ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

PURPOSE:The aim of this article was to examine local recurrence after curative resection for carcinoma of the rectum in which the surgical technique of total mesorectal excision was not performed.METHODS:A single surgeon managed the patients and the data collected prospectively. Total excision of the distal mesorectum was not performed in the upper third or mid rectum.RESULTS:From 1969 to 1993 curative resections were performed in 549 patients, of which 17 died postoperatively, leaving 532 for analysis. Sphincter‐saving resection was performed in 468 patients (88 percent) and abdominoperineal excision in 58 (10.9 percent). The pathology stages (Dukes) were A, 158 (29.7 percent); B, 184 (34.7 percent); and C, 190 (35.7 percent). Five hundred seventeen patients (97.2 percent) were followed up for a minimum of five years. The median period of follow‐up was 82 months. Local recurrence confined to the pelvis occurred in 17 patients, and local recurrence associated with distant metastases occurred in 24 patients. The total five‐year local recurrence rate was 7.6 percent. Local recurrence was increased in Stage C tumors (P=<0.0001). Diathermy dissection in the pelvis was associated with a decreased local recurrence rate (P=0.023). The five‐year survival rate in curative resections was 72.5 percent.CONCLUSIONS:It is essential that articles presenting local recurrence rates should include both local recurrence in isolation and that which occurs with distant metastases. Although total mesorectal excision for rectal cancer was not performed in this study, the local recurrence rate is not materially different from that in several articles where total mesorectal excision has been used. Whether the distal mesorectum needs to be pursued in mid‐rectal cancer is not yet proven.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

PURPOSE:Inflammation of the ileoanal pouch (pouchitis) is one of the main complications after restorative proctocolectomy, yet its cause remains poorly understood. A standardized definition and diagnostic procedures in pouchitis are lacking.METHOD:We analyzed all cases of pouchitis occurring in a group of 308 patients (210 with ulcerative colitis, 98 with familial adenomatous polyposis) who took part in a prospective long‐term follow‐up program. The severity of pouchitis was measured using a pouchitis activity score (Heidelberg Pouchitis Activity Score). An algorithm for the classification and management of pouchitis was established which enables the clinician: 1) to determine theseverityof pouchitis, 2) to differentiate betweenprimary pouchitisand pouchitis caused by surgical complications (secondary pouchitis), and 3) to evaluate the course (acute vs. chronic(>3 months)).RESULTS:The median duration of follow‐up was 48 (range, 13‐119) months. At least one episode of pouchitis was diagnosed in 29 percent of patients with ulcerative colitis and in 2 percent of familial adenomatous polyposis patients. Secondary pouchitis occurred in 6 percent of ulcerative colitis patients and was cured by surgical treatment in 13 (87 percent) of 15 cases. Primary pouchitis was diagnosed in 23 percent of ulcerative colitis patients, including 6 percent of all ulcerative colitis patients with chronic primary pouchitis. The latter showed poor response to medical treatment. In one case multifocal high‐grade dysplasia occurred. Histologic examination of the excised pouch identified a carcinoma originating from the ileal mucosa.CONCLUSIONS:Ulcerative colitis patients after restorative proctocolectomy face a high risk of developing pouchitis. The algorithm used in this study was highly efficient in identifying patients with a secondary pouchitis who require surgical treatment and patients with chronic primary pouchitis. For the latter, long‐term surveillance seems mandatory because of the risk of malignant transformation of the pouch mucosa.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

PURPOSE:Historically, complication rates after colorectal surgery have been stratified by disease process, type of operation, or anesthesia risk derived after an intensive review of the medical record. Newer computer applications purport to shorten this process and predict the probability of postoperative complications by distinguishing them from comorbidities that are commingled on uniform discharge codes. We analyzed CaduCIS™ software, which uses discharge codes, to determine whether its predictions of comorbidity and complications were comparable to what was interpreted on the medical record.METHODS:Two‐hundred seventy patients were analyzed according to the principal and secondary diagnoses coded on discharge. Coding inaccuracies of clinical occurrences were identified by physician review of each medical record. The actual incidences of 17 common preoperative comorbidities and 11 postoperative complications were compared with those predicted by CaduCIS™.RESULTS:The CaduCIS™‐predicted distribution of comorbidities was similar to the actual occurrences in 15 of 17 categories. The overall incidence of complications obtained by physician (actual) review was 47 percent, compared with 46 percent predicted by CaduCIS™. However, there was a statistical difference between the CaduCIS™‐predicted and the actual complication rates in 5 of the 11 categories. The most common preoperative comorbidity and complication was cardiopulmonary (47 percent and 28 percent, respectively).CONCLUSION:The overall complication rate interpreted from the medical record (47 percent) was accurately predicted by CaduCIS™ (46 percent). Predictions of 5 of 11 individual complications were underestimated because of charting and coding inaccuracies, not because of computerized errors. Because uniform discharge coding of commingled comorbidity and complications is increasingly used to rapidly compute surgical outcomes, colon and rectal surgeons need to ensure compatibility of the actual and coded medical records.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

