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Fadel MG, Ahmed M, Shaw A, Fehervari M, Kontovounisios C, Brown G. Oncological outcomes of local excision versus radical surgery for early rectal cancer in the context of staging and surveillance: A systematic review and meta-analysis. Cancer Treat Rev 2024; 128:102753. [PMID: 38761791 DOI: 10.1016/j.ctrv.2024.102753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 05/09/2024] [Accepted: 05/11/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Local resection (LR) methods for rectal cancer are generally considered in the palliative setting or for patients deemed a high anaesthetic risk. This systematic review and meta-analysis aimed to compare oncological outcomes of LR and radical resection (RR) for early rectal cancer in the context of staging and surveillance assessment. METHODS A literature search of MEDLINE, Embase and Emcare databases was performed for studies that reported data on clinical outcomes for both LR and RR for early rectal cancer from January 1995 to April 2023. Meta-analysis was performed using random-effect models and between-study heterogeneity was assessed. The quality of assessment was assessed using the Newcastle-Ottawa Scale for observational studies and the Cochrane Risk of Bias 2.0 tool for randomised controlled trials. RESULTS Twenty studies with 12,022 patients were included: 6,476 patients had LR and 5,546 patients underwent RR. RR led to an improvement in 5-year overall survival (OR 1.84; 95 % CI 1.54-2.20; p < 0.0001; I2 20 %) and local recurrence (OR 3.06; 95 % CI 2.02-4.64; p < 0.0001; I2 39 %) when compared to LR. However, when staging and surveillance methods were clearly adopted in LR cases, there was an improvement in R0 rates (96.7 % vs 85.6 %), 5-year disease-free survival (93.0 % vs 77.9 %) and overall survival (81.6 % vs 79.0 %) compared to when staging and surveillance was not reported/performed. CONCLUSIONS LR may be appropriate for selected patients without poor prognostic factors in early rectal cancer. This study also highlights that there is currently no single standardised staging or surveillance approach being adopted in the management of early rectal cancer. A more specified and standardised preoperative staging for patient selection as well as clinical and image-based surveillance protocols is needed.
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Affiliation(s)
- Michael G Fadel
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom; Department of Colorectal and General Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Mosab Ahmed
- Department of Colorectal and General Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Annabel Shaw
- Department of Colorectal and General Surgery, Epsom and St. Helier University Hospitals NHS Trust, London, United Kingdom
| | - Matyas Fehervari
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom; Department of Gastrointestinal Surgery, Maidstone and Tunbridge Wells NHS Trust, Kent, United Kingdom
| | - Christos Kontovounisios
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom; Department of Colorectal and General Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom; Department of Colorectal Surgery, Royal Marsden NHS Foundation Trust, London, United Kingdom; 2nd Surgical Department Evaggelismos Athens General Hospital, Athens, Greece.
| | - Gina Brown
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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Megafu OM. Statistical Fragility in Minimally Invasive Colorectal Surgery Studies: A Review of Randomized Trials. J Laparoendosc Adv Surg Tech A 2024. [PMID: 38900698 DOI: 10.1089/lap.2024.0121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2024] Open
Abstract
Purpose: The P value has been used as a statistical tool in randomized controlled trials (RCTs) to establish significance but does not provide information on the robustness of a study when used alone. The fragility index (FI) provides a supplemental approach for demonstrating robustness in RCTs that report dichotomous outcomes. This study aims to determine the statistical fragility of RCTs that compare minimally invasive techniques with open techniques in managing benign and malignant colorectal diseases. Methods: Dichotomous outcomes of minimally invasive surgery versus open surgery in RCTs from 2000 to 2023 were assessed. The overall FI and fragility quotient (FQ) of each study were calculated. Results: Of the 1377 screened studies, 50 met the inclusion criteria. In total, 820 outcomes were recorded with 747 outcomes reported as not significant (P ≥ .05) and 73 as significant (P < .05). The overall FI for all studies including all outcomes was 5 (interquartile range [IQR] 4-7) with a FQ of 0.031 (IQR 0.014-0.062). Of the 50 RCTs, 6 (12%) reported a loss to follow-up that was greater than the overall FI of 5. Conclusions: As RCTs are judged increasingly beyond just the P value, practicing colorectal surgeons will benefit from using and interpreting the FI, FQ, and the P value of studies both in analyzing future RCTs and in determining whether or not to make a change in their clinical practice if there is an efficiently true discovery.
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Affiliation(s)
- Olajumoke M Megafu
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
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Jiang SX, Zarrin A, Shahidi N. T1 colorectal cancer management in the era of minimally invasive endoscopic resection. World J Gastrointest Oncol 2024; 16:2284-2294. [DOI: 10.4251/wjgo.v16.i6.2284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 04/02/2024] [Accepted: 04/24/2024] [Indexed: 06/13/2024] Open
Abstract
T1 colorectal cancer (CRC), defined by tumor invasion confined to the submucosa, has historically been managed by surgery. Improved understanding of recurrence and lymph node metastases risk, coupled with advances in endoscopic resection techniques, have led to an increasing capacity for organ-sparing local excision. Minimally invasive management of T1 CRC begins with optical evaluation of the lesion to diagnose invasive disease and quantify depth of invasion, which informs therapeutic decision making. Modality selection between various available endoscopic resection techniques depends upon lesion characteristics, technique risk-benefit profiles, and location-specific implications. Following endoscopic resection, established histopathology features determine the risk of recurrence and subsequent management including surveillance or adjuvant surgical excision. The management of non-operative candidates deviates from conventional recommendations with emerging treatment strategies in select populations.
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Affiliation(s)
- Shirley Xue Jiang
- Department of Medicine, University of British Columbia, Vancouver V6Z2K5, British Columbia, Canada
| | - Aein Zarrin
- Department of Medicine, University of British Columbia, Vancouver V6Z2K5, British Columbia, Canada
| | - Neal Shahidi
- Department of Medicine, University of British Columbia, Vancouver V6Z2K5, British Columbia, Canada
- Division of Gastroenterology, St. Paul’s Hospital, Vancouver V6Z2K5, British Columbia, Canada
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Meng Z, Liu Z. Comparison of local excision and total mesorectal excision for rectal cancer: Systematic review and meta-analysis of randomised controlled trial. Heliyon 2024; 10:e30027. [PMID: 38720742 PMCID: PMC11076819 DOI: 10.1016/j.heliyon.2024.e30027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 04/17/2024] [Accepted: 04/18/2024] [Indexed: 05/12/2024] Open
Abstract
To report the first and largest systematic review and meta-analysis of radomised controlled trials (RCTs) to compare the efficacy and safety of transanal endoscopic microsurgery (TEM) and total mesorectal excision (TME) for rectal cancer for perioperative and oncological outcomes. Methods: We conducted a systematic literature retrieval via PubMed, Embase, Web of Science, and Cochrane until December 2022 for RCTs which evaluated the efficacy and/or safety between TEM and TME for rectal cancer. Outcomes included operative time, blood loss, transfusion rates, hospital stay, complication rates, recurrence rates, and mortality. Results: A total of 5 RCTs involving 545 patients (272 TEM versus 273 TME) were included for the meta-analysis. There were no significant differences between the two groups for age, gender, and distance from lower border of tumor to anal verge. Meta-analysis found that the TEM group was significantly favorable than the TME group for blood loss (WMD: 172.01; 95 % CI: 212.78, -131.24; P < 0.00001), hospital stay (WMD: 2.58; 95 % CI: 3.01, -2.16; P < 0.00001), operative time (WMD: 81.86; 95 % CI: 87.51, -76.21; P < 0.00001) and transfusion rates (RR: 0.05; 95 % CI: 0.01, 0.38; P = 0.004). The complication rates (RR: 0.60; 95 % CI: 0.32, 1.11; P = 0.10), recurrence rates (RR: 1.10; 95 % CI: 0.66, 1.83; P = 0.72), and mortality (RR: 1.23; 95 % CI: 0.67, 2.26; P = 0.51) were similar in the two groups. Conclusions: TEM was an effective and safe approach with advantages in perioperative outcomes compared with TME approach. Caution should be exercised in interpreting the differences in surgical complications between TEM and TME group due to significant heterogeneity and instability.
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Affiliation(s)
- Zan Meng
- Department of Nursing, Leshan Vocational and Technical College, Leshan, 614000, China
| | - Zehong Liu
- Department of Physiology, Chongqing Medical and Pharmaceutical College, Chongqing, 401331, China
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Schaffitzel KM, Zu Putlitz S, Gölder SK, Kurek R, Siech M. [Transanal Endoscopic Microsurgery (TEM) is a surgical option to preserve fecal continence in selected low rectal cancers]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024. [PMID: 38198803 DOI: 10.1055/a-2183-2175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
INTRODUCTION Despite its existence for more than 40 years, the TEM method has not become widespread. The main reasons are the high acquisition costs, the sophisticated technology and alternative procedures (especially radical resection procedures), which provide greater oncological safety. However, avoiding major abdominal surgery with the creation of a stoma and higher complication rates can outweigh the higher risk of recurrence for some patients. We examined the results using V-TEM with reduced acquisition costs in the resection of adenomas and carcinomas and discussed its importance by literature . METHOD From 2003 to 2019, 154 patients with 170 findings were operated by V-TEM technology. Data on the operation and follow-up were collected and analyzed retrospectively. RESULTS The median age was 67 years, 89 patients were male and 65 female. V-TEM was performed on 79 carcinomas, 77 adenomas and 14 other findings. The complication rate was 21.2 %. R0 resection was achieved in 78.8 %. The adenoma recurrence rate was 7.3 %, the overall recurrence rate for carcinomas 11.9 %, local recurrences were observed in 6.8 %. The disease-specific survival is 100 % at 5 years and 94.2 % at ten years. DISCUSSION The successful use of TEM in adenomas and early carcinomas is undisputed. When treating carcinomas from a T1 high risk stage using TEM, recurrence rates higher than 10 % must be expected. Better results can be achieved with radical procedures, this is why they are considered the therapy of choice in these cases. However, there are no differences in terms of survival rates and TEM offers proven better postoperative quality of life. In particular, the combination of neoadjuvant procedures with TEM delivered promising results in more advanced stages. Further studies on TEM and the possibility of lower acquisition costs through modification to V-TEM could make the method more popular in the future.
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Affiliation(s)
| | - Stephanie Zu Putlitz
- Klinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Ostalb-Klinikum Aalen, Aalen, Germany
| | - Stefan Karl Gölder
- Klinik für Gastroenterologie, Hämatoonkologie und Pneumologie, Ostalbkreis, Aalen, Germany
| | - Ralf Kurek
- Radioonkologie Netzwerk Ostwürttemberg, Aalen, Germany
| | - Marco Siech
- Klinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Ostalb-Klinikum Aalen, Aalen, Germany
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Loria A, Tejani MA, Temple LK, Justiniano CF, Melucci AD, Becerra AZ, Monson JRT, Aquina CT, Fleming FJ. Practice Patterns for Organ Preservation in US Patients With Rectal Cancer, 2006-2020. JAMA Oncol 2024; 10:79-86. [PMID: 37943566 PMCID: PMC10636650 DOI: 10.1001/jamaoncol.2023.4845] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/08/2023] [Indexed: 11/10/2023]
Abstract
Importance In March 2023, the National Comprehensive Cancer Network endorsed watch and wait for those with complete clinical response to total neoadjuvant therapy. Neoadjuvant therapy is highly efficacious, so this recommendation may have broad implications, but the current trends in organ preservation in the US are unknown. Objective To describe organ preservation trends among patients with rectal cancer in the US from 2006 to 2020. Design, Setting, and Participants This retrospective, observational case series included adults (aged ≥18 years) with rectal adenocarcinoma managed with curative intent from 2006 to 2020 in the National Cancer Database. Exposure The year of treatment was the primary exposure. The type of therapy was chemotherapy, radiation, or surgery (proctectomy, transanal local excision, no tumor resection). The timing of therapy was classified as neoadjuvant or adjuvant. Main Outcomes and Measures The primary outcome was the absolute annual proportion of organ preservation after radical treatment, defined as chemotherapy and/or radiation without tumor resection, proctectomy, or transanal local excision. A secondary analysis examined complete pathologic responses among eligible patients. Results Of the 175 545 patients included, the mean (SD) age was 63 (13) years, 39.7% were female, 17.4% had clinical stage I disease, 24.7% had stage IIA to IIC disease, 32.1% had stage IIIA to IIIC disease, and 25.7% had unknown stage. The absolute annual proportion of organ preservation increased by 9.8 percentage points (from 18.4% in 2006 to 28.2% in 2020; P < .001). From 2006 to 2020, the absolute rate of organ preservation increased by 13.0 percentage points for patients with stage IIA to IIC disease (19.5% to 32.5%), 12.9 percentage points for patients with stage IIIA to IIC disease (16.2% to 29.1%), and 10.1 percentage points for unknown stages (16.5% to 26.6%; all P < .001). Conversely, patients with stage I disease experienced a 6.1-percentage point absolute decline in organ preservation (from 26.4% in 2006 to 20.3% in 2020; P < .001). The annual rate of transanal local excisions decreased for all stages. In the subgroup of 80 607 eligible patients, the proportion of complete pathologic responses increased from 6.5% in 2006 to 18.8% in 2020 (P < .001). Conclusions and Relevance This case series shows that rectal cancer is increasingly being managed medically, especially among patients whose treatment historically relied on proctectomy. Given the National Comprehensive Cancer Network endorsement of watch and wait, the increasing trends in organ preservation, and the nearly 3-fold increase in complete pathologic responses, international professional societies should urgently develop multidisciplinary core outcome sets and care quality indicators to ensure high-quality rectal cancer research and care delivery accounting for organ preservation.
