Carcinoma of the rectum. Choice between anterior resection and abdominal perineal resection of the rectum.
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Abdomen↗
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Results for “Sigmoid Neoplasms”
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Carcinoma associated with mucosal ulcerative colitis, and with transmural colitis and enteritis (Crohn's disease).
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Adolescent↗
Proceedings: Changing patterns of colorectal carcinoma.
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Colonic Neoplasms↗
Preoperative radiation therapy. A plan for combined therapy by the Radiation Therapy Oncology Group and the Central Oncology Group.
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Evaluation Studies as Topic↗
Preoperative irradiation and surgery for certain cancers.
Failure to cure cancer by surgery is caused by inability to remove all local extensions of the lesion or from prior or synchronous dissemination of tumor cells. Laboratory evidence has suggested that preoperative irradiation of the primary tumor can increase cure rates. In the clinical realm, the efficacy of preoperative irradiation appears to vary with specific tumors. Lung cancer shows no improvement in survival. Cancers of the bladder and breast may show enhancement of cure rate. Data indicate that cancer of the rectosigmoid does benefit from preoperative therapy. Adherence to important factors of dosage and timing of operation is necessary to prevent undesirable complications. Randomized clinical trials are needed to establish the efficacy of this combined modality treatment system. This is particularly true since both these modalities can be applied on a wide-scale basis if beneficial effects are conclusively demonstrated.
Breast Neoplasms↗
Preoperative radiotherapy for adenocarcinoma of the rectosigmoid.
Ninety-seven patients with adenocarcinoma of the rectosigmoid have been treated with high dose (5000-6000 rad) preoperative irradiation from 1960 through 1972 at the University of Oregon Health Sciences Center. Fifty-seven were initially clinically resectable and 40 were initially inoperable. Forty of the 57 initially clinically resectable patients had "curative" resections and are at risk for more than 5 years. An increase in 5-year survival (from 38% to 53%) and an absence of pelvic recurrence have occurred in those patients receiving preoperative irradiation and "curative" resection. Four of the 40 initially inoperable patients are alive without tumor. Three of the four survivors had irradiation and surgery; one had irradiation only. An additional four patients had no evidence of tumor at death. Tumor was totally sterilized by irradiation and nine patients and reduced to microfocal extent in an additional three of the 97 patients. Incidence of complications was no greater than has been reported in a surgical series from the same institution.
Adenocarcinoma↗
Abdominoperineal resection following anterior resection.
A series of 11 patients undergoing abdoninoperineal resection for "suture line recurrence" following anterior resection is presented. Five-year survival is 10%. Technically, the procedure is difficult and major problems are encountered, including large blood loss and ureteral complications. These patients had an inadequate distal margin of resection at the time of anterior resection. The survival of this group of patients underscores the importance of making the correct judgment about anterior or abdominoperineal resection at the time of the initial presentation of the patient. The phrase "suture line recurrence" is a misnomer; all of these patients had advanced pelvic malignancy. If the adequacy of the distal margin is questionable or a distal margin of 5 cm cannot be obtained safely at the time of anterior resection, abdominoperineal resection should be performed, as the opportunity for cure of a recurrence should this rule be compromised is limited.
Female↗
Radiation therapy of colorectal cancer.
Radiation therapy has been used with increasing frequency in patients with carcinoma of the rectum and rectosigmoid. After surgical resection alone, local failure rates of 20 to 60% are noted, with the rate increasing with degree of penetration of tumor through the bowel wall and with presence of lymph node involvement. Preoperative or postoperative radiation therapy has been shown to decrease the local failure rate significantly, and may improve survival rates. In patients who present with locally unresectable disease, preoperative irradiation has been shown to convert a large percentage of these tumors to resectable lesions, with eventual cure in perhaps 30% of patients. Newer techniques such as intraoperative electron beam radiation therapy, may be effective in decreasing the high local failure rate in these patients, by allowing the radiation therapist to increase safely the dose to the tumor volume. Even without surgical resection, external radiation therapy alone can cure approximately 10% of these patients. For small, superficial, well-differentiated tumors within 10 cm of the anal verge, endocavitary radiation therapy is an effective method of locally controlling these tumors, while avoiding general anesthesia and avoiding colostomy.
