A single-centre experience of chemoradiotherapy for rectal cancer: is there potential for nonoperative management?

AIM: The aim of the study was to assess the outcome of patients who received chemoradiotherapy (CRT) for locally advanced rectal cancer, specifically those with complete clinical response (CCR) and who were then managed nonoperatively with a 'Watch and Wait' follow-up protocol. METHOD: A retrospective study was carried out of patients undergoing preoperative CRT for rectal cancer, conducted in a district general hospital managing rectal cancer through the multidisciplinary team process. RESULTS: Forty-nine patients received preoperative CRT over a 5-year period (2004-2009). Twelve (24%) were considered potentially to have had a complete response on MRI. Of these, six subsequently had clinical evidence of residual disease, leading to surgery (mean time to surgery, 24 weeks; range, 12-36 weeks). The remaining six had CCR, avoiding surgery (mean follow up, 26 months; range, 12-45 months), with all six patients disease free to date. A further six patients had complete pathological response (CPR) following surgery after comprehensive histopathological assessment of the specimen. CONCLUSION: In this consecutive series of patients with locally advanced rectal cancer treated with CRT, 12% demonstrated a CCR and have been actively managed conservatively, thereby avoiding surgery. With further improvements in diagnostic assessment of response to CRT, this figure may rise.

Short-term outcomes of the prone perineal approach for extra-levator abdomino-perineal excision (elAPE).

BACKGROUND: Many studies report that low rectal cancer treated with abdomino-perineal excision (APE) have higher rates of CRM involvement with associated local recurrence and worse survival when compared to low anterior resection. We present a single surgeon's short-term outcomes using the prone perineal extra-levator (elAPE) approach. METHODS: Thirty-one patients between 2006 and 2010 underwent elAPE with curative intent. Data was collected prospectively recording patient tumour characteristics and histological outcome. Outcome measures included circumferential resection margins, recurrence rates, 30-day morbidity and mortality. RESULTS: Mean distance of tumour from anal verge was 3.63 ± SD 1.52 cm. 14 patients had pre-operative chemo-radiotherapy. The involved circumferential resection margin rate was 3.2%. Median follow-up was 20 (0-45) months, with overall mortality of 13.3% and 30 day mortality of 6.6%. CONCLUSIONS: The prone position elAPE has a low circumferential resection margin involved rate and, through improved vision, reduces the risk of inadvertent tumour or specimen perforation.

Transient myocarditis associated with fulminant colitis.

Case Summary. An 18-year old man presented with a three-week history of abdominal pain, weight loss and bloody diarrhoea. He was profoundly septic, with generalised abdominal tenderness. CT and flexible sigmoidosopy confirmed colitis of the colon with rectal sparing. Laparotomy was performed when conservative management failed to improve his condition. Subtotal colectomy, with end ileostomy and mucus fistula formation, was performed in light of active colitis. Despite successful operative intervention the patient acute left ventricular failure, raising the possibility of giant cell myocarditis, which fully resolved before a definitive diagnosis could be reached. Discussion. It is possible that the transient cardiac failure in this case may represent an overwhelming inflammatory response or myocarditis. Inflammatory bowel disease is rarely associated with giant cell myocarditis (GCM). GCM usually affects a young population and its prognosis is variable, ranging from complete recovery, remission with recurrence and fatality. The management of this group of patients is still relatively experimental. Conclusion. Fulminant colitis can be associated with a rapid deterioration in cardiac function. Causes include sepsis, systemic inflammatory response syndrome or myocarditis. GCM should be considered in patients with new onset of left ventricular failure that decline rapidly.

Popliteal venous aneurysm causing pulmonary embolism and paradoxical embolisation in a patient with antiphospholipid syndrome.

INTRODUCTION: Popliteal venous aneurysms are rare and can cause recurrent pulmonary emboli despite adequate anticoagulation. REPORT: A 43-year old patient with known antiphospholipid syndrome developed an extensive pulmonary embolus and ischaemic stroke despite anticoagulation. Duplex ultrasound confirmed a right popliteal venous aneurysm containing non-adherent multi-layered thrombus. At operation an 8 cm x 5 cm true aneurysm of the popliteal vein was excised. A postoperative echocardiogram revealed a patent foramen ovale. DISCUSSION: This case is unusual as the patient suffered a paradoxical embolism due to his patent foramen ovale. Although antiphospholipid syndrome is associated with venous thrombosis, this is usually prevented by therapeutic anticoagulation.

Immunomonitoring of renal transplant recipients in the early posttransplant period by sequential analysis of chemokine and chemokine receptor gene expression in peripheral blood mononuclear cells.

INTRODUCTION: We sought to determine whether sequential changes in chemokine ligand/receptor gene expression in the early posttransplant period of human renal allografts can be detected in peripheral blood mononuclear cells (PBMCs) and whether any such changes are predictive of clinical events. METHODS: Blood samples from 106 renal transplant recipients and 29 donor nephrectomy patients were taken preoperatively and daily for 14 days. Within the study period 22 patients had biopsy-proven acute rejection. From each blood sample PBMCs were separated and gene expression levels for chemokines CCL3, CCL4, CCL5, CXCL10, and their receptors CCR1, CCR5, and CXCR3, were determined using real-time quantitative PCR. RESULTS: Different gene expression patterns were seen between the rejector and nonrejector groups with decreases in CCL4 and CCR5 expression on days 6 to 8 and increases in CCR1 expression on days 9 and 10 posttransplant. With CXCL10, decreases in expression were seen in the nonrejector group but increases were seen in the rejector group posttransplant. With data aligned to time of rejection diagnosis, statistically significant increases, that preceded the clinical detection of acute rejection were seen in CCR1 and CXCL10 expression. Both their expression levels returned to pretransplant baseline values after successful antirejection therapy. CONCLUSION: We have demonstrated that changes in chemokine receptor/ligand gene expression by sequential monitoring in PBMCs can be detected in the early posttransplant period. In particular, CCR1 and CXCL10, which showed increased expression prior to rejection and returned to baseline levels with antirejection therapy, may have potential use in immunomonitoring and as predictive factors of rejection prior to its clinical manifestation.