Perineal Resection Research Articles

Recurrent metastatic vulvar carcinoma treated with cisplatin plus cetuximab

Recurrent vulvar carcinoma with metastasis has few effective treatment options, which are mainly directed toward palliation of symptoms. A 70-year-old woman was originally treated in 1999 for vulvar squamous cell carcinoma (SCC) with radical vulvectomy and bilateral inguinofemoral groin dissection. She represented in 2005 with a new lesion distinct from the margin of her first disease occurrence. Although treatment of this area included surgical resection and chemoradiation, she recurred 3 months later. Despite radical surgical resection with an anal perineal resection, she presented 2 months later with widely metastatic disease. Epidermal growth factor receptor (EGFR) staining of the tumor cells showed 3+ staining in 100% of the cells. She was treated with palliative radiation therapy (RT) and a cetuximab plus cisplatin chemotherapy protocol. A partial response was obtained for 5 months with palliation of symptoms. Few treatment options exist for recurrent metastatic vulvar carcinoma. The combination of the EGFR antagonist cetuximab with cisplatin has shown modest success in other metastatic SCCs. The partial response experienced in our patient suggests its potential use in women with recurrent or metastatic vulvar carcinoma.

Adenocarcinoma after restorative proctocolectomy for cancer in ulcerative colitis

Dear Editor, Restorative proctocolectomy with creation of an ileal pouch-anal anastomosis is currently the procedure of choice for elective treatment of patients affected by ulcerative colitis with medically refractory disease, dysplasia or cancer. Although dysplastic transformation within the ileal pouch mucosa and in the rectal cuff in patients operated for ulcerative proctocolitis seems to be rare, 22 cases of adenocarcinoma adjacent to the ileo-anal anastomotic site after restorative proctocolectomy for ulcerative colitis have been described in literature so far. We report the case of a 52-year-old woman who was diagnosed with ulcerative colitis in 1980 at the age of 27. After the diagnosis, she required many hospital admissions for severe disease treated with sulphasalazine and steroids with good results. Past medical history also included a posttransfusional HCV infection treated in 2000 with interferon and ribavirin. In 2003, a colonoscopy revealed foci of adenocarcinoma and high-grade dysplasia in the descending and sigmoid colon. Consequently, the patient underwent restorative proctocolectomy with the formation of an ileal J pouch with double-stapled ileo-anal anastomosis. Histology of the surgical specimen revealed well-differentiated adenocarcinoma next to two non-invasive high-grade and low-grade lesions in the ascending colon; another welldifferentiated adenocarcinoma with necrotic areas was found in the transverse colon (G2T2N0M0). The rectum was clear of dysplasia or cancer. The phenotypic characterization of the lesions demonstrated <10% of neoplastic necrosis with no vascular nor perineural neoplastic invasion. No neoplastic lesions were found in the referred biopsy locations in the descending and sigmoid colon. Thirty-two months after the operation, a routine endoscopy showed a polipoid lesion at the anastomotic cuff in the anal transitional zone. Biopsies revealed high-grade dysplasia with foci of invasive adenocarcinoma. The patient underwent an abdominal–perineal resection with excision of the pouch and anus and formation of an end ileostomy. Surgical pathology evidenced a tubular-villous adenoma with predominant villous aspects; diffuse high-grade dysplasia and well-differentiated adenocarcinoma invading the stalk and into the submucosa of the bowel wall were demonstrated in association to a solitary ulcer and active ulcerative colitis (G1T1N0). Six months later the patient is doing well and is disease-free. Restorative proctocolectomy for patients with ulcerative colitis and co-existing colorectal cancer can be performed with a favourable prognosis and function. It is appropriate for curative intent, given that an adequate margin without tumour is obtained. Lee et al. reported three cases of adenocarcinoma after restorative proctocolectomy with a handsewn anastomosis adding to the 16, which had been previously reported. The authors noted that the overall incidence was extremely low and that the evidence to support surveillance was controversial with no clear defined dysplasia and carcinoma sequence. Factors that seemed to be related to the reported cases included a long history of antecedent ulcerative colitis (10–15 years), dysplasia or carcinoma in the original specimen, poor post-operative surveillance or severe or delayed presentation of pouchitis. Anal transitional zone dysplasia after ileal pouch-anal anastomosis is infrequent, usually self-limiting, most common in the first 2 to 3 years post-operatively and may Int J Colorectal Dis (2007) 22:1557–1558 DOI 10.1007/s00384-006-0269-4

