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The aim of surgery performed for rectal cancer is to remove the primary tumor along with a wide margin of tumor-free tissue and lymph nodes in the area. If the tumor is low-lying and close to the rectum, an anterior perineal resection may be performed with elimination of the anus and diversion of the bowel to the abdominal wall to form a colostomy. Patients without tumor spread to the lymph nodes do not need to undergo this radical a procedure if the tumor can be locally controlled. Unfortunately, there is currently no reliable system of determining this prior to surgery. There is a correlation between the probability of microscopic lymph node disease and the depth of invasion of the tumor into the bowel wall, but these correlations vary. An analysis is presented of 26 patients with colorectal cancer who underwent anal sphincter saving treatment. The patients met specifically defined criteria to enter this study. The patients had either in situ cancer (T0); cancer penetration to the submucosa (T1); penetration into, but not through, the muscularis (T2); or penetrating through the muscularis (T3). The results indicated that tumors that invade only the submucosa can be treated with sphincter-saving surgery alone; patients with invasion to the muscularis or further can be treated with surgery and chemoradiotherapy. Average follow-up has been 21 months with no cancer recurrence. All patients are continent. These preliminary findings suggest that sphincter-saving surgery, possibly with chemoradiotherapy, can achieve disease control similar to that of more radical surgery, which leaves the patient with a permanent colostomy. (Consumer Summary produced by Reliance Medical Information, Inc.)

Carcinoembryonic antigen (CEA) is a protein associated with malignant tumors, but its function is not known. Its levels are elevated in the blood of patients with colon cancer. Since 80 percent of patients who die of colorectal cancer (CRC) also have metastasis (spread of their cancer) to the liver, it is possible that CEA, which itself binds to liver cells, promotes liver metastasis by enhancing the binding of CRC cells to liver cells. To determine whether CEA makes cancer cells more metastatic, mice were injected with it and then given injections of different types of cancer cells. The effect of CEA on the metastatic potential of the cell lines was then determined. Results showed that CEA was taken up by most liver cells after 30 minutes, and the number of cells containing CEA was used to calculate two doses ('high' and 'low') for use in the subsequent experiments. Pretreatment with CEA increased the production of liver metastases; 33 percent and 48 percent of the mice treated with low-dose and high-dose CEA, respectively, developed metastases after injection of a cell line that ordinarily does not metastasize well, as compared with only two percent of mice that did not receive CEA. CEA pretreatment did not, however, alter the metastatic potential of an ordinarily nonmetastatic cell line, nor of another that is highly metastatic. Further experiments determined that CEA does not affect CRC cells by causing them to multiply faster, but, rather, that it appears to increase adhesion of the cells whose metastatic potential it increased. When CEA is injected, it apparently binds to liver cells in such a way that circulating CRC cells find it easier to implant there. It may affect different types of cells differently, depending on the cells' own capabilities to invade, implant, and survive in the liver. A discussion of the steps necessary for metastasis is provided. (Consumer Summary produced by Reliance Medical Information, Inc.)

OBJECTIVES: To evaluate the accuracy of intraoperative ultrasound (IOUS) liver imaging at the time of primary colorectal cancer resection, which might eliminate incurable patients from adjuvant chemotherapy trials or permit earlier resection of curable metastases. DESIGN: A prospective trial of routine IOUS liver imaging during resections of primary colorectal cancer. The rate of detection of occult metastases by IOUS imaging alone and the false-negative rate over 22.7 months of follow-up were determined. SETTING: A tertiary care referral center in Boston, Mass. PATIENTS: Fifty-five patients undergoing 56 operations for colorectal carcinoma between May 1990 and June 1992. MAIN OUTCOME MEASURES: The rate of detection, by IOUS imaging alone, of otherwise occult hepatic metastases, the total number of patients with metastases detected at any time during follow-up, and the rate of false-negative findings on IOUS imaging and direct examination. RESULTS: Occult hepatic metastases were detected by IOUS imaging alone in 5% of patients. Restriction of IOUS imaging to patients with T3 or T4 lesions or recurrent cancers would have identified all metastases and increased the detection rate to 10%. Occult metastases were detected by IOUS imaging alone in 12.5% of patients with T3, N0 lesions. The rate of false-negative findings on IOUS imaging was 13% overall, 0% for patients with T1 or T2 lesions, 3% for patients with node-negative findings, and 7% for patients with T3, N0 lesions. CONCLUSIONS: The small increment in the detection of occult metastases by IOUS liver imaging does not warrant its use in all patients with colorectal cancer. Selective use in patients with T3 or T4 lesions or recurrent cancers increased the incremental gain in detection. The observed frequency of occult metastases in patients with T3, N0 lesions is sufficient to impact on results of adjuvant chemotherapy trials. Longer follow-up in more patients is needed to determine whether a negative IOUS study is an additional favorable prognosticator in patients with T1 and T2 lesions and node-negative findings.(Arch Surg. 1994;129:431-436)

• Since the introduction of BCG intralesional immunotherapy for melanoma, severe complications, including death, have been reported after treatment in hypersensitized individuals. This is a case report of BCG dissemination with ulceration, skin necrosis, lymphadenitis, and abscess formation following the first intralesional injection of a minimal dose of BCG in a PPD-negative patient. The case demonstrates that severe complications can occur in patients who are not hypersensitized, anergic, or debilitated or who have been treated multiple times. This patient's complication further suggests that migration of BCG after intralesional therapy may play a role in the regression of uninjected nodules seen in some patients.(Arch Surg 113:893-896, 1978)

• The purpose of this study was to assess anal function and to compare the morbidity of local excision and postoperative radiotherapy for rectal adenocarcinoma with the morbidity of abdominoperineal resection. A posterior parasacral approach was used for local excision. All patients had negative margins, and all but one were continent after completion of radiotherapy. Seven patients (29%) had either a wound infection or a fistula in the local excision group. No local failures occurred, although follow-up was only 13 months. Thirteen (50%) of the 26 patients who underwent an abdominoperineal resection developed at least one complication. Combined treatment that spares the rectal sphincters may be preferable in selected patients with low rectal cancer, if long-term disease-free survival is maintained.(Arch Surg 1989;124:67-70)

• The antibody response of patients was used to characterize the autoantigens in human colorectal carcinoma. Twenty-seven primary and 13 metastatic carcinomas with paired normal tissues were extracted and transferred onto nitrocellulose membranes by the Western transfer technique. After the transfers were incubated with the serum of the patient from whom the tumor was derived, autoantigens were indentified by indirect immunoperoxidase staining. All tumors contained at least one autoantigen. Six tumor-associated autoantigens, ranging in molecular weight from 26 to 58 kilodaltons (kD), were identified by antibodies in 25% or more of the sera. Eleven metastases expressed a 41-kD autoantigen that was present in only a third of the extracts of normal liver or lung. Thus, the number of dominant polypeptide autoantigens in colorectal carcinoma is restricted to six molecules. These autoantigens may be organ-associated antigens that are expressed by neoplastic cells. The 41-kD autoantigen may be a potential marker for metastases. A generic vaccine appears to be feasible for colorectal carcinoma since the number of dominant antigens is limited.(Arch Surg 1987;122:1435-1439)