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Rectal cancer: Current issues1
Surgical Oncology Rectal Cancer: Current Issues Guest Reviewers: Jeffrey P. Kavolius, LTC, MC, USA, and Elizabeth LoRe, CPT, MC, USA, Department of Surgery, Tripler Army Medical Center, Honolulu, Hawaii REVIEWER COMMENTS
The Swedish Rectal Cancer Trial was a prospective, randomized multicenter trial evaluating the role of preoperative radiation therapy in patients with resectable rectal cancer. Patients were randomly assigned to undergo preoperative irradiation followed by surgery 1 week later or to have surgery alone. The intensive short-course accelerated fractionation (25 Gy in 5 daily fractions using a 3- or 4-field technique) followed by surgery 1 week later is what sets this trial apart from other similar trials. It is the only prospective, randomized trial of preoperative radiation therapy that has shown both a statistically significant reduction in the rate of local recurrence (11% vs 27%) as well as an improvement in survival (58% vs 48%) when compared with the surgery-only group after 5 years of follow-up. Data from single institutions as well as from several nonrandomized trials (to include a recent metaanalysis) have, however, shown a survival benefit with preoperative radiation in addition to a decease in the local recurrence rate.1-5 The EORTC multi-institutional trial of high-dose preoperative radiation (3450 Gy in 19 days) also showed that for patients treated with preoperative radiation, the 5-year survival rate was 69% compared with 59% in those undergoing surgery alone (p ⫽ 0.08).6 Despite the results of the SRCT, the strategy proposed has not been widely accepted, particularly in the United States, where the standard of care has been combination therapy in the adjuvant setting for T3N0 or higher stage rectal cancer.7-11 In 1990, the National Institutes of Health Consensus Conference on adjuvant therapy for patients with colon and rectal cancer12 recommended external beam radiation therapy and 5fluorouracil (5FU)-based chemotherapy as stan32
IMPROVED SURVIVAL WITH PREOPERATIVE RADIOTHERAPY IN RESECTABLE RECTAL CANCER. Swedish Rectal Cancer Trial.N Engl J Med 1997;336: 980-987. Objective: In patients with resectable rectal cancer, to evaluate whether preoperative
radiotherapy alone using an intensive short-course accelerated fractionation (25 Gy over 5 days) followed by surgery within 1 week results in a reduction in the rate of local recurrence as well as an improvement in survival. Design: Prospective, randomized multi-institutional trial. Setting: Collaboration of six regional oncologic centers in Sweden. Participants: Between March 1987 and February 1990, 1168 patients under the age of 80 with biopsy-proven rectal adenocarcinoma were randomly assigned to undergo preoperative irradiation followed by surgery within 1 week or to have surgery alone. Results: In 3% of the patients in both groups, the tumor was unresectable or metastatic at the time of surgery. In-hospital mortality in the 2 groups was comparable. After 5 years of follow-up, the local recurrence rate in the group that received radiotherapy before surgery was 11% (63 of 553) and 27% (150 of 557) in the group treated with surgery alone (p ⬍ 0.001). This difference was found in all Dukes’s stages. The overall survival 5-year survival rate was 58% in the radiotherapy-plus-surgery group and 48% in the surgery-alone group (p ⫽ 0.004). The cancer-specific survival rates at 9 years among patients treated with curative resection were 74% and 65%, respectively (p ⫽ 0.002). Conclusions: Preoperative radiotherapy alone using an intensive short-course accelerated fractionation (25 Gy over 5 days) followed by surgery within 1 week results in a statistically significant reduction in the rate of local recurrence as well as an improvement in survival in patients with resectable rectal cancer.
This article contains the opinions of the authors only and does not represent the opinion of the United States Army or the Department of Defense.
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REVIEWER COMMENTS (Con’t)
dard postoperative treatment for patients with stage II or III disease. Induction therapy is currently the subject of investigation and intense debate. Preoperative chemoradiation using 5FUbased chemotherapy followed by a delay in surgery of 4 to 6 weeks has generally been more attractive to investigators in the United States. The rationale for this approach is based on data from adjuvant trials. The best results with respect to local recurrence and survival have been in those trials in which combined modality therapy was used. The rationale for a more “conventional” approach is that it increases the chance of downstaging and, thus, sphincter preservation. A total of 10% to 30% of patients may, in fact, have a complete pathologic response. Preoperative therapy is also generally better tolerated and associated with less toxicity.13-23 An intensive short course of radiation therapy followed by surgery 1 week later as recommended in the SCRT does not allow this, nor is it felt to be compatible with concurrent chemotherapy. In addition, rapidly irradiated patients may have increased perineal wound complications as well as worse functional outcomes.24 The SRCT data will need further confirmation before it should be considered an “integral part of the routine care of patients with rectal cancer,” as recommended by the authors.
IMPROVED SURVIVAL AND REDUCTION IN LOCAL FAILURE RATES AFTER PREOPERATIVE RADIOTHERAPY: EVIDENCE FOR THE GENERALIZABILITY OF THE RESULTS OF SWEDISH RECTAL CANCER TRIAL. Dahlberg M, Glimelius B, Pa ¨ hlman L.Ann Surg 1999;229:493-497. Objective: Assess the validity of the Swedish Rectal Cancer Trial (SRCT). Design: A multicenter rectrospective review. Setting: Departments of Oncology and Surgery, University Hospital, Uppsala, Swe-
den. Participants: Data on all rectal cancer cases reported to the Swedish Cancer Registry between the years 1987 to 1990 at 57 of 68 of the participating hospitals in the Swedish Rectal Cancer Trial were collected. All patients eligible but not included in the Swedish Rectal Cancer Trial were compared with the surgery-only arm of the SRCT. Results: Patient characteristics in the eligible-but-not-randomized and the surgeryonly arm of the SCRT were similar with the exception of a higher number of women and a higher number of anterior resections in the nonrandomized group. No differ-
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REVIEWER COMMENTS
This study is an attempt to validate the results of the SRCT. The authors have retrospectively identified a control group from the same cancer registry that was eligible-but-not-randomized in the SRCT. They then compared this group with the surgery-only arm of the SRCT. Although the statistical validity of this is arguable, the authors should be commended for attempting to further confirm and validate their original study. In this follow-up study, the overall 5-year survival rate of 48% in the eligible-but-not-randomized group was identical to the overall survival rate in the SRCT surgery-alone group. Likewise, the cancer-specific 5-year survival rates 33
REVIEWER COMMENTS (Con’t)
between the 2 groups were the same (65% and 66%), as was the incidence of local recurrence (27%). The authors conclude that “the SRCT data are representative of the entire Swedish population.” Furthermore, “since it was a large, prospectively randomized clinical trial that included most Swedish hospitals it possesses sufficient validity.” One of the main criticisms of this trial, however, is the large number of hospitals participating in the trial, and an even larger number of surgeons with a lack of standardization of the surgical technique.25 What this review of the eligible-butnot-randomized group with the surgeryonly group of the SRCT does allow is the evaluation of the practice patterns of practicing general surgeons throughout Sweden. The trial also reinforces the importance of local control in maximizing long-term survival rates. The authors correctly note that a local recurrence of 27% is unacceptably high and reinforces the need for optimized surgery or the addition of further adjuvant therapy. Their recommendation is for preoperative radiotherapy. This question will hopefully be answered when the data mature from the Dutch Colorectal Cancer Group trial.26 In this prospective, randomized trial, patients with nonfixed, resectable rectal cancer are randomized to total mesorectal excision with preoperative external beam radiation therapy (25Gy) versus total mesorectal excision alone.
