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Conticchio M, Papagni V, Notarnicola M, Delvecchio A, Riccelli U, Ammendola M, Currò G, Pessaux P, Silvestris N, Memeo R. Laparoscopic vs. open mesorectal excision for rectal cancer: Are these approaches still comparable? A systematic review and meta-analysis. PLoS One 2020; 15:e0235887. [PMID: 32722694 PMCID: PMC7386630 DOI: 10.1371/journal.pone.0235887] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 06/25/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND To analyze pathologic and perioperative outcomes of laparoscopic vs. open resections for rectal cancer performed over the last 10 years. METHODS A systematic literature search of the following databases was conducted: Cochrane Central Register of Controlled Trials, MEDLINE (through PubMed), EMBASE, and Scopus. Only articles published in English from January 1, 2008 to December 31, 2018 (i.e. the last 10 years), which met inclusion criteria were considered. The review only included articles which compared Laparoscopic rectal resection (LRR) and Open Rectal Resection (ORR) for rectal cancer and reported at least one of the outcomes of interest. The analyses followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement checklist. Only prospective randomized studies were considered. The body of evidence emerging from this study was evaluated using the Grading of Recommendations Assessment Development and Evaluation (GRADE) system. Outcome measures (mean and median values, standard deviations, and interquartile ranges) were extracted for each surgical treatment. Pooled estimates of the mean differences were calculated using random effects models to consider potential inter-study heterogeneity and to adopt a more conservative approach. The pooled effect was considered significant if p <0.05. RESULTS Five clinical trials were found eligible for the analyses. A positive involvement of CRM was found in 49 LRRs (8.5%) out of 574 patients and in 30 ORRs out of 557 patients (5.4%) RR was 1.55 (95% CI, 0.99-2.41; p = 0.05) with no heterogeneity (I2 = 0%). Incorrect mesorectal excision was observed in 56 out of 507 (11%) patients who underwent LRR and in 41 (8.4%) out of 484 patients who underwent ORR; RR was 1.30 (95% CI, 0.89-1.91; p = 0.18) with no heterogeneity (I2 = 0%). Regarding other pathologic outcomes, no significant difference between LRR and ORR was observed in the number of lymph nodes harvested or concerning the distance to the distal margin. As expected, a significant difference was found in the operating time for ORR with a mean difference of 41.99 (95% CI, 24.18, 59.81; p <0.00001; heterogeneity: I2 = 25%). However, no difference was found for blood loss. Additionally, no significant differences were found in postoperative outcomes such as postoperative hospital stay and postoperative complications. The overall quality of the evidence was rated as high. CONCLUSION Despite the spread of laparoscopy with dedicated surgeons and the development of even more precise surgical tools and technologies, the pathological results of laparoscopic surgery are still comparable to those of open ones. Additionally, concerning the pathological data (and particularly CRM), open surgery guarantees better results as compared to laparoscopic surgery. These results must be a starting point for future evaluations which consider the association between ''successful resection" and long-term oncologic outcomes. The introduction of other minimally invasive techniques for rectal cancer surgery, such as robotic resection or transanal TME (taTME), has revealed new scenarios and made open and even laparoscopic surgery obsolete.
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Affiliation(s)
| | | | | | | | | | - Michele Ammendola
- Department of Health Sciences, General Surgery, Magna Græcia University, Medicine School of Germaneto, Catanzaro, Italy
| | - Giuseppe Currò
- Department of Health Sciences, General Surgery, Magna Græcia University, Medicine School of Germaneto, Catanzaro, Italy
| | - Patrick Pessaux
- IRCAD-IHU, General, Digestive, and Endocrine Surgery, University of Strasbourg, Strasbourg, France
| | - Nicola Silvestris
- Medical Oncology Unit, IRCCS Cancer Institute "Giovanni Paolo II", Bari, Italy
- Department of Biomedical Sciences and Human Oncology, University of Bari ‘Aldo Moro’, Bari, Italy
| | - Riccardo Memeo
- Department of Hepato-Pancreato-Biliary (HPB) Surgery, Miulli Hospital, Acquaviva delle Fonti, Bari, Italy
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Bogner A, Kirchberg J, Weitz J, Fritzmann J. State of the Art - Rectal Cancer Surgery. Visc Med 2019; 35:252-258. [PMID: 31602388 DOI: 10.1159/000501133] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 05/22/2019] [Indexed: 12/24/2022] Open
Abstract
Background In an aging society, the incidence and relevance of rectal cancer as one of the most frequent gastrointestinal cancers gains in importance. Excellent surgery and up-to-date multimodal treatments are essential for adequate oncological results and good quality of life. Summary In this review, we describe modern developments in rectal cancer surgery and its embedment in modern multimodal therapy concepts. Key Message Distinguished interdisciplinary cooperation combined with an outstanding surgical expertise is the basic requirement for an optimal treatment of rectal cancer. Thus, high standards of oncological outcome and patient's quality of life can be achieved.
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Affiliation(s)
- Andreas Bogner
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Johanna Kirchberg
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Jürgen Weitz
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Johannes Fritzmann
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
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Reece MM, Chapuis PH, Keshava A, Stewart P, Suen M, Rickard MJFX. When does curatively treated colorectal cancer recur? An Australian perspective. ANZ J Surg 2018; 88:1163-1167. [DOI: 10.1111/ans.14870] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 08/07/2018] [Indexed: 12/13/2022]
Affiliation(s)
- Mifanwy M. Reece
- Department of Colorectal Surgery; Concord Repatriation General Hospital; Sydney New South Wales Australia
| | - Pierre H. Chapuis
- Department of Colorectal Surgery; Concord Repatriation General Hospital; Sydney New South Wales Australia
- Discipline of Surgery, Sydney Medical School; The University of Sydney; Sydney New South Wales Australia
| | - Anil Keshava
- Department of Colorectal Surgery; Concord Repatriation General Hospital; Sydney New South Wales Australia
- Discipline of Surgery, Sydney Medical School; The University of Sydney; Sydney New South Wales Australia
| | - Peter Stewart
- Department of Colorectal Surgery; Concord Repatriation General Hospital; Sydney New South Wales Australia
| | - Michael Suen
- Department of Colorectal Surgery; Concord Repatriation General Hospital; Sydney New South Wales Australia
| | - Matthew J. F. X. Rickard
- Department of Colorectal Surgery; Concord Repatriation General Hospital; Sydney New South Wales Australia
- Discipline of Surgery, Sydney Medical School; The University of Sydney; Sydney New South Wales Australia
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Vaglini M, Cascinelli F, Chiti A, Deraco M, Inglese MG, Rebuffoni G, Rizzi M, Sala B, Santoro N, Santinami M. Isolated Pelvic Perfusion for the Treatment of Unresectable Primary or Recurrent Rectal Cancer. TUMORI JOURNAL 2018; 82:459-62. [PMID: 9063524 DOI: 10.1177/030089169608200510] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Between May 1990 and December 1995, 16 patients with primary or recurrent unresectable rectal cancer were treated by isolated pelvic perfusion. All patients had been previously treated and were considered unsuitable for surgery or further systemic chemotherapy or radiotherapy. The treatment was based on a perfusion lasting 90 min at 40.5 C° with 5-fluorouracil, mitomycin-C and mitoxantrone. Whenever technically feasible (10 cases), continuous intraarterial chemotherapy (through a Medtronic device with a catheter in the inferior mesenteric artery) was administered postoperatively. Two complete responses and 2 partial responses were observed; 8 other patients showed stable disease. One patient did not show any response. Finally, 3 patients for various reasons were not assessable. All patients experienced immediate relief of pain. No major side effects directly related to isolated pelvic perfusion were recorded; a transitory bone marrow depletion was observed in all cases. In conclusion, isolated pelvic perfusion is useful in inoperable disease of the pelvis by reliably relieving pain and thereby improving the patients quality of life.
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Affiliation(s)
- M Vaglini
- Istituto Nazionale per lo Studio e.la Cura dei Tumori, Milan, Italy
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Kim IK, Kang J, Baik SH, Lee KY, Sohn SK. The efficacy of cap-assisted colonoscopy performed by a single endoscopist in patients after colorectal resection. Medicine (Baltimore) 2016; 95:e4869. [PMID: 27631254 PMCID: PMC5402597 DOI: 10.1097/md.0000000000004869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The use of a transparent cap is regarded as a simple method to obtain better outcomes compared with standard colonoscopy. In this study, we investigated whether cap-assisted colonoscopy can improve the quality of procedure-related outcomes in patients with a history of colorectal resection. METHODS This study was designed as a prospective, randomized, controlled trial conducted at a single tertiary center by a single endoscopist (Kang J.). A total 183 patients after colorectal resection due to primary colorectal cancer were enrolled and 1:1 randomized to undergo either cap-assisted colonoscopy (CAP group) or standard colonoscopy (non-CAP group). The primary endpoint was the comparison of cecal intubation time between the 2 groups. RESULTS The mean cecal intubation time of the CAP group (n = 89) was significantly shorter than that of the non-CAP group (n = 89) (538 seconds vs 677 seconds, P = 0.024). In the CAP group, the endoscopist performed faster intubation than average more often compared with the non-CAP group (71.9% vs 57.3%). In regard to moving average curve, the CAP group showed a gentle slope during the learning period, while the non-CAP group showed a steep decrease. CONCLUSION The cap-assisted colonoscopy could reduce cecal intubation time and achieve more frequent faster intubation compared with standard colonoscopy in patients after colorectal resection.
