Psychological and sexual distress in rectal cancer patients and partners.

BACKGROUND: Rectal cancer (RC) patients experience unique sources of distress, including sexual dysfunction and body image concerns, which can also cause distress among partners. This preliminary study investigated patterns of psychological distress, sexual functioning, sexual distress, and relationship satisfaction among RC patient-partner couples at pivotal points during cancer treatment. METHODS: Twenty couples participated (N = 40). Patients and partners completed a series of validated measures of psychological distress (ET), sexual functioning (FSFI; IIEF), sexual distress (GMSEX; Sexual Distress Scale) and relationship satisfaction (GMREL) at time of diagnosis, 3 weeks after radiation, 4 weeks post-surgery, and after chemotherapy and surgery for ostomy closure. Descriptive statistics, t-tests, and repeated-measures ANOVA were used to analyze scores over time, first for patients and partners, and then by sex. RESULTS: Relationship satisfaction remained elevated over time. In this sample, 55% of patients and 78.9% of partners reported clinically significant rates of psychological distress at diagnosis, which decreased to 23% and 46% respectively at the last assessment. Sexual satisfaction and distress worsened for patients and partners between baseline and surgery for ostomy closure. Both male and female participants reported statistically significant declines in sexual function from baseline to end of treatment (p < 0.05). DISCUSSION: Relative to relationship satisfaction, psychological and sexual health outcomes seem more vulnerable to the effects of RC treatment during the first year after diagnosis, both for patients and partners and for men and women. Results support the need for psychosocial care and sexual education/counseling for couples coping with RC.

Management of bowel obstruction in patients with stage IV cancer: predictors of outcome after surgery.

BACKGROUND: Patients with stage IV cancer and bowel obstruction (BO) present a complicated management problem. We sought to determine if specific parameters could predict outcome after surgery. METHODS: Records of patients with stage IV cancer and BO treated from 1991 to 2008 were reviewed. For surgical patients, 30-day morbidity and 90-day mortality were assessed using exact multivariable logistic regression methods. RESULTS: Of 198 patients, 132 (66.7%) underwent surgery, 66 medical treatment alone, and demographics were similar. A total of 41 patients (20.7%) were diagnosed with stage IV cancer and BO synchronously, all treated surgically; the remaining presented metachronously. Medically managed patients were more likely to have received chemotherapy in the 30 days prior to BO (45 of 66 [68.2%] vs 40 of 132 [30.3%], p < .01). In the surgical group, 30-day morbidity was 35.6%, while 90-day mortality was 42.3%. Median overall survival for synchronous patients was 14.1 months (95% confidence interval [95% CI] 7.6-23.2), and 3.7 months (95% CI 2.5-5.2) and 3.6 months (95% CI 1.5-5.2) for metachronous patients treated surgically and medically, respectively. A multivariate model for 90-day surgical mortality identified low serum albumin, metachronous presentation, and ECOG > 1 as predictors of death (p < .05). A model for 30-day surgical morbidity yielded low hematocrit as a predictive factor (p < .05). CONCLUSIONS: This cohort identifies characteristics indicative of morbidity and mortality in stage IV cancer and BO. Low serum albumin, ECOG > 1, and metachronous presentation predicted for 90-day surgical mortality. These data suggest factors that can be used to frame treatment discussion plans with patients.

Anorectal melanoma: diagnosis and treatment.

An increase in the incidence of anorectal melanoma has recently been noted in the United States. Anorectal melanoma is an uncommon and lethal condition, with a median survival of <20 months. Unfortunately, nonspecific symptoms also attributable to common and benign conditions (eg, hemorrhoids) cause significant delay in its diagnosis. Although it has not been validated by clinical trials, abdominoperineal resection has historically been the treatment of choice for this disease. However, for the past 2 decades, a lack of clear survival benefit has led to a shift toward less-mutilating wide local excisions. Controversy still exists regarding the benefit of radiation therapy and chemotherapy. Furthermore, the value of nodal surgery in anorectal melanoma is unclear. In this article, we review the history and current status of management of anorectal melanoma, with a particular focus on surgical controversies and challenges in optimizing survival.

Should total number of lymph nodes be used as a quality of care measure for stage III colon cancer?

