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Excision repair of pyrimidine dimers from simian virus 40 minichromosomes in vitro.

The ability of DNA repair enzymes to carry out excision repair of pyrimidine dimers in SV40 minichromosomes irradiated with 16 to 64 J/m2 of UV light was examined. Half of the dimers were substrate for the DNA glycosylase activity of phage T4 UV endonuclease immediately after irradiation, but this limit decreased to 27% after 2 h at 0 degrees C. Moreover, the apyrimidinic (AP) endonuclease activity of the enzyme did not incise all of the AP sites created by glycosylase activity, although all AP sites were substrate for HeLa AP endonuclease II. The initial rate of the glycosylase was 40% that upon DNA. After incision by the T4 enzyme, excision was mediated by HeLa DNase V (acting with an exonuclease present in the chromatin preparation). Under physiological salt conditions, excision did not proceed appreciably beyond the damaged nucleotides in DNA or chromatin. With chromatin, about 70% of the accessible dimers were removed, but at a rate slower than for DNA. Finally, HeLa DNA polymerase beta was able to fill the short gaps created after dimer excision, and these patches were sealed by T4 DNA ligase. Overall, roughly 30% of the sites incised by the endonuclease were ultimately sealed by the ligase. The resistance of some sites was due to interference with the ligase by the chromatin structure, as only 30-40% of the nicks created in chromatin by pancreatic DNase could be sealed by T4 or HeLa DNA ligases. The overall excision repair process did not detectably disrupt the chromatin structure, since the repair label was recovered in Form I DNA present in 75 S condensed minichromosomes. Although other factors might stimulate the rate of this repair process, it appears that the enzymes utilized could carry out excision repair of chromatin to a limit near that observed at the initial rate in mammalian cells in vivo.

Chromosomes↗

Immunosuppression following excision of burn eschar and syngeneic grafting in major thermal trauma.

Recent reports have suggested that very early excision (less than 24 hours post-burn) and primary closure of burn wounds might circumvent the immunosuppression which follows severe thermal trauma. The total body surface are (TBSA) involved in burn injuries of human subjects at risk for significant post-burn immunosuppression is large enough to require grafting. In the present study cell-mediated immunity was measured via one-way allogeneic mixed lymphocyte reactions (MLR) in mice subjected to full-thickness scald wounds over 25-30 percent TBSA followed by escharectomy and syngeneic full-thickness skin grafting. A significant decrease in the proliferative capability of T-cells could be demonstrated on days five and seven post-treatment in unburned grafted animals (day five, 30.7 percent; day seven, 24.8 percent) over untreated normals. T-cells from animals burned but not excised also showed significant hyporesponsiveness (day five, 33.2 percent; day seven, 26.1 percent normal MLR). Animals undergoing both burning and excision showed even more profound immunosuppression (day five, 18.3 percent to 23.7 percent; day seven, 7.4 percent to 11.6 percent normal MLR). Surgical incision without excising the skin did not suppress cell-mediated immunity (day five, 90.8 percent; day seven, 90.4 percent normal MLR). When T-cells from treated animals of each group (with the exception of the incision control group) were added to normal MLR cultures, significant (greater than 50 percent) cell-mediated suppression by suppressor T-cells could be demonstrated. This study showed that the trauma of excision and grafting alone results in depression of cell-mediated immunity. These data call into question the ability of very early excision and grafting to alter the immunosuppression which follows severe thermal trauma.

Animals↗

Survey of surgical management of malignant melanoma in Canada: optimal margins of excision and lymph-node dissection.

