Interactions in the aetiology, presentation and management of synchronous and metachronous adenocarcinoma of the prostate and rectum.

Adenocarcinoma of the prostate and rectum are common male pelvic cancers and may present synchronously or metachronously due to their anatomic proximity. The treatment of rectal or prostate cancer (in particular surgery and/or radiotherapy) may alter the presentation, incidence and management should a metachronous tumour develop. This review focuses on the interaction between prostatic and rectal cancer diagnosis and management. We have restricted the scope of this large topic to general considerations, management of rectal cancer after prostate cancer treatment and vice versa, management of synchronous disease and cancer follow-up issues.

Timely closure of loop ileostomy following anterior resection for rectal cancer.

The implications of constructing a temporary ileostomy as part of the primary surgery for some rectal cancers must not be underestimated and many patients are particularly keen to have their stoma closed as early as possible. Currently, there are no set protocols in place which determine when this should take place, meaning that stoma reversal can be extremely variable between hospitals in the UK. We have created a policy to give patients a provisional date for ileostomy closure at discharge from primary surgery, which takes into account any necessary adjuvant treatment. We compared time to closure of ileostomy between two adjacent centres that share common stoma-care and oncology teams to see what benefit this policy provides. Patients were recruited over a 2-year period from 2005 to 2007 from two adjacent centres. Centre 1 had a policy to provide patients with a provisional date for closure of their ileostomy. The notes were studied retrospectively to determine time to closure of the ileostomy and reasons for any delays in closure. A total of 107 patients fulfilled the inclusion criteria, of which 83 patients (72%) had their stomas closed. Thirty patients had their stomas closed within 12 weeks (37%) - more than 67% (23/34) in centre 1 against 15% (7/48) in centre 2. At 1 year, all patients in centre 1 had their ileostomy closed, while 10% (5/48) were still waiting in centre 2. The mean time to closure was 13.47 and 25.25 weeks for centres 1 and 2 respectively -P-value < 0.0001. Offering patients a date for ileostomy closure at discharge from their primary resection results in the majority of stomas being closed within 12 weeks. For those patients who are to undergo adjuvant chemotherapy, we aim to perform this surgery in between the second and third cycles of treatment.

The long-term results of diltiazem treatment for anal fissure.

The effects of diltiazem treatment on symptoms of chronic anal fissures and their long-term outcome were investigated. One hundred and twelve patients were supplied with 6-week course of 2% diltiazem cream for twice-daily topical application. The medical notes and extended follow-up by telephone for 112 patients were recorded and statistically analysed. The success rate and satisfaction of topical diltiazem were each over two thirds. Nearly 80% of patients reported no adverse effects, and it seems that those complaints attributed to diltiazem rarely led to reduced compliance. After diltiazem therapy for fissure, 59% of patients required further treatment (medical and/or surgical) over the average 2-year period of follow-up. The reported adverse effects of topical diltiazem treatment in patients with anal fissures were more common than previously thought, although compliance was rarely affected. During consultation regarding the advantages and disadvantages of surgical vs. chemical sphincterotomy, patients should be aware that the majority of patients receiving diltiazem as the primary treatment for anal fissure subsequently require further treatment.

Enhanced angiogenesis following allogeneic blood transfusion.

Blood transfusions are associated with recurrence of solid cancers. Angiogenesis is essential for cancer growth. Our aim was to determine for the first time in a prospective cohort study the effect of prestorage allogeneic leucodepleted SAGM (saline, adenine, glucose, mannitol) red cell transfusion on angiogenic factor levels and in vitro angiogenesis. Forty pretransfusion adult hospital inpatients were selected consecutively. Serum vascular endothelial growth factor (VEGF) and endostatin were measured in each patient before and after prestorage allogeneic leucodepleted SAGM red cell transfusion. All samples were exposed to an in vitro endothelial cell proliferation assay and 10 sample groups were also exposed to an in vitro whole angiogenesis assay. The median number of units transfused was 2 (minimum-maximum, 2-4). Twenty-nine (73%) patients had a rise in VEGF, with an overall increase of 118 pg/ml (quartiles -5, 306; P < 0.01). Twenty-eight (70%) patients had a decrease in endostatin, with an overall reduction of 1.2 ng/ml (quartiles 4.0, 0.0; P = 0.017). There was an overall 33% increase in endothelial cell proliferation (P < 0.01) and a 9.4% increase in in vitro whole assay angiogenesis (P < 0.01). Prestorage allogeneic leucodepleted SAGM red cell transfusions are associated with a favourable angiogenic factor imbalance and an elevation in in vitro angiogenesis.