OBJECTIVE: To assess whether TNODS is an independent prognostic factor after adjusting for the lymph node ratio (LNR). SUMMARY BACKGROUND DATA: The medical literature has suggested that the TNODS is associated with better survival in stage II and III colon cancer. Thus TNODS was endorsed as a quality measure for patient care by American College of Surgeons, National Quality Forum. There is, however, little biologic rationale to support this linkage. METHODS: : A total of 24,477 stage III colon cancer patients were identified from Surveillance, Epidemiology, and End Results cancer registry and categorized into 4 groups, LNR1 to LNR4, according to LNR interval: <0.07, 0.07 to 0.25, 0.25 to 0.50, and >0.50. Patients were also stratified according to TNODS into high TNODS (> or = 12) and low TNODS (<12) groups. The method of Kaplan-Meier was used to estimate the 5-year survival and the log-rank test was used to test the survival difference among the different groups. RESULTS: Patients with high TNODS have better survival compared with those with low TNODS (5-year survival 51.0% vs. 45.0%, P < 0.0001). However, after stratifying by LNR status, there was no significant survival difference between patients with high TNODS and those with low TNODS within strata LNR2 (5-year survival 56.3% vs. 56.0%, P = 0.26). Ironically, patients with high TNODS had significantly worse survival than those with low TNODS within strata LNR3 (5-year survival 41.2% vs. 47.4%, P = 0.0009) and LNR 4 (5-year survival 22.0% vs. 32.1%, P < 0.0001). CONCLUSIONS: The previously reported prognostic effect of TNODS on node-positive colon cancer was confounded by LNR. This observation calls into question the use of TNODS as a quality measure for colon cancer patients' care.

Adenocarcinoma arising from chronic perianal Crohn's disease: case report and review of the literature.

Perianal disease is a common manifestation of Crohn's disease. Rarely malignancy arises in perianal fistulas. The etiology of fistula related cancer remains a subject of debate. We present a unique case of a perianal Crohn's disease with adenomatous epithelialization of a fistula tract and an associated mucinous adenocarcinoma. Our case demonstrates that mucinous adenocarcinoma can arise in long standing perianal Crohn's disease and may be associated with adenomatous transformation of the epithelial lining of the fistula tract.

Safety and efficacy of first-line chemotherapy in unresected metastatic colorectal cancer.

BACKGROUND: Primary tumor resection in patients with metastatic colorectal cancer is considered highly controversial. Historical data suggest a low risk of primary tumor-related complications in patients treated with first-line 5-fluorouracil (5-FU) chemotherapy. However, there are very limited data on the safety and efficacy of first-line combination chemotherapy in this unresected-primary population, especially in the setting of rectal cancer. PATIENTS AND METHODS: We performed a single-institution retrospective study to evaluate the primary tumor-related complication rate and outcome of patients with unresected metastatic colorectal cancer treated with first-line chemotherapy. Estimation of the overall and progression-free survival distributions were done using the Kaplan-Meier method. RESULTS: Thirty-eight patients were identified: 26 had primary colon cancers and 12 had primary rectal cancers. Thirty-one patients were treated with first-line FOLFOX (oxaliplatin/leucovorin/5-FU) with or without bevacizumab. In patients with colon tumors, only 2 (7%) required surgery, both for obstruction. In patients with rectal tumors, 3 (25%) developed progressive obstructive symptoms, and 2 developed worsening pain. Four of these patients were adequately palliated with chemoradiation; only 1 patient required a diverting colostomy. The median progression-free survival was 7 months, and overall survival was 17.3 months. Twenty-two patients died because of disease progression, only 3 of whom developed obstructive symptoms at the primary tumor site before death. CONCLUSION: First-line chemotherapy is feasible and safe in patients with unresected colon and nonirradiated rectal cancer. The rate of bowel obstruction requiring surgical intervention in this population was < 10%. These results support an approach that defers surgery in non-obstructed, noncurable patients in favor of systemic chemotherapy as initial treatment.

Viability of endoscopic and excisional treatment of early rectal carcinoids.

