Wegener's granulomatosis is a necrotizing vasculitic disease principally affecting upper and lower airways and commonly the kidneys. The disease process may, however, manifest itself in any organ system and cases continue to be reported to substantiate this (Hoffman et al, 1992).

bound cyanocobalamin. We accept that gastric biopsies to test for achlohydria ⁄ hypochlorhydria and faecal elastase tests to exclude chronic pancreatitis as causes would have strengthened the study. Although not stated in our article, none of patients were taking H2-antagonists.We recognize that folate deficiency may result in falsely low serum cobalamin levels and these figures from our cohort will be included in a comprehensive paper describing the outcome of all haematological parameters following restorative proctocolectomy, currently being prepared for submission to Colorectal Disease. We will also be describing our results using the more sensitive indicator, plasma homocysteine, to diagnose subclinical cobalamin deficiency in our cohort.Dear Sir, We read with interest the case described by Bounavas et al. [1]. Whilst there is limited literature describing the association of concomitant rectal prolapse and rectal adenocarcinoma, our experience illustrates that this association is not as rare as the authors suggest. As well as the three articles describing the association of colonic adenocarcinoma with rectal prolapse, colonic lipomas [2] and adenomas [3] resulting in complete rectal prolapse have also been described. Furthermore we have been involved in two cases within the last year where complete rectal prolapse led to the diagnosis of primary sigmoid or rectal adenocarcinoma.Most recently, a 72-year-old lady was referred to the general surgeons with a 5-month history of complete prolapse of the rectum and associated procidentia (Fig. 1). On examination it was immediately apparent that there was an 8 · 4 cm fungating cancer at the apex of the rectal prolapse. Biopsies confirmed invasive adenocarcinoma and staging investigations were initiated. Barium enema failed because of complete lack of anal tone. Flexible sigmoidosocopy revealed a synchronous sigmoid adenocarcinoma. CT scanning revealed a possible single liver metastasis; the patient therefore underwent resection. The operation performed was Hartmann's procedure with end colostomy, total hysterectomy, pelvic floor repair, repair of rectocele and cystocele. The histology of the rectal tumour was pT3N2, that of the sigmoid lesion pT2N0. She made an excellent recovery from surgery and has had no further problem with prolapse. In view of the histology, she was referred for adjuvant chemotherapy. Unfortunately, 2 months later she was found to have multiple liver metastases and has now been converted to second-line chemotherapy.The fourfold increase in risk of colorectal cancer in the series of patients with symptomatic prolapse presented by Rashid and Basson [4] provides a compelling argument for the routine preoperative assessment of these patients, and has indeed influenced routine practice in some colorectal units. Barium enema is likely to prove futile in these cases as the anal tone is decreased. Flexible sigmoidoscopy therefore offers the most useful screening. In view of our recent experiences, we would certainly concur that all patients with rectal...

In this small cohort of patients with R1 positive rectal cancers, response to NAC is the strongest predictor of poor overall and disease-free survival. In patients who respond to NAC, OS and DFS has been shown to be positive, with a reduced rate of EMV.

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