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Affiliation(s)
- Anthony Loria
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | | | - Larissa K. Temple
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Carla F. Justiniano
- Division of Colon and Rectal Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Alexa D. Melucci
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Adan Z. Becerra
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - John R. T. Monson
- Departments of Colorectal Surgery and Surgical Oncology, AdventHealth Orlando, Orlando, Florida
| | - Christopher T. Aquina
- Departments of Colorectal Surgery and Surgical Oncology, AdventHealth Orlando, Orlando, Florida
| | - Fergal J. Fleming
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, New York
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Kwik C, El-Khoury T, Pathma-Nathan N, Toh JWT. Endoscopic and trans-anal local excision vs. radical resection in the treatment of early rectal cancer: A systematic review and network meta-analysis. Int J Colorectal Dis 2023; 39:13. [PMID: 38157077 DOI: 10.1007/s00384-023-04584-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2023] [Indexed: 01/03/2024]
Abstract
PURPOSE The management of early-stage rectal cancer in clinical practice is controversial. The aim of this network meta-analysis was to compare oncological and postoperative outcomes for T1T2N0M0 rectal cancers managed with local excision in comparison to conventional radical resection. METHODS A systematic review of Medline, Embase and Cochrane electronic databases was performed. Relevant studies were selected using PRISMA guidelines. The primary outcomes measured were 5-year local recurrence and overall survival. Secondary outcomes included rates of postoperative complication, 30-day mortality, positive margin and permanent stoma formation. RESULTS Three randomized controlled trials and 27 observational studies contributed 8570 patients for analysis. Radical resection was associated with reduced 5-year local recurrence in comparison to local excision. This was statistically significant in comparison to trans-anal local excision (odds ratio (OR) 0.23; 95% confidence interval 0.16-0.30) and favourable in comparison to endoscopic techniques (OR 0.40; 95% confidence interval 0.13-1.23) although this did not reach clinical significance. Positive margin rates were lowest for radical resection. However, 30-day mortality rates, perioperative complications and permanent stoma rates all favoured local excision with no statistically significant difference between endoscopic and trans-anal techniques. CONCLUSION Radical resection of early rectal cancer is associated with the lowest 5-year local recurrence rates and the lowest rate of positive margins. However, this must be balanced with its higher 30-day mortality and complication rates as well as the increased risk of permanent stoma. The emerging potential role of neoadjuvant therapy prior to local resection, and the heterogeneity of its use, as an alternative treatment for early rectal cancer further complicates the treatment paradigm and adds to controversy in this field.
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Affiliation(s)
- Charlotte Kwik
- Department of Colorectal Surgery, Westmead Hospital, Cnr Hawkesbury Road and Darcy Road, Westmead, NSW, Australia.
| | - Toufic El-Khoury
- Department of Colorectal Surgery, Westmead Hospital, Cnr Hawkesbury Road and Darcy Road, Westmead, NSW, Australia
| | - Nimalan Pathma-Nathan
- Department of Colorectal Surgery, Westmead Hospital, Cnr Hawkesbury Road and Darcy Road, Westmead, NSW, Australia
| | - James Wei Tatt Toh
- Department of Colorectal Surgery, Westmead Hospital, Cnr Hawkesbury Road and Darcy Road, Westmead, NSW, Australia.
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
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Pan H, Gao Y, Ruan H, Chi P, Huang Y, Huang S. Transanal local excision versus intersphincteric resection for low rectal cancer with stage ypT0-1ycN0 after neoadjuvant chemoradiotherapy: an inverse probability weighting analysis for oncological and functional outcomes. J Cancer Res Clin Oncol 2023; 149:17383-17394. [PMID: 37843558 DOI: 10.1007/s00432-023-05454-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 09/30/2023] [Indexed: 10/17/2023]
Abstract
OBJECTIVES This study aimed to compare the efficacy of local excision (LE) and intersphincteric resection (ISR) in patients with locally advanced rectal cancer who achieved a significant or complete pathological response following neoadjuvant chemoradiotherapy. METHODS We performed a retrospective analysis of data from patients with stage ypT0-1ycN0 low rectal cancer after neoadjuvant chemoradiotherapy who underwent LE or ISR between June 2016 and June 2021. Baseline characteristics, short-term outcomes, long-term oncological outcomes, and functional outcomes, were compared between the two groups. To reduce the selection bias, inverse probability of treatment weighting (IPTW) was performed. RESULTS This study included 106 patients (LE group: n = 51, ISR group: n = 55). There were significant differences in baseline characteristics between the two groups (P < 0.05). After IPTW, there were almost no significant differences in baseline data between the two groups. The LE group showed less postoperative complications and better function outcomes compared to the ISR group. The LE group had significantly lower rates of complications (13.7% vs. 36.4%, P = 0.014). There were no significant differences between the two groups in terms of long-term oncological outcomes. CONCLUSIONS For patients with locally advanced low rectal cancer achieving significant or complete pathological response after neoadjuvant therapy, both LE and ISR present comparable oncological outcomes. Yet, LE seems to show more advantages in terms of postoperative complications and functional outcomes. These findings offer important insights for surgical decision-making, emphasizing the necessity to consider both oncological and functional outcomes in selecting the optimal surgical approach.
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Affiliation(s)
- Hongfeng Pan
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yihuang Gao
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Haoyang Ruan
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Pan Chi
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China.
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China.
| | - Ying Huang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China.
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China.
| | - Shenghui Huang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China.
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China.
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Lei Y, Lin L, Shao Q, Chen W, Liu G. Long-term efficacy of transanal local excision versus total mesorectal excision after neoadjuvant treatment for rectal cancer: A meta-analysis. PLoS One 2023; 18:e0294510. [PMID: 37983236 PMCID: PMC10659211 DOI: 10.1371/journal.pone.0294510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 11/02/2023] [Indexed: 11/22/2023] Open
Abstract
AIM The purpose of this meta-analysis is to compare the long-term efficacy of transanal local excision (TLE) versus total mesorectal excision (TME) following neoadjuvant therapy for rectal cancer. METHOD The Web of Science, Pubmed, Medline, Embase, and the Cochrane Library were systematically searched for correlational research. The Newcastle-Ottawa Scale and the Cochrane risk of bias tool were used to assess the quality of cohort studies (CSs) and randomized controlled trials (RCTs), respectively. Statistically analyzed using RevMan5.4. RESULT A total of 13 studies, including 3 randomized controlled trials (RCTs) and 10 cohort studies (CSs), involving 1402 patients, were included in the analysis. Of these, 570 patients (40.66%) underwent TLE, while 832 patients (59.34%) underwent TME. In the meta-analysis of CSs, no significant difference was observed between the TLE group and TME group regarding 5-year overall survival (OS) and 5-year disease-free survival (DFS) (P > 0.05). However, the TLE group had a higher rates of local recurrence (LR) [risk ratio (RR) = 1.93, 95%CI (1.18, 3.14), P = 0.008] and a lower rates of 5-years local recurrence-free survival (LRFS) [hazard ratio (HR) = 2.79, 95%CI (1.04, 7.50), P = 0.04] compared to the TME group. In the meta-analysis of RCTs, there was no significant difference observed between the TLE group and TME group in terms of LR, 5-year OS, 5-year DFS, and 5-year disease-specific survival (P > 0.05). CONCLUSION After undergoing neoadjuvant therapy, TLE may provide comparable 5-year OS and DFS to TME for rectal cancer. However, neoadjuvant therapy followed by TLE may has a higher LR and lower 5-year LRFS compared to neoadjuvant therapy followed by TME, so patients should be carefully selected. Neoadjuvant therapy followed by TLE may be a suitable option for patients who prioritize postoperative quality of life. However, the effectiveness of this approach requires further research to draw a definitive conclusion.
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Affiliation(s)
- Yihui Lei
- The School of Clinical Medical, Fujian Medical University, Fuzhou, Fujian, China
| | - Li Lin
- Department of Gastrointestinal Surgery, Zhongshan Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, Fujian, China
| | - Qiming Shao
- The School of Clinical Medical, Fujian Medical University, Fuzhou, Fujian, China
| | - Weiping Chen
- The School of Clinical Medical, Fujian Medical University, Fuzhou, Fujian, China
| | - Guoyan Liu
- Department of Gastrointestinal Surgery, Zhongshan Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, Fujian, China
- Institute of Gastrointestinal Oncology, Medical College of Xiamen University, Xiamen, Fujian, China
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Lynch P, Ryan OK, Donnelly M, Ryan ÉJ, Davey MG, Reynolds IS, Creavin B, Hanly A, Kennelly R, Martin ST, Winter DC. Comparing neoadjuvant therapy followed by local excision to total mesorectal excision in the treatment of early stage rectal cancer: a systematic review and meta-analysis of randomised clinical trials. Int J Colorectal Dis 2023; 38:263. [PMID: 37924372 DOI: 10.1007/s00384-023-04558-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/26/2023] [Indexed: 11/06/2023]
Abstract
INTRODUCTION Total mesorectal excision (TME) is the standard-of-care in early, clinical stage (cT2-3 N0 M0) rectal cancer. Local excision (LE) may be an alternative after adequate response to neoadjuvant therapy (NAT), with either long-course chemoradiotherapy (nCRT) or short-course radiotherapy (SCRT), as a means of preserving the rectum and potentially obviating the morbidity of TME. METHODS A systematic review was performed according to PRISMA guidelines for studies that randomly assigned patients with cT2-3 N0 M0 rectal cancer to either NAT + LE or TME that reported radiologic, oncologic, surgical, and morbidity outcomes. RESULTS A total of 4 RCTs comprise 462 patients (232 patients receiving NAT + LE; nCRT n = 205; SCRT n = 27) and 230 undergoing TME, respectively. NAT compliance was 98.86%. The rate of early completion TME in the NAT + LE group was 22.3%, while the proportion of patients achieving durable organ preservation was 75.4% at mean follow-up of 5.6 years. There was no difference in disease-free survival (DFS) (HR [hazard ratio] 1.19; 95% CI 0.95, 1.49; p = 0.13) or overall survival (OS) (HR 0.94; 95% CI 0.72, 1.23; p = 0.63]) according to the assigned treatment arm. The local recurrence rate (LRR) (HR 1.22; 95% CI 0.5-3.02; p = 0.66) and distant metastases (HR 0.92; 95% CI 0.45, 1.90; p = 0.82) were also comparable between the groups. There was a significant reduction in major (OR 0.45; 95% CI 0.21, 0.95; p = 0.04) and minor morbidity (OR 0.45; 95% CI 0.24, 0.85; p = 0.01) for patients undergoing NAT + LE. Overall stoma formation was decreased in the NAT + LE group (OR 0.03; 95% CI 0.0, 0.23; p ≤ 0.00001). CONCLUSION NAT + LE reduces adverse effects of TME, without any compromise in oncological outcomes, and the potential for an organ preserving strategy should be discussed with patients with T2-3N0 rectal cancers prior to treatment.
