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Smart CJ, Korsgen S, Hill J, Speake D, Levy B, Steward M, Geh JI, Robinson J, Sebag-Montefiore D, Bach SP. Multicentre study of short-course radiotherapy and transanal endoscopic microsurgery for early rectal cancer. Br J Surg 2016; 103:1069-75. [DOI: 10.1002/bjs.10171] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 02/17/2016] [Accepted: 02/18/2016] [Indexed: 12/13/2022]
Abstract
Abstract
Background
Organ-preserving treatment for early-stage rectal cancer may avoid the substantial perioperative morbidity and functional sequelae associated with total mesorectal excision (TME). The initial results of an organ-preserving approach using preoperative short-course radiotherapy (SCRT) and transanal endoscopic microsurgery (TEMS) are presented.
Methods
Patients with cT1–2N0 rectal cancers staged using high-quality MRI and endorectal ultrasonography received SCRT, with TEMS 8–10 weeks later, at four regional referral centres between 2007 and 2013. Patients were generally considered high risk for TME surgery (a small number refused TME).
Results
Following SCRT and TEMS, 60 (97 per cent) of 62 patients had an R0 resection. Histopathological staging identified 20 ypT0 tumours, 23 ypT1, 18 ypT2 and one ypT3. Preoperative uT category was significantly associated with a complete pathological response, which was achieved in 13 of 27 patients with uT0/uT1 disease and in five of 29 with uT2 (P = 0·010). Acute complications affected 19 patients, the majority following TEMS. No fistulas occurred and no stomas were formed. Surveillance detected four intraluminal local recurrences at a median follow-up of 13 months, all in patients with tumours staged as ypT2. Salvage TME achieved R0 resection in three patients and a stent was placed in one patient owing to co-morbidities.
Conclusion
SCRT with TEMS was effective in the majority of patients considered high risk for (or who refused) TME surgery.
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Affiliation(s)
- C J Smart
- Department of Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - S Korsgen
- Department of Surgery, Good Hope Hospital, Sutton Coldfield, UK
| | - J Hill
- Department of Surgery, Manchester Royal Infirmary, Manchester, UK
| | - D Speake
- Department of Surgery, Western General Hospital, Edinburgh, UK
| | - B Levy
- Department of Surgery, St Richard's Hospital, Chichester, UK
| | - M Steward
- Department of Surgery, Bradford Royal Infirmary, Bradford, UK
| | - J I Geh
- Department of Clinical Oncology, Queen Elizabeth Hospital, Birmingham, UK
| | - J Robinson
- Department of Surgery, Bradford Royal Infirmary, Bradford, UK
| | | | - S P Bach
- Department of Surgery, Queen Elizabeth Hospital, Birmingham, UK
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52
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Mukkai Krishnamurty D, Wise PE. Importance of surgical margins in rectal cancer. J Surg Oncol 2016; 113:323-32. [DOI: 10.1002/jso.24136] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 11/18/2015] [Indexed: 12/14/2022]
Affiliation(s)
- Devi Mukkai Krishnamurty
- Section of Colon and Rectal Surgery; Washington University School of Medicine in St. Louis; St. Louis Missouri
| | - Paul E. Wise
- Section of Colon and Rectal Surgery; Washington University School of Medicine in St. Louis; St. Louis Missouri
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Xynos E, Tekkis P, Gouvas N, Vini L, Chrysou E, Tzardi M, Vassiliou V, Boukovinas I, Agalianos C, Androulakis N, Athanasiadis A, Christodoulou C, Dervenis C, Emmanouilidis C, Georgiou P, Katopodi O, Kountourakis P, Makatsoris T, Papakostas P, Papamichael D, Pechlivanides G, Pentheroudakis G, Pilpilidis I, Sgouros J, Triantopoulou C, Xynogalos S, Karachaliou N, Ziras N, Zoras O, Souglakos J. Clinical practice guidelines for the surgical treatment of rectal cancer: a consensus statement of the Hellenic Society of Medical Oncologists (HeSMO). Ann Gastroenterol 2016; 29:103-26. [PMID: 27064746 PMCID: PMC4805730 DOI: 10.20524/aog.2016.0003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
In rectal cancer management, accurate staging by magnetic resonance imaging, neo-adjuvant treatment with the use of radiotherapy, and total mesorectal excision have resulted in remarkable improvement in the oncological outcomes. However, there is substantial discrepancy in the therapeutic approach and failure to adhere to international guidelines among different Greek-Cypriot hospitals. The present guidelines aim to aid the multidisciplinary management of rectal cancer, considering both the local special characteristics of our healthcare system and the international relevant agreements (ESMO, EURECCA). Following background discussion and online communication sessions for feedback among the members of an executive team, a consensus rectal cancer management was obtained. Statements were subjected to the Delphi methodology voting system on two rounds to achieve further consensus by invited multidisciplinary international experts on colorectal cancer. Statements were considered of high, moderate or low consensus if they were voted by ≥80%, 60-80%, or <60%, respectively; those obtaining a low consensus level after both voting rounds were rejected. One hundred and two statements were developed and voted by 100 experts. The mean rate of abstention per statement was 12.5% (range: 2-45%). In the end of the process, all statements achieved a high consensus. Guidelines and algorithms of diagnosis and treatment were proposed. The importance of centralization, care by a multidisciplinary team, adherence to guidelines, and personalization is emphasized.
