Annals of Coloproctology

Volume 22(2); April 2006

Original Articles

Distributions of MTHFR Gene Polymorphism according to the Location of Colon Cancer.: Kim, Jong Woo , Oh, Doyeun , Chong, So Young , Yim, Dong Jin , Kim, Jin Kyeoung , Kim, Nam Keun; J Korean Soc Coloproctol. 2006;22(2):69-74.

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Abstract PDF: PURPOSE
Colon carcinogenesis seems to vary according to the original location of tumor, especially theright and the left sides. Two common methylenetetrahydrofolate reductase (MTHFR) polymorphisms, 677C->T and 1298A->C, are now known. Especially, the TT type of the 677C->T mutation shows reduced catalytic activity at a rate 30% that of wild type. The aim of this study is to investigate the distributions of MTHFR polymorphisms of 677C->T and 1298A->C according to the location of the colon cancer.
METHODS
Blood samples were collected from 112 patients diagnosed in our hospital, as having colon cancer: 34 proximal and 78 distal cases to the splenic flexure and 448 healthy control subjects. In order to characterize MTHFR polymorphisms, we applied the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP).
RESULTS
The distributions of MTHFR 677C->T polymorphisms as genotypes CC, CT, and TT were 32.4%, 53.1%, and 14.5% in the control group, and 34.8%, 58.0%, and 7.1% in the cancer group (P=0.056). In the 34 proximal cancers, the CC, CT, and TT distributions were 44.1%, 55.9%, and 0% (P<0.05), respectively. In the distal group, they were 30.8%, 59.0%, and 10.3%. The distributions of the MTHFR 1298 A->C polymorphism by genotypes, AA, AC, CC were 69.6%, 28.6%, and 1.8% in the control group, and 58.9%, 38.4%, and 2.7% in the cancer group. The proximal and the distal groups show genotype distributions of 44.1%, 53.0%, and 2.9% and 65.4%, 32.0%, and 2.6%, respectively, but the differences were not statistically significant.
CONCLUSIONS
There are no definite differences between control subjects and colon-cancer patients in the two polymorphisms 677C->T and 1298A->C. However, the TT genotype shows a lower frequency in the cancer group than in the control group with a marginal statistical value (P=0.056), which suggest a reduced risk of cancer incidence for this type, compared with a CC or a CT type.

Methodologic Evaluation of EGFR Expression in Colorectal Cancer.: Oh, Soo Youn , Yoon, Se Jin , Cheon, Seung Hui , Lee, Ryung Ah , Kang, Bo Young , Lee, Shi Nae , Chung, Soon Sup , Kim, Kwang Ho; J Korean Soc Coloproctol. 2006;22(2):75-80.

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Abstract PDF: PURPOSE
The epidermal growth factor receptor (EGFR) is a one of the transmembrane receptor proteins that play an important role in initiating tumor cell signaling and growth and is regarded as a promising target for cancer therapy. The EGFR expression rate has been reported to vary according to the detection method. The aims of this study were to evaluate the EGFR expression rate of a colorectal carcinoma by using immunohistochemical staining (IHC) and semiquantitative reverse transcription-polymerase chain reaction (RT-PCR) and to analyze the correlation between these methods.
METHODS
EGFR expression was investigated in tissue sections from 33 patients with a colorectal adenocarcinoma by using IHC and semiquantitative RT-PCR. IHC was performed with antibodies in a 1:40 dilution and a 1:80 dilution. The results of the three detection methods were compared with one another.
RESULTS
The mean age of the patients was 61.9+/-12.2 years, and the male-to-female ratio was 1.2:1. The EGFR expression rates were 93.9% (31/33) in IHC with a 1:40 dilution, 87.9% (29/33) in IHC with a 1:80 dilution, and 66.7% (22/33) in RT-PCR. The result of IHC with a 1:40 dilution significantly correlated with the result of IHC with a 1:80 dilution (Pearson correlation 0.684, P<0.01). There was no correlation between semiquantitative RT-PCR and IHC (1:40 dilution, 1:80 dilution).
CONCLUSIONS
The EGFR expression obtained by using IHC was consistent with different antibody dilutions. The expression rate obtained by using RT-PCR was significantly lower than that obtained by using IHC, and there was no statistical correlation between the expressions of EGFR obtained by using RT-PCR and IHC. A standardization for EGFR detection methods is needed to draw any conclusion concerning their activity in colorectal cancer.