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Affiliation(s)
- Paul Lynch
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Odhrán K Ryan
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Mark Donnelly
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Éanna J Ryan
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland.
| | - Matthew G Davey
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Ian S Reynolds
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Ben Creavin
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Ann Hanly
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Rory Kennelly
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Seán T Martin
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Des C Winter
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
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11
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Gao Y, Wu A. Organ Preservation in MSS Rectal Cancer. Clin Colon Rectal Surg 2023; 36:430-440. [PMID: 37795468 PMCID: PMC10547535 DOI: 10.1055/s-0043-1767710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
Rectal cancer is a heterogeneous disease with complex genetic and molecular subtypes. Emerging progress of neoadjuvant therapy has led to increased pathological and clinical complete response (cCR) rates for microsatellite stable (MSS) rectal cancer, which responds poorly to immune checkpoint inhibitor alone. As a result, organ preservation of MSS rectal cancer as an alternative to radical surgery has gradually become a feasible option. For patients with cCR or near-cCR after neoadjuvant treatment, organ preservation can be implemented safely with less morbidity. Patient selection can be done either before the neoadjuvant treatment for higher probability or after with careful assessment for a favorable outcome. Those patients who achieved a good clinical response are managed with nonoperative management, organ preservation surgery, or radiation therapy alone followed by strict surveillance. The oncological outcomes of patients with careful selection and organ preservation seem to be noninferior compared with those of radical surgery, with lower postoperative morbidity. However, more studies should be done to seek better regression of tumor and maximize the possibility of organ preservation in MSS rectal cancer.
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Affiliation(s)
- Yuye Gao
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Unit III, Gastrointestinal Cancer Center, Peking University Cancer Hospital and Institute, Beijing, China
| | - Aiwen Wu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Unit III, Gastrointestinal Cancer Center, Peking University Cancer Hospital and Institute, Beijing, China
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12
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Calmels M, Labiad C, Lelong B, Lefevre JH, Tuech JJ, Benoist S, Mège D, Denost Q, Panis Y. Local excision after neoadjuvant chemoradiotherapy for mid and low rectal cancer: a multicentric French study from the GRECCAR group. Colorectal Dis 2023; 25:1973-1980. [PMID: 37679892 DOI: 10.1111/codi.16742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 07/29/2023] [Accepted: 08/03/2023] [Indexed: 09/09/2023]
Abstract
AIM A complete or subcomplete tumour response (CTR) is observed in 10%-25% of patients with mid/low rectal cancer after neoadjuvant chemoradiotherapy (CRT). The aim of our study was to report a multicentric French experience in local excision (LE) after CRT. METHOD All patients who underwent LE for mid/low rectal cancer with suspected CTR after CRT, from 2006 to 2019 in seven GRECCAR centres were included. LE was considered adequate if the specimen showed a ypT0/Tis/T1R0 tumour, otherwise, a completion total mesorectal excision (TME) was discussed. Morbi-mortality, functional results and oncological outcomes were studied. RESULTS A total of 257 patients were included. LE specimens showed 36% ypT0, 4% ypTis and 19% ypT1. Thus, 108 patients (42%) had theoretical indication of completion TME, which was performed in only 42 patients. Overall, 30-day morbidity after LE was 11%, including 2% Clavien-Dindo grade III or IV complications. After completion TME, 47% described major low anterior resection syndrome versus 5% after LE alone (p < 0.001). After a mean follow-up of 4 years (range 2-6 years), the recurrence rate was 11% after LE, 32% after completion TME and 20% in patients for whom completion TME was indicated but not performed (p = 0.021). CONCLUSION TME remains the gold standard for mid/low rectal cancer after CRT. LE in selected patients is safe for operative and functional, but also oncological, results. However, completion TME was indicated in 42% of patients after LE, highlighting the difficulty of the preoperative diagnosis of CTR after CRT.
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Affiliation(s)
- Mélanie Calmels
- Department of Colorectal Surgery, DMU Digest, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris-Cité, Clichy, France
| | - Camélia Labiad
- Department of Colorectal Surgery, DMU Digest, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris-Cité, Clichy, France
| | - Bernard Lelong
- Surgical Oncology Department, Institut Paoli Calmettes, Marseille, France
| | - Jérémie H Lefevre
- Surgery Department, Saint Antoine University Hospital, Paris, France
| | | | - Stéphane Benoist
- Digestive Surgery Department, Bicêtre University Hospital, Le Kremlin-Bicêtre, France
| | - Diane Mège
- Surgery Department, Timone University Hospital, Marseille, France
| | - Quentin Denost
- Surgery Department, Saint André University Hospital, Bordeaux, France
| | - Yves Panis
- Centre de Chirurgie Colorectale, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly-sur-Seine, France
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13
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Smits LJH, van Lieshout AS, Bosker RJI, Crobach S, de Graaf EJR, Hage M, Laclé MM, Moll FCP, Moons LMG, Peeters KCMJ, van Westreenen HL, van Grieken NCT, Tuynman JB. Clinical consequences of diagnostic variability in the histopathological evaluation of early rectal cancer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:1291-1297. [PMID: 36841695 DOI: 10.1016/j.ejso.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 02/14/2023] [Indexed: 02/19/2023]
Abstract
INTRODUCTION In early rectal cancer, organ sparing treatment strategies such as local excision have gained popularity. The necessity of radical surgery is based on the histopathological evaluation of the local excision specimen. This study aimed to describe diagnostic variability between pathologists, and its impact on treatment allocation in patients with locally excised early rectal cancer. MATERIALS AND METHODS Patients with locally excised pT1-2 rectal cancer were included in this prospective cohort study. Both quantitative measures and histopathological risk factors (i.e. poor differentiation, deep submucosal invasion, and lymphatic- or venous invasion) were evaluated. Interobserver variability was reported by both percentages and Fleiss' Kappa- (ĸ) or intra-class correlation coefficients. RESULTS A total of 126 patients were included. Ninety-four percent of the original histopathological reports contained all required parameters. In 73 of the 126 (57.9%) patients, at least one discordant parameter was observed, which regarded histopathological risk factors for lymph node metastases in 36 patients (28.6%). Interobserver agreement among different variables varied between 74% and 95% or ĸ 0.530-0.962. The assessment of lymphovascular invasion showed discordances in 26% (ĸ = 0.530, 95% CI 0.375-0.684) of the cases. In fourteen (11%) patients, discordances led to a change in treatment strategy. CONCLUSION This study demonstrated that there is substantial interobserver variability between pathologists, especially in the assessment of lymphovascular invasion. Pathologists play a key role in treatment allocation after local excision of early rectal cancer, therefore interobserver variability needs to be reduced to decrease the number of patients that are over- or undertreated.
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Affiliation(s)
- Lisanne J H Smits
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Annabel S van Lieshout
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | | | - Stijn Crobach
- Department of Pathology, Leiden University Medical Center, Leiden, the Netherlands
| | - Eelco J R de Graaf
- Department of Surgery, IJsselland Hospital, Cappelle aan de IJssel, the Netherlands
| | - Mariska Hage
- Department of Pathology, Deventer Hospital, Deventer, the Netherlands
| | - Miangela M Laclé
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Freek C P Moll
- Department of Pathology, Isala Clinics, Zwolle, the Netherlands
| | - Leon M G Moons
- Department of Gastroenterology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Koen C M J Peeters
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Nicole C T van Grieken
- Department of Pathology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Jurriaan B Tuynman
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands.
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14
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Motamedi MAK, Mak NT, Brown CJ, Raval MJ, Karimuddin AA, Giustini D, Phang PT. Local versus radical surgery for early rectal cancer with or without neoadjuvant or adjuvant therapy. Cochrane Database Syst Rev 2023; 6:CD002198. [PMID: 37310167 PMCID: PMC10264720 DOI: 10.1002/14651858.cd002198.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Total mesorectal excision is the standard of care for stage I rectal cancer. Despite major advances and increasing enthusiasm for modern endoscopic local excision (LE), uncertainty remains regarding its oncologic equivalence and safety relative to radical resection (RR). OBJECTIVES To assess the oncologic, operative, and functional outcomes of modern endoscopic LE compared to RR surgery in adults with stage I rectal cancer. SEARCH METHODS We searched CENTRAL, Ovid MEDLINE, Ovid Embase, Web of Science - Science Citation Index Expanded (1900 to present), four trial registers (ClinicalTrials.gov, ISRCTN registry, the WHO International Clinical Trials Registry Platform, and the National Cancer Institute Clinical Trials database), two thesis and proceedings databases, and relevant scientific societies' publications in February 2022. We performed handsearching and reference checking and contacted study authors of ongoing trials to identify additional studies. SELECTION CRITERIA We searched for randomized controlled trials (RCTs) in people with stage I rectal cancer comparing any modern LE techniques to any RR techniques with or without the use of neo/adjuvant chemoradiotherapy (CRT). DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. We calculated hazard ratios (HR) and standard errors for time-to-event data and risk ratios for dichotomous outcomes, using generic inverse variance and random-effects methods. We regrouped surgical complications from the included studies into major and minor according to the standard Clavien-Dindo classification. We assessed the certainty of evidence using the GRADE framework. MAIN RESULTS Four RCTs were included in data synthesis with a combined total of 266 participants with stage I rectal cancer (T1-2N0M0), if not stated otherwise. Surgery was performed in university hospital settings. The mean age of participants was above 60, and median follow-up ranged from 17.5 months to 9.6 years. Regarding the use of co-interventions, one study used neoadjuvant CRT in all participants (T2 cancers); one study used short-course radiotherapy in the LE group (T1-T2 cancers); one study used adjuvant CRT selectively in high-risk patients undergoing RR (T1-T2 cancers); and the fourth study did not use any CRT (T1 cancers). We assessed the overall risk of bias as high for oncologic and morbidity outcomes across studies. All studies had at least one key domain with a high risk of bias. None of the studies reported separate outcomes for T1 versus T2 or for high-risk features. Low-certainty evidence suggests that RR may result in an improvement in disease-free survival compared to LE (3 trials, 212 participants; HR 1.96, 95% confidence interval (CI) 0.91 to 4.24). This would translate into a three-year disease-recurrence risk of 27% (95% CI 14 to 50%) versus 15% after LE and RR, respectively. Regarding sphincter function, only one study provided objective results and reported short-term deterioration in stool frequency, flatulence, incontinence, abdominal pain, and embarrassment about bowel function in the RR group. At three years, the LE group had superiority in overall stool frequency, embarrassment about bowel function, and diarrhea. Local excision may have little to no effect on cancer-related survival compared to RR (3 trials, 207 participants; HR 1.42, 95% CI 0.60 to 3.33; very low-certainty evidence). We did not pool studies for local recurrence, but the included studies individually reported comparable local recurrence rates for LE and RR (low-certainty evidence). It is unclear if the risk of major postoperative complications may be lower with LE compared with RR (risk ratio 0.53, 95% CI 0.22 to 1.28; low-certainty evidence; corresponding to 5.8% (95% CI 2.4% to 14.1%) risk for LE versus 11% for RR). Moderate-certainty evidence shows that the risk of minor postoperative complications is probably lower after LE (risk ratio 0.48, 95% CI 0.27 to 0.85); corresponding to an absolute risk of 14% (95% CI 8% to 26%) for LE compared to 30.1% for RR. One study reported an 11% rate of temporary stoma after LE versus 82% in the RR group. Another study reported a 46% rate of temporary or permanent stomas after RR and none after LE. The evidence is uncertain about the effect of LE compared with RR on quality of life. Only one study reported standard quality of life function, in favor of LE, with a 90% or greater probability of superiority in overall quality of life, role, social, and emotional functions, body image, and health anxiety. Other studies reported a significantly shorter postoperative period to oral intake, bowel movement, and off-bed activities in the LE group. AUTHORS' CONCLUSIONS Based on low-certainty evidence, LE may decrease disease-free survival in early rectal cancer. Very low-certainty evidence suggests that LE may have little to no effect on cancer-related survival compared to RR for the treatment of stage I rectal cancer. Based on low-certainty evidence, it is unclear if LE may have a lower major complication rate, but probably causes a large reduction in minor complication rate. Limited data based on one study suggest better sphincter function, quality of life, or genitourinary function after LE. Limitations exist with respect to the applicability of these findings. We identified only four eligible studies with a low number of total participants, subjecting the results to imprecision. Risk of bias had a serious impact on the quality of evidence. More RCTs are needed to answer our review question with greater certainty and to compare local and distant metastasis rates. Data on important patient outcomes such as sphincter function and quality of life are very limited. Results of currently ongoing trials will likely impact the results of this review. Future trials should accurately report and compare outcomes according to the stage and high-risk features of rectal tumors, and evaluate quality of life, sphincter, and genitourinary outcomes. The role of neoadjuvant or adjuvant therapy as an emerging co-intervention for improving oncologic outcomes after LE needs to be further defined.
