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Objective To examine the independent prognostic value of ALN status in patients with stage III CRC. Summary of background data Early CRC staging classified nodal involvement by level of involved nodes in the operative specimen, including both locoregional and apical node status, in contrast to the American Joint Committee on Cancer/tumor nodes metastasis (TNM) system where tumors are classified by the number of nodes involved. Whether ALN status has independent prognostic value remains controversial. Methods Consecutive patients who underwent curative resection for Stage III CRC from 1995 to 2012 at Concord Hospital, Sydney, Australia were studied. ALN status was classified as: (i) ALN absent, (ii) ALN present but not histologically involved, (iii) ALN present and involved. Outcomes were the competing risks incidence of CRC recurrence and CRC-specific death. Associations between these outcomes and ALN status were compared with TNM N status results. Results In 706 patients, 69 (9.8%) had an involved ALN, 398 (56.4%) had an uninvolved ALN and 239 (33.9%) had no ALN identified. ALN status was not associated with tumor recurrence [adjusted hazard ratio (HR) 1.02, 95% confidence interval (CI) 0.84-1.26] or CRC-specific death (HR 1.14, CI 0.91-1.43). However, associations persisted between TNM N-status and both recurrence (HR 1.58, CI 1.21-2.06) and CRC-specific death (HR 1.59, CI 1.19-2.12). Conclusions No further prognostic information was conferred by ALN status in patients with stage III CRC beyond that provided by TNM N status. ALN status is not considered to be a useful additional component in routine TNM staging of CRC.

Conventionally, lymphatic spread is regarded as the principal mechanism by which haematogenous metastasis occurs in colorectal cancer. The aim of this cross sectional study was to determine the relative strengths of direct tumour spread, the presence of lymph node metastasis and histologically demonstrated venous invasion as drivers of haematogenous metastasis diagnosed at the time of resection of colorectal cancer. The data were drawn from a hospital database of consecutive bowel cancer resections between 1995 and 2017 inclusive. The presence of haematogenous metastasis was determined at the time of surgery by imaging or other investigations or operative findings. Where possible, histological confirmation was obtained. Specimen dissection and reporting followed a standardised procedure. Tumour staging was according to the 7th edition of the UICC/AJCC pTNM system. Analysis was by multivariable logistic regression. After exclusions 3133 patients remained, among whom 380 (12.1%) had one or more haematogenous metastases. In bivariate analyses, the frequency of haematogenous metastasis was directly associated with increasing T status (p

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.

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.

The pTNM staging system for colorectal cancer (CRC) is not entirely effective in discriminating between potentially curative and non-curative resections because it does not account for local residual tumour in patients with stages I, II or III. This study aimed to evaluate the prognostic importance of histologically verified tumour in any line of resection of the bowel resection specimen (TLR) in relation to pTNM stages and to demonstrate how TLR may be integrated into pTNM staging. Information on patients in the period 1995 to 2010 with complete follow-up to the end of 2015 was extracted from a prospective database of CRC resections. The outcome variables were the competing risks incidence of CRC recurrence and CRC-specific death. After exclusions, 2220 patients remained. In 1930 patients with pTNM stages I-III tumour, recurrence was markedly higher in those with TLR than in those without (HR 6.0, 95% CI 4.2-8.5, p 0.001) and this persisted after adjustment for covariates associated with recurrence. CRC-specific death was markedly higher in the presence of TLR (HR 7.7, CI 5.3-11.2, p 0.001), which persisted after adjustment for relevant covariates. These results justify removing patients with TLR from pTNM stages I to III and placing them in stage IV, thereby allowing the categorisation of all patients with any known residual tumour into three prognostically distinct groups. This study demonstrates how TLR may be integrated into pTNM staging, thus improving the definition of the three stages which are considered potentially curable (I, II and III).

Background The aim of this study was to identify patient and tumour characteristics that might assist in developing an improved approach to patient selection for chemotherapy after resection of clinicopathological stage C colonic cancer. Methods Clinical, pathological and follow-up data have been collected prospectively for all patients undergoing resection for colorectal cancer at Concord Hospital since 1971. From an initial 2980 patients, after exclusions 378 remained who had a potentially curative operation for colonic cancer with nodal metastases and did not receive adjuvant chemotherapy. Associations between several pathological features and survival were examined by proportional hazards regression. Results In a multivariate model, both overall and colonic cancer-specific survival rates were negatively associated with serosal surface involvement, apical node metastasis, high histological grade and venous invasion. The survival of patients with stage C disease who had none of these adverse features was not significantly different from that of patients with stage B lesions. However, survival diminished significantly when one or more of the adverse features were present. Conclusion Patients with a stage C tumour but with none of the identified adverse features experience relatively good survival and are unlikely to benefit from adjuvant chemotherapy. In this series such patients accounted for 40·5 per cent of patients with stage C disease.

