Local excision of rectal cancer can be a part of treatment of this tumor. The authors do not feel that this procedure is only palliative. Clinical staging I and II, tumor diameter less than 3 cm, malignancy grade 1 or 2, invasion no deeper than the submucosa, and no signet-cell carcinoma are all requisites for limited, local excision of rectal carcinoma. Patients operated upon under these criteria have a five-year survival rate of 89.6 +/- 21.7 per cent for those with invasion into the submucosa and 78 +/- 49.9 per cent for those with invasion into the muscularis propria. But to get such good results, strict self control must be exercised in selecting patients.

The predictive value of the route of venous drainage on prognosis was investigated in a consecutive series of 44 patients who underwent curative resection of pulmonary metastases from colorectal carcinoma. The primary tumor was located in the colon in 14 patients and in the upper third of the rectum in 11 patients, thus indicating blood drainage directed toward the portal vein (Group I). In 10 and 9 cases, respectively, the initial growth was in the middle and lower thirds of the rectum with the venous outflow at least partially directed into the vena cava (Group II). There was no obvious difference between the two groups regarding the initial site of cancer relapse. The liver was involved in 4 of 15 patients failing in Group I as opposed to 4 of 13 patients with hematogenous relapse in Group II. Median survival and tumor-free survival times were significantly longer in patients in Group I (58.4 and 50.2 months) than in patients in Group II (30.9 and 16.8 months), and, even more pronounced, in colon cancer patients (75.4 and 60.2 months) when compared with rectal cancer patients (31.0 and 17.9 months). In contrast, survival curves did not differ significantly if either the two groups with different routes of drainage (5-year survival 53 percent vs. 38 percent, 5-year tumor-free survival 43 percent vs. 37 percent), or tumors of the colon and rectum (5-year survival 67 percent vs. 38 percent, 5-year tumor-free survival 60 percent vs. 32 percent) were compared using the log-rank test. Similar trends were obtained for the subgroup of 34 patients without previous or simultaneous extrapulmonary recurrent disease at the time of lung resection. The primary tumor site does therefore not become a major criterion in selecting patients for surgical resection.

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Between 1985 and 1992, 46 patients with epidermoid carcinoma of the anal canal were treated prospectively by a protocol of combined radiation and chemotherapy with 5-Fluorouracil and Mitomycin C. The survival rate, NED-survival rate and local tumour control rate were 84%, 71% and 83% at 5 years. Anorectal function was retained in 33 of 41 patients (80%). We observed severe acute toxicity including three deaths, but very little late morbidity. The only marginally significant prognostic factor (P = 0.06) for local tumour control was T-stage. NED-survival was significantly affected (P = 0.02) by reduction of chemotherapy during the second course.

Rectal carcinomas are increasingly treated by more and more differentiated regimens. Until the 1970s, the rectal excision was standard, whereas in 58% sphincter-saving procedures were performed during the last years. Locoregional recurrences are the main problem of surgical treatment for rectum carcinomas. They are of decisive importance for the patients. Without locoregional recurrence during the first two years, the overall five-year survival is 85% which decreases tremendously to 23% in case of a locoregional recurrence. Overall, this rate depends primarily on patho-histological parameters of the primary, as well as on therapeutic modalities and quality, too. For this reason, the arguments for routine neo- or adjuvant radio-(chemo-)therapy, increasingly arising during the last two years, is debatable. Global recommendations do not realize that low rates of locoregional recurrences may be achieved by surgery alone, e.g., 13% in the surgical Department of the University of Erlangen. However, these patients do include some groups with increased risk, for example, those who have positive lymph nodes along the course of a named vascular trunk (18%). These patients at increased risk may profit from adjuvant-radio-(chemo-)therapy. This is not yet, however, proven by any prospective study.

There is an obvious advantage to partial duodenopancreatectomy with occlusion of the pancreatic duct by prolamine (a rapidly solidifying aminoacid solution) for the prevention of recurrences, while preserving the stomach and proximal duodenum, in the treatment of severe destruction of the pancreas, localised to the head or generalised. The death rate of partial duodenopancreactectomy has been lowered from 8.5 to 2.3% since using this method. Compared with total duodenopancreatectomy which--according to the authors' earlier results carried a postoperative mortality of 20%--the operative risk has been reduced to a tenth. Taking into account the benign nature of chronic pancreatitis, on the other hand, and the extent of the operative operation, on the other, the present death-rate of 2.3% would appear reasonable. Occlusion of the pancreatic duct with prolamine in order to exclude any still present excretory pancreatic function in the residual pancreatic tissue has made all patients pain-free. No early recurrence has been observed.

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