high-risk patients.

Malignant melanoma of the anorectum

Melanoma is a virulent tumor that can be widely disseminated and is genrally incurable even when the primary growth is small. Review of the cases of 34 patients with primary melanoma of the anorectum, with follow-up ranging from two to five years, suggests that improvement in survival depends on acute surgical awareness and aggressive surgical intervention.

Long-Term Outcome of Perianal Paget’s Disease

AbstractPURPOSE: Extramammary Paget’s disease of the perianal region is a rare finding that often results in delayed diagnosis and treatment. Although the natural history of the disease is not well characterized, it historically has been associated with other cancers. This study summarizes the history and treatment of all patients diagnosed with perianal Paget’s disease at a single institution. METHODS: Charts of all patients with a diagnosis of extramammary Paget’s disease of the perianal region confirmed or treated at Memorial Sloan-Kettering Cancer Center between 1950 and 2000 were reviewed. Patients with vulvar Paget’s disease or Bowen’s disease were excluded except when Paget’s disease of the perianal region was diagnosed first. Whenever possible, follow-up information was updated. Estimates of overall and disease-free survival were made by the method of Kaplan and Meier. RESULTS: Twenty-seven patients with a median age of 63 years were diagnosed with perianal Paget’s disease. Most patients (74 percent) were treated with wide excision. Local recurrence occurred in 37 percent of all patients treated and in 30 percent of patients (6/20) undergoing a wide excision as part of their treatment. An invasive component was identified in 44 percent of patients (12/27) with perianal Paget’s disease. Six patients (22 percent) required a colostomy as part of the treatment for their disease. Adjuvant chemoradiotherapy was used in 22 percent of patients (6/27) who had more aggressive disease. At a median follow-up of 67 months, 56 percent (15/27) had no evidence of disease, and two patients had died of metastatic disease. The overall and disease-free survival at five years was 59 and 64 percent, respectively, which decreased to 33 and 39 percent, respectively, by ten years. CONCLUSIONS: Perianal Paget’s disease is a rare finding even at a large referral center. The disease process is generally a prolonged one marked by frequent recurrences, and the treatment of first choice is wide excision. Patients with invasive malignancies require more extensive surgery. The role of chemoradiotherapy remains undefined in this disease.

Favorable short-term and long-term outcome after elective radical rectal cancer resection in patients 75 years of age or older

PURPOSE: Because the elderly population in Western countries is rapidly increasing, as is their life expectancy, studies aimed at determining the impact of major surgery for primary rectal cancer in this group are warranted. The purpose of this study was to compare perioperative morbidity and mortality and long-term disease-specific and overall survival in primary rectal cancer patients, older and younger than 75 years of age, subject to major pelvic surgery. METHODS: From September 1986 to December 1996, the Prospective Colorectal Service Database identified 1,120 consecutive patients who underwent major pelvic surgery for primary rectal cancer. Of these, 157 (15 percent) were 75 years of age or older and comprise the elderly group. From the remaining 963 patients younger than 75 years of age, a representative random sample of 174 was selected and constitutes the younger group. Data were obtained from computerized databases and confirmed via chart review and telephone interviews. RESULTS: Perioperative complications were observed in 53 (34 percent) elderly and 63 (36 percent;P=not significant) younger patients. Perioperative deaths occurred in two (1.3 percent) elderly and one (0.6 percent;P=not significant) younger patient. The median follow-up time was 48 months. Although the overall survival was lower in the elderly group (P=0.02; the 5-year overall survival rates were 51 and 66 percent), the disease-specific survival rate was similar in the two groups (P=0.75; the 5-year disease-specific survival rates were 69 and 71 percent). CONCLUSION: In select individuals 75 years of age or older, major pelvic surgery for primary rectal cancer can be done with perioperative morbidity and mortality rates comparable to those obtained in younger individuals, while achieving excellent disease-specific and overall long-term survival.

Anorectal carcinoid tumors. Is aggressive surgery warranted

The management of large carcinoid tumors of the anorectum is controversial. Most carcinoid tumors of the rectum and anus are early lesions, adequately treated by local excision. However, because of their relative rarity, the number of advanced cases seen at most institutions is small. Forty-three patients with anorectal carcinoid tumors were treated at our institution between 1960 and 1988 with complete follow-up. The median age of onset was 56 years. Eleven patients had no symptoms and the tumor was detected incidentally in eight additional patients with other diseases. Twenty tumors were larger than 2 cm in diameter and all patients had symptoms. Eight patients had another malignancy and three patients had ulcerative colitis. An association between ulcerative colitis and rectal carcinoid tumors is not widely appreciated. Eighteen tumors were treated by local excision, 16 by radical surgery, and nine underwent only biopsy. With complete resection of the primary lesion, local recurrence was never a problem. The median survival from diagnosis was 38 months in this series and 23 patients died of disease. After detection of metastases, the median survival time was 10 months. Tumors more advanced that T2 or larger than 2 cm in diameter were always fatal. All 13 patients with involved lymph nodes died of metastatic disease, with a median survival of 10 months, although one lived 9 years. Advanced rectal carcinoid tumors are aggressive malignancies. Adequate local excision controls regional disease but rectal carcinoid tumors are cured only when they are discovered before the T3 stage, measure less than 2 cm in diameter, and when lymph nodes are not involved. Consequently if a local excision permits complete resection, radical extirpative surgery will provide little benefit.