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Affiliation(s)
| | - Nicole T Mak
- Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Carl J Brown
- Head, Division of General Surgery, St. Paul's Hospital, Vancouver, Canada
| | - Manoj J Raval
- Department of Surgery, St. Paul's Hospital, University of British Columbia, Vancouver, Canada
| | - Ahmer A Karimuddin
- Department of Surgery, St. Paul's Hospital, University of British Columbia, Vancouver, Canada
| | - Dean Giustini
- Faculty of Medicine, University of British Columbia Library, Vancouver, Canada
| | - Paul Terry Phang
- Department of Surgery, St. Paul's Hospital, University of British Columbia, Vancouver, Canada
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15
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Sailer M. [Transanal Tumor Resection: Indication, Surgical Technique and Management of Complications]. Zentralbl Chir 2023; 148:244-253. [PMID: 37267979 DOI: 10.1055/a-2063-3578] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Transanal resection procedures are special operations for the minimally invasive treatment of rectal tumours. Apart from benign tumours, this procedure is suitable for the excision of low-risk T1 rectal carcinomas, if these can be completely removed (R0 resection). With stringent patient selection, very good oncological results are achieved. Various international trials are currently evaluating whether local resection procedures are oncologically sufficient if there is a complete or near complete response after neoadjuvant radio-/chemotherapy. Numerous studies have shown that the functional results and the postoperative quality of life after local resection are excellent, especially considering the well-known functional deficits of alternative operations, such as low anterior or abdominoperineal resection.Severe complications are very rare. Most complications, such as urinary retention or subfebrile temperatures, are minor in nature. Suture line dehiscences are usually clinically unremarkable. Major complications comprise significant haemorrhage and the opening of the peritoneal cavity. The latter must be recognized intraoperatively and can usually be managed by primary suture. Infection, abscess formation, rectovaginal fistula, injury of the prostate or even urethra are extremely rare complications.
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Affiliation(s)
- Marco Sailer
- Klinik für Chirurgie, Agaplesion Bethesda Krankenhaus Bergedorf, Hamburg, Deutschland
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16
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Tan S, Ou Y, Huang S, Gao Q. Surgical, oncological, and functional outcomes of local and radical resection after neoadjuvant chemotherapy or chemoradiotherapy for early- and mid-stage rectal cancer: a systematic review and meta-analysis. Int J Colorectal Dis 2023; 38:132. [PMID: 37193915 DOI: 10.1007/s00384-023-04433-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND Radical resection is typically the standard treatment for early- and mid-stage rectal cancer as local resection may result in a high rate of recurrence and risk of distant metastasis. A growing number of studies have shown that local excision after neoadjuvant chemotherapy or chemoradiotherapy can significantly reduce recurrence rates and is a feasible strategy to preserve the rectum as an alternative to conventional radical resection. OBJECTIVE This study aims to compare the efficacy of local resection after neoadjuvant chemotherapy or chemoradiotherapy with radical surgery for early- and mid-stage rectal cancer and to report the evidence-based clinical advantages of both techniques. METHODS Clinical trials comparing oncologic and perioperative outcomes of local and radical resection after neoadjuvant chemotherapy or chemoradiotherapy in patients with early- to mid-stage rectal cancer were searched in PubMed, Embase, Web Of Science, and Cochrane databases, and a total of 5 randomized controlled trials and 11 cohort study trials were included. RESULTS In terms of oncology and perioperative outcomes, there were no statistically significant differences between the radical resection group and the local resection group in terms of OS [HR = 0.99, 95%CI (0.85, 1.15), p = 0.858], DFS [HR = 1.01, 95%CI (0.64, 1.58), p = 0.967], distant metastasis rate [RR = 0.76, 95%CI (0.36,1.59), p = 0.464], and local recurrence rate [RR = 1.30, 95%CI (0.69, 2.47), p = 0.420]. However, there were significant differences in the outcomes of complications [RR = 0.49, 95% CI (0.33, 0.72), p < 0.001], length of hospital stays [WMD = - 5.13, 95%CI (- 6.22, - 4.05), p < 0.001], enterostomy [RR = 0.13, 95%CI (0.05, 0.37), p < 0.001], operative time [- 94.31, 95%CI (- 117.26, - 71.35), p < 0.001], and emotional functioning score [WMD = 2.34, 95% CI (0.94, 3.74), p < 0.001]. CONCLUSION Local resection after neoadjuvant chemotherapy or chemoradiotherapy may be an effective alternative to radical surgery in patients with early and middle rectal cancer.
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Affiliation(s)
- Shufa Tan
- Shaanxi University of Chinese Medicine, Shaanxi, China
| | - Yan Ou
- Affiliated Hospital of Shaanxi University of Traditional Chinese Medicine, Shaanxi Province, Deputy No. 2, West Weiyang Road, Xianyang City, 712000, China
| | - Shuilan Huang
- Shaanxi University of Chinese Medicine, Shaanxi, China
| | - Qiangqiang Gao
- Affiliated Hospital of Shaanxi University of Traditional Chinese Medicine, Shaanxi Province, Deputy No. 2, West Weiyang Road, Xianyang City, 712000, China.
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17
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Borelli B, Germani MM, Carullo M, Mattioni R, Manfredi B, Sainato A, Rossi P, Vagli P, Balestri R, Buccianti P, Morelli L, Antoniotti C, Cremolini C, Masi G, Moretto R. Total neoadjuvant treatment and organ preservation strategies in the management of localized rectal cancer: a narrative review and evidence-based algorithm. Crit Rev Oncol Hematol 2023; 186:103985. [PMID: 37059274 DOI: 10.1016/j.critrevonc.2023.103985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 03/26/2023] [Accepted: 04/11/2023] [Indexed: 04/16/2023] Open
Abstract
The multimodal approach with total mesorectal excision preceded by neoadjuvant (chemo)radiotherapy represented the mainstay treatment for locally advanced rectal cancer (LARC) for a long time. However, the benefit of adjuvant chemotherapy in terms of distant relapse reduction is limited. Recently, chemotherapy regimens administered before surgery and incorporated with (chemo)radiotherapy in total neoadjuvant treatment protocols have been established as new options in the management of LARC. Meanwhile, patients with clinical complete response to neoadjuvant treatment can benefit from organ preservation strategies, aimed at sparing surgery and long-term post-operative morbidities, while preserving an adequate disease control. However, the introduction of a non-operative management in clinical practice is a matter of debate with some concerns regarding the risk of local recurrence and long-term outcomes. In this review, we discuss how these recent advances are reshaping the multimodal management of localized rectal cancer and propose an algorithm to place them in the clinical practice.
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Affiliation(s)
- Beatrice Borelli
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy; Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Marco Maria Germani
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Martina Carullo
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy; Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Roberto Mattioni
- Radiation Oncology Unit, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Bruno Manfredi
- Radiation Oncology Unit, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Aldo Sainato
- Radiation Oncology Unit, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Piercarlo Rossi
- Diagnostic and Interventional Radiology Unit, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Paola Vagli
- Diagnostic and Interventional Radiology Unit, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Riccardo Balestri
- General Surgery, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Piero Buccianti
- General Surgery, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Luca Morelli
- General Surgery, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Carlotta Antoniotti
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Chiara Cremolini
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy; Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Gianluca Masi
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy; Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Roberto Moretto
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy.
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18
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Li J, Ma Y, Wen L, Zhang G, Yao X. Outcomes after the watch-and-wait strategy and local excision treatment for rectal cancer: a meta-analysis. Expert Rev Anticancer Ther 2023; 23:555-564. [PMID: 36795784 DOI: 10.1080/14737140.2023.2181796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
BACKGROUND The watch-and-wait (W&W) strategy and local excision (LE) have been used in patients with clinical complete response (cCR) for rectal cancer, but the comparative outcomes of the two strategies are controversial. We compared the efficacy of the W&W strategy with LE for rectal cancer patients after neoadjuvant chemoradiotherapy (nCRT) or total neoadjuvant therapy (TNT). RESEARCH DESIGN AND METHODS Several domestic and foreign databases were searched for the relevant literature on comparative trials of the W&W strategy and LE surgery for rectal cancer after neoadjuvant therapy with the following outcomes; differences in local recurrence (LR), distant metastasis (DM/DM+LR), 3-year disease-free survival (DFS), 3-year local recurrence-free survival (LRFS) and 3-year overall survival (OS). RESULTS Nine articles, were analyzed. Overall, 442 patients were included, with 267 and 175 patients in the W&W and LE groups, respectively. Meta-analysis results showed no significant differences the between W&W and LE groups with respect to LR, DM/DM+LR, 3-year DFS, 3-year LRFS, and 3-year OS. This study has been registered in PROSPERO (registration number: CRD42022331208). CONCLUSION The W&W strategy may be preferred for some rectal cancer patients who select LE and reach cCR or near cCR after nCRT or TNT.
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Affiliation(s)
- Jinghui Li
- Gannan Medical university, Ganzhou, Jiangxi, China.,Ganzhou Hospital of Guangdong Provincial People's Hospital, Ganzhou Municipal Hospital, Ganzhou, Jiangxi, China.,Department of Gastrointestinal Surgery, Department of General Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, PR, China
| | - Yongli Ma
- Gannan Medical university, Ganzhou, Jiangxi, China.,Ganzhou Hospital of Guangdong Provincial People's Hospital, Ganzhou Municipal Hospital, Ganzhou, Jiangxi, China
| | - Liang Wen
- Gannan Medical university, Ganzhou, Jiangxi, China.,Ganzhou Hospital of Guangdong Provincial People's Hospital, Ganzhou Municipal Hospital, Ganzhou, Jiangxi, China.,Department of Gastrointestinal Surgery, Department of General Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, PR, China
| | - Guosheng Zhang
- Gannan Medical university, Ganzhou, Jiangxi, China.,Ganzhou Hospital of Guangdong Provincial People's Hospital, Ganzhou Municipal Hospital, Ganzhou, Jiangxi, China
| | - Xueqing Yao
- Gannan Medical university, Ganzhou, Jiangxi, China.,Ganzhou Hospital of Guangdong Provincial People's Hospital, Ganzhou Municipal Hospital, Ganzhou, Jiangxi, China.,Department of Gastrointestinal Surgery, Department of General Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, PR, China
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19
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Li W, Xiang XX, Da Wang H, Cai CJ, Cao YH, Liu T. Transanal endoscopic microsurgery versus radical resection for early-stage rectal cancer: a systematic review and meta- analysis. Int J Colorectal Dis 2023; 38:49. [PMID: 36800079 PMCID: PMC9938057 DOI: 10.1007/s00384-023-04341-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2023] [Indexed: 02/18/2023]
Abstract
PURPOSE In the treatment of early-stage rectal cancer, a growing number of studies have shown that transanal endoscopic microsurgery is one of the alternatives to radical surgery adhering to total mesorectal excision that can reduce the incidence of adverse events without compromising treatment outcomes. The purpose of this meta-analysis is to compare the safety and treatment effect of transanal endoscopic microsurgery and radical surgery adhering to total mesorectal excision to provide a basis for clinical treatment selections. METHOD We searched the literatures of four major databases, PubMed, Embase, Web of science, and Cochrane Library, without limitation of time. The literatures included randomized controlled studies and cohort studies comparing two surgical procedures of transanal endoscopic microsurgery and radical surgery adhering to total mesorectal excision. Treatment effectiveness and safety results of transanal endoscopic microsurgery and radical surgery were extracted from the included literatures and statistically analyzed using RevMan5.4 and stata17. RESULT Ultimately, 13 papers were included in the study including 5 randomized controlled studies and 8 cohort studies. The results of the meta-analysis showed that the treatment effect and safety of both transanal endoscopic microsurgery and radical surgery in distant metastasis (RR, 0.59 (0.34, 1.02), P > 0.05), overall recurrence (RR, 1.49 (0.96, 2.31), P > 0.05), disease-specific-survival (RR, 0.74 (0.09, 1.57), P > 0.05), dehiscence of the sutureline or anastomosis leakage (RR, 0.57 (0.30, 1.06), P > 0.05), postoperative bleeding (RR, 0.47 (0.22, 0.99), P > 0.05), and pneumonia (RR, 0.37, (0.10, 1.40), P > 0.05) were not significantly different. However, they differ significantly in perioperative mortality (RR, 0.26 (0.07, 0.93, P < 0.05)), local recurrence (RR, 2.51 (1.53, 4.21), P < 0.05),_overall survival_ (RR, 0.88 (0.74, 1.00), P < 0.05), disease-free-survival (RR, 1.08 (0.97, 1.19), P < 0.05), temporary stoma (RR, 0.05 (0.01, 0.20), P < 0.05), permanent stoma (RR, 0.16 (0.08, 0.33), P < 0.05), postoperative complications (RR, 0.35 (0.21, 0.59), P < 0.05), rectal pain (RR, 1.47 (1.11, 1.95), P < 0.05), operation time (RR, -97.14 (-115.81, -78.47), P < 0.05), blood loss (RR, -315.52 (-472.47, -158.57), P < 0.05), and time of hospitalization (RR, -8.82 (-10.38, -7.26), P < 0.05). CONCLUSION Transanal endoscopic microsurgery seems to be one of the alternatives to radical surgery for early-stage rectal cancer, but more high-quality clinical studies are needed to provide a reliable basis.