The feasibility of clinical trials involving the surgical management of primary melanoma was assessed through a survey of Canadian surgeons who treat this disease. Surgeons were polled as to their current practice regarding node dissection and margins of resection of the primary lesion. Their interest in randomized trials addressing these practices was also assessed. Two hundred and forty questionnaires were distributed to 20 centres across Canada. The total number of patients with melanoma seen annually by the 131 surgeons who responded was 790 - of the approximately 1000 new cases of melanoma diagnosed in Canada each year. Of responding surgeons, 63% currently perform wide excision (taking 3 to 5 cm of normal tissue) for lesions less than 1.5 mm in depth and 37% perform limited excision (including 1 to 2 cm of normal tissue). Of all surgeons responding, 76% were interested in a randomized trial comparing wide and limited excision in these superficial lesions. Currently, 90% of surgeons perform wide excision of lesions 1.5 mm or more in depth and 10% perform limited excision. Fifty-nine percent were interested in a randomized trial comparing wide and limited excision in these deeper lesions. Twenty-four percent of surgeons routinely perform prophylactic node dissection on all patients with lesions 1.5 mm or more in depth; 66% wait until there is clinical suspicion of nodal metastases and 9% follow some other policy. The results of this survey indicate that (a) surgical management is varied, (b) radical surgery remains common practice and (c) surgeons are interested in randomized trials that will determine optimal treatment.

Canada↗

[Excision repair of plasmid in competent Escherichia coli cells].

Excision repair in calcium-treated cells E. coli K12, which are usually used for transformation, was studied. A great decrease in excision repair capacity of calcium-treated cells compared to that of untreated cells was observed when cells were incubated in buffer. Analysis of excision repair in E. coli cells were performed by following methods: (1) plasmid DNA, treated in vivo with 8-methoxypsoralen (8-MOP) plus light (lambda less than 310 nm) was transformed into calcium-treated E. coli cells and excision of 8-MOP monoadducts was measured by method of repeated irradiation; (2) plasmid DNA, treated with 8-MOP plus light or irradiated at 254 nm in calcium-treated cells, was isolated, and conversion of supercoil plasmid DNA to relaxing form was detected by agarose gel electrophoresis. Excision repair capacity of calcium-treated cells was restored to the level of that of intact cells after the addition of carbon nutrients (L-broth, glucose). It is supposed that decrease in excision repair capacity of calcium-treated cells is due to the limitation of the intracellular energy sources (probably, ATP), required for the formation of single-stranded nicks in damaged DNA by UVR ABC--endonuclease.

Calcium↗

[Radiosurgical excision in the treatment of cervical intraepithelial neoplasia].

39 patients affected by CIN had undergone radio surgical excision. This non-traumatic method employs 3.8 MHz radio waves are employed to cut and/or coagulate. The radio surgical excision was carried out by a loop electrode, or microneedle, according to the colposcopic, histologic and microcolpohysteroscopic characteristics of the cervical lesion. In fact 14 patients, among whom 11 affected by CIN I and 4 by CIN II with a total visibility of squamous columnar junction and not extended lesion of the cervical canal, had undergone radio surgical excision through various dimensions loop according to the size of the tissue to be excised. Whereas 10 CIN II patients who had not entirely visible squamous columnar junction or large cervical canal lesion, and 14 CIN III patients underwent to radiosurgical conization through a subtle and extensible tungsten thread according to the size of the tissue to be excised. In the 100% of the both groups the recovery was confirmed after three and six months. Inno cases cervical canal stenosis was observed and the squamous columnar junction resulted well visible. In both groups no thermal damages on the excised tissue, which could create difficulties on the histological diagnosis, were observed. Therefore, this method resulted an easy and cheap technique to be executed in surgery with excellent results under the therapeutic and economical aspect.

Adult↗

Metabolic processing of cyclobutyl pyrimidine dimers and (6-4) photoproducts in UV-treated human cells. Evidence for distinct excision-repair pathways.

