Annals of Coloproctology

Volume 16(6); December 2000

Original Article

Clinical Significance of Cyclooxygenase-2 Expression in Colorectal Adenoma and Carcinoma.: Rhyou, Jai Hyun , Kim, Kwang Ho , Shim, Kang Sup , Koo, Hae Soo , Park, Eung Bum; J Korean Soc Coloproctol. 2000;16(6):351-355.

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Abstract PDF: PURPOSE
Interest is mounting in developing prevention strategies for patients at high risk of developing colorectal cancer. Recent epidemiological investigations indicate an inverse relationship between the intake of NSAIDs and colorectal cancer risk. Cyclooxygenase (COX) enzyme may be involved in the initiation and/or the promotion of carcinogenesis. A major action of NSAIDs is the inhibition of COX. We have studied the clinical significance of COX-2 expression in colorectal adenoma and carcinoma.
METHODS
We studied 19 patients with colorectal adenomas (15 males and 4 females: ages 30~73 years) and 20 patients with colorectal carcinoma (12 males and 8 females: ages 35~80 years). COX-2 status were determined by immunohistochemical methods using the mouse monocolnal antibody for COX-2 (Transduction Lab, USA) on paraffin sections.
RESULTS
Immunoreactive COX-2 were expressed in 9 patients (47%) of colorectal adenoma and 9 patients (45%) of colorectal carcinoma. 57% of villous adenoma and 42% of tubular adenoma were positive for COX-2 in colorectal adenoma (p=0.650). COX-2 were expressed in 12.5% of stage B and 73% of stage C of colorectal cancer (p=0.006). COX-2 expression did not relate with the size of adenoma and carcinoma.
CONCLUSIONS
The data suggest that COX-2 may be more expressed in villous adenoma and advanced carcinoma. Therefore, enhanced expression of COX-2 may play a role in the carcinogenesis of colorectal cancer.

Randomized Controlled Trials

Preventive Effects for Wound Infection of Intra-incisional Metronidazole Infiltration Preoperatively in Appendectomy.: Park, Bu Il , Kim, Byung Seok , Moon, Duk Jin , Park, Ju Sub; J Korean Soc Coloproctol. 2000;16(6):356-359.

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Abstract PDF: PURPOSE
The aim of this prospective study was to evaluate the effect of metronidazole for wound infection by using intra-incisional infiltration before appendectomy.
METHODS
From January to May 2000, 176 patients with acute appendicitis received appendectomy. All patients were randomly divided into two groups. Group I (n=50) was the treatment group and group II (n=126) was the control group. After anesthesizing the patients of group I, 7.5 mg/kg of metronidazole was injected into subcutaneous tissue and muscle. All patients of group I and II were given intravenous injection of cephalosporin and intravenous or intramuscular injection of aminoglycoside.
RESULTS
In the 50 cases of group I, the rate of wound infection was 2% and the rate of wound infection in the 126 cases of group II was 4.8%. The rate of anaerobic bacteria of organisms cultured from wound of patients with infection was 0% in group I and 33% in group II. The statistical analysis using chi-square test was not significant (p=0.676) but the rate of wound infection was reduced, especially in infection caused by anaerobic bacteria.
CONCLUSIONS
The rate of wound infection was not significant statistically but it was reduced after intra-incisional infiltration of metronidazole. Therefore we suggest that this method can be one of methods that reduce the rate of wound infection after appendectomy.

Topical Glyceryl Trinitrate (GTN) Versus Conservative Treatment (CT) in Chronic Anal Fissure: Prospective and Randomized Study.: Lee, Kwang Real , Cho, Kyung Ah , Hwang, Do Yeon , Kim, Kuhn Uk , Park, Weon Kap , Yoon, Seo Gu , Kim, Hyun Shig , Lee, Jong Kyun; J Korean Soc Coloproctol. 2000;16(6):360-364.

