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Background Posteriorly fixed anorectal cancer is often considered incurable, but may be resectable using transsacral approaches. Methods We reviewed 45 patients undergoing transsacral exenteration for this problem since 1983 to determine outcome of such surgery. Results The group consisted of 38 men and 7 women; 17 had primary tumors, 28 had recurrent cancer: local excision, 1; low anterior resection, 11; or abdominoperineal resection, 16. Thirty-nine had prior XRT. Operative mortality was 4%. Severe pain was relieved in 16 of 22 (72%) patients. Crude recurrence rates are local 22%, local plus distant 11%, distant 16%. Five-year disease-free survival is 31% for primary disease, 32% for recurrence. Median survival is abdominoperineal resection recurrence, 24 months; primary cancer, 30 months; low anterior resection recurrence, 37 months. Conclusions Transsacral exenteration relieved pain in 70% of patients with fixed anorectal cancer, and led to long-term survival in 31% to 32%. Prognosis trended toward benefit for recurrence after low anterior resection.

Purpose: The goal of this work was to use CBCTimages taken at the time of treatment to derive PTV margin sizes that would account for inter and intra‐fractional systematic and random errors associated with CTV position for patients treated prone on a new couch top belly board (CDR Systems Inc.). Methods: Twenty‐four patients (12 male and 12 female) were included in this study. CBCT data was acquired once every 5 fractions for a total of 5 images per patient. A 3D‐3D bony anatomy auto‐match was performed offline and the residual difference used as a surrogate for inter‐fractional positional errors of the CTV. Systematic and random variations in CTV position were evaluated in a manner consistent with that of Stroom et al and used in PTVmargin = 1.96Σ + 0.7σ. The influence of hypothetical intra‐fractional motion was included in the margin evaluation by introducing the following values: 1.0, 2.0 and 3.0mm.Results: PTVmargin required to account for inter‐fraction positional errors was found to be (AP, SI, LR) = (5.2 mm, 3.1 mm, 2.8 mm). If we assume any intra‐fractional motion to be similar to that presented by Xu et al, then the required PTVmargin increases to (AP, SI, LR) = (7.0 mm, 5.0 mm, 5.0 mm). A 7.0 mm AP expansion is consistent with that quoted in the “Elective Clinical Target Volumes in Anorectal Cancer: An RTOG Consensus Contouring Atlas“, which recommends a margin between 7.0 and 10.0 mm. However, 7.0 mm is 2.0 mm greater than the 5.0 mm margin specified in the RTOG 0822 trial. Conclusions: A PTVmargin expansion of (AP, SI, LR) = (7.0 mm, 5.0 mm, 5.0 mm) will account for inter and intra‐fractional systematic and random errors associated with CTV position for patients treated prone on a new couch top belly board.

PURPOSE: The purpose of this study was to present a technique of abdominosacral resection and its results in patients with locally advanced primary or locally recurrent rectal cancer with dorsolateral fixation. METHODS: Between 1994 and 1999, 13 patients with locally advanced primary rectal cancer and 37 patients with locally recurrent rectal cancer underwent abdominosacral resection as part of a multimodality treatment, i.e., preoperative irradiation, surgery, and Intraoperative irradiation. After the abdominal phase, the patient was turned from supine to prone position to perform the transsacral phase of the resection. RESULTS: Margins were microscopically negative in 26 patients (52 percent), microscopically positive in 18 (36 percent), and positive with gross residual disease in 6 patients. Operation time ranged from 210 to 590 (median, 390) minutes, and blood loss ranged from 400 to 10,000 (median, 3,500) ml. No operative or hospital deaths occurred. Postoperative complications occurred in 41 patients (82 percent); most notable were perineal wound infections or dehiscence (n = 24, 48 percent). Other complications were postoperative urinary retention or incontinence (n = 9, 18 percent), peritonitis (n = 4), grade II neuropathy (n = 1), and fistula formation (n = 3). Kaplan-Meier 3-year overall survival, disease-free survival, and local control rates were, respectively, 41 percent, 31 percent, and 61 percent. Completeness of the resection (negative vs. positive margins) was a significant factor influencing survival (P = 0.04), disease-free survival (P = 0.0006), and local control (P = 0.0002). CONCLUSION: The abdominosacral resection provides wide access and may be the therapeutic solution for the accomplishment of a radical resection for distally situated, dorsally or dorsolaterally fixed primary or locally recurrent rectal cancers.

Purpose To develop a Radiation Therapy Oncology Group (RTOG) atlas of the elective clinical target volume (CTV) definitions to be used for planning pelvic intensity-modulated radiotherapy (IMRT) for anal and rectal cancers.