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Affiliation(s)
- Im-kyung Kim
- Department of Surgery, Gangnam Severance Hospital
| | - Jeonghyun Kang
- Department of Surgery, Gangnam Severance Hospital
- Correspondence: Jeonghyun Kang, Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea (e-mail: )
| | | | - Kang Young Lee
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Luo YJ, Liu ZL, Ye PC, Fu ZM, Lu F, Suleiman AA, Liao J, Xiao JW. Safety and efficacy of intraoperative iodine-125 seed implantation brachytherapy for rectal cancer patients: A retrospective clinical research. J Gastroenterol Hepatol 2016; 31:1076-84. [PMID: 26643583 DOI: 10.1111/jgh.13261] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 11/27/2015] [Accepted: 11/29/2015] [Indexed: 01/20/2023]
Abstract
BACKGROUND This pilot study was performed to evaluate the risk of anastomotic leakage (AL) and pelvic autonomic nerve dysfunction, and the effects of (125) I brachytherapy after intraoperative permanent implantation of iodine-125 seeds within the patients with rectal carcinoma. METHODS In a cohort consisting of 80 rectal cancer patients who received potentially curative resection of rectal carcinoma with implantation of (125) I brachytherapy or radical resection of rectal carcinoma underwent total mesorectal excision. The incidences of AL, fecal incontinence, urinary dysfunction, and sexual dysfunction were calculated for comparison, and risk factors for these complications were analyzed by logistic regression. Rates of tumor recurrence and overall survival were evaluated. RESULTS Six out of 17 (35.29%) patients in the (125) I implant group and 1 out of 34 (2.94%) patients in the non-implant group were complicated with AL (P = 0.006). The incidences of urinary dysfunction (P = 0.005) and fecal incontinence (P = 0.023) were significantly different between the two groups. Multivariate analyses revealed that (125) I brachytherapy was an independent risk factor for AL (odds ratio, 18.702; 95%CI, 1.802-194.062; P = 0.014) and urinary dysfunction (odds ratio, 4.340; 95%CI, 1.158-16.264; P = 0.029), respectively. At postoperative 2-year, the recurrence rates were 5.56% in the (125) I implant group and 9.09% in the non-implant group (P = 0.029). CONCLUSIONS Intraoperative implantation of (125) I brachytherapy significantly increases the risk of AL, fecal incontinence, urinary dysfunction, and improves local control and do not improve overall survival after total mesorectal excision.
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Affiliation(s)
- Ya-Jun Luo
- Department of Gastrointestinal Surgery, The Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China.,Institute of Hepatobiliary, Pancreatic and Intestinal Disease, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Zi-Lin Liu
- Department of Gastrointestinal Surgery, The Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China.,Institute of Hepatobiliary, Pancreatic and Intestinal Disease, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Peng-Cheng Ye
- Department of Gastrointestinal Surgery, The Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China.,Institute of Hepatobiliary, Pancreatic and Intestinal Disease, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Zhi-Ming Fu
- Department of Gastrointestinal Surgery, The Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China.,Institute of Hepatobiliary, Pancreatic and Intestinal Disease, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Fei Lu
- Department of Gastrointestinal Surgery, The Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China.,Institute of Hepatobiliary, Pancreatic and Intestinal Disease, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Abdihakin Ali Suleiman
- Department of Gastrointestinal Surgery, The Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China.,Institute of Hepatobiliary, Pancreatic and Intestinal Disease, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Juan Liao
- Department of Digestive Internal Medicine, The Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Jiang-Wei Xiao
- Department of Gastrointestinal Surgery, The Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China.,Institute of Hepatobiliary, Pancreatic and Intestinal Disease, North Sichuan Medical College, Nanchong, Sichuan, China
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Reinert T, Schøler LV, Thomsen R, Tobiasen H, Vang S, Nordentoft I, Lamy P, Kannerup AS, Mortensen FV, Stribolt K, Hamilton-Dutoit S, Nielsen HJ, Laurberg S, Pallisgaard N, Pedersen JS, Ørntoft TF, Andersen CL. Analysis of circulating tumour DNA to monitor disease burden following colorectal cancer surgery. Gut 2016; 65:625-34. [PMID: 25654990 DOI: 10.1136/gutjnl-2014-308859] [Citation(s) in RCA: 314] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 01/07/2015] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To develop an affordable and robust pipeline for selection of patient-specific somatic structural variants (SSVs) being informative about radicality of the primary resection, response to adjuvant therapy, incipient recurrence and response to treatment performed in relation to diagnosis of recurrence. DESIGN We have established efficient procedures for identification of SSVs by next-generation sequencing and subsequent quantification of 3-6 SSVs in plasma. The consequence of intratumour heterogeneity on our approach was assessed. The level of circulating tumour DNA (ctDNA) was quantified in 151 serial plasma samples from six relapsing and five non-relapsing colorectal cancer (CRC) patients by droplet digital PCR, and correlated to clinical findings. RESULTS Up to six personalised assays were designed for each patient. Our approach enabled efficient temporal assessment of disease status, response to surgical and oncological intervention, and early detection of incipient recurrence. Our approach provided 2-15 (mean 10) months' lead time on detection of metastatic recurrence compared to conventional follow-up. The sensitivity and specificity of the SSVs in terms of detecting postsurgery relapse were 100%. CONCLUSIONS We show that assessment of ctDNA is a non-invasive, exquisitely specific and highly sensitive approach for monitoring disease load, which has the potential to provide clinically relevant lead times compared with conventional methods. Furthermore, we provide a low-coverage protocol optimised for identifying SSVs with excellent correlation between SSVs identified in tumours and matched metastases. Application of ctDNA analysis has the potential to change clinical practice in the management of CRC.
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Affiliation(s)
- Thomas Reinert
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Lone V Schøler
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Rune Thomsen
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Heidi Tobiasen
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Søren Vang
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Iver Nordentoft
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Philippe Lamy
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Sofie Kannerup
- Department of Surgical Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Frank V Mortensen
- Department of Surgical Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Katrine Stribolt
- Institute of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Hans J Nielsen
- Department of Surgical Gastroenterology, University of Copenhagen, Hvidovre Hospital, Hvidovre, Denmark
| | - Søren Laurberg
- Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark
| | | | - Jakob S Pedersen
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Torben F Ørntoft
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Claus L Andersen
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
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Rectal Cancer. Surg Oncol 2015. [DOI: 10.1007/978-1-4939-1423-4_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kim D. What is the Role of Surveillance for Colorectal Cancer? COLORECTAL CANCER 2014. [DOI: 10.1002/9781118337929.ch15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Dieguez A. Rectal cancer staging: focus on the prognostic significance of the findings described by high-resolution magnetic resonance imaging. Cancer Imaging 2013; 13:277-97. [PMID: 23876415 PMCID: PMC3719056 DOI: 10.1102/1470-7330.2013.0028] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2013] [Indexed: 12/14/2022] Open
Abstract
High-resolution (HR) magnetic resonance imaging (MRI) has become an indispensable tool for multidisciplinary teams (MDTs) addressing rectal cancer. It provides anatomic information for surgical planning and allows patients to be stratified into different groups according to the risk of local and distant recurrence. One of the objectives of the MDT is the preoperative identification of high-risk patients who will benefit from neoadjuvant treatment. For this reason, the correct evaluation of the circumferential resection margin (CRM), the depth of tumor spread beyond the muscularis propria, extramural vascular invasion and nodal status is of the utmost importance. Low rectal tumors represent a special challenge for the MDT, because decisions seek a balance between oncologic safety, in the pursuit of free resection margins, and the patient's quality of life, in order to preserve sphincter function. At present, the exchange of information between the different specialties involved in dealing with patients with rectal cancer can rank the contribution of colleagues, auditing their work and incorporating knowledge that will lead to a better understanding of the pathology. Thus, beyond the anatomic description of the images, the radiologist's role in the MDT makes it necessary to know the prognostic value of the findings that we describe, in terms of recurrence and survival, because these findings affect decision making and, therefore, the patients' life. In this review, the usefulness of HR MRI in the initial staging of rectal cancer and in the evaluation of neoadjuvant treatment, with a focus on the prognostic value of the findings, is described as well as the contribution of HR MRI in assessing patients with suspected or confirmed recurrence of rectal cancer.
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Affiliation(s)
- Adriana Dieguez
- Diagnóstico Médico, Junín 1023 (C1113AAE), Ciudad Autónoma de Buenos Aires, Argentina.
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Uraoka T, Horii J, Goto O, Shimoda M, Yahagi N. Metachronous adenoma on ileorectal anastomosis suture line and submucosal deep invasive cancer suspected of rapid growth in rectal remnant following long-term interval after curative surgery for advanced colon cancer. Dig Endosc 2013; 25 Suppl 2:46-51. [PMID: 23617649 DOI: 10.1111/den.12094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 02/14/2013] [Indexed: 02/08/2023]
Abstract
There is general agreement as to the value of postoperative surveillance and the effectiveness of colonoscopy in the early detection of metachronous colorectal lesions. In the present case, a 56-year-old woman with no family history of colon cancer underwent surveillance colonoscopy in which a metachronous flat adenoma was detected following an interval of 23 years after a colectomy and 20 years subsequent to treatment for uterine cancer. A second metachronous flat lesion histopathologically determined to be a submucosal (sm) deep invasive cancer with lymphovascular involvement was detected 12 months later. This second metachronous lesion was suspected of having developed rapidly in the rectal remnant accounting for its sm deep invasion. The findings of this case suggest colonoscopy surveillance guidelines proposed for individuals at high risk should be evaluated based on cancer history and an analysis of possible mismatch repair gene mutations. In addition, the first metachronous lesion was located directly on the suture line of the anastomosis. Endoscopic submucosal dissection (ESD) was indicated despite severe fibrosis into the sm layer. This case also demonstrates the successful use of improved ESD instruments, sm injection agents and technique refinements in the treatment of a technically difficult lesion with a high risk of complications.
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Affiliation(s)
- Toshio Uraoka
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, School of Medicine, Keio University, Tokyo, Japan.