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Abstract PDF: PURPOSE
This study was designed to compare the effect of treatment using glyceryl trinitrate (GTN) ointment with that of conservative treatment (CT) on chronic anal fissure.
METHODS
As a preliminary study, maximal resting pressures of the anal canal were checked in 13 patients having chronic anal fissure before and 10 minutes after application of 0.2% GTN ointment. As the study groups, 59 patients having chronic anal fissure were randomly allocated to the GTN and the placebo groups. All the patients in both groups were given oral analgesics, sedatives, and bulk-forming agents. They had applied 0.2% GTN ointment or a placebo ointment three times a day to their perianal skin. Maximal resting pressures of the anal canal were checked at the beginning and at the endpoint of the treatment period which continued for 6 weeks. If there was complete healing of the fissure in the middle of the treatment, the treatment was stopped. Sixteen patients were lost during the study.
RESULTS
Among the rest, 22 and 21 patients were included in the GTN group and the placebo group, respectively. The maximal resting pressure decreased significantly in all groups (p<0.05). The healing rates, the recurrence rates, and the operation rates were not significantly different between the GTN group and placebo group (p>0.05).
CONCLUSION
The effect of GTN on the symptomatic relief and results of treatment in patients having chronic anal fissure is not superior to that of conservative treatment.

The Effects of Pudendal Block in Voiding Complication after Anal Surgery.: Kim, Jae Hwang , Jang, Seon Mo , Shim, Min Chul , Jee, Dae lim; J Korean Soc Coloproctol. 2000;16(6):365-370.

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Abstract PDF: Urinary retention in common benign anal surgery is a burden to ambulatory surgery. PURPOSE: To reduce voiding complication pudendal nerve block (PB) was applied in hemorrhoids surgery.
METHODS
We compared PB with spinal anesthesia (SA) for anal surgery. In this prospective study, 163 patients undergoing elective hemorrhoids surgery by single surgeon were randomized to receive either PB with 0.5% bupivacaine (n=81) with 1: 20,000 epinephrine or SA with 0.5% bupivacaine (n=83).
RESULTS
There were no statistically significant differences in patient demographics, total amount of administered fluid, time to onset of block, or intraoperative pain. All patients had a successful block for surgery however, puborectalis muscle relaxation with PB was not complete. The time from injection of the anesthetics to first development of pain was longer in the patients who received PB (9.1 vs 3.1h; P<0.001). Urinary catheterization needed in only 6 patients in PB group compared with 57 cases in SA group (p<0.001). Degree of pain was significantly low in PB (2.7 vs 5.2 with VAS; p<0.001) Injected analgesics was significantly reduced in PB (16/81 vs 45/82; p<0.001) CONCLUSIONS: Our results suggest that PB with bupivacaine results in fewer postoperative voiding complications and less pain compared with traditional SA in hemorrhoidectomy.

Effects of Intraoperative Injection of Tarasyn for Pain Relief on Patients Undergoing Hemorrhoidectomy: Result of a prospective, randomized trial.: Kim, Min Chan , Choi, Hong Jo; J Korean Soc Coloproctol. 2000;16(6):371-375.

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Abstract PDF: PURPOSE
The aim of this prospective study was to evaluate whether additional intraoperative injection of Tarasyn (ketorolac tromethamine) provided a preemptive analgesic effect that improved postoperative pain.
METHODS
Sixty patients scheduled for hemorrhoidectomy were randomly assigned to the study and control groups. For the control group (n=32), patients were treated with standard intravenous injections of Nubain (Nalbuphine hydrochloride; Jeil Pharmaceuticals Co, Seoul) per 8 hours for three times postoperatively for pain relief. In the study group (Tarasyn group, n=28), 60 mg of Tarasyn (ketorolac tromethamine; Roche Korea, Seoul) was injected into the internal sphincter muscle and around the operative wound at the time of hemorrhoidectomy as well as standard intravenous injections of Nubain . Parameters were measured of pain score from 0 (no pain) to 10 (agonizing pain), painless sound sleep, additional analgesic requirements, time to first bowel movement, and postoperative urinary retention.
RESULTS
Rate of painless sound sleep was 75.0% and 53.1% in the Tarasyn and the control groups, respectively, which was significant statically between two groups (P<0.05). Time to first bowel movement was 2 and 3.2 days in Tarasyn and the control groups, respectively, which was also significant statistically (P<0.05). Voiding difficulty developed in one case (3.5%) in the Tarasyn group and he needed catheterization. In the control group, however, the number (15 cases, 46.9%; P<0.001) was much higher requiring more catherization (13 cases, 40.9%; P<0.001). Mean pain scores was significant statically between two groups (P<0.001).
CONCLUSION
The data suggest that the use of intraoperative injection of Tarasyn is associated with a significant decrease in pain and urinary complications after hemorrhoidectomy.