A new nuclease digestion assay was developed to elucidate the human excision-repair system operating on cyclobutyl pyrimidine dimers and (6-4) photoproducts. We analyzed lesions that accumulated in excised oligonucleotide fragments during incubation of UV-treated cultured fibroblasts. (6-4) photoproducts were removed intact, whereas excised cyclobutyl dimers often contained ruptured interpyrimidine phosphodiester bonds, raising the possibility that the intradimer backbone-cleavage reaction may help promote the bypass of unexcised dimers by the DNA replication or RNA transcription machinery. Cell strains representing eight different inherited forms of the cancer-prone skin disease xeroderma pigmentosum (XP) were generally found to exhibit characteristic abilities to excise the two classes of photolesions, ranging from total deficiency in groups A and G to normal proficiency in the variant. The capacity of any given XP group to act on one class of photoproducts in no way predicted its ability to act on the other. Finally, in those XP strains displaying significant levels of dimer removal, the ratio of intact-versus-modified dimers was normal, implying that rupture of the intradimer backbone linkage occurs independently of subsequent excision-repair reactions. Our data indicate that cyclobutyl dimers and (6-4) photoproducts are processed by distinct nucleotide-excision-repair pathways in human cells.

DNA↗

Recurrent pilonidal sinus after excision with closed or open treatment: final result of a randomised trial.

OBJECTIVE: To find out the recurrence rate of chronic pilonidal sinus after excision and primary suture compared with open excision and healing by second intention. DESIGN: Randomised trial. SETTING: Teaching hospital, Norway. SUBJECTS: 120 Patients treated between 1987 and 1989. INTERVENTIONS: 60 Patients were treated by excision and primary suture and 60 by open excision. The median follow-up period was 4.2 years. RESULTS: Recurrent pilonidal sinus was seen in six patients (10%) after primary suture compared with three patients (5%) after open treatment (p = 0.49); 57 (95%) and 55 (92%), respectively, were satisfied with the outcome of treatment at follow-up (p = 0.72). CONCLUSION: Excision and primary suture compares favourably with open excision and healing by second intention in the treatment of chronic pilonidal sinus.

Adolescent↗

Anterior resection controls cancer of the rectum as well as abdominoperineal excision.

OBJECTIVE: To evaluate our results of anterior resection and abdominoperineal (AP) excision for the treatment of rectal cancer in terms of survival and local recurrence, and to assess the importance of clinical anastomotic leaks in the development of local recurrence. DESIGN: Retrospective study. SETTING: University hospital, Finland. SUBJECTS: 199 patients who underwent elective and curative operations for rectal cancer during the period 1981-1990. INTERVENTIONS: 83 AP excisions and 116 anterior resections. MAIN OUTCOME MEASURES: Five year survival and rate of local recurrence. RESULTS: The proportion of anterior resections increased (compared with AP excisions) significantly from 43% (40/94) in the period 1981-1985 to 72% (77/107) in the period 1986-1990, but five year survival did not change (71% and 68%, respectively). 81 patients (41%) developed recurrences, 56 (28%) of which were local and 40 (20%) were restricted to the pelvis. Local recurrence was significantly more common after AP excision (30/83, 36%) than after anterior resection (26/116, 22%, p < 0.05). Advanced stage (Dukes' C) was a risk factor for local recurrence, but not the distance of the tumour from the anal verge. There were no significant differences between AP excision and anterior resection in patients with tumours in the distal two thirds of the rectum in terms of local recurrence (30/82, 37% compared with 14/62, 23%) and estimated overall five year survival (52/82, 63%, compared with 43/62, 69%). The corresponding figures for each stage were stage A, 19/21 (90%) compared with 20/21 (95%); stage B, 23/34 (68%) compared with 21/24 (88%); and stage C, 10/27 (37%) compared with 5/16 (31%). There were no significant differences between patients who developed clinical leaks (6/19, 32%) and those who did not (20/97, 21%) by stage in proportion of patients free from local recurrence and survival at five years. CONCLUSION: The significantly increased number of anterior resections compared with AP excisions of the rectumin did not compromise our results in terms of local recurrence and five year survival, but did reduce the number of permanent colostomies.

Adult↗

Results of local excision for rectal carcinoma.

