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Background The aim of this study was to describe temporal trends in presentation, surgical management and immediate postoperative outcomes in patients recorded in a registry of colorectal cancer resections that was initiated at Concord Hospital, Sydney, Australia, in 1971. A companion paper describes tumour pathology and long-term recurrence and survival. Methods This report is based on 5217 consecutive resections up to 2013, with no exclusions. Categories in variables examined were expressed as percentages over annual totals of relevant patients or annual mean values. The statistical significance of trends was examined by least squares regression. Results The percentage of asymptomatic patients increased over time, whereas urgent presentations declined. Tumour size declined. The percentage of rectal cancers fell but the percentage of low rectal tumours rose. Initially, restorative rectal resections increased rapidly but later remained stable. There was no trend in medical complications, whereas surgical complications declined. Anastomotic leakage after restorative rectal resections declined but it was low and stable for colonic tumours. The rate of early reoperation remained stable, whereas 30-day mortality declined. Neoadjuvant radiotherapy for rectal cancer and adjuvant chemotherapy for stages B and C were introduced in 1992 and applied increasingly thereafter. Conclusion Our findings, based on a 43-year prospective study, indicate sustained trends towards the earlier diagnosis of colorectal cancer and favourable short-term outcomes following bowel resection. [ABSTRACT FROM AUTHOR]

Background The aim of this study was to describe temporal trends in tumour pathology and long-term outcomes in 5217 patients recorded in a registry of colorectal cancer resections initiated at Concord Hospital, Sydney, Australia, in 1971. Methods This report is based on consecutive resections up to December 2013, with no exclusions. Categories in variables examined were expressed as percentages over annual totals of relevant patients or annual mean values. The statistical significance of temporal trends was examined by least squares regression. Results The percentages of patients with local spread beyond the muscularis propria, nodal metastasis, distant metastasis and tumour in a line of resection all declined significantly. In consequence, the percentage of stage D patients fell, whereas the percentage in stage A rose. Other tumour variables that increased significantly were polypoid morphology, contiguous adenoma and invasion of a free serosal surface. Tumours in which an adherent adjacent structure was partly or completely removed also increased. There were significant declines in high-grade malignancy, venous invasion and tumour size. The recurrence rate for rectal cancers declined significantly, whereas for rectal and colonic cancers combined, both the overall 5-year survival rate and the 5-year cancer-specific survival rate increased markedly. Conclusion These results show a reduction in adverse pathology findings and favourable trends in recurrence and survival after colorectal cancer resections in a high-incidence country over a period of 43 years. [ABSTRACT FROM AUTHOR]

Background To our knowledge, immediate post-operative complication rates after resection of colorectal cancer ( CRC) have not been compared between public and private hospitals in the Australian health care system. We compared the frequency of surgical and medical complications between a public tertiary referral hospital and a private hospital. Methods Data were drawn from a prospective registry of all patients having a resection for CRC between 2000 and 2010 performed by members of the Concord Hospital colorectal surgical unit, either at this hospital or at a single private hospital with which they were affiliated. Complication rates were compared after adjustment for preoperative and perioperative features by logistic regression. Results Among the 16 surgical complications, the only significant difference after adjustment for other features was a higher rate of septicaemia in the public hospital (odds ratio ( OR) 2.2, 95% confidence interval ( CI) 1.1-4.6). Among the seven medical complications, the only significant differences were a higher risk of cardiac complications in patients with cardiac co-morbidity ( OR 1.8, 95% CI 1.1-3.0) and of respiratory complications in patients without respiratory co-morbidity ( OR 3.1, 95% CI 2.2-5.9) in the public hospital. Conclusion In this study, where the same group of surgeons performed all reported CRC resections in the two hospitals, no independent effect of the type of hospital was found on 15 of 16 surgical complications and 5 of 7 medical complications. Type of hospital had no impact on rates of specific complications apart from septicaemia and cardiorespiratory complications, which were higher in the public hospital. [ABSTRACT FROM AUTHOR]