Survival and treatment trends of rectal cancer patients in a population with suboptimal local control

Aim To explore trends in rectal cancer survival in Manitoba, particularly in patients where local control was an issue. Method Patients diagnosed with rectal or rectosigmoid adenocarcinoma from 1985 to 1999 were included. Demographic, treatment and mortality information were abstracted from the registry. Relative survival was examined for all patients for the periods 1985–1989, 1990–1994 and 1995–1999, and subsequently limited to those who underwent major surgery (Hartmann's, anterior, and abdominal perineal resection). Results Of the 2925 patients identified, 2163 (74%) had undergone a major surgery. Five-year relative survival was 46%, 54% and 53% for all patients for the three periods, respectively; major surgery results were 53%, 59% and 60%. Radiotherapy was used in 32% of cases in 1985–1989 and in 40% of cases in 1995–1999. Chemotherapy was used in 13% of cases in 1985–1989 and in 37% of cases in 1995–1999. Conclusion Consistent with other studies, overall rectal cancer survival in Manitoba has improved since 1985. Better local control, as suggested in other studies, does not appear to be a major factor in that improvement. Future work should include review of the local control strategy in Manitoba and factors to explain the improved survival.

Anatomical considerations in TNM staging and therapeutical procedures for low rectal cancer

Separation of the mesoderm-derived muscular structures and the endoderm-derived structures of the hindgut and reclassification of their involvement based on their embryological origin may be of clinical importance in providing anatomical support for a more standardized perineal resection during abdominoperineal resection. The aim of this study was to utilize magnetic resonance images and histological studies of fetal and neonatal specimens to redefine the T3/T4 distinction by reassessment of the intersphincteric plane and the pelvic diaphragm as they pertain to cancer infiltration and as part of the embryological development of the pelvic floor muscles and their connective tissue compartments. Pelvic floor anatomy was studied in seven newborn children and 120 embryos and fetuses. Anatomical data were completed by magnetic resonance imaging in 82 patients with T3 and T4 rectal cancers (64 T3, 18 T4; 35 women and 47 men) undergoing neoadjuvant chemoradiation for locally advanced (T3 or T4) rectal cancers. Clear demarcation between mesodermal and endodermal structures of the pelvic floor, which is equally evident in plastinated sections and magnetic resonance images, is already visible in early fetal stages. There is a constitutive overlap between the endoderm- and the ectoderm-derived components of the pelvic floor. Our data suggest that the current classification of rectal cancer staging is confusing, where the routinely used TNM classification system unnecessarily differentiates between embryologically identical muscular structures. Tumor spread along the musculature of the hindgut beyond the dentate line could possibly explain the occasional involvement of lymph nodes outside the conventional mesorectum.

Resultados do tratamento do carcinoma espinocelular anal e do seu precursor em doentes HIV-positivos

Incidence of anal squamous cell carcinoma is increasing mainly among HIV-positive patients. Treatment consists of radiotherapy and chemotherapy, sometimes followed by tumor resection. The objective was to evaluate the follow-up of such patients to verify recurrences and evolution from HAIN to cancer. This is a report of cases treated at the "Instituto de Infectologia Emílio Ribas", Sao Paulo, Brazil. We attended 45 HIV-positive patients between July 1996 and June 2006. Most were male (97.7%), with ages ranging from 23 to 55 years (mean: 38.5 years). Thirty patients had high grade anal intra-epithelial neoplasia (HAIN), treated with local resection, and 15 with anal canal invasive squamous cell carcinoma were first submitted to chemo radiation, while biopsies were obtained during follow-up. Patients with HAIN had recurrences in 16.7% of cases and remained cancer free for up to five years. Chemoradiation was not possible in five patients with invasive carcinoma (40%) because three had advanced AIDS and two refused treatment. Eight (88.8%) out of nine patients had complete response to chemoradiation and remained cancer free for a period from three to six years. Chemoradiation failed in the ninth patient: abdominal perineal resection was performed, and there was no recurrence over a five-year period. We concluded that HAIN can recur after local resection in HIV-positive patients but does not evolve to invasive carcinoma. Invasive cancer can be treated in the same way as in HIV seronegative persons, when clinical conditions permit.