REVIEWER COMMENTS
This is an excellent study from an experienced group of colorectal surgeons from 1 institution with consistent practice patterns. The results of this study remind us that even despite strict selection criteria, local recurrences can occur at a disturbingly high frequency in those patients undergoing local excision alone for rectal cancer. The authors of this study note that the unusually high local recurrence rate in their series compared with the published literature may in part reflect variation in the duration or completeness of follow-up. Most local recurrences were picked up on proctoscopic 34
ences occurred in in-hospital mortality rates. The local recurrence rate (27%) was the same for both groups as was the 5-year cancer-specific survival (65% and 66%). Among eligible patients, no significant differences occurred in the treatment results as a function of gender. Conclusions: No statistically significant differences in local recurrence rates and
5-year survival occurred between patients who were eligible but not randomized to the SRCT and the surgery-only group included in the SRCT. Therefore, because the population in the SCRT was representative, it was concluded that the study results are reliable.
LOCAL EXCISION OF RECTAL CANCER WITHOUT ADJUVANT THERAPY: A WORD OF CAUTION. Garcia-Aguilar J, Mellgren A, Sirivongs P, Buie D, Madoff RD, Rothenberger DAAnn Surg 2000;231:345-351. Objective: To evaluate the results of local excision alone for the treatment of rectal
cancer. Design: Retrospective database. Setting: Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota Cancer Center, Minneapolis, Minnesota. Participants: All patients with T1 or T2 rectal cancers who underwent transanal excision with curative intent during a 10-year period. All lesions were full-thickness excision with approximately a 1-cm margin of normal rectal wall. All tumors were localized to the rectal wall at pathologic examination, had negative excision margins, and were well or moderately differentiated, without blood or lymphatic vessel invasion,
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and without mucinous components. All patients had, as part of their extent of disease examination, a chest x-ray and an abdominal and pelvic computed tomography (CT) scan to exclude metastatic disease and local extrarectal invasion. Fifty-nine of the 82 patients included in the study underwent preoperative ERUS. Results: End points of the study included local and distant tumor recurrence and patient survival. A total of 82 patients with T1 (n ⫽ 55) or T2 (n ⫽ 27) were included. At 54 months, 10 of the 55 patients with T1 tumors (18%) and 10 of the 27 patients with T2 tumors (37%) had a recurrence, for an overall recurrence rate of 24%. The average time to recurrence was 18 months in both groups. In patients with T1 tumors, 9 patients had a local recurrence, 1 had distant metastasis, and 1 had both local and distant recurrence. Six of these local recurrences involved the mucosa only and were diagnosed at proctoscopy, whereas 4 were extramucosal and diagnosed with ERUS. In the T2 group, 8 patients had an isolated local recurrence and 2 had both local and distant recurrence. The recurrence involved the mucosa in 8 patients and was exclusively extrarectal in 2. At an average of 54 months of follow-up, 77% of the T1 patients and 55% of the T2 patients were alive without evidence of disease. Of the 20 patients who recurred, 17 underwent salvage surgery. The survival rate was 98% for patients with T1 tumors and 89% for patients with T2 tumors. One patient in the T1 group died of cancer, and 2 patients died of cancer in the T2 group.
REVIEWER COMMENTS (Con’t)
examination or ERUS. The reader should conclude from this study that accurate preoperative staging is essential and that strict selection criteria be adhered to if patients are offered local excision for rectal cancer. Strong consideration should be given for adjuvant chemoradiation in T2 tumors (even those with favorable pathology). Furthermore, patients who have undergone local excision should have routine follow-up with both proctoscopy and ERUS. The schedule outlined here (every 4 months for the first 3 years after surgery and every 6 months for the next 2 years) certainly is reasonable.
Conclusions: Local excisions of early rectal cancers are followed by a much higher recurrence rate than previously reported. Salvage surgery with radical resection can be performed in most patients, but the long-term outcome is unknown.
LONG-TERM FOLLOW-UP OF PATIENTS WITH RECTAL CANCER MANAGED BY LOCAL EXCISION WITH AND WITHOUT ADJUVANT IRRADIATION. Chakravarti A, Compton CC, Shellito PC, et al.Ann Surg 1999;230:49-54. Objective: To determine long-term outcomes of patients undergoing local excision
with and without pelvic irradiation, and to define the role of adjuvant irradiation after local excision of T1 and T2 rectal cancers. Design: Retrospective review. Setting: Departments of Radiation Oncology, Surgery, Medical Oncology and Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, and the Departments of Surgery and Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia. Participants: Data on 99 patients with T1 and T2 rectal cancers who underwent local excision between January 1966 to January 1997. Fifty-two patients were treated by local excision alone (LE), and 47 patients were treated by local excision plus adjuvant irradiation (EBRT). Of these 47, 21 patients were treated by LE ⫹ EBRT, and 26 patients were treated by LE ⫹ EBRT ⫹ 5FU chemotherapy. Results: A statistically significant difference did not occur in the overall risk of local
recurrence or the recurrence-free survival (RFS) between those patients undergoing LE versus those undergoing LE with EBRT ⫾ chemotherapy. Subset analysis by T-stage was performed, however, and adjuvant irradiation significantly improved the 5-year actuarial local control rate and the 5-year recurrence-free survival in the T2 group. Further subgroup analysis was performed on those patients who received LE ⫹ EBRT versus LE ⫹ EBRT ⫹ 5FU chemotherapy. The difference in local control and RFS was not statistically significant with the addition of chemotherapy. Time to recurrence was shorter in the LE-alone group (13.5 months) compared with the LE ⫹ EBRT group (55 months). High-risk pathologic features were associated with lower 5-year actuarial LC rates. A statistically significant improvement in the LC rate and RFS was noted with the addition of EBRT. CURRENT SURGERY • Volume 59/Number 1 • January/February 2002
REVIEWER COMMENTS
This study addresses several important issues in the management of patients with rectal cancer that are managed by local excision: recognizing unfavorable histology as a risk factor for local failure, especially in T1 lesions, and identifying which subset of patients should be treated with adjuvant chemoradiation (T2 lesions and T1 lesions with unfavorable histology). Unfortunately, it lacks the statistical power to do so conclusively. The study also suffers in that it is retrospective and spans over a 30-year period, during which time surgical and radiation techniques have been evolving and therefore not standardized. Furthermore, because of the heterogeneity of the data set, the authors use subset analysis from which they draw their conclusions, further diluting the statistical power of the study. Although the point is made that this series represents some of the longest follow-up in the literature, all the data presented are actuarial data. Several important points are brought out in this paper, however. Unfavorable histology is associated with increased local failure and decreased recurrence-free survival. Therefore, adjuvant combination therapy should be included as part of 35
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the treatment strategy. The authors recommend chemoradiation for all patients undergoing local excision for T2 tumors, and for T1 tumors with high-risk pathologic features. They also stress that careful long-term follow-up is a necessity given the fact that 4 cases of late recurrence occur in this series. Of the 18 local recurrences, 17 were mucosal and 1 was a nodal recurrence. This further underscores the need for a thorough endoscopic evaluation with liberal use of ERUS.