Original Articles

Usefulness of Manometry in Anorectal Diseases.: Kim, Chang Nam , Park, Sang Kyu , Kim, Sook Young , Yu, Chang Sik , Kim, Jin Cheon; J Korean Soc Coloproctol. 2000;16(6):376-382.

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Abstract PDF: PURPOSE
Anorectal manometry is an objective means of assessing the anorectal function through the anorectal sphincter muscles. The purpose of this study was to assess the usefulness of anorectal manometry.
METHODS
Manometric findings of 1145 patients with anorectal diseases were analyzed.
RESULTS
In hemorrhoids, the maximum resting pressure (MRP) was significantly decreased postoperatively (P<0.05), and the maximum squeezing pressure (MSP) was decreased postoperatively. The MRP was increased in hemorrhoids, internal sphincter hypertonia, and chronic anal fissure (CAF). The MRP and MSP were significantly decreased in CAF, anal fistula, and anal stricture postoperatively (P<0.05). In anal fistula, the high pressure zone length and sphincter length were significantly decreased postoperatively (P<0.05), and the vector symmetric index was decreased to 0.79 postoperatively. Fourteen of the 57 patients with fecal incontinence did not show rectoanal inhibitory reflex (RAIR). In 22 of the 25 patients were clinically suspected of congenital megacolon (CMC), unnecessary surgery was avoided with RAIR. Twelve of the 15 patients with CMC, who had undergone surgery, showed the RAIR. In patients treated by total proctocolectomy (TPC) with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) and familial adenomatous polyposis (FAP), the MRP and MSP were decreased postoperatively, and the sensation of fullness (SOF) was significantly decreased postoperatively (P<0.05). In patients with rectal cancer treated by low anterior resection, the MRP, MSP, SOF, and compliance were significantly decreased until 12 months postoperatively (P<0.05).
CONCLUSIONS
Manometry appears to be an important tool to evaluate anorectal function that enables adequate surgery or treatment for the most of anorectal diseases. Furthermore, it is a valuable tool in assessing functional recovery after surgeries associated with a sphincter injury.

Mechanical Bowel Preparation for Elective Colorectal Surgery: A Prospective Randomized Study Comparing Two Liters and Four Liters of Polyethylene Glycol-Based Oral Lavage Solutions.: Cho, Shin Il , Yun, Seong Hyun , Park, Jae Kun , Kim, Nam Kyu , Sohn, Seung Kook , Min, Jin Sik; J Korean Soc Coloproctol. 2000;16(6):383-387.