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Kim J. Pelvic exenteration: surgical approaches. JOURNAL OF THE KOREAN SOCIETY OF COLOPROCTOLOGY 2012; 28:286-93. [PMID: 23346506 PMCID: PMC3548142 DOI: 10.3393/jksc.2012.28.6.286] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Accepted: 12/28/2012] [Indexed: 01/27/2023]
Abstract
Although the incidence of local recurrence after curative resection of rectal cancer has decreased due to the understanding of the anatomy of pelvic structures and the adoption of total mesorectal excision, local recurrence in the pelvis still remains a significant and troublesome complication. While surgery for recurrent rectal cancer may offer a chance for a cure, conservative management, including radiation and chemotherapy, remain widely accepted courses of treatment. Recent improvement in imaging modalities, perioperative care, and surgical techniques, including bone resection and wound coverage, have allowed for reductions in operative mortality, though postoperative morbidity still remains high. In this review, the techniques, including surgical approaches, employed for management of locally recurrent rectal cancer are highlighted.
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Affiliation(s)
- Jin Kim
- Division of Colorectal Surgery, Department of Surgery, Korea University College of Medicine, Seoul, Korea
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Harji DP, Sagar PM, Boyle K, Maslekar S, Griffiths B, McArthur DR. Outcome of surgical resection of second-time locally recurrent rectal cancer. Br J Surg 2012; 100:403-9. [PMID: 23225371 DOI: 10.1002/bjs.8991] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2012] [Indexed: 11/06/2022]
Abstract
BACKGROUND Locally recurrent rectal cancer relapses in the pelvis in up to 60 per cent of patients following resection. This study assessed the surgical and oncological outcomes of patients who underwent surgery for re-recurrent rectal cancer. METHODS Patients who underwent second-time resection of locally recurrent rectal cancer between 2001 and 2010 were eligible for inclusion. Data were collected on demographics, presentation of disease, preoperative staging imaging, adjuvant therapy, operative detail, histopathology and follow-up status (clinical and imaging) for the primary tumour, and first and second recurrences. RESULTS Thirty patients (of 56 discussed at the multidisciplinary meeting) underwent resection of re-recurrent rectal cancer. Postoperative morbidity occurred in nine patients but none died within 30 days. Negative resection margins (R0) were achieved in ten patients, microscopic margin positivity (R1) was evident in 15 and macroscopic involvement (R2) was found in five. Although no patient had distant metastatic disease, 22 had involvement of the pelvic side wall. One- and 3-year overall survival rates were 77 and 27 per cent respectively, with a median overall survival of 23 (range 3-78) months. An R0 resection conferred a survival benefit (median survival 32 (11-78) months versus 19 (6-33) months after R1 and 7 (3-10) months after R2 resection). CONCLUSION Surgical resection of re-recurrent rectal cancer had comparable surgical and oncological outcomes to initial recurrences in well selected patients.
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Affiliation(s)
- D P Harji
- John Goligher Department of Colorectal Surgery, St James's University Hospital, Beckett Street, Leeds LS7 7TF, UK
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Georgiou PA, Tekkis PP, Brown G. Pelvic colorectal recurrence: crucial role of radiologists in oncologic and surgical treatment options. Cancer Imaging 2011; 11 Spec No A:S103-11. [PMID: 22186112 PMCID: PMC3266566 DOI: 10.1102/1470-7330.2011.9025] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Radical resection is the only potential cure for patients with locally advanced primary and recurrent rectal cancer and is considered curative only when the histologic margins are clear of tumour. Early diagnosis of the disease is essential as it increases the likelihood of a potentially curative resection and prevention of dissemination. Clinical examination, tumour markers and radiologic modalities such as ultrasonography, computed tomography, magnetic resonance imaging and positron emission tomography are routinely used in an effort to accurately stage these patients and provide useful information for the selection of patients for further treatment/management. This review describes the methods of staging patients with locally advanced primary and recurrent rectal cancer prior to surgery emphasizing the role that radiologists have in this process.
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Affiliation(s)
- P A Georgiou
- Department of Colorectal Surgery, The Royal Marsden Hospital, Fulham Road, London, UK
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Bae SH, Park W, Choi DH, Nam H, Kang WK, Park YS, Park JO, Chun HK, Lee WY, Yun SH, Kim HC. Palliative radiotherapy in patients with a symptomatic pelvic mass of metastatic colorectal cancer. Radiat Oncol 2011; 6:52. [PMID: 21600018 PMCID: PMC3130661 DOI: 10.1186/1748-717x-6-52] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2011] [Accepted: 05/21/2011] [Indexed: 12/17/2022] Open
Abstract
Background To evaluate the palliative role of radiotherapy (RT) and define the effectiveness of chemotherapy combined with palliative RT (CCRT) in patients with a symptomatic pelvic mass of metastatic colorectal cancer. Methods From August 1995 to December 2007, 80 patients with a symptomatic pelvic mass of metastatic colorectal cancer were treated with palliative RT at Samsung Medical Center. Initial presenting symptoms were pain (68 cases), bleeding (18 cases), and obstruction (nine cases). The pelvic mass originated from rectal cancer in 58 patients (73%) and from colon cancer in 22 patients (27%). Initially 72 patients (90%) were treated with surgery, including 64 complete local excisions; 77% in colon cancer and 81% in rectal cancer. The total RT dose ranged 8-60 Gy (median: 36 Gy) with 1.8-8 Gy per fraction. When the α/β for the tumor was assumed to be 10 Gy for the biologically equivalent dose (BED), the median RT dose was 46.8 Gy10 (14.4-78). Twenty one patients (26%) were treated with CCRT. Symptom palliation was assessed one month after the completion of RT. Results Symptom palliation was achieved in 80% of the cases. During the median follow-up period of five months (1-44 months), 45% of the cases experienced reappearance of symptoms; the median symptom control duration was five months. Median survival after RT was six months. On univariate analysis, the only significant prognostic factor for symptom control duration was BED ≥40 Gy10 (p < 0.05), and CCRT was a marginally significant factor (p = 0.0644). On multivariate analysis, BED and CCRT were significant prognostic factors for symptom control duration (p < 0.05). Conclusions RT was an effective palliation method in patients with a symptomatic pelvic mass of metastatic colorectal cancer. For improvement of symptom control rate and duration, a BED ≥ 40 Gy10 is recommended when possible. Considering the low morbidity and improved symptom palliation, CCRT might be considered in patients with good performance status.
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Affiliation(s)
- Sun Hyun Bae
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Advanced synchronous adenoma but not simple adenoma predicts the future development of metachronous neoplasia in patients with resected colorectal cancer. J Clin Gastroenterol 2010; 44:495-501. [PMID: 20351568 DOI: 10.1097/mcg.0b013e3181d6bd70] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Patients with resected colorectal cancer remain at a high risk for developing metachronous neoplasia in the remnant colorectum. The aim of this study was to identify baseline clinical and colonoscopic features predictive of metachronous neoplasia after curative resection of colorectal cancer. METHODS The baseline clinical and colonoscopic data and follow-up details of 503 patients who had colonoscopic surveillance after curative colorectal resection between January 2000 and October 2005 in a single tertiary institution were analyzed. Univariate and multivariate analyses were done to identify risk factors for metachronous adenoma. RESULTS Metachronous adenomas were diagnosed in 176 patients (35.0%) and advanced adenomas in 39 (7.8%) during the follow-up period (35.7+/-20.9 mo). Among the clinical and colonoscopic factors at baseline, advanced age (> or = 60 y) (odds ratio (OR)=3.64; 95% confidence intervals (CI), 1.55-8.52), the presence of advanced synchronous adenoma (OR=4.38; 95% CI, 1.77-10.85), and longer total follow-up period (OR=1.03; 95% CI, 1.01-1.04) were independently correlated with developing advanced metachronous adenoma. Patients who had synchronous tubular adenoma without advanced features at baseline were not found to have an increased risk for future development of advanced metachronous adenoma compared with those in the synchronous adenoma-free group (OR=1.75; 95% CI, 0.69-4.43, P=0.650). CONCLUSIONS Our data showed that patients with advanced synchronous adenoma at baseline were identified to have an increased risk of advanced metachronous neoplasia during a longer follow-up period but those with tubular adenoma without advanced features at baseline were not.
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Mirnezami AH, Sagar PM. Surgery for recurrent rectal cancer: technical notes and management of complications. Tech Coloproctol 2010; 14:209-16. [PMID: 20461538 DOI: 10.1007/s10151-010-0585-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Accepted: 04/21/2010] [Indexed: 12/12/2022]
Abstract
Local recurrence following surgery for rectal cancer remains a significant clinical problem and poses major therapeutic challenges. Radical surgical salvage is the only option with potential for curative treatment and is indicated in carefully selected patients. Surgery also provides acceptable palliation in certain cases. Nevertheless, such surgery is challenging, not commonly used, and historically associated with considerable morbidity and mortality. In more recent times, improvements in surgical techniques, reconstruction methods and management of perioperative complications have helped expand the options available for patients with recurrent rectal cancer. This review article highlights the techniques employed at our institution for the management of locally recurrent rectal cancer with particular emphasis on the surgical approaches, the methods used for reconstruction and the avoidance of complications.
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Affiliation(s)
- A H Mirnezami
- John Goligher Colorectal Unit, Clarendon Wing, Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, UK
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Hohenberger W, Lahmer G, Fietkau R, Croner RS, Merkel S, Göhl J, Sauer R. [Neoadjuvant radiochemotherapy for rectal cancer]. Chirurg 2009; 80:294-302. [PMID: 19350306 DOI: 10.1007/s00104-009-1707-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Neoadjuvant radiochemotherapy has become established treatment for rectal cancer. It is indicated when primary R0 resection is not an option, in cases of higher risk of locoregional relapse following surgical treatment alone, and when initially impossible conservation of the anal sphincter becomes possible in conjunction with neoadjuvant radiochemotherapy. The indication for radiochemotherapy in the upper third of the rectum is still controversial. Reevaluation of the tumor situation following neoadjuvant treatment is necessary before decisions on operative strategy. Modern imaging techniques are limited in this respect, as they hardly allow differentiation between living tumor tissue and lesions. In case of doubt clarity is possible only through surgical exploration, taking R1 resection into account. Overall the recognition of lymph node metastasis is not a sufficient indicator of local relapse. The frequency of postoperative complications following neoadjuvant radiochemotherapy is independent of the operative method. The effect of neoadjuvant radiochemotherapy on long-term survival and formation of distant metastases is still not clarified. Current studies seek clarification through the use of new chemotherapies and modified treatment regimes. Further, the correct time interval between the end of neoadjuvant radiochemotherapy and the following surgical therapy has yet to be determined. This applies also to the management of patients following complete remission.
