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David A Rothenberger

Publications and source records attributed to David A Rothenberger.

At least 19 recordsLinked to original sources
PubMed2006

Population-based analyses of lymph node metastases in colorectal cancer.

BACKGROUND & AIMS: The potential presence of lymph node metastases in patients with colorectal cancer (CRC) limits the application of minimally invasive techniques of resection. We used data from the National Cancer Institute's Surveillance, Epidemiology, and End Results registry to better understand the underlying risk of lymph node metastases and factors that influence this risk in a population-based fashion. METHODS: In a cohort of 124,180 CRC patients diagnosed from 1988 through 2002 treated with radical surgery without neoadjuvant irradiation, we assessed the proportion of patients who were lymph node positive and determined factors that influenced the risk of lymph node metastases including patient characteristics, anatomic location, and histopathologic factors. RESULTS: Among all patients, the proportion of lymph node metastases was 34.5%. The overall proportion of node positivity was 8% for T1 tumors, 18.5% for T2 tumors, 42% for T3 tumors, and 50% for T4 tumors. Nodal metastases were noted in 7% of proximal T1 colon tumors, 7.5% of distal T1 colon tumors, and 10.1% of T1 rectal tumors. Patients with poorly differentiated tumors were much more likely to be node positive (52%) than patients with well-differentiated tumors (20%) (P<.0001). CONCLUSIONS: Even patients with superficial CRCs have a significant risk of nodal metastases. This risk should be considered when balancing the risks and benefits of minimally invasive techniques such as local excision or endoscopic resection for the treatment of CRC.

Adenocarcinoma↗
PubMed2006

Surgical treatment of colon cancer.

Over 100,000 Americans are diagnosed each year with colon cancer and approximately 90% are treated surgically. Most undergo a curative intent resection, but 30 to 50 percent will have a recurrence of their disease. While much of the variability in outcomes depends on the stage of the disease and other tumor variables, it is now clear that surgeon variables such as caseload and training affect both local recurrence and patient survival. Operative techniques including laparoscopic and other minimally invasive procedures and surgical decisions including choice of operative procedure, management of cancer arising in polyps and treatment of metastatic disease affect outcomes. The role of postoperative surveillance for recurrence remains controversial.

Adenocarcinoma↗
PubMed2005

Lymph node evaluation in colorectal cancer patients: a population-based study.

BACKGROUND: Adequate lymph node evaluation is required for proper staging of colorectal cancer, and the number of lymph nodes examined is associated with survival. According to current guidelines, the recommended minimum number of lymph nodes examined to ensure adequate sampling is 12. We used data from the National Cancer Institute's Surveillance, Epidemiology, and End Results program to determine the proportion of colorectal cancer patients in the United States who receive adequate lymph node evaluation. METHODS: For 116,995 adults with colorectal adenocarcinoma, diagnosed from 1988 through 2001, who underwent radical surgery and did not receive neoadjuvant radiation, we evaluated the number of lymph nodes, the likelihood of receiving adequate lymph node evaluation (i.e., at least 12 lymph nodes examined), and the influence of tumor and patient factors on lymph node evaluation. All statistical tests were two-sided. RESULTS: Among all patients, the median number of lymph nodes examined was nine. Only 37% of all patients received adequate lymph node evaluation. The proportion of patients receiving adequate lymph node evaluation increased from 32% in 1988 to 44% in 2001 (P(trend)<.001, Cochran-Armitage test). Advanced tumor stage was statistically significantly associated with adequate lymph node evaluation (odds ratio [OR] of receiving adequate lymph node evaluation=2.27, 95% confidence interval [CI] = 2.18 to 2.35). Older patients (> or =71 years, OR = 0.45, 95% CI = 0.44 to 0.47) were less likely to receive adequate lymph node evaluation than younger patients, and those with left-sided (OR = 0.45, 95% CI = 0.44 to 0.47) or rectal (OR = 0.52, 95% CI = 0.50 to 0.54) cancers were less likely to receive adequate lymph node evaluation than patients with right-sided cancers. In all analyses, geographic location was an important predictor of adequate lymph node evaluation, which ranged from 33% to 53%, depending on geographic location. CONCLUSIONS: In 2001, the majority of patients with colorectal cancer still received inadequate lymph node evaluation. The association of demographic variables, particularly patient age and geographic location, with adequate lymph node evaluation indicates that local surgical and pathology practice patterns may affect adequacy of lymph node evaluation.