Colonic Neoplasms↗
Low-dose preoperative irradiation, surgery, and elective postoperative radiation therapy for resectable rectum and rectosigmoid carcinoma.
A regimen of low-dose preoperative radiation therapy (RT), surgery, and elective postoperative RT for resectable carcinomas of the rectum and rectosigmoid is presented. Initial results in a group of 36 patients is discussed. In four patients clinically silent metastatic disease was discovered. Of 16 patients without indications for postoperative RT, only one died with disease. Indications for postoperative irradiation were found in 15 patients and four relapses (26%) subsequently occurred. Since the surgicopathologic stage of the tumor is the best prognostic predictor for rectal cancer, this regimen allows for the delivery of high-dose adjuvant irradiation only to those at high risk of local recurrence. Thus, this combination selects patients likely to benefit from postoperative RT while preserving the advantages of preoperative RT.
Female↗
Patterns of recurrence of rectal cancer after potentially curative surgery.
The results of surgical treatment alone for 142 cases of carcinoma of the rectum and rectosigmoid from the Massachusetts General Hospital were reviewed. The incidence of local failure as any component of failure was found to be strongly dependent on the pathologic stage, and for Dukes' A was 8.0% (3/39); Dukes' B, 31% (18/59), and Dukes' C, 50% (22/44). The incidence of local failure for tumors without lymph node metastasis was 17% with only microscopic extension through the wall (modified Astler-Coller Stage MAC-B2m), but increased to 54% in tumors that were adherent to or invading adjacent organs and structures (MAC-B3). Similarly, in tumors with positive lymph nodes, there was a 36% incidence of local failure for tumors confined to the wall or with only microscopic extension through the wall (MAC-C1/C2m), compared to a 67% incidence for tumors with adherence or involvement of adjacent organs (MAC-C3). Other predictors of local recurrence were the tumor location, grade, number of lymph nodes, and blood vessel invasion. The pathologic factors predicting distant metastasis are also presented. Five-year survival for Dukes' A was 77% (30/39); Dukes' B, 44% (26/59); and Dukes' C, 23% (10/44). The implications for future adjuvant therapy based on the identification of patients with the highest risk for local and distant failure are discussed.
Follow-Up Studies↗
Complications following postoperative combined radiation and chemotherapy in adenocarcinoma of the rectum and rectosigmoid. A randomized trial that failed.
A randomized multicenter trial was started to evaluate the effect of irradiation combined with 5-fluorouracil and methotrexate on survival after surgery for rectal and rectosigmoidal carcinoma, Dukes' stages B and C. The trial was terminated prematurely after entrance of 34 patients due to frequent and serious complications. Three patients died as a direct consequence of the adjuvant treatment.
Adenocarcinoma↗
Adjuvant postoperative radiotherapy in carcinoma of the rectum and rectosigmoid.
Local recurrence occurs in 30% to 50% of rectal cancer patients treated with surgery alone if there is tumor extension beyond the bowel wall alone or in conjunction with nodal involvement. This analysis is of 97 such patients who received postoperative irradiation (XRT) in prospective and standardized fashion at Massachusetts General Hospital (MGH) (4500 rad in 25 fractions to large fields and minimum dose of 5040 rad in 28 fractions within a boost field). Results were compared with a group of 103 previously analyzed patients treated with surgery alone at MGH. A statistically significant decrease in local recurrence was seen in four of the six irradiated subgroups (modified Astler-Coller Stages B2g, B3, C1 + C2m, and C2g) at an interval 3 years from resection. This improvement was achieved with no increase in small bowel complications (4% with XRT versus 5% with surgery alone) in view of efforts at surgical reconstruction and use of multiple-field XRT techniques, bladder distension, etc.