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Affiliation(s)
- W Hohenberger
- Chirurgische Klinik, Universität Erlangen-Nürnberg, Krankenhausstrasse 12, Erlangen, Germany.
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A comparison between the treatment of low rectal cancer in Japan and the Netherlands, focusing on the patterns of local recurrence. Ann Surg 2009; 249:229-35. [PMID: 19212175 DOI: 10.1097/sla.0b013e318190a664] [Citation(s) in RCA: 161] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE Differences exist between Japan and The Netherlands in the treatment of low rectal cancer. The purpose of this study is to analyze these, with focus on the patterns of local recurrence. METHODS In The Netherlands, 755 patients were operated by total mesorectal excision (TME) for low rectal cancer, 379 received preoperative radiotherapy (RT+TME). Applying the same selection criteria resulted in 324 patients in the Japanese (NCCH) group, who received extended surgery consisting of lateral lymph node dissection and a wider abdominoperineal excision. The majority received no (neo) adjuvant therapy. Local recurrence images were examined by a radiologist and a surgeon. RESULTS Five-year local recurrence rates were 6.9% for the Japanese NCCH group, 5.8% in the Dutch RT+TME group, and 12.1% in the Dutch TME group. Recurrence rate in the lateral pelvis is 2.2%, 0.8%, and 2.7% in the Japanese, RT+TME group, and TME group, respectively. The incidence of presacral recurrences was low in the NCCH group (0.6%), compared with 3.7% and 3.2% in the RT+TME and TME groups, respectively. CONCLUSIONS Both extended surgery and RT+TME result in good local control, as compared with TME alone. Preoperative radiotherapy can sterilize lateral extramesorectal tumor particles. A wider abdominoperineal resection probably results in less presacral local recurrence. Comparison of the results is difficult because of differences in patient groups.
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MESSIOU C, CHALMERS AG, BOYLE K, WILSON D, SAGAR P. Pre-operative MR assessment of recurrent rectal cancer. Br J Radiol 2008; 81:468-73. [DOI: 10.1259/bjr/53300246] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Jacques AET, Rockall AG, Alijani M, Hughes J, Babar S, Aleong JAC, Cottrill C, Dorudi S, Reznek RH. MRI demonstration of the effect of neoadjuvant radiotherapy on rectal carcinoma. Acta Oncol 2008; 46:989-95. [PMID: 17851843 DOI: 10.1080/02841860701317865] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND PURPOSE In patients with locally advanced rectal cancer, neoadjuvant long course (45-54 Gy in 25-30 fractions) chemoradiotherapy (CRT) may reduce tumour size and result in downstaging. In patients with primary resectable tumour short course (25 Gy in 5 fractions) radiotherapy (SCRT) reduces local recurrence but downstaging the disease or altering tumour size has not been described. We aimed to assess change in tumour size on MRI after SCRT or CRT. MATERIALS AND METHODS Nineteen patients with rectal carcinoma underwent MRI before and after SCRT or CRT. In each case, tumour length and width were documented and number of locoregional lymph nodes recorded. Total mesorectal excision was performed in 15 patients and MR findings correlated with histopathology. RESULTS Ten patients received SCRT and nine CRT. Tumour length reduced by 19% overall (15% following SCRT, 23% following CRT). Greater than 30% reduction (partial response) in maximum tumour thickness was seen in 4/10 (40%) following SCRT and 5/9 (56%) following CRT. CONCLUSIONS Significant reduction in tumour size can be achieved with preoperative long course CRT and SCRT. This unexpected finding following SCRT has not been previously described.
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Affiliation(s)
- Audrey E T Jacques
- Academic Department of Radiology, St. Bartholomews' Hospital, London, UK.
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23
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Extended radical resection: the choice for locally recurrent rectal cancer. Dis Colon Rectum 2008; 51:284-91. [PMID: 18204879 DOI: 10.1007/s10350-007-9152-9] [Citation(s) in RCA: 162] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2007] [Revised: 08/30/2007] [Accepted: 09/02/2007] [Indexed: 02/06/2023]
Abstract
PURPOSE Surgery for recurrent rectal cancer is the only therapy with curative potential. This study was designed to assess factors that affect survival after surgery for locally recurrent rectal cancer. METHODS Prospective databases of patients undergoing surgical resection for recurrent rectal cancer at three tertiary centers between 1990 and 2006 were combined and analyzed. Cox regression and Kaplan-Meier survival analysis were used to assess factors associated with survival. RESULTS A total of 160 patients (96 males) underwent surgery (median age, 63 (range, 27-93) years). Ninety-five patients (59 percent) received neoadjuvant radiotherapy. Sixty-three patients (39 percent) underwent radical resection and 90 (56 percent) underwent extended radical resection. Seven patients (5 percent) were irresectable. There was one death and 27 percent had major postoperative complications, independent of extent of resection. Negative resection margins were obtained in 98 patients (R0 61 percent). Median cancer-specific and overall survival was 48 months (41.5 percent 5-year survival) and 43 months (36.6 percent 5-year survival), respectively. Margin involvement was a significant predictor of cancer-specific (P<0.001) and overall survival (P<0.02). CONCLUSIONS Resection for recurrent rectal cancer results in good survival with acceptable morbidity, unaffected by the extent of resection. Extended radical resection to obtain clear resection margins is the appropriate management of locally recurrent rectal cancer.
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Patterns of recurrence following therapy for rectal cancer. COLORECTAL CANCER 2007. [DOI: 10.1017/cbo9780511902468.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kobayashi A, Sugito M, Ito M, Saito N. Predictors of Successful Salvage Surgery for Local Pelvic Recurrence of Rectosigmoid Colon and Rectal Cancers. Surg Today 2007; 37:853-9. [PMID: 17879034 DOI: 10.1007/s00595-007-3518-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2006] [Accepted: 02/06/2007] [Indexed: 10/22/2022]
Abstract
PURPOSE We investigated the predictors of successful resection of recurrent tumors and improved survival in patients with local pelvic recurrence of rectosigmoid colon and rectal cancer. METHODS We analyzed the clinicopathological factors of 94 patients who underwent treatment between 1993 and 2002 for the local pelvic recurrence of curatively resected primary rectosigmoid colon and rectal adenocarcinoma. RESULTS Of the 94 patients, 48 underwent salvage surgery and 46 were treated conservatively. The survival rate of the patients who underwent salvage surgery was significantly higher than that of those treated conservatively (P < 0.0001). Logistic regression analysis revealed that the following factors were significantly associated with successful salvage surgery: tumor differentiation (well or moderately; P < 0.04), a long interval between the initial operation and the detection of recurrence (P < 0.03), and negative lymph node status at the initial operation (P < 0.02). The Cox proportional hazard model revealed the following predictors of better survival after surgery: tumor differentiation (well and moderate), negative lymph node status at the initial operation (pN0), and a perianastomotic pattern of recurrence. CONCLUSION The predictors of successful salvage surgery are the tumor differentiation and nodal status of the primary tumor, the interval between the initial operation and the detection of recurrence, and the pattern of tumor recurrence.
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Affiliation(s)
- Akihiko Kobayashi
- Division of Colorectal and Pelvic Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba 277-8577, Japan
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Sarikaya I, Povoski SP, Al-Saif OH, Kocak E, Bloomston M, Marsh S, Cao Z, Murrey DA, Zhang J, Hall NC, Knopp MV, Martin EW. Combined use of preoperative 18F FDG-PET imaging and intraoperative gamma probe detection for accurate assessment of tumor recurrence in patients with colorectal cancer. World J Surg Oncol 2007; 5:80. [PMID: 17634125 PMCID: PMC1941735 DOI: 10.1186/1477-7819-5-80] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2007] [Accepted: 07/16/2007] [Indexed: 11/20/2022] Open
Abstract
Background The purpose of this study was to combine intraoperative gamma probe (GP) detection with preoperative fluorine 18-fluoro-2-deoxy-glucose positron emission tomography (18F FDG-PET) imaging in order to improve detection of tumor recurrence in colorectal cancer (CRC) patients. Methods Twenty-one patients (12 females, 9 males) with a mean age of 54 years (range 31–78) were enrolled. Patients were suspected to have recurrent CRC by elevated CEA (n = 11), suspicious CT findings (n = 1), and clinically suspicious findings (n = 9). Preoperative FDG-PET scan and intraoperative GP study were performed in all patients. Mean time interval between preoperative FDG-PET scan and surgery was 16 days (range 1–41 days) in 19 patients. For intraoperative GP studies, 19 patients were injected with a dose of 10–15 mCi 18F FDG at approximately 30 minutes before the planned surgery time. In two patients, the intraoperative GP study was performed immediately after preoperative FDG-PET scan. Results Preoperative FDG-PET and intraoperative GP detected 48 and 45 lesions, respectively. A total of 50 presumed site of recurrent disease from 20 patients were resected. Thirty-seven of 50 presumed sites of recurrent disease were histological-proven tumor positive and 13 of 50 presumed sites of recurrent disease were histological-proven tumor negative. When correlated with final histopathology, the number of true positive lesions and false positive lesions by preoperative FDG-PET and intraoperative GP were 31/9 and 35/8, respectively. Both preoperative FDG-PET and intraoperative GP were true positive in 29 lesions. Intraoperative GP detected additional small lesions in the omentum and pelvis which were not seen on preoperative FDG-PET scan. FDG-PET scan demonstrated additional liver metastases which were not detected by intraoperative GP. Preoperative FDG-PET detected distant metastasis in the lung in one patient. The estimated radiation dose received by a surgeon during a single 18F FDG GP surgery was below the occupational limit. Conclusion The combined use of preoperative FDG-PET and intraoperative GP is potentially helpful to the surgeon as a roadmap for accurately locating and determining the extent of tumor recurrence in patients with CRC. While intraoperative GP appears to be more sensitive in detecting the extent of abdominal and pelvic recurrence, preoperative FDG-PET appears to be more sensitive in detecting liver metastases. FDG-PET is also a valuable method in detecting distant metastases.
