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Papers by Gerald Marks

Diseases of the Colon & Rectum, 1979

Surgical Clinics of North America, 1989

Because extraordinary benefits accrue to the patient when the surgeon can view the site of diseas... more Because extraordinary benefits accrue to the patient when the surgeon can view the site of disease first-hand, the gastrointestinal surgeon must be a proficient endoscopist, and endoscopy must be part of gastrointestinal surgery. Leaders of surgical organizations and surgeon educators, upon whom rests the responsibility for shaping policy and educating medical students and residents, should remain alert to the need to maintain a substantial surgical presence in gastrointestinal endoscopy.

Surgical Endoscopy, 2016

Introduction Natural orifice transluminal endoscopic surgery (NOTES) represents the ultimate expr... more Introduction Natural orifice transluminal endoscopic surgery (NOTES) represents the ultimate expression of minimally invasive surgery. We have developed and present here an initial feasibility and safety study of transanal total mesorectal excision (TME) with splenic flexure release, high ligation of the IMA and IMV, and side-to-end coloanal anastomosis with temporary diverting ileostomy for rectal cancer. Methods A program of full NOTES TME resection with release of the splenic flexure, high ligation of the IMA/ IMV, with side-to-end coloanal anastomosis was performed transanally from December 2013 to July 2014. Demographics, preoperative, perioperative, and postoperative data were prospectively obtained. Operative components were broken into TME, colonic mobilization, splenic flexure release, IMA/IMV transection, transanal extraction of specimen, and coloanal anastomosis for analysis of performance completion. Results There were 3 women and 1 man on whom we operated. Mean age was 56 (46-65). Mean BMI was 26

Transanal Endoscopic Microsurgery, 2008

Surgical Endoscopy, 2008

Patients with major comorbidities often are denied laparoscopic colorectal resections because the... more Patients with major comorbidities often are denied laparoscopic colorectal resections because they are thought to be at too "high risk." Paradoxically, these patients generally have the most to gain from a minimally invasive surgical approach. This study aimed to examine the feasibility and safety of laparoscopic colorectal resection to determine whether it is contraindicated for "high-risk" patients. From August 1996 to February 2004, 368 consecutive patients (95 men) undergoing a laparoscopic colorectal procedure by a single surgeon were prospectively studied with regard to pre-, peri-, and postoperative events. High-risk patients (n = 190) were defined as elderly (age, >80 years; n = 28), morbidly obese (body mass index [BMI], >30 kg/m(2); n = 55), American Society of Anesthesiology (ASA) 3 or 4 (n = 130), and recipients of preoperative radiotherapy (n = 54). Multiple risk factors were found for 67 patients, 7 of whom had three risk factors. The median age of the patients was 66 years (range, 19-92 years). The diagnoses included rectal cancer (n = 48), diverticulitis (n = 43), colon cancer (n = 34), benign polyp (n = 26), and other (n = 39). The following procedures were performed: colon resection (n = 114; left, 63; right, 41; total abdominal colectomy, 10), rectal resection (low anterior resection or pouch) (n = 49), coloanal anastomosis (n = 23), and other (n = 4). Data regarding intent to treat, operative events, morbidity, mortality, and outcomes were analyzed and form the basis of this report. No mortalities occurred. The major morbidity rate was 2%. There were no anastomotic leaks. The cases were laparoscopically performed (94%) or laparoscopically assisted, or were converted to open procedure (3%). The median estimated blood loss was 200 ml, and only 5% required perioperative transfusion. The perioperative course involved the following median periods: 2 days until flatus, 3 days until bowel movement, 1 day until clear liquid diet, 3 days until a regular diet, and 5 days until hospital discharge. In experienced hands, laparoscopic colorectal resection can be performed safely for "high-risk" surgical patients. The better than expected outcomes in this patient population reinforce the benefits of minimally invasive surgery for this patient group and argues against using parameters of increased age, morbid obesity, high ASA class, or preoperative radiation alone as contraindications to even complex laparoscopic colorectal procedures.

Surgery, 1997

AGGRESSIVE ANGIOMYXOMA (AA) is a rare, locally infiltrative, benign neoplasm of the female pelvis... more AGGRESSIVE ANGIOMYXOMA (AA) is a rare, locally infiltrative, benign neoplasm of the female pelvis and perineum. It was first described in 1983, and approximately 88 cases exist in the world literature. We report a case of AA presenting to a surgical service as a levator hernia. A review of the literature and rationale for our treatment are discussed.