Conclusions: Adjuvant radiation significantly improves local control and recur-
rence-free survival in patients undergoing local excision for T2 tumors, and for T1 tumors with high-risk pathologic features.
REVIEWER COMMENTS
SURGICAL TREATMENT OF ADENOCARCINOMA OF THE RECTUM. Za-
This paper highlights the evolving paradigm shift in the appropriate surgical technique required for complete excision of rectal cancer and, therefore, remains relevant today. Furthermore, the questions addressed in this series are purely surgical in nature and, by the study design, are not obscured by the addition of chemotherapy or radiation therapy. It is clear, as pointed out by these authors, that the experience and technique of the individual surgeon plays a fundamentally important role in the management of patients with rectal cancer. The recognition that the lateral margin of resection as well as tumor deposits within the mesorectum are important factors responsible for local recurrence has been the impetus for the standardization of the surgical technique for rectal cancer. Total mesorectal excision (TME), which was popularized by Heald 27-29 involves removal of the rectum and mesentery as an intact unit. In contrast to conventional blunt dissection, TME emphasizes a more precise dissection technique, thereby avoiding disruption of the mesentery. Using this technique, local recurrence rates have been consistently less than 10%.30,31 The authors question the need for TME in all patients, noting that it may be associated with increased morbidity and the need for routine proximal diversion. For patients with high rectal tumors, the dissection is carried at least 5 cm below the level of the tumor and not “coned” in. The lateral dissection is performed at the pelvic sidewalls. With this type of “tu-
heer S, Pemberton JH, Farouk R, Dozois RR, Wolff BG, Ilstrup D.Ann Surg 1998;
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227:800-811. Objective: To determine survival and recurrence rates in patients undergoing resec-
tion of rectal cancer achieved by abdominoperineal resection (APR), coloanal anastomosis (CAA), and anterior resection (AR) without adjuvant therapy. Design: Retrospective review. Setting: Division of Colon and Rectal Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota. Participants: The medical records of 1423 consecutive patients found to have rectal carcinoma during the period 1982 to 1989 were reviewed. Exclusion criteria included transanal or posterior excision for nonmetastatic disease, recurrent disease, primary treatment elsewhere, history of another primary tumor within 4 years of treatment for rectal carcinoma, carcinoma in situ, or patients who received adjuvant therapy. A total of 514 patients with primary, invasive adenocarcinoma of the rectum and rectosigmoid treated for cure by surgery-alone made up the target population. Total mesorectal excision was performed in all patients undergoing APR and CAA. For those patients who underwent an AR, an appropriately wide rectal mesentery resection technique was performed if the tumor was high; if the tumor was in the middle or low rectum, all mesentery was resected. Results: Information was available for 495 of the 514 patients. Median age of the group was 67 years. A total of 316 men and 198 women were included. The overall 5-year survival rate was 64%, with a disease-free survival of 79%. The probability of developing a recurrence of any type at 5 years was 21%. Overall, the local recurrence rate for all stages of disease and all operations was 7%. The local recurrence rates following AR, CAA, and APR were 7%, 6%, and 4%, respectively, for all patients and all stages of disease. The 5-year disease-free survival rates were 78% after AR, 63% after CAA, and 80% after APR. For patients with stage III disease, the local recurrence rate was higher (13%) after AR than that achieved by APR (7%) and CAA (0%). On univariate analysis of determinants of survival and recurrence, tumor size, depth of penetration of tumor, involvement of lymph nodes by tumor, and presence of metastasis were found to be statistically significant. On multivariate analysis, depth of penetration by tumor, number of lymph nodes involved by tumor, and the presence of distant metastasis were found to be associated with decreased survival and increased recurrence.
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Conclusions: No significant differences occurred between rates of recurrence and type of procedure performed. Appropriate “tumor-speicific” mesorectal excision is associated with low mortality, low morbidity, low local recurrence, and good 5-year survival rates. An overall failure rate of 40% in stage III disease was independent of surgical technique.
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mor-specific” mesorectal excision, the operation is tailored to the tumor and is associated with an equivalent local recurrence rate as for TME. They should be commended for their outstanding results utilizing a uniform surgical technique with a standardized practice pattern.