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Affiliation(s)
- Evaghelos Xynos
- General Surgery, InterClinic Hospital of Heraklion, Greece (Evangelos Xynos)
| | - Paris Tekkis
- Colorectal Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK (Paris Tekkis, Panagiotis Georgiou)
| | - Nikolaos Gouvas
- General Surgery, Metropolitan Hospital of Piraeus, Greece (Nikolaos Gouvas)
| | - Louiza Vini
- Radiation Oncology, Iatriko Center of Athens, Greece (Louza Vini)
| | - Evangelia Chrysou
- Radiology, University Hospital of Heraklion, Greece (Evangelia Chrysou)
| | - Maria Tzardi
- Pathology, University Hospital of Heraklion, Greece (Maria Tzardi)
| | - Vassilis Vassiliou
- Radiation Oncology, Oncology Center of Bank of Cyprus, Nicosia, Cyprus (Vassilis Vassiliou)
| | - Ioannis Boukovinas
- Medical Oncology, Bioclinic of Thessaloniki, Greece (Ioannis Boukovinas)
| | - Christos Agalianos
- General Surgery, Athens Naval & Veterans Hospital, Greece (Christos Agalianos, George Pechlivanides)
| | - Nikolaos Androulakis
- Medical Oncology, Venizeleion Hospital of Heraklion, Greece (Nikolaos Androulakis)
| | | | | | - Christos Dervenis
- General Surgery, Konstantopouleio Hospital of Athens, Greece (Christos Dervenis)
| | - Christos Emmanouilidis
- Medical Oncology, Interbalkan Medical Center, Thessaloniki, Greece (Christos Emmanouilidis)
| | - Panagiotis Georgiou
- Colorectal Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK (Paris Tekkis, Panagiotis Georgiou)
| | - Ourania Katopodi
- Medical Oncology, Iaso General Hospital, Athens, Greece (Ourania Katopodi)
| | - Panteleimon Kountourakis
- Medical Oncology, Oncology Center of Bank of Cyprus, Nicosia, Cyprus (Panteleimon Kountourakis, Demetris Papamichael)
| | - Thomas Makatsoris
- Medical Oncology, University Hospital of Patras, Greece (Thomas Makatsoris)
| | - Pavlos Papakostas
- Medical Oncology, Ippokrateion Hospital of Athens, Greece (Pavlos Papakostas)
| | - Demetris Papamichael
- Medical Oncology, Oncology Center of Bank of Cyprus, Nicosia, Cyprus (Panteleimon Kountourakis, Demetris Papamichael)
| | - George Pechlivanides
- General Surgery, Athens Naval & Veterans Hospital, Greece (Christos Agalianos, George Pechlivanides)
| | | | - Ioannis Pilpilidis
- Gastroenterology, Theageneion Cancer Hospital, Thessaloniki, Greece (Ioannis Pilpilidis)
| | - Joseph Sgouros
- Medical Oncology, Agioi Anargyroi Hospital of Athens, Greece (Joseph Sgouros)
| | | | - Spyridon Xynogalos
- Medical Oncology, George Gennimatas General Hospital, Athens, Greece (Spyridon Xynogalos)
| | - Niki Karachaliou
- Medical Oncology, Dexeus University Institute, Barcelona, Spain (Niki Karachaliou)
| | - Nikolaos Ziras
- Medical Oncology, Metaxas Cancer Hospital, Piraeus, Greece (Nikolaos Ziras)
| | - Odysseas Zoras
- General Surgery, University Hospital of Heraklion, Greece (Odysseas Zoras)
| | - John Souglakos
- Medical Oncology, University Hospital of Heraklion, Greece (John Souglakos)
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Allaix ME, Arezzo A, Morino M. Transanal endoscopic microsurgery for rectal cancer: T1 and beyond? An evidence-based review. Surg Endosc 2016; 30:4841-4852. [DOI: 10.1007/s00464-016-4818-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 02/04/2016] [Indexed: 12/17/2022]
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55
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Lefevre JH, Benoist S. Controversies in the management of rectal cancer. A survey of French surgeons, oncologists and radiotherapists. Colorectal Dis 2016; 18:128-34. [PMID: 26679469 DOI: 10.1111/codi.13240] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 12/11/2015] [Indexed: 02/08/2023]
Affiliation(s)
- J H Lefevre
- Department of General and Digestive Surgery, Hôpital Saint Antoine (AP-HP), Paris VI University, Paris, France
| | - S Benoist
- Department of General and Digestive Surgery, Hôpital Kremlin-Bicetre (AP-HP), Paris XI University, Paris, France
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56
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Local Failure After Conservative Treatment of Rectal Cancer. Updates Surg 2016. [DOI: 10.1007/978-88-470-5767-8_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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57
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Gérard JP, Doyen J, Barbet N. New Neoadjuvant Treatment Strategies for Non-Metastatic Rectal Cancer (M0). CURRENT COLORECTAL CANCER REPORTS 2015. [DOI: 10.1007/s11888-015-0287-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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58