Adult↗
PubMed2005

Impact of preoperative radiation for rectal cancer on subsequent lymph node evaluation: a population-based analysis.

PURPOSE: To determine the impact of preoperative radiotherapy (RT) on the accuracy of lymph node staging (LNS). Preoperative RT is a well-established component of rectal cancer treatment but its impact on LNS is unknown. METHODS AND MATERIALS: The Surveillance, Epidemiology and End Results (SEER) registry, representing 14% of the U.S. population, was used to assess the impact of preoperative RT on LNS. Our study population consisted of adults with rectal cancer between 1998 and 2000 who underwent radical resection. RESULTS: In our 3-year study period, 5647 patients met the selection criteria and 1034 (19.5%) underwent preoperative RT. The preoperative RT group was younger (average age, 61 years) than those who did not undergo preoperative RT (average age, 69 years) and more likely to be male (22% of men vs. 16% of women). On average, fewer nodes were examined in patients who underwent preoperative RT (7 nodes) vs. those who did not (10 nodes); this difference was statistically significant, controlling for potential confounders (p < or = 0.0001). In 16% of the preoperative RT patients (vs. 7.5% without), no nodes were identified (p < or = 0.0001). If one used a minimum of 12 nodes as the standard, only 20% of patients who underwent preoperative RT underwent adequate LNS. CONCLUSION: Lymph node staging in patients who undergo preoperative RT must be interpreted with caution. Studies are needed to evaluate the clinical relevance of node number and pathologic staging after preoperative RT for rectal cancer.

Aged↗
PubMed2005

Association between fecal hydrogen sulfide production and pouchitis.

PURPOSE: The beneficial effect of antibiotics in pouchitis suggests that an unidentified fecal bacterial product causes this condition. A candidate compound is hydrogen sulfide, a highly toxic gas produced by certain fecal bacteria, which causes tissue injury in experimental models. We investigated hydrogen sulfide release and sulfate-reducing bacterial counts in pouch contents to determine whether hydrogen sulfide production correlates with pouchitis. METHODS: During incubation at 37 degrees C, the production of hydrogen sulfide, methylmercaptan, carbon dioxide, and hydrogen were studied using fresh fecal specimens obtained from 50 patients with ileoanal pouches constructed after total proctocolectomy for ulcerative colitis (n = 45) or for familial adenomatous polyposis (n = 5). Patients with ulcerative colitis were divided into five groups: a) no history of pouchitis (pouch for at least 2 years; n = 8); b) past episode(s) of pouchitis but no active disease for the previous year (n = 9); c) pouchitis in the past year but presently inactive (n = 9); d) ongoing antibiotic treatment (metronidazole or ciprofloxacin) for pouchitis (n = 11); e) currently suffering from pouchitis (n = 8). RESULTS: Release of hydrogen sulfide when pouchitis was active (6.06 +/- 1.03 micromol g(-1) 4 h(-1)) or had occurred in the past year (4.71 +/- 0.41 pmol g(-1) 4 h(-1)) was significantly higher (P < 0.05) than when pouchitis had never occurred (1.71 +/- 0.43 micromol g(-1) 4 h(-1)) or had been inactive in the past year (2.62 +/- 0.49 micromol g(-1) 4 h(-1)). Antibiotic therapy was associated with very low hydrogen sulfide release (0.68 +/- 0.29 micromol g(-1) 4 h(-1)). Pouch contents from familial adenomatous polyposis patients produced significantly less hydrogen sulfide (0.75 +/- 0.09 micromol g(-1) 4 h(-1)) than did any group of nonantibiotic-treated ulcerative colitis patients. Sulfate-reducing bacterial counts in active pouchitis (9.5 +/- 0.5 log10/g) were significantly higher than in those who never experienced pouchitis (7.38 +/- 0.32 log10/g), and these counts fell dramatically with antibiotic treatment. No statistically significant differences in carbon dioxide and hydrogen were observed among the groups not receiving antibiotics. CONCLUSIONS: Pouch contents of patients with ongoing pouchitis or an episode within the previous year released significantly more hydrogen sulfide than did the contents of patients who never had an attack of pouchitis and those with longstanding inactive disease. The response to therapy with metronidazole or ciprofloxacin was associated with marked reductions in hydrogen sulfide release and sulfate-reducing bacteria. These results provide a rationale for additional studies to determine whether the high sulfide production is a cause or effect of pouchitis. The lower hydrogen sulfide production by pouch contents of familial adenomatous polyposis vs. patients with ulcerative colitis suggests a fundamental difference in gut sulfide metabolism that could have implications for the etiology of ulcerative colitis as well as the pouchitis of patients with ulcerative colitis.