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Affiliation(s)
- Ismet Sarikaya
- Division of Nuclear Medicine, Section of PET, Department of Radiology, The Ohio State University, Columbus, OH 43210, USA
| | - Stephen P Povoski
- Division of Surgical Oncology, Department of Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and Comprehensive Cancer Center, The Ohio State University, Columbus, OH 43210, USA
| | - Osama H Al-Saif
- Division of Surgical Oncology, Department of Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and Comprehensive Cancer Center, The Ohio State University, Columbus, OH 43210, USA
| | - Ergun Kocak
- Division of Surgical Oncology, Department of Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and Comprehensive Cancer Center, The Ohio State University, Columbus, OH 43210, USA
| | - Mark Bloomston
- Division of Surgical Oncology, Department of Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and Comprehensive Cancer Center, The Ohio State University, Columbus, OH 43210, USA
| | - Steven Marsh
- Division of Nuclear Medicine, Section of PET, Department of Radiology, The Ohio State University, Columbus, OH 43210, USA
| | - Zongjian Cao
- Department of Radiology, Medical College of Georgia, Augusta, GA 30912, USA
| | - Douglas A Murrey
- Division of Surgical Oncology, Department of Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and Comprehensive Cancer Center, The Ohio State University, Columbus, OH 43210, USA
| | - Jun Zhang
- Division of Nuclear Medicine, Section of PET, Department of Radiology, The Ohio State University, Columbus, OH 43210, USA
| | - Nathan C Hall
- Division of Nuclear Medicine, Section of PET, Department of Radiology, The Ohio State University, Columbus, OH 43210, USA
| | - Michael V Knopp
- Division of Nuclear Medicine, Section of PET, Department of Radiology, The Ohio State University, Columbus, OH 43210, USA
| | - Edward W Martin
- Division of Surgical Oncology, Department of Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and Comprehensive Cancer Center, The Ohio State University, Columbus, OH 43210, USA
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Ballesté B, Bessa X, Piñol V, Castellví-Bel S, Castells A, Alenda C, Paya A, Jover R, Xicola RM, Pons E, Llor X, Cordero C, Fernandez-Bañares F, de Castro L, Reñé JM, Andreu M. Detection of metachronous neoplasms in colorectal cancer patients: identification of risk factors. Dis Colon Rectum 2007; 50:971-80. [PMID: 17468913 DOI: 10.1007/s10350-007-0237-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Patients with colorectal cancer have a high risk of developing metachronous neoplasms. Identification of predictive factors associated with such conditions would allow individualized follow-up strategies in these patients. This study was designed to identify individual and familial factors associated with the development of metachronous colorectal neoplasms in patients with colorectal cancer. METHODS In the context of a prospective, multicenter, general population-based study-the EPICOLON project-all patients with colorectal cancer attended in ten Spanish hospitals during a one-year period were included. Patients with familial adenomatous polyposis or inflammatory bowel disease were excluded. All patients were monitored by colonoscopy within two years of the diagnoses. Demographic, clinical, pathologic, molecular (microsatellite instability status and immunohistochemistry for MSH2 and MLH1), and familial characteristics (fulfillment of Amsterdam I or II criteria, and revised Bethesda guidelines) were analyzed. RESULTS A total of 353 patients were included in the study. At two years of follow-up, colonoscopy revealed the presence of adenomas in 89 (25 percent) patients and colorectal cancer in 14 (3.9 percent) patients, in 7 cases restricted to anastomosis. Univariate analysis demonstrated that development of metachronous neoplasm (adenoma or colorectal cancer) was associated with personal history of previous colorectal cancer (odds ratio, 5.58; 95 percent confidence interval, 1.01-31.01), and presence of previous or synchronous adenomas (odds ratio, 1.77; 95 percent confidence interval, 1.21-3.17). Although nonstatistical significance was achieved, metachronisms were associated with gender (P<0.09) and differentiation degree (P<0.08). Multivariate analysis identified previous or synchronous adenomas (odds ratio, 1.98; 95 percent confidence interval, 1.16-3.38) as independent predictive factor. Neither presence of tumor DNA microsatellite instability nor family history correlated with the presence of metachronous neoplasms. CONCLUSIONS Patients with previous or synchronous colorectal adenoma have an increased risk of developing metachronous colorectal neoplasms. Accordingly, this subgroup of patients may benefit from specific surveillance strategies.
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Affiliation(s)
- Belen Ballesté
- Gastroenterology Department, Hospital del Mar, and University of Barcelona, Spain
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Chong PS, Finlay IG. Surgical options in the management of advanced and recurrent colorectal cancer. Surg Oncol 2007; 16:25-31. [PMID: 17532208 DOI: 10.1016/j.suronc.2007.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Peter S Chong
- University Department of Surgery, Glasgow Royal infirmary, 84, Castle Street, Glasgow, UK.
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Sarikaya I, Bloomston M, Povoski SP, Zhang J, Hall NC, Knopp MV, Martin EW. FDG-PET scan in patients with clinically and/or radiologically suspicious colorectal cancer recurrence but normal CEA. World J Surg Oncol 2007; 5:64. [PMID: 17555577 PMCID: PMC1896164 DOI: 10.1186/1477-7819-5-64] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2007] [Accepted: 06/07/2007] [Indexed: 12/19/2022] Open
Abstract
Background Although frequently used for tumor surveillance, the sensitivity of carcinoembryonic antigen (CEA) to detect recurrent colorectal cancer (CRC) is not optimal. Fluorine 18-fluoro-2-deoxy-glucose-positron emission tomography (18F FDG-PET) scans promise to improve recurrent CRC detection. We aimed to review PET scans of patients with clinically and/or radiologically suspicious tumor recurrence but normal CEA. Methods A retrospective review of an electronic database of 308 patients with CRC who had PET scans was performed. Only PET studies of patients with normal CEAs and suspected tumor recurrence who had pathological verification were selected for further analysis. Thirty-nine patients met the inclusion criteria. Results PET was positive in 26 patients (67%) and normal in 13 (33%). Histopathologic evidence of tumor recurrence was seen in 27 of the 39 patients (69%). When correlated with histopathology, PET was true positive in 22 patients, false positive in 4, true negative in 8 and false negative in 5. Overall, the accuracy of PET was 76.9%, negative predictive value (NPV) was 61.5%, and positive predictive value (PPV) was 84.6%. PPV value of PET for liver metastases was 88.8% compared to 73.3% for local recurrence. In two patients with confirmed recurrence, CEA became positive 2 months after PET scan indicating earlier detection of disease with PET. The false positive PET findings were mainly in the bowel and were secondary to acute/chronic inflammation and granulation tissue. In 3 patients with false negative PET, histopathology was consistent with mucinous adenocarcinoma. Conclusion PET yields high PPV for recurrent CRC, particularly for liver metastases, in spite of normal CEA levels and should be considered early in the evaluation of patients with suspected tumor recurrence.
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Affiliation(s)
- Ismet Sarikaya
- Division of Nuclear Medicine, Section of PET, Department of Radiology, The Ohio State University, Columbus, OH, 43210, USA
| | - Mark Bloomston
- Division of Surgical Oncology, Department of Surgery, Arthur G. James Cancer Hospital The Ohio State University, Columbus, OH 43210, USA
- Richard J. Solove Research Institute and Comprehensive Cancer Center, The Ohio State University, Columbus, OH 43210, USA
| | - Stephen P Povoski
- Division of Surgical Oncology, Department of Surgery, Arthur G. James Cancer Hospital The Ohio State University, Columbus, OH 43210, USA
- Richard J. Solove Research Institute and Comprehensive Cancer Center, The Ohio State University, Columbus, OH 43210, USA
| | - Jun Zhang
- Division of Nuclear Medicine, Section of PET, Department of Radiology, The Ohio State University, Columbus, OH, 43210, USA
| | - Nathan C Hall
- Division of Nuclear Medicine, Section of PET, Department of Radiology, The Ohio State University, Columbus, OH, 43210, USA
| | - Michael V Knopp
- Division of Nuclear Medicine, Section of PET, Department of Radiology, The Ohio State University, Columbus, OH, 43210, USA
| | - Edward W Martin
- Division of Surgical Oncology, Department of Surgery, Arthur G. James Cancer Hospital The Ohio State University, Columbus, OH 43210, USA
- Richard J. Solove Research Institute and Comprehensive Cancer Center, The Ohio State University, Columbus, OH 43210, USA
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Gavioli M, Losi L, Luppi G, Iacchetta F, Zironi S, Bertolini F, Falchi AM, Bertoni F, Natalini G. Preoperative therapy for lower rectal cancer and modifications in distance from anal sphincter. Int J Radiat Oncol Biol Phys 2007; 69:370-5. [PMID: 17524570 DOI: 10.1016/j.ijrobp.2007.03.049] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2007] [Revised: 03/19/2007] [Accepted: 03/20/2007] [Indexed: 01/08/2023]
Abstract
PURPOSE To assess the frequency and magnitude of changes in lower rectal cancer resulting from preoperative therapy and its impact on sphincter-saving surgery. Preoperative therapy can increase the rate of preserving surgery by shrinking the tumor and enhancing its distance from the anal sphincter. However, reliable data concerning these modifications are not yet available in published reports. METHODS AND MATERIALS A total of 98 cases of locally advanced cancer of the lower rectum (90 Stage uT3-T4N0-N+ and 8 uT2N+M0) that had undergone preoperative therapy were studied by endorectal ultrasonography. The maximal size of the tumor and its distance from the anal sphincter were measured in millimeters before and after preoperative therapy. Surgery was performed 6-8 weeks after therapy, and the histopathologic margins were compared with the endorectal ultrasound data. RESULTS Of the 90 cases, 82.5% showed tumor downsizing, varying from one-third to two-thirds or more of the original tumor mass. The distance between the tumor and the anal sphincter increased in 60.2% of cases. The median increase was 0.73 cm (range, 0.2-2.5). Downsizing was not always associated with an increase in distance. Preserving surgery was performed in 60.6% of cases. It was possible in nearly 30% of patients in whom the cancer had reached the anal sphincter before the preoperative therapy. The distal margin was tumor free in these cases. CONCLUSION The results of our study have shown that in very low rectal cancer, preoperative therapy causes tumor downsizing in >80% of cases and in more than one-half enhances the distance between the tumor and anal sphincter. These modifications affect the primary surgical options, facilitating or making sphincter-saving surgery possible.