Background Widely varying rates have been reported in the extensive literature published in the English language on local recurrence after curative excision of rectal carcinoma. These variations may be attributable to differences in the case mix of pathological factors influencing recurrence, differences in surgical technique or expertise, differences in the administration of adjuvant therapy and various combinations of these. They may also arise from methodological differences among studies. Methods This paper reviews the adequacy of methodology and reporting in 21 recent studies of local recurrence after curative resection of rectal cancer. Results Many flaws in reporting and apparent inadequacies in methodology were identified. On an index of 26 criteria examined, eight studies scored no more than 8 and only three studies scored more than 11. Conclusion To date, the value of reports of local recurrence rates following curative excision of rectal cancer has been limited by inadequacies in documentation and methodology. Suggestions are made for preferred procedures to be followed in the reporting of future studies.

Background Colorectal cancers exhibiting microsatellite instability (MSI) appear to have unique biological behaviour. This study analyses the association between extensive MSI (MSI-H), clinicopathological features and survival in an unselected group of patients with sporadic Australian Clinico-Pathological Stage (ACPS) C (tumour node metastasis stage III) colorectal cancer. Methods Some 255 patients who underwent resection for sporadic ACPS C colorectal cancer between 1986 and 1992 were studied. No patient had received chemotherapy. Minimum follow-up for all patients was 5 years. Archival normal and tumour DNA was extracted and amplified by polymerase chain reaction using a radioactive labelling technique. MSI-H was defined as instability in 40 per cent or more of seven markers. Results Twenty-one patients showed MSI-H. No association was found between MSI and age or sex. Tumours exhibiting MSI-H were more commonly right sided (P < 0·00001), larger (P = 0·002) and more likely to be high grade (P = 0·049). After adjustment for age, sex and other pathological variables, patients whose cancers exhibited MSI-H had improved survival (P = 0·015). Conclusion Recognition of MSI-H in sporadic ACPS C tumours identifies a subset of cancers with improved prognosis. Such stratification should be considered in trials of adjuvant therapy and may be relevant to therapeutic decision making.

Background Laparoscopically-assisted resection for large bowel cancer is technically feasible. Sixty-six patients who had resection of the colon or rectum for cancer have been audited prospectively. Methods Clinical and pathological data were collected prospectively as part of the ongoing Concord Hospital colorectal cancer project. Patients were followed up for a median of 29 months. Results In 57 of 66 patients in whom laparoscopic resection was attempted the operation was completed laparoscopically. Three patients died from perioperative myocardial infarction. The median postoperative stay was 14 days. There was a high incidence of postoperative respiratory and cardiac complications. One patient developed a port-site metastasis. Conclusion There was no obvious benefit from laparoscopically-assisted resection of large bowel cancer in these patients.

PURPOSE: The aim of this study was to identify and categorize the independent prognostic effects of patient, clinical, operative, and pathology variables on long-term survival after anterior resection or abdominoperineal excision of the rectum for cancer. METHODS: Proportional hazards regression analysis was used to analyze prospective data from 709 patients who underwent surgery at Concord Hospital during a 23-year period. No patient received adjuvant therapy. RESULTS AND CONCLUSIONS: After adjusting for age and clinicopathologic stage, significantly poorer survival was experienced by males, patients with extensive tumor adherent to other organ(s), those with a high-grade tumor or a tumor showing venous invasion, those who had a postoperative cardiovascular or respiratory complication, and those who did not undergo surgery by a colorectal surgeon specialist. The nature of the operation performed had no independent effect on survival.

Background. Approximately half of all patients treated for colorectal carcinoma by bowel resection have neither lymph node metastases nor known residual tumor (clinicopathologic Stages A and B). The aim of this study was to compare the survival of these patients with that of the general population and to explain any significant difference. Methods. Prospectively collected data recorded for 910 patients from one institution during a period of 21.5 years were used in the analysis. Patient follow-up ranged from 6 months to 21.5 years. The “Survival” procedure, developed by the Finnish Cancer Registry, was used to compare the observed survival of patients with their expected survival, based on age- and sex-matched data from the population of New South Wales. Survival analysis was performed by the Kaplan-Meier method. Multivariate models were examined using Cox proportional hazards regression. Results. Males with tumor spread beyond the muscularis propria (Stage B) was the only group with significantly poorer survival than expected. The reduced survival in this group was due to the effects of four clinical variables (cardiovascular complication, permanent stoma, urgent operation, respiratory complication) and one pathologic variable (direct spread involving a free serosal surface) acting independently. Conclusion. The survival of patients with clinicopathologic Stages A or B tumors closely matched their expected survival as predicted from the general population. Males with Stage B tumors were the only exception and their significantly reduced survival was largely due to clinical, as distinct from pathologic factors. These findings suggest that the risk of occult metastases is low for patients with Stages A and B tumors using this classification. Cancer 1995; 76:564–71.