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García-Flórez LJ, Otero-Díez JL. Local excision by transanal endoscopic surgery. World J Gastroenterol 2015; 21:9286-9296. [PMID: 26309355 PMCID: PMC4541381 DOI: 10.3748/wjg.v21.i31.9286] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 05/10/2015] [Accepted: 07/03/2015] [Indexed: 02/06/2023] Open
Abstract
Transanal endoscopic surgery (TES) consists of a series of anorectal surgical procedures using different devices that are introduced into the anal canal. TES has been developed significantly since it was first used in the 1980s. The key point for the success of these techniques is how accurately patients are selected. The main indication was the resection of endoscopically unresectable adenomas. In recent years, these techniques have become more widespread which has allowed them to be applied in conservative rectal procedures for both benign diseases and selected cases of rectal cancer. For more advanced rectal cancers it should be considered palliative or, in some controlled trials, experimental. The role of newer endoscopic techniques available has not yet been defined. TES may allow for new strategies in the treatment of rectal pathology, like transanal natural orifice transluminal endoscopic surgery or total mesorectal excision.
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59
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Current status of local treatment for early rectal cancer in Japan: a questionnaire survey by the 81st Congress of the Japanese Society for Cancer of the Colon and Rectum (JSCCR) in 2014. Int J Clin Oncol 2015; 21:320-328. [PMID: 26266639 DOI: 10.1007/s10147-015-0882-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 07/24/2015] [Indexed: 01/24/2023]
Abstract
PURPOSE The aim of this questionnaire survey was to assess the change in treatment modality over time and the current status of clinical outcomes of local treatment in Japanese patients with pathological T1 (pT1) rectal tumors. METHODS A questionnaire survey was conducted by the 81st Congress of the Japan Society for Cancer of the Colon and Rectum. Clinical and pathological outcomes of all eligible patients undergoing local treatment were retrospectively collected from the medical records of each participating hospital. RESULTS A total of 1371 pT1 patients from January 2006 to December 2008 (Period A), and 659 patients in 2013 (Period B) were registered. Approximately 70 % of patients underwent radical surgery in both periods. The rate of patients undergoing laparoscopic surgery increased from 46.5 % in Period A to 84.7 % in Period B. The indications for local excision were comparable with those for endoscopic intervention in 78 % of institutions. The rate of endoscopic submucosal dissection (ESD) increased from 20.1 % in Period A to 37.9 % in Period B, whereas local excision decreased from 36.9 to 24.1 %. Few patients received adjuvant therapy, and approximately 40 % of patients underwent additional surgery in both periods. Local recurrence was observed in 9.2 % of patients in Period A, with the median follow-up period being 59 months. Eighty-two percent of patients with local recurrence underwent salvage surgery. CONCLUSIONS Local treatment with various modalities was properly performed for early rectal cancer. The number of less invasive modalities, such as laparoscopic surgery and ESD, increased between study periods.
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60
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Putte DV, Nieuwenhove YV, Willaert W, Pattyn P, Ceelen W. Organ preservation in rectal cancer: current status and future perspectives. COLORECTAL CANCER 2015. [DOI: 10.2217/crc.15.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
With the introduction of population screening initiatives, more patients may be amenable to local, transanal excision (LE) of early-stage rectal cancer. The most important drawback of LE is the risk of understaging node-positive disease. The most powerful predictors of node-positive disease are lymphatic invasion, submucosal invasion depth and width, tumor budding and poor differentiation. Therefore, LE should be reserved for low-risk T1 tumors in those reluctant or unable to undergo major surgery. Neoadjuvant chemoradiation followed by LE for T2 tumors allows adequate local control, and is currently being compared with anterior resection alone in randomized trials. A mere watchful waiting approach has been proposed in clinical complete responders to chemoradiation. However, given the very poor accuracy of current imaging modalities to predict a true pathological complete response, this strategy should not be offered outside of well-controlled trials.