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Affiliation(s)
- Margherita Gavioli
- Divisione di Chirurgia II, Nuovo Ospedale Civile S. Agostino-Estense, Modena, Italy.
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Jeffery M, Hickey BE, Hider PN. Follow-up strategies for patients treated for non-metastatic colorectal cancer. Cochrane Database Syst Rev 2007:CD002200. [PMID: 17253476 DOI: 10.1002/14651858.cd002200.pub2] [Citation(s) in RCA: 166] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND It is common clinical practice to follow patients with colorectal cancer (CRC) for several years following their definitive surgery and/or adjuvant therapy. Despite this widespread practice there is considerable controversy about how often patients should be seen, what tests should be performed and whether these varying strategies have any significant impact on patient outcomes. OBJECTIVES To review the available evidence concerning the benefits of intensive follow up of colorectal cancer patients with respect to survival. Secondary endpoints include time to diagnosis of recurrence, quality of life and the harms and costs of surveillance and investigations. SEARCH STRATEGY Relevant trials were identified by electronic searches of MEDLINE, EMBASE, CINAHL, CANCERLIT, Cochrane Controlled Trials Register, Science Citation Index, conference proceedings, trial registers, reference lists and contact with experts in the field. SELECTION CRITERIA Only randomised controlled trials comparing different follow-up strategies for patients with non-metastatic CRC treated with curative intent were included. DATA COLLECTION AND ANALYSIS Trial eligibility and methodological quality were assessed independently by the three authors. MAIN RESULTS Eight studies were included in this update of the review. There was evidence that an overall survival benefit at five years exists for patients undergoing more intensive follow up OR was 0.73 (95% CI 0.59 to 0.91); and RD -0.06 (95% CI -0.11 to -0.02). The absolute number of recurrences was similar; OR was 0.91 (95% CI 0.75 to 1.10); and RD -0.02 (95% CI -0.06 to 0.02) and although the weighted mean difference for the time to recurrence was significantly reduced by -6.75 (95% CI -11.06 to -2.44) there was significant heterogeneity between the studies. Analyses demonstrated a mortality benefit for performing more tests versus fewer tests OR was 0.64 (95% CI 0.49 to 0.85), and RD -0.09 (95%CI -0.14 to -0.03) and liver imaging versus no liver imaging OR was 0.64 (95% CI 0.49 to 0.85), and RD -0.09 (95%CI -0.14 to -0.03). There were significantly more curative surgical procedures attempted in the intensively followed arm: OR 2.41(95% CI 1.63 to 3.54), RD 0.06 (95%CI 0.04 to 0.09). No useful data on quality of life, harms or cost-effectiveness were available for further analysis. AUTHORS' CONCLUSIONS The results of our review suggest that there is an overall survival benefit for intensifying the follow up of patients after curative surgery for colorectal cancer. Because of the wide variation in the follow-up programmes used in the included studies it is not possible to infer from the data the best combination and frequency of clinic (or family practice) visits, blood tests, endoscopic procedures and radiological investigations to maximise the outcomes for these patients. Nor is it possible to estimate the potential harms or costs of intensifying follow up for these patients in order to adopt a cost-effective approach in this clinical area. Large clinical trials underway or about to commence are likely to contribute valuable further information to clarify these areas of clinical uncertainty.
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Affiliation(s)
- M Jeffery
- Christchurch Hospital, Oncology Service, Private Bag 4710, Christchurch, New Zealand.
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Abstract
OBJECTIVE Despite improvement in management of primary rectal cancer, 2.6-32% of patients develop local recurrence. A proportion of these patients can be amenable to salvage surgery. The present article reviews the evidence for and against the surgical management for local recurrence of rectal cancer, the role of adjuvant and intraoperative radiotherapy (IORT), and evaluates short and long-term outcomes. METHOD A literature search was performed using Medline, Embase, Ovid and Cochrane database for studies between 1980 and 2005 assessing surgical management of local recurrence of rectal cancer and the evidence was critically evaluated. RESULTS Nearly 50% of rectal cancer recurrences are local and are therefore potentially amenable to curative resection. Preoperative imaging is important for appropriate selection of patients for surgery and preoperative adjuvant therapy is essential. Five-year survival following resection ranges from 18% to 58% with 5-year survival following complete resection of over 35% though morbidity ranges from 21% to 82%. Neoadjuvant radiotherapy is beneficial and IORT may have a contributory role in treatment. Aggressive surgical treatment favourably affects quality of life and is cost effective. Surgery for local recurrence can result in significant long-term survival with acceptable morbidity and improved quality of life in appropriately selected patients. Assessment in a specialist centre familiar with these techniques is essential.
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Affiliation(s)
- A G Heriot
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.
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Okaro AC, Worthington T, Stebbing JF, Broughton M, Caffarey S, Marks CG. Curative resection for low rectal adenocarcinoma: abdomino-perineal vs anterior resection. Colorectal Dis 2006; 8:645-9. [PMID: 16970573 DOI: 10.1111/j.1463-1318.2006.01045.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Local recurrence after abdomino-perineal excision of the rectum for tumours has been reported to occur in up to a third of patients in contrast to 4% after restorative anterior resection. METHOD Low rectal tumours were defined as tumours within 8 cm of the anal verge and were treated by either stapled low anterior resection (SLAR) or abdomino-perineal excision of the rectum (APER). One hundred and seventy-eight patients with tumours in the lower third of the rectum (30% of 591 rectal cancers) underwent surgical resection between 1980 and 2001. Data were collected prospectively; 68 (38%) had SLAR and 110 (62%) had APER with median follow up of approximately 12 years; 54 SLAR (79%) and 76 APER (69%) had curative procedures on clinical and pathological criteria. RESULTS Local and distant recurrence occurred in seven (13%) and eight (15%) patients in the SLAR group and six (8%) and 14 (18%) patients in the APER group, respectively. Overall 5-year survival was 63% and 60% in the SLAR and APER groups, respectively CONCLUSION For rectal cancers within 8 cm of the anal verge, both procedures achieved equivalent results measured by low local recurrence rates and overall survival.
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Affiliation(s)
- A C Okaro
- Colorectal Unit, Royal Surrey County Hospital, Guildford, Surrey, UK
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Melton GB, Paty PB, Boland PJ, Healey JH, Savatta SG, Casas-Ganem JE, Guillem JG, Weiser MR, Cohen AM, Minsky BD, Wong WD, Temple LK. Sacral resection for recurrent rectal cancer: analysis of morbidity and treatment results. Dis Colon Rectum 2006; 49:1099-107. [PMID: 16779712 DOI: 10.1007/s10350-006-0563-9] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Composite sacropelvic resection for locally advanced recurrent rectal cancer is a high-risk procedure that benefits select patients. We reviewed our recent institutional experience to evaluate case selection, morbidity, and outcomes. METHODS Between 1987 and 2004, 29 patients underwent composite resection for recurrent locoregional rectal cancer (17 females; median age, 60 years). Clinicopathologic indicators were evaluated as indicators of survival by log-rank test and Cox proportional hazards model. RESULTS Of 29 total patients, 27 (93 percent) received radiotherapy with their previous surgery (n = 10; 34 percent) or before sacrectomy (n = 17; 59 percent), and 12 (41 percent) received intraoperative therapy. Sacral resections were performed at S2/S3 (55 percent) or S4/S5 (45 percent) using anterior (41 percent) or combined anterior-posterior approach (59 percent), with adherence to (62 percent) or cortical invasion in (38 percent) the sacrum. A majority of those who had undergone previous abdominoperineal resection had total exenteration (9/13), whereas most patients who had undergone a previous sphincter-preserving procedure had abdominoperineal resection (12/16) and none had exenteration. Pedicle flaps (omental, 11; abdominal rectus, 7) often were used. A median of five (range, 1-33) units of blood was given intraoperatively. Transfusions were associated with previous abdominoperineal resection (P < 0.03), correlating strongly with postoperative morbidity (P < 0.02). There were 33 complications in 17 (59 percent) patients, most commonly perineal wound breakdown (9 (31 percent)) and pelvic abscess (5 (17 percent)). Median hospital stay was 18 (range, 7-56) days, significantly longer in patients with previous abdominoperineal resection (P < 0.02) or postoperative morbidity (P < 0.03). The only postoperative death was from pelvic sepsis. Resection was complete (R0) in 18 patients (62 percent), with microscopically positive margins (R1) in 10 (34 percent) and grossly positive margins (R2) in 1 (3 percent). Two-year and five-year recurrence rates were 47 and 85 percent, respectively; disease-specific survival was 63 and 20 percent, respectively. Less transfusion (P = 0.03), R0 resection (P = 0.005), lack of anterior organ involvement (P = 0.02), and absence of cortical bone invasion (P < 0.001) were associated with better survival on univariate analysis; original colorectal cancer stage was not. CONCLUSIONS Sacrectomy for rectal cancer is a high-risk procedure that can achieve clear resection margins with low mortality in select patients. This procedure has a low cure rate but may provide local disease control with acceptable morbidity.