A Phase II Study of Preoperative Capecitabine and Radiation Therapy in Patients With Rectal Cancer

The purpose of this study was to evaluate the safety and efficacy of preoperative capecitabine and radiation therapy (RT) in patients with locally advanced rectal cancer (LARC). Patients with adenocarcinoma of the rectum stage >or=T3 or >or=N1 were treated with capecitabine 1330 mg/m per day in 2 divided doses days 1 to 42 and 50.4 Gy of RT in 28 1.8-Gy fractions. Patients with metastatic disease were eligible provided that operative intervention on primary site was anticipated. Surgery resection occurred 4 to 6 weeks after completion of preoperative therapy. Thirty eligible patients were enrolled at two institutions. Median age and performance status were 62 years and 90%, respectively. Twenty-eight patients (93%) completed combined modality therapy and 27 underwent resection, including 17 abdominal-perineal and 9 low anterior resections. Three of 27 (11%) had pathologic complete response (pCR) with an additional 7 (26%) having minimal residual disease. Two patients who were felt to require abdominal perineal resection prior to combined modality therapy (CMT) were able to have sphincter-sparing surgery. No patients had progression during CMT which precluded surgical resection. Treatment was well tolerated with >or=grade 3 toxicities limited to diarrhea (5 patients), hand-foot syndrome (1 patient), dermatitis (1 patient). Twenty-four patients are living, 18 with no evidence of disease. The combination of preoperative capecitabine and RT in patients with LARC has significant antitumor activity, efficacy, and a low toxicity profile.

A pilot study of local injection of TNFerade biologic in addition to neo-adjuvant chemoradiation for the treatment of primary and recurrent rectal cancer

14585 Background: Rectal cancer presents unique therapeutic considerations due to competing concerns regarding sphincter preservation and local recurrence. Treatments using pre-operative chemoradiation are employed to decrease local recurrence and improve the probability of sphincter preservation. Agents, which improve the pathologic response rate may be of further benefit. Methods: TNFerade biologic is a replication deficient adenovirus expressing human TNF-alpha driven by a radiation inducible promoter. TNFerade biologic (4X10e10 pfu) is injected locally into rectal tumors once a week for 5 weeks. Patients receive concurrent chemoradiation utilizing oral capecitabene (937.50 mg/m2 BID, Monday-Friday) and external beam radiotherapy (1.8 Gy/day, 5 days per week to a total dose of 45 Gy). A boost dose of 5.4–9 Gy is delivered to sites of gross disease. After treatment, patients recover for 6–9 weeks before surgery. Patients are scored prior to the start of neo-adjuvant therapy for the feasibility of a sphincter preserving operation versus an abdominal perineal resection (APR). Following surgery the specimen (entire area submitted for processing) is examined for the percent of viable tumor remaining. The goal of the study is to show a target pathologic response rate of &lt;10% viable tumor in more than 30% of patients treated. Results: Six patients have been treated (4M, 2F). There has been no toxicity attributable to the TNFerade biologic, and the chemoradiation has been well tolerated with only mild, expected toxicities. Five of the six patients have undergone surgery (one is awaiting surgery). Three of these five patients were thought to require an APR prior to treatment due to the size and location of their tumor. All five patients have successfully undergone sphincter- preserving operations. On examination of the five specimens, 3 had less than 5% viable tumor while 2 had greater than 50% viable tumor. All resections were margin negative. The target pathologic response rate of &lt;10% viable tumor was achieved in 60% of the patients evaluated. Conclusion: The addition of TNFerade biologic to pre-operative chemoradiation was well tolerated and a prospective randomized trial comparing the addition of this agent to chemoradiation is warranted. No significant financial relationships to disclose.