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Affiliation(s)
- Dirk Vande Putte
- Department of Gastrointestinal Surgery, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium
| | - Yves Van Nieuwenhove
- Department of Gastrointestinal Surgery, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium
| | - Wouter Willaert
- Department of Gastrointestinal Surgery, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium
| | - Piet Pattyn
- Department of Gastrointestinal Surgery, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium
| | - Wim Ceelen
- Department of Gastrointestinal Surgery, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium
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61
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Kotake K, Kobayashi H, Asano M, Ozawa H, Sugihara K. Influence of extent of lymph node dissection on survival for patients with pT2 colon cancer. Int J Colorectal Dis 2015; 30:813-20. [PMID: 25808013 DOI: 10.1007/s00384-015-2194-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/11/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE The optimal extent of lymph node dissection for early-stage colon cancer (CC) remains undefined. This study assessed the influence of the extent of lymph node dissection on overall survival (OS) in patients with pT2 CC. METHODS We retrospectively examined data from the multi-institutional registry system of the Japanese Society for Cancer of the Colon and Rectum and used a propensity score matching method to balance potential confounders of lymph node dissection. We extracted 463 matched pairs from 1433 patients who underwent major resections for pT2 CC between 1995 and 2004. RESULTS Lymph node metastasis was found in 301 (21.0%) of 1433 patients with pT2 CC. In this cohort, significant independent risk factors for lymph node metastasis were lymphatic invasion and venous invasion. Patients who underwent D3 or D2 lymph node dissection did not significantly differ in OS, either among the propensity score-matched cohort (estimated hazard ratio [HR] 0.85, 95% confidence interval [CI] 0.536-1.346, P = 0.484) or in the cohort as a whole (HR 0.720, 95% CI 0.492-1.052, P = 0.089). CONCLUSIONS For patients with pT2 CC, D3 lymph node dissection did not add to OS. D2 lymph node dissection may be adequate for pT2 CC.
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Affiliation(s)
- Kenjiro Kotake
- Department of Colorectal Surgery, Tochigi Cancer Center, 4-9-13 Yohnan, Utsunomiya, Tochigi, 320-0834, Japan,
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62
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Verseveld M, de Graaf EJR, Verhoef C, van Meerten E, Punt CJA, de Hingh IHJT, Nagtegaal ID, Nuyttens JJME, Marijnen CAM, de Wilt JHW. Chemoradiation therapy for rectal cancer in the distal rectum followed by organ-sparing transanal endoscopic microsurgery (CARTS study). Br J Surg 2015; 102:853-60. [PMID: 25847025 DOI: 10.1002/bjs.9809] [Citation(s) in RCA: 137] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2014] [Revised: 02/15/2015] [Accepted: 02/18/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND This prospective multicentre study was performed to quantify the number of patients with minimal residual disease (ypT0-1) after neoadjuvant chemoradiotherapy and transanal endoscopic microsurgery (TEM) for rectal cancer. METHODS Patients with clinically staged T1-3 N0 distal rectal cancer were treated with long-course chemoradiotherapy. Clinical response was evaluated 6-8 weeks later and TEM performed. Total mesorectal excision was advocated in patients with residual disease (ypT2 or more). RESULTS The clinical stage was cT1 N0 in ten patients, cT2 N0 in 29 and cT3 N0 in 16 patients. Chemoradiotherapy-related complications of at least grade 3 occurred in 23 of 55 patients, with two deaths from toxicity, and two patients did not have TEM or major surgery. Among 47 patients who had TEM, ypT0-1 disease was found in 30, ypT0 N1 in one, ypT2 in 15 and ypT3 in one. Local recurrence developed in three of the nine patients with ypT2 tumours who declined further surgery. Postoperative complications grade I-IIIb occurred in 13 of 47 patients after TEM and in five of 12 after (completion) surgery. After a median follow-up of 17 months, four local recurrences had developed overall, three in patients with ypT2 and one with ypT1 disease. CONCLUSION TEM after chemoradiotherapy enabled organ preservation in one-half of the patients with rectal cancer.
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Affiliation(s)
- M Verseveld
- Department of Surgery, IJsselland Hospital, Capelle aan den IJssel, Rotterdam, The Netherlands; Division of Surgical Oncology, Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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63
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Abstract
The history of rectal cancer management informs current therapy and points us in the direction of future improvements. Multidisciplinary team management of rectal cancer will move us to personalized treatment for individuals with rectal cancer in all stages.