Colonic and rectal cancers differ in their clinicopathologic features and treatment strategies. Molecular markers such as gene methylation, microsatellite instability and KRAS mutations, are becoming increasingly important in guiding treatment decisions in colorectal cancer. However, their association with clinicopathologic variables and utility in the management of rectal cancer is still poorly understood. We analyzed CDKN2A gene methylation, CpG island methylator phenotype (CIMP), microsatellite instability and KRAS/ BRAF mutations in a cohort of 381 rectal cancers with extensive clinical follow-up data. BRAF mutations (2%), CIMP-high (4%) and microsatellite instability-high (2%) were rare, whereas KRAS mutations (39%), CDKN2A methylation (20%) and CIMP-low (25%) were more common. Only CDKN2A methylation and KRAS mutations showed an association with poor overall survival but these did not remain significant when analyzed with other clinicopathologic factors. In contrast, this prognostic effect was strengthened by the joint presence of CDKN2A methylation and KRAS mutations, which independently predicted recurrence of cancer and was associated with poor overall and cancer-specific survival. This study has identified a subgroup of more aggressive rectal cancers that may arise through the KRAS-p16 pathway. It has been previously shown that an interaction of p16 deficiency and oncogenic KRAS promotes carcinogenesis in the mouse and is characterized by loss of oncogene-induced senescence. These findings may provide avenues for the discovery of new treatments in rectal cancer. [ABSTRACT FROM AUTHOR]

I Dear Editor i , Amidst an ongoing scoping of the literature on transanal total mesorectal excision (TaTME), we read with interest the International Expert Consensus Guidance by the TaTME Guidance Group [1]. One advantage of the Delphi technique over the nominal group and consensus development panel is that the Delphi technique seeks to achieve consensual agreement among expert panellists through repeated iterations of anonymized opinions [ 3 ]. Such eligibility criteria may devalue the credibility of the International Expert Consensus Guidance, as it is likely that the Delphi process was started with the majority of panellists already being in favour of TaTME. [Extracted from the article]

Aims: Controversy continues regarding the treatment of patients with resectable rectal cancer, particularly in regard to the effects of adjuvant therapies on long-term survival. The benefits of adjuvant chemotherapy alone in patients with stage III rectal cancer after curative resection remain unclear. The aim of this study was to compare the overall survival of patients who had received adjuvant chemotherapy after resection of a stage III rectal cancer (111 patients) with the survival of a historical control group who had surgery alone before chemotherapy was introduced (129 patients). Methods: Treatment and outcomes data were drawn from a prospective hospital registry of consecutive patients who had a resection for stage III rectal cancer. Results: The estimated Kaplan-Meier overall 5-year survival rate in patients who received chemotherapy (68.7%, 95% CI 58.3-77.1%, log-rank P < 0.001) was improved compared with the historical controls (40.5%, 95% CI 31.4-49.5%, log-rank P < 0.001 ). No systematic differences between the treated and control group were found. Conclusion: This study has shown improved survival after adjuvant chemotherapy in patients with stage III rectal cancer as compared with historical controls treated by surgery alone. Hence, there could be subsets of patients whom when treated with surgery in a specialized surgical unit, may benefit from chemotherapy and spared the toxicities of adjuvant radiotherapy. This should be explored further in a cooperative trial group setting. [ABSTRACT FROM AUTHOR]

Tan K L, Jankova L, Chan C, Fung C L-S, Clarke C, Lin B P C, Robertson G, Molloy M, Chapuis P H, Bokey L, Dent O F & Clarke S J (2011) Histopathology 59, 1057-1070 Clinicopathological correlates and prognostic significance of glutathione S-transferase Pi expression in 468 patients after potentially curative resection of node-positive colonic cancer Aims: This study investigated the association between glutathione S-transferase Pi (GST Pi) expression, histopathology and overall survival in 468 patients after resection of stage C colonic adenocarcinoma. Methods and results: Data were drawn from a prospective hospital registry of consecutive bowel cancer resections with a minimum follow-up of 5 years. Nuclear and cytoplasmic GST Pi expression, assessed by both intensity of staining and percentage of stained cells at both the central part of the tumour and the invasive tumour front, were evaluated retrospectively by tissue microarray immunohistochemistry on archival specimens. The most effective measure of GST Pi expression was the percentage of immunostained nuclei in central tumour tissue, where >40% stained was associated significantly with high grade, invasion beyond the muscularis propria, involvement of a free serosal surface or apical node, and invasion into an adjacent organ or structure. After adjustment of other predictors, GST Pi expression remained independently prognostic for reduced overall survival (hazard ratio 1.4, P = 0.002). Conclusions: In patients with clinicopathological stage C colonic cancer, GST Pi expression is associated with features of tumour aggressiveness and with reduced overall survival. Further appropriately designed studies should aim to discover whether GST Pi can predict response to adjuvant chemotherapy. [ABSTRACT FROM AUTHOR]