OBJECTIVE: To determine the results peranal excision for rectal carcinoma. DESIGN: Retrospective case series. SETTING: A university-affiliated hospital. PATIENTS: Of 178 patients who presented for curative resection of rectal carcinoma between 1975 and 1993, 19 (10.7%) were deemed suitable for local excision. There were 10 men and 9 women with a mean age of 71.2 years. The follow-up ranged from 13 to 184 months. INTERVENTION: Peranal excision. MAIN OUTCOME MEASURES: Histologic differentiation, gross morphology, depth of invasion and size of the carcinoma, adequacy of margins of excision, complications of operation, rates of recurrence, results of salvage therapy and 5-year survival. RESULTS: There were no intraoperative complications. Postoperative complications included urinary retention (one patient) and bleeding (one patient). There were five local recurrences (26%). Salvage operations were performed in three (60%) patients and were successful in two of them. The 5-year cancer-specific survival rate was 82%. The recurrence rate was higher in patients with inadequate margins of excision and ulcerative lesions. Neither size nor grade of the carcinoma correlated with recurrence. CONCLUSIONS: Local excision of rectal carcinoma can be performed successfully in selected patients. Diligent follow-up is required, because up to 60% of local recurrences can be treated successfully.

Aged↗

Nucleotide excision repair of melphalan monoadducts.

The nucleotide-excision repair (NER) system removes bulky DNA adducts and is thought to be involved in resistance to chemotherapeutic drugs, which act by damaging DNA. In this study, we have investigated the ability of the NER system to recognize and excise melphalan monoadducts from a 140-mer DNA substrate. We show that rodent and human cell-free extracts (CFEs) excise 26-29-nt-long oligomers from a synthetic 140-mer containing centrally located melphalan adducts. CFEs from cell lines with mutations in xeroderma pigmentosum group F or G genes did not excise these alkylated oligomers; however, mixing the two CFEs restored excision activity to the level found with wild-type CFEs. These results demonstrate the ability of the NER system to excise melphalan monoadducts, and are consistent with the hypothesis that NER may be involved in resistance to melphalan chemotherapy.

Alkylation↗

Lymphoscintigraphy of melanoma: lymphatic channel activity guides localization of sentinel lymph nodes, and gamma camera imaging/counting confirms presence of radiotracer in excised nodes.

UNLABELLED: Lymphoscintigraphy has become a standard preoperative procedure to map the cutaneous lymphatic channel for progression of nodal metastasis of melanoma of the skin. Lymphoscintigraphy was employed to visualize lymphatic channels as a guide to identify sentinel lymph nodes (SLNs). Excised tissue was imaged with a gamma camera to verify the findings of presurgical lymphoscintigraphy. Percent counts of SLN(s) among the total counts of the excised melanoma tumor or scar tissue and SLN(s) were calculated. METHODS: Eleven patients with cutaneous melanoma received four to ten intradermal injections of Tc-99m sulfur colloid at elual distances around the melanoma site. Images were made immediately after injection: 1 minute per image for 15 min; and then 5 minutes or 1,000,000 counts per image for 30 min. After surgery, the excised melanoma tumor or scar and SLN(s) were imaged/counted with a gamma camera. Percent counts of SLNs among the total counts of the excised melanoma tumor or scar tissue and SLNs were calculated. To validate the specimen count accuracy, an experimental phantom study was done. RESULTS: Linear lymphatic channels were identified between the injected sites and the SLNs in each patient. Gamma camera images demonstrated radioactivity in the SLNs of all patients, verifying the lymphoscintigraphy findings. Uptake in the SLNs of ten of the eleven patients ranged from 0.4 to 7.2% (mean 2.2%) of the total counts in excised tissue. We noted that a node with lower uptake should not be ignored because a lower percent of SLN activity does not necessarily rule out existing metastasis. In two of eleven patients, histopathologic showed metastases. One patient's melanoma on the middle back had lymphatic channel activity directed to both axillae. The results of the phantom study validated accuracy of our specimen counts. CONCLUSIONS: Because linear lymphatic channels existed between lymph nodes and the injected sites in all eleven patients, these lymphatic channels could be used as a guide for localizing SLNs. The SLNs indicated by presurgical lymphoscintigraphy were verified by postoperative gamma camera imaging, and radiotracer localization in the SLNs averaged 2.2%.