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Affiliation(s)
- Wei Li
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan , Hubei Province, 430022, China
| | - Xing Xing Xiang
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan , Hubei Province, 430022, China
| | - Hong Da Wang
- Department of Trauma Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan , Hubei Province, 430022, China
| | - Chen Jun Cai
- Department of Trauma Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan , Hubei Province, 430022, China
| | - Ying Hao Cao
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
| | - Tao Liu
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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20
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Kennecke HF, O'Callaghan CJ, Loree JM, Moloo H, Auer R, Jonker DJ, Raval M, Musselman R, Ma G, Caycedo-Marulanda A, Simianu VV, Patel S, Pitre LD, Helewa R, Gordon VL, Neumann K, Nimeiri H, Sherry M, Tu D, Brown CJ. Neoadjuvant Chemotherapy, Excision, and Observation for Early Rectal Cancer: The Phase II NEO Trial (CCTG CO.28) Primary End Point Results. J Clin Oncol 2023; 41:233-242. [PMID: 35981270 PMCID: PMC9839227 DOI: 10.1200/jco.22.00184] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
PURPOSE Organ-sparing therapy for early-stage I/IIA rectal cancer is intended to avoid functional disturbances or a permanent ostomy associated with total mesorectal excision (TME). The objective of this phase II trial was to determine the outcomes and organ-sparing rate of patients with early-stage rectal cancer treated with neoadjuvant chemotherapy followed by transanal excision surgery (TES). METHODS This phase II trial included patients with clinical T1-T3abN0 low- or mid-rectal adenocarcinoma eligible for endoscopic resection who were treated with 3 months of chemotherapy (modified folinic acid-fluorouracil-oxaliplatin 6 or capecitabine-oxaliplatin). Those with evidence of response proceeded to transanal endoscopic surgery 2-6 weeks later. The primary end point was protocol-specified organ preservation rate, defined as the proportion of patients with tumor downstaging to ypT0/T1N0/X and who avoided radical surgery. RESULTS Of 58 patients enrolled, all commenced chemotherapy and 56 proceeded to surgery. A total of 33/58 patients had tumor downstaging to ypT0/1N0/X on the surgery specimen, resulting in an intention-to-treat protocol-specified organ preservation rate of 57% (90% CI, 45 to 68). Of 23 remaining patients recommended for TME surgery on the basis of protocol requirements, 13 declined and elected to proceed directly to observation resulting in 79% (90% CI, 69 to 88) achieving organ preservation. The remaining 10/23 patients proceeded to recommended TME of whom seven had no histopathologic residual disease. The 1-year and 2-year locoregional relapse-free survival was, respectively, 98% (95% CI, 86 to 100) and 90% (95% CI, 58 to 98), and there were no distant recurrences or deaths. Minimal change in quality of life and rectal function scores was observed. CONCLUSION Three months of induction chemotherapy may successfully downstage a significant proportion of patients with early-stage rectal cancer, allowing well-tolerated organ-preserving surgery.
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Affiliation(s)
- Hagen F. Kennecke
- Providence Cancer Institute and Earle A Chiles Research Institute, Portland, OR,Hagen F. Kennecke, MD, MHA, Providence Cancer Institute, 4805 NE Glisan St, Portland, OR 97213; Twitter: @HKENNECKE; e-mail:
| | | | | | - Hussein Moloo
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Rebecca Auer
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Manoj Raval
- Providence-St. Paul's Hospital, Vancouver, BC, Canada
| | | | - Grace Ma
- Health Sciences North, Sudbury, ON, Canada
| | | | | | - Sunil Patel
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | | | | | | | | | | | - Max Sherry
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | - Dongsheng Tu
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | - Carl J. Brown
- Providence-St. Paul's Hospital, Vancouver, BC, Canada
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21
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Roeder F, Jensen AD, Lindel K, Mattke M, Wolf F, Gerum S. Geriatric Radiation Oncology: What We Know and What Can We Do Better? Clin Interv Aging 2023; 18:689-711. [PMID: 37168037 PMCID: PMC10166100 DOI: 10.2147/cia.s365495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 04/22/2023] [Indexed: 05/13/2023] Open
Abstract
Elderly patients represent a growing subgroup of cancer patients for whom the role of radiation therapy is poorly defined. Older patients are still clearly underrepresented in clinical trials, resulting in very limited high-level evidence. Moreover, elderly patients are less likely to receive radiation therapy in similar clinical scenarios compared to younger patients. However, there is no clear evidence for a generally reduced radiation tolerance with increasing age. Modern radiation techniques have clearly reduced acute and late side effects, thus extending the boundaries of the possible regarding treatment intensity in elderly or frail patients. Hypofractionated regimens have further decreased the socioeconomic burden of radiation treatments by reducing the overall treatment time. The current review aims at summarizing the existing data for the use of radiation therapy or chemoradiation in elderly patients focusing on the main cancer types. It provides an overview of treatment tolerability and outcomes with current standard radiation therapy regimens, including possible predictive factors in the elderly population. Strategies for patient selection for standard or tailored radiation therapy approaches based on age, performance score or comorbidity, including the use of prediction tests or geriatric assessments, are discussed. Current and future possibilities for improvements of routine care and creation of high-level evidence in elderly patients receiving radiation therapy are highlighted.
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Affiliation(s)
- Falk Roeder
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University Hospital, Salzburg, Austria
- Correspondence: Falk Roeder, Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University Hospital, Müllner Hauptstrasse 48, Salzburg, 5020, Austria, Tel +43 57255 55569, Email
| | - Alexandra D Jensen
- Department of Radiation Oncology, University Hospital Marburg-Giessen, Giessen, Germany
| | - Katja Lindel
- Department of Radiation Oncology, Städtisches Klinikum, Karlsruhe, Germany
| | - Matthias Mattke
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University Hospital, Salzburg, Austria
| | - Frank Wolf
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University Hospital, Salzburg, Austria
| | - Sabine Gerum
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University Hospital, Salzburg, Austria
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22
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Short- and long-term outcomes in ypT2 rectal cancer patients after neoadjuvant therapy and local excision: a multicentre observational study. Tech Coloproctol 2023; 27:53-61. [PMID: 36239872 PMCID: PMC9807481 DOI: 10.1007/s10151-022-02712-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 10/04/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Although local excision (LE) after neoadjuvant treatment (NT) has achieved encouraging oncological outcomes in selected patients, radical surgery still remains the rule when unfavorable pathology occurs. However, there is a risk of undertreating patients not eligible for radical surgery. The aim of this study was to evaluate the outcomes of patients with pathological incomplete response (ypT2) in a multicentre cohort of patients undergoing LE after NT and to compare them with ypT0-is-1 rectal cancers. METHODS From 2010 to 2019, all patients who underwent LE after NT for rectal cancer were identified from five institutional retrospective databases. After excluding 12 patients with ypT3 tumors, patients with ypT2 tumors were compared to patients with ypT0-is-1 tumors). The endpoints of the study were early postoperative and long-term oncological outcomes. RESULTS A total of 177 patients (132 males, 45 females, median age 70 [IQR 16] years) underwent LE following NT. There were 46 ypT2 patients (39 males, 7 females, median age 72 [IQR 18.25] years) and 119 ypT0-is-1 patients (83 males, 36 females, median age 69 [IQR 15] years). Patients with pathological incomplete response (ypT2) were frailer than the ypT0-is-1 patients (mean Charlson Comorbidity Index 6.15 ± 2.43 vs. 5.29 ± 1.99; p = 0.02) and there was a significant difference in the type of NT used for the two groups (long- course radiotherapy: 100 (84%) vs. 23 (63%), p = 0.006; short-course radiotherapy: 19 (16%) vs. 17 (37%), p = 0.006). The postoperative rectal bleeding rate (13% vs. 1.7%; p = 0.008), readmission rate (10.9% vs. 0.8%; p = 0.008) and R1 resection rate (8.7% vs. 0; p = 0.008) was significantly higher in the ypT2 group. Recurrence rates were comparable between groups (5% vs. 13%; p = 0.15). Five-year overall survival was 91.3% and 94.9% in the ypT2 and ypT0-is-1 groups, respectively (p = 0.39), while 5-year cancer specific survival was 93.4% in the ypT2 group and 94.9% in the ypT0-is-1 group (p = 0.70). No difference was found in terms of 5-year local recurrence free-survival (p = 0.18) and 5-year distant recurrence free-survival (p = 0.37). CONCLUSIONS Patients with ypT2 tumors after NT and LE have a higher risk of late-onset rectal bleeding and positive resection margins than patients with complete or near complete response. However, long-term recurrence rates and survival seem comparable.
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23
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Morini A, Annicchiarico A, De Giorgi F, Ferioli E, Romboli A, Montali F, Crafa P, Costi R. Local excision of T1 colorectal cancer: good differentiation, absence of lymphovascular invasion, and limited tumor radial infiltration (≤4.25 mm) may allow avoiding radical surgery. Int J Colorectal Dis 2022; 37:2525-2533. [PMID: 36335216 DOI: 10.1007/s00384-022-04279-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/26/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Early colorectal cancer (ECC) is defined as T1NXM0 colorectal cancer (CRC). Although a non-negligible number of T1-CRCs presents metastatic lymph-nodes, local excision is increasingly proposed as alternative to radical resection. Several criteria have been suggested to identify low-risk T1-CRC, but recommendations on this topic are still heterogeneous. This study aims to identify criteria associated with N+ T1-CRC, to select patients to undergo (or not) local excision. METHODS A retrospective analysis of demographic, clinical, and histology criteria of 122 consecutive T1-CRC patients undergoing radical resection at Parma University Hospital between 2000 and 2018 has been performed. RESULTS Lymph-node metastasis (LNM) was observed in 15/122 patients (12.3%). No LNM was observed among well-differentiated (G1) tumors (0/37), while 10/65 (15.4%) G2 cases as well as 5/20 (25%) G3 patients presented LNM. G1 was associated with absence of LNM (p = 0.013). After excluding G1 patients, the rate of N + T1-CRC was 17.6% (15/85). LNM was observed in 4/8 (50%) patients with lymphovascular invasion (LVI) and in 11/77 (14.2%) without LVI. LVI resulted being associated with LNM (p < 0.042). LNM was reported in 28.3% of cases with a tumor infiltration >4.25 mm (13/46), compared to 5.1% in cases with an infiltration ≤4.25 mm (2/39) (p = 0.012). In Cox regression analysis, the higher hazard ratio (HR) was reported for the LVI + and infiltration >4.25 mm (HR 24.849). CONCLUSIONS In patients with ECC (pT1NXM0), good differentiation (G1), absence of lymphovascular invasion (LVI-), and tumor radial infiltration ≤4.25 mm may allow performing local resection and avoiding radical surgery.