Preoperative chemoradiotherapy with capecitabine and oxaliplatin in locally advanced rectal carcinoma: A phase II trial

4044 Background: The aim of this phase II trial was to assess the impact of preoperative external radiation therapy combined with Capecitabine and Oxaliplatin on pathologic tumor response, sphincter preservation and tumor control in patients with locally advanced rectal carcinoma. Methods: Sixty-seven patients with locally advanced rectal carcinoma (T3/T4 or N+) received radiotherapy (50.4 Gy/28 fractions) and chemotherapy with Capecitabine 825 mg/m2/12 hours on days 1–5 + Oxaliplatin 50 mg/m2 on day 1 every week (weeks 1–6). Surgery with TME was performed 6–7 weeks after the end of the treatment. Adjuvant chemotherapy was administered after surgery according investigator‘s crtiteria. Results: Patients have been recruited between February 2005 and June 2006. 47 male/20 female. Median age 67 years (range 38–79). Performance status (ECOG) 0 in 45 patients. Clinical stage (determined by EUS+CT or RMI): cT2 3p/cT3 58p/cT4 6p/cN+ 47p. Tumor location (from anal verge): = 5 cm in 27p. Median CEA level 3,69 ng/ml (0,7–391). Surgery (performed in 65 patients) consisted of low anterior resection in 37p, abdominal perineal resection in 28p. Tumor downstaging was observed in 52p (78%), 50 (76,9%) had negative lymph nodes, including 13p with complete pathological response (19,4%) and ten with only microfoci of tumor remaining (14,9%). 80% of the patients received adjuvant chemotherapy. Main adverse effects (NCI-CTC): diarrhea G3/4 25%, sensitive peripheral neurotoxicity G1 60%, skin G2 9%, skin G3 3%, nausea/vomiting G2 7.5%, fatigue G2 50%, fatigue G3 4%, neutropenia G3/4 4%. Conclusions: Those results show that preoperative chemoradiotherapy with capecitabine and oxaliplatin is a well tolerated regimen for locally advanced operable rectal cancer leading to a high probability of tumor downstaging. No significant financial relationships to disclose.

CR22P PERINEAL FLAP RECONSTRUCTION FOLLOWING EXTENDED RESECTION FOR PELVIC MALIGNANCY

Purpose Extended resection for colorectal pelvic malignancy has shown good outcome but may involve extensive perineal resection necessitating plastic surgical reconstruction. The aim was to assess the indications, techniques, morbidity, and outcome of perineal flap reconstruction for extended pelvic resection.Methods Patients requiring perineal flap reconstruction following colorectal resection at a tertiary centre from 1994 to 2006 were identified from a prospective colorectal database. Details of the indication, procedure, morbidity, and outcome were obtained from the database and retrospective chart review.Results 21 patients (11 male, 10 female), median age 59 years (range 26–80) underwent perineal flap reconstruction. Indications for resection were advanced primary colorectal cancer (7), recurrent rectal carcinoma (8), recurrent anal carcinoma (3), and other pelvic malignancy (3). 18/21 patients had neoadjuvant radiotherapy. Reconstruction was by pedicled flap in 14 patients (5 gracilis flap, 7 vertical rectus abdominal muscle flap; 1 gluteal rotation flap) and latissimus dorsi free flap with microvascular anastomosis in 7 patients. Eighteen patients had immediate reconstruction and three were delayed. Five patients underwent vaginal reconstruction following posterior vaginectomy. There were four major flap complications (19%) requiring five unplanned reoperations. There were 2 minor complications (10%) requiring 1 unplanned reoperation. There were no donor site or longterm flap complications.Conclusion Perineal flap reconstruction by both pedicled and free flaps may be achieved with low morbidity following extended pelvic resection.

Risk factors and the management of anastomotic leakage after anus-preserving operation for rectal cancer

To investigate the risk factors and management of anastomotic leakage after radical resection for rectal cancer and preservation of anal sphincter. The clinical data of 190 rectal cancer patients, undergone sphincter preserving procedures from Jan. 2004 to Jan. 2006, were analyzed retrospectively. The incidence of anastomotic leakage among the 190 rectal cancer patients was 7.9% (15 patients). The leakage occurred from 2 to 17 days postoperatively and the average time of appearance was 5.8 days. Thirteen cases of anastomotic leakage were healed by conservative therapy. The treatment included nutritional support, catheter drainage of abdominal abscesses and the use of antibiotics. Healing time ranged from 10 to 60 days and the mean time was 21.8 days. The other 2 patients were healed by abdominal perineal resection and loop colostomy of transverse colon respectively. The complication of anastomotic leakage was associated with age (10.2% in older than 60 years versus 3.2% in younger than 60 years), physical status (20.7% in poor condition patients versus 5.6% in good condition patients), bowel obstruction (19.1% with obstruction versus 6.5% without obstruction), anastomotic procedure (12.2% in Parks' anastomosis versus 6.7% Dixon anastomosis), anastomotic location (9.2% for outside of peritoneal anastomosis versus 2.7 for inside of peritoneal anastomosis). The rates of anastomotic leakage in staple-line manual reinforce group and postoperative anorectal drainage group were significantly decreased than those in control groups (1.9% versus 11.4% and 2.9% versus 10.7%)(P<0.05). Elderly patients, poor general condition, preoperative tumor obstruction, outside of peritoneal anastomosis are independent risk factors for the development of anastomotic leakage. Manual staple-line reinforce after stapled anastomosis and postoperative placement of drainage in rectum may be effective in decreasing the rate of anastomotic failure. Early and active conservative approach should be considered as the main treatment of anastomotic leakage.