Adult↗

Cervical lymph node metastasis after local excision of early squamous cell carcinoma of the oral cavity.

A total of 54 patients with stage I and stage II squamous cell carcinoma of the oral cavity were reviewed as to treatment modality, adequacy of treatment, and site of failure. Surgery was employed as the sole initial treatment modality in 52 patients. Forty-three underwent primary tumor excision alone and 9 underwent elective neck dissection at the time of primary tumor excision. The patients who underwent elective neck dissection at the time of excision of the primary tumor had a 3 year survival rate of 88 percent, in comparison to a survival rate of 77 percent in those patients whose initial therapy was directed solely at the primary tumor. A low incidence of local recurrence (2 percent) and a high incidence of neck recurrence (42 percent) were documented in those patients treated by primary tumor excision alone. Patients who underwent salvage neck dissection for recurrent neck node metastases had a 3 year survival rate of 56 percent. This study has documented a high incidence of cervical node recurrence in patients with T1 and T2 squamous cell carcinomas of the oral cavity treated by primary tumor excision alone and a poor survival rate after salvage therapy. A small group of patients who underwent elective neck dissection had a demonstrably high survival rate. These observations lend support to the call for elective neck dissection in patients with stage I and II oral cavity carcinoma but are not conclusive. Therapeutic decisions regarding elective treatment of the neck will continue to be made according to the best judgment and prejudices of the individual surgeon until a prospective, randomized multi-institutional study addressing this specific issue is undertaken.

Adult↗

Sentinel lymph-node biopsy after previous wide local excision for melanoma.

OBJECTIVE: To document experience with sentinel lymph-node biopsy in patients who have already undergone a wide local excision for melanoma because in many centres previous wide excision has been a contraindication for sentinel lymph-node biopsy. DESIGN: A prospective cohort study. SETTING: A tertiary care academic cancer centre. PATIENTS: One hundred patients who presented with cutaneous melanoma (depth >1 mm or Clark level IV) after having undergone wide local excision of the primary lesion that was not situated in the head or neck. The follow-up was 3 years. INTERVENTIONS: Sentinel lymph-node biopsy. Patients with truncal melanoma had preoperative lymphoscintigraphy to document the nodal basins at risk. Technetium-99m sulfur colloid (0.5-1 mCi in 0.5 mL) was injected intradermally around the scar, and the sentinel lymph node was excised with the aid of a hand-held gamma detector. OUTCOME MEASURES: Accuracy of the biopsy and false-negative rates in this setting. RESULTS: Of the 100 patients, 44 had truncal and 56 had extremity lesions. The average tumour depth was 3.47 mm and 3.07 mm respectively. Thirty-one patients had a sentinel lymph node positive for melanoma metastasis. Biopsies were positive for melanoma in 18 (41%) truncal lesions and 13 (23%) extremity lesions. There were 3 (9%) false-negative sentinel lymph-node biopsies as diagnosed by clinically evident nodal disease subsequently appearing in the nodal basin subjected to biopsy. Two occurred in patients after large rotation flap closures of truncal lesions. The third patient had a subungual melanoma of the great toe. No disease was found in the 2 nodes dissected. Two of the 3 false-negative biopsy results were obtained before serial sections and immunohistochemical staining were used to examine the sentinel lymph nodes. CONCLUSIONS: Sentinel lymph-node biopsies can successfully identify clinically occult nodal metastases in patients who have had previous wide local excision of a melanoma, but the false-negative rate in patients with rotation flap closures should be taken into consideration.

Contraindications↗

An assessment of incomplete facial Basal cell carcinoma excision.