International Journal of Radiation Oncology*Biology*Physics, 2000

To evaluate the prognostic significance of postchemoradiation pathologic stage and implications f... more To evaluate the prognostic significance of postchemoradiation pathologic stage and implications for further therapy following preoperative chemoradiation and surgery for advanced/recurrent rectal cancer. Seventy-seven patients with advanced (fixed or tethered T4) or recurrent rectal cancer were treated with preoperative chemoradation followed by surgical resection of disease. Chemotherapy consisted of either of bolus 5-FU 500 mg/m(2) per day or continuous venous infusion 225 mg/m(2) per day for the duration of radiation. Radiation therapy was planned to be delivered to the whole pelvis to a dose of 45 Gy followed by a boost to the area of the tumor of 5-15 Gy. Total radiation doses ranged from 40 to 63 Gy with a median of 55.8 Gy. Surgical resection was then carried out 6-10 weeks following the completion of treatment (median, 7 weeks). Twenty-eight patients underwent abdominoperineal resection and and 49 patients had sphincter-sparing surgical procedures. None of the patients received postoperative chemotherapy. Follow-up in these patients ranges from 1 year to 8 years with a median of 3 years. Significant downstaging of disease was observed with 12/77 (16%) having no residual disease(pT0) and 13% (10/77) found to have pT1-2, N0 disease, 31% (24/77) with pT3-4, N0 and 40% (31/77) for pT0-4, N1-2 cancers. Survival by pathologic stage was 100% for pT0-2, N0 cancers, 80% for pT3-4, N0 and 73% for pTx, N1-2. Local recurrence of disease was observed in 0% of patients with pT0-2, N0 as compared with 13% (3/24) in pT3-4, N0 and 16% (5/31) in pT0-4, N1-2 patients. Downstaging following preoperative chemoradiation is a significant prognostic factor. Patients with pT0, T1, or T2 disease have an excellent prognosis and are unlikely to fail locally or with systemic disease. However, patient with T3/T4 or N+ disease may benefit from further adjuvant chemotherapy.

International Journal of Radiation Oncology*Biology*Physics, 1991

and the Comprehensive Rectal Cancer Center Two hundred twenty patients with adenocarcinoma of the... more and the Comprehensive Rectal Cancer Center Two hundred twenty patients with adenocarcinoma of the rectum have heen treated in a program using high dose (NUIOO cGy) preoperative irradiation followed by radical surgical resection. The patients were staged on the basis of pretreatment clinical mobility of the cancers. Seventy-four patients had mobile cancers, 49 had partial fixation (tethered), 85 patients had total tumor fixation, and 12 patients had a frozen pelvis (unresectable). Patients were treated with high energy photons using a four field box technique with total doses ranging from 4000 to 6000 cGy. The overall incidence of local recurrence was 15% (32/220). Patients with fixed and unresectabte tumors had a higher incidence of local recurrence, 20% (21/97) as compared with patients with mobile and partially fixed tumors, 10% (13/l 23). Local recurrence by pathological stage of disease was 6% for patients with Stages 0, A, Bl versus 20% for patients with Stages B2 and C cancer. Overall S-year survival of the total group was 67%. The 5-year survival by clinical stages of disease was 87% for mobile tumors, 74% for partially fixed tumors, 70% for fixed tumors, and 22% for the unresectable group. The 5-year survival by pathological stages of disease was 90% for those with Stage 0, A, Bl and 71, 75, and 47%. respectively, for Stages B2, Cl, and C2 disease. Rectal cancer, Preoperative radiation therapy, High dose preoperative radiation therapy.

International Journal of Radiation Oncology*Biology*Physics, 1994

International Journal of Radiation Oncology*Biology*Physics, 1988

Sphincter preservation surgery for cancer of the distal rectum is recognized as being associated ... more Sphincter preservation surgery for cancer of the distal rectum is recognized as being associated with a high incidence of local recurrence. High dose preoperative radiation with new surgical techniques is described as an attempt to widen the scope of sphincter preservation in patients who by conventional management would have an abdomino-perineal resection and permanent colostomy and to reduce the incidence of local recurrence. Since 1976,121 patients with cancers of the rectum have selectively been treated with high dose preoperative radiation (4000 cGy to 6000 cGy) followed by combined abdominotranssacral resection (56); transanal abdominotransanal resection (28); anterior resection (21), or a full thickness wide local excision (16). This report details the results of 43 patients observed for a minimum of 2 years whose tumors were located from O-6 cm of the dentate line. All patients received the full course of preoperative radiation, a minimum dose of 4000-4500 cGy in approximately 4f weeks that was delivered using 180-250 cGy per fraction. Patients with tumor fixation were given an additional boost of 1000-1500 cGy preoperatively. Surgery was carried out 4-6 weeks following the completion of radiation. There was no perioperative mortality. Anastomotic failure occurred in 3 patients and was reconstituted in two. Sphincter function was maintained in all but 6 patients (86%), 2 of these had a subsequent abdominoperineal resection, and 3 a diverting colostomy. Seven of 43 (16%) patients with tumors below 6 cm developed a local recurrence, and 6 of the 7 recurrences occurred in patients with fixed tumors, especially those located from O-3 cm from the dentate line. Eleven patients are dead of disease. The S-year actuarial survival rate for this group is 72%. Results indicate that high dose preoperative radiation can significantly extend the scope of sphincter preservation to selected cancers of the disal rectum with excellent survival without increasing the risk of pelvic perineal recurrence. Cancer of the distal rectum, Sphincter preservation, Preoperative radiation.