Two recent reviews reached opposing conclusions regarding the apparent detrimental effect of peri-operative blood transfusion on patient survival after resection of colorectal cancer. However, both studies agree that the influence of confounding variables has not been controlled adequately in most studies. The present study is based on 433 patients who had a curative resection for colorectal cancer between 1984 and 1989 and whose details and follow-up information were recorded in the Concord Hospital Colorectal Cancer Registry, Sydney. The association between peri-operative transfusion and patient survival after resection of colorectal cancer was examined taking into account 20 other prognostic variables. A proportional hazards regression model showed that transfusion did not have a statistically significant independent effect on survival after controlling for the patients' poor general condition, the complexity of the surgery and the occurrence of postoperative complications.

Background. Patients with colorectal carcinoma found to have regional lymph node metastases after curative resection form a large and prognostically diverse group. This study aims to determine which pathology variables have independent prognostic effects. Methods. The data from the 579 patients used in this analysis were collected prospectively during a period of 21.5 years. The patients were from one institution, and the pathologic documentation was standardized. Patient follow-up ranged between 6 months and 21.5 years. Survival analysis was by the Kaplan-Meier method. Multivariate models were examined using Cox proportional hazards regression. Results. On univariate analysis, eight pathology variables had a significant association with survival. Six of these variables showed significant independent effects on survival on multivariate analysis. In diminishing potency, these variables were: apical lymph node involvement; spread involving a free serosal surface; invasion beyond the muscularis propria; location in the rectum; venous invasion; high tumor grade. Significant independent effects also were shown for patient age and gender. The number of involved lymph nodes added no significant independent prognostic information. Conclusion. Six pathology variables have been identified that act independently in determining the survival of patients with colorectal carcinoma and lymph node metastases. The most potent of these variables, apical lymph node involvement, was used by Dukes to subclassify Stage C tumors. Another variable, direct spread beyond the muscularis propria, defines the Astler-Coller subclassification. It is recommended that all six independent variables be included in any future protocol for stratifying this prognostically diverse group of patients.

Background. A lack of comprehensive information exists on the nature, incidence, and prognostic significance of known residual tumor in colorectal cancer patients treated by bowel resection. This study aims to provide this information. Methods. A prospective series of 1766 consecutive patients from the Concord Hospital Colorectal Cancer Registry (Concord, Australia) was used for the analysis. Residual tumor was defined as distant metastases diagnosed clinically or pathologically or tumor demonstrated histologically in a line of resection. The pathologic study was highly standardized. Patient follow-up ranged from 6 months to 20.5 years. Survival analysis was by the Kaplan–Meier method. Multivariate models were examined using Cox proportional hazards regression. Results. The prevalence of residual tumor was 20.9% and the median survival was 11.6 months. In 4.5%, tumor transaction alone occurred, 14.5% had distant metastases alone, and 1.9% had both. The difference in survival between the first two groups was at marginal statistical significance (P = 0.076). When each of these two groups was compared with the third group, significant differences were noticed (P = 0.001 and P = 0.004, respectively). Five of 14 pathology variables examined had a significant effect on survival using univariate analysis. On multivariate analysis only tumor transection and distant metastases had significant independent effects. Conclusions. Known residual tumor was common in this series: one in five resections. Survival studies show that tumor transection, as defined, is a valid criterion for residual tumor. Survival is significantly reduced when tumor transection and distant metastases both are present. These findings should be heeded when staging colorectal cancer and when stratifying patients for postoperative adjuvant therapy.

Today, a standardized method of staging that is internationally accepted is urgently needed for the management of patients with colorectal cancer. The use of a uniform, sensitive staging system would greatly improve case selection and avoid unnecessary bias when entering patients into adjuvant therapy trials. This would allow a more accurate evaluation of new treatment protocols and assist in the development of more effective follow-up programmes.

The histology and immunohistochemistry of 896 polyps and other focal epithelial abnormalities detected macroscopically in 86 surgical resections from patients with colorectal adenocarcinoma and benign bowel disorders were studied. The lesions identified included 177 adenomas, 387 hyperplastic (metaplastic) polyps, and 202 non-neoplastic polyps designated 'focal cryptal hyperplasia'. Numbers of both neoplastic and non-neoplastic polyps were significantly increased in resections for carcinoma, with 72 per cent of all polyps in right and 10 per cent in left hemicolectomy specimens being neoplastic. Thirty per cent of adenomas were less than 2 mm in diameter and 6 per cent larger than 10 mm. Observations on polyp size, number, distribution, histological appearance, and antigenic composition suggested that focal cryptal hyperplasia evolves into the hyperplastic polyp. In doing so, there is loss of expression of a tissue specific antigen. Hyperplastic polyps were significantly larger in colons with adenoma than in those without.