PURPOSE:With improved antiretroviral therapy, HIV‐positive patients are achieving a longer life expectancy. An increased incidence of anal squamous cell carcinomas has been noted in these patients. The purpose of this study was to determine the outcome of HIV‐positive patients with anal squamous cell carcinomas.METHODS:We conducted a review based on our tumor registry from 1980 through 1999. We identified 73 patients with anal squamous cell carcinoma treated at the University of Texas Southwestern Medical Center affiliated hospitals; 23 were HIV positive (18 had AIDS). In the HIV‐positive group, 9 hadin situsquamous carcinomas and 14 had invasive squamous cell carcinomas. Data collected included age, CD4 count, treatment, complications, and survival; these data were analyzed by Student'st‐test.RESULTS:All patients were male. Those with squamous cell cancer of the anus were offered radiation therapy and chemotherapy. Beginning in 1998, all patients received highly active antiretroviral therapy before treatment. Seven of 14 anal squamous cell carcinoma patients had their therapy adjusted owing to toxicity. Morbidity included proctocolitis and diarrhea (n=2) requiring diversion (n=1), hemorrhagic cystitis (n=1), neutropenic fever (n=3), bone marrow suppression (n=1), and urethral stricture (n=1). Mean age was 42 years for anal squamous cell carcinoma patients and 36 years for squamous cell carcinomain situpatients (P=0.05). Mean CD4 count was 222 cells/ml in patients with infiltrating carcinoma and 200 in thein situpatients (P=NS). One‐year and five‐year mortality rates, respectively, were 40 percent and 80 percent for infiltrating carcinoma patients and 17 percent and 50 percent for thein situpatients. Both of thein situpatients who died had CD4 counts <20 cells/ml at diagnosis, whereas the rest had CD4 counts >100 cells/ml and are currently without anal disease. Mean CD4 count at diagnosis for all patients who died was 133 cells/ml, whereas for those surviving, it was 261 cells/ml (P=0.03). Eight (all with infiltrating carcinoma) of the 10 patients who died had persistent anal disease, but none had metastasis.CONCLUSION:HIV‐positive patients within situcarcinomas present at an earlier age than those with infiltrating lesions.In situpatients with CD4 counts as low as 105 cells/ml do well with local excision. A low CD4 count at diagnosis without highly active antiretroviral therapy predicts a poor prognosis. Because these patients appear to succumb to their HIV status and not the anal disease, anal squamous cell carcinoma should be included with cervical squamous cell carcinoma as an AIDS‐defining illness. HIV‐positive patients, particularly AIDS patients, with invasive anal cancers and without effective antiretroviral therapy obtain little benefit and significant toxicity from current radiation therapy and chemotherapy. Initiation of highly active antiretroviral therapy in HIV‐positive patients before radiation therapy and chemotherapy are begun may decrease toxicity and improve survival. Additional clinical trials are warranted to test this theory.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

PURPOSE:This study was designed to evaluate the down‐staging effect and acute toxicity of preoperative radiation and chemoradiation for primary adenocarcinoma of the rectum.METHODS:The results of pretreatment staging with transrectal ultrasound and computed tomography were compared with final histologic stage in 260 consecutive patients who underwent neoadjuvant therapy and proctectomy for primary adenocarcinoma of the rectum. Patients underwent short‐course radiation (2,000 cGy in five fractions), long‐course radiation (4,500 cGy in 25 fractions), or chemoradiation (4,500 cGy in 25 fractions with concurrent chemotherapy).RESULTS:Down‐staging of one or more T stages occurred in 116 of 260 (45 percent) patients overall (short‐course radiation 34/82 (42 percent), long‐course radiation 55/122 (45 percent), chemoradiation 27/56 (48 percent),P= not significant). Down‐staging of one or more N stages occurred in 85 of 178 (48 percent) patients overall (short‐course radiation 12/45 (27 percent), long‐course radiation 49/86 (57 percent), chemoradiation 24/47 (51 percent),P=0.003). Complete pathologic response was observed in 16 of 260 (6 percent) patients overall (short‐course radiation 4/82 (5 percent), long‐course radiation 5/122 (4 percent), chemoradiation 7/56 (13 percent),P=0.08). Resection with negative margins (distal, proximal, and radial) was achieved in 211 of 227 patients (93 percent) in whom complete radial margin data were available. Permanent stomas were created in 35 percent of patients; temporary stomas were created in 15 percent. Thirty‐three Grade 3 or 4 toxicities occurred in 22 of 260 (8 percent) patients overall during neoadjuvant therapy. Toxicity was more frequent in patients receiving chemoradiation (14/56; 25 percent) and long‐course radiation (8/122; 7 percent) than in those receiving short‐course radiation (0/82; 0 percent),P<0.0001. Perioperative complications occurred in 93 patients overall (36 percent). The postoperative mortality rate was 0.4 percent (1/260). There was no significant difference in the complication rate between patients treated with short‐course radiation (26/82; 32 percent), long‐course radiation (46/122; 36 percent), and chemoradiation (21/56; 38 percent).CONCLUSION:Neoadjuvant therapy for adenocarcinoma of the rectum is well tolerated and can produce substantial down‐staging and a high curative resection rate. Chemoradiation can achieve high complete pathologic response rates, although toxicity during neoadjuvant therapy is greater than for radiation alone. Short‐course radiation can achieve down‐staging of both T stage and N stage.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