Ferguson versus Stapled Hemorrhoidectomy.: Lee, Ho Won , Song, Seung Kyu , Suh, Kwang Wook; J Korean Soc Coloproctol. 2006;22(2):81-85.

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Abstract PDF: PURPOSE
The circular stapled hemorrhoidectomy is a newly introduced treatment modality for hemorrhoids. This study was aimed to prove the clinical efficacy of a stapled hemorrhoidectomy.
METHODS
This prospective study analyzed 100 patients who underwent a hemorrhoidectomy from Jan 2002 to June 2004 at Ajou University Hospital. Among them, 50 patents underwent a stapled hemorrhoidectomy and the remaining patients underwent Ferguson's closed hemorrhoidectomy. The surgical severity and the postoperative complications were analyzed based on the medical records.
RESULTS
Neither groups showed significant postoperative complications. In the stapled hemorrhoidectomy group, the hospital stay and the mean operation time were shorten during the postoperative period, and the analagesic requirement was lower (P<0.05).
CONCLUSIONS
The circular stapled hemorrhoidectomy is safe, less painful, and those related easy to perform. Also, the complications related to this procedure are similar to those related to a conventional hemorrhoidectomy. Considering the advantages, the circular stapled hemorrhoidectomy is an acceptable modalities for hemorrhoids requiring surgical treatment.

Anal Diseases among Patients with Leukemia.: Kang, Won Kyung , Jeon, Hyo Sin , Kim, Hyung Jin , Lee, In Kyu , Jeon, Hae Myung , Lee, Myung Ah , Chang, Suk Kyun , Oh, Seong Taek; J Korean Soc Coloproctol. 2006;22(2):86-90.

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Abstract PDF: PURPOSE
Anal diseases are a common complication among patients with leukemia, and the perianal abscess may prove to be the most fatal among anal diseases. We report here the prevalence, the treatment methods, and the prognosis for anal diseases among patients with leukemia.
METHODS
Among the 310 patients who were diagnosed with and treated for leukemia between October 1999 and September 2000, we investigated the medical records of 53 patients with complications due to anal diseases.
RESULTS
Among the 310 patients with leukemia, 53 (17.1%) reported anal diseases. There were 30 patients with hemorrhoids, 15 patients with a perianal abscess, 3 patients with an anal fistula, 3 patients with a fissure and 2 patients with hemorrhoids and fistulas. Anal pain was the most common complaint. Conservative treatment improved the symptoms in 42 patients (79.2%) while surgery was necessary in the remaining 11 patients (20.8%). A hemorrhoidectomy was undertaken in 4 patients, a drainage procedure in 4 paients, and a fistulotomy in 3 patients. Throughout the study period, 6 patients died (11.3%), 3 of them with perianal abscesses. Among the 15 patients with a perianal abscess, 13 showed fever (87%), and 9 patients underwent drainage (4 surgical drainages and 5 natural drainages). E. coli was the most commonly cultured organism.
CONCLUSIONS
The incidence of anal diseases in patients with leukemia was high. Nonsurgical methods were sufficient for hemorrhoids and fistulas. For a perianal abscess, drainage should be undertaken when abscess formation is evident. When abscess formation is not evident, medical treatment is the primary modality, and surgery should be considered only when medical treatment fails to improve or worsens the patient's condition, but the prognosis is poor.

Clinical Features of Colorectal Serrated Adenomas.: Kim, Hyung Joon , Kim, Tae Hyo , Lim, Byung Lyul , Jung, Gyung Ah , Kim, Hyun Jin , Jung, Woon Tae , Joo, Young Tae , Choi, Sang Kyung , Lee, Jung Hee; J Korean Soc Coloproctol. 2006;22(2):91-96.

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Abstract PDF: PURPOSE
Colorectal cancer is believed to progress through an adenoma-carcinoma sequence. However, recent evidence increasingly supports the existence of an alternative route for colorectal carcinogenesis through a serrated adenoma, which combines the architectural features of hyperplastic polyps with the cytological features of traditional adenomas. We assessed the characteristics and the endoscopic features of serrated adenomas and compared them with those of hyperplastic polyps and traditional adenomas in Korea.
METHODS
The medical records of 344 consecutive patients who underwent a colonoscopic biopsy or polypectomy from January 2003 through August 2004 at Gyeongsang National University Hospital were analyzed retrospectively.
RESULTS
Serrated adenomas were seen in 12 cases (3.4%), and the most common site was the rectum (50%). Endoscopically in most cases, the serrated adenomas had small diameters (< or = 0.5 cm) and were single polyps. Morphologically, the serrated adenomas were flat and non-pedunculated. The coincidental rate of the carcinomas was 8.3%.
CONCLUSIONS
According to this study, serrated adenomas are generally single, sessile adenomas with diameters less than 5 mm, and they are commonly observed in the left colon, especially in the rectum.