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Affiliation(s)
- James W Fleshman
- Department of Surgery, Baylor University Medical Center at Dallas, Dallas, Texas
| | - Nathan Smallwood
- Department of Surgery, Baylor University Medical Center at Dallas, Dallas, Texas
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64
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Burke JP, Albert M. Transanal minimally invasive surgery (TAMIS): Pros and cons of this evolving procedure. SEMINARS IN COLON AND RECTAL SURGERY 2015. [DOI: 10.1053/j.scrs.2014.10.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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65
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Transanal endoscopic microsurgery versus standard transanal excision for the removal of rectal neoplasms: a systematic review and meta-analysis. Dis Colon Rectum 2015; 58:254-61. [PMID: 25585086 DOI: 10.1097/dcr.0000000000000309] [Citation(s) in RCA: 132] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Transanal endoscopic microsurgery is the intraluminal excision of rectal lesions with the use of instrumentation to maintain a stable pneumorectum, enabling a magnified view of the target lesion. Despite suggested benefits over traditional transanal excision, there is no consensus on which technique is superior. OBJECTIVE The aim of the current study is to use meta-analytical techniques to compare transanal endoscopic microsurgery with transanal excision. DATA SOURCES A comprehensive literature search of PubMed, Embase, and The Cochrane Library was performed. STUDY SELECTION All studies comparing transanal endoscopic microsurgery with transanal excision were included. INTERVENTIONS Transanal endoscopic microsurgery was compared with transanal excision by using random-effects methods to combine data. Data are presented as ORs with 95% CIs. MAIN OUTCOME MEASURES The main outcomes measured were postoperative complication rate, negative microscopic margin rate, specimen fragmentation rate, and lesion recurrence. RESULTS Six comparative series comparing outcomes following 927 local excisions were identified. There was no difference between techniques in postoperative complication rate (OR, 1.018; 95% CI, 0.658-1.575; p = 0.937). Transanal endoscopic microsurgery had a higher rate of negative microscopic margins in comparison with transanal excision (OR, 5.281; 95% CI, 3.201-8.712; p < 0.001). Transanal endoscopic microsurgery had a reduced rate of specimen fragmentation (OR, 0.096; 95% CI, 0.044-0.209; p < 0.001) and lesion recurrence (OR, 0.248; 95% CI, 0.154-0.401; p < 0.001) compared with transanal excision. There was no across-study heterogeneity for any end point. LIMITATIONS Most studies were retrospectively designed, and there were variations in patient populations and duration of follow-up. CONCLUSIONS Available data are limited because of a lack of randomized controlled trials. However, based on current evidence, transanal endoscopic microsurgery is oncologically superior to transanal excision for the excision of rectal neoplasms.
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Abstract
BACKGROUND Local excision of rectal cancer is an attractive option because it avoids the morbidity of radical resection. Concerns have arisen during the past decade, however, regarding substandard oncologic results. OBJECTIVE Using the most recent Survey of Epidemiology and End Results-Medicare data, we examined the change in the use of local excision for rectal cancer from 2000 to 2009 and examined patient, surgeon, and hospital factors related to its use. DESIGN This study is a retrospective cohort study. SETTINGS This study was conducted at a tertiary care medical center using Survey of Epidemiology and End Results-Medicare data. PATIENTS Patients with pathologic Tis, T1, or T2 rectal cancer who were >65 years of age and underwent primary radical resection or local excision between 2000 and 2009 were included in this study. MAIN OUTCOME MEASURES The change in the use of local excision for rectal cancer from 2000 to 2009 was the main outcome measured. RESULTS A total of 8966 patients were identified. The use of local excision decreased significantly between 2000 and 2009. Women and patients who were older and had more comorbidities were significantly more likely to undergo local excision. Having a colorectal surgeon perform the surgery increased the odds of local excision by 1.5 times (p < 0.001). Similar trends were seen in patients operated on at the National Cancer Institute (OR, 1.7; p <0.001) and teaching hospitals (OR, 1.2; p = 0.003). Younger surgeons were more likely to perform local excisions. For surgeons graduating in 1980-1989 or 1990 and after, the odds of local excision were 1.40 (p = 0.001) and 2.1 (p <0.001) compared with surgeons graduating before 1970. LIMITATIONS The study was limited by the retrospective design, and the data were collected by multiple healthcare officials in their representative institutions. CONCLUSIONS In patient >65 years of age, the odds of undergoing local excision for early stage rectal cancer decreased significantly between 2000 and 2009, coincident with evidence of oncologic inferiority. However, there was still significant variation in its use. More studies are needed to better understand these variations in an attempt to bring more uniformity to the use of local excision in early stage rectal cancer.