Anti-Infective Agents↗
PubMed2005

Primary perineal wound closure after preoperative radiotherapy and abdominoperineal resection has a high incidence of wound failure.

PURPOSE: Neoadjuvant radiation therapy has been used increasingly to downstage rectal cancer and decrease local recurrence. Despite its efficacy, preoperative radiation therapy may inhibit healing and contribute to wound complications. This study was designed to evaluate perineal wound complications after abdominoperineal resection. METHODS: The clinical records of a consecutive series of patients who underwent abdominoperineal resection for rectal carcinoma between 1988 and 2002 were reviewed. Demographic data, disease stage, and use of preoperative radiation therapy were recorded. Major wound complications included delayed wound healing (>1 month), wound infection requiring drainage/debridement, or reoperation. RESULTS: A total of 160 patients underwent abdominoperineal resection with primary closure of the perineal wound (mean age, 63 +/- 12 years); 117 (73 percent) patients received preoperative radiation therapy; 114 received radiation therapy for rectal cancer (radiation therapy + chemotherapy = 107, radiation therapy alone = 7); 3 received radiation therapy for other pelvic malignancies. Median radiation dose was 5,040 (range, 900-5,400) cGY. Overall wound complication rate was 41 percent. Major wound complication rate was 35 percent. Delayed healing was the most common complication (24 percent), followed by infection (10 percent). Radiation therapy increased the risk of any wound complication (47 vs. 23 percent; P = 0.005), risk of a major wound complication (41 vs. 19 percent; P = 0.021), and risk of infection (14 vs. 0 percent; P = 0.015). Risk of wound complications did not correlate with age, gender, disease stage, smoking, or diabetes. CONCLUSIONS: Wound complications are frequent after abdominoperineal resection and primary closure of the perineum. Preoperative radiation therapy doubles the rate of total and major perineal wound complications. Alternatives to primary perineal closure should be considered, particularly after radiation therapy.

Aged↗
PubMed2005

Endorectal ultrasound in the management of patients with malignant rectal polyps.