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Affiliation(s)
- Genevieve B Melton
- Division of Colorectal Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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Messiou C, Chalmers A, Boyle K, Sagar P. Surgery for recurrent rectal carcinoma: The role of preoperative magnetic resonance imaging. Clin Radiol 2006; 61:250-8. [PMID: 16488206 DOI: 10.1016/j.crad.2005.11.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2005] [Revised: 10/24/2005] [Accepted: 11/01/2005] [Indexed: 12/13/2022]
Abstract
Despite apparent curative resection of rectal carcinoma, local recurrence rates of between 3 and 32% have been reported. For those patients, radical surgical resection offers the only hope of cure. We present a review of the magnetic resonance imaging (MRI) findings and contraindications to curative surgery demonstrated using imaging.
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Folkesson J, Birgisson H, Pahlman L, Cedermark B, Glimelius B, Gunnarsson U. Swedish Rectal Cancer Trial: long lasting benefits from radiotherapy on survival and local recurrence rate. J Clin Oncol 2005; 23:5644-50. [PMID: 16110023 DOI: 10.1200/jco.2005.08.144] [Citation(s) in RCA: 544] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To evaluate the long-term effects on survival and recurrence rates of preoperative radiotherapy in the treatment of curatively operated rectal cancer patients. PATIENTS AND METHODS Of 1,168 randomly assigned patients in the Swedish Rectal Cancer Trial between 1987 and 1990, 908 had curative surgery; 454 of these patients had surgery alone, and 454 were administered preoperative radiotherapy (25 Gy in 5 days) followed by surgery within 1 week. Follow-up was performed by matching against three Swedish nationwide registries (the Swedish Cancer Register, the Hospital Discharge Register, and the Cause of Death Register). RESULTS Median follow-up time was 13 years (range, 3 to 15 years). The overall survival rate in the irradiated group was 38% v 30% in the nonirradiated group (P = .008). The cancer-specific survival rate in the irradiated group was 72% v 62% in the nonirradiated group (P = .03), and the local recurrence rate was 9% v 26% (P < .001), respectively. The reduction of local recurrence rates was observed at all tumor heights, although it was not statistically significant for tumors greater than 10 cm from the anal verge. CONCLUSION Preoperative radiotherapy with 25 Gy in 1 week before curative surgery for rectal cancer is beneficial for overall and cancer-specific survival and local recurrence rates after long-term follow-up.
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Affiliation(s)
- Joakim Folkesson
- Department of Surgical Sciences and Oncology, Uppsala University Hospital, 751 85 Uppsala, Sweden.
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37
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Zaks T, Sun W. Cancers of the large bowel and hepatobiliary tract. ACTA ACUST UNITED AC 2005; 22:443-69. [PMID: 16110624 DOI: 10.1016/s0921-4410(04)22020-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Affiliation(s)
- Tal Zaks
- University of Pennsylvania Cancer Center, Philadelphia, PA 19104-4283, USA
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38
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Boyle KM, Sagar PM, Chalmers AG, Sebag-Montefiore D, Cairns A, Eardley I. Surgery for locally recurrent rectal cancer. Dis Colon Rectum 2005; 48:929-37. [PMID: 15785880 DOI: 10.1007/s10350-004-0909-0] [Citation(s) in RCA: 114] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Resection of locally recurrent rectal cancer after curative resection represents a difficult clinical problem and a surgical challenge. The aim of this study was to assess the outcome of a series of patients who underwent resection of locally recurrent rectal cancer with curative intent. METHODS A retrospective review was performed of 64 patients who underwent surgical exploration with a view to cure for locally recurrent rectal cancer under the care of one surgeon between April 1997 and April 2004. Details were obtained on the primary tumor and the operation, the indication for investigation of recurrence, preoperative imaging, operative findings, morbidity and mortality, and histopathology. RESULTS The median time interval between resection of primary tumor and surgery for locally recurrent disease was 31 (interquartile range, 21 to 48) months. Twenty-three patients had central disease, 10 patients had sacral involvement, 21 patients had pelvic sidewall involvement, and 10 patients had both sacral and sidewall involvement. Fifty-seven patients underwent resection of the tumor. Thirty-nine of the 57 patients underwent wide resection (abdominoperineal excision of rectum, anterior resection, or Hartmann's procedure) whereas 18 patients (31.6 percent) required radical resection (pelvic exenteration or sacrectomy). Curative, negative resection margins were obtained in 21 of 57 patients who had tumor excision (36.8 percent). Perioperative mortality was 1.6 percent. Significant postoperative morbidity occurred in 40 percent of patients. CONCLUSIONS This study has shown that a significant proportion of patients with locally recurrent rectal cancer can undergo resection with negative margins.
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Affiliation(s)
- Kirsten M Boyle
- Department of Surgery, The General Infirmary at Leeds, Leeds LS1 3EX, UK
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Sun W, Haller D. Cancers of the large bowel and hepatobiliary tract. ACTA ACUST UNITED AC 2004; 21:509-34. [PMID: 15338761 DOI: 10.1016/s0921-4410(03)21024-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Affiliation(s)
- Weijing Sun
- University of Pennsylvania Cancer Center, Philadelphia 19104-4283, USA.
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Peeters KCMJ, van de Velde CJH. Quality assurance of surgery in gastric and rectal cancer. Crit Rev Oncol Hematol 2004; 51:105-19. [PMID: 15276175 DOI: 10.1016/j.critrevonc.2004.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2004] [Indexed: 12/16/2022] Open
Abstract
Multimodality and quality controlled treatment result in improved treatment outcome in patients with solid tumours. Quality assurance focuses on identifying and reducing variations in treatment strategy. Treatment outcome is subsequently improved through the introduction of programs that reduce treatment variations to an acceptable level and implement standardised treatment. In chemotherapy and radiotherapy, such programmes have been introduced successfully. In surgery however, there has been little attention for quality assurance so far. Surgery is the mainstay in the treatment of patients with gastric and rectal cancer. In gastric cancer, the extent of surgery is continuously being debated. In Japan, extended lymph node dissection is favoured whereas in the West this type of surgery is not routinely performed with two large European trials concluding that there is no survival benefit from regional lymph node clearance. Post-operative chemoradiation is part of the standard treatment in the United States, although its role in combination with adequate surgery has not been established yet. These global differences in treatment policy clearly relate to the extent and quality of surgical treatment. As for gastric cancer, surgical treatment of rectal cancer patients determines patient's prognosis to a large extent. With the introduction of total mesorectal excision, local control and survival have improved substantially. Most rectal cancer patients receive adjuvant treatment, either pre- or post-operatively. The efficacy of many adjuvant treatment regimens has been investigated in combination with conventional suboptimal surgery. Traditional indications of adjuvant treatment might have to be re-examined, considering the substantial changes in surgical practise. Quality assurance programs enable the introduction of standardised and quality controlled surgery. Promising adjuvant regimens should be investigated in combination with optimal surgery.
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Affiliation(s)
- K C M J Peeters
- Department of Surgery, Leiden University Medical Center, K6-R, P.O. Box 9600, 2300 RC Leiden, The Netherlands.
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41
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Abstract
Pre- and postoperative adjuvant treatments for locally advanced, operable (R0 resection) rectum carcinoma have led to improved results. In principle, according to the interdisciplinary consensus of the German Cancer Society, the recommended treatment for rectum carcinoma (T3/4; N0; M0; any T stage; N+; M0) is still postoperative adjuvant radiochemotherapy. In the meantime, however, based on the good results obtained from various clinical trials preoperative adjuvant treatment is favored internationally. Not only does this treatment scheme show a comparably better compliance of the patients but it also seems to be better tolerated. One treatment option for resectable T3 tumors immediately followed by surgery is the sole hypofractionated preoperative 3-4 field external beam radiotherapy. An additional benefit can be expected from protracted preoperative radiochemotherapy (single dose 2 Gy, total dose >40 Gy, chemotherapy based on 5-FU) followed by operation several weeks later. For T4 tumors with expected R1 or R2 resection, preoperative treatment is urgently recommended. A further aim in compliance with the surgical approach (R0 resection!) and multimodal treatment may be for individual cases the preservation of continence.
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Affiliation(s)
- F Zimmermann
- Klinik und Poliklinik für Strahlentherapie und Radiologische Onkologie, Klinikum rechts der Isar der Technischen Universität München
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42
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Abstract
Rectal cancer is one of the most frequent neoplasias, with an incidence of 40 in 100,000. For the effective use of new, differentiated treatment options, exact preoperative tumour staging is essential. The tumour stage determines whether radiation or chemotherapy should be used in addition to surgery. Endosonography allows exact differentiation of the rectal wall layers and thus of tumour stages 1-3 with median accuracy of 89%. Magnetic resonance imaging (MRI) can be employed in high and stenosing tumours and leads to an average accuracy of 85%. In recent studies, it has been shown that MRI is a valuable tool to identify the mesorectal fascia. This is a very important feature concerning the resectability and the risk of recurrence. Both, Endosonograpy and MRI plays an important and complimentary role in staging rectal cancer.
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Affiliation(s)
- Andrea Maier
- Department of Radiology, University of Vienna, Wachringer Guertel 18-20, Vienna 1090, Austria.