Objective: To report the pattern of presentation of colorectal carcinoma and the outcome of surgical therapy in a tertiary care hospital in Riyadh Saudi Arabia. Methods: The case reports of all patients diagnosed to have colorectal cancer were retrospectively examined for: age, sex, symptoms and clinical findings, site of primary tumour and extent of metastases, operative management, histopathology results and the outcome of surgical therapy. Results: There were forty-three (33 male, 10 female) patients, with a mean age of 42.7 years (range, 23-79 years). Sixteen (37.2%) cases presented with rectal bleeding, ten (23.2%) with abdominal pain, eight (18.5%) had altered bowel habits whereas anaemia was found to be the most frequent clinical result reported in twenty (46.4%) patients. Right side tumour was encountered in twentyone (48.8%) cases, left side tumour in twelve (27.9%) and anorectal cancer in ten (23.2%).For these lesions, thirty (69.7%) curative and thirteen (30.3%) palliative procedures were undertaken. All patients were reported to have adenocarcinomas: six (13.9%) patients had Dukes Stage A, eight (18.6%) Dukes B, twenty (46.1%) Dukes C and nine (20.9%) Dukes D. There were two post operative deaths, and four (9.3%) patients died due to tumour dissemination and cachexia, while twenty nine (67.4%) subjects had disease free survival. Conclusion: There is a substantial proximal shift of the colorectal carcinoma with more advanced lesions at the time of presentation. Surgical resection should be the mainstay treatment with potentially curable tumours.

Urologic complications arose in 23.7 per cent of 569 patients who underwent abdominoperineal or low anterior resection for anorectal cancer. No radomization of the two operations was attempted, low anterior resection being performed whenever resection 5 cm below the tumor was possible. Complications were more frequent after abdominoperineal resection and in men. Preoperative intravenous pyelography was performed in the cases of 541 of the patients, including 60 who underwent palliative colostomy. The pyelograms of 30 per cent of these patients were abnormal. The abnormalities were anatomic variations of the urinary tract in 25 per cent and urologic diseases in 75 per cent. None of the postoperative urologic complications was related to an abnormal preoperative pyelogram. No relation was found between the radicality of abdominoperineal and low anterior resection and the pyelographic signs of tumor involvement.

過去14年間において教室で切除を行った直腸肛門癌は172例であり, リンパ節転移陽性症例は89例 (52%) であった.これらのうち, リンパ節跳躍転移はRaで3例, Rbで1例, Pで2例に認められ, リンパ節転移症例の7%(6/89例) を占めていた.リンパ節跳躍転移形式として, 第1群リンパ節を素通りして直接第2群リンパ節へ跳躍する形式が5例に認められた.また, 腫瘍下縁が歯状線上方2.5cmにあるにもかかわらず, 鼠径リンパ節へ転移が認められた直腸癌症例において, 第1群リンパ節から第4群リンパ節へ跳躍する形式が認められた.これらの症例における, リンパ節転移の跳躍経路について考察した.

Traditional methods to the perineal wound after combined abdominoperineal excision (Miles operation) for anorectal cancer employ partial closure of the wound with open-tube drainage or gauze tamponade. The postoperative care of these wound is still troublesome and prolonged. Several weeks are required for final healing when these techniques are adopted. It sometimes takes over half a year when a perineal sinus is occured.In the present study, primary closure of the perineal wound has been used in combination with polyethylene tube drainage of the pelvic dead space formed between peritoneal suture and suture of the levator muscles. The drainage tube without continuous suction was introduced through the distal end of the abdominal wound and was withdrawn 5 to 6 days posteperatively depend upon the daily output.Primary healing was achieved in 8 of total 9 cases one of which was infected and opened.Lesser distress was experienced from the wound and the patients were easily and early mobilized and moved more unimpeded than patients with traditional methods. The postoperative nursing was facilitated and the hospital stay reduced.

Thirteen patients with an anal or rectal carcinoma were given curative radiotherapy. Four had medically inoperable tumors, one had a surgically inoperable tumor, and eight refused abdominoperineal resection. Six patients received external radiotherapy only. Seven patients received external radiotherapy and an interstitial implant. Nine of thirteen patients (69 per cent) are alive without evidence of disease from fifteen to fifty-five months (average, 30 months). Six of seven patients who received external radiotherapy combined with an interstitial implant were controlled locally, whereas three of six patients who received external radiotherapy only were controlled. Patients who underwent total excision and/or fulguration prior to irradiation had better local control than those who underwent either biopsy only or a subtotal excision. This treatment method may be offered as an alternative to abdominoperineal resection in patients who are medically unfit or who refuse surgery.