PURPOSE: This study was designed to determine the efficacy of endorectal ultrasound in the management of patients with malignant rectal polyps removed by snare excision during colonoscopy. METHODS: A retrospective review of the medical records and endorectal ultrasound images of 63 patients with endoscopically removed rectal polyps containing invasive adenocarcinoma subsequently staged by endorectal ultrasound. Patients underwent surgery or were followed at a single institution. The polyp characteristics and ultrasound images were compared with the presence of residual tumor in the surgical specimen in patients who underwent further surgery or with recurrence in patients who did not. RESULTS: The morphology of the polyps was described in 31 patients (49 percent); they were sessile in 26 (41 percent) and pedunculated in 6 (9 percent). The margins were positive in 22 patients (35 percent), negative in 19 (30 percent), and not specified in 22 (35 percent). Most tumors were well or moderately differentiated; only 3 (5 percent) were poorly differentiated. Thirty-three patients underwent further surgery (3 low anterior resection, and 30 transanal excision); 30 had no further surgery. The accuracy of endorectal ultrasound in assessing the presence of residual cancer in the rectal wall in patients who had surgery was 54 percent, with a 39 percent positive predictive value and 65 percent negative predictive value. Endorectal ultrasound accurately identified metastatic lymph nodes in two of three patients who had radical surgery. Endorectal ultrasound was more useful than polyp morphologic or histologic criteria to determine the presence of residual cancer in the rectal wall. CONCLUSIONS: Endorectal ultrasound does not definitely exclude the possibility of residual tumor in the rectal wall or mesenteric nodes of patients who had a malignant polyp snared endoscopically. Consequently, decisions regarding the definitive management of these patients cannot be based exclusively on the endorectal ultrasound images of the polypectomy site.

Adenocarcinoma↗
PubMed2005

Increased risk of rectal cancer after prostate radiation: a population-based study.

BACKGROUND & AIMS: Radiation therapy for prostate cancer has been associated with an increased rate of pelvic malignancies, particularly bladder cancer. The association between radiation therapy and colorectal cancer has not been established. METHODS: We conducted a retrospective cohort study using Surveillance, Epidemiology, and End Results (SEER) registry data from 1973 through 1994. We focused on men with prostate cancer, but with no previous history of colorectal cancer, treated with either surgery or radiation who survived at least 5 years. We evaluated the effect of radiation on development of cancer for 3 sites: definitely irradiated sites (rectum), potentially irradiated sites (rectosigmoid, sigmoid, and cecum), and nonirradiated sites (the rest of the colon). Using a proportional hazards model, we evaluated the effect of radiation on development of colorectal cancer over time. RESULTS: A total of 30,552 men received radiation, and 55,263 underwent surgery only. Colorectal cancers developed in 1437 patients: 267 in irradiated sites, 686 in potentially irradiated sites, and 484 in nonirradiated sites. Radiation was independently associated with development of cancer over time in irradiated sites but not in the remainder of the colon. The adjusted hazards ratio for development of rectal cancer was 1.7 for the radiation group, compared with the surgery-only group (95% CI: 1.4-2.2). CONCLUSIONS: We noted a significant increase in development of rectal cancer after radiation for prostate cancer. Radiation had no effect on development of cancer in the remainder of the colon, indicating that the effect is specific to directly irradiated tissue.

Aged↗
PubMed2004

Quantification of colorectal cancer micrometastases in lymph nodes by nested and real-time reverse transcriptase-PCR analysis for carcinoembryonic antigen.

PURPOSE: Reverse-transcriptase PCR (RT-PCR) assays for carcinoembryonic antigen (CEA) have been described to identify lymph node micrometastases. These assays are not quantitative and can be confounded by false-positive results. The purpose of this study was to determine whether quantification of CEA in lymph nodes could more readily identify clinically relevant groups. EXPERIMENTAL DESIGN: Specimens included 400 lymph nodes from 64 patients undergoing colon resections. Specimens were tested by immunohistochemistry and by RT-PCR using nested primers for CEA. Specimens from 59 patients that were positive by nested RT-PCR were further quantified by detection of CEA mRNA fluorescence increase at a threshold PCR cycle. RESULTS: CEA was detected by nested RT-PCR analysis in 4 of 34 (12%) nodes of nonneoplastic disease, 2 of 13 (15%) nodes from T(1)N(0) patients, 32 of 81 (40%) nodes of T(2)N(0) patients, 49 of 109 (45%) nodes from T(3)N0 patients, and 92 of 163 (56%) nodes from T(1-4)N(1-2) patients. The overall presence of any RT-PCR-detectable CEA in nodes did not differentiate patient groups. Immunohistochemistry was positive in nodes from 7% of T(3)N(0) patients and 100% of T(1-3)N(1-2) patients. CEA quantification revealed that 0 of 7 patients with nonneoplastic disease and 2 of 17 (12%) patients with stage I T(1-2)N(0) cancers had one or more lymph nodes with >/=1.0 x 10(2) CEA transcripts per sample. In contrast, 4 of 13 (31%) patients with stage II T(3)N(0) cancer and 10 of 22 (45%) stage III patients with known metastases had lymph nodes with >/=1.0 x 10(2) CEA transcripts. CONCLUSIONS: These data suggest that quantification of CEA levels in lymph nodes may more accurately identify patients at risk for cancer recurrence than does routine nested RT-PCR or immunohistochemistry.