Colorectal cancers (CRCs) may be categorised according to the degree of microsatellite instability (MSI) exhibited, as MSI-high (MSI-H), MSI-low (MSI-L), or microsatellite stable (MSS). MSI-H status confers a survival advantage to patients with sporadic CRC.To determine if low levels of MSI are related to the clinicopathological features and prognosis of sporadic stage C CRC.A total of 255 patients who underwent resection for sporadic stage C CRC were studied. No patient received chemotherapy. Minimum follow up was five years.DNA extracted from archival malignant and non-malignant tissue was amplified by polymerase chain reaction using a panel of 11 microsatellites. MSI-H was defined as instability ator =40% of markers, MSS as no instability, and MSI-L as instability at0% but40% of markers. Patients with MSI-H CRC were excluded from analysis as they have previously been shown to have better survival.Thirty three MSI-L and 176 MSS CRCs were identified. There was no difference in biological characteristics or overall survival of MSI-L compared with MSS CRC but MSI-L was associated with poorer cancer specific survival (hazard ratio 2.0 (95% confidence interval 1.1-3.6)).Sporadic MSI-L and MSS CRCs have comparable clinicopathological features. Further studies are required to assess the impact of MSI-L on prognosis.

Background. Karyomegalic nephropathy, first identified in 1974, represents an increasingly recognized, but perhaps underdiagnosed condition associated with interstitial nephritis. It undoubtedly leads to end-stage renal disease requiring renal support. Methods and results. We present a series of six cases of karyomegalic nephropathy. The age at diagnosis was 9‐51 years, median 33 years. Impaired renal function, proteinuria, and haematuria were present in the majority of cases. Non-specific elevated liver enzymes were present in three cases. Two patients died soon after transplantation from overwhelming respiratory sepsis. The classical histological features of large, abnormal hyperchromatic nuclei with irregular outlines within epithelial cells were present in renal epithelial cells. Abnormality of DNA ploidy distributions compared with age- and sex-matched controls, and characterized by the presence of significant numbers of cells with high ploidy values was present in cases but not in controls. Mitotic figures were absent. Proliferation markers, Ki-67 and proliferating cell nuclear antigenucyclin were not significantly elevated in those cases examined. Human leukocyte antigen analysis did not support the clustering of A9 or B35, in the cases or their families. Conclusions. The presence of significant renal impairment, positive urine sediment, abnormal liver enzymes, and early age of onset should alert one to the presence of karyomegalic nephropathy. It represents an underdiagnosed disorder with a high degree of ploidy indicative of karyotypic abnormality.

Background and aims. In rectal cancer altered expression of p53 or DCC may be indicative of poor patient prognosis. This study determined by immunohistochemistry the tumour status of p53 protein and DCC protein in patients with rectal cancer who had a curative resection and were followed-up prospectively and examined the correlation to clinical and pathology variables. Patients and methods. The study included 171 who had a curative resection for rectal cancer: 88 at Concord Hospital (CH) followed up for a mean of 11 years and 83 at Royal Prince Alfred Hospital (RPAH) followed up prospectively for a mean of 4.3 years. Specimens were assessed by immunohistochemical assay of p53 expression (n=170) and of DCC expression (n=168). Results. p53 over-expression was demonstrated in 58% of CH tumours and 59% of RPAH tumours. Absence of normal DCC expression was demonstrated in 66% of CH tumours and 52% of RPAH tumours. On both separate and combined analysis of these groups there were no significant associations by univariate analysis between p53 expression or DCC expression or combinations of p53 and DCC expression and the pathology variables: extent of penetration through bowel wall, lymph node involvement, presence of venous invasion, and tumour differentiation. Conclusion. The immunohistochemical p53 and DCC status of rectal tumours was not associated with other clinical or pathology variables, nor predictive of outcome.

A 20-year-old man with heavy exposure to upholsterers' glue presented with life-threatening acute myocarditis, and then rapidly developed acute hepatic necrosis and acute renal failure. He made a rapid and complete recovery from this florid acute illness, only to present three months later with supradiaphragmatic non-Hodgkin's lymphoma. These illnesses have all been described in association with solvent exposure. The unique feature of this case is the occurrence of multiple manifestations which might be attributed to solvent exposure, both acute and chronic, in the same individual.

An optimised protocol for the production of two-dimensional protein patterns of human colonic mucosal cells using immobilised pH gradients in the first dimension is presented. We tested a wide variety of solubilising agents and electrophoretic parameters, separately and in combination. Protein solubilisation was found to be best using a lysis solution containing 9 M urea, 2% Triton X-100, 2% 2-mercaptoethanol, 0.8% Pharmalyte pH 3-10 and 8 mM phenylmethylsulfonyl fluoride (PMSF). Horizontal streaking of basic proteins in the first dimension was virtually eliminated by a combination of washing Immobiline strips in 100 mM asorbic acid, pH 4.5, for 24 h before use and isoelectric focusing samples at 40 degrees C. The presence of 2% glycerol in the first dimension resulted in tighter resolution throughout the entire pH range. The use of these conditions may prove to have broad applicability to the generation of optimally resolved Immobiline-based two-dimensional protein patterns of many other tissues.