In 2001, the American Cancer Society estimates that 37,200 people in the United States will be found to have rectal carcinoma, with 8600 expected deaths from the disease.32 A number of relevant issues continue to be enthusiastically debated in the literature in our efforts to better understand this disease and care for these patients. The 5 papers reviewed in this issue of Current Surgery were selected to review the following topics, which include defining what is the optimal surgical strategy for rectal cancer, the role of local excision with or without chemoradiation, and determining what is the appropriate adjuvant therapy in those patients with resectable disease. It is clear that despite the increased use of multimodality therapy for the treatment of solid tumors, in general, and for rectal cancer, specifically, the surgeon’s role in the management of this disease remains paramount. Whether patients are treated with local excision or radical resection (with or without sphincter preservation), surgeon experience and technique have been shown to be directly related to outcome.33 Adherence to basic surgical oncologic principles is mandatory. Preoperatively, a number of factors must be considered when devising a treatment strategy for patients with rectal cancer. Patient factors include age, performance status, comorbid conditions, body habitus, and continence. Tumor factors include its location from the sphincter mechanism, local extent, size, bulkiness, and high-risk pathology. Accurate staging is critical in formulating the operative plan. The presence or absence of metastatic disease as well as the local extent (TNM) of the tumor will, necessarily, tailor the surgical procedure chosen. The Society of Surgical Oncology recommends that an appropriate extent of disease examination should include a physical examination, chest x-ray, CBC and chemistry profile, colonoscopy (or air-contrast barium enema) to evaluate the rest of the colon, pelvic CT scan in selected patients, and ERUS (for better definition of the T and N stage) if treatment will be altered. Routine use of abdominal CT scan or liver ultrasound (unless metastatic disease is suspected) as well as preoperative CEA are not recommended.10 Goals of surgery include cure, control of local and regional disease, sphincter preservation, acceptable functional results with low morbidity, and accurate pathologic staging. Criteria for local excision are well accepted. These include mobile tumors less than 4 cm in diameter, less than one-third the circumference of the bowel wall, and less than 8 cm from the anal verge. The primary should be well-to-moderately differentiated and have no evidence of vascular, lymphatic, or perineural invasion. Only T1N0 and T2N0 tumors by ERUS should be considered. The technical details of local excision are important. A full-thickness excision with negative margins is the goal of surgery. Local excision alone should be reserved for patients with small T1 lesions that contain no adverse pathologic features. T1N0 tumors with adverse pathologic features as well as T2N0 tumors should be considered for additional therapy.34-44 Endoscopic ultrasonography has become increasingly more important as a staging tool in assessing local tumor extent as well as lymph node involvement and, therefore, allows for more appropriate patient selection for local therapy.45-48 Patient education and close postoperative follow-up with physical examination, proctoscopy, and liberal use of ERUS are essential and will enhance the ability to detect a local recurrence and, ultimately, enhance the chance for long-term cure. Radical resection should be performed in those patients with transmural disease with or without nodal involvement. Because total mesorectal excision consistently demonstrates local recurrence rates less than 10% compared with conventional surgical CURRENT SURGERY • Volume 59/Number 1 • January/February 2002
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techniques, the push for this to become the standard surgical approach appears justified.27-31,49 As noted in the reviewed article by Zaheer et al, “tumor-specific” mesorectal excision, however, may be appropriate particularly for higher rectal lesions. Despite the fact that most patients with rectal cancer present with localized disease, locoregional failure and the rate of distant metastasis may be as high as 30% after potentially curative surgery. Multimodality therapy, therefore, has become the cornerstone of treatment. In 1990, the National Institutes of Health Consensus Conference on adjuvant therapy for patients with colon and rectal cancer7 recommended external beam radiation therapy and 5FU-based chemotherapy as standard postoperative treatment for patients with stage II or III disease. The use of preoperative radiation with or without chemotherapy is currently being studied in the United States and in Europe and is the focus of 2 of the abstracts reviewed. The advantages of conventional preoperative combination therapy with a delay in surgery for 4 to 6 weeks have already been discussed. Colorectal cancer remains a significant public health problem. However, advances have been made in disease prevention, screening, and diagnosis. As our understanding of the pathophysiology and tumor biology of colon and rectal cancer continues to improve, future therapies are likely to be directed at the molecular level. Treatment remains multidisciplinary in nature, with a number of surgical options available to the surgeon. Continued refinement and standardization of surgical techniques as well as the information gained from randomized, prospective trials of adjuvant therapy will continue to aid us in understanding this disease and enable surgeons to more effectively treat these patients. S0149-7944(01)00567-0
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preoperative staging of rectal tumors: a learning experience. Dis Colon Rectum. 1990;33:654-659. 47. Ng A, Recht A, Busse PM. Sphincter preservation therapy for distal rectal cancer:
a review. Cancer. 1997;79:671-683. 48. Hulsmans FJH, Tio TL, Fockens P, et al. Assessment of tumor infiltration depth
in rectal cancer with transrectal sonography. Radiology. 1994;190:715-720. 49. Kapiteijn E, van De Velde CJ. European trials with total mesorectal excision.
Semin Surg Oncol. 2000;19:350-357.
Surgical Oncology Who Was Sister Mary Joseph? Guest Reviewer: Howard A. Zaren, MD, Department of Surgery, Cook County Hospital, Chicago, Illinois VIGNETTES IN MEDICAL HISTORY: SR. MARY JOSEPH AND HER NODE.
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Hill M, O’Leary P.Am Surg 1996;62:328-329.
This historical account by the authors of the Sr. Mary Joseph Node or Nodule is an interesting reminiscence of important surgical lore. Their article not only describes the history of its discovery, but also includes the individual whose name has been most often associated with this entity. The Sr. Mary Joseph Nodule was usually considered a physical sign of such poor prognosis, with survival measured on an average of 10 months, that surgical intervention was considered by many surgeons to not be a consideration.
Objective: To present a vignette describing Sr. Mary Joseph, her background, her
training, and her designation as the first person to attach significance and anatomic pathologic meaning to the presence of a para-umbilical nodule, which often indicated advanced intra-abdominal malignancy. Design: A vignette in medical history. Setting: Surgery Department, Louisiana State University Medical Center, New Orleans, Louisiana. Conclusions: The authors describe the life of Sister Mary Joseph from the time she was born as Julia Dempsey on May 14, 1856, in Salamanca, New York, and chronicle her life from that date. Her parents were Irish immigrants who moved to Minnesota before the Civil War. At the age of 22, she became a member of the Third Order Regular of St. Francis of the Congregation of the Lady of Lourdes of Rochester, Minnesota, in 1878. At that time, she took the name Sr. Mary Joseph. In 1880, at the age of 24, she became director of the congregation’s missionary school in Ashland, Kentucky, and then returned to Rochester to work in St. Mary’s Hospital. A major project of the Minnesota’s order of the Sisters of St. Francis was to establish St. Mary’s Hospital in 1889. This hospital was constructed by William W. Mayo, father of the Mayo brothers. Sr. Mary Joseph was assigned to the hospital and, having had no formal nursing training, was mentored by Edith Graham. Ms. Graham was the first formally trained nurse in this area of Minnesota, after having graduated from the Women’s Hospital School of Nursing in Chicago. Sr. Mary Joseph went on to become head nurse and within 3 years became superintendent of the hospital. At this time, she was still involved in clinical care and became the first surgical assistant of Dr. William Mayo. Sr. Mary Joseph was the first individual to describe the presence of a paraumbilical nodule that was often the only physical indication of intra-abdominal malignancy that was of advanced stage. She first noticed the presence of such a nodule during the surgical preparation of the abdomen and was said to have pointed it out to Dr. Mayo. He agreed that this peri-abdominal nodule was physical evidence of advanced intra-abdominal malignancy. It was not until 1949 that Hamilton Bailey in publishing the 11th edition of his textbook, Physical Signs in Clinical Surgery, gave her credit for her observation and named the nodule after her. In historical retrospect, this