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Morino M, Risio M, Bach S, Beets-Tan R, Bujko K, Panis Y, Quirke P, Rembacken B, Rullier E, Saito Y, Young-Fadok T, Allaix ME. Early rectal cancer: the European Association for Endoscopic Surgery (EAES) clinical consensus conference. Surg Endosc 2015; 29:755-73. [DOI: 10.1007/s00464-015-4067-3] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 01/07/2015] [Indexed: 12/13/2022]
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68
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Zinicola R, Hill J, Fiocca R. Surgery for colorectal polyps: histological features, current indications, critical points, future perspective and ongoing studies. Colorectal Dis 2015; 17 Suppl 1:52-60. [PMID: 25511862 DOI: 10.1111/codi.12822] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- R Zinicola
- Department of Emergency Surgery, University Hospital, Parma, Italy
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69
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Local resection compared with radical resection in the treatment of T1N0M0 rectal adenocarcinoma: a systematic review and meta-analysis. Dis Colon Rectum 2015; 58:122-40. [PMID: 25489704 DOI: 10.1097/dcr.0000000000000293] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Local resection for early rectal cancer is thought to be less invasive but oncologically inferior to radical resection. OBJECTIVE The aim of this study was to compare local with radical resection in terms of oncologic control (survival and local recurrence), postoperative complications, and the need for a permanent stoma in adult patients with T1N0M0 rectal adenocarcinoma. DATA SOURCES Data were retrieved from Medline, Embase, Central, www.clinicaltrials.gov, and conference proceedings. STUDY SELECTION Two reviewers independently screened studies and assessed the risk of bias. INTERVENTIONS Local resection (transanal procedures, excluding endoscopic polypectomy) versus radical resection were considered. MAIN OUTCOME MEASURES The primary outcomes measured were overall survival, major postoperative complications, and the 'need for permanent stoma.' RESULTS : One randomized controlled trial and 12 observational studies contributed 2855 patients for analysis. The randomized controlled trial was inadequately powered. Observational study meta-analysis showed that local resection was associated with significantly lower 5-year overall survival (72 more deaths per 1000 patients; 95%CI 30-120). However, the transanal endoscopic microsurgery subgroup did not yield significantly lower overall survival than radical resection. Local resection was associated with higher local recurrence but with lower perioperative mortality (relative risk 0.31, 95% CI 0.14-0.71), major postoperative complications (relative risk 0.20, 95% CI 0.10-0.41), and need for a permanent stoma (relative risk 0.17, 95% CI 0.09-0.30). Findings were robust to sensitivity analyses. Meta-regression suggests that the higher overall survival associated with radical resection may be explained by increased use of local resection on tumors in the lower third of the rectum, which have poorer prognosis. LIMITATIONS This systematic review of nonrandomized studies had inherent biases that may persist despite our rigorous use of systematic review methodology and sensitivity analyses. CONCLUSIONS Local resection does not offer oncologic control comparable to radical surgery. However, this finding may be driven by the higher prevalence of cancers with poorer prognosis in local resection groups. Local resection is associated with lower postoperative complications, mortality, and the need for a permanent stoma. Local resection with transanal endoscopic microsurgery appears to offer oncologic control similar to that of radical resection while offering all the benefits of local resection.
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70
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Sanders M, Vabi BW, Cole PA, Kulaylat MN. Local Excision of Early-Stage Rectal Cancer. Surg Oncol 2015. [DOI: 10.1007/978-1-4939-1423-4_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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71
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Abstract
Improved treatment strategies have eliminated local control as the major problem in rectal cancer. With increasing awareness of long-term toxic effects in survivors of rectal cancer, organ-preservation strategies are becoming more popular. After chemoradiotherapy, both watchful waiting and local excision are used as possible alternatives for radical surgery. Although these seem attractive strategies, many issues about the safety of organ preservation remain. Additionally, radiotherapy strategies are mainly aimed at intermediate and high-risk rectal tumours, and adaptation of this standard practice for a completely new treatment indication has yet to start. This Review will discuss the options and problems of organ preservation, and address the research questions that need to be answered in the coming years, with a specific focus on radiotherapy.
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Affiliation(s)
- Corrie A M Marijnen
- Department of Clinical Oncology, Leiden University Medical Center, Leiden, Netherlands.
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72
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Abstract
BACKGROUND Local excision, as an alternative to radical resection for patients with pathological complete response (ypT0) after preoperative chemoradiation, is under investigation. OBJECTIVE The aim of the present study was to evaluate the long-term clinical outcome of a selected group of patients with ypT0 rectal cancer who underwent local excision with transanal endoscopic microsurgery as a definitive treatment. PATIENTS Between 1993 and 2013, 43 patients with rectal adenocarcinoma underwent complete full-thickness local excision with a transanal endoscopic microsurgery procedure after a regimen of chemoradiation. In all patients, rectal wall penetration was preoperatively assessed by endorectal ultrasound and/or magnetic resonance. Chemoradiation and transanal endoscopic microsurgery were indicated in patients refusing radical procedures or patients unfit for major abdominal procedures. MAIN OUTCOME MEASURES Patient characteristics, operative record, pathology report, and tumor recurrence were analyzed at a median follow-up of 81 months. The potential prognostic factors for recurrence, screened in univariate analysis, were analyzed by multivariate analysis by using the Cox regression model. RESULTS Thirteen patients (30.2%), without residual tumor in the surgical specimen (ypT0), were treated with transanal endoscopic microsurgery only. In this ypT0 group, 2 patients (15.4%) had postoperative complications: 1 bleeding and 1 suture dehiscence. Postoperative mortality was nil. No local and distal recurrences were observed, and no tumor-related mortality occurred. In 30 patients (69.8%), partial tumor chemoradiation response or the absence of tumor chemoradiation response was observed. In this group, recurrence occurred in 17 patients (56.7%). LIMITATIONS The study was limited by its retrospective nature, different protocols of chemoradiation and preoperative staging over time, and the small sample size. CONCLUSIONS Local excision with transanal endoscopic microsurgery can be considered a definitive therapeutic option in patients with rectal cancer treated with preoperative chemoradiation, when no residual tumor is found in the specimen. In this selected group, local excision offers excellent results in terms of survival and recurrence rates. In the presence of residual tumor, transanal endoscopic microsurgery should be considered as a large excisional biopsy (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A157).