Background The wide variability of reported local recurrence rates after curative resection of rectal cancer without adjuvant therapy may be a consequence of many different factors. However, few studies have investigated the potential effects of such factors on local recurrence by multivariate analysis. The present study examined clinical and tumour characteristics, operation type and operative technique as potential predictors of local recurrence in patients treated by surgery alone. Methods Prospective data were analysed by bivariate and multivariate methods including actuarial survival and proportional hazards regression. Results Local recurrence (pelvic or pelvic and systemic) was diagnosed in 59 of 596 patients. The 5-year actuarial local recurrence rate was 11·1 (95 per cent confidence interval 8·7–14·3) per cent. Independent predictive factors for local recurrence were: positive nodes (hazard ratio (HR) 5·5, P < 0·01); distal margin of 1 cm or less (HR 3·8, P < 0·01); venous invasion (HR 2·0, P = 0·02) and total anatomical dissection of the rectum (HR 2·0, P = 0·01). There was no difference in local recurrence between patients who had the mesorectum divided and those in whom it was totally excised. Conclusion Nodal involvement is the most potent predictor of local recurrence. In patients in whom total anatomical dissection is performed, total mesorectal excision confers no additional protection against local recurrence.

This study analyses time trends in clinical features tumour pathology and treatment outcomes of patients with colorectal cancer (CRC) treated by surgery alone during the period 1971 to 1994 in a large Australian tertiary referral centre. Throughout this period, both surgical technique and pathology reporting were standardized and a specialized unit of colon and rectal surgery was established in 1980. Improvement in overall survival during this 24 year period reflects changes in tumour stage with an increasing proportion of stage A tumours, declining proportions of stage D tumours, and some improvement in survival for stages B and C colon cancer only.

Laparoscopically-assisted resection for large bowel cancer is technically feasible. Sixty-six patients who had resection of the colon or rectum for cancer have been audited prospectively.Clinical and pathological data were collected prospectively as part of the ongoing Concord Hospital colorectal cancer project. Patients were followed up for a median of 29 months.In 57 of 66 patients in whom laparoscopic resection was attempted the operation was completed laparoscopically. Three patients died from perioperative myocardial infarction. The median postoperative stay was 14 days. There was a high incidence of postoperative respiratory and cardiac complications. One patient developed a port-site metastasis.There was no obvious benefit from laparoscopically-assisted resection of large bowel cancer in these patients.

Background: The development of colorectal cancer (CRC) is thought to be a multistage process involving alterations to several types of genes, including oncogenes and tumour suppressor genes. This study examined the associations between allelic deletions of chromosome 17p in the region of the p53 gene and K-ras gene mutation and survival among CRC patients. Methods: Resected specimens from 233 patients were examined. Point mutation of codon 12 of K-ras was assessed using a modified polymerase chain reaction method. Allelic deletion of 17p was demonstrated by loss of heterozygosity (LOH) with the marker Mfd144. Results: Fifty-seven tumours (24%) showed somatic point mutation of codon 12 of K-ras and 86 tumours (37%) showed LOH of Mfd144. There were 107 tumours (46%) with either K-ras mutation or LOH and 18 tumours (8%) with both. Compared with patients with neither alteration, significantly poorer survival was experienced only by those with both alterations (P= 0.015). However, when this variable was introduced into a multivariate analysis controlling for the patient's age and tumour stage, it failed to show a statistically significant independent effect on survival. Conclusions: Point mutation of K-ras and LOH of Mfd144 in CRC does not add to the prognostic information already available from clinicopathological staging.

PURPOSE: This study was undertaken to compare morbidity, mortality, and pathology after laparoscopically assisted right hemicolectomy (LARHC) or open right hemicolectomy (ORHC) for cancer of the right colon. METHODS: Patients undergoing either LARHC or ORHC for invasive carcinoma of the right colon during a 30-month period were studied. Data were collected from two sources. All morbidity, mortality, and pathology data were collected prospectively in a form suitable for computer storage and analysis as part of the ongoing Concord Hospital Colorectal Cancer Registry. Data concerning in hospital course were obtained by casenote review. RESULTS: Twenty-eight patients underwent LARHC, and 33 had an ORHC during the study period. The two groups were well matched with respect to age, sex, weight, associated comorbidities, and tumor stage. Mean operating room use time was significantly higher for LARHC (LARHC=261 minutes; ORHC=203 minutes;P

Approximately half of all patients treated for colorectal carcinoma by bowel resection have neither lymph node metastases nor known residual tumor (clinicopathologic Stages A and B). The aim of this study was to compare the survival of these patients with that of the general population and to explain any significant difference.Prospectively collected data recorded for 910 patients from one institution during a period of 21.5 years were used in the analysis. Patient follow-up ranged from 6 months to 21.5 years. The "Survival" procedure, developed by the Finnish Cancer Registry, was used to compare the observed survival of patients with their expected survival, based on age- and sex-matched data from the population of New South Wales. Survival analysis was performed by the Kaplan-Meier method. Multivariate models were examined using Cox proportional hazards regression.Males with tumor spread beyond the muscularis propria (Stage B) was the only group with significantly poorer survival than expected. The reduced survival in this group was due to the effects of four clinical variables (cardiovascular complication, permanent stoma, urgent operation, respiratory complication) and one pathologic variable (direct spread involving a free serosal surface) acting independently.The survival of patients with clinicopathologic Stages A or B tumors closely matched their expected survival as predicted from the general population. Males with Stage B tumors were the only exception and their significantly reduced survival was largely due to clinical, as distinct from pathologic factors. These findings suggest that the risk of occult metastases is low for patients with Stages A and B tumors using this classification.