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The Swedish Rectal Cancer Trial was a prospective, randomized multicenter trial evaluating the role of preoperative radiation therapy in patients with resectable rectal cancer. Patients were randomly assigned to undergo preoperative irradiation followed by surgery 1 week later or to have surgery alone. The intensive short-course accelerated fractionation (25 Gy in 5 daily fractions using a 3- or 4-field technique) followed by surgery 1 week later is what sets this trial apart from other similar trials. It is the only prospective, randomized trial of preoperative radiation therapy that has shown both a statistically significant reduction in the rate of local recurrence (11% vs 27%) as well as an improvement in survival (58% vs 48%) when compared with the surgery-only group after 5 years of follow-up. Data from single institutions as well as from several nonrandomized trials (to include a recent metaanalysis) have, however, shown a survival benefit with preoperative radiation in addition to a decease in the local recurrence rate.1-5 The EORTC multi-institutional trial of high-dose preoperative radiation (3450 Gy in 19 days) also showed that for patients treated with preoperative radiation, the 5-year survival rate was 69% compared with 59% in those undergoing surgery alone (p ⫽ 0.08).6 Despite the results of the SRCT, the strategy proposed has not been widely accepted, particularly in the United States, where the standard of care has been combination therapy in the adjuvant setting for T3N0 or higher stage rectal cancer.7-11 In 1990, the National Institutes of Health Consensus Conference on adjuvant therapy for patients with colon and rectal cancer12 recommended external beam radiation therapy and 5fluorouracil (5FU)-based chemotherapy as stan32
IMPROVED SURVIVAL WITH PREOPERATIVE RADIOTHERAPY IN RESECTABLE RECTAL CANCER. Swedish Rectal Cancer Trial.N Engl J Med 1997;336: 980-987. Objective: In patients with resectable rectal cancer, to evaluate whether preoperative
radiotherapy alone using an intensive short-course accelerated fractionation (25 Gy over 5 days) followed by surgery within 1 week results in a reduction in the rate of local recurrence as well as an improvement in survival. Design: Prospective, randomized multi-institutional trial. Setting: Collaboration of six regional oncologic centers in Sweden. Participants: Between March 1987 and February 1990, 1168 patients under the age of 80 with biopsy-proven rectal adenocarcinoma were randomly assigned to undergo preoperative irradiation followed by surgery within 1 week or to have surgery alone. Results: In 3% of the patients in both groups, the tumor was unresectable or metastatic at the time of surgery. In-hospital mortality in the 2 groups was comparable. After 5 years of follow-up, the local recurrence rate in the group that received radiotherapy before surgery was 11% (63 of 553) and 27% (150 of 557) in the group treated with surgery alone (p ⬍ 0.001). This difference was found in all Dukes’s stages. The overall survival 5-year survival rate was 58% in the radiotherapy-plus-surgery group and 48% in the surgery-alone group (p ⫽ 0.004). The cancer-specific survival rates at 9 years among patients treated with curative resection were 74% and 65%, respectively (p ⫽ 0.002). Conclusions: Preoperative radiotherapy alone using an intensive short-course accelerated fractionation (25 Gy over 5 days) followed by surgery within 1 week results in a statistically significant reduction in the rate of local recurrence as well as an improvement in survival in patients with resectable rectal cancer.
This article contains the opinions of the authors only and does not represent the opinion of the United States Army or the Department of Defense.
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dard postoperative treatment for patients with stage II or III disease. Induction therapy is currently the subject of investigation and intense debate. Preoperative chemoradiation using 5FUbased chemotherapy followed by a delay in surgery of 4 to 6 weeks has generally been more attractive to investigators in the United States. The rationale for this approach is based on data from adjuvant trials. The best results with respect to local recurrence and survival have been in those trials in which combined modality therapy was used. The rationale for a more “conventional” approach is that it increases the chance of downstaging and, thus, sphincter preservation. A total of 10% to 30% of patients may, in fact, have a complete pathologic response. Preoperative therapy is also generally better tolerated and associated with less toxicity.13-23 An intensive short course of radiation therapy followed by surgery 1 week later as recommended in the SCRT does not allow this, nor is it felt to be compatible with concurrent chemotherapy. In addition, rapidly irradiated patients may have increased perineal wound complications as well as worse functional outcomes.24 The SRCT data will need further confirmation before it should be considered an “integral part of the routine care of patients with rectal cancer,” as recommended by the authors.
IMPROVED SURVIVAL AND REDUCTION IN LOCAL FAILURE RATES AFTER PREOPERATIVE RADIOTHERAPY: EVIDENCE FOR THE GENERALIZABILITY OF THE RESULTS OF SWEDISH RECTAL CANCER TRIAL. Dahlberg M, Glimelius B, Pa ¨ hlman L.Ann Surg 1999;229:493-497. Objective: Assess the validity of the Swedish Rectal Cancer Trial (SRCT). Design: A multicenter rectrospective review. Setting: Departments of Oncology and Surgery, University Hospital, Uppsala, Swe-
den. Participants: Data on all rectal cancer cases reported to the Swedish Cancer Registry between the years 1987 to 1990 at 57 of 68 of the participating hospitals in the Swedish Rectal Cancer Trial were collected. All patients eligible but not included in the Swedish Rectal Cancer Trial were compared with the surgery-only arm of the SRCT. Results: Patient characteristics in the eligible-but-not-randomized and the surgeryonly arm of the SCRT were similar with the exception of a higher number of women and a higher number of anterior resections in the nonrandomized group. No differ-
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This study is an attempt to validate the results of the SRCT. The authors have retrospectively identified a control group from the same cancer registry that was eligible-but-not-randomized in the SRCT. They then compared this group with the surgery-only arm of the SRCT. Although the statistical validity of this is arguable, the authors should be commended for attempting to further confirm and validate their original study. In this follow-up study, the overall 5-year survival rate of 48% in the eligible-but-not-randomized group was identical to the overall survival rate in the SRCT surgery-alone group. Likewise, the cancer-specific 5-year survival rates 33
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between the 2 groups were the same (65% and 66%), as was the incidence of local recurrence (27%). The authors conclude that “the SRCT data are representative of the entire Swedish population.” Furthermore, “since it was a large, prospectively randomized clinical trial that included most Swedish hospitals it possesses sufficient validity.” One of the main criticisms of this trial, however, is the large number of hospitals participating in the trial, and an even larger number of surgeons with a lack of standardization of the surgical technique.25 What this review of the eligible-butnot-randomized group with the surgeryonly group of the SRCT does allow is the evaluation of the practice patterns of practicing general surgeons throughout Sweden. The trial also reinforces the importance of local control in maximizing long-term survival rates. The authors correctly note that a local recurrence of 27% is unacceptably high and reinforces the need for optimized surgery or the addition of further adjuvant therapy. Their recommendation is for preoperative radiotherapy. This question will hopefully be answered when the data mature from the Dutch Colorectal Cancer Group trial.26 In this prospective, randomized trial, patients with nonfixed, resectable rectal cancer are randomized to total mesorectal excision with preoperative external beam radiation therapy (25Gy) versus total mesorectal excision alone.