Safety and Efficacy of Colonoscopic Tattooing of a Colorectal Neoplasm Prior to a Laparoscopic Resection.: Kim, Duck Woo , Sohn, Dae Kyung , Choi, Hyo Seong , Chang, Hee Jin , Han, Kyung Soo , Lim, Seok Byung , Chung, Seung Yong , Park, Jae Gahb; J Korean Soc Coloproctol. 2006;22(2):97-102.

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Accurate tumor localization prior to a laparoscopic surgical resection is the critical. India ink tattoos properly placed in the colorectum are long lasting and have been reported to probably remain constantly in previous studies. The present study was done to review the safety and reliability of colonoscopic tattooing prior to a laparoscopic resection of a colorectal neoplasm.
METHODS
Between May 2003 and August 2004, 20 patients underwent colonoscopic tattooing of a colorectal neoplasm prior to laparoscopic surgery. The clinical data were retrospectively reviewed.
RESULTS
Among the 20 patients, 14 (70%) had tumors located in the sigmoid colon, 4 (20%) had tumors in the rectosigmoid junction, and 1 had a tumor (5%) in the upper rectum and descending colon. In six patients (30%) who had received an endoscopic mucosal resection (EMR), an additional surgical resection was required to remove the tumor completely, and those 6 patients needed another preoperative colonoscopy for India ink tattooing. The median time between tattooing and resection was 2 days (range: 1 to 18 days). Tattoos were visualized intraoperatively and localized the tumor accurately in 15 patients (75%). Seven patients underwent intraoperative colonoscopy; five didn't have tattoos that could be visualized intraoperatively, and two patients with visible tattoos needed intraoperative colonoscopy to confirm the site of tumor. Only one patient (5%) had mild fever with abdominal discomfort, which were relieved by hydration and administration of intravenous antibiotics for one day.
CONCLUSIONS
A colorectal neoplasm can be localized with an acceptable reliability by using preoperative colonoscopic tattooing. India ink tattooing at the time of the EMR may reduce unnecessary colonoscopies if we doubt a complete resection has been achieved by using an EMR. The complications following colonoscopic tattooing were minimal.

Follow-up Results of Endoscopic Mucosal Resection for Early Colorectal Cancer.: Lee, Hyung Suk , Lee, Seokyoung , Seo, Ji Hyun , Kwack, Kyeng Kunn , Kim, Joo Sung , Jung, Hyun Chae , Song, In Sung; J Korean Soc Coloproctol. 2006;22(2):103-112.

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Abstract PDF: PURPOSE
Endoscopic mucosal resection (EMR) for early colorectal cancer (ECC) is increasing, but in Korea, little is known about long-term results of this treatment, especially in cases of incomplete resection. In this study, we reviewed the records of patients with ECC who underwent EMR, and we analysed the clinical, endoscopic, and histologic findings, as well as the follow-up data, to evaluate the effectiveness and the long-term results of EMR.
METHODS
From May 1995 to December 2003, 45 patients underwent EMR for ECC at Seoul National University Hospital and followed for over 10 months. Their medical records were reviewed retrospectively.
RESULTS
45 patients with average age of 62 accounted for 47 ECCs out of 164 colon mucosal lesions. En-bloc resection rate was 78.7%. Submucosal invasion was found in 10 cases (21.3%). De novo cancer rate was 12.8% and relatively high in submucosal cancer (40%). The complete resection rate was 70.2%. During the mean follow-up period of 25 months, residual tumor growth occurred in 3 out of 14 incompletely resected cases, and that was related to piecemeal resection. One of those 3 patients underwent surgical resection due to submucosal invasion, and the other two were treated endoscopically with no additional abnormal findings. No tumor recurred in completely resected cases.
CONCLUSIONS
A complete en-bloc resection was a prerequisite for prevention of tumor recurrence. In cases of incomplete resection, especially those performed using piecemeal method, within 3 months after the resection and within 1 year thereafter, follow-ups are essential for the early detection of tumor regrowth, and additional endoscopic treatment can achieve complete removal of residual tumor, despite initial incomplete resection.