Incidence and prognostic influence of lymph node micrometastases in rectal cancer

Aims The aim of this study was to determine the rate of lymph node micrometastases and evaluate their prognostic significance in rectal cancer. Methods Patients with either Dukes A or B rectal carcinoma who had undergone curative resection by either low anterior resection or abdominal perineal resection between 1991 and 2000 were selected from a prospectively collated database. None of the patients had metastasis at the time of surgery and none received adjuvant or neoadjuvant therapy. A single section from each lymph node was stained with haematoxylin and eosin (H + E) and with CAM 5.2 by immunohistochemistry. Statistical analyses were performed with Chi-square test. Results A total of 774 lymph nodes with a median of 14 lymph nodes per patient were examined, from a cohort of 56 patients with a median age of 66 years. In the 56 patients in whom lymph node metastases were not detected by haematoxylin–eosin staining, cytokeratin staining was positive in 15 lymph nodes from 10 patients. Nine patients had disease recurrence at a median follow-up of 98 months. The presence of lymph node micrometastases by immunohistochemistry did not predict either disease-free ( p = 0.44) or overall survival ( p = 0.63). Conclusion Immunohistochemical staining detects micrometastases in rectal cancer which are not observed with H + E staining. However, no significant relationship was observed between disease relapse and rectal micrometastases detected by immunohistochemistry.

Local recurrence after curative resection for rectal cancer – role of the multi – disciplinary team

Objective: We believe optimal management of rectal cancer should be tailored to the individual patient. This is achieved by close liaison within a well established multidisciplinary team (MDT). Patients also benefit from the unusual alliance between our district general hospital (DGH) and regional oncology centre with expertise in radiotherapy for rectal cancer. To test our beliefs we reviewed the incidence of local recurrence following curative resection for rectal cancer.Method: A total of 201 consecutive cases of rectal cancer treated from 01/04/1999 to 31/03/2002 were reviewed by one author (GK). 100% case note retrieval was achieved of which 122 curative resections were identified (122/201 = 60.7%). Mean follow up 4½ years.Conclusion: The incidence of local recurrence was 2.5% (3/122). All occurred in patients having Hartmann's operation. There were no local recurrences following anterior resection or abdomino–perineal resection. Number (%) Average distance from anal verge (cm) Number (%) receiving preoperative radiotherapy Anterior resection 76/122 (62.3) 11.2 13/76 (17.3) Hartmanns 9/122 (7.4) 8 4/9 (44.4) Abdomino–perineal Resection 27/122 (22.1) 4.7 11/27 (40.7) Discussion: Data support our belief that, combining modern surgical techniques with radiotherapy +/‐ chemotherapy, high quality outcomes are achievable when care is tailored to individuals by a functional MDT.

Resection of recurrent cervical cancer after total pelvic exenteration

The objective of this study was to describe the management of patients with recurrent cervical cancer after total pelvic exenteration (TPE). We reviewed the records of patients who underwent TPE for recurrent cervical cancer between June 1992 and December 2003 and subsequently developed recurrent disease. Thirty-seven patients underwent TPE during the study period, and 25 (68%) subsequently developed recurrence proven by radiographic and/or biopsy studies. Recurrence sites included pelvic (12), inguinal (5), retroperitoneal (5), hepatic (4), vulva (2), perineum (1), transposed ovary (1), and lung (1). The median time to recurrence was 7 months (range 2-73 months), with 92% (23/25) occurring within 2 years of TPE. Management of recurrence was known in 21 of 25 patients, which included chemotherapy (10), surgical resection (7), and no further treatment (4). Surgically resected recurrences were isolated to the groin (2), vulva (2), perineum (1), transposed ovary (1), and psoas muscle (1). The four patients who underwent ovarian, perineal, and vulvar resections succumbed to their disease in a median time of 13 months (range 2-21 months). Of the two patients with surgically resected groin recurrences, one is alive with disease 21 months after initial recurrence and the other is alive without evidence of disease 85 months later. One patient had an isolated 4-cm recurrence involving the psoas muscle and the femoral nerve and is without the evidence of disease 9 months later. Resection of isolated recurrences after TPE is a reasonable option in selected patients, particularly in those with solitary inguinal metastases.