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73
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Kulu Y, Müller-Stich BP, Bruckner T, Gehrig T, Büchler MW, Bergmann F, Ulrich A. Radical Surgery with Total Mesorectal Excision in Patients with T1 Rectal Cancer. Ann Surg Oncol 2014; 22:2051-8. [DOI: 10.1245/s10434-014-4179-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Indexed: 01/03/2023]
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74
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Elmessiry MM, Van Koughnett JAM, Maya A, DaSilva G, Wexner SD, Bejarano P, Berho M. Local excision of T1 and T2 rectal cancer: proceed with caution. Colorectal Dis 2014; 16:703-9. [PMID: 24787457 DOI: 10.1111/codi.12657] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 03/16/2014] [Indexed: 12/13/2022]
Abstract
AIM This study aimed to compare the clinical outcome between local excision (LE) and total mesorectal excision (TME) for early rectal cancer. METHOD After Institutional Review Board approval, charts of patients with T1 or T2 N0M0 rectal adenocarcinoma treated by curative LE or TME without preoperative radiotherapy from 2004 to 2012 were reviewed. Categorical and continuous variables were compared using chi-square analysis and the ANOVA test. Kaplan-Meier analysis compared survival rates. RESULTS The study included 153 patients: 79 underwent TME and 74 LE. Postoperative infection was more common after TME (P = 0.009). There was tumour involvement of the margins in 13.5% after LE compared with 0% after TME (P = 0.001). Of the patients treated initially by LE, 13.5% had additional surgery for unfavourable histological findings and 4.1% had residual tumour. Median follow up was 35 (17-96) months. No deaths were recorded in 56 patients with a pT1 lesion. There was no significant difference in local recurrence (P = 0.332) or 3-year disease-free survival (DFS; P = 0.232) between patients having LE or TME. The 68 patients with a T2 lesion had higher local recurrence (P = 0.025) and lower DFS following LE compared with TME (P = 0.044). There was no difference in overall survival (P = 0.351). CONCLUSION LE of early rectal cancer is associated with higher local recurrence and decreased DFS. These disadvantages are significant for T2 lesions.
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Affiliation(s)
- M M Elmessiry
- Department of Surgery, University of Alexandria, Alexandria, Egypt
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75
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Mondal D, Betts M, Cunningham C, Mortensen NJ, Lindsey I, Slater A. How useful is endorectal ultrasound in the management of early rectal carcinoma? Int J Colorectal Dis 2014; 29:1101-4. [PMID: 24953057 DOI: 10.1007/s00384-014-1920-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/08/2014] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Endorectal ultrasonography (EUS) is used to T stage early rectal tumours and select patients to whom transanal endoscopic microsurgery (TEM) could be offered. Published papers have shown that EUS can have good accuracy, but there is little literature on how EUS influences patient management. The study aim is to ascertain the value of EUS in the management of early rectal tumours. METHODS Patients with adenomas/early rectal carcinoma being considered for TEM were prospectively studied. Each patient underwent EUS. The surgeon recorded the expected T stage, confidence level of the T stage and management plan for each patient on a proforma before and after the ultrasound result was revealed. Comparison was made between the ultrasound stage and final pathological stage where available. RESULTS Ninety-six patients were referred over 2 years. Nine were out of reach of the rigid probe and were excluded. Proformas were completed on 53/87 patients (age range 28-87 years, mean age 66 years, 30 males/23 females). Forty-eight patients had a pathological report to compare with the EUS T stage. Ultrasound agreed with the pathological T staging in 43 patients (90%). Patient management was changed in five patients. In 30% of (16/53) patients, EUS increased the confidence level for T staging. CONCLUSION Although EUS has a high accuracy in predicting the T stage of early rectal cancers, it never changes the management plan for lesions thought to be benign. It seldom changes the pre-operative selection process when clinical examination is considered with other imaging modalities (MRI/CT). EUS should be reserved for answering specific questions in difficult cases rather than for all patients.