PURPOSE: The aim of this study was to report the prevalence of postoperative complications and mortality of patients with colorectal cancer when treated by conventional surgery. METHODS: Morbidity and mortality following open resection for colorectal cancer were analyzed in 1,846 patients whose clinical, operative, and pathology data were prospectively documented over a 20-year period. RESULTS: Mortality following elective resection of the left and right colon was low, whereas overall morbidity was high (37.2 percent). Respiratory and cardiac complications were especially common. Incidence of clinically significant leakage was similar following right (0.5 percent) or left (1.1 percent) hemicolectomy. Incidence of anastomotic leakage was significantly higher after emergency right hemicolectomy (4.3 percent). Overall morbidity following excision of the rectum was high (40.2 percent). Respiratory and cardiac complications predominated. Incidence of clinically significant anastomotic leakage following anterior resection was low (2.9 percent). Over the years, there has been a decline in the number of patients with tumor demonstrated histologically in a line of resection, suggesting an improved local surgical clearance. CONCLUSIONS: These results following conventional surgery may be useful when evaluating new techniques.

Samples (3 mm3) of histopathologically normal (n = 15) and carcinomatous tissue (n = 15) were obtained from colectomy specimens and examined by 1H MRS. A combination of one- and two-dimensional spectra, obtained with appropriate acquisition and processing parameters, provide multiple diagnostic parameters allowing the distinction between normal and carcinomatous tissue. The diagnostic parameters include resonances from choline, choline-based, and other metabolites, cell surface fucosylation, and altered lipid profiles. Tissues histopathologically classified as normal, while remaining distinct from the malignant spectral profile, were found to fit into two categories, one of which had some of the spectral characteristics of malignancy. These results indicate that 1H MRS identifies abnormal colorectal mucosa, which is not morphologically manifest. Such abnormalities have been reported previously to exist in premalignant colorectal tissue by monoclonal antibody studies. Collectively, these results suggest that a clinical study of colorectal biopsies by 1H MRS could provide support for the use of MRS as an adjunct to current pathological procedures.

A lack of comprehensive information exists on the nature, incidence, and prognostic significance of known residual tumor in colorectal cancer patients treated by bowel resection. This study aims to provide this information.A prospective series of 1766 consecutive patients from the Concord Hospital Colorectal Cancer Registry (Concord, Australia) was used for the analysis. Residual tumor was defined as distant metastases diagnosed clinically or pathologically or tumor demonstrated histologically in a line of resection. The pathologic study was highly standardized. Patient follow-up ranged from 6 months to 20.5 years. Survival analysis was by the Kaplan-Meier method. Multivariate models were examined using Cox proportional hazards regression.The prevalence of residual tumor was 20.9% and the median survival was 11.6 months. In 4.5%, tumor transection alone occurred, 14.5% had distant metastases alone, and 1.9% had both. The difference in survival between the first two groups was at marginal statistical significance (P = 0.076). When each of these two groups was compared with the third group, significant differences were noticed (P = 0.001 and P = 0.004, respectively). Five of 14 pathology variables examined had a significant effect on survival using univariate analysis. On multivariate analysis only tumor transection and distant metastases had significant independent effects.Known residual tumor was common in this series: one in five resections. Survival studies show that tumor transection, as defined, is a valid criterion for residual tumor. Survival is significantly reduced when tumor transection and distant metastases both are present. These findings should be heeded when staging colorectal cancer and when stratifying patients for postoperative adjuvant therapy.

Between September 1981 and August 1987 420 patients with 565 adenomas underwent colonoscopic polypectomy to produce a 'clean colon'. Data from these patients were analysed to identify associations between patient characteristics (age and sex), polyp characteristics (site, size, shape, multiplicity and villous content) and the degree of dysplasia in the index adenoma. In univariate analysis, severe dysplasia in the index adenoma was significantly but weakly associated with size (> or = 10 mm), peduncular shape and villous architecture. Logistic regression confirmed an independent effect only from villous architecture. These findings suggest that it is unlikely that strong predictors of a patient developing a metachronous adenoma or colorectal cancer can be identified on the basis of an index adenoma found at initial colonoscopy. These patients will continue to be followed to investigate this question.

Embryonal rhabdomyosarcoma of the prostate is a rare, highly malignant tumor that occurs predominantly in male infants and children, in whom it is the most common prostatic sarcoma. Six cases occurring in adults have been published, and the authors report three additional cases. The natural history is characterized by rapid growth, with the typical formation of large pelvic or abdominal masses, often leading renal failure due to bilateral ureteric obstruction. The tumor eventually disseminates widely, mainly to the lungs, bone, liver, and serosal surfaces, and unlike most other sarcomas, regional lymph node metastases are common. Combined modality therapy has resulted in marked improvement in survival rates and reduced surgical morbidity for children with these tumors. However, in adults the prognosis remains poor, with all patients dying of disseminated disease within 16 months of histologic diagnosis (mean survival, 8 months).