Immunoscintigraphy of local recurrent rectal cancer with99mTc-labeled anti-CEA monoclonal antibody CL58

To explore a specific diagnostic method for local recurrent rectal cancer. Immunoscintigraphy with (99m)Tc-labeled anti-CEA monoclonal antibody (MoAb) CL-58 was performed for patients suspected of having a postoperative local recurrent rectal cancer and the findings were compared with the results of conventional imaging and pathology. A total of 36 patients with a suspected local recurrent rectal cancer underwent immunoscintigraphy with (99m)Tc-conjugated CL58. Local recurrence of rectal cancer was identified in 31 patients and established in 30 during operation, endoscopy and pathological examination. No local recurrence was found in 5 patients without specific accumulation of (99m)Tc during the follow-up. Immunoscintigraphy had a positive rate of 86.11%, a specificity of 83.33%, and a sensitivity of 100%. Immunoscintigraphy has a highly specific and predictive value for detecting local recurrent rectal cancer, especially after abdominal perineal resection (APR).

Sequential Linear Stapling Technique for Perineal Resection of Intractable Pediatric Rectal Prolapse

Rectal prolapse (RP), although most frequently encountered in the frail elderly, may also occur in children. This condition is most troublesome in the premature infant with significant associated comorbidities. Pediatric RP most often can be managed conservatively with expectant and/or judicious use of laxative-based bowel regimens. In rare instances of intractable RP, surgical intervention ranging from simple (sclerotherapy, Thiersch wire) to complex (perineal or transabdominal bowel resection) becomes necessary. We describe a modification of the Altemeier technique using a novel sequential linear stapling technique to treat intractable RP in a 5.0-kg infant with severe coexisting life-threatening comorbidities. The child had resumption of bowel movements on postoperative Day 1 and has had no recurrences. Sequential linear stapling technique for perineal resection of intractable pediatric RP appears to be a safe and potentially attractive alternative.

Entero-anal fistula: A rare complication after abdomino perineal resection and radiotherapy—Case report

Abdominoperineal resection (APR) is the surgery most commonly performed for cancers involving lower third of the rectum. It is an extensive resection surgery resulting in the disturbed anatomy of pelvic fossa. With the introduction of chemo radiotherapy, the control rate and survival figures have gone up with the associated increase in the treatment related toxicities. We present an extremely unusual complication of entero-anal fistula following APR and radiation therapy in a 40-year-old male with rectal carcinoma. The present report describes the possible cause for the development of this rare event along with highlighting some of the important issues that needs to be considered under such conditions.

2184: Radiotherapy for Anal Canal Cancer in Japan: A Retrospective Multi-Institutional Study

2184: Radiotherapy for Anal Canal Cancer in Japan: A Retrospective Multi-Institutional Study