OBJECTIVE: To determine the rate and cause(s) of incomplete excision of basal cell carcinoma, occurring on face. DESIGN: A non-interventional, descriptive study. PLACE AND DURATION OF STUDY: Plastic Surgery Unit, Hayatabad Medical Complex, Peshawar, from January 2002 to March 2004. PATIENTS AND METHODS: Patients with basal cell carcinoma of the face reporting to the OPD were included in the study and were booked for surgery. After excision, all tumors specimens were marked at 12 o'clock and sent to laboratory for histopathology to confirm the diagnosis and to know the completeness/incompleteness of tumor excision. If biopsy reported residual tumor in any of the margins it was noted and projected as percentage for the purpose of our results. RESULTS: Out of 56 patients, 49 (87.5%) had complete excision of tumor. Six (10.7%) had residual tumor while in one (1.7%) patient, biopsy report failed to mention the involvement/clearance of margins. Six patients with residual tumor were given postoperative radiotherapy. All patients were followed for a minimum of 2-1/2 years (critical period for recurrence) with careful watch on those with residual tumor. So far, only 2 of these 6 had recurrence of lesion. Both of them were greater than 2 cm in diameter and were located on medial canthal and nasolabial region. CONCLUSION: Chances of incomplete tumor excision are more on the mid face region. Patients with residual tumor are more prone to recurrence.

Adult↗

Comparison of fine needle aspiration cytology with excision biopsy of breast lump.

OBJECTIVE: To evaluate the results of fine needle aspiration cytology (FNAC) of breast lump by histopathology of excision biopsy specimen in the same group of patients. DESIGN: A descriptive study. PLACE AND DURATION OF STUDY: Department of Surgery, Federal Government Services Hospital, Islamabad from October, 2000 to March, 2001. MATERIALS AND METHODS: There were 50 patients in the study, who were subjected to fine needle aspiration cytology with a needle of 22G mounted on 20 cc syringe. Smears were fixed on the slides with 95% alcohol and later stained with hematoxylin and eosin stain. After FNAC, all the patients were subjected to excision biopsy. The specimen were reported by the Histopathologist and results evaluated and compared. RESULTS: All patients were among the total number of 61 FNAC performed, conclusive malignancy (C5) was found in 20(40%) patients and in 1(2%) patient, malignancy was suspected (C4). Conclusive benign lesions (C2) were found in 26(52%) patients and 2 patients had atypia i.e. (C3). Inadequate specimen (C1) was found in 2(4%) patients. On excision biopsy, 22(44%) patients had malignant lumps and 28(56%) benign. FNAC was able to detect 20 malignant lumps with sensitivity of 90.90%. All of them were also reported malignant on excision biopsy with specificity of 100%. False positive were zero and false negative were 9.1%. CONCLUSION: FNAC is simple, quick, safe, tolerable, cosmetically acceptable, reliable and cost-effective method of determining histology of breast lumps. The absence of false positives conclusively confirmed its place not only as a complimentary adjunct but also a substitute of excision biopsy in majority of instances.

Adolescent↗

Effect of pterygium morphology on pterygium recurrence in a controlled trial comparing conjunctival autografting with bare sclera excision.