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Abstract PDF: PURPOSE
This study was undertaken to determine whether a mechanical bowel preparation with 2 liters polyethylene glycol solution combined with a Bisacodyl 20 mg (Group II) increases the acceptability of bowel preparation and reduces discomfort compared with 4 liters of polyethylene glycol solution (Group I).
METHODS
We conducted a prospective randomized single-blinded study. Eighty patients undergoing an elective colorectal surgery in Severance hospital from April 1999 to September 1999 were included in this study. The patients' tolerance, cleansing ability and surgeon's satisfaction were assessed by a structured questionnaire. Postoperative complications were also evaluated.
RESULTS
The patients' tolerance of the group II (2 liters polyethylene glycol solution combined with a Bisacodyl 20 mg) was better than that of the groups I (4 liters of polyethylene glycol solution). The cleaning ability and surgeon's satisfaction were not different between two groups (p=0.225, p=0.322). The incidence of postoperative complications was 2.3 percent in Group I and 2.7 percent in Group II.
CONCLUSIONS
The mechanical bowel preparation with two liters of polyethylene glycol solution with a Bisacodyl 20 mg was more comfortable to patients and equally efficient compared with the mechanical bowel preparation with the 4 liters of polyethylene glycol solution regimen before elective colorectal surgery.

The Comparison between Transanal and Transvaginal Ultrasonography of Anal Sphincter in Normal Women.: Moon, Seong Pyo , Park, Sang Heon , Kim, Cheong Yong , Byun, Joo Nam; J Korean Soc Coloproctol. 2000;16(6):388-390.

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Abstract PDF: PURPOSE
The purpose of this study was to evaluate the normal value of the anal canal structures by transvaginal sonography in normal woman and compare this technique with the more commonly used transanal technique.
METHODS
Transvaginal ultrasonography was performed in 25 parous patients between 4th and 8th decade of age, using a Bruel and Kajer type-1890. This procedure was followed by transanal sonography using the same system. The thickness of mucosa and submucosa, internal and external anal sphincter and puborectalis muscle were measured by both methods.
RESULTS
The thickness of mucosa- submucosa, internal anal sphincter, external anal sphincter and puborectalis muscle by transvaginal sonography were 2.84 0.2 (2.6~3.0) mm, 2.98 0.4 (2.6~3.3) mm, 7.4 0.3 (7.1~7.7) mm, 7.5 0.5 (7.4~7.6) mm respectively(mean value standard deviation and range). The detection rate of external anal sphincter and puborectalis muscle by transvaginal sonography were between 55.5% (5/9) and 71.4% (5/7).
CONCLUSIONS
The thickness of internal anal sphincter was increased with age(p<0.05). The thickness of mucosa-submucosa, internal anal sphincter measured.

Clinical Results of Subtotal Colectomy in Chronic Constipation Patients.: Nam, Kee Hyun , Sohn, Seung Kook; J Korean Soc Coloproctol. 2000;16(6):395-401.

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Abstract PDF: PURPOSE
The aim of this study was to assess the outcome of subtotal colectomy on patients with a diagnosis of chronic constipation.
METHODS
A retrospective review of 11 consecutive patients who underwent subtotal colectomy between January 1990 and July 1999 was undertaken. Preoperative testings included complete history and physical examination, anorectal manometry, videodefecography, and colonic transit studies.
RESULTS
The 11 patients consisted of 5 men and 6 women, with a mean age of 44 (range, 25~62) years. The most common symptom was inability to defecation and mean duration of this symptom was 13.6 (range, 0.75~45) years. Ten patients had slow colon transit and one patient had normal colon transit with anismus. All patients were followed up for mean duration of 33 (range, 5~120) months. Mean bowel frequency was 4 times per day after colectomy. Nine patients were satisfied with the results of surgery and showed improvement in quality of life. One patient was less satisfied due to diarrhea even with several times bowel movement per day. One patient felt that the operation was not so effective due to incontinence for liquid stool and 7 bowel movement per day. Three patients frequently used antidiarrheal medication after surgery. Three patients had postoperative small bowel obstruction and were treated without surgery.
CONCLUSION
Subtotal colectomy with ileorectal anastomosis produces a satisfactory functional outcome in the majority of patients with proven slow transit constipation.

Association between Poor Bowel Habit and Non-Relaxing Puborectalis Syndrome.: Kim, Tae Hyeon , Choi, Suck Chei , Nah, Yong Ho; J Korean Soc Coloproctol. 2000;16(6):402-406.