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Affiliation(s)
- D Mondal
- Department of Radiology, John Radcliffe Hospital, Oxford, UK
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76
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Bhangu A, Kiran RP, Audisio R, Tekkis P. Survival outcome of operated and non-operated elderly patients with rectal cancer: A Surveillance, Epidemiology, and End Results analysis. Eur J Surg Oncol 2014; 40:1510-6. [PMID: 24704032 DOI: 10.1016/j.ejso.2014.02.239] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 02/12/2014] [Accepted: 02/19/2014] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND With an ageing population, surgery is increasingly offered to elderly patients with rectal cancer, although outcomes for the oldest patients remain poorly defined. This study aimed to determine whether operative intervention improves outcome in elderly patients. METHOD Patients aged 18+ years diagnosed with rectal adenocarcinoma between 1998 and 2009 were identified from the Surveillance, Epidemiology, and End Results database. The primary endpoint was adjusted hazard ratios (HR) for 5-year cancer specific survival (CSS); the secondary endpoint was 5-year overall survival (OS). RESULTS With increasing age, patients were less likely to undergo surgery, receive a complete stage or receive neoadjuvant radiotherapy. CSS and OS increasingly diverged with age in patients undergoing surgery. Those aged 80+ had reduced CSS compared to those aged 70-79 years (stages I-III, respective adjusted HR 2.14, 1.58, 1.48, all p < 0.001). However, stage II patients aged 80+ treated with resection and neoadjuvant therapy had similar survival to those aged 70-79 years (adjusted HR 1.26, p = 0.149). For only patients aged 80+ years, those treated non-operatively had lower survival than those undergoing surgery, who in turn had the best survival when treated with neoadjuvant radiotherapy (adjusted HR 0.74, p = 0.001). CONCLUSION Contrary to common expectation, in patients aged over 80 with rectal cancer, surgery with or without other modalities was associated with better survival than non-operative treatment. Despite selection bias in this observational study, these findings support consideration of maximal therapy regardless of age in selected patients deemed to be fit, since this leads to outcomes equivalent to younger patients.
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Affiliation(s)
- A Bhangu
- Department of Colorectal Surgery, Royal Marsden Hospital, Fulham Road, London, UK; Division of Surgery, Imperial College, Chelsea and Westminster Campus, London, UK
| | - R P Kiran
- Division of Colorectal Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, USA
| | - R Audisio
- Department of Surgery, University of Liverpool, Liverpool, UK
| | - P Tekkis
- Department of Colorectal Surgery, Royal Marsden Hospital, Fulham Road, London, UK; Division of Surgery, Imperial College, Chelsea and Westminster Campus, London, UK.
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Bhangu A, Kiran RP, Brown G, Goldin R, Tekkis P. Establishing the optimum lymph node yield for diagnosis of stage III rectal cancer. Tech Coloproctol 2014; 18:709-17. [DOI: 10.1007/s10151-013-1114-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2013] [Accepted: 12/29/2013] [Indexed: 12/12/2022]
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78
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Abstract
The management of rectal cancer has improved considerably in recent decades. Surgery remains the cornerstone of the treatment. However, the role of preoperative imaging has made it possible to optimize the treatment plan in rectal patients. Neoadjuvant treatment may be indicated in efforts to sterilize possible tumor deposits outside the surgical field, or may be used to downsize and downstage the tumor itself. The optimal sequence of treatment modalities can be determined by a multidisciplinary team, who not only use pretreatment imaging, but also review pathologic results after surgery. The pathologist plays a pivotal role in providing feedback about the success of surgery, i.e., the distance between the tumor and the circumferential resection margin, the quality of surgery, and the effect of neoadjuvant treatment. Registry and auditing of all treatment variables can further improve outcomes. In this century, rectal cancer treatment has become a team effort.
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Hou L, Zhao MM, Sun BM, Xing HJ. Expression of c-Met protein in gastrointestinal tumors: Recent research progress. Shijie Huaren Xiaohua Zazhi 2013; 21:3230-3235. [DOI: 10.11569/wcjd.v21.i30.3230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
There is a close relationship between HGF/c-Met and many human cancers. The activation and overexpression of HGF/c-Met can cause the growth, invasion and metastasis of breast cancer, ovarian cancer, endometrial cancer, lung cancer, and digestive system tumors. Since c-Met plays an important role in the growth and metastasis of tumors, targeting the HGF/c-Met pathway has become a hotspot for anti-cancer research. Currently, there have been many reports about c-Met expression in digestive tumors. In this paper we try to elaborate the latest progress in research related to c-Met expression in digestive tumors, with an aim to help clinicians gain a systematic understanding of this issue.
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