Adenocarcinoma↗
Argyrophilic prostatic carcinoma. Case report with literature review on prostatic carcinoid and "carcinoid-like" prostatic carcinoma.
An unusual prostatic neoplasm characterized by a carcinoid-like light microscopic pattern together with argyrophilia of tumor cells is described. Immunoperoxidase stain for prostatic specific antigen, however, was positive, indicating that this neoplasm was an argyrophilic prostatic carcinoma. Although the clinical significance of a carcinoid-like pattern and/or argyrophilia in prostatic carcinoma is currently unknown, pathologic recognition of these features is of paramount importance because prostatic carcinoma with these features has to be distinguished from true primary prostatic carcinoid tumor or, in areas of metastasis, from metastatic carcinoid originating from other sites such as the gastrointestinal or respiratory tracts. The value of the immunoperoxidase technique for prostatic specific antigen as well as prostatic acid phosphatase in this differentiation is stressed.
Adenocarcinoma↗
Postoperative radiotherapy in Dukes' B and C carcinoma of the rectum and rectosigmoid. A randomized multicenter study.
Results obtained during the first 5 years of a randomized study of postoperative radiotherapy (50 Gy) are presented. Criteria for randomization were fulfilled in 494 of 861 patients with Dukes' B and C tumors, when the trial was closed. Severe complications from radiotherapy approximated 10%. Probability of survival without local failure within 24 months was significantly higher after radiotherapy in patients with Dukes' C tumors, and the time of local failure was delayed 1 year. Patients with Dukes' B tumors had no benefit from radiotherapy. Risks of distant metastases and death were not influenced by radiotherapy in the main groups. Plasma-CEA measurements were evaluated blindly, and radiotherapy changed the critical levels of CEA for detection of recurrent cancer. It was concluded that patients with Dukes' C tumors may benefit from radiotherapy and plasma-CEA levels are influenced by radiotherapy, which may be important, when these are used in screening for recurrent cancer.
Actuarial Analysis↗
Preoperative prediction of outcome in patients with rectal and rectosigmoid cancer.
This study evaluated the possibility of dividing patients with primary rectal carcinoma into prognostic groups before surgery based on preoperative serum levels of carcinoembryonic antigen (CEA), tissue polypeptide antigen (TPA), and an antigen defined by the monoclonal antibody C-50 (CA-50), as well as on some easily available clinical characteristics providing prognostic information. The evaluation was made both for patients who were "potentially curable" by surgery and, among those, for patients who were "potentially cured." Using the Cox regression model, the serum levels of the three tumor markers, together with the knowledge of whether or not the tumor was polypoid were combined to make up the set of variables that best predicted patient outcome. These variables and their associated regression coefficients were used to classify the patients according to prognosis. The cancer-specific mortality rate for the 24% of potentially curable patients with the best prognosis was 15%; for the 26% of potentially curable patients with the worst prognosis, the cancer-specific mortality rate was 57%. For potentially cured patients among those who were potentially curable, the cancer-specific mortality rates for patients with the best and worst prognoses were 14% and 47%, respectively. The information provided by these preoperatively available variables together was comparable with that given by Dukes' staging system, but the latter system was more informative. On the other hand, some of the preoperative variables provided information not provided by Dukes' staging system.
Adult↗
Intraoperative electron beam radiation therapy for recurrent locally advanced rectal or rectosigmoid carcinoma.