International Journal of Radiation Oncology*Biology*Physics, 1985

In a study to evaluate the effect of increasing dose per fraction on radiation response in rectal... more In a study to evaluate the effect of increasing dose per fraction on radiation response in rectal cancer, two groups of 29 patients each, matched for extent and size of disease, were evaluated. Group A was treated with conventional dose/fraction (180-200 cGy) X 5 days/week and Group B was treated with 250 cGy/fraction X 4 days/week. Total dose was reduced by 10% in Group B patients to allow comparison of biologically equivalent doses. Two categories of patients were analyzed in each group: patients receiving planned high dose preoperative radiation (4000-4500 cGy); and patients receiving high dose radiation for post-surgical recurrent tumors or locally advanced inoperable tumors (5500-6000 cGy). Tumor regression was markedly better in patients treated with the 250 cGy/fraction. Overall response (greater than 50% regression) was 35% (10/29) in Group A and 62% (18/29) in Group B. Nine of 10 patients in Group B, treated preoperatively, had greater than 50% regression in tumor size, with two patients having no evidence of disease on surgico-pathological evaluation. Six of 10 similar patients in Group A had greater than 50% tumor regression.

International Journal of Radiation Oncology*Biology*Physics, 1993

The inordinately high rate of locoregional recurrence following sphincter-preserving surgery for ... more The inordinately high rate of locoregional recurrence following sphincter-preserving surgery for cancer ofistal rectum led to the conviction that restorative surgery was inappropriate for the low level cancer. A rectal cancer management program initiated in 1976 that selectively uses high-dose preoperative radiition and sphincter-preserving surgery produced lower than expected local recurrence rates. Exploring the safety of extending the indication for sphincter-sparing surgery to include post-radiation mobile cancers as low as the 0.5 cm level is the purpose of this report. Methods and Materials: Of 218 rectal cancer patients treated with high-dose preoperative radiation and sphincterpreserving procedures, 69 had radical curative surgery for cancers at or below the 3 cm level. Data regarding the first 52 patients whose ages ranged from 39 to 77 years form the basis of this report. Fifty-seven percent were men. Twenty-five (48%) patients had post-radiation unfavorable cancers (B2, Cl, C2). Forty-five to sixty Gy high energy photon radiitlon was administered over 4f to 6 weeks followed by a similar interval prior to radical proctosigmoidectomy with anastomosis in the distal 1 cm of rectum. Temporary fecal diversion was performed in all patients; colostomies were closed after 8 weeks. Results: There was zero mortality and two self-limiting anastomotic leaks. Local recurrence developed in 6/43 (14%) patients followed for 24 months or longer. By stage, there were O/21 (0%) recurrences among 0, A, Bl tumors; 6/22 (27%) among unfavorable tumors. By distal margins, l/9 (11%) occurred in .3-l cm; 4/13 (31%) 1.1-2 cm; l/18 (5%) 2.1-3 cm. Five-year Kaplan Meier actuarial survival for the 52 patients was 85%. Conclusion: Our data indicates that sphincter preservation can be accomplished in cancers of the distal 3 cm of rectum if high-dose preoperative radiation is administered and fixed cancers are excluded. This is the first reported study of sphincter-preserving surgery for the distal rectal cancer after highdose radiation. The data are important to the design of new treatment options. High dose preoperative radiation therapy, Distal rectal cancer, Sphincter preservation surgery.

Diseases of the Colon & Rectum, 1981

Sixty-two patients with carcinoma of the rectum were treated with "selective sandwich&am... more Sixty-two patients with carcinoma of the rectum were treated with "selective sandwich" adjuvant radiotherapy in a pilot study which began in September 1976 at Thomas Jefferson University Hospital. All patients received 500 rads preoperative irradiation on the day of or day preceding surgery. Following surgery, the lesions were staged pathologically according to Astler-Coller's modification of Dukes' staging. Patients with poor prognostic characteristics (Stages B2, C1, and C2) were treated with aggressive postoperative pelvic irradiation (4500 rads in five weeks). All 62 patients received the single preoperative dose of 500 rads. Forty-four patients underwent abdominoperineal resection, four patients, a low anterior resection, ten patients, a combined abdominotranssacral resection, and four patients found to have liver metastasis at laparotomy had colostomy followed by palliative therapy. Twenty-one patients found to have early disease (Stages A or B1) were given no further therapy. Of 37 patients with Stages B2 or C disease, 21 received postoperative irradiation. Follow-up ranged from 6 months to 36 months, with a median of 18 months. Of patients with Stage A or B1 disease, one patient has died with metastasis. Two of 21 patients receiving postoperative irradiation have developed metastatic disease; neither has failed in the pelvis. Of 16 patients who did not receive postoperative irradiation, three have had metastasis to the pelvis and two others have developed distant metastasis.

