CORRESPONDENCE

A lowering in 4444 patients with coronary were rendered incurable because of

1·8 Non-haemorrhagic stroke heart disease: the Scandinavian Simvastatin
Haemorrhagic stroke biopsy track recurrence.5
1·6 Total stroke
Survival Study (4S). Lancet 1994; 344:
1·4 1383–89. To answer this question, which
1·2 could be relevant to prognosis, best
Fatal strokes/10 000 patient years

1·0 surgical practice, and medicolegal

0·8 considerations, a further large series of
0·6 patients with colorectal cancer is
0·4
Does biopsy before
necessary in which: (i) the tumour site
0·2 resection compromise is accurately located but not sampled;
0
prognosis in colorectal (ii) the tumour is resected with
B minimum handling, followed by
7 cancer? histological assessment and further
6 excision if necessary; and (iii) the basis
Sir—In P Rougier and colleagues’ trial
5 (June 6, p 1677)1 of 1235 patients with for inclusion in this trial should also be
4 colorectal cancer, 619 had resection of no distant metastases. A control series
3 the tumour only (controls) and the of patients with biopsy would not be
2 other 616 patients had resection plus necessary because the 1235 patients in
an infusion of fluoracil and heparin Rougier’s trial provide such a series
1
into the portal vein. The latter proved and the results are known. This
0 protocol may not be suitable for rectal
to have no significant effect on 3–5-
1 ·2 ·2 ·2 2 carcinoma since the surgical approach
4· –5 –6 –7 7· year survival, progression of disease, or
⬍ 1 3 3 ⬎ presence of metastases. The basis for can vary according to whether the
4· 5· 6·
Serum cholesterol (mmol/L) inclusion in the trial was “histological tumour is benign or malignant.
Relations between non-haemorrhagic, confirmation of resectable cancer of However, it may be possible to
haemorrhagic, and total fatal stroke and the colon or rectum without distant accumulate a sufficient number of
serum cholesterol in men without metastases”, implying that all, rectal-cancer patients, without biopsy
previous myocardial infarction or most tumours were sampled before excision, to see whether there is
(A) rates in men screened for MRFIT;3 (B) before being resected. Any any beneficial effect on patients’
predicted rates in survivors of myocardial effects resulting from the biopsy were outlook.
infarction with cholesterol/stroke relations not considered. The assumption that most of the
(without previous myocardial infarction) and
ratio of non-haemorrhagic/haemorrhagic
Colonoscopy and biopsy is now the tumours in this series were sampled
stroke after myocardial infarction recorded standard method for identifying bowel before resection may be incorrect
in MRFIT.3,4 cancer but there is a real risk that because randomisation occurred just
forcep biopsy of vascular tumour before or during the surgery, and it
the initial level of 6·7 mmol/L, is not tissue releases tumour cells into the was not stated how many patients were
surprising. venous circulation which then pass to diagnosed by colonoscopy and biopsy,
This interpretation of the evidence the liver via the portal vein. How often or by contrast radiology. The trend is
can also explain why substantial stroke this happens is not known; the for most bowel tumours to be
reduction was recorded in all three important question is, do preoperative diagnosed by colonoscopy and biopsy,
trials of statins for secondaty or operative biopsies compromise and, therefore, there is a need to
prevention, but not in two trials for outlook of patients with colorectal assess any possible adverse effect of
primary prevention. There is no need carcinoma? biopsy on the subsequent surgical
to search for mechanisms other than The liver is the main site of outcome.
cholesterol reduction to explain stroke haematogenous metastases in
prevention by statins. colorectal cancer; it is the only site in A D McCutcheon
30–40% of necropsy studies and it
28 Maitland Avenue, East Kew, Victoria,
carries a very poor prognosis.2 In a 3102, Australia
*E J Wallis, L E Ramsay, W W Yeo,
study of 109 patients with colorectal
P R Jackson
cancer,5 isolated tumour cells were 1 Rougier P, Sahmond T, Nitti D, et al.
Section of Clinical Pharmacology and
Therapeutics, Clinical Sciences Division found in the peritoneal cavity in 34 Adjuvant portal-vein infusion of fluoracil
(31%) and in bone marrow in 53 and heparin in colorectal cancer: a
(CSUH site), University of Sheffield, Royal
Hallamshire Hospital, Sheffield S10 2JF, UK randomised trial. Lancet 1998; 351:
(49%). The latter showed little 1677–81.
(e-mail: e.j.wallis@sheffield.ac.uk)
prognostic value and bone marrow 2 Daly JM, Kemeny Nancy E. Metastatic
1 Blauw GJ, Lagaay AM, Westendorp RGJ. metastases are rare in cancer of the cancer of the liver. In: De Vita Jr VT,
Statins for prevention of stroke. Lancet colon (an unsuitable environment?), Hellman S, Rosenberg SA, eds. Principles
1998; 352: 144. and practice of oncology, 5th edn. New
but the findings in the peritoneal
2 Fey RE. Statins for prevention of stroke. York: Lippincott-Raven, 1997: 2551.
Lancet 1998; 352: 144–45.
cavity correlated with 4-year survival.
3 Schott A, Vogel I, Krueger U, et al.
3 Iso H, Jacobs DR, Wentworth D, Neaton The investigators suggested that Isolated tumour cells are frequently
JD, Cohen JD, for the MRFIT Research tumour cells reach the peritoneum via detectable in the peritoneal cavity of gastric
Group. Serum cholesterol levels and six- pores and lymph channels;4 and this and colorectal cancer patients and serve as
year mortality from stroke in 350,977 men process could be accelerated by biopsy a new prognostic marker. Ann Surg 1998;
screened for the Multiple Risk Factor 227: 372–79.
Intervention Trial. N Engl J Med 1989;
trauma. There is a recent case report
4 Basha G, Ectors N, Penninckx F, Geboes
320: 904–10. of tumour-cell implantation in the K. Tumour cell implantation after
4 Neaton JD, Wentworth DN, Cutler J, rectal mucosa 12 cm proximal to a colonoscopy with biopsies in a patient with
Stamler J, Kuller L, for the Multiple Risk rectal adenocarcinoma after renal cancer: report of a case. Dis Colon
Factor Intervention Trial Research Group. colonoscopy and biopsy,4 and two Rectum 1997; 40: 1508–10.
Risk factors for death from different types 5 Jordan JL, Stubbs RS. Percutaneous
of stroke. Ann Epidemiol 1993; 3: 493–99.
cases of potentially resectable
biopsy of operable liver lesions; is it
5 Scandinavian Simvastatin Survival Study (curative) liver tumours, in which necessary or advisable? NZ Med J 1996;
Group. Randomised trial of cholesterol percutaneous liver biopsies were done, 109: 469–70.

910 THE LANCET • Vol 352 • September 12, 1998