Quality-of-life management of patients with colorectal cancer.

We have reviewed management of the patient with colorectal cancer both after primary treatment and in the palliative setting. Although we have addressed quantitative measures of quality of life as applied to patients with colorectal cancer, the limitations of combining disparate variables that encompass morbidity, an idealized lifestyle, and personal variation in interpretation of that lifestyle into a single number or point on a graph are self-evident. The caring family physician has a better intuitive integration of patient complexity than does the outcomes analyst. When the apparently cured patient returns to the family physician after initial operative treatment, recovery is just beginning. We have addressed the morbidity of surgery, the role of adjuvant treatments, the short-term and long-term effects of adjuvant treatments on quality of life, and the management of these effects. Restoration of quality of life extends beyond cure or survival and embraces repair of the patient's confidence and psychosocial well-being. The patient with persistent or recurrent colorectal cancer merits the entire range of medical skills of the family physician. Not all patient findings arise from cancer; other treatable medical and surgical diseases occur. If findings are from recurrent colorectal cancer, the patient may still be curable by treatment or may enjoy prolonged quality of life with or without anticancer treatment. Do not rush to judgment about remaining life span. Although pain control is the benchmark of palliative care, psychological elements that affect severity of pain and the invariably associated depression of the patient require the emotional support and compassion of the family physician.

Cyclooxygenase-2 overexpression and tumor formation are blocked by sulindac in a murine model of familial adenomatous polyposis.

Inducible cyclooxygenase (Cox-2), also known as prostaglandin H synthase 2 (PGH-2) is a key enzyme in the formation of prostaglandins and thromboxanes. Cox-2 is the product of an immediate-early gene that is expressed in response to growth factors, tumor promoters, or cytokines. Overexpression of Cox-2 is associated with both human colon cancers and suppression of apoptosis in cultured epithelia] cells, an activity that is reversed by the nonsteroidal anti-inflammatory drug, sulindac sulfide. To address the relationship between Cox-2, apoptosis, and tumor development in vivo, we studied C57BL/6J-Min/+(Min) mice, a strain containing a fully penetrant dominant mutation in the Apc gene, leading to the development of gastrointestinal adenomas by 110 days of age. Min mice were fed AIN-76A chow diet and given sulindac (0.5 +/- 0.1 mg/day) in drinking water. Control Min mice and homozygous C57BL/6J-+/+ normal littermates lacking the Apc mutation (+/+) were fed AIN-76A diet and given tap water to drink. At 110 days of age, all mice were sacrificed, and their intestinal tracts were examined. Control Min mice had 11.9 +/- 7.8 tumors per mouse compared to 0.1 +/- 0.1 tumors for sulindac-treated Min mice. As expected, +/+ littermates had no macroscopic tumors. Examination of histologically normal-appearing small bowel from Min animals revealed increased amounts of Cox-2 and prostaglandin E(2) compared to +/+ littermates. Using two different in situ techniques, terminal transferase-mediated dUTP nick end labeling and a direct immunoperoxidase method, Min animals also demonstrated a 27-47% decrease in enterocyte apoptosis compared to +/+ animals. Treatment with sulindac not only inhibited tumor formation but decreased small bowel Cox-2 and prostaglandin E(2) to baseline and restored normal levels of apoptosis. These data suggest that overexpression of Cox-2 is associated with tumorigenesis in the gastrointestinal epithelium, and that both are inhibited by sulindac administration.

Disorders of the rectus abdominis muscle and sheath: a 22-year experience.

OBJECTIVES: To determine the spectrum of diseases that can involve the rectus abdominis muscle and sheath (RMS) and to describe the clinical features of these conditions. METHOD: A retrospective medical record review of RMS disorders seen at The New York Hospital-Cornell Medical Center from 1971 to 1992. RESULTS: A total of 40 patients with diseases of the RMS were identified. Thirty patients had primary diseases of the RMS, most commonly desmoid tumor and hematoma. Secondary disorders of the RMS included abscesses from diverticulitis, a perforated sigmoid carcinoma, gallbladder empyema, and disseminated actinomycosis. Eleven of 18 patients with desmoid tumors had familial adenomatous polyposis (FAP). The desmoid tumors in patients with FAP resulted in greater morbidity and mortality than those in patients without FAP. All patients with hematomas were on anticoagulation or had a history of trauma, vigorous coughing, or physical exertion. CONCLUSIONS: 1) RMS disease should be suspected in patients with a palpable abdominal mass and a history of familial adenomatous polyposis, trauma, anticoagulation, or vigorous coughing or exercise. 2) The most common non-neoplastic condition of the RMS is a hematoma. 3) The desmoid tumor is the most common neoplasm of the RMS. 4) Abdominal ultrasonography and CT readily distinguish RMS disease from intraabdominal pathology.

MRI for evaluation of perianal inflammation.

BACKGROUND: We describe the value of using magnetic resonance imaging (MRI) in six distinct clinical settings often encountered in cases of perirectal inflammatory disease. METHODS: MRI was performed on six patients with known perianal inflammatory disease; the number, anatomic extent, location, and signal intensities of various lesions and their associated complications were assessed. RESULTS: MRI is a noninvasive technique that is useful in the diagnosis and management of perirectal inflammatory disease. CONCLUSIONS: In patients with known fistulas, MRI may determine the lesion's anatomic extent, localize unsuspected fistulas, and confirm or exclude the inflammation of the fistulous tract(s). Information obtained by MRI examination may, in turn, be used to determine treatment of patients with perirectal inflammatory lesions and can be a useful adjunct in following results of therapy.

Surgical prophylaxis of familial colon cancer: prevention of death from familial colorectal cancer.