Diseases of the Colon & Rectum, 1973

Diseases of the Colon & Rectum, 1974

THE FIRST REFERENCE tO insertion of a sterile sigmoidoscope into the colon during laparotomy, for... more THE FIRST REFERENCE tO insertion of a sterile sigmoidoscope into the colon during laparotomy, for inspection of the lumen, was made in 1952, and following this publication a series of articles describing various techniqnes, indications, advantages, and hazards related to "coloscopy ''13, 16 appeared in the surgical literature. Early literature indicated a general acceptance of the procedure among surgeons, but in 1960, a controversial element was introduced when Kleinfeld and Gump TM reported a disturbingly high incidence of postoperative complications associated with the addition of "coloscopy" to colotomy. Swinton and Weakley, 20 in a direct rebuttal, reported an incidence of complications associated with "coloscopy" and colotomy which did not vary significantly from that associatect with colotomy alone. Kratzer's~S current status report of "coloscopy", conducted in the early 60's, was based upon a survey of 140 colorectal surgeons and followed, too closely perhaps, the opposing articles to adequately measure their impact on the practices of surgeons relating to the use of "coloscopy." Since so little has been written of "coloscopy" in the past ten years, the impact of this controversy cannot be measured from the literature alone, and because new diagnostic and therapeutic techniques which might further affect the use of "coloscopy" * Read at the meeting of the Pennsylvania So

Cancer, 1996

This study was conducted to assess the prognostic significance of adjunctive radiation in the sur... more This study was conducted to assess the prognostic significance of adjunctive radiation in the surgical management of rectal carcinoma patients with tumor fixation. Two hundred and ninety-seven patients with a histologic diagnosis of adenocarcinoma of the rectum were treated with high dose preoperative radiation ( > or = 45 Gray [Gy]) followed by surgical resection of the tumor (Group A). One hundred and seventy-four patients underwent initial curative surgery (Group B) followed by selective postoperative radiation (45-50 Gy) for those with pathologic T3, T4, or N+ (B2, C) cancers (N = 143). The two patient groups were compared by presenting clinical stage of the disease to assess the prognostic significance of tumor fixation on results of adjunctive therapy. Follow-up ranged from 24 months to 180 months. The 5-year actuarial survival of Groups A and B was similar, 69% and 61% respectively. Survival was significantly better for Group A patients with fixed cancer (57% vs. 33%, P = 0.003). Survival was also better for patients in Group A with tumors located in the distal rectum (70% vs. 56%, P = 0.02). The local recurrence rate for patients with tumors located in the distal rectum was 17% for Group A and 19% for Group B (P = 0.74). The local recurrence rate for fixed cancers was 23% and 50% for Group A and Group B respectively (P = 0.0009). The incidence of small bowel complications (Grade 3 or 4) was lower for patients undergoing preoperative radiation compared with patients treated with postoperative radiation, (4% vs. 13%, P < 0.05). When special considerations of sphincter-preserving surgery are not an issue, mobile rectal carcinoma may be effectively treated with surgery and selective postoperative radiation. However, fixed tumors, especially those located in the distal rectum, are better treated with high dose preoperative radiation.

Arquivos de Gastroenterologia, 2008

RACIONAL: A literatura médica aceita ressecção local como opção válida em casos selecionados de t... more RACIONAL: A literatura médica aceita ressecção local como opção válida em casos selecionados de tumores de reto. A seleção dos pacientes requer exata estimativa dos riscos e avaliação pré-operatória precisa, tanto no aspecto clínico como histopatológico. OBJETIVO: Avaliar os resultados da microcirurgia endoscópica transanal em seguimento de 18 meses. MÉTODOS: De abril de 2002 a abril de 2006, 50 pacientes com tumores de reto foram submetidos a microcirurgia endoscópica transanal, selecionados por suas características clínicas e histopatológicas. Os critérios de inclusão foram: adenomas sésseis maiores do que 3 cm e menores do que 8 cm não-circunferenciais; neoplasia intra-epitelial de alto grau; carcinoma retal pT1, e em casos especiais pT2. Todos esses tumores foram submetidos ao mesmo procedimento cirúrgico. RESULTADOS: O resultado histopatológico final revelou 9 adenomas, 26 neoplasias intra-epiteliais de alto grau, 13 carcinomas (9 pT1 e 4 pT2) e 2 carcinóides. A menor idade foi...