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Affiliation(s)
- Andrea Morini
- Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italia.,Unità di Chirurgia Oncologica, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Arcispedale Santa Maria Nuova di Reggio Emilia, Reggio Emilia, Italia
| | - Alfredo Annicchiarico
- Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italia. .,Unità Operativa di Chirurgia Generale, Sede Ulteriore dell'Università di Parma, Ospedale di Vaio, Azienda Sanitaria Locale di Parma, Fidenza (Parma), Italia.
| | - Federica De Giorgi
- Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italia.,Unità Operativa di Anatomia Patologica, Azienda Ospedaliero-Universitaria di Parma, Parma, Italia
| | - Elena Ferioli
- Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italia.,Unità Operativa di Anatomia Patologica, Azienda Ospedaliero-Universitaria di Parma, Parma, Italia
| | - Andrea Romboli
- Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italia
| | - Filippo Montali
- Unità Operativa di Chirurgia Generale, Sede Ulteriore dell'Università di Parma, Ospedale di Vaio, Azienda Sanitaria Locale di Parma, Fidenza (Parma), Italia
| | - Pellegrino Crafa
- Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italia.,Unità Operativa di Anatomia Patologica, Azienda Ospedaliero-Universitaria di Parma, Parma, Italia
| | - Renato Costi
- Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italia.,Unità Operativa di Chirurgia Generale, Sede Ulteriore dell'Università di Parma, Ospedale di Vaio, Azienda Sanitaria Locale di Parma, Fidenza (Parma), Italia
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24
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Liu PL, Wang DD, Pang CJ, Zhang LZ. Impact of adequate lymph nodes dissection on survival in patients with stage I rectal cancer. Front Oncol 2022; 12:985324. [DOI: 10.3389/fonc.2022.985324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 10/28/2022] [Indexed: 11/21/2022] Open
Abstract
Background and AimsThe NCCN guidelines recommended an assessment of ≥ 12 lymph nodes (LN) as an adequate LN dissection (LND) for rectal cancer (RC). However, the impact of adequate LND on survival in stage I RC patients remained unclear. Thus, we aimed to compare the survival between stage I RC patients with adequate and inadequate LND.MethodsA total of 1,778 stage I RC patients in the SEER database from 2010 to 2017 treated with radical proctectomy were identified. The association between ≥ 12 LND and survival was examined using the multivariate Cox regression and the multivariate competing risk model referenced to < 12 LND.ResultsStage I RC patients with ≥ 12 LND experienced a significantly lower hazard of cancer-specific death compared with those with < 12 LND in both multivariate Cox regression model (adjusted HR [hazard ratio], 0.44, 95% CI, 0.29-0.66; P < 0.001) and the multivariate competing risk model (adjusted subdistribution HR [SHR], 0.45, 95% CI, 0.30-0.69; P < 0.001). Further, subgroup analyses performed by pT stage. No positive association between ≥ 12 LND and survival was found in pT1N0 RC patients (adjusted HR: 0.62, 95%CI, 0.32-1.19; P = 0.149; adjusted SHR: 0.63, 95%CI, 0.33-1.20; P = 0.158), whereas a positive association between ≥ 12 LND and survival was found in pT2N0 RC patients (adjusted HR: 0.35, 95%CI, 0.21-0.58; P < 0.001; adjusted SHR: 0.36, 95%CI, 0.21-0.62; P < 0.001).ConclusionsThe long-term survival benefit of adequate LND was not found in pT1N0 but in pT2N0 RC patients, which suggested that pT2N0 RC patients should be treated with adequate LND and those with inadequate LND might need additional therapy.
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25
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Peltrini R, Imperatore N, Di Nuzzo MM, Pellino G. Towards personalized treatment of T2N0 rectal cancer: A systematic review of long-term oncological outcomes of neoadjuvant therapy followed by local excision. J Gastroenterol Hepatol 2022; 37:1426-1433. [PMID: 35614027 PMCID: PMC9545053 DOI: 10.1111/jgh.15898] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 05/17/2022] [Accepted: 05/19/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIM Total mesorectal excision (TME) remains the treatment of choice in T2N0 tumors. However, evidence suggest that one-size-fits-all approach is not always beneficial for this group of patients. The aim of this study is to synthesize data on long-term outcomes after neoadjuvant therapy (NAT) followed by local excision (LE) in T2N0 rectal cancer patients in the perspective of a rectal-preserving strategy. METHODS A systematic search of PubMed/MEDLINE, SCOPUS, and Web of Science databases was conducted until October 2021 to identify studies comparing LE after NAT and TME or reporting oncologic outcomes after conservative approach. A pooled analysis was conducted using a fixed-effect model in the case of non-significant heterogeneity (P > 0.1), and a random effect model (DerSimonian-Laird method) when significant heterogeneity was present (P < 0.1) CRD42022300344. RESULTS Nine studies were included in the analysis. Three of them were comparative studies. The pooled 3-year DFS, 5-year DFS, 3-year OS, 5-year OS, local and distant recurrence rates were 92.8% (95% CI 81.6-99.5%), 91.3% (95% CI 88.3-94.3%), 96.1% (95% CI 90.5-100%), 72.6% (95% CI 57.5-87.7%), 4% (95% CI 18-63%), and 4.9% (95% CI 2-7.8%), respectively, in subjects treated with NAT followed by LE. No heterogeneity was found for all these analyses, except for the 5-year OS sub-analysis (I2 95.5%, P < 0.001). Complete pathological response (ypT0) rate after NAT and LE ranges from 26.7% to 59%. CONCLUSION LE following neoadjuvant CRT may provide comparable survival benefit to radical surgery for patients with clinical stage T2N0 in selected patients although the evidence is still limited to provide solid recommendations. A personalized therapeutic approach taking into account tumor and patient-related factors should be considered.
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Affiliation(s)
- Roberto Peltrini
- Department of Public Health, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Nicola Imperatore
- Gastroenterology and Endoscopy Unit, AORN Antonio Cardarelli, Naples, Italy
| | - Maria Michela Di Nuzzo
- Department of Public Health, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitell", Naples, Italy.,Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
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26
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Tan S, Xu C, Ma H, Chen S, Yang Y, Zhan Y, Wu J, Sun Z, Ren B, Zhou Q, Cu Y. Local resection versus radical resection for early-stage rectal cancer: a systematic review and meta-analysis. Int J Colorectal Dis 2022; 37:1467-1483. [PMID: 35622160 DOI: 10.1007/s00384-022-04186-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE The optimal surgical approach for early-stage rectal cancer remains controversial. Radical resection is considered to be the gold standard for rectal cancer treatment. More and more studies show that local resection can replace traditional radical resection in the treatment of early rectal cancer. This research aimed to compare the efficacy of local excision and radical surgery for early-stage rectal cancer and report the evidence-based clinical advantages of both techniques. METHODS The clinical trials comparing oncological and perioperative local and radical resection outcomes for early-stage rectal cancer were searched from 7 national and international databases. RESULTS Finally, 3 randomized controlled trials and 14 cohort studies were included. In terms of oncology and perioperative outcomes, there were no statistically significant differences between the radical resection group and the local resection group in terms of OS (HR = 1.05, 95% CI (0.98, 1.13), DFS [HR = 1.18, 95% CI (0.93, 1.48), p = 0.168), distant metastasis rate (RR = 1.04, 95% CI (0.49, 2.20), p = 0.928), and mortality rate (RR = 1.52, 95% CI (0.80, 2.91), p = 0.200). However, there were significant differences in the outcomes of complications (RR = 2.85, 95% CI (2.07, 3.92), p < 0.001), length of hospital stays (WMD = 5.41, 95% CI (3.94, 6.87), p < 0.001), stoma rate (RR = 7.69, 95% CI (2.39, 24.77), p = 0.001), local recurrence rate (RR = 0.48, 95% CI (0.27, 0.86), p = 0.013), operative time (WMD = 74.68, 95% CI (68.00, 81.36), p < 0.001), blood loss (WMD = 156.36, 95% CI (95.48, 217.21, p < 0.001), and adverse events (RR = 1.59, 95% CI (1.05, 2.41), p = 0.027). CONCLUSION Local excision may be a viable alternative to radical resection for early-stage rectal cancer, but higher quality clinical studies are needed to confirm this.
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Affiliation(s)
- Shufa Tan
- Shaanxi University of Chinese Medicine, Shaanxi, China
| | - Chenxi Xu
- Fuling Hospital Affiliated to Chongqing University, 2 Gaosuntang Road, Fuling District, Chongqing City, 408099, China
| | - Hongbo Ma
- Fuling Hospital Affiliated to Chongqing University, 2 Gaosuntang Road, Fuling District, Chongqing City, 408099, China
| | - Shikai Chen
- Shaanxi University of Chinese Medicine, Shaanxi, China
| | - Yunyi Yang
- Shanghai University of Chinese Medicine, Shanghai, China
| | - Yanrong Zhan
- Shaanxi University of Chinese Medicine, Shaanxi, China
| | - Jiyun Wu
- Shaanxi University of Chinese Medicine, Shaanxi, China
| | - Zhenfu Sun
- Shaanxi University of Chinese Medicine, Shaanxi, China
| | - Bozhi Ren
- Shaanxi University of Chinese Medicine, Shaanxi, China
| | - Qi Zhou
- Fuling Hospital Affiliated to Chongqing University, 2 Gaosuntang Road, Fuling District, Chongqing City, 408099, China.
| | - Yaping Cu
- Department of Anorectal, Affiliated Hospital of Shaanxi University of Traditional Chinese Medicine, No. 2, Weiyang West Road, Qindu District, Xianyang City, 712099, Shaanxi, China.
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27
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Read M, Felder S. Transanal Approaches to Rectal Neoplasia. SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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28
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Transanal minimally invasive surgery (TAMIS) for rectal cancer. SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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29
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Ketelaers SHJ, Jacobs A, Verrijssen ASE, Cnossen JS, van Hellemond IEG, Creemers GJM, Schreuder RM, Scholten HJ, Tolenaar JL, Bloemen JG, Rutten HJT, Burger JWA. A Multidisciplinary Approach for the Personalised Non-Operative Management of Elderly and Frail Rectal Cancer Patients Unable to Undergo TME Surgery. Cancers (Basel) 2022; 14:2368. [PMID: 35625976 PMCID: PMC9139821 DOI: 10.3390/cancers14102368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/05/2022] [Accepted: 05/09/2022] [Indexed: 02/07/2023] Open
Abstract
Despite it being the optimal curative approach, elderly and frail rectal cancer patients may not be able to undergo a total mesorectal excision. Frequently, no treatment is offered at all and the natural course of the disease is allowed to unfold. These patients are at risk for developing debilitating symptoms that impair quality of life and require palliative treatment. Recent advancements in non-operative treatment modalities have enhanced the toolbox of alternative treatment strategies in patients unable to undergo surgery. Therefore, a proposed strategy is to aim for the maximal non-operative treatment, in an effort to avoid the onset of debilitating symptoms, improve quality of life, and prolong survival. The complexity of treating elderly and frail patients requires a patient-centred approach to personalise treatment. The main challenge is to optimise the balance between local control of disease, patient preferences, and the burden of treatment. A comprehensive geriatric assessment is a crucial element within the multidisciplinary dialogue. Since limited knowledge is available on the optimal non-operative treatment strategy, these patients should be treated by dedicated multidisciplinary rectal cancer experts with special interest in the elderly and frail. The aim of this narrative review was to discuss a multidisciplinary patient-centred treatment approach and provide a practical suggestion of a successfully implemented clinical care pathway.
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Affiliation(s)
- Stijn H. J. Ketelaers
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
| | - Anne Jacobs
- Department of Gerontology and Geriatrics, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands;
| | - An-Sofie E. Verrijssen
- Department of Radiation Oncology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (A.-S.E.V.); (J.S.C.)
| | - Jeltsje S. Cnossen
- Department of Radiation Oncology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (A.-S.E.V.); (J.S.C.)
| | - Irene E. G. van Hellemond
- Department of Medical Oncology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (I.E.G.v.H.); (G.-J.M.C.)
| | - Geert-Jan M. Creemers
- Department of Medical Oncology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (I.E.G.v.H.); (G.-J.M.C.)
| | - Ramon-Michel Schreuder
- Department of Gastroenterology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands;
| | - Harm J. Scholten
- Department of Anaesthesiology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands;
| | - Jip L. Tolenaar
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
| | - Johanne G. Bloemen
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
| | - Harm J. T. Rutten
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
- GROW, School for Oncology and Reproduction, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Jacobus W. A. Burger
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
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Wyatt JNR, Powell SG, Altaf K, Barrow HE, Alfred JS, Ahmed S. Completion Total Mesorectal Excision After Transanal Local Excision of Early Rectal Cancer: A Systematic Review and Meta-analysis. Dis Colon Rectum 2022; 65:628-640. [PMID: 35143429 DOI: 10.1097/dcr.0000000000002407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Completion total mesorectal excision is recommended when local excision of early rectal cancers demonstrates high-risk histopathological features. Concerns regarding the quality of completion resections and the impact on oncological safety remain unanswered. OBJECTIVE This study aims to summarize and analyze the outcomes associated with completion surgery and undertake a comparative analysis with primary rectal resections. DATA SOURCES Data sources included PubMed, Cochrane library, MEDLINE, and Embase databases up to April 2021. STUDY SELECTION All studies reporting any outcome of completion surgery after transanal local excision of an early rectal cancer were selected. Case reports, studies of benign lesions, and studies using flexible endoscopic techniques were not included. INTERVENTION The intervention was completion total mesorectal excision after transanal local excision of early rectal cancers. MAIN OUTCOME MEASURES Primary outcome measures included histopathological and long-term oncological outcomes of completion total mesorectal excision. Secondary outcome measures included short-term perioperative outcomes. RESULTS Twenty-three studies including 646 patients met the eligibility criteria, and 8 studies were included in the meta-analyses. Patients undergoing completion surgery have longer operative times (standardized mean difference, 0.49; 95% CI, 0.23-0.75; p = 0.0002) and higher intraoperative blood loss (standardized mean difference, 0.25; 95% CI, 0.01-0.5; p = 0.04) compared with primary resections, but perioperative morbidity is comparable (risk ratio, 1.26; 95% CI, 0.98-1.62; p = 0.08). Completion surgery is associated with higher rates of incomplete mesorectal specimens (risk ratio, 3.06; 95% CI, 1.41-6.62; p = 0.005) and lower lymph node yields (standardized mean difference, -0.26; 95% CI, -0.47 to 0.06; p = 0.01). Comparative analysis on long-term outcomes is limited, but no evidence of inferior recurrence or survival rates is found. LIMITATIONS Only small retrospective cohort and case-control studies are published on this topic, with considerable heterogeneity limiting the effectiveness of meta-analysis. CONCLUSIONS This review provides the strongest evidence to date that completion surgery is associated with an inferior histopathological grade of the mesorectum and finds insufficient long-term results to satisfy concerns regarding oncological safety. International collaborative research is required to demonstrate noninferiority. REGISTRATION NO CRD42021245101.