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This is an excellent study from an experienced group of colorectal surgeons from 1 institution with consistent practice patterns. The results of this study remind us that even despite strict selection criteria, local recurrences can occur at a disturbingly high frequency in those patients undergoing local excision alone for rectal cancer. The authors of this study note that the unusually high local recurrence rate in their series compared with the published literature may in part reflect variation in the duration or completeness of follow-up. Most local recurrences were picked up on proctoscopic 34
ences occurred in in-hospital mortality rates. The local recurrence rate (27%) was the same for both groups as was the 5-year cancer-specific survival (65% and 66%). Among eligible patients, no significant differences occurred in the treatment results as a function of gender. Conclusions: No statistically significant differences in local recurrence rates and
5-year survival occurred between patients who were eligible but not randomized to the SRCT and the surgery-only group included in the SRCT. Therefore, because the population in the SCRT was representative, it was concluded that the study results are reliable.
LOCAL EXCISION OF RECTAL CANCER WITHOUT ADJUVANT THERAPY: A WORD OF CAUTION. Garcia-Aguilar J, Mellgren A, Sirivongs P, Buie D, Madoff RD, Rothenberger DAAnn Surg 2000;231:345-351. Objective: To evaluate the results of local excision alone for the treatment of rectal
cancer. Design: Retrospective database. Setting: Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota Cancer Center, Minneapolis, Minnesota. Participants: All patients with T1 or T2 rectal cancers who underwent transanal excision with curative intent during a 10-year period. All lesions were full-thickness excision with approximately a 1-cm margin of normal rectal wall. All tumors were localized to the rectal wall at pathologic examination, had negative excision margins, and were well or moderately differentiated, without blood or lymphatic vessel invasion,
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and without mucinous components. All patients had, as part of their extent of disease examination, a chest x-ray and an abdominal and pelvic computed tomography (CT) scan to exclude metastatic disease and local extrarectal invasion. Fifty-nine of the 82 patients included in the study underwent preoperative ERUS. Results: End points of the study included local and distant tumor recurrence and patient survival. A total of 82 patients with T1 (n ⫽ 55) or T2 (n ⫽ 27) were included. At 54 months, 10 of the 55 patients with T1 tumors (18%) and 10 of the 27 patients with T2 tumors (37%) had a recurrence, for an overall recurrence rate of 24%. The average time to recurrence was 18 months in both groups. In patients with T1 tumors, 9 patients had a local recurrence, 1 had distant metastasis, and 1 had both local and distant recurrence. Six of these local recurrences involved the mucosa only and were diagnosed at proctoscopy, whereas 4 were extramucosal and diagnosed with ERUS. In the T2 group, 8 patients had an isolated local recurrence and 2 had both local and distant recurrence. The recurrence involved the mucosa in 8 patients and was exclusively extrarectal in 2. At an average of 54 months of follow-up, 77% of the T1 patients and 55% of the T2 patients were alive without evidence of disease. Of the 20 patients who recurred, 17 underwent salvage surgery. The survival rate was 98% for patients with T1 tumors and 89% for patients with T2 tumors. One patient in the T1 group died of cancer, and 2 patients died of cancer in the T2 group.
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examination or ERUS. The reader should conclude from this study that accurate preoperative staging is essential and that strict selection criteria be adhered to if patients are offered local excision for rectal cancer. Strong consideration should be given for adjuvant chemoradiation in T2 tumors (even those with favorable pathology). Furthermore, patients who have undergone local excision should have routine follow-up with both proctoscopy and ERUS. The schedule outlined here (every 4 months for the first 3 years after surgery and every 6 months for the next 2 years) certainly is reasonable.
Conclusions: Local excisions of early rectal cancers are followed by a much higher recurrence rate than previously reported. Salvage surgery with radical resection can be performed in most patients, but the long-term outcome is unknown.
LONG-TERM FOLLOW-UP OF PATIENTS WITH RECTAL CANCER MANAGED BY LOCAL EXCISION WITH AND WITHOUT ADJUVANT IRRADIATION. Chakravarti A, Compton CC, Shellito PC, et al.Ann Surg 1999;230:49-54. Objective: To determine long-term outcomes of patients undergoing local excision
with and without pelvic irradiation, and to define the role of adjuvant irradiation after local excision of T1 and T2 rectal cancers. Design: Retrospective review. Setting: Departments of Radiation Oncology, Surgery, Medical Oncology and Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, and the Departments of Surgery and Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia. Participants: Data on 99 patients with T1 and T2 rectal cancers who underwent local excision between January 1966 to January 1997. Fifty-two patients were treated by local excision alone (LE), and 47 patients were treated by local excision plus adjuvant irradiation (EBRT). Of these 47, 21 patients were treated by LE ⫹ EBRT, and 26 patients were treated by LE ⫹ EBRT ⫹ 5FU chemotherapy. Results: A statistically significant difference did not occur in the overall risk of local
recurrence or the recurrence-free survival (RFS) between those patients undergoing LE versus those undergoing LE with EBRT ⫾ chemotherapy. Subset analysis by T-stage was performed, however, and adjuvant irradiation significantly improved the 5-year actuarial local control rate and the 5-year recurrence-free survival in the T2 group. Further subgroup analysis was performed on those patients who received LE ⫹ EBRT versus LE ⫹ EBRT ⫹ 5FU chemotherapy. The difference in local control and RFS was not statistically significant with the addition of chemotherapy. Time to recurrence was shorter in the LE-alone group (13.5 months) compared with the LE ⫹ EBRT group (55 months). High-risk pathologic features were associated with lower 5-year actuarial LC rates. A statistically significant improvement in the LC rate and RFS was noted with the addition of EBRT. CURRENT SURGERY • Volume 59/Number 1 • January/February 2002
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This study addresses several important issues in the management of patients with rectal cancer that are managed by local excision: recognizing unfavorable histology as a risk factor for local failure, especially in T1 lesions, and identifying which subset of patients should be treated with adjuvant chemoradiation (T2 lesions and T1 lesions with unfavorable histology). Unfortunately, it lacks the statistical power to do so conclusively. The study also suffers in that it is retrospective and spans over a 30-year period, during which time surgical and radiation techniques have been evolving and therefore not standardized. Furthermore, because of the heterogeneity of the data set, the authors use subset analysis from which they draw their conclusions, further diluting the statistical power of the study. Although the point is made that this series represents some of the longest follow-up in the literature, all the data presented are actuarial data. Several important points are brought out in this paper, however. Unfavorable histology is associated with increased local failure and decreased recurrence-free survival. Therefore, adjuvant combination therapy should be included as part of 35
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the treatment strategy. The authors recommend chemoradiation for all patients undergoing local excision for T2 tumors, and for T1 tumors with high-risk pathologic features. They also stress that careful long-term follow-up is a necessity given the fact that 4 cases of late recurrence occur in this series. Of the 18 local recurrences, 17 were mucosal and 1 was a nodal recurrence. This further underscores the need for a thorough endoscopic evaluation with liberal use of ERUS.