Fung C L-S, Chan C, Jankova L, Dent O F, Robertson G, Molloy M, Bokey L, Chapuis P H, Lin B P C & Clarke S J (2010) Histopathology 56, 319–330 Clinicopathological correlates and prognostic significance of maspin expression in 450 patients after potentially curative resection of node-positive colonic cancer Aims: The tumour suppressor maspin has been investigated for its association with conventional histopathological features in colorectal cancer and for its potential as an independent predictor of survival and response to adjuvant chemotherapy. The aim of this study was to examine associations between maspin expression, other histopathology and survival in a large consecutive series of patients after potentially curative resection of node-positive colonic adenocarcinoma. Methods and results: Nuclear and cytoplasmic maspin expression in both superficial and deep parts of the tumour were assessed retrospectively by tissue microarray and immunohistochemistry in specimens from 450 patients whose other histopathology had been recorded in a prospective hospital registry of large bowel cancer resections from 1971 to 2001 with a minimum follow-up of 5 years. Among 13 clinicopathological features examined, the only associations that persisted across all four maspin assessments were stronger expression in right- than in left-sided tumours ( P = 0.001–0.011) and stronger expression in high-grade tumours ( P < 0.001–0.007). There was no significant association between intensity of maspin expression and overall survival. Conclusions: In this large and thoroughly documented series of patients with clinicopathological stage C colonic tumour, maspin expression was correlated with few other conventional histopathology variables and was not a significant prognostic factor. [ABSTRACT FROM AUTHOR]

AbstractBackground and Aims: Clinical practice is determined by many different factors, but with the advent of evidence-based medicine, there may be a tendency to concentrate upon the scientific facts when decision-making rather than focusing on the patient. Furthermore, individual clinician opinion or bias may potentially influence patient management. This study outlines clinician opinion with regard to management of patients with hepatic colorectal metastases, and compares it to present practice in the Sydney metropolitan area. Methods: Clinician opinion was assessed by using a questionnaire and compared to results from a prospective multicenter study looking at patterns of care of patients with hepatic colorectal metastases. Results: Clinicians participating in the present study had a good knowledge of the current evidence concerning hepatic colorectal metastases and its treatment. However, there was a discrepancy between clinician knowledge that matched scientific evidence and actual clinical practice. Conclusions: This study suggests that clinician bias/opinion does influence patterns of care for patients with hepatic colorectal metastases. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to an article in the previous issue which discusses the tailoring treatment of rectal cancer rather than on recommended guidelines through circumferential resection margin involvement (CRMI) and histopathological features of the resected specimen.

The article discusses the views of authors on the level of anatomy taught to medical students. They say that the debate as to how, when and what anatomy to teach to medical students has generated a considerable interest. They emphasize the aspects to consider in addressing the insecurity of many medical students about their anatomical knowledge. They stress that a core curriculum for anatomy is important.

The authors discuss the use of problem-based learning (PBL) in medical education and programs in Australia, wherein students acquired knowledge in basic sciences. Topics include the integration of basic sciences in hospital clinical services, the growth of information technology in patient care models, and the concerns among students on whether their knowledge about gross anatomy is adequate for cadaver dissection and medical practice.

Discusses the role of the surgeon in the development of the staging for colorectal cancer. Description of staging system proposed by J.P. Lockhart-Mummery; Description of staging system developed by Dukes; Description of staging system created by Turnbull.

Comments on the importance of evidence-based medicine (EBM) in health care, education and research. Influence of EBM on community and individual health care decisions; Principal scientific tools of EBM; Improvement in the health care delivery.

Introduction: Colorectal cancer is common. At presentation 25% of patients have established hepatic metastases and overall at least half will develop hepatic metastases. Many different therapeutic options have been proposed. This study evaluates the current resources available and patterns of care for patients with hepatic colorectal metastases in the Sydney metropolitan area. Methods: Prospective data were collated describing all patients presenting to any one of nine hospitals within the Sydney metropolitan area in a 12-month period, diagnosed with hepatic metastases. The data included patient demographics and background, treatment of the primary tumour, diagnosis and treatment of the hepatic metastases and histopathology both of the primary and of the hepatic metastases. Results: There were 194 patients in the study. Most when diagnosed with hepatic colorectal metastases were independent, active, retired and usually had existing social supports. The majority had had their primary colorectal cancer resected and were later treated with systemic chemotherapy. Conclusions: This study highlights the need for a comprehensive multicentre, prospective data collection of patients with hepatic metastatic disease. This would clarify the effectiveness or otherwise of the health system caring for such patients and provide additional information for the development and implementation of guidelines. [ABSTRACT FROM AUTHOR]

Comments on an article about teaching anatomy. Significance of anatomy to surgery; Need to change the curriculum for anatomy education; Clinical significance of anatomy.