American Journal of Clinical Oncology, 1994

Diseases of the Colon & Rectum, 1979

Surgical Clinics of North America, 1989

Because extraordinary benefits accrue to the patient when the surgeon can view the site of diseas... more Because extraordinary benefits accrue to the patient when the surgeon can view the site of disease first-hand, the gastrointestinal surgeon must be a proficient endoscopist, and endoscopy must be part of gastrointestinal surgery. Leaders of surgical organizations and surgeon educators, upon whom rests the responsibility for shaping policy and educating medical students and residents, should remain alert to the need to maintain a substantial surgical presence in gastrointestinal endoscopy.

Surgical Endoscopy, 2016

Introduction Natural orifice transluminal endoscopic surgery (NOTES) represents the ultimate expr... more Introduction Natural orifice transluminal endoscopic surgery (NOTES) represents the ultimate expression of minimally invasive surgery. We have developed and present here an initial feasibility and safety study of transanal total mesorectal excision (TME) with splenic flexure release, high ligation of the IMA and IMV, and side-to-end coloanal anastomosis with temporary diverting ileostomy for rectal cancer. Methods A program of full NOTES TME resection with release of the splenic flexure, high ligation of the IMA/ IMV, with side-to-end coloanal anastomosis was performed transanally from December 2013 to July 2014. Demographics, preoperative, perioperative, and postoperative data were prospectively obtained. Operative components were broken into TME, colonic mobilization, splenic flexure release, IMA/IMV transection, transanal extraction of specimen, and coloanal anastomosis for analysis of performance completion. Results There were 3 women and 1 man on whom we operated. Mean age was 56 (46-65). Mean BMI was 26

Transanal Endoscopic Microsurgery, 2008

Surgical Endoscopy, 2008

Patients with major comorbidities often are denied laparoscopic colorectal resections because the... more Patients with major comorbidities often are denied laparoscopic colorectal resections because they are thought to be at too "high risk." Paradoxically, these patients generally have the most to gain from a minimally invasive surgical approach. This study aimed to examine the feasibility and safety of laparoscopic colorectal resection to determine whether it is contraindicated for "high-risk" patients. From August 1996 to February 2004, 368 consecutive patients (95 men) undergoing a laparoscopic colorectal procedure by a single surgeon were prospectively studied with regard to pre-, peri-, and postoperative events. High-risk patients (n = 190) were defined as elderly (age, >80 years; n = 28), morbidly obese (body mass index [BMI], >30 kg/m(2); n = 55), American Society of Anesthesiology (ASA) 3 or 4 (n = 130), and recipients of preoperative radiotherapy (n = 54). Multiple risk factors were found for 67 patients, 7 of whom had three risk factors. The median age of the patients was 66 years (range, 19-92 years). The diagnoses included rectal cancer (n = 48), diverticulitis (n = 43), colon cancer (n = 34), benign polyp (n = 26), and other (n = 39). The following procedures were performed: colon resection (n = 114; left, 63; right, 41; total abdominal colectomy, 10), rectal resection (low anterior resection or pouch) (n = 49), coloanal anastomosis (n = 23), and other (n = 4). Data regarding intent to treat, operative events, morbidity, mortality, and outcomes were analyzed and form the basis of this report. No mortalities occurred. The major morbidity rate was 2%. There were no anastomotic leaks. The cases were laparoscopically performed (94%) or laparoscopically assisted, or were converted to open procedure (3%). The median estimated blood loss was 200 ml, and only 5% required perioperative transfusion. The perioperative course involved the following median periods: 2 days until flatus, 3 days until bowel movement, 1 day until clear liquid diet, 3 days until a regular diet, and 5 days until hospital discharge. In experienced hands, laparoscopic colorectal resection can be performed safely for "high-risk" surgical patients. The better than expected outcomes in this patient population reinforce the benefits of minimally invasive surgery for this patient group and argues against using parameters of increased age, morbid obesity, high ASA class, or preoperative radiation alone as contraindications to even complex laparoscopic colorectal procedures.

Surgery, 1997

AGGRESSIVE ANGIOMYXOMA (AA) is a rare, locally infiltrative, benign neoplasm of the female pelvis... more AGGRESSIVE ANGIOMYXOMA (AA) is a rare, locally infiltrative, benign neoplasm of the female pelvis and perineum. It was first described in 1983, and approximately 88 cases exist in the world literature. We report a case of AA presenting to a surgical service as a levator hernia. A review of the literature and rationale for our treatment are discussed.