OBJECTIVES: To compare success rates of conjunctival autografting and bare sclera excision for primary and recurrent pterygium in the tropics and to evaluate risk factors for pterygium recurrence. METHODS: A prospective, controlled clinical trial was performed in which 123 primary and 34 recurrent pterygia, matched for age and pterygium morphology, were randomized in 2 separate studies to receive either bare sclera excision or conjunctival autograft. The surgical procedures were performed by one surgeon and reviewed at 1, 3, 6, and 12 months after surgery by an independent observer. Pterygium morphology was clinically graded as atrophic, intermediate, or fleshy according to an assessment of pterygium translucency. Risk factors were assessed using likelihood ratio tests. Weibull curves were used to estimate recurrence rates allowing for the interval censoring. RESULTS: In the group with primary pterygium (mean follow-up, 15.1 months), 38 (61%) of the 62 cases of bare sclera excision (heretofore referred to as the bare sclera group) had pterygium recur in contrast with 1 (2%) of the 61 cases of conjunctival autograft (heretofore referred to as the conjunctival autograph group) (P<.001, likelihood ratio X2 test). Nontranslucency, or fleshiness of the pterygium, and not age was a significant risk factor for recurrence in the bare sclera group (P<.001, likelihood ratio X2 test). In the group with recurrent pterygium (mean follow-up, 13.2 months), 14 (82%) of the 17 bare sclera group had pterygium recur, while no recurrences occurred among 17 cases in the conjunctival autograft group. Nontranslucency was again a highly significant factor for recurrence (P<.001, likelihood ratio X2 test). CONCLUSIONS: Pterygium recurrence is related to pterygium morphology and fleshiness of the pterygium is a significant risk factor for recurrence if bare sclera excision is performed. Conjunctival autografting for primary and recurrent pterygium is effective in reducing pterygium recurrence compared with bare sclera excision.

Adult↗

Carbon dioxide laser excision of earlobe keloids. A prospective study and critical analysis of existing data.

When steroid injections have failed, the most common approach for the treatment of earlobe keloids is surgical excision. The carbon dioxide laser has recently been used with varying reported success in the treatment of keloids and hypertrophic scars. Proponents of this technique claim that the intrinsic properties of laser surgery, which slows fibroblast proliferation, may be responsible for delaying or preventing the recurrence of keloids. We report results on the effectiveness of carbon dioxide laser excision of earlobe keloids. Eighteen patients were followed up from 8 months to 2 years, or up to a recurrence. Four patients within this group with bilateral keloids provided a self-controlled sample. One ear was randomly chosen for laser excision and the other for scalpel excision. There were recurrences in both groups. There were also 17 recurrences in a group of 23 keloids excised by laser, 9 occurring between 6 and 12 months postoperatively. We failed to demonstrate a lower recurrence rate of earlobe keloids using the carbon dioxide laser and discuss some of the factors responsible for this outcome.

Adolescent↗

Rectal cancer: the Basingstoke experience of total mesorectal excision, 1978-1997.

OBJECTIVE: To examine the role of total mesorectal excision in the management of rectal cancer. DESIGN: A prospective consecutive case series. SETTING: A district hospital and referral center in Basingstoke, England. PATIENTS: Five hundred nineteen surgical patients with adenocarcinoma of the rectum treated for cure or palliation. INTERVENTIONS: Anterior resections (n = 465) with low stapled anastomoses (407 total mesorectal excisions), abdominoperineal resections (n = 37), Hartmann resections (n = 10), local excisions (n = 4), and laparotomy only (n = 3). Preoperative radiotherapy was used in 49 patients (7 with abdominoperineal resections, 38 with anterior resections, 3 with Hartmann resections, and 1 with laparotomy). MAIN OUTCOME MEASURES: Local recurrence and cancer-specific survival. RESULTS: Cancer-specific survival of all surgically treated patients was 68% at 5 years and 66% at 10 years. The local recurrence rate was 6% (95% confidence interval, 2%-10%) at 5 years and 8% (95% confidence interval, 2%-14%) at 10 years. In 405 "curative" resections, the local recurrence rate was 3% (95% confidence interval, 0%-5%) at 5 years and 4% (95% confidence interval, 0%-8%) at 10 years. Disease-free survival in this group was 80% at 5 years and 78% at 10 years. An analysis of histopathological risk factors for recurrence indicates only the Dukes stage, extramural vascular invasion, and tumor differentiation as variables in these results. CONCLUSIONS: Rectal cancer can be cured by surgical therapy alone in 2 of 3 patients undergoing surgical excision in all stages and in 4 of 5 patients having curative resections. In future clinical trials of adjuvant chemotherapy and radiotherapy, strategies should incorporate total mesorectal excision as the surgical procedure of choice.

Adenocarcinoma↗