A Comparative Study of Outcomes between Emergency and Elective Surgeries for Colon Cancer.: Yoo, Dae Hyung , Yon, Joon Moh , Lee, Mun Seob , Shin, Dong Jun , Ahn, Byeong Yul , Kim, Byung Wook; J Korean Soc Coloproctol. 2006;22(2):113-117.

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The purpose of this study was to compare the efficacy of curative emergency surgery for complicated colon cancer in terms of tumor recurrence and survival compared with that of elective surgery.
METHODS
A total of 238 primary surgeries for colon cancer were performed. All patients were deemed to have undergone a curative resection. Patients were classified into an emergency surgery group for complicated colon cancers (n=40) and an elective surgery group for uncomplicated colon cancers (n=198).
RESULTS
Emergency colonic cancers present at a more advanced stage (P=0.002). The postoperative mortality rate in the emergency group was significantly higher than it was in the elective group (15.0% vs. 2.5%, P= 0.004). There were differences between the two groups in tumor recurrence (32.5% vs. 13.1%, P=0.003), overall survival (52.5% vs. 71.7%, P=0.017), and disease-free survival (50.0% vs. 69.7%, P=0.016). However, after the patients were stratified according to tumor stage, no statistical differences were observed.
CONCLUSIONS
When compared with uncomplicated colon cancers, complicated colon cancers present at a more advanced stage with a higher postoperative mortality and an overall worse prognosis. However, the difference decreases when patients are stratified according to the tumor stage. The negative prognostic efficacy of emergency surgery for complicated colon cancers appears to be confined to the perioperative period. Despite the more advanced stage of tumors in patients undergoing emergency surgery, the aim of the surgeon should be to offer a curative resection for better survival, if possible.

Laparoscopic Resection of Rectal Cancer: Oncologic Results of 110 Patients with Minimum 2-year Follow-up after a Curative Resection.: Joh, Yong Geul , Kim, Seon Hahn , Hahn, Koo Yong , Yu, Sang Hwa , Chung, Choon Sik , Lee, Dong Keun; J Korean Soc Coloproctol. 2006;22(2):118-124.

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This study aimed to assess the oncologic outcomes after a laparoscopic resection in rectal cancer patients with minimum 2-year follow-up.
METHODS
Among the 312 patients undergoing a laparoscopic rectal cancer resection between Jan. 2000 and Dec. 2004 at Hansol Hospital, 110 patients who had been followed-up for longer than 24 months (mean 33, range 24~56) after the curative resection were included in this study. Two patients (1.8%) received preoperative chemoradiation. Five patients (4.5%) received radiotherapy postoperatively.
RESULTS
TNM stage was 0 in 5 patients, I in 25 (22.7%), II in 35 (31.8%), and III in 45 (40.9%). The T stage was as follows; Tis:T1:T2:T3:T4=4.5%:3.6%:25.5%:40.9%:25.5%. A protective ileostomy was performed in nine patients. The mean operative time was 208 minutes, and the mean blood loss was 179 ml. The mean number of removed lymph nodes was 18, and the mean distal margin was 3.0 cm. The radial margin was positive in one case. Conversion was required in three cases (2.7%). The overall morbidity rate was 17.2%. Anastomotic leak age occurred in five patients (5.5%). There was no operative mortality. During 33 months of mean follow-up, distant metastases and local recurrence were seen in 17 (15.5%) and 5 patients (4.5%), respectively. None had port-site recurrence. For the 94 patients with rectal cancer within 12 cm from the anal verge, the rate of local recurrence was 5.3%. The overall survival rate was 88.9% at 3 years (stage 0, I: 100.0%, stage II: 100.0%, stage III: 72.6%). The disease free survival rate was 78.8% at 3 years (stage 0, I: 100.0%, stage II: 88.6%, stage III: 56.9%).
CONCLUSIONS
A laparoscopic resection of rectal cancer provides an acceptable safety profile. If the highly selective indications for radiotherapy (6.3%) and the rather high volume of advanced cancers (stage III 40.9%, T3/4 66.4%) of this study are considered, a 4.5% local recurrence rate is promising. Optimal surgery for rectal cancer by using a laparoscopic technique may reduce the need for radiotherapy.

