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Computed tomography (CT) has proved to be a powerful tool in the detection and staging of carcinomas of the colon and rectum. It is unsurpassed in the detection of recurrent colon cancer and is particularly useful in patients who have undergone abdominal-perineal resections for rectal neoplasms. The current applications of CT in colon cancer are contrasted with barium studies, endoscopy, and magnetic resonance imaging.
Many studies in the literature have confirmed the role of combined therapy in the treatment of rectal neoplasms. Aim of the Authors' study was to evaluate the efficacy of preoperative neoadjuvant radiochemotherapy in these patients. The study group consisted of 15 patients, affected by rectal adenocarcinoma T < 4 M0 with age < 75 years, observed from January to August 1998, who underwent to RT of pelvis with three fields--total dose 32 Gy- in ten days associated with 5 FU(500 mg/m2) during the first five. After restaging the patients were operated on. Anterior resections (AR) were followed by mechanical colorectal anastomosis in 10 patients, coloendoanal anastomosis in 4, while in 1 case an abdominoperineal resection (APR) was performed. The protocol was well tolerated in every patient and perioperative complications were similar to those in the control group. A considerable reduction of the mass was obtained in a great percentage of patients studied, confirmed by pathologic examination like "down staging" of cancer. In no case a complete response to the therapy was observed (pT0N0). Survival in the patients operated on for rectal adenocarcinoma in about 50% and local relapse is the most important site of recurrent disease. The aim of neoadjuvant protocol is the control of lymphatic spread and reduction rectal neoplasm allowing coloanal anastomosis in the treatment of the 1/3 inferior rectal cancer. Literature data confirm a significant decrease of local relapse, probably with a better survival. The Authors study confirms that combined preoperative therapy is well tolerated in most of the cases and it represents the protocol of choice in the patient affected by rectal cancer.
Twenty-five intrarectal ultrasound (US) scannings were performed preoperatively for assessing the depth of infiltration of rectal neoplasms. One tumour located in the distal rectum could not be visualized on the ultrasonogram. US could correctly identify extraintestinal infiltration in 13 out of 14 cases with proved extrarectal involvement on histopathological examination. The overall accuracy of US in demonstrating tumour growth outside the rectal wall was 88%, sensitivity 93% and specificity 80%. Intrarectal US is a useful additional method in the preoperative evaluation of rectal neoplasms and provides more information about the depth of tumor infiltration compared with conventional methods thus helping decide the most appropriate therapy for the patient.
Between 1978 and 1984, 34 patients carrier of rectal neoplasms, were observed and treated in Divisione di Chirurgia Generale of Casale Monferrato Hospital. Twenty of such patients had been operated with curative procedures and 14 with palliative procedures. At the moment of this investigation 14 patients were still alive. The survival rate at 5 years, referred to '78, '79, '80, '81, respectively was 37.2%. For the last three years, the fifth year delay time shall be waited. The survival rates per year, have been reported her, for the whole period of the investigation. The AA, have evaluated the gross incidence rate for male and female patients (3.1 and 2.1 respectively). Survival and incidence data have been composed to those reported in the literature. Whilst survival rates agree with those from other authors, the incidence rates result considerably lower than those from other West Countries. It could be abscribed to an underestimation of the actual number of rectal neoplasm bearing patients, which could escape the investigation because diagnosticed and treated elsewhere. It should be noted nevertheless that the Casale Hospital supplies a scarcely industrialized urban area, and a wide rural environment, so that resident population might be included within one of the groups partially protected by environmental and alimentary conritions against the disease. In conclusion the AA. consider of a primary importance the development of centres suitable for base medicine aimed at assuring a real and effective prevention activity.
PURPOSE: Transrectal ultrasound is the most accurate means of assessing the degree of invasion for rectal neoplasms. A learning curve for performing and interpreting these studies exists, but it is unknown how long or steep it is. We reviewed our initial results with transrectal ultrasound to determine our accuracy and to define the learning curve. METHODS: All patients undergoing transrectal ultrasound during our initial 30 months of experience were included. Each patient was staged with transrectal ultrasound and, after resection, the histopathologic stage was compared with transrectal ultrasound staging. The accuracy of transrectal ultrasound was calculated at intervals as experience was gained. RESULTS: A total of 42 examinations were performed on 41 neoplasms in 41 patients. Comparison between transrectal ultrasound and the pathologic stage could be made in 36 studies. Overall accuracy of degree of wall invasion was 78 percent. Overstaging occurred with eight neoplasms, and one lesion was understaged. Accuracy of transrectal ultrasound staging improved with time: 58 percent of the initial 12 studies were staged correctly compared with 87.5 percent accuracy in the remaining 24 examinations (P = 0.048). CONCLUSION: A definite learning curve was apparent. We conclude that transrectal ultrasound is a relatively simple procedure to learn and, once a moderate degree of experience is gained, should be routinely incorporated into the evaluation of rectal neoplasms.
Gastrointestinal stromal tumors are non-epithelial neoplasms that arise from the gastrointestinal tract. Their variable cytologic atypia makes it difficult to predict their prognosis. We report a case of right hepatectomy for a giant metastasis detected 12 years after the surgical treatment of a rectal neoplasm, histologically demonstrated as a low-grade leiomyosarcoma initially, having morphological and immunohistochemical features of low malignancy. Histological examination of the hepatic metastases demonstrated that the tumors were composed of spindle cells similar to those in the rectal neoplasm. Immunohistochemical staining of the hepatic metastases with Ki-67 revealed stronger than the primary tumor. In conclusion, although histological and immunohistochemical analyses provide useful prognostic information, the prognosis of gastrointestinal stromal tumors is difficult to predict. Therefore, a patient with gastrointestinal stromal tumor diagnosed as low-grade malignancy requires carefully long-term follow-up.