Carcinoembryonic Antigen↗
PubMed2004

Endorectal ultrasound in the follow-up of rectal cancer patients treated by local excision or radical surgery.

PURPOSE: This study was designed to investigate the role of a scheduled follow-up protocol using endorectal ultrasonography for the diagnosis of local recurrence after local excision and radical surgery for rectal cancer. METHODS: A selected group of 275 patients with invasive rectal cancer followed prospectively by endorectal ultrasonography after curative-intent local excision (n = 108) or radical surgery (n = 167) was reviewed. For the radical-surgery group, results were compared with a group of 176 rectal cancer patients who had similar operations during the same period of time and were not entered in follow-up protocol. Excluded were patients with invasive cancers removed by snare excision, male patients treated by abdominoperineal resection, and patients treated by endocavitary radiation. Student's unpaired t-test was used to compare tumor and patient characteristics. Survival curves were estimated using the Kaplan-Meier method and compared using the log-rank test. RESULTS: In the local-excision group, 32 patients developed local recurrence, 26 (81 percent) were asymptomatic, and 10 of them (31 percent) were diagnosed only by endorectal ultrasound. We found no difference in the rates of salvage surgery or survival between patients diagnosed of recurrence by ultrasound or other methods. In the radical-surgery group, 12 patients developed local recurrence, 5 (42 percent) were asymptomatic, and 4 of them (33 percent) were diagnosed only by endorectal ultrasound. More patients with isolated local recurrence in the follow-up group underwent salvage surgery (4/9 patients; 44 percent) compared with patients without follow-up (3/13 patients; 23 percent), but the differences were not significant. CONCLUSIONS: Endorectal ultrasound identifies one-third of asymptomatic local recurrences that were missed by digital examination or proctoscopic examination. However, the impact of the earlier diagnosis in patient survival can only be determined by a larger, prospective, randomized trial.

Aged↗
PubMed2004

Minnesota Colorectal Cancer Initiative: successful development and implementation of a community-based colorectal cancer registry.

PURPOSE: The aim of the Minnesota Colorectal Cancer Initiative is to implement risk-specific interventions to decrease colorectal cancer morbidity and mortality by 1) assisting clinicians to identify and educate individuals and families at high and increased risk for colorectal cancer; 2) providing professional and community education; 3) maintaining a database to evaluate the effectiveness of preventive intervention strategies; and 4) facilitating colorectal cancer research. METHODS: Two physician groups and the University Cancer Center founded the Minnesota Colorectal Cancer Initiative as a not-for-profit organization. Health care organizations, pharmaceutical companies, a consulting firm, and other practice groups provide continuing financial and other support. A database registry, risk-assessment survey, and consent document were developed and then were approved by an institutional review board. A trial enrollment was conducted. Minnesota Colorectal Cancer Initiative services are available to the public. Participants are actively recruited through member organizations. Minnesota Colorectal Cancer Initiative assesses hereditary risk and will document family history in the medical record on request. A personally targeted reply letter reviews risk factors and recommends specific screening and surveillance strategies for participants and their family members, and when appropriate, provides information regarding genetic counseling and testing services. Minnesota Colorectal Cancer Initiative services are free to participants. RESULTS: Since 1999, Minnesota Colorectal Cancer Initiative has sent individually tailored reply letters providing risk-specific information about colorectal cancer to 717 participants and more than 3200 of their first-degree and second-degree relatives. More than 200 families, previously unidentified as having histories suggestive of hereditary colorectal cancer (attenuated familial polyposis and hereditary nonpolyposis colorectal cancer), have been identified; genetic services were explained and recommended. A formal program evaluation confirmed that Minnesota Colorectal Cancer Initiative provides useful information and materials and promotes intrafamilial communication about colon cancer risk and recommendations. CONCLUSIONS: Minnesota Colorectal Cancer Initiative is a model of effective collaboration between academic and community health care providers. A community-based registry is a unique way to identify and provide personal, risk-specific information to large numbers of people at increased or high risk for colorectal cancer.