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Abstract PDF: PURPOSE
Constipation in children usually is due to poor bowel habit. Ignoring the urge to have a bowel movements initiates a viscious cycle of constipation. After a period of time children may stop feeling the urge, leading to fecal impaction. This leads to loss of anorectal reflex. What is the outcome of the children with long-standing poor bowel habit? METHODS: Forty-two patients with obstructed defecation (non-relaxing puborectalis syndrome) diagnosed by defecogram and anorectal manometry were investigated with rectal sensation and elasticity studies (threshold of sense: TS, defecation sensation volume: DS, maximal tolerable volume: MTV, rectal compliance: RC), and colon transit time (CTT). All detailed questionnaires on the subject were completed. Eighteen patients (11F: 7M, mean age 39 years, range 16~75) with history of poor bowel habits since childhood were compared with 24 (16F: 8M, mean age 40 years, range 16~31) with no history of poor bowel habit.
RESULTS
Studies of colonic transit time demonstrated no significant difference in the right and left colon between two groups, but the rectosigmoid transit time in the poor bowel habits group was more increased than in the normal bowel habit group (P<0.05). The rectal wall compliance was increased in the poor bowel habit group as compared to the normal bowel habits group (P<0.01). Maximal tolerable volume and defecation sensation volume were greater in the poor bowel habits group than in the control group (P<0.01), but there was no significant difference in the threshold of sense between two groups.
CONCLUSIONS
Prolonged poor bowel habit in childhood period leads to loss of rectal sensation, and provide an explanation for one of the pathophysiologic mechanism of non-relaxing puborectalis syndrome.

Results of Delorme's Procedure for Rectal Prolapse.: Byun, Sung Whan , Kim, Han Sun; J Korean Soc Coloproctol. 2000;16(6):407-414.

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Abstract PDF: PURPOSE
This retrospective study was designed to review and analyze the results of Delorme's procedure for rectal prolapse.
METHODS
Between 1990 and 1999, twenty-nine patients with rectal prolapse underwent Delorme's procedure. These patients had had no previous operation for rectal prolapse. This study was proceeded retrospectively through the out-patient clinic and by telephone questionnare.
RESULTS
Twelve cases (41%) were males and 17 cases (59%) were females. Mean age was 55.5 years (range, 23~86 years). The duration of the symptoms was ranged from 3 months to 60 years, with the mean period of 12.2 years. The follow-up period after the operation was from 3 months to 10 years (mean follow-up, 45 months). The internal rectal prolapses were 11 cases (38%), and the complete rectal prolapses were 18 cases (62%). The common preoperative bowel habits were incontinence with 6 cases (21%) and constipation with 10 cases (34%). After the operation, incontinence and constipation were improved in 4 cases (67%) and 6 cases (60%) respectively. Additional 2 cases of constipation occurred among 19 cases who hadn't had it preoperatively but the use of laxative helped in improving the symptom. The mean operation time was 71 minutes and in 24 cases (83%), the operation was proceeded with spinal anesthesia. In 27 cases (93%), the amount of bleeding during the operation was less than 100 cc, and in 1 case (3.4%), blood transfusion was needed because the amount was more than 400 cc. The three patients (10%) had postoperative complications(one perianal abscess due to anastomotic dehiscence and two urinary retention). There was one case of recurrence (3.4%) after the operation and no postoperative mortality.
CONCLUSIONS
Delorme's procedure has the short operation time, causes less bleeding and is possible with regional anesthesia. Delorme's procedure has low complication rate, results in good bowel function and has a low recurrence rate. Therefore, Delorme's procedure can be performed with satisfactory outcome in elderly patients and the poor general conditioned patients as well as younger patients. As recurrence rates is low and continence is improved, this procedure may be the preferred initial treatment of all patients with rectal prolapse.

Surgical Treatment of Crohn's Disease.: Kim, Jong Kwan , Lee, Jae Gil , Byun, Chang Gyoo , Sohn, Seung Kook , Kim, Nam Kyu , Min, Jin Sik; J Korean Soc Coloproctol. 2000;16(6):415-422.