A multimodality approach of moderate-dose to high-dose preoperative radiation therapy, surgical resection, and intraoperative electron beam radiation therapy (IORT) has been used for patients with locally recurrent rectal or rectosigmoid carcinoma. The 5-year actuarial local control and disease-free survival for 30 patients undergoing this treatment program were 26% and 19%, respectively. The most important factor predicting a favorable outcome was complete resection with negative pathologic resection margins. The determinant local control and disease-free survival for 13 patients undergoing complete resection were 62% and 54%, respectively, whereas for 17 patients undergoing partial resection these figures were 18% and 6%, respectively. There did not appear to be a difference in local control or survival based on the original surgical resection (abdominoperineal resection versus low anterior resection). However, the likelihood of obtaining a complete resection after preoperative radiation therapy was higher in patients who had previously undergone a low anterior resection than patients undergoing prior abdominoperineal resection. For the 30 patients undergoing external beam irradiation, resection, and IORT, the most significant toxicities were soft tissue or sacral injury and pelvic neuropathy. Efforts to further improve local control are directed toward the concurrent use of chemotherapy (5-fluorouracil with and without leucovorin) as radiation dose modifiers during external beam irradiation and the use of additional postoperative radiation therapy.
Adult↗
Preoperative high-dose leucovorin/5-fluorouracil and radiation therapy for unresectable rectal cancer.
Twenty patients with primary or recurrent unresectable rectal cancer limited to the pelvis were entered on a Phase I trial of preoperative pelvic radiation therapy (RT) (5040 cGy) and two cycles of combined high-dose leucovorin (LV) and 5-fluorouracil (5-FU), followed by surgery and ten cycles of postoperative LV/5-FU (sequential). Maximum tolerated doses (MTD) were determined for preoperative combined LV/5-FU and RT and for postoperative sequential LV/5-FU. 5-FU was escalated 50 mg/m2 while the LV remained constant at 200 mg/m2. The initial doses of 5-FU were combined LV/5-FU and RT (200 mg/m2) and sequential LV/5-FU (325 mg/m2). The median follow-up time was 14 months. The resectability rate was 89%, and the pathologic complete response rate was 21%. The MTD for combined LV/5-FU and RT was 300 mg/m2; therefore, the recommended dose of 5-FU is 250 mg/m2. The recommended dose of 5-FU for sequential LV/5-FU is 375 mg/m2. The dose-limiting toxicities in this trial were diarrhea, tenesmus, increased bowel movements, dysuria, and myelosuppression. For the six patients who received 5-FU at the recommended dose level, the median low counts were leukocyte count, 3.7/microliters (range, 2.4 to 4.9/microliters); hemoglobin, 9.0 g/dl (range, 8.2 to 11.9 g/dl); and platelet count (X1000), 146/microliters (range, 89 to 182/microliters). The incidence rate of any Grade 3 toxicity was 17% (diarrhea and frequent bowel movements). The recommended doses of 5-FU used in this protocol were well tolerated. Because there was a long delay before optimal doses of 5-FU could be delivered, the authors do not recommend that high-dose LV be used in conjunction with combined 5-FU and RT with the treatment regimen as currently designed. However, because the resectability and complete response rates were higher than those previously reported for preoperative RT alone, the authors are encouraged by the combined technique approach. New trials are currently being undertaken to determine if the use of a low-dose LV regimen is more tolerable.
Antineoplastic Combined Chemotherapy Protocols↗
Use of fibrinogen to enhance the antitumor effect of OK-432. A new approach to immunotherapy for colorectal carcinoma.
OK-432 (5 KE), an immunomodulatory agent prepared from an attenuated strain of Streptococcus pyogenes, was dissolved in 1 ml of aprotinin (1000 KIE) and mixed with 80 mg of fibrinogen containing Factor XIII. A single intratumoral injection of the mixture was performed preoperatively under endoscopy in 20 patients with colorectal carcinoma. Postoperative histopathologic examinations revealed the formation of fibrin fibers at the site of injection and marked infiltration of inflammatory cells into the tumor stroma on the day after injection; the formation of granulomas containing many giant cells after 4 to 7 days; and extensive regression of tumor tissue after 14 days. This study suggests that the high concentration of exogenous fibrinogen gelatinized enough to trap OK-432 in tumor stroma and that OK-432 induced granulomatous hypersensitivity to degenerate tumor stroma, thereby causing regression of the tumors.
Adenocarcinoma↗