International Journal of Radiation Oncology*Biology*Physics, 2000

To evaluate the prognostic significance of postchemoradiation pathologic stage and implications f... more To evaluate the prognostic significance of postchemoradiation pathologic stage and implications for further therapy following preoperative chemoradiation and surgery for advanced/recurrent rectal cancer. Seventy-seven patients with advanced (fixed or tethered T4) or recurrent rectal cancer were treated with preoperative chemoradation followed by surgical resection of disease. Chemotherapy consisted of either of bolus 5-FU 500 mg/m(2) per day or continuous venous infusion 225 mg/m(2) per day for the duration of radiation. Radiation therapy was planned to be delivered to the whole pelvis to a dose of 45 Gy followed by a boost to the area of the tumor of 5-15 Gy. Total radiation doses ranged from 40 to 63 Gy with a median of 55.8 Gy. Surgical resection was then carried out 6-10 weeks following the completion of treatment (median, 7 weeks). Twenty-eight patients underwent abdominoperineal resection and and 49 patients had sphincter-sparing surgical procedures. None of the patients received postoperative chemotherapy. Follow-up in these patients ranges from 1 year to 8 years with a median of 3 years. Significant downstaging of disease was observed with 12/77 (16%) having no residual disease(pT0) and 13% (10/77) found to have pT1-2, N0 disease, 31% (24/77) with pT3-4, N0 and 40% (31/77) for pT0-4, N1-2 cancers. Survival by pathologic stage was 100% for pT0-2, N0 cancers, 80% for pT3-4, N0 and 73% for pTx, N1-2. Local recurrence of disease was observed in 0% of patients with pT0-2, N0 as compared with 13% (3/24) in pT3-4, N0 and 16% (5/31) in pT0-4, N1-2 patients. Downstaging following preoperative chemoradiation is a significant prognostic factor. Patients with pT0, T1, or T2 disease have an excellent prognosis and are unlikely to fail locally or with systemic disease. However, patient with T3/T4 or N+ disease may benefit from further adjuvant chemotherapy.

International Journal of Radiation Oncology*Biology*Physics, 1991

and the Comprehensive Rectal Cancer Center Two hundred twenty patients with adenocarcinoma of the... more and the Comprehensive Rectal Cancer Center Two hundred twenty patients with adenocarcinoma of the rectum have heen treated in a program using high dose (NUIOO cGy) preoperative irradiation followed by radical surgical resection. The patients were staged on the basis of pretreatment clinical mobility of the cancers. Seventy-four patients had mobile cancers, 49 had partial fixation (tethered), 85 patients had total tumor fixation, and 12 patients had a frozen pelvis (unresectable). Patients were treated with high energy photons using a four field box technique with total doses ranging from 4000 to 6000 cGy. The overall incidence of local recurrence was 15% (32/220). Patients with fixed and unresectabte tumors had a higher incidence of local recurrence, 20% (21/97) as compared with patients with mobile and partially fixed tumors, 10% (13/l 23). Local recurrence by pathological stage of disease was 6% for patients with Stages 0, A, Bl versus 20% for patients with Stages B2 and C cancer. Overall S-year survival of the total group was 67%. The 5-year survival by clinical stages of disease was 87% for mobile tumors, 74% for partially fixed tumors, 70% for fixed tumors, and 22% for the unresectable group. The 5-year survival by pathological stages of disease was 90% for those with Stage 0, A, Bl and 71, 75, and 47%. respectively, for Stages B2, Cl, and C2 disease. Rectal cancer, Preoperative radiation therapy, High dose preoperative radiation therapy.

International Journal of Radiation Oncology*Biology*Physics, 1994

International Journal of Radiation Oncology*Biology*Physics, 1988

Sphincter preservation surgery for cancer of the distal rectum is recognized as being associated ... more Sphincter preservation surgery for cancer of the distal rectum is recognized as being associated with a high incidence of local recurrence. High dose preoperative radiation with new surgical techniques is described as an attempt to widen the scope of sphincter preservation in patients who by conventional management would have an abdomino-perineal resection and permanent colostomy and to reduce the incidence of local recurrence. Since 1976,121 patients with cancers of the rectum have selectively been treated with high dose preoperative radiation (4000 cGy to 6000 cGy) followed by combined abdominotranssacral resection (56); transanal abdominotransanal resection (28); anterior resection (21), or a full thickness wide local excision (16). This report details the results of 43 patients observed for a minimum of 2 years whose tumors were located from O-6 cm of the dentate line. All patients received the full course of preoperative radiation, a minimum dose of 4000-4500 cGy in approximately 4f weeks that was delivered using 180-250 cGy per fraction. Patients with tumor fixation were given an additional boost of 1000-1500 cGy preoperatively. Surgery was carried out 4-6 weeks following the completion of radiation. There was no perioperative mortality. Anastomotic failure occurred in 3 patients and was reconstituted in two. Sphincter function was maintained in all but 6 patients (86%), 2 of these had a subsequent abdominoperineal resection, and 3 a diverting colostomy. Seven of 43 (16%) patients with tumors below 6 cm developed a local recurrence, and 6 of the 7 recurrences occurred in patients with fixed tumors, especially those located from O-3 cm from the dentate line. Eleven patients are dead of disease. The S-year actuarial survival rate for this group is 72%. Results indicate that high dose preoperative radiation can significantly extend the scope of sphincter preservation to selected cancers of the disal rectum with excellent survival without increasing the risk of pelvic perineal recurrence. Cancer of the distal rectum, Sphincter preservation, Preoperative radiation.