Patients at risk for inherited colorectal cancer constitute a heterogeneous population. A total colectomy is minimal treatment for those patients with invasive cancer or those with established risk factors. For others at risk, predictive genetic markers, correlated with clinical and pathologic determinants, will establish the basis for policies of surveillance and preventive surgery.

Evidence for adenoma-carcinoma sequence in the duodenum of patients with familial adenomatous polyposis. The Leeds Castle Polyposis Group (Upper Gastrointestinal Committee).

AIMS: To explore the association between duodenal adenoma and carcinoma in patients with familial adenomatous polyposis (FAP). METHODS: A multicentre survey of 1262 patients with FAP yielded 47 cases of duodenal cancer. The association between adenoma and cancer was assessed in these cases. RESULTS: Adenomatous tissue was found within duodenal cancer in 29 of 44 (66%) patients with FAP and in mucosa adjacent to duodenal cancer in 31 of 42 (73%) such patients. Adenomas were found as a component of, or adjacent to, duodenal cancer in 38 of 45 (84%) patients. CONCLUSIONS: These observations support the existence of the adenomacarcinoma sequence in the duodenum of patients with FAP. Factors associated with malignant change included villous histology, moderate or severe dysplasia, and the presence of stage IV duodenal polyposis.

Colorectal cancer: detection, treatment, and rehabilitation.

In the United States, colorectal cancer is the second most common cause of cancer mortality after lung cancer. However, incidence and mortality rates have been falling, reflecting improvements in primary prevention, early detection, and treatment. This article reviews the major advances in the understanding and management of colorectal cancer.

Gender and colorectal cancer.

Studies of gender differences in colorectal cancer have shown temporal shifts in incidence and site distribution which can be attributed, in part, to environmental and behavioural factors. In high-risk populations, rectal cancer and left-sided colon cancer have been more frequent in older men, whereas right-sided colon cancer has been more commonly found in older women. Among known associations with reduced colorectal cancer risk, women appear to ingest more dietary fibre, seem to benefit more from physical activity and body mass, and consume less alcohol. Although these differences may contribute to the risk differential, hormonal events during reproductive years also appear to affect women's risk at older age. The interactions of sex hormone metabolism and nutrition, including dietary fibre, in colorectal carcinogenesis provide a rewarding field for investigation.

Colonic mucosal pH in humans.

Mucosal pH was measured at specific anatomic segments within the colon using a flexible pH probe in patients prepared for colonoscopy. The data revealed similar pH measurements along the length of the colon, irrespective of the presence or absence of colorectal neoplasia. Patients exhibited a relatively acidic right colon; a more alkaline transverse, left, and sigmoid colon; and a relatively acidic rectum. There were no apparent gender- or age-related effects on colonic mucosal pH.

Treatment options for the patient with colorectal cancer.

Treatment decisions for patients with colorectal cancer depend on the site and extent of the cancer. Medical factors rarely preclude appropriate treatment. For colonic and upper rectal cancer, curative treatment is almost entirely operative. Even patients with disseminated colon cancer merit a limited palliative resection to abort bleeding and prevent obstruction. When surgery is elective, colostomy is rarely necessary, although it may be required in patients who have obstructed or perforated colon cancer. For distal rectal cancer, various treatment options, including radiation therapy, have reduced the need for a colostomy, although maintaining comparable cure rates. Currently, only about one in seven patients with rectal cancer requires a permanent colostomy.

Loss of colonic HLA antigens in familial adenomatous polyposis.

The loss of HLA antigens by neoplastic cells is considered important for tumor growth and metastasis, since it may allow tumors to escape immune surveillance. We studied the expression of HLA class I and II antigens in the colons of 10 patients with familial adenomatous polyposis (FAP), a condition which leads inevitably to colorectal cancer. Expression of HLA class antigens was studied by immunohistochemistry in (a) adenomas from patients with FAP, (b) histologically normal mucosa distant from the adenomas, and (c) histologically normal colonic mucosa from normal subjects. The expression of HLA class I and II antigens was decreased in histologically normal mucosa from FAP patients compared to normal controls. Adenomas showed a similar but quantitatively more pronounced reduction (or loss) of HLA antigen expression. The reduction of HLA expression in adenomas was comparable to that observed in sporadic colon carcinomas. This generalized suppression of HLA gene expression in the colon of FAP patients, which precedes the onset of overt histological manifestations of neoplasia, may be an important early event in colon carcinogenesis.

Multivariate analysis of morbidity and mortality from the initial surgical management of obstructing carcinoma of the colon.

Eighty consecutive patients presenting with complete large intestinal obstruction from primary carcinoma were evaluated. A multivariate analysis was performed to evaluate perioperative morbidity and mortality. There were five deaths in the immediate postoperative period (30 days). Extensive and lesser complications occurred in eight and 11 patients, respectively. There were 25 lesions of the right colon, whereas in 55 patients, the lesion was located distal to the left branch of the middle colic artery. Females were more likely to present with obstructed carcinomas of the left colon than males. Patients with an obstruction of the left colon more frequently presented with dehydration than those with a tumor of the right colon (p less than 0.05). Most carcinomas of the right colon were resected, whereas lesions of the left colon were managed with diverting colostomy in 33 patients and by primary resection in 22. Thirteen patients with carcinomas of the left colon had an immediate anastomosis without mortality. Preoperative severe cardiopulmonary disease, Acute Physiology and Chronic Health Evaluation score and advanced carcinoma (Dukes' C or D) were statistically related to early hospital morbidity and mortality, while individual physiologic parameters, site of lesion or operation performed were not. Primary resection may be performed safely in selected patients. Multivariate assessment and clinical staging may allow for appropriate patient selection and improve immediate outcome.