Treatment of locally advanced rectal cancer with preoperative CMT followed by TME can provide for a durable 10-year OS of 58% and RFS of 62%. Patients who achieve a >95% response to preoperative CMT have an improved long-term oncologic outcome, a novel finding that deserves further study.

Perineal closure with a RAM flap significantly decreases the incidence of perineal wound complications in patients undergoing external beam pelvic radiation and APR for anorectal neoplasia. Because other complications are not increased, RAM flap closure of the perineal wound should be strongly considered in this patient population.

Our comprehensive pathologic analysis suggests that, following preoperative CMT and a TME-based resection, distal margins of 1 cm may provide for complete removal of locally advanced rectal cancer. Although residual cancer following preoperative CMT was more likely in the setting of distally located tumors, occult tumor beneath the mucosal edge was rare and, when present, limited to less than 1 cm. Our results extend the indications for sphincter preservation, as distal resection margins of only 1 cm may be acceptable for rectal cancer treated with preoperative CMT.

Rectal cancer patients with pCR after preoperative CMT have improved RFS, OS, and sphincter preservation compared with patients without downstaging. Because pCR seems to be associated with better outcome, an understanding of the factors governing the response to CMT should be pursued.

Clinical examination underestimates the extent of rectal cancer response to preoperative CMT. Given the inaccuracy of DRE following preoperative CMT, it should not be used as a sole means of assessing efficacy of therapy nor for selecting patients following CMT for local surgical therapies.

PURPOSE-We evaluated a large cohort of patients with longstanding ulcerative colitis in a colonoscopic surveillance program to determine predictors of colectomy.METHODS-We queried a retrospective database of patients who had symptoms of ulcerative colitis for seven years or more. Histologic inflammation in biopsies was graded on a validated fourpoint scale: absent, mild, moderate, severe. We performed a multivariate analysis of the inflammation scores and other variables to determine predictive factors for colectomy. Patients who underwent colectomy for neoplasia were censored at the time of surgery; those who did not undergo colectomy were censored at the time of last contact.RESULTS-A total of 561 patients were evaluated, with a median follow-up of 21.4 years since disease onset. A total of 97 patients (17.3 percent) underwent surgery; 25 (4.5 percent) for reasons other than dysplasia. These 25 constitute events for this analysis. For univariate analysis, mean inflammation (P < 0.001) and steroid use (P = 0.01) were predictors of colectomy. For multivariable proportional hazards analysis, mean inflammation (P < 0.001) and steroid use (P = 0.03) were predictors of colectomy, whereas salicylate use (P = 0.007) was protective.CONCLUSIONS-Higher median inflammation scores and corticosteroid use were predictors of colectomy in this patient population. The overall rate of colectomy during a long period of followup was low (<1 percent per year). KeywordsUlcerative colitis; Colectomy; Dysplasia; Inflammation Colon resection is a common outcome in patients with ulcerative colitis (UC). Overall, 30 percent of patients diagnosed with UC will at some point undergo colectomy-a rate that has not changed significantly during the last 50 years. 1,2 Importantly, resection of the colon and rectum, with or without creation of an ileal pouch as a neorectum, can have significant morbidity. Therefore, identification of patients with UC who will ultimately require colectomy is of great clinical value, in that this knowledge may spare some patients the complications of prolonged medical management while avoiding premature or unnecessary surgery in others. NIH-PA Author ManuscriptThere is considerable literature about factors that predict urgent or emergent colectomy in patients with acute UC flares. Lack of response to steroids, continued diarrhea and bloody bowel movements, and persistently elevated inflammatory markers all have been shown to predict colectomy in hospitalized patients with UC. [3][4][5][6] However, there are few data concerning predictive factors for colectomy in patients with longstanding disease. 7 There is broad agreement in most studies that patients with pancolitis at diagnosis are more likely to require colectomy than those with more limited disease. [8][9][10][11] Various genetic markers, including certain HLA haplotypes, also have been shown to contribute to increased risk of colectomy. [12][13][14] Evidence for other potential predictive factors, such as malnutrition, inability to wean steroids, or...

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