Trends in rectal cancer survival in relation to the local control strategy

13536 Background: The Swedish Rectal Cancer Trial showed improved survival with improved local control due to adjuvant radiotherapy. Improved survival in several population-based studies, credited to improved local control due to quality assurance programs involving surgery, ± radiotherapy, has also been reported. In Manitoba (Canada) local control in rectal cancer was suboptimal in the mid 1990’s (local recurrence &gt;18% in stage I-III) despite adopting the 1991 NIH chemo-radiotherapy guidelines. There continues to be no quality assurance program. We were interested in exploring trends in survival in Manitoba, particularly in the subset of patients where local control is an issue. Methods: All patients diagnosed with rectum and rectosigmoid adenocarcinoma from 1985 to 1999 were identified from the Manitoba Cancer Registry. Demographic, peri-operative and operative treatment information, and death dates were abstracted from the Registry. Manitoba population and death counts used in the calculation of age-specific relative survival probabilities were obtained from Statistics Canada. Survival was examined for all patients for the time periods of 1985–89, 1990–94 and 1995–99 and subsequently limited to those that underwent major rectal cancer surgery (Hartmann’s, anterior, and abdominal perineal resection). The Ederer II method was used in the estimation of survival probabilities. Results: A total of 3021 rectal cancer patients were identified with 1723 (57.0%) having major surgery. Five-year relative survival for all patients was 48.7%, 49.6% and 56.2% for the three periods respectively. The major surgery group results were 56.9%, 58.1% and 59.7%. Peri-operative radiotherapy was used in 38% of the 1995–99 major surgery group, twice the rate of 1985–89; peri-operative chemotherapy 41%, a ten-fold increase. Conclusions: Consistent with other studies, overall rectal cancer five-year survival in Manitoba has improved since 1985. Smaller survival improvements in the major surgery subgroup, despite increased radiotherapy use (as well as chemotherapy), suggests that better local control was not the major factor in the overall survival improvement, as has been suggested in other studies. Future work should include review of the local control strategy and factors to explain the improved survival. No significant financial relationships to disclose.

Prospective Multicenter Trial of Staging Adequacy in Colon Cancer

Lymph node evaluation is an important prognostic factor in colorectal cancer (CRC). A 25% recurrence rate in patients with node-negative CRC suggests that current staging practices are inadequate. Focused analysis of the sentinel node (SN) by multiple sectioning and immunohistochemistry improves staging accuracy. Prospective phase 2 multicenter trial. Tertiary referral cancer centers. Between March 2001 and June 2005, 132 patients were enrolled with clinical stage I and II CRC in a prospective multicenter trial (R01-CA90484). During a standard oncologic resection, lymphatic mapping was performed and the SN identified either by the surgeon or the pathologist. Hematoxylin-eosin staining was performed on all lymph nodes and immunohistochemistry, on lymph nodes negative by hematoxylin-eosin staining. Micrometastases greater than 0.2 mm but less than 2 mm and isolated tumor cells less than 0.2 mm were defined according to the sixth edition of the American Joint Committee on Cancer Cancer Staging Manual. The 63 men and 69 women had a median age of 74 years. Sixty-eight patients (52%) underwent a right hemicolectomy; 3 (2.3%), a transverse colectomy; 9 (7%), a left colectomy; 15 (11%), a sigmoid colectomy; 34 (26%), a low anterior resection; 1 (1%), an abdominal perineal resection; and 2 (2%), a total colectomy. Of the 111 evaluable primary tumors, 19 (17%) were T1 lesions; 17 (15%), T2; 72 (65%), T3; and 3 (2.7%), T4 tumors. Thirty-three patients (30%) were classified as stage I; 46 (41%), stage II, and 32 (29%), stage III. The SN was identified by the surgeon in 127 patients (96%) and by the pathologist in 5 patients (4%). The median number of SNs and total lymph nodes examined were 3 and 14.5, respectively. The sensitivity of lymphatic mapping and SN analysis was 88.2% and the false-negative rate, 7.4% (6/81). Of the 6 false-negative results, 4 were attributed to lymphatic channels obliterated by tumor. Upstaging occurred in 28 patients (23.6%). In a multicenter trial, ultrastaging of colon cancer is feasible and accurate. In stage II CRC, 24% of patients had nodal carcinoma cells not detected by conventional staging methods. Surgical technique (adequate lymph node retrieval) and focused pathological analysis may improve staging accuracy and the selection of patients for chemotherapy. The unnecessary toxicity and expense of chemotherapy may be avoided in those patients who are truly node negative.

Anal Melanoma

Anal melanoma is rare and aggressive malignancy. Patients commonly present with advanced, even metastatic disease. Unlike cutaneous melanoma, anal melanoma has no known risk factors. Surgical excision remains the cornerstone of therapy. There are no long-term survivors of stage II or III disease; therefore, early diagnosis and treatment remain crucial. There are no trials definitively proving abdominal perineal resection (APR) or wide local excision (WLE) to yield superior long-term survival. APR may offer a higher rate of local control, whereas WLE offers a much less morbid operation. Adjuvant chemotherapy, interferon, and radiation may offer some benefit.