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Background and Aim: The aim of this study was to review the literature regarding the use of pre- and/or postoperative antibiotics in the management of appendicitis, using data obtained from PubMed and the Cochrane Library.Material and Methods: A literature search was conducted using the terms “appendicitis” combined with “antibiotics.” Studies were selected based on relevance for the evidence on prophylactic and postoperative treatment with regard to the route and duration of drug administration and the findings of surgery.Results: Patients with acute appendicitis should receive preoperative, broad-spectrum antibiotics. The use of postoperative antibiotics is only recommended in cases of perforation, and treatment should then be given intravenously, for a minimum period of 3–5 days for adult patients, until clinical signs such as fever resolve and laboratory parameters such as C-reactive protein curve and white blood cell (WBC) start to decline.Conclusion: Preoperative antibiotic prophylaxis is recommended in all patients with acute appendicitis, whereas postoperative antibiotics only in cases of perforation.

Abstract: Background: The laparoscopic approach is increasingly applied in colorectal surgery. Although laparoscopic surgery in colon cancer has been proved to be safe and feasible with equivalent long-term oncological outcome compared to open surgery, safety and long-term oncological outcome of laparoscopic surgery for rectal cancer remain controversial. Laparoscopic rectal cancer surgery might be efficacious, but indications and limitations are not clearly defined. Therefore, the European Association for Endoscopic Surgery (EAES) has developed this clinical practice guideline. Methods: An international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. The expert panel constituted for a consensus development conference in May 2010. Thereafter, the recommendations were presented at the annual congress of the EAES in Geneva in June 2010 in a plenary session. A second consensus process (Delphi process) of the recommendations with the explanatory text was necessary due to the changes after the consensus conference. Results: Laparoscopic surgery for extraperitoneal (mid- and low-) rectal cancer is feasible and widely accepted. The laparoscopic approach must offer the same quality of surgical specimen as in open surgery. Short-term outcomes such as bowel function, surgical-site infections, pain and hospital stay are slightly improved with the laparoscopic approach. Laparoscopic resection of rectal cancer is not inferior to the open in terms of disease-free survival, overall survival or local recurrence. Laparoscopic pelvic dissection may impair genitourinary and sexual function after rectal resection, like in open surgery. Conclusions: Laparoscopic surgery for mid- and low-rectal cancer can be recommended under optimal conditions. Still, most level 1 evidence is for colon cancer surgery rather than rectal cancer. Upcoming results from large randomised trials are awaited to strengthen the evidence for improved short-term results and equal long-term results in comparison with the open approach.

Aim:The aim of this study was to evaluate the patterns of compliance and the frequency of adenomas and neoplasms in a Swedish population.

Male Wistar rats were subjected to colonic resection and randomized to one of four groups: control group (intraperitoneal NaCl, intravenous NaCl); 5-fluorouracil(5-FU) group (intraperitoneal 5-FU, intravenous NaCl); folinic acid group (intraperitoneal NaCl, intravenous, folinic acid); and 5-FU-folinic acid group (intraperitoneal 5-FU, intravenous folinic acid). Treatment was started immediately after surgery and continued until the animals were killed at 3 or 7 days. Anastomotic complications (abscesses or dehiscence) occurred in four of 33 animals in the control group, 12 of 36 in the 5-FU group, one of 32 in the, folinic acid group and nine of 36 in the 5-FU—folinic acid group. Anastomotic and skin breaking strength did not differ between groups on day 3 but by day 7 were significantly reduced in the 5-FU group. In rats given 5-FU—folinic acid, breaking strength was also reduced, but less so than in the 5-FU group. Breaking strength in animals receiving, folinic acid was similar to that in the control group. In this model colonic healing was impaired after intraperitoneal 5-FU administration, but when folinic acid was added no further deterioration occurred.