International Journal of Radiation Oncology*Biology*Physics, 1985

In a study to evaluate the effect of increasing dose per fraction on radiation response in rectal... more In a study to evaluate the effect of increasing dose per fraction on radiation response in rectal cancer, two groups of 29 patients each, matched for extent and size of disease, were evaluated. Group A was treated with conventional dose/fraction (180-200 cGy) X 5 days/week and Group B was treated with 250 cGy/fraction X 4 days/week. Total dose was reduced by 10% in Group B patients to allow comparison of biologically equivalent doses. Two categories of patients were analyzed in each group: patients receiving planned high dose preoperative radiation (4000-4500 cGy); and patients receiving high dose radiation for post-surgical recurrent tumors or locally advanced inoperable tumors (5500-6000 cGy). Tumor regression was markedly better in patients treated with the 250 cGy/fraction. Overall response (greater than 50% regression) was 35% (10/29) in Group A and 62% (18/29) in Group B. Nine of 10 patients in Group B, treated preoperatively, had greater than 50% regression in tumor size, with two patients having no evidence of disease on surgico-pathological evaluation. Six of 10 similar patients in Group A had greater than 50% tumor regression.

International Journal of Radiation Oncology*Biology*Physics, 1993

The inordinately high rate of locoregional recurrence following sphincter-preserving surgery for ... more The inordinately high rate of locoregional recurrence following sphincter-preserving surgery for cancer ofistal rectum led to the conviction that restorative surgery was inappropriate for the low level cancer. A rectal cancer management program initiated in 1976 that selectively uses high-dose preoperative radiition and sphincter-preserving surgery produced lower than expected local recurrence rates. Exploring the safety of extending the indication for sphincter-sparing surgery to include post-radiation mobile cancers as low as the 0.5 cm level is the purpose of this report. Methods and Materials: Of 218 rectal cancer patients treated with high-dose preoperative radiation and sphincterpreserving procedures, 69 had radical curative surgery for cancers at or below the 3 cm level. Data regarding the first 52 patients whose ages ranged from 39 to 77 years form the basis of this report. Fifty-seven percent were men. Twenty-five (48%) patients had post-radiation unfavorable cancers (B2, Cl, C2). Forty-five to sixty Gy high energy photon radiitlon was administered over 4f to 6 weeks followed by a similar interval prior to radical proctosigmoidectomy with anastomosis in the distal 1 cm of rectum. Temporary fecal diversion was performed in all patients; colostomies were closed after 8 weeks. Results: There was zero mortality and two self-limiting anastomotic leaks. Local recurrence developed in 6/43 (14%) patients followed for 24 months or longer. By stage, there were O/21 (0%) recurrences among 0, A, Bl tumors; 6/22 (27%) among unfavorable tumors. By distal margins, l/9 (11%) occurred in .3-l cm; 4/13 (31%) 1.1-2 cm; l/18 (5%) 2.1-3 cm. Five-year Kaplan Meier actuarial survival for the 52 patients was 85%. Conclusion: Our data indicates that sphincter preservation can be accomplished in cancers of the distal 3 cm of rectum if high-dose preoperative radiation is administered and fixed cancers are excluded. This is the first reported study of sphincter-preserving surgery for the distal rectal cancer after highdose radiation. The data are important to the design of new treatment options. High dose preoperative radiation therapy, Distal rectal cancer, Sphincter preservation surgery.

Diseases of the Colon & Rectum, 1981

Sixty-two patients with carcinoma of the rectum were treated with "selective sandwich&am... more Sixty-two patients with carcinoma of the rectum were treated with "selective sandwich" adjuvant radiotherapy in a pilot study which began in September 1976 at Thomas Jefferson University Hospital. All patients received 500 rads preoperative irradiation on the day of or day preceding surgery. Following surgery, the lesions were staged pathologically according to Astler-Coller's modification of Dukes' staging. Patients with poor prognostic characteristics (Stages B2, C1, and C2) were treated with aggressive postoperative pelvic irradiation (4500 rads in five weeks). All 62 patients received the single preoperative dose of 500 rads. Forty-four patients underwent abdominoperineal resection, four patients, a low anterior resection, ten patients, a combined abdominotranssacral resection, and four patients found to have liver metastasis at laparotomy had colostomy followed by palliative therapy. Twenty-one patients found to have early disease (Stages A or B1) were given no further therapy. Of 37 patients with Stages B2 or C disease, 21 received postoperative irradiation. Follow-up ranged from 6 months to 36 months, with a median of 18 months. Of patients with Stage A or B1 disease, one patient has died with metastasis. Two of 21 patients receiving postoperative irradiation have developed metastatic disease; neither has failed in the pelvis. Of 16 patients who did not receive postoperative irradiation, three have had metastasis to the pelvis and two others have developed distant metastasis.