Radioactive needle implants were used to treat 44 patients with inoperable anorectal cancer. An implant dose of 60 Gy or higher was administered to 27 patients at a mean dose rate of 0.493 Gy/h (SE +/- 0.167 Gy/h). In five patients this was preceded by external beam irradiation. A further 17 patients received an implant dose of less than 60 Gy; this followed external irradiation in 10 patients. A complete response was achieved in 52% (16 out of 31) of patients assessed. Three of these patients later relapsed locally. The median duration of response was 23 months. A partial response of median duration 3 months was achieved by a further 13 patients. Five year actuarial survival was 23.9%. Serious morbidity occurred in six patients; three developed strictures and three necrosis. Features of the tumour and the treatment technique contributing to successful management are discussed. It is suggested that radioactive needle implants have an important part to play in the management of low-lying inoperable anorectal cancers.

• Postirradiation "fixed" anorectal tumors are often considered incurable. Since 1980, we have carried out 12 pelvic and seven sacropelvic exenterations for this problem (adenocarcinoma, 18; squamous cancer, one). Nine tumors were primary; ten were recurrent (five after an anterior resection and five after an abdominoperineal resection). Prior irradiation ranged from 3000 to 12000 rad (30 to 120 Gy). Four patients had synchronous distant metastases; three died of disease (one with local recurrence), and the fourth patient has been living with disease (distant metastasis). Fifteen patients (four with B2 tumors and 11 with Astler-Coller C2 disease) had no extrapelvic disease. One patient died of postoperative complications; two others died free of disease. Three of the 15 patients died of disease (all with local recurrence), and one has been living with disease (local recurrence). Eight (53%) of 15 patients have been living free of disease 12+ to 53+ months. The results suggest that many patients with fixed postirradiation anorectal tumors may be salvaged by aggressive surgery. ( Arch Surg 1987;122:537-541)

To the Editor.— The article by Daling and colleagues (1982;247:1988) regarding the positive correlation between homosexual behavior and the incidence of anal cancer will undoubtedly stimulate a search for the etiologic factors responsible. While the authors themselves suggest a few possible mechanisms, namely, the trauma that results from anal intercourse, anorectal herpes, anorectal warts, and other sexually transmitted diseases, they do not consider the recently gathered information on the cancer promoting and initiating ability of certain factors in human seminal plasma, particularly prostaglandins (PGs). Fischer et al 1 have shown that tumor promotion is enhanced by PG E 2 and PG F 2 and initiation is enhanced by PG E 2 , PG F 2 , and PG E 1 . All three types of PGs are present in high concentrations in human seminal plasma; indeed, semen contains more PGs than any other biologic tissue or fluid. 2 Ablin et al 3 have

To the Editor.— Interest in Dahling and co-workers' (1982;247:1988) postulation of a higher incidence of rectal cancer among homosexual men has led to consideration of the causes of such carcinoma. Kondlapoodi (1982; 248:2114) lists arguments he believes "strongly implicate seminal plasma as a cause of anorectal cancer." Before the beguiling plausibility of this hypothesis edges it into popular belief, alternative and possibly multiorigin explanations should be considered. Among these should be the effect of fat- or oil-based lubricants often used during anal intercourse. A substantial medical literature exists relating oil products to the development of oleogranulomas in general and in the anorectal area in particular. 1-4 Moreover, of various oils, mineral oil, a frequent ingredient in sexual lubricants, has been reported to produce decidedly the greatest adverse reaction in tissues. 1,3 Oleogranulomas in the rectum can become large enough to obstruct the intestine and in other organs and tissues have

In Reply.— Dr Voeller's hypothesis on the carcinogenic role of oil lubricants in anorectal carcinoma is interesting. From the literature cited, I would tend to share Dr Voeller's concern that these substances may be possible causes of this cancer in homosexual men. He suggests a way to solve the etiologic puzzle by comparing populations with different sexual preferences and habits, eg, choice of lubricant. While such studies may provide valuable clues, the incidence of anal cancer in male homosexuals is so low (1982;247:1988-1990) that patient populations sufficient in numbers for adequate statistical analyses may be difficult to obtain. Indeed, I was able to gather only six cases of cloacogenic carcinoma of the anorectum in male homosexuals from the world literature for a recent publication. 1 The cloacogenic variety of anorectal cancer is the kind that has been described in this population. Recently, Li and associates 2 from the National Cancer