ObjectiveTo evaluate the safety and efficacy of local excision in patients with T2 and T3 distal rectal cancers that have been downstaged by preoperative chemoradiation. Summary Background DataT2 and T3 cancers treated by local excision alone are associated with unacceptably high recurrence rates. The authors hypothesized that preoperative chemoradiation might downstage both T2 and T3 lesions and significantly expand the indications for local excision. MethodsLocal excision was performed after preoperative chemoradiation on patients with a complete clinical response or on patients who were either ineligible for or refused to undergo abdominoperineal resection. Local excision was approached transanally by removing full-thickness rectal wall and the underlying mesorectum. ResultsFrom 1994 to 2000, 95 patients with rectal cancers underwent preoperative chemoradiation and surgical resection for curative intent. Of these, 26 patients (28%), 19 men and 7 women, with a mean age of 63 years (range 44 -90), underwent local excision. Pretreatment endoscopic ultrasound classifications included 5 T2N0, 13 T3N0, 7 T3N1, and 1 not done. Pathologic partial and complete responses were achieved in 9 of 26 (35%) and 17 of 26 (65%) patients, respectively. Two of nine partial responders underwent immediate abdominoperineal resection. The mean follow-up was 24 months (median 19, range 6 -77). The only recurrence was in a patient who refused to undergo abdominoperineal resection after a partial response. There was one postoperative death from a stroke. This treatment was associated with a low rate of complications. ConclusionLocal excision appears to be an effective alternative treatment to radical surgical resection for a highly select subset of patients with T2 and T3 adenocarcinomas of the distal rectum who show a complete pathologic response to preoperative chemoradiation.Colorectal cancer is the third most common site for cancer in men and women in the United States. It is estimated that there will be 36,400 new diagnoses of rectal cancer and 8,600 deaths from rectal cancer in the year 2000.1 The current standard treatment for distal rectal cancer is abdominoperineal resection (APR), low anterior resection, or resection with coloanal anastomosis. These operations are associated with significant rates of death and complications, and local or distant recurrences occur in 10% to 65% of patients.2 The complications associated with radical rectal surgical procedures include urinary dysfunction in 10% to 70%, sexual dysfunction in 13% to 70%, and anastomotic leaks in 5% to 17%, with death rates of 2% to 6%.3-10 Compared with a radical resection for distal rectal cancer, local excision avoids a laparotomy, permanent colostomy, and the complications associated with pelvic dissection.The incidence of local recurrence even after radical surgery ranges from 10% to 29%.11-14 A recent review of published series reported an 18.5% overall local recurrence

Biochemotherapy remains a promising new treatment for metastatic melanoma. A large Intergroup trial E3695 comparing concurrent biochemotherapy to combination chemotherapy alone is powered to answer important survival questions.

Major revisions have been made to form a new AJCC staging system for melanoma, which will become official in 2002. This system will provide more accurate and precise information regarding patient prognosis. Validation studies are needed to confirm the accuracy of this revised staging system.