Diseases of the Colon & Rectum, 1973

Diseases of the Colon & Rectum, 1974

THE FIRST REFERENCE tO insertion of a sterile sigmoidoscope into the colon during laparotomy, for... more THE FIRST REFERENCE tO insertion of a sterile sigmoidoscope into the colon during laparotomy, for inspection of the lumen, was made in 1952, and following this publication a series of articles describing various techniqnes, indications, advantages, and hazards related to "coloscopy ''13, 16 appeared in the surgical literature. Early literature indicated a general acceptance of the procedure among surgeons, but in 1960, a controversial element was introduced when Kleinfeld and Gump TM reported a disturbingly high incidence of postoperative complications associated with the addition of "coloscopy" to colotomy. Swinton and Weakley, 20 in a direct rebuttal, reported an incidence of complications associated with "coloscopy" and colotomy which did not vary significantly from that associatect with colotomy alone. Kratzer's~S current status report of "coloscopy", conducted in the early 60's, was based upon a survey of 140 colorectal surgeons and followed, too closely perhaps, the opposing articles to adequately measure their impact on the practices of surgeons relating to the use of "coloscopy." Since so little has been written of "coloscopy" in the past ten years, the impact of this controversy cannot be measured from the literature alone, and because new diagnostic and therapeutic techniques which might further affect the use of "coloscopy" * Read at the meeting of the Pennsylvania So

Cancer, 1996

This study was conducted to assess the prognostic significance of adjunctive radiation in the sur... more This study was conducted to assess the prognostic significance of adjunctive radiation in the surgical management of rectal carcinoma patients with tumor fixation. Two hundred and ninety-seven patients with a histologic diagnosis of adenocarcinoma of the rectum were treated with high dose preoperative radiation ( > or = 45 Gray [Gy]) followed by surgical resection of the tumor (Group A). One hundred and seventy-four patients underwent initial curative surgery (Group B) followed by selective postoperative radiation (45-50 Gy) for those with pathologic T3, T4, or N+ (B2, C) cancers (N = 143). The two patient groups were compared by presenting clinical stage of the disease to assess the prognostic significance of tumor fixation on results of adjunctive therapy. Follow-up ranged from 24 months to 180 months. The 5-year actuarial survival of Groups A and B was similar, 69% and 61% respectively. Survival was significantly better for Group A patients with fixed cancer (57% vs. 33%, P = 0.003). Survival was also better for patients in Group A with tumors located in the distal rectum (70% vs. 56%, P = 0.02). The local recurrence rate for patients with tumors located in the distal rectum was 17% for Group A and 19% for Group B (P = 0.74). The local recurrence rate for fixed cancers was 23% and 50% for Group A and Group B respectively (P = 0.0009). The incidence of small bowel complications (Grade 3 or 4) was lower for patients undergoing preoperative radiation compared with patients treated with postoperative radiation, (4% vs. 13%, P < 0.05). When special considerations of sphincter-preserving surgery are not an issue, mobile rectal carcinoma may be effectively treated with surgery and selective postoperative radiation. However, fixed tumors, especially those located in the distal rectum, are better treated with high dose preoperative radiation.

Arquivos de Gastroenterologia, 2008

RACIONAL: A literatura médica aceita ressecção local como opção válida em casos selecionados de t... more RACIONAL: A literatura médica aceita ressecção local como opção válida em casos selecionados de tumores de reto. A seleção dos pacientes requer exata estimativa dos riscos e avaliação pré-operatória precisa, tanto no aspecto clínico como histopatológico. OBJETIVO: Avaliar os resultados da microcirurgia endoscópica transanal em seguimento de 18 meses. MÉTODOS: De abril de 2002 a abril de 2006, 50 pacientes com tumores de reto foram submetidos a microcirurgia endoscópica transanal, selecionados por suas características clínicas e histopatológicas. Os critérios de inclusão foram: adenomas sésseis maiores do que 3 cm e menores do que 8 cm não-circunferenciais; neoplasia intra-epitelial de alto grau; carcinoma retal pT1, e em casos especiais pT2. Todos esses tumores foram submetidos ao mesmo procedimento cirúrgico. RESULTADOS: O resultado histopatológico final revelou 9 adenomas, 26 neoplasias intra-epiteliais de alto grau, 13 carcinomas (9 pT1 e 4 pT2) e 2 carcinóides. A menor idade foi...

American Journal of Clinical Oncology, 1994