With the advent of endoscopy, the incidence of rectal carcinoid tumors has not only risen, but the majority are localized at presentation. This has led to excisional and/or ablative therapy in lieu of radical resections. A single institute's experience with rectal carcinoids was reviewed to determine the impact this approach has had on outcomes, and evaluate any selection criteria for optimizing patient survival. A single institute's tumor registry was retrospectively queried, identifying 14 patients with rectal carcinoid tumors over a 28-year period. The mean age at diagnosis was 52.1 +/- 14.4 years. Six of the 14 patients were female. Presenting symptoms included a change in bowel habits in six (38%), rectal bleeding in six (38%), and abdominal pain or distention in five (31%) patients. No patient had symptoms consistent with carcinoid syndrome. The rectal carcinoids were a mean 9.2 +/- 3.4 cm from the anal verge and a mean 9 +/- 6 mm in size. Endoscopic and/or transanal excision/fulguration techniques treated 11 (79%) patients, whereas two (14%) patients underwent a low anterior resection (LAR). Surveillance entailed periodic endoscopy for a median 65 months (range 8-281). No patient developed recurrent carcinoid disease for a 20-year overall survival of 70%.

Surgical and nonsurgical therapy for lung metastasis: indications and outcomes.

The management of pulmonary metastasis is a broad and multifaceted topic. Because of the filtration function and the favorable microenvironment of the lung, most malignancies cause pulmonary metastases. This article focuses on recent experience with secondary lung malignancies and their newer treatment options, indications, and technical aspects.

Educating the surgeon-scientist: A qualitative study evaluating challenges and barriers toward becoming an academically successful surgeon.

BACKGROUND: The advancement of surgical science relies on educating new generations of surgeon-scientists. Career development awards (K Awards) from the National Institutes of Health, often considered a marker of early academic success, are one way physician-scientists may foster skills through a mentored research experience. This study aimed to develop a conceptual framework to understand institutional support and other factors leading to a K Award. METHODS: A national, qualitative study was conducted with academic surgeons. Participants included 15 K Awardees and 12 surgery department Chairs. Purposive sampling ensured a diverse range of experiences. Semistructured, in-depth telephone interviews were conducted. Interviews were audio recorded and transcribed verbatim, and 2 reviewers analyzed the transcripts using Grounded Theory methodology. RESULTS: Participants described individual and institutional factors contributing to success. K Awardees cited personal factors such as perseverance and team leadership skills. Chairs described the K Awardee as an institutional "investment" requiring protected time for research, financial support, and mentorship. Both K Awardees and Chairs identified a number of challenges unique to the surgeon-scientist, including financial strains and competing clinical demands. CONCLUSION: Institutional support for surgeons pursuing K Awards is a complex investment with significant initial costs to the department. Chairs act as stewards of institutional resources and support those surgeon-scientists most likely to be successful. Although the K Award pathway is one way to develop surgeon-scientists, financial burdens and challenges may limit its usefulness. These findings, however, may better prepare young surgeons to develop career plans and identify new mechanisms for academic productivity.

Evolving therapies and FAK inhibitors for the treatment of cancer.

Despite advances in medical and surgical therapy, cancer kills more than half a million people in the United States annually, and the majority of these patients succumb to metastatic disease. The traditional approach to treating systemic disease has been the use of cytotoxic chemotherapy. However, chemotherapy is rarely curative and toxicity is often dose limiting. In addition, the effects of chemotherapy are nonspecific, targeting both malignant and normal tissues. As a result, recent efforts increasingly have focused on developing agents that target specific molecules in tumor cells in order to both improve efficacy and limit toxicity. This review summarizes the history and current use of targeted molecular therapy for cancer, with a special emphasis on recently developed inhibitors of Focal Adhesion Kinase (FAK).

Colorectal cancer surgery in the elderly: acceptable morbidity?

BACKGROUND: Because of the increase in the geriatric population, an increasing number of elderly patients are being treated for colorectal cancer. The purpose of this study was to evaluate perioperative morbidity and mortality in this population. METHODS: A retrospective chart review was performed for patients 80 years of age or older who underwent surgery for colorectal cancer (1993-2006). RESULTS: Ninety patients were identified, with a median age of 84 years. More than 90% presented with symptoms; the remaining were diagnosed by screening colonoscopy. Emergent surgery was required in 10%. The morbidity rate was 21% and the overall 30-day mortality rate was 1.1%. Morbidity was higher in patients who required surgery emergently. CONCLUSIONS: Despite advanced age, the majority of patients in this study did well. Postoperative morbidity was higher than in the general population, but we believe it was acceptably low in most patients. Colorectal surgery appears to be safe in most elderly patients.