Adult↗
PubMed2004

Are we overtreating some patients with rectal cancer?

The definition of overtreatment of rectal cancer is controversial, and thus it is difficult to accurately quantitate its prevalence. All components of rectal cancer treatment are associated with significant potential for morbidity and dysfunction that may have a negative impact on the patient's quality of life. No one would disagree with the tenet that overtreatment should be avoided whenever possible. Despite that consensus, little attention is given in the literature to the issues of overtreatment of rectal cancer. This review article presents a variety of clinical scenarios and summarizes available data demonstrating that overtreatment of some patients with rectal cancer is occurring on a regular basis. It is hoped that this will stimulate clinicians to critically review their own practices to eliminate such overtreatment. Development of new clinical trials to determine whether current practice guidelines are promoting overtreatment of selected rectal cancer patients is proposed.

Chemotherapy, Adjuvant↗
PubMed2003

Evidence of a preferred molecular pathway in patients with synchronous colorectal cancer.

BACKGROUND: A small proportion of patients with colorectal carcinoma (CRC) have synchronous tumors at the time of diagnosis. A subset of sporadic CRCs display microsatellite instability (MSI) that is associated with MLH1 silencing due to promoter methylation. In the current study, the authors investigated the proportion of tumors with MSI in patients with synchronous colorectal carcinoma (SCRC) and the concordance in MSI status among tumors in a given individual. In addition, the authors examined MLH1 and MSH2 expression and MLH1 promoter methylation in SCRCs. METHODS: The current study included 77 patients, with a combined total of 170 invasive SCRCs, who were identified from a database of 2884 patients with CRC. Instability was determined by polymerase chain reaction (PCR) amplification using a set of five markers. Tumors that were unstable at two or more markers were considered unstable (MSI); otherwise, they were considered microsatellite stable (MSS). Expression of MLH1 and MSH2 was determined by immunohistochemistry. Methylation of the MLH1 gene promoter was determined by a methylation-specific PCR assay. Statistical comparisons were made using the chi-square test or the Student t test. RESULTS: Of the 77 patients in the study, 21 (27%) had a family history of hereditary nonpolyposis colon carcinoma-related malignancy, but none fulfilled the Amsterdam II criteria. Fifty-four of 170 tumors (32%) were found to be MSI. Patients with MSI tumors were older and more frequently female. All but 1 MSI tumor lacked expression of MLH1 (n = 44) or MSH2 (n = 8), or both (n = 1). All MLH1-negative tumors, compared with only 3 MLH1-positive tumors, were methylated at the MLH1 promoter. Most patients (n = 67; 87%) had either all MSS tumors (n = 48; 62%) or all MSI tumors (n = 19; 25%); 10 patients (13%) had both MSS and MSI tumors. The observed MSI/MSS distribution was significantly different from the distribution expected based on an assumption of independence (P < 0.0001). CONCLUSIONS: There is a strong concordance in MSI/MSS status among tumors in the same individual. This finding suggests that the tumors in patients with SCRC develop along a preferred molecular pathway.