Intrarectal ultrasonography (IRUS) was used in the preoperative staging of 17 patients with rectal neoplasms. Fourteen patients had biopsy proven adenocarcinoma, and three others had large villous adenomas. Comparisons were made between clinical examination, IRUS staging and subsequent histopathologic staging. IRUS was performed with a Bruel and Kjaer radial scanner, type 1849, equipped with a 7.0 MHz transducer. IRUS accurately staged 3/3 rectal villous adenomas, and 11/13 rectal adenocarcinomas compared with histopathology. Clinical exam correctly staged all three villous tumors, and 6/9 carcinomas (24% of lesions were not palpable). IRUS correctly diagnosed the status of regional nodes in 88% of patients. IRUS is a highly accurate preoperative staging tool for rectal cancers both in delineating depth of bowel wall invasion and in assessing regional lymph nodes. It is easy to perform, safe, and well tolerated by the patients. IRUS has definitely arrived as the state of the art in evaluating rectal neoplasms and may impact heavily on surgical decision making for these neoplasms.
BACKGROUND: The role of surgery in the therapeutic balance of locally advanced rectal neoplasms needs to be redefined in the light of recent reports on the efficacy of radio- and chemotherapy in neoadjuvant treatment. METHODS: For this purpose, the authors analysed the results of 104 locally advanced rectal neoplasms during the decade 1987-1996 all of whom had undergone priority surgery (100% operability) using a decidedly radical approach. Of this continuous series, 70 were T4 M0 (Group A) and 34 T4 M1 (Group B). Resectability in Group A was 97.1% (87% R0 excisions) with sphincteric recovery in 72.8%. Resectability was 73.5% in Group B (20% R0 excisions) with sphincteric recovery in 60%. RESULTS: Total operative mortality was 4.7% (2.9% for R0 operations, 10.2% for R2), morbidity was 24%. No survivor died during the follow-up: there were 6 local recidivations for 68 R0 operations (8.8%), half of which were only local. The mean survival for the entire series was 34 months: 4-5 months for R0 operations; for R1-R2 operations: 18 months for M0, 8 months for M1. None of the patients with local residual disease undergoing postoperative radiochemotherapy were recovered during surgery. CONCLUSIONS: A comparative evaluation of the results obtained with those reported in the literature involving single or multicentre series pretreated with radio- or chemotherapy is relatively difficult and non-indicative owing to the numerous disparate aspects that have been the subject of debate and comment, ranging from the definition of locally advanced rectal cancer to the grounds for selecting patients and the comparative groups treated with out-of-date surgical standards.
Surgery is the initial treatment of choice for most patients with rectal neoplasms. The objectives are to remove of tumor and drain the primary nodes. In stage I disease the surgical approach is though to be sufficiently effective. However, at least in the case of abdominoperineal resection, this causes considerable morbidity. Therefore, at the present time, there are efforts to reduce the extent of the resection by applying other treatment modalities in stage I disease. After curative resection in stage II/III disease a considerable number of patients suffer from local recurrence or distant metastases. In these patients adjuvant therapy is currently recommended. In locally advanced disease, primary resection is not feasible. Different treatment settings which apply combinations of all treatment modalities are possible. The article reviews the literature and shows future directions.
Sensitivity of 142 human large bowel malignancies to gastroenteropancreatic hormones (VIP, glucagon and pentogastrin) and calcitonin was studied using in vitro adenylate cyclase reaction of tumor. At least 40-55% of the tumors proved hormone sensitive. Heteroresponse (reaction to calcitonin) was most characteristic for colonic tumors whereas weak reaction to VIP and glucagon-for rectal neoplasms. A certain relationship was established between adenylate cyclase reaction to hormone stimulation, on the one hand, and peculiarities of tumor (degree of cell differentiation) and the body (gender), on the other. In patients who survived over 4 years, tumor adenylate cyclase had initially been more sensitive to hormone stimulation than in those who died over that period. It is concluded that tumor adenylate cyclase reaction to hormone stimulation is quite a reliable test for evaluating hormone sensitivity of large bowel tumors and, possibly, for choosing hormonal therapy.
A case of rectal and gastric location of Kaposi's sarcoma is reported. Although the typical location is cutaneous, gastrointestinal involvement of Kaposi's sarcoma is not an uncommon finding. Usually, it is detected when endoscopic, radiologic and autopsy studies are performed in patients with previous AIDS diagnosis. The patient we herein report ignored to be affected by the human immunodeficiency virus (HIV). He had not shown any sign or symptom for AIDS to be suspected. Presenting symptoms were weight loss, asthenia, loss of appetite, diarrhea and rectal bleeding. This case report underlines the importance of differential diagnosis with other rectal neoplasms that call for a totally different therapeutic approach.
From 1987 to 1992, 91 rectal neoplasms were operated in the Istituto di Patologia Speciale Chirurgica of the University of Bologna: 50 anterior resections and 41 abdomino-perineal amputations. The local recurrence rate shows no significant difference between the two groups. The mortality rate is 7.6% in anterior resections and 14.2% in abdomino-perineal amputations. Our results and literature review show that local recurrence and mortality rates depend more from the tumor stage than from the surgical procedure.
A 24-year-old woman had a rectal neoplasm which occurred 20 years after she had undergone ureterosigmoidostomy for exstrophy of the bladder. Only 41 cases of bening or malignant tumours of the large bowel developing after ureterosigmoidostomy have previously been reported in the literature. Adenocarcinoma of the colon is most frequently found and can develop even after urine has been diverted away from the colon. The presenting symptoms are either those of ureteral obstruction or of colorectal neoplasm. This rare complication remains intriguing and the possible pathogenetic mechanisms are discussed.
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