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Abstract PDF: PURPOSE
This study was undertaken to investigate the preoperative diagnosis, indication for operation, postoperative complication, postoperative medical treatment and recurrence rate in patients with Crohn's disease who were treated with operation.
METHODS
Forty patients with Crohn's diseases had been operated on at the Department of Surgery, Yonsei University College of Medicine during the period from Jan 1986 to May 1999 and they were reviewed retrospectively. We studies symptoms, surgical indications, preoperative and postoperative treatments, involvement sites, types of operation and recurrence rate in Crohn's disease.
RESULTS
The male to female ratio was 1.5: 1, and age distribution was from 8 to 69 years old with mean age of 33 years old. The duration of symptoms varies from within 1 day to above 10 years and most of them had within 1 month as 17 cases (42.5%). Symptoms are abdominal pain, hematochezia, anorexia, abdominal mass and diarrhea. The most frequent symptom was the abdominal pain as 85%. Crohn's disease was diagnosed only 45% before operation, less than what we expected. In another hand it surprised us find out that tuberculosis enteritis was diagnosed as much as 20%. The most common indication of operation was medical treatment failure as 13 cases, and fistula was 7 cases, intestinal obstruction with stenosis and tumor were 6 cases each other. The involvement of small bowel was most common as 40%, and the most common operative findings were ulceration and fistula for 17 cases and 12 cases respectively. Small bowel cases were treated with segmental resection and anastomosis in all 16 cases. Large bowel cases were performed right hemicolectomy in 10 cases and total colectomy in 1 case. Both small and large bowel involvement cases, right hemicolectomy was done in 4 cases, right hemicolectomy and segmental resection of small bowel was done in 6 cases. The recurrence rate of postoperative medical treatment was 16% and 28% for 5 years and 10 years respectively. The recurrence rate with no postoperative medical treatment was 13% and 26% for each 5 years and 10 years. There was no significantly difference in both groups.
CONCLUSION
The major surgical indications for Crohn's disease were medical treatment failure, fistula and intestinal obstruction. Specially in Korea, differential diagnosis with tuberculosis enteritis was very important. Postoperative complication and recurrence rate has relatively low incidence. Our study suggest that postoperative medical treatment was controversial.

Analysis of the Risk Factors in Colorectal Injuries.: Yeo, Jun Hee , Jeon, Goan Hee , Lee, Tae Hoon , Kim, Jong Hun; J Korean Soc Coloproctol. 2000;16(6):423-428.

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Abstract PDF: PURPOSE
To evaluate factors that influence morbidity and mortality in colorectal injuries.
METHODS
We reviewed the medical records of 59 patients who underwent emergency operation in JNUH from Jan. 1988 through Dec. 1997. Univariate and multivariate analyses were used to calculate the prognostic significance of the following variables: sex, age, time to operation, preoperative shock, penetrating abdominal trauma index (PATI), APACHE II score, site of injury, organ injury scale (OIS), Flint grade, associated intraabdominal injuries, the sum of transfusion during 48hours of preoperative and postoperative period and operative method.
RESULTS
Univariate analysis showed that colorectal organ iujury scale, and operative method were related to the complication, and preoperative shock, APACHE II score, PATI, and transfusion in 48hrs of injury were related to the mortality of colorectal injury. Multivariate logistic regression analysis showed that colorectal organ injury scale (2 vs 1) was significant risk factor in the development of complication, and the odds ratios were 5.0 and 1.69 respectively. The sum of transfusion in 48hours of injury was a only significant risk factor in the mortality and the odds ratio was 1.5.
CONCLUSIONS
We concluded that preoperative condition was very important and preservation of hemodynamic stability was critical in improvement of prognosis. We also concluded that the shortening of operative time and proper management of associated injury may reduce the development of complication and even death.

Closure of the Colostomy.: Cha, Su Ho , Kim, Byung Seok , Moon, Duk Jin , Park, Ju Sub; J Korean Soc Coloproctol. 2000;16(6):429-435.