Adaptor Proteins, Signal Transducing↗
PubMed2003

Measuring fecal incontinence.

The measurement of fecal incontinence is challenging. Because fecal incontinence is a symptom, the subjective perception of the patient must be the foundation of any evaluation of incontinence or the impact of incontinence. The lack of a criterion standard makes testing measures for reliability and validity more difficult. Despite this, many measures are available and can be divided into three broad categories: descriptive measures that do not provide summary scores; severity measures that assess the frequency and type of incontinence; and impact measures that assess the effect of incontinence on quality of life. The strengths and weaknesses of currently available measures are presented in this review.

Endpoint Determination↗
PubMed2003

A pathologic complete response to preoperative chemoradiation is associated with lower local recurrence and improved survival in rectal cancer patients treated by mesorectal excision.

PURPOSE: Preoperative chemoradiation reduces tumor size and nodal metastasis in patients with rectal cancer. Tumor downstaging has been associated with an increased probability of a sphincter-saving procedure and with improved local control. However, pathologic complete response to chemoradiation has not been correlated with local control and patient survival. We studied the prognostic value of pathologic complete response to preoperative chemoradiation in rectal cancer patients. METHODS: We have prospectively followed up 168 consecutive patients with ultrasound Stages II (46) and III (122) rectal cancer treated by preoperative chemoradiation followed by radical resection with mesorectal excision; 161 had a curative resection. Recurrence and survival were compared with tumor characteristics and pathologic complete response. Average follow-up was 37 months. RESULTS: Tumor downstaging occurred in 97 (58 percent) patients, including 21 (13 percent) patients who had a pathologic complete response. None of the clinical or pathologic variables was associated with pathologic complete response. The estimated 5-year rate of local recurrence was 5 percent; of distant metastasis, 14 percent. None of the patients with pathologic complete response has developed disease recurrence. We found no difference in survival among patients with pathologic Stages I, II, or III tumors. CONCLUSIONS: A pathologic complete response to preoperative chemoradiation is associated with improved local control and patient survival. For patients without pathologic complete response, the pathology stage does not have prognostic significance.

Adult↗
PubMed2003

Surgical therapy for anorectal melanoma.

BACKGROUND: Anorectal melanoma is a rare but highly lethal malignancy. Historically, radical resection was considered the "gold standard" for treatment of potentially curable anorectal melanoma. The dismal prognosis of this disease has prompted us to recommend wide local excision as the initial therapeutic approach. The purpose of this study was to review our results in patients who underwent wide local excision or radical surgery (abdominoperineal resection [APR]) for localized anorectal melanoma. STUDY DESIGN: We reviewed the charts of all patients referred for resection of anorectal melanoma between 1988 and 2002. Endpoints included overall survival, disease-free survival, and local, regional, or systemic recurrence. RESULTS: Fifteen patients underwent curative-intent surgery; four underwent APR and 11 underwent wide local excision. Eight patients (53%) are alive; 7 (47%) are disease-free (followup 6 months to 13 years). Of 12 patients who have been followed for more than 2 years, 4 are alive (33%) and 3 are disease-free (25%). Seven patients have been followed for more than 5 years and two are alive and disease-free (29%). All of the longterm survivors underwent local excision as the initial operation. There were no differences in local recurrence, systemic recurrence, disease-free survival, or overall survival between the APR group and the local excision group. Local recurrence occurred in 50% of the APR group and 18% of the local excision group; regional recurrence occurred in 25% versus 27%. Distant metastases were common (75% versus 36%). CONCLUSION: In patients who have undergone resection with curative intent for anorectal melanoma, most recurrences occur systemically regardless of the initial surgical procedure. Local resection does not increase the risk of local or regional recurrence. APR offers no survival advantage over local excision. We advocate wide local excision as primary therapy for anorectal melanoma when technically feasible.

Adult↗