The purpose of tumour staging for colorectal cancer (CRC) is to help define clinical management, facilitate communication between physicians, provide a basis for stratification and analysis of treatment results in prospective studies, and provide some prognostic information for patients and their families. The World Congresses of Gastroenterology, Digestive Endoscopy, and Coloproctology, Working Party on staging for CRC studied six commonly used systems to review their strengths and weaknesses. Although it was concluded that defining a new staging system was unnecessary, it was recognized that there is a need to define a terminology to describe the full anatomic extent of spread of CRC. Furthermore, we note that there are several additional features, derived from both clinical and pathology information, which have had prognostic significance shown by appropriately constructed multivariate analyses and which can be used to formulate a more accurate prognostic index than that provided by a description of anatomical tumour spread. Thus the Working Party came to two principal conclusions. First, a standard format should be adopted for the collection of the essential data required for prospective studies, and we recommend the 'International Documentation System (IDS) for CRC' for this purpose. Second, a nomenclature which describes the full anatomical extent of tumour spread and residual tumour status in CRC has been defined and should be adopted, from which all currently used staging systems can be derived. We have called this nomenclature the 'International Comprehensive Anatomical Terminology (ICAT) for CRC'. In the event that these recommendations are adopted, we envision that there will be improved clarity in the documentation of treatment outcome for patients with CRC and improved communication of results derived from prospective studies. Furthermore, an acceptance of IDS and ICAT would set the scene to develop a prognostic index for individual patients with CRC by the expansion of anatomical clinicopathology staging information to include additional factors which have independent prognostic significance.

The accuracy of ultrasound in predicting the extent of local tumour spread through the rectal wall and in identifying involved perirectal lymph nodes was evaluated prospectively in 25 patients with rectal cancer. For each patient, the ultrasonic appearances recorded on videotape were compared with operative findings and/or the histology of the tumour. The extent of direct spread was classified into four curable and two incurable categories and was correctly predicted in 20 of 25 patients (80% accuracy). Lymph node status was correctly predicted in 16 of 20 patients (80% accuracy). These results suggest that pre-operative assessment of patients with rectal cancer using transrectal ultrasound is a useful technique which may assist the surgeon in his choice of operation and in the selection of those patients who may benefit from pre-operative radiotherapy.

To determine the biological and prognostic significance of DNA ploidy, 492 consecutive and prospectively documented cases of colorectal cancer were retrieved from the archives of Concord Hospital. 35 cases were excluded due to poor preparations. Nuclei were extracted from paraffin blocks and analysed by DNA flow cytometry. A tumour was classified as diploid when only one G 0 -G 1 peak was detected and aneuploid when there were two or more G 0 -G 1 peaks. The DNA index (DI) was derived from the ratio between the mean fluorescence intensities of the second or aberrant G 0 -G 1 peak and the reference 2N peak. Anatomical Site Diploid Hyperdiploid DI DI ≥ 1.4 Proximal Colon 58 27 37 Distal Colon 56 25 81 Rectum 67 26 80 After a follow-up of 7 years DNA ploidy was of marginal importance as a prognostic indicator (p=0.055). Clinical staging (ACPS), extent of direct tumour spread and extent of lymph node involvement were the most relevant prognostic indicators, once other factors were taken into account. Aneuploidy was also significantly correlated with absence of contiguous adenoma, tumour ulceration and venous invasion. The degree of aneuploidy or DI was greater in distal colorectal (DCR) i.e. splenic flexure and beyond than proximal colon (PC) cancers (p

Properties which determine whether circulating immune complexes are nephritogenic in man could be influenced by immunological factors affecting antigen antibody ratios, size of complexes, and other characteristics of antibody production. There are conflicting reports on effects of antibody affinity on the development of glomerulonephritis in experimental situations and in human SLE. Our study examines whether the response to immunization with tetanus toxoid differs in patients with glomerulonephritis when compared with normal controls, and whether these differences could reflect the histological type of disease. In patients with glomerulonephritis the hemagglutinating antibody response to tetanus toxoid was reduced compared to normal controls. Mean antibody affinity before injection was higher in patients than in controls, and it rose after immunization in both groups. Six of eight patients with diffuse proliferative glomerulonephritis showed a fall in antibody affinity following injection, in contrast to 10 of 13 controls and 15 of 21 patients with other histological types of disease whose affinity increased. This rise was particularly marked in 3 of 4 patients with mesangiocapillary glomerulonephritis. These data suggest differences in antibody responses of patients with glomerulonephritis and could explain seemingly inconsistent results of previous studies where due regard has not been paid to histological categories. Pathogenesis may vary in different histological forms of the disease in man as in experimental models of the disease.

Comparison of 122 patients who have had an abdominoperineal excision of the rectum with 118 patients treated by conventional anterior resection showed no significant difference in patient survival. The grounds were comparable in respect of age, sex, tumour level and pathology. This suggests that conventional restorative resection for rectal cancer may be undertaken without adversely affecting survival.