Conclusions: Adjuvant radiation significantly improves local control and recur-
rence-free survival in patients undergoing local excision for T2 tumors, and for T1 tumors with high-risk pathologic features.
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SURGICAL TREATMENT OF ADENOCARCINOMA OF THE RECTUM. Za-
This paper highlights the evolving paradigm shift in the appropriate surgical technique required for complete excision of rectal cancer and, therefore, remains relevant today. Furthermore, the questions addressed in this series are purely surgical in nature and, by the study design, are not obscured by the addition of chemotherapy or radiation therapy. It is clear, as pointed out by these authors, that the experience and technique of the individual surgeon plays a fundamentally important role in the management of patients with rectal cancer. The recognition that the lateral margin of resection as well as tumor deposits within the mesorectum are important factors responsible for local recurrence has been the impetus for the standardization of the surgical technique for rectal cancer. Total mesorectal excision (TME), which was popularized by Heald 27-29 involves removal of the rectum and mesentery as an intact unit. In contrast to conventional blunt dissection, TME emphasizes a more precise dissection technique, thereby avoiding disruption of the mesentery. Using this technique, local recurrence rates have been consistently less than 10%.30,31 The authors question the need for TME in all patients, noting that it may be associated with increased morbidity and the need for routine proximal diversion. For patients with high rectal tumors, the dissection is carried at least 5 cm below the level of the tumor and not “coned” in. The lateral dissection is performed at the pelvic sidewalls. With this type of “tu-
heer S, Pemberton JH, Farouk R, Dozois RR, Wolff BG, Ilstrup D.Ann Surg 1998;
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227:800-811. Objective: To determine survival and recurrence rates in patients undergoing resec-
tion of rectal cancer achieved by abdominoperineal resection (APR), coloanal anastomosis (CAA), and anterior resection (AR) without adjuvant therapy. Design: Retrospective review. Setting: Division of Colon and Rectal Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota. Participants: The medical records of 1423 consecutive patients found to have rectal carcinoma during the period 1982 to 1989 were reviewed. Exclusion criteria included transanal or posterior excision for nonmetastatic disease, recurrent disease, primary treatment elsewhere, history of another primary tumor within 4 years of treatment for rectal carcinoma, carcinoma in situ, or patients who received adjuvant therapy. A total of 514 patients with primary, invasive adenocarcinoma of the rectum and rectosigmoid treated for cure by surgery-alone made up the target population. Total mesorectal excision was performed in all patients undergoing APR and CAA. For those patients who underwent an AR, an appropriately wide rectal mesentery resection technique was performed if the tumor was high; if the tumor was in the middle or low rectum, all mesentery was resected. Results: Information was available for 495 of the 514 patients. Median age of the group was 67 years. A total of 316 men and 198 women were included. The overall 5-year survival rate was 64%, with a disease-free survival of 79%. The probability of developing a recurrence of any type at 5 years was 21%. Overall, the local recurrence rate for all stages of disease and all operations was 7%. The local recurrence rates following AR, CAA, and APR were 7%, 6%, and 4%, respectively, for all patients and all stages of disease. The 5-year disease-free survival rates were 78% after AR, 63% after CAA, and 80% after APR. For patients with stage III disease, the local recurrence rate was higher (13%) after AR than that achieved by APR (7%) and CAA (0%). On univariate analysis of determinants of survival and recurrence, tumor size, depth of penetration of tumor, involvement of lymph nodes by tumor, and presence of metastasis were found to be statistically significant. On multivariate analysis, depth of penetration by tumor, number of lymph nodes involved by tumor, and the presence of distant metastasis were found to be associated with decreased survival and increased recurrence.
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Conclusions: No significant differences occurred between rates of recurrence and type of procedure performed. Appropriate “tumor-speicific” mesorectal excision is associated with low mortality, low morbidity, low local recurrence, and good 5-year survival rates. An overall failure rate of 40% in stage III disease was independent of surgical technique.
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mor-specific” mesorectal excision, the operation is tailored to the tumor and is associated with an equivalent local recurrence rate as for TME. They should be commended for their outstanding results utilizing a uniform surgical technique with a standardized practice pattern.
In 2001, the American Cancer Society estimates that 37,200 people in the United States will be found to have rectal carcinoma, with 8600 expected deaths from the disease.32 A number of relevant issues continue to be enthusiastically debated in the literature in our efforts to better understand this disease and care for these patients. The 5 papers reviewed in this issue of Current Surgery were selected to review the following topics, which include defining what is the optimal surgical strategy for rectal cancer, the role of local excision with or without chemoradiation, and determining what is the appropriate adjuvant therapy in those patients with resectable disease. It is clear that despite the increased use of multimodality therapy for the treatment of solid tumors, in general, and for rectal cancer, specifically, the surgeon’s role in the management of this disease remains paramount. Whether patients are treated with local excision or radical resection (with or without sphincter preservation), surgeon experience and technique have been shown to be directly related to outcome.33 Adherence to basic surgical oncologic principles is mandatory. Preoperatively, a number of factors must be considered when devising a treatment strategy for patients with rectal cancer. Patient factors include age, performance status, comorbid conditions, body habitus, and continence. Tumor factors include its location from the sphincter mechanism, local extent, size, bulkiness, and high-risk pathology. Accurate staging is critical in formulating the operative plan. The presence or absence of metastatic disease as well as the local extent (TNM) of the tumor will, necessarily, tailor the surgical procedure chosen. The Society of Surgical Oncology recommends that an appropriate extent of disease examination should include a physical examination, chest x-ray, CBC and chemistry profile, colonoscopy (or air-contrast barium enema) to evaluate the rest of the colon, pelvic CT scan in selected patients, and ERUS (for better definition of the T and N stage) if treatment will be altered. Routine use of abdominal CT scan or liver ultrasound (unless metastatic disease is suspected) as well as preoperative CEA are not recommended.10 Goals of surgery include cure, control of local and regional disease, sphincter preservation, acceptable functional results with low morbidity, and accurate pathologic staging. Criteria for local excision are well accepted. These include mobile tumors less than 4 cm in diameter, less than one-third the circumference of the bowel wall, and less than 8 cm from the anal verge. The primary should be well-to-moderately differentiated and have no evidence of vascular, lymphatic, or perineural invasion. Only T1N0 and T2N0 tumors by ERUS should be considered. The technical details of local excision are important. A full-thickness excision with negative margins is the goal of surgery. Local excision alone should be reserved for patients with small T1 lesions that contain no adverse pathologic features. T1N0 tumors with adverse pathologic features as well as T2N0 tumors should be considered for additional therapy.34-44 Endoscopic ultrasonography has become increasingly more important as a staging tool in assessing local tumor extent as well as lymph node involvement and, therefore, allows for more appropriate patient selection for local therapy.45-48 Patient education and close postoperative follow-up with physical examination, proctoscopy, and liberal use of ERUS are essential and will enhance the ability to detect a local recurrence and, ultimately, enhance the chance for long-term cure. Radical resection should be performed in those patients with transmural disease with or without nodal involvement. Because total mesorectal excision consistently demonstrates local recurrence rates less than 10% compared with conventional surgical CURRENT SURGERY • Volume 59/Number 1 • January/February 2002