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Affiliation(s)
- James N R Wyatt
- Department of Colorectal Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
- University of Liverpool, Liverpool, United Kingdom
| | - Simon G Powell
- Department of Colorectal Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
- University of Liverpool, Liverpool, United Kingdom
| | - Kiran Altaf
- Department of Colorectal Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Hannah E Barrow
- Department of Colorectal Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Joshua S Alfred
- Department of Colorectal Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Shakil Ahmed
- Department of Colorectal Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
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Tang J, Zhang Y, Zhang D, Zhang C, Jin K, Ji D, Peng W, Feng Y, Sun Y. Total Mesorectal Excision vs. Transanal Endoscopic Microsurgery Followed by Radiotherapy for T2N0M0 Distal Rectal Cancer: A Multicenter Randomized Trial. Front Surg 2022; 9:812343. [PMID: 35178428 PMCID: PMC8844472 DOI: 10.3389/fsurg.2022.812343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 01/10/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction Transanal endoscopic microsurgery (TEM) is an organ-preserving treatment alternative for patients with early rectal cancer. However, TEM alone is associated with greater risk of local recurrence and inferior survival in comparison with total meso-rectal excision (TME). As an important adjuvant therapy, radiotherapy can effectively reduce the local recurrence rate of rectal cancer. This study aimed to investigate whether TEM followed by radiotherapy can be a valid alternative to TME in T2N0M0 distal rectal cancer treatment. Methods We plan to recruit 168 participants meeting established inclusion criteria. Following informed consent, participants will randomly receive treatment protocols of TEM followed by radiotherapy (a total dose of 45–50.4 Gy given in 25–28 factions) or TME. Depending on post-operative pathology, the participants will receive either long-term follow-up or further treatment. The primary endpoint of this trial is 3-year local recurrence rate. The secondary end points include 3-year disease-free survival rate, 3-year overall survival rate, 3-year mortality rate, post-operative quality of life, post-operative safety index, intraoperative evaluation index and post-operative short-term evaluation index. Discussion This trial is the first prospective randomized trial to investigate the rectum preserving treatment by using transanal local excision followed by radiotherapy. Clinical trial registration The trial was prospectively registered at ClinicalTrials.gov NCT04098471 on September 20, 2019.
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Affi Koprowski M, Sutton TL, Brinkerhoff BT, Chen EY, Nabavizadeh N, Tsikitis VL. Conservative management of malignant colorectal polyps in select cases is safe in long-term follow-up: An institutional review. Am J Surg 2022; 224:658-663. [DOI: 10.1016/j.amjsurg.2022.02.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 02/03/2022] [Accepted: 02/25/2022] [Indexed: 01/24/2023]
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Collard MK, Rullier E, Panis Y, Manceau G, Benoist S, Tuech JJ, Alves A, Laforest A, Mege D, Cazelles A, Beyer-Berjot L, Christou N, Cotte E, Lakkis Z, O'Connell L, Parc Y, Piessen G, Lefevre JH. Nonmetastatic ypt0 rectal cancer after neoadjuvant treatment and total mesorectal excision: Lessons from a retrospective multicentric cohort of 383 patients. Surgery 2022; 171:1193-1199. [PMID: 35078629 DOI: 10.1016/j.surg.2021.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 10/04/2021] [Accepted: 10/04/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND A better understanding of pathological features and oncological survival in ypT0 rectal cancer after neoadjuvant chemoradiotherapy is required to improve patient selection criteria for rectal-preserving approach by local excision. Our aim was to define risk of lymph node metastasis and oncological outcomes in ypT0 rectal cancer after chemoradiotherapy and total mesorectal excision. METHODS All consecutive patients who underwent total mesorectal excision for a nonmetastatic rectal adenocarcinoma classified ypT0 after neoadjuvant chemoradiotherapy, with or without locoregional lymph node involvement (ypN+ or ypN-), in 14 French academic centers between 2002 and 2015 were included. Data were collected retrospectively. Overall and disease-free survival were explored. RESULTS Among the 383 ypT0 patients, 6% were ypN+ (23/283). Before chemoradiotherapy, 86% (327/380) were staged cT3-T4 and 41% (156/378) were staged cN+. The risk of ypN+ did not differ between cT3-T4 and cT1-T2 patients (P = .345) or between cN+ and cN- patients (P = .384). After a median follow-up of 61.1 months, we observed 95% confidence interval (92%-97%) of 5-year overall survival and 93% confidence interval (91%-96%) of 5-year disease-free survival. In Cox multivariate analysis, overall survival was altered by intra-abdominal septic complications (hazard ratio = 2.53, confidence interval [1.11-5.78], P = .028). Regarding disease-free survival, ypN+ status and administration of adjuvant chemotherapy were associated with a reduced disease-free survival (P = .001 for both). cT3/T4 staging and cN+ staging did not modify overall survival (P = .332 and P = .450) nor disease-free survival (P = .862 and P = .124). CONCLUSION The risk of lymph node metastasis and the oncological survival do not depend on the initial cT or cN staging in cases of ypT0 complete rectal tumor regression.
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Affiliation(s)
- Maxime K Collard
- Department of Digestive Surgery, Saint Antoine Hospital, Sorbonne University Paris, France
| | - Eric Rullier
- Department of Digestive Surgery, Saint André Hospital, Bordeaux, France
| | - Yves Panis
- Department of Colorectal Surgery, Beaujon Hospital, Clichy, France
| | - Gilles Manceau
- Department of General and Digestive Surgery, Université de Paris, Faculté de Médecine, Paris, France
| | - Stéphane Benoist
- Department of Digestive Surgery, Kremlin-Bicêtre Hospital, France
| | | | - Arnaud Alves
- Department of Digestive Surgery, Rouen Hospital, France
| | - Anais Laforest
- Department of Digestive Surgery, Montsouris Institut, Paris, France
| | - Diane Mege
- Department of Digestive Surgery, Aix Marseille Univ, APHM, Timone University Hospital, Marseille, France
| | | | | | - Niki Christou
- Department of Digestive Surgery, Limoges Hospital, Limoges, France
| | - Eddy Cotte
- Department of Digestive Surgery, Hopital Lyon Sud, Lyon, France
| | - Zaher Lakkis
- Department of Digestive Surgery, Jean Minoz Hospital, Besançon, France
| | - Lauren O'Connell
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Yann Parc
- Department of Digestive Surgery, Saint Antoine Hospital, Sorbonne University Paris, France
| | | | - Jérémie H Lefevre
- Department of Digestive Surgery, Saint Antoine Hospital, Sorbonne University Paris, France.
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Prabhakaran S, Yang TWW, Johnson N, Bell S, Chin M, Simpson P, Carne P, Farmer C, Skinner S, Warrier SK, Kong JCH. Latest evidence on the management of early‐stage and locally advanced rectal cancer: a narrative review. ANZ J Surg 2022; 92:365-372. [DOI: 10.1111/ans.17429] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 11/21/2021] [Accepted: 12/10/2021] [Indexed: 02/03/2023]
Affiliation(s)
- Swetha Prabhakaran
- Department of Colorectal Surgery Alfred Health Melbourne Victoria Australia
| | | | - Nicholas Johnson
- Department of Colorectal Surgery Alfred Health Melbourne Victoria Australia
| | - Stephen Bell
- Department of Colorectal Surgery Alfred Health Melbourne Victoria Australia
- Central Clinical School Monash University Melbourne Victoria Australia
| | - Martin Chin
- Department of Colorectal Surgery Alfred Health Melbourne Victoria Australia
- Central Clinical School Monash University Melbourne Victoria Australia
| | - Paul Simpson
- Department of Colorectal Surgery Alfred Health Melbourne Victoria Australia
- Central Clinical School Monash University Melbourne Victoria Australia
| | - Peter Carne
- Department of Colorectal Surgery Alfred Health Melbourne Victoria Australia
- Central Clinical School Monash University Melbourne Victoria Australia
| | - Chip Farmer
- Department of Colorectal Surgery Alfred Health Melbourne Victoria Australia
- Central Clinical School Monash University Melbourne Victoria Australia
| | - Stewart Skinner
- Department of Colorectal Surgery Alfred Health Melbourne Victoria Australia
- Central Clinical School Monash University Melbourne Victoria Australia
| | - Satish K Warrier
- Department of Colorectal Surgery Alfred Health Melbourne Victoria Australia
- Central Clinical School Monash University Melbourne Victoria Australia
- Division of Cancer Surgery Peter MacCallum Cancer Centre Melbourne Victoria Australia
- The Sir Peter MacCallum Centre Department of Oncology The University of Melbourne Parkville Victoria Australia
| | - Joseph CH Kong
- Department of Colorectal Surgery Alfred Health Melbourne Victoria Australia
- Central Clinical School Monash University Melbourne Victoria Australia
- Division of Cancer Surgery Peter MacCallum Cancer Centre Melbourne Victoria Australia
- The Sir Peter MacCallum Centre Department of Oncology The University of Melbourne Parkville Victoria Australia
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Son GM, Lee IY, Cho SH, Park BS, Kim HS, Park SB, Kim HW, Oh SB, Kim TU, Shin DH. Multidisciplinary treatment strategy for early rectal cancer A review. PRECISION AND FUTURE MEDICINE 2021. [DOI: 10.23838/pfm.2021.00163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2022] Open
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Kastner C, Petritsch B, Reibetanz J, Germer CT, Wiegering A. [Complete response after neoadjuvant therapy of rectal cancer: implications for surgery]. Chirurg 2021; 93:144-151. [PMID: 34878582 DOI: 10.1007/s00104-021-01540-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2021] [Indexed: 12/17/2022]
Abstract
For (locally advanced) rectal cancer, a multimodal therapy concept comprising neoadjuvant radiotherapy/chemoradiotherapy, radical surgical resection with partial/complete mesorectal excision and subsequent adjuvant chemotherapy represents the current international standard of care. Further developments in neoadjuvant therapy concepts, such as the principle of total neoadjuvant therapy, lead to an increasing number of patients who show a complete clinical response in restaging after neoadjuvant therapy without clinically detectable residual tumor. In view of the risk associated with radical surgical resection in terms of perioperative morbidity and a potentially non-continence-preserving procedure, the question of the oncological justifiability of an organ-preserving procedure in the case of a complete clinical response under neoadjuvant therapy is increasingly being raised. The therapeutic principle of watch and wait, defined by refraining from immediate radical surgical resection and inclusion in a close-meshed, structured follow-up program, currently appears to be oncologically justifiable based on the current study situation; however, for the initial evaluation of the extent of the clinical response and for the structuring of the close-meshed follow-up program, further optimization and standardization based on broadly designed studies appear necessary in order to be able to provide this concept to a clearly defined patient collective as an oncologically equivalent therapy principle also outside specialized centers.
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Affiliation(s)
- Carolin Kastner
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum für operative Medizin, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
- Institut für Biochemie und molekulare Biologie, Julius-Maximilians-Universität Würzburg, Würzburg, Deutschland
| | - Bernhard Petritsch
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Joachim Reibetanz
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum für operative Medizin, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Christoph-Thomas Germer
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum für operative Medizin, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
- Comprehensive Cancer Center Mainfranken, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Armin Wiegering
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum für operative Medizin, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland.