A clinicopathologic staging method for colorectal carcinoma was applied prospectively to 503 patients treated by surgical resection over a period of 7 1/2 years. The method grouped separately those patients known to be incurable at the time of resection and allowed for an anatomically precise definition of the extent of tumor spread. Survival studies showed that prognosis did not significantly deteriorate with spread of tumor beyond the bowel wall unless there were demonstrable metastases, infiltration of a free serosal surface, or if local resection was incomplete. Highly significant decrements in survival occurred when lymph node metastases were demonstrable and when unresected tumor was known to be present. The staging system from which these observations were made formed an improved guide to prognosis when compared with the original Dukes' method. Patients with histologically high-grade tumors had a poorer survival rate than those with low or average tumors with the same extent of spread.

This study further assesses a previously reported clinicopathologic staging system for colorectal carcinoma. By using carefully defined anatomic criteria, various substages of tumor spread have been examined prospectively for their prognostic significance in a group of 1117 patients accessioned over 14 years and documented by the same pathologist. Spread from the muscularis propria into surrounding tissues was not associated with a significant deterioration in prognosis if the lines of resection were clear of tumor and there were no known metastases or free mesothelial surface invasion. Free mesothelial surface invasion by potentially curable tumors was associated with a significant reduction in patient survival. Patients with potentially curable tumors but with lymph node metastases had a significantly poorer probability of survival if the apical lymph node was involved. Among those with incurable tumors, there was no significant difference in survival depending on whether incurability was due to distant metastases or surgical transection of tumor. Substaging offers a means of refining the ability to predict tumor behavior.

Data on 709 patients who had a resection for colorectal carcinoma at Concord Hospital between 1971 and 1980 were studied to determine the independent effects on survival of several patient characteristics and pathological variables using the Cox regression model. Clinicopathological stage had the strongest association. Other variables ranked according to their relative importance independent of stage were: histological grade, level of direct spread, the presence of venous invasion, age and sex of the patient and the presence of obstruction.

Between 1971 and 1980, 346 patients had a carcinoma of the colon resected. Seventy-seven patients had an urgent operation with a hospital mortality of 13.3%; 269 patients had an elective operation with a mortality of 3.8%. Three patients died as a result of anastomotic leakage. Other complications were thromboembolism (2%) and wound infection (14.5%). The overall median survival was 28.4 months and 57 months following curative resection. The clinicopathological staging system used identified 28% of patients as incurable at the time of resection.

Out of 338 patients undergoing laparotomy and resection of a primary colorectal carcinoma, 49 (14.5%) were found to have liver metastases. The average age was 70 years. The median period of survival was 11.4 months. The histological grade of malignancy of the primary tumour did not appear to influence the survival rate. Compared with similar tumours in patients without hepatic metastases, the primary growth showed a significantly increased incidence of venous invasion, a higher grade of malignancy, and a more frequent origin from the right colon. When the local spread of the primary tumours was investigated it was found that one-third of them had not progressed beyond Stage Dukes A or B.

There is nothing more to add except that I believe this symposium to be of very great educational value. If you, the reader, are a surgeon I hope you will wish to share its message with your colleagues in the pathology department.

This study, using prospective data, compares the survival of 1011 patients who had a colorectal cancer resected at Concord Hospital between 1971 and 1983. The results are expressed both in terms of Australian clinicopathologic (CP) staging and the modified pTNM method proposed by the American Joint Committee for Cancer Staging and End Results reporting. The aim of the study was to determine which of the two staging methods gave the better guide to prognosis. The results indicate that pTNM does not add to information beyond that given by CP staging. We conclude that the pTNM classification is only partially able to separate patients into different survival groups; it is complicated and difficult to memorize, and does not give useful prognostic information beyond that provided by the simpler CP system.

A tumour arising from the body of the eighth thoracic vertebra is believed to be the first recordedexample of a primary fibroxanthosarcoma of bone. Apart from the absence of a demonstrable storiform pattern, the histology conformed to that of fibroxanthosarcoma of the soft tissues. Ultrastructural studies showed that asteroid-like bodies seen in the cytoplasm of some tumour cells consisted of aggregated centrioles surrounded by cytoplasmic vacuoles. The finding of Langerhans cell granules in some tumour cells supported their identification as histiocytes. These granules have not previously been recorded in the fibrous histiocytoma group of tumours.

Twenty patients (10%) developed a local recurrence following 200 consecutive curative resections for colorectal carcinoma. Analysis of the pathology of the primary tumours suggests that invasion of adjacent tissues, and lymph node involvement, were more important predisposing factors for the development of local recurrence than the margin of resection on the mucosa. The average time interval between resection and diagnosis of local recurrence was 17 months. The average survival time following diagnosis was 10 months. Nineteen out of 20 of these patients developed evidence of disseminated disease subsequent to the diagnosis of local recurrence. The most effective palliation occurred in patients in whom the local recurrence could be resected.