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techniques, the push for this to become the standard surgical approach appears justified.27-31,49 As noted in the reviewed article by Zaheer et al, “tumor-specific” mesorectal excision, however, may be appropriate particularly for higher rectal lesions. Despite the fact that most patients with rectal cancer present with localized disease, locoregional failure and the rate of distant metastasis may be as high as 30% after potentially curative surgery. Multimodality therapy, therefore, has become the cornerstone of treatment. In 1990, the National Institutes of Health Consensus Conference on adjuvant therapy for patients with colon and rectal cancer7 recommended external beam radiation therapy and 5FU-based chemotherapy as standard postoperative treatment for patients with stage II or III disease. The use of preoperative radiation with or without chemotherapy is currently being studied in the United States and in Europe and is the focus of 2 of the abstracts reviewed. The advantages of conventional preoperative combination therapy with a delay in surgery for 4 to 6 weeks have already been discussed. Colorectal cancer remains a significant public health problem. However, advances have been made in disease prevention, screening, and diagnosis. As our understanding of the pathophysiology and tumor biology of colon and rectal cancer continues to improve, future therapies are likely to be directed at the molecular level. Treatment remains multidisciplinary in nature, with a number of surgical options available to the surgeon. Continued refinement and standardization of surgical techniques as well as the information gained from randomized, prospective trials of adjuvant therapy will continue to aid us in understanding this disease and enable surgeons to more effectively treat these patients. S0149-7944(01)00567-0
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with or without preoperative radiotherapy in the treatment of primary rectal cancer: Prospective randomized trial with standard operative and histopathologCURRENT SURGERY • Volume 59/Number 1 • January/February 2002
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ical techniques. Dutch ColoRectal Cancer Group. Eur J Surg. 1999;165:410420. 27. Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery: the
clue to pelvic recurrence? Br J Surg. 1982;69:613-616. 28. Heald RJ, Ryall RD. Recurrence and survival after total mesorectal excision for
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operative treatment of carcinoma of the rectum. J Am Coll Surg. 1995;181:335346. 31. Merchant NB, Guillem JG, Paty PB, et al. T3N0 rectal cancer: results following
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total mesorectal excision. ASCO: 2001 Educational Book. 210-214. 34. The society of surgical oncology practice guidelines. Oncology. 1997;11:6-9. 35. Minsky BD, Rich T, Recth A, et al. Selection criteria for local excision with or
without adjuvant radiation therapy for rectal cancer. Cancer. 1989;63:14211429. 36. Enker WE, Paty PB, Minsky BD, Cohen AM. Restorative or preservative oper-
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carcinoma by a multimodality treatment approach. Surg Oncol Clin N Am. 1992; 1(1):137-145. 40. Ota DM, Skibber J, Rich T. M.D. Anderson experience with local excision and
multimodality therapy for rectal cancer. Surg Oncol Clin N Am. 1992;1(1):147152. 41. Wood WC, Willett CG. Update of the Massachusetts General Hospital Experi-
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preoperative staging of rectal tumors: a learning experience. Dis Colon Rectum. 1990;33:654-659. 47. Ng A, Recht A, Busse PM. Sphincter preservation therapy for distal rectal cancer:
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Semin Surg Oncol. 2000;19:350-357.
Surgical Oncology Who Was Sister Mary Joseph? Guest Reviewer: Howard A. Zaren, MD, Department of Surgery, Cook County Hospital, Chicago, Illinois VIGNETTES IN MEDICAL HISTORY: SR. MARY JOSEPH AND HER NODE.
REVIEWER COMMENTS
Hill M, O’Leary P.Am Surg 1996;62:328-329.
This historical account by the authors of the Sr. Mary Joseph Node or Nodule is an interesting reminiscence of important surgical lore. Their article not only describes the history of its discovery, but also includes the individual whose name has been most often associated with this entity. The Sr. Mary Joseph Nodule was usually considered a physical sign of such poor prognosis, with survival measured on an average of 10 months, that surgical intervention was considered by many surgeons to not be a consideration.
Objective: To present a vignette describing Sr. Mary Joseph, her background, her
training, and her designation as the first person to attach significance and anatomic pathologic meaning to the presence of a para-umbilical nodule, which often indicated advanced intra-abdominal malignancy. Design: A vignette in medical history. Setting: Surgery Department, Louisiana State University Medical Center, New Orleans, Louisiana. Conclusions: The authors describe the life of Sister Mary Joseph from the time she was born as Julia Dempsey on May 14, 1856, in Salamanca, New York, and chronicle her life from that date. Her parents were Irish immigrants who moved to Minnesota before the Civil War. At the age of 22, she became a member of the Third Order Regular of St. Francis of the Congregation of the Lady of Lourdes of Rochester, Minnesota, in 1878. At that time, she took the name Sr. Mary Joseph. In 1880, at the age of 24, she became director of the congregation’s missionary school in Ashland, Kentucky, and then returned to Rochester to work in St. Mary’s Hospital. A major project of the Minnesota’s order of the Sisters of St. Francis was to establish St. Mary’s Hospital in 1889. This hospital was constructed by William W. Mayo, father of the Mayo brothers. Sr. Mary Joseph was assigned to the hospital and, having had no formal nursing training, was mentored by Edith Graham. Ms. Graham was the first formally trained nurse in this area of Minnesota, after having graduated from the Women’s Hospital School of Nursing in Chicago. Sr. Mary Joseph went on to become head nurse and within 3 years became superintendent of the hospital. At this time, she was still involved in clinical care and became the first surgical assistant of Dr. William Mayo. Sr. Mary Joseph was the first individual to describe the presence of a paraumbilical nodule that was often the only physical indication of intra-abdominal malignancy that was of advanced stage. She first noticed the presence of such a nodule during the surgical preparation of the abdomen and was said to have pointed it out to Dr. Mayo. He agreed that this peri-abdominal nodule was physical evidence of advanced intra-abdominal malignancy. It was not until 1949 that Hamilton Bailey in publishing the 11th edition of his textbook, Physical Signs in Clinical Surgery, gave her credit for her observation and named the nodule after her. In historical retrospect, this
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