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Hartley JE, Lopez RA, Paty PB, Wong WD, Cohen AM, Guillem JG. Resection of locally recurrent colorectal cancer in the presence of distant metastases: can it be justified? Ann Surg Oncol 2003; 10:227-33. [PMID: 12679306 DOI: 10.1245/aso.2003.05.039] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND We aimed to determine the outcome of resections for local recurrence of colorectal carcinoma in the presence of distant (M1) disease. METHODS Patients who underwent resection of local recurrence in the presence of potentially resectable M1 disease were identified from the colorectal database. Outcome was determined by chart review. RESULTS Forty-two patients (23 men) of mean age 60 years (range, 34-88 years) underwent complete gross resection of their local recurrence in the presence of M1 disease. Thirteen of the 42 underwent synchronous M1 resections to render them free of gross disease (R0). Nine of the 29 patients who left with residual disease (R1) subsequently underwent staged M1 resection, so that 22 of 42 were rendered R0 by surgery. The median survival of all patients was 14.5 months (interquartile range, 6-30 months), and that of patients rendered R0 was 23 months (interquartile range, 10-37 months), in comparison with 7 months (interquartile range, 3-25 months) for those of R1 status (P =.006; log-rank method). Ability to achieve R0 status by synchronous or staged resection was the only factor predictive of survival. CONCLUSIONS The presence of M1 disease per se should not preclude resection of local recurrence, although case selection is problematic.
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Affiliation(s)
- J E Hartley
- Colorectal Service, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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44
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Tumores sacropélvicos primarios y secundarios. Tratamiento con cirugía radical y radioterapia intraoperatoria. Cir Esp 2003. [DOI: 10.1016/s0009-739x(03)72096-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Miner TJ, Jaques DP, Paty PB, Guillem JG, Wong WD. Symptom control in patients with locally recurrent rectal cancer. Ann Surg Oncol 2003; 10:72-9. [PMID: 12513964 DOI: 10.1245/aso.2003.03.040] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Although resection of locally recurrent rectal cancer has been associated with improved survival, clinical outcomes after such repeat surgery have been incompletely characterized. METHODS From 1997 to 1999, 105 consecutive patients requiring repeat surgery for locally recurrent rectal cancer were identified. Patients were observed for a minimum of 2 years or until death. RESULTS An operation was performed with palliative intent in 23% of patients. Before repeat surgery, 79% of the palliative-intent patients had symptoms: 21% bleeding, 42% obstruction, and 21% pain. After repeat surgery with palliative intent, improvement was noted in 40% with bleeding, 70% with obstruction, and 20% with pain. Additional or recurrent symptoms were noted in 87% during follow-up. Seventy-seven percent of patients had an operation with nonpalliative intent. Before repeat surgery, 57% of nonpalliative patients had symptoms, with 32% experiencing bleeding, 11% obstruction, and 19% pain. After repeat surgery with nonpalliative intent, initial improvement was noted in 88% with bleeding, 78% with obstruction, and 40% with pain. During follow-up, symptoms arose in 37% of the initially asymptomatic patients, and additional or recurrent symptoms were seen in 63% of those previously symptomatic. CONCLUSIONS Although symptomatic relief is associated with repeat surgery, the recurrence or development of alternate symptoms makes a completely asymptomatic clinical course uncommon.
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Affiliation(s)
- Thomas J Miner
- Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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Esnaola NF, Cantor SB, Johnson ML, Mirza AN, Miller AR, Curley SA, Crane CH, Cleeland CS, Janjan NA, Skibber JM. Pain and quality of life after treatment in patients with locally recurrent rectal cancer. J Clin Oncol 2002; 20:4361-7. [PMID: 12409336 DOI: 10.1200/jco.2002.02.121] [Citation(s) in RCA: 97] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Because survival in patients with locally recurrent rectal cancer (LRRC) is limited, pain control and quality of life (QOL) are important parameters. The purpose of this study was to assess the prevalence of posttreatment pain and QOL of patients with LRRC treated with nonsurgical palliation or resection and identify predictors of poor outcome. PATIENTS AND METHODS Posttreatment pain severity and QOL were prospectively assessed in 45 patients with LRRC using the Brief Pain Inventory and Functional Assessment of Cancer Therapy-Colorectal questionnaire. RESULTS Fifteen patients received nonsurgical palliation, and 30 patients underwent resection of their pelvic tumors. There was a significant association between higher posttreatment pain scores and worse QOL (P <.001). Patients treated with nonsurgical palliation reported moderate to severe pain beyond the third month of treatment. Resected patients reported comparable levels of pain during the first 3 postoperative years, particularly after bony resections; long-term survivors (beyond 3 years), however, reported minimal pain and good QOL. Female sex, pelvic/sciatic pain at presentation, total pelvic exenteration, and bony resection were associated with higher rates of moderate to severe posttreatment pain (P =.04, P <.001, P =.04, and P =.02, respectively). Pain at presentation was an independent predictor of posttreatment pain (odds ratio, 7.4 [95% confidence interval, 1.8 to 30.3]; P =.006). CONCLUSION Patients with LRRC treated with nonsurgical palliation or resection experience significant levels of pain after treatment. Close posttreatment pain monitoring is warranted in patients presenting with pelvic pain, and more aggressive pain management strategies may improve posttreatment QOL.
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Affiliation(s)
- Nestor F Esnaola
- Department of Surgery, Pain Research Group, The University of Texas M.D. Anderson Cancer Center, Houston 77030-4009, USA.
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47
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Kapiteijn E, van de Velde CJH. The role of total mesorectal excision in the management of rectal cancer. Surg Clin North Am 2002; 82:995-1007. [PMID: 12507205 DOI: 10.1016/s0039-6109(02)00040-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
During the past decade, it has been clearly demonstrated that adjuvant treatment has the potential of improving not only prognosis in terms of local recurrence, but also in terms of overall survival. However, one of the largest improvements in the outcome of rectal cancer has been the introduction of total mesorectal excision. TME, with its large decline in local recurrence rate, has become the new standard of operative management for rectal cancers, replacing conventional resection technique [68]. In addition, current clinical trials examining the role of adjuvant therapy in patients who are undergoing standardized operations are now setting the standard of surgical care in several countries.
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Affiliation(s)
- E Kapiteijn
- Department of Surgery K6-R, Leiden University Medical Center, Post Office Box 9600, 2300 RC Leiden, The Netherlands
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48
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Abstract
With effective chemotherapy as adjuvant treatment, the survival benefit is clearly achieved for certain (stage III) colorectal cancer patients, though there still exist many unsettled issues including the controversies in the treatment of stage II disease. Advances in the development of a new generation of cytotoxic agents in the past several years have allowed us to move forward from the "fluorouracil-only era" in the treatment of advanced/metastatic colorectal cancer. It is still not very clear how best to minimize toxicity without compromising efficacy of the combination therapy with newer agents, or how to maximize the benefit of chemotherapy (concurrent versus sequential). There are many current ongoing clinical trials designed to address these issues. With better understanding of the signal transduction and molecular biology characteristics of colorectal cancer, and the development of biologic and molecular target agents, the outcomes of patients with colorectal cancer will be improved further. Future clinical trials should be focused on optimizing and individualizing therapy for patients based on their molecular profiles to achieve maximal clinical benefit.
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Affiliation(s)
- Weijing Sun
- Hematology/Oncology Division, Univeristy of Pennsylvania Medical Center, 16 Penn Tower, 3400 Spruce Street, Philadelphia, PA 19104-4283, USA.
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49
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Dowdall JF, Maguire D, McAnena OJ. Experience of surgery for rectal cancer with total mesorectal excision in a general surgical practice. Br J Surg 2002; 89:1014-9. [PMID: 12153627 DOI: 10.1046/j.1365-2168.2002.02158.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Results from specialist centres have shown that total mesorectal excision (TME) produces excellent control of local disease in patients with carcinoma of the rectum. METHODS The results of TME were reviewed in a surgical practice in which patients with rectal cancer comprised 1 per cent of the total caseload and mean case numbers were less than 15 each year. RESULTS Eighty-two consecutive patients underwent rectal excision with TME over a 72-month period (68 anterior resection, eight abdominoperineal excision and six Hartmann's procedure). Sixty-nine operations were deemed 'curative' at the time of surgery. Anastomotic leak occurred in two (3 per cent) of 68 patients, both of whom recovered without additional surgery. There were two local recurrences (3 per cent) among 69 patients who underwent 'curative' surgery. At a median follow-up of 190 weeks, the survival rate for Dukes' stage A, B, C and 'D' was 100, 83, 68 and 18 per cent respectively. CONCLUSION Outcome as measured by perioperative morbidity and local disease control achieved in a surgical practice with a broad case mix and relatively low annual case volume was comparable to that from larger centres. Appropriate surgical training and attention to technical detail may be as important as case volume in determining outcome after surgery for rectal cancer.
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Affiliation(s)
- J F Dowdall
- Department of Surgery, University College Hospital, Galway, Ireland
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Steup WH, Moriya Y, van de Velde CJH. Patterns of lymphatic spread in rectal cancer. A topographical analysis on lymph node metastases. Eur J Cancer 2002; 38:911-8. [PMID: 11978516 DOI: 10.1016/s0959-8049(02)00046-1] [Citation(s) in RCA: 107] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The presence of lymph node (LN) metastases is the most important prognostic factor in rectal cancer. The exact LN status can only be known when an extended lymph node dissection (LND) has been performed, a process not routinely performed. If the likelihood of LN metastases can be more accurately assessed preoperatively, then an optimal multimodality treatment plan can be established. 605 patients with primary rectal cancer operated upon with wide LND (D3 level) were analysed for LN metastases combining topographical localisation and morphological features of the tumour. More distal rectal tumours tend to more LN metastases and more lateral lymphatic spread. Tumours >or=3 cm show more LN metastases compared with those smaller than 3 cm. Depth of bowel wall invasion is strongly related to the presence of LN metastases. The peritoneal reflection has no discriminating role in the mode of spread. Intra-operative assessment by the surgeon for presence of LN metastases is not reliable. When localisation, depth of bowel wall invasion and diameter of a rectal tumour are known, a likelihood of LN metastases can be assessed pre-operatively, not intra-operatively.
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Affiliation(s)
- W H Steup
- Department of Surgery, Leyenburg Hospital, The Hague, The Netherlands.
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