Expression of Survivin and Its Correlation with Prognosis in Colorectal Cancer.: Baek, Moo Jun , Lee, Eung Min , Kim, Chang Jin , Park, Nae Kyung , Shin, Eung Jin , Jang, Yong Seog , Kim, Jae Jun , Kim, Sung Yong , Lee, Moon Soo , Kim, Chang Ho , Song, Ok Pyung; J Korean Soc Coloproctol. 2006;22(2):125-131.

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Survivin is involved in both the control of cell division and the inhibition of apoptosis. Specifically, its anti-apoptotic function is related to the ability to inhibit caspases directly or indirectly. This study examined the expression patterns of survivin in normal colorectal tissues and in colorectal cancer tissues to determine whether the expression of survivin is associated with either the colorectal cancer characteristics or the prognosis.
METHODS
4micrometer sections of the formalin-fixed paraffin-embedded samples of colorectal cancer tissues were the immunostained using antibodies for survivin. The immunostain was recorded as 0~3 depending on the stain intensity distribution in the cytoplasm and the nucleus.
RESULTS
Survivin was localized in the nucleus and/or cytoplasm of tumor cells. We could differentiate between cytoplasmic and nuclear localization of survivin protein expression. Among the cancer expressions, 35.8% demonstrated nuclear staining, and 51.9% demonstrated cytoplasm staining. Statistical analysis revealed that cytoplasmic survivin expression was correlated with lymph-node metastasis, tumor stage, and patient survival.
CONCLUSIONS
Survivin expression was correlated with clinicopathologic prognostic parameters and with the outcome. Thus, it can be both a useful diagnostic marker for colorectal carcinomas and an important source of prognostic information for patients with a colorectal carcinoma. Survivin will become a potential new target in anti-cancer therapy in near future.

Case Report

Primary Malignant Fibrous Histiocytoma of the Mesoappendix: Report of a Case.: Seong, Seuong Hoon , Cho, Min Soo , Kim, Ik Yong , Park, Kwang Hwa , Kim, Dae Sung; J Korean Soc Coloproctol. 2006;22(2):132-136.

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Abstract PDF: A primary malignant fibrous histiocytoma (MFH) is a soft tissue sarcoma of mesenchymal origin. A primary MFH occurs most commonly in the extremities and the trunk in adults, but rarely in the alimentary tract. We report a case of MFH of the mesoappendix in a 49-year-old male who presented with a periappendiceal abscess. To the best of our knowledge, this is the first report of MFH in the large intestinal tract, including the appendix, in Korea. The patient recovered well after a right hemicolectomy and was given adjuvant chemotherapy.

Review

Imrpoving Outcomes with Chemotherapy in Colorectal Cancer: Current Options, Current Evidence.: Kim, Ik Yong; J Korean Soc Coloproctol. 2006;22(2):137-149.

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Abstract PDF: The last several years have major advances in chemotherapy treatment for adjuvant and metastatic colorectal cancer. We've come from an overall survival of 6 months in patients treated with best supportive care in the mid 1980s and even in the early 1990s. The use of 5-FU/leucovorin alone generates an overall survival of about 6 months. The addition of irinotecan/oxaliplatin allows patients to live a median of about 15 to 17 months. If we make use of all 3 active drugs, FOLFOX and FOLFIRI in a sequential manner, we'll be able to generate an overall survival of about 20 months. Recently, the addition of molecular therapy, in particular bevacizumab and cetuximab to these cytotoxic drugs has allowed us to break the brick wall that was placed at about 2 years median overall survival in large phase 3 trials in patients with metastatic colorectal cancer. The recent presentations provided further evidence that the standard of care in the treatment of advanced CRC consists of a combination of highly active cytotoxic chemotherapy plus the addition of a biologic agents, For clinical research, investigation of the best therapy for CRC has clearly shifted away from investigating conventional chemotherapy toward the question of how to make best use of all available active agents, particularly the novel biologics. Randomized trials have also shown that preoperative chemoradiation yields higher rates of pathologic complete response and local control, compared with radiotherapy alone. In this article, I review recent trials on preoperative and adjuvant therapy of localized rectal cancer. The roles of newer agents, such as capecitabine, oxaliplatin, and bevacizumab, are also discussed, and other key issues in the treatment of localized rectal cancer are reviewed. The planned phase 3 first-line trial will continue to elucidate the role of the currently available biologics in the treatment of CRC. In this article, the important advances in optimal chemotherapy of colorectal cancer will be summarized and approaches to multidisciplinary treatment decision-making in both adjuvant and metastatic settings will be reviewd.

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