- Institut für Biochemie und molekulare Biologie, Julius-Maximilians-Universität Würzburg, Würzburg, Deutschland.
- Comprehensive Cancer Center Mainfranken, Universitätsklinikum Würzburg, Würzburg, Deutschland.
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Marchegiani F, Palatucci V, Capelli G, Guerrieri M, Belluco C, Rega D, Morpurgo E, Coco C, Restivo A, De Franciscis S, Aschele C, Perin A, Bonomo M, Muratore A, Spinelli A, Ramuscello S, Bergamo F, Montesi G, Spolverato G, Del Bianco P, Gambacorta MA, Delrio P, Pucciarelli S. Rectal Sparing Approach After Neoadjuvant Therapy in Patients with Rectal Cancer: The Preliminary Results of the ReSARCh Trial. Ann Surg Oncol 2021; 29:1880-1889. [PMID: 34855063 DOI: 10.1245/s10434-021-11121-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 10/12/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Rectum-preservation for locally advanced rectal cancer has been proposed as an alternative to total mesorectal excision (TME) in patients with major (mCR) or complete clinical response (cCR) after neoadjuvant therapy. The purpose of this study was to report on the short-term outcomes of ReSARCh (Rectal Sparing Approach after preoperative Radio- and/or Chemotherapy) trial, which is a prospective, multicenter, observational trial that investigated the role of transanal local excision (LE) and watch-and-wait (WW) as integrated approaches after neoadjuvant therapy for rectal cancer. METHODS Patients with mid-low rectal cancer who achieved mCR or cCR after neoadjuvant therapy and were fit for major surgery were enrolled. Clinical response was evaluated at 8 and 12 weeks after completion of chemoradiotherapy. Treatment approach, incidence, and reasons for subsequent TME were recorded. RESULTS From 2016 to 2019, 160 patients were enrolled; mCR or cCR at 12 weeks was achieved in 64 and 96 of patients, respectively. Overall, 98 patients were managed with LE and 62 with WW. In the LE group, Clavien-Dindo 3+ complications occurred in three patients. The rate of cCR increased from 8- to 12-week restaging. Thirty-three (94.3%) of 35 patients with cCR had ypT0-1 tumor. At a median 24 months follow-up, a tumor regrowth was found in 15 (24.2%) patients undergoing WW. CONCLUSIONS LE for patients achieving cCR or mCR is safe. A 12-week interval from chemoradiotherapy completion to LE is correlated with an increased cCR rate. The risk of ypT > is reduced when LE is performed after cCR.
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Affiliation(s)
- Francesco Marchegiani
- Department of Surgical, Oncological and Gastroenterological Sciences, First Surgical Clinic, University of Padova, Padua, Italy
| | - Valeria Palatucci
- Department of Surgical, Oncological and Gastroenterological Sciences, First Surgical Clinic, University of Padova, Padua, Italy
| | - Giulia Capelli
- Department of Surgical, Oncological and Gastroenterological Sciences, First Surgical Clinic, University of Padova, Padua, Italy
| | - Mario Guerrieri
- Surgery Clinic, Marche Polytechnic University, Ancona, Italy
| | - Claudio Belluco
- Oncological Surgery Department, Centro di Riferimento Oncologico, National Cancer Institute, Aviano, Italy
| | - Daniela Rega
- National Cancer Institute, IRCCS Fondazione "G.Pascale", Naples, Italy
| | - Emilio Morpurgo
- Department of Surgery, Regional Center for Laparoscopic and Robotic Surgery, Camposampiero Hospital, Padua, Italy
| | - Claudio Coco
- Department of Surgical Sciences, Catholic University of Rome, Rome, Italy
| | - Angelo Restivo
- Department of Surgery, Colorectal Surgery Center, University of Cagliari, Cagliari, Italy
| | | | | | - Alessandro Perin
- Department of Surgical, Oncological and Gastroenterological Sciences, First Surgical Clinic, University of Padova, Padua, Italy
| | | | - Andrea Muratore
- Division of General Surgery, E. Agnelli Hospital, Pinerolo, Turin, Italy
| | - Antonino Spinelli
- Colon and Rectal Surgery Unit, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | | | | | - Giampaolo Montesi
- Radiation Oncology Unit, Santa Maria della Misericordia Hospital, Rovigo, Italy
| | - Gaya Spolverato
- Department of Surgical, Oncological and Gastroenterological Sciences, First Surgical Clinic, University of Padova, Padua, Italy.
| | | | | | - Paolo Delrio
- National Cancer Institute, IRCCS Fondazione "G.Pascale", Naples, Italy
| | - Salvatore Pucciarelli
- Department of Surgical, Oncological and Gastroenterological Sciences, First Surgical Clinic, University of Padova, Padua, Italy
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Goffredo P, Smith JJ. The Paradox of Early Stage Rectal Cancer: More ReSeARCh in the Right Direction. Ann Surg Oncol 2021; 29:1513-1515. [PMID: 34850305 DOI: 10.1245/s10434-021-11124-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 11/11/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Paolo Goffredo
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - J Joshua Smith
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Smits LJH, van Lieshout AS, Grüter AAJ, Horsthuis K, Tuynman JB. Multidisciplinary management of early rectal cancer - The role of surgical local excision in current and future clinical practice. Surg Oncol 2021; 40:101687. [PMID: 34875460 DOI: 10.1016/j.suronc.2021.101687] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/30/2021] [Accepted: 11/22/2021] [Indexed: 12/14/2022]
Abstract
The implementation of bowel cancer screening programs has led to a rise in the incidence of early rectal cancer. The combination of increased incidence and the growing interest in organ-sparing treatment options has led to an amplified importance of local excision techniques in treatment strategies for early rectal cancer. In addition, developments in new technologies of single-port surgery have popularized surgical techniques. Although local treatment of early rectal cancer seems promising, a multidisciplinary approach is necessary and awareness of the oncological robustness is warranted to enable shared decision-making. This review illustrates the position of surgical local excision in the treatment of early rectal cancer and reflects on its role in current and future clinical practice.
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Affiliation(s)
- Lisanne J H Smits
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, the Netherlands.
| | - Annabel S van Lieshout
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, the Netherlands
| | - Alexander A J Grüter
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, the Netherlands
| | - Karin Horsthuis
- Department of Radiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, the Netherlands
| | - Jurriaan B Tuynman
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, the Netherlands.
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Shulman RM, Meyer JE. Current Trends in the Treatment of Locally Advanced Rectal Cancer: Where We Are and How We Got Here. CURRENT COLORECTAL CANCER REPORTS 2021. [DOI: 10.1007/s11888-021-00471-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Anker CJ, Lester-Coll NH, Akselrod D, Cataldo PA, Ades S. The Potential for Overtreatment With Total Neoadjuvant Therapy (TNT): Consider One Local Therapy Instead. Clin Colorectal Cancer 2021; 21:19-35. [DOI: 10.1016/j.clcc.2021.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/03/2021] [Accepted: 11/14/2021] [Indexed: 11/11/2022]
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42
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Dou R, He S, Deng Y, Wang J. Comparison of guidelines on rectal cancer: exception proves the rule? Gastroenterol Rep (Oxf) 2021; 9:290-298. [PMID: 34567560 PMCID: PMC8460091 DOI: 10.1093/gastro/goab034] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/14/2021] [Accepted: 07/07/2021] [Indexed: 12/19/2022] Open
Abstract
The standard of care for early or locally advanced rectal cancer is promoted by multiple clinical practice guidelines globally, but the considerable differences between the guidelines may cause confusion. We compared the latest updated clinical practice guidelines from five professional societies/authorities: National Comprehensive Cancer Network, American Society of Colorectal Surgeons, European Society of Medical Oncology, Chinese National Health Commission, and Chinese Society of Clinical Oncology. Key evidence is discussed for a better understanding of some seemingly contradictory recommendations.
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Affiliation(s)
- Ruoxu Dou
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Siqi He
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Yanhong Deng
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China.,Department of Medical Oncology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Jianping Wang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China.,Department of Gastrointestinal Surgery, Foresea Life Insurance Guangzhou General Hospital, Guangzhou, Guangdong, P. R. China
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Ahmad NZ, Abbas MH, Abunada MH, Parvaiz A. A Meta-analysis of Transanal Endoscopic Microsurgery versus Total Mesorectal Excision in the Treatment of Rectal Cancer. Surg J (N Y) 2021; 7:e241-e250. [PMID: 34541316 PMCID: PMC8440057 DOI: 10.1055/s-0041-1735587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 07/22/2021] [Indexed: 11/23/2022] Open
Abstract
Background
Transanal endoscopic microsurgery (TEMS) has been suggested as an alternative to total mesorectal excision (TME) in the treatment of early rectal cancers. The extended role of TEMS for higher stage rectal cancers after neoadjuvant therapy is also experimented. The aim of this meta-analysis was to compare the oncological outcomes and report on the evidence-based clinical supremacy of either technique.
Methods
Medline, Embase, and Cochrane databases were searched for the randomized controlled trials comparing the oncological and perioperative outcomes of TEMS and a radical TME. A local recurrence and postoperative complications were analyzed as primary end points. Intraoperative blood loss, operation time, and duration of hospital stay were compared as secondary end points.
Results
There was no statistical difference in the local recurrence or postoperative complications with a risk ratio of 1.898 and 0.753 and
p
-values of 0.296 and 0.306, respectively, for TEMS and TME. A marked statistical significance in favor of TEMS was observed for secondary end points. There was standard difference in means of −4.697, −6.940, and −5.685 with
p
-values of 0.001, 0.005, and 0.001 for blood loss, operation time, and hospital stay, respectively.
Conclusion
TEMS procedure is a viable alternative to TME in the treatment of early rectal cancers. An extended role of TEMS after neoadjuvant therapy may also be offered to a selected group of patients. TME surgery remains the standard of care in more advanced rectal cancers.
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Affiliation(s)
- Nasir Zaheer Ahmad
- Department of Surgery, University Hospital Limerick, Limerick, Republic of Ireland
| | - Muhammad Hasan Abbas
- Department of Surgery, Russells Hall Hospital, NHS Trust, West Midlands, Dudley, United Kingdom
| | | | - Amjad Parvaiz
- Faculty of Health Sciences, University of Portsmouth, Portsmouth, England.,Department of Colorectal Surgery, Poole NHS Trust, Poole, United Kingdom
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Abstract
Robotic transanal surgery is the culmination of major developments in rectal cancer management and minimally invasive surgery. It is the result of continuous efforts to tackle the challenges inherent to rectal cancer surgery. This latest technology holds great promise and excitement for the care of the rectal cancer patient. In this article, we will describe the evolution of transanal rectal cancer surgery and describe how the convergence of transanal transabdominal, transanal endoscopic microsurgery, transanal minimally invasive surgery (TAMIS), transanal total mesorectal excision (taTME), and the different robotic platforms have culminated in the development of single port robotic transanal minimally invasive surgery (SP rTAMIS) and single port robotic transanal total mesorectal excision (SP rtaTME). We will describe the indications, technical aspects, outcomes, benefits, and limitations of the SP rTAMIS and SP rtaTME.
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Affiliation(s)
- John H Marks
- Department of Colorectal Surgery, Lankenau Medical Center, Wynnewood, Pennsylvania
| | - Rafael E Perez
- Department of Colorectal Surgery, Lankenau Medical Center, Wynnewood, Pennsylvania
| | - Jean F Salem
- Department of Colorectal Surgery, Lankenau Medical Center, Wynnewood, Pennsylvania
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45
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Yuval JB, Garcia-Aguilar J. Watch-and-wait Management for Rectal Cancer After Clinical Complete Response to Neoadjuvant Therapy. Adv Surg 2021; 55:89-107. [PMID: 34389102 DOI: 10.1016/j.yasu.2021.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Jonathan B Yuval
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
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46
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Podda M, Sylla P, Baiocchi G, Adamina M, Agnoletti V, Agresta F, Ansaloni L, Arezzo A, Avenia N, Biffl W, Biondi A, Bui S, Campanile FC, Carcoforo P, Commisso C, Crucitti A, De'Angelis N, De'Angelis GL, De Filippo M, De Simone B, Di Saverio S, Ercolani G, Fraga GP, Gabrielli F, Gaiani F, Guerrieri M, Guttadauro A, Kluger