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Abstract PDF: PURPOSE
To investigate the timing of colostomy closure and the associated risk factors that affect the development of complication after colostomy closure.
METHODS
We have reviewed and analyzed the results of 28 patients with colostomy closure at the Kwangju Christian Hospital from January 1993 to December 1997. We investigated to associated literatures on this subject for timing of colostomy closure, preparing a patient for colostomy closure, suture technique, wound management, underlying disease process related to the incidence of complication and experience of surgeons.
RESULT
Wound infection developed in 4 patients (14.4%). Anastomotic leakage occurred in one patient (3.6%). Small bowel obstruction developed in two patients (7.2%). Overall incidence of complication was 25%. The incidence of complications in patients with trauma who underwent colostomy was 44.4% and patients without trauma, 15.8%. Complication rate was 16.6% for loop colostomies and 40% for end colostomies. The morbidity was 40% for colostomies on the left side, 18.7% for transverse colostomies, and 0% for colostomies (2 ileostomies) on the right side. The morbidity rate for closures within 6 weeks for the initial operation was 50%; for those within 6 to 12 weeks, 8.3%; and for those after 12 weeks, 16.6%.
CONCLUSION
The optimal timing of closure varies from patient to patient, but closure within 6 weeks of the initial operation significantly increased the morbidity. Colostomies on the left side are associated with a higher morbidity rate than transverse colostomies or colostomies on the right side.

p53, Bcl-2 and Ki-67 Expression according to Tumor Response after Concurrent Chemoradiation Treatment for Advanced Rectal Cancer.: Kim, Nam Kyu , Park, Jae Kyun , Yang, Woo Ik , Yun, Seong Hyeon , Sung, Jin Sil , Min, Jin Sik; J Korean Soc Coloproctol. 2000;16(6):436-443.

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Abstract PDF: PURPOSE
Concurrent chemoradiation treatment (CCRT) for locally advanced rectal cancer is an important modality for curative resection, but its tumor response shows wide spectrum. The aim of study is to investigate any correlation between a related genetic mutations, proliferative index and tumor response after CCRT.
METHODS
A twenty three patients with rectal cancer, which preoperatively staged as over T3N1 or T4 determined by transrectal ultrasonography and MRI. Enrolled patients were given 5 FU 450 mg/m2 and leucovorin 20 mg/m2 intravenously for 5 days during the first and fifth weeks of radiation therapy (45~54 Gy). 4 weeks after completion of scheduled treatment, surgical resection was performed. Tumor response was classified into CR (complete remission), PR (partial response: 50% of diminution of tumor volume and downstaging), NR (no response). Paraffin-embedded tissues obtained before chemoradiation treatment were studied with immunohistochemical staining of p53, Bcl-2 and Ki-67. The extent of tumor response was correlated with proliferative activity as measured by immunostaining of Ki-67 proliferative antigen and expression of p53 and bcl-2 oncoproteins (less than 10%: negative, 10~25%: , 25~50%: , more than 50%: , Ki-67: to count a labeled cells per 1,000 cells).
RESULTS
All patients were resectable. CR was obtained in 4 (17.4%), PR in 10 (43.3%) and NR in 9 (39.2%). p53 mutation was noted in 16 (70%). p53 mutation was found in NR: 5 (31.3%), PR: 9 (56.2%), CR: 2 (12.5%), respectively. Bcl-2 expression was noted in 11 (48%). NR as in 4 (36.3%), PR: 3 (28.4%) and CR: 4 (36.3%), respectively. Ki-67 labeling index was NR: 615.4 446.2, PR: 663.2 296.4, CR: 765.5 188.3, respectively (CR PR Vs NR, p=0.029).
CONCLUSIONS
Immunohistochemical Expression of p53 and bcl-2 does not correlate with tumor response after CCRT, but Ki-67 labeling may be useful parameters for good radiosensitive tumor selected for CCRT.

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