PURPOSE:The goal was to investigate the prognostic value of various molecular markers like CEA, Cyclin D1, Bcl‐2, c‐Myc, p53, p21ras, Ki‐67, CD44, Factor VIII‐related antigen, cytokeratin‐19, adenoma antigen, and prolactin in patients with Dukes B and Dukes C colorectal adenocarcinoma.METHODS:These molecular markers were localized immunohistochemically in nonmalignant (n=36) and malignant (n=98) diseases of the colorectum. Data were analyzed statistically using the SPSS software program. The patients with colorectal cancer were followed for a period of five years or their death within that period.RESULTS:The expression of carcinoembryonic antigen, Cyclin D1, Bcl‐2, CD44, cytokeratin‐19 and prolactin was significantly higher in malignant diseases (P<0.05), whereas, p21raswas found to be significantly higher in nonmalignant diseases (P=0.002) as compared with their respective counterparts. Besides Dukes stage, multivariate analysis indicated a significantly reduced relapse‐free survival in patients expressing CD44 and cytokeratin‐19 (P<0.005). Similarly, besides Dukes stage, multivariate analysis indicated a significantly poor overall survival in patients expressing CD44, cytokeratin‐19 and prolactin (P<0.01). In patients with Dukes B disease, only cytokeratin‐19 and CD44 expression attained statistical significance (P<0.05), whereas in patients with Dukes C disease, CD44, p21rasand c‐Myc expression attained statistical significance (P<0.018). Also, a multivariate analysis in relation to treatment given was performed using CD44 and cytokeratin‐19.CONCLUSION:Besides Dukes stage, multivariate analysis of all the studied molecular markers showed that patients expressing CD44 and cytokeratin‐19 had a significantly reduced relapse‐free and poor overall survival. Moreover, patients expressing both these markers (CD44 and cytokeratin‐19) had the lowest significant relative risk for developing recurrence than patients with both markers negative when treated with surgery followed by adjuvant chemotherapy as compared with patients treated with surgery alone. Thus, in patients with colorectal cancer, immunohistochemical localization of CD44 and cytokeratin‐19 may be included as a part of routine pathologic evaluation along with conventional prognostic factors.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

PURPOSE:The incidence of anogenital squamous‐cell carcinoma was observed to have increased since the beginning of the human immunodeficiency virus infection epidemic among male homosexuals, both with acquired immunodeficiency syndrome and without acquired immunodeficiency syndrome. It seems that immunosuppression is the most important risk factor for the progression of anogenital lesions, recurrences of anal condyloma, and development of anal carcinoma, in particular in acquired immunodeficiency syndrome. High‐grade anal intraepithelial neoplasia was predominantly observed in the human immunodeficiency virus‐positive men. We have also observed a high rate of recurrences of anal lesions in cases of high‐grade anal intraepithelial neoplasia. However, there are many cases of recurrences of low‐grade anal intraepithelial neoplasia that cannot be predicted by routine histologic studies. By using immunohistochemical methods, we studied the expression of Ki‐67 in epithelial cells of low‐grade anal intraepithelial neoplasia of patients with acquired immunodeficiency syndrome to try to predict recurrence of these lesions.METHODS:Anal biopsies of 38 patients were studied retrospectively. Of these patients, 14 had no recurrences (Group 1), and 24 patients had recurrence of the anal lesions before one year of follow‐up (Group 2).RESULTS:The median percentage of Ki‐67‐positive cells in Group 1 was 6.3±7.03 and in Group 2 was 24.1±16,72. The difference between Groups 1 and 2 was statistically significant (P<0.001).CONCLUSIONS:Our results showed a high correlation between the percentage of Ki‐67‐positive cells and recurrences. We concluded that Ki‐67 counting in low‐grade anal intraepithelial neoplasia can aid in predicting recurrences and therefore aid in the follow‐up of these patients.

ISSN:0012-3706    

出版商:OVID    

年代:2001

数据来源: OVID