The relative survival of all patients (n= 61 769) in the entire Swedish population reported to have a malignant tumour of the colon and rectum between 1960 and 1981 was analysed with special reference to patients under 40 years of age. The 5-year relative survival rate of patients with a tumour of the colon, irrespective of histopathological diagnosis, was 62·0 per cent below the age of 40 years and 44·4 per cent in those 40 years of age or older (P< 0·05). The corresponding figures for patients with a tumour of the rectum were 46·6 per cent and 39·1 per cent, respectively. When the relative survival was analysed separately for patients with a histopathologically demonstrated adenocarcinoma, the 5-year survival rate among patients with a cancer of the colon was 50·9 per cent in patients below 40 years of age and 48-6 per cent in those 40 years of age or older. In patients with adenocarcinoma of the rectum, the 5-year relative survival rate was 41·1 per cent in patients younger than 40 years of age and 40·7 per cent in patients 40 years of age or older. Thus, patients below the age of 40 years with an adenocarcinoma of the colon and rectum as a group appear to have the same or even a better prognosis than older patients if all tumours are considered, irrespective of histopathological diagnosis.

In an experimental study resembling clinical use of adjuvant 5-fluorouracil (5-FU) treatment of colorectal carcinoma, 97 male Wistar rats were operated on with a standardized left colonic resection. Treatment was given as a daily intraperitoneal injection. The animals were randomized to one of four groups: early treatment with 5-FU 20 mg/kg or saline 0·1 mol/l from the third day after operation to the day 7 after operation, and delayed treatment with 5-FU 20 mg/kg or saline 0·1 mol/l from the third day after operation to the day before killing. The animals were killed in groups on day 7 or 10 after operation. In the group receiving early 5-FU treatment there was an increased rate of anastomotic complications (seven of 26) compared with none in the control or delayed 5-FU groups. The anastomotic breaking strength in animals having early 5-FU treatment (day 7, median 1·45 (range 0·20–2·95) N; day 10, median 1·80 (range 0·95–3·20) N) was significantly lower than that in controls on both day 7 (median 3·20 (range 2·50–3·80) N) and day 10 (median 3·20 (range 2·20–3·60) N). In the delayed 5-FU treatment group anastomotic breaking strength did not differ from that in controls. Colonic healing was not impaired when intraperitoneal 5-FU treatment was started on day 3 after operation, whereas immediate postoperative administration of 5-FU had a detrimental effect on wound healing.

In a defined population between 1973 and 1992 151 patients with irresectable metastatic or local rectal cancer were identified. Eighty-one patients underwent resection of the primary tumour (group 1) whereas the primary tumour was left in situin 70 patients (group 2). During the same time period, 444 patients underwent curative resection. The median survival was 7·5 months in group 1, and 3·5 and 1·9 months for surgically and non-surgically treated patients respectively in group 2. A colostomy for intestinal obstruction became necessary in 12 per cent of the patients with a retained primary tumour. Bilateral hepatic involvement, abnormal liver function test results, peritoneal growth or abdominal lymph node metastases correlated with a short survival (P< 0·01). These results support a selective approach to patients with incurable rectal cancer.

Since October 1980 a randomized multicentre trial has been in progress among patients with rectal carcinoma, in whom high-dose fractionated pre-operative irradiation (total dose 25.5 Gy in 5–7 days) is being tested against postoperative irradiation to a high dose level using a conventional fractionation scheme (totally 60 Gy in 8 weeks) delivered only to a high-risk group of patients (Dukes' stages B and C). The primary aim of the trial is to investigate whether local recurrence rate differs between the two groups, and a secondary aim is to see whether 5-year survival will differ between the two groups of patients. Up to October 1984, 360 patients have been randomly allocated to these two groups. Locally curative surgery has been performed in 161 patients in the pre-operative irradiation group and in 152 patients in the postoperative irradiation group. Pre-operative irradiation was extremely well tolerated and there were no irradiation-related complications; 95 per cent of these patients received their treatment according to the intended schedule. However, 48 of the 161 patients had a tumour in Dukes' stage A. Pre-operative radiotherapy had no impact on postoperative mortality or the occurrence of anastomosis dehiscence, but significantly more patients with perineal wound sepsis after an abdominoperineal resection were found in the group of patients receiving pre-operative radiotherapy. This prolonged the stay in hospital after surgery. Postoperative radiotherapy was not so well tolerated as pre-operative treatment, and in a substantial number of patients the treatment could not be commenced until a relatively long time after surgery. To date, the local recurrence rate is acceptably low (≈ 10 per cent) in both treatment groups.

The sensitivity between double contrast barium enema (DCBE) and sigmoideoscopy in diagnosing neoplastic lesions in the sigmoid colon was compared in patients with diverticulosis. In 52 patients with severe diverticulosis (≥15 diverticulas) the DCBE detected one out of 4 polyps found by sigmoideoscopy. In the remaining 54 patients with mild diverticulosis (<15 diverticulas) DCBE detected 7 out of 10 polyps found by sigmoideoscopy. Successful bowel preparation did not influence the outcome of the DCBE. Sigmoideoscopy was incomplete in 17 (16%) of the patients; females were more difficult to examine than males (p= 0.012), as were those with a previous pelvic operation (p= 0.032). We conclude that neither DCBE nor sigmoideoscopy alone is sufficient to detect all neoplastic lesions in the sigmoid colon in patients with sigmoid diverticulosis of the colon.

Thirty-four patients with nonresectable adenocarcinoma of the rectum, defined as tumor fixation at digital examination, were examined with MR. All 34 patients had, according to MR imaging, perirectal tumor growth. In 23 (68%) of the patients, the tumor has reached an adjacent organ. Eight of these patients had disturbances of the MR characteristics in the adjacent organ which proved to be due to overgrowth, i.e., to tumor invasion into these structures. In the remaining 15 patients, without disturbed MR characteristics, 7 had tumor overgrowth at laparotomy. When there was a visible space between the tumor and adjacent organs, there was no sign of tumor overgrowth at laparotomy, except in one case. In 24 patients, examined both before and after combined irradiation and drug therapy, tumor regression was registered after treatment. MR imaging seems to be useful in the assessment of resectability and to evaluate preoperative anticancer treatment in patients with nonresectable rectal carcinoma.

Purpose: to evaluate the use of laparoscopy, CT, colonic enema (CE), and laboratory tests (white blood cell count (WBC), sedimentation rate (SR), and C-reactive protein (CRP)) in diagnosing diverticulitis of the sigmoid colonMaterial and Methods: the diagnostic methods were prospectively evaluated in 88 patients, 30 of whom were referred for laparoscopyResults: Fifty-two patients were found to have sigmoid diverticulitis: 20 patients by laparoscopy, 21 by CT, and 11 by CE combined with one positive laboratory test. Laparoscopy proved to be superior to the other diagnostic methods in diagnosing diverticulitis of the sigmoid colon. CT had a high specificity (1.0; 95 CI: 0.92–1.0) but low sensitivity (0.69; 95 CI: 0.56–0.79) in detecting diverticulitis. CE had a higher sensitivity (0.82; 95 CI: 0.71–0.90) but a lower specificity (0.81; 95 CI: 0.67–0.91) than CTConclusion: CT was the best method for diagnosing abdominal pathology outside the colon. CT can be recommended as the first examination in seriously ill patients where abscesses and other causes of the symptoms than diverticulitis must first be ruled out. Laparoscopy is probably the most accurate method in diagnosing diverticulitis

A dynamic ultrasound sector scanner with 5.0 and 7.5 MHz transducers was used for examination of resected bowel specimens with rectal carcinoma. Pathologic structures, i.e. tumour extension into or beyond the bowel wall, and perirectal lymph nodes, were marked. Corresponding parts of the tissue were embedded in paraffin and a detailed comparison between the findings at ultrasound and those in the histopathological sections was made. There was a good accordance between the histopathologic and ultrasonic findings which makes it possible to perform an exact preoperative staging of rectal carcinomas with ultrasound. Twenty patients with primary tumours of the rectum preoperatively underwent ultrasonography with a prototype transrectal probe with the same type of crystals and frequences. In the 14 cases, however, where ultrasound findings could be compared with the histopathologic findings only six (43%) were correctly staged at ultrasonography. Certain difficulties were encountered in the preoperative examinations with a rigid probe as used in this study.

Computed tomography (CT) was performed on 204 patients with rectal carcinoma in an attempt to determine the tumour stage preoperatively. In 154 patients CT and histopathology could be compared. Correct staging was achieved in 60 to 70 per cent of the patients, but considerable over- and understaging limit the use of CT in preoperative staging of rectal carcinoma.

A total of 191 colorectal adenocarcinomas, obtained from consecutive patients with a median follow-up of 6 years, were studied in order to evaluate the possible association of Ki-rasmutations with tumour stage, tumour differentiation and survival time. Resected full-cross tumour samples were screened for Ki-rasmutations in codons 12 and 13 using temporal temperature gradient gel electrophoresis (TTGE). Ki-rasmutations were detected in 62 (32%) of the samples. The most frequent mutation, observed in 21 samples, was from GGT to GAT changing glycine to aspartic acid in codon 12. The study did not show any association between Ki-rasmutations and Dukes’ stage or tumour differentiation. Patients with Ki-rasmutations had a marginally shorter survival time (median 50 months) compared with patients without (median 59 months), but the difference was not statistically significant. The results indicate that Ki-rasgene mutations have no relevant prognostic importance in this cohort of colorectal cancer patients.

Abstract: The role of paradoxical puborectalis contraction in the aetiology of constipation and how to best diagnose this condition is controversial. The aims of this study were to investigate whether absolute or relative paradoxical electrical activity during electromyography (EMG) are related to rectal emptying and to compare EMG, defecography and digital examination in the diagnosis of paradoxical puborectalis contraction. Included in the study were 171 consecutive patients with idiopathic constipation; 136 of these cases were also classified as paradoxical or unclear or not paradoxical at digital examination. Absolute amplitudes and a strain/squeeze index were used to grade the EMG activity in the puborectalis and external sphincter muscle. Rectal evacuation was analysed by defecography with image analysis of rectal area. The results showed that 142 patients had paradoxical EMG activity during straining. There was a correlation between rectal evacuation and amplitudes (r=–0.20 to –0.03, P<0.01) and between evacuation and index (r=–0.34 to –0.39, P<0.0001). Forty-two patients with an index of >50 had impaired rectal evacuation compared with those with an index ≤50 (P<0.0001). Thirty-three of 34 cases (n=136) with an index of >50 also were paradoxical at defecography whereas 19 were diagnosed digitally. In conclusion, paradoxical puborectalis contraction is associated with impaired rectal evacuation. The activity seems to be best reflected by a strain/squeeze index. The best correlation in diagnostic methods was between EMG and defecography.

PURPOSE: To review the long-term results of anterior levatorplasty for fecal incontinence. METHODS: Fifty-four women with obstetric trauma and 31 with idiopathic incontinence responded to a questionnaire 1.5 to 18.5 (median, 8.5) years after anterior levatorplasty. Results were classified as excellent, good, fair, or poor. RESULTS: An excellent or good result was reported in 40 of 54 (74 percent) patients with an obstetric injury and in 14 of 31 (45 percent) patients in the idiopathic group (P<0.01). The presence of a cloaca (P<0.05) and a young age (P<0.05) were associated with a favorable outcome in the obstetric and idiopathic group, respectively. Length of follow-up and preoperative severity of incontinence were not significantly related to outcome. CONCLUSIONS: This study suggests that every second patient undergoing anterior levatorplasty for fecal incontinence has a successful result that is sustained in the long term. Obstetric trauma, presence of a cloaca, and young age are associated with a successful outcome.

In a series of 328 patients with adenocarcinorna of the rectum and rectosigrnoid, 39 had a turnour which was considered locally non-resectable (19 patients) or borderline resectable (20 patients). Twenty-eight of these patients received radiation therapy with a daily target dose of 2 Gy up to a total of 46 Gy. If the turnour was still considered non-resectable 3 weeks later, radiation therapy was usually continued up to a total dose of 64 Gy together with 5-fluorouracil. Fifteen patients with a non-resectable turnour received radiation therapy up to a total dose of either 46 Gy (7 patients) or 64 Gy (8 patients). Only two patients underwent resection. Of the 20 patients with a turnour that was considered borderline resectable, 13 received 46 Gy. Nine patients in this group were radically resected. Totally 11 turnours were resected, constituting 39 per cent of the patients who were treated up to 46 Gy or more. Truly locally inoperable tumours in this series were thus rarely converted to extirpable tumours by means of radiation therapy. Most patients with a turnour considered borderline resectable seemed to benefit from the treatment. In addition, the palliative effect of radiation therapy was excellent.

Twenty-one consecutive patients with anal carcinoma of squamous cell type were evaluated by transanorectal ultrasonography (Brüel & Kjæer) prior to radiation therapy. The normal anal anatomy, with three distinct layers, was easily demonstrated both in vitro and in vivo. The middle, low echogenic layer corresponded above the dentate line to the muscularis propria and more distally to the internal and external sphincters. A hypoechoic area, representing tumour, was detected in all patients. Using the ultrasound findings, it appeared possible to classify the depth of tumour invasion into four levels with respect to whether or not invasion had reached or penetrated beyond the muscular wall or into adjacent organs. Eighteen of 21 tumours had penetrated the muscular wall. In 3 cases low echogenic, rounded structures, interpreted as enlarged lymph nodes, were identified. The ultrasonographic findings were compared with digital staging. Tumour invasion had penetrated the muscular wall in 2 out of 3 stage T1 patients and in 10 out of 11 stage T2 patients. Prospective studies will show whether estimates of tumour size and depth of invasion in relation to various normal structures, as judged by ultrasonography, are of value prognostically and for the choice of therapy.

Serum p53 antibody levels were analysed using an enzyme-linked immunosorbent assay in serum samples obtained before surgery from 184 consecutive patients with primary colorectal cancer. Possible associations with tumour stage and tumour differentiation and the relation to patient survival time after a median follow-up of 6 years were studied. Analysis of serum p53 antibodies in the entire material demonstrated prognostic value in univariate analysis (P = 0.02); a finding that did not remain (P = 0.07) when the Dukes' stage was included in a multivariate analysis model. When the survival analysis was restricted to the potentially cured patients in Dukes' stages A-C, the serum p53 antibody levels retained independent prognostic value (P = 0.03). No clear association with tumour differentiation was found. We conclude that analysis of serum p53 antibodies may be of value for the identification of patients with different prognoses. This may be of relevance for selection of patients for adjuvant treatment.

This analysis was conducted to evaluate the independent relationship between survival and response to chemotherapy in advanced colorectal cancer. In order to correct for the guarantee time effect, patients dying before the response evaluation were excluded from the analyses. A previously constructed prognostic model containing 11 variables was applied to 324 patients. When the response categories were analysed together with the prognostic variables, it was found that a response was associated with a definite survival advantage (P < 0.001), whereas the influence of all the other variables decreased. The corrected survival advantage (relative progressive disease) was 11 months after a complete response, 6 months after a partial response and 4 months after stable disease. The survival advantage was of a similar magnitude when the analyses were repeated in an independent population comprising 198 patients in whom the prognostic model was extended to include also a set of laboratory values. The results show that a response to chemotherapy is associated with a longer survival also after correction for the guarantee time effect and the distribution of prognostic variables.

Twenty-one consecutive patients with anal carcinoma of squamous cell type were evaluated by transanorectal ultrasonography (Brüel & Kjæer) prior to radiation therapy. the normal anal anatomy, with three distinct layers, was easily demonstrated both in vitro and in vivo. the middle, low echogenic layer corresponded above the dentate line to the muscularis propria and more distally to the internal and external sphincters. A hypoechoic area, representing tumour, was detected in all patients. Using the ultrasound findings, it appeared possible to classify the depth of tumour invasion into four levels with respect to whether or not invasion had reached or penetrated beyond the muscular wall or into adjacent organs. Eighteen of 21 tumours had penetrated the muscular wall. in 3 cases low echogenic, rounded structures, interpreted as enlarged lymph nodes, were identified. the ultrasonographic findings were compared with digital staging. Tumour invasion had penetrated the muscular wall in 2 out of 3 stage T1 patients and in 10 out of 11 stage T2 patients. Prospective studies will show whether estimates of tumour size and depth of invasion in relation to various normal structures, as judged by ultrasonography, are of value prognostically and for the choice of therapy

PURPOSE: This study was undertaken to investigate the factors that influenced the risk of symptomatic recurrence in patients with Crohn's disease who were treated with primary resective surgery. METHODS: Data regarding age, gender, time from diagnosis to surgery, medication, preoperative infectious complications, laboratory values, emergency/elective surgery, location and extent of disease, and resection margins were analyzed in relation to recurrence in 353 patients who were undergoing a “curative” resection in 1969 to 1986. RESULTS: Univariate analyses showed a higher risk of recurrence in women with ileal and ileocolonic disease than in men (P<0.05), in patients with ileocolonic disease compared with those with isolated ileal disease (P<0.05), and in ileal disease patients with an increased disease extent (P<0.05). In a multivariate analysis performed on patients with ileal disease, increased disease extent, limited resection on the colonic side, and referral from other hospitals were three independent variables that indicated an increased risk of recurrence (P< 0.05). Length of disease-free resection margins did not influence the risk of recurrence either in univariate or in multivariate analysis (P>0.05). CONCLUSIONS: Disease extent has prognostic value regarding the risk of symptomatic recurrence in Crohn's disease, whereas the length of resection margins does not influence the risk of relapse. These results favor a conservative approach, particularly in patients with extensive disease.

Fifty patients were randomized to receive adjuvant intraperitoneal 5-fluorouracil (5-FU, 500 mg/m2/day) and intravenous leucovorin (60 mg/m2/day) and 51 to receive placebo after curative surgery for colorectal cancer. Treatment started on the day after surgery and continued for 6 days. One case of stomatitis, one of leucopenia and one case of abnormal liver function tests were the only chemotherapy-related toxic effects. From the second day of treatment, pain during intraperitoneal infusions occurred more frequently in the 5-FU group, although statistical significance was only attained on day 2 (P<0.05). The groups did not differ substantially regarding any other adverse effects, the incidence of surgical complications, second laparotomies, time from surgery to discharge, or premature treatment terminations. The postoperative course after intraperitoneal 5-FU and intravenous leucovorin was thus not more complicated than that in patients treated with placebo. The tolerance was acceptable and chemotherapy-related toxicity was rare. Thus important prerequisites exist for more widespread use of the present regimen in order to evaluate its impact on survival.

Sixty-three patients with mobile rectal cancer were examined preoperatively with endorectal ultrasonography (EUS). The depth of infiltration and the presence of mesorectal lymph node metastases could be assessed in 53 patients. Doppler ultrasonography was performed in 16 cases with suspected lymph node enlargement in order to discriminate between lymph nodes and blood vessels. Tumour growth in the bowel wall was correctly estimated in 43 (81%) patients. The degree of spread was overestimated in five patients and underestimated in five. The evaluation of the mesorectal lymph node status was also accurate in 43 (81%) patients. Nine patients had one or several regional lymph node metastases, but the EUS revealed only some of the metastatic lymph nodes in each case. In the other 34, no lymph node metastases were found. In two patients the EUS was falsely positive since no lymph nodes could be demonstrated in the operative specimens. In eight patients the examination was falsely negative. EUS is considered to be an accurate method for preoperative assessment of tumour infiltration in the bowel wall as the risk of understaging was under 10%. Preoperative irradiation and surgery may be chosen based on the EUS-determined tumour extension into the rectal wall.

The heterogeneity in the DNA content was analysed in multiple biopsies from the surgical specimens in 77 cases of colonic and 46 cases of rectal adenocarcinomas. Frozen and unfixed tumour tissue was analysed with the flow cytometric technique. A total of 78/123 (63%) of all tumours displayed aneuploid stemlines in one or more pieces of tumour tissue; 45 were homogeneously aneuploid and 33 were heterogeneous, presenting both aneuploid and near-diploid samples. The remaining 45 tumours were homogeneously near-diploid. The heterogeneity in ploidy tended to be slightly higher if ten as compared with four samples from each tumour were analysed. Ploidy correlated to localization in the bowel and gender, but not to age, histopathological tumour stage, tumour differentiation or to the resectability rate for cure. The mean value of the S-phase fraction was 17% (range 7–31%) in the near-diploid and 14% (range 8–20%) in the aneuploid tumours. The range of the intratumoural variation was small for the DNA index (at most 5%) and high for the S-phase fraction (19% for neardiploid and 24% for aneuploid tumour pieces). Neither the mean value nor the heterogeneity in the DNA index and in the S-phase fraction displayed any correlation with the studied characteristics. In conclusion, the ploidy and the S-phase fraction varied considerably both within and between the tumours. As a consequence, multiple sampling is mandatory for a correct classification of colorectal adenocarcinomas based on the DNA content.

Abstract: Background: The treatment of primary epidermoid anal carcinoma has changed substantially the latest 2 decades. Radical radiotherapy with or without chemotherapy has been widely accepted. However, the optimal treatment is not yet settled. Methods: Since 1978, patients from the Uppsala region, Sweden, were primarily treated with radiotherapy plus bleomycin with surgery only in those with residual disease after a dose of 40 Gy. The total radiation dose in patients not having surgery was approximately 60 Gy. This policy was not introduced in most other Swedish regions until 1984. Population-based materials between 1978 and 1984 from the Uppsala (n=50) and the Stockholm (n=91) Health Care Regions were compared. Results: Comparisons of these entirely unselected materials indicate that a primarily nonsurgical approach improves 5-year survival in the order of 25 to 30% units. Results are favourable also after long-term follow-up. Bleomycin does not seem to add therapeutic benefit. Conclusions: A primarily non-surgical approach is to be preferred, first because it more often results in preserved anal function than surgery, and second because it also improves survival. The place for surgery is still unknown. Should it be used early in patients where the likelihood of tumor control with radio-chemotherapy is not sufficiently high as adapted in Sweden, or should it be reserved for patients in whom the cancer recurs? The latter approach may seem more attractive since it maximizes anal preservation, but healing after surgery in an area where a high tumoricidal radiation dose has been given is impaired. This is not the case after a lower, preoperative dose where the aim is to kill microscopic disease only. Therefore, an interdisciplinary management of this group of patients is essential, where surgeons, radiotherapists and medical oncologists work close to each other. Since anal carcinoma is a rare condition, it is also necessary to centralize the treatment.

The reaction patterns of eight antibodies directed against blood group substances A, B and H, respectively, against Lewis B antigen, difucosylated carbohydrate antigens (DFCA), gastrointestinal cancer antigen CA 19-9 (GICA), carcinoma-associated antigen CA-50 and CEA, were studied in 68 rectal carcinomas using the avidin-biotin-peroxidase method. A pronounced intratumoral antigenic heterogeneity was revealed for most antigens. It thus became evident that an interpretation based upon small preoperative biopsies would be inaccurate. The overall proportion of positive carcinoma cells, however, did not vary much between larger samples taken postoperatively from different regions of the tumours. The intertumoral antigenic variability was also considerable: nearly all tumours had an individual immunohistochemical profile according to the proportions of positive cells. Heterogeneous staining patterns were also present within metastases, and lymph node metastases from the primary tumour in some cases differed completely from each other. The staining pattern did not correlate with Dukes' stage, and degree of differentiation; the expression of any individual antigen, or several antigens in combination.

Thirty-four patients with nonresectable adenocarcinoma of the rectum, defined as tumor fixation at digital examination, were examined with MR. All 34 patients had, according to MR imaging, perirectal tumor growth. in 23 (68) of the patients, the tumor has reached an adjacent organ. Eight of these patients had disturbances of the MR characteristics in the adjacent organ which proved to be due to overgrowth, i.e., to tumor invasion into these structures. in the remaining 15 patients, without disturbed MR characteristics, 7 had tumor overgrowth at laparotomy. When there was a visible space between the tumor and adjacent organs, there was no sign of tumor overgrowth at laparotomy, except in one case. in 24 patients, examined both before and after combined irradiation and drug therapy, tumor regression was registered after treatment. MR imaging seems to be useful in the assessment of resectability and to evaluate preoperative anticancer treatment in patients with nonresectable rectal carcinoma

Between 1978 and 1984, two unselected population-based groups of patients with anal epidermoid carcinoma were analysed: (1) a retrospective group (Stockholm region, 90 cases), where the treatment varied considerably (partly radiation therapy ± chemotherapy ± surgery, partly surgery alone), and (2) a prospective group (Uppsala region, 51 cases) mainly treated by primary irradiation ± chemotherapy followed by surgery in some cases. At diagnosis, 106 of the patients were free from metastases. Two of these patients died before treatment began. Of the remaining 104 patients, 77 received primary radiotherapy ± chemotherapy, 44 to a dose of 30–40 Gy and 33 to a higher dose level, 55–65 Gy. Radiotherapy was followed by surgery in 28 cases. Twenty-seven patients were operated on primarily. The projected 5-year survival rate was significantly higher in the Uppsala than in the Stockholm region (all patients: 55% versus 43%; patients with no initial dissemination: 75% versus 48%). The prognosis was better in patients initially treated with radiotherapy than in those initially treated with surgery. Long-term disease-free survival was 88% in patients treated with radiation alone to an adequate (high) dose level. Multivariate analyses indicated that besides stage and sex, initial treatment and region gave statistically significant prognostic information. There was no evidence that chemotherapy (Bleomycin) conferred any additional benefit. It is concluded that the initial treatment in anal carcinoma should be radiotherapy (±chemotherapy). In patients with no initial dissemination, this therapy seems to improve 5-year survival by 25–30% compared with primary surgery.

The possibility of predicting late cancer-specific deaths from (a) the preoperative serum levels of three tumour markers, carcinoembryonic antigen (CEA), tissue polyptide antigen (TPA) and an antigen defined by the C-50 antibody (CA-50), from (b) one clinical factor of independent prognostic relevance, polypoid tumour growth, and from (c) Dukes' stage was evaluated in 276 patients with rectal carcinoma operated upon with curative intent (“potentially curable”), and in the 251 of those patients who were considered to be “potentially cured” after surgery. Using the Cox regression model, the preoperative serum levels of the tumour markers strongly predicted the cancer-specific mortality within the first year after surgery. This ability of S-CEA and S-CA-50 diminished for the mortality during the second year after surgery, and virtually disappeared thereafter. The ability of S-TPA to predict cancer-specific deaths did not change as dramatically with time as that of the other two markers, particularly in the group of “potentially cured” patients. Patients with polypoid tumour growth had a good prognosis which did not appear to change with time. Similarly, the prognostic information provided by Dukes' staging system was valid at all studied time intervals after surgery, although it declined after the second year. The importance of these results in relation to the selection of patients for adjuvant treatment is discussed.

The clinical and pathological features of 164 patients with anal epidermoid carcinoma were investigated in a population-based study between 1978 and 1984. Twenty-three tumours, the majority of which were small and well differentiated squamous cell carcinomas, were situated in the perianal region. Twenty of these patients are alive and disease-free. Of 141 tumours in the anal canal two-thirds were of the cloacogenic type, i.e. displaying transitional cell differentiation. The overall 5-year survival was between 40 and 50% for both cloacogenic and squamous cell carcinomas, respectively. However, poorly differentiated squamous cell carcinomas and cloacogenic carcinomas without any squamous cell differentiation (subtype A) had a more aggressive course, especially in men, than the other subgroups. Clinical stage also had an impact on prognosis. Both stage, sex, degree of differentiation and histologic subtypes revealed independent prognostic information. Although the primary aim of this study was not to evaluate therapy, it was noted that patients primarily treated with irradiation (with or without chemotherapy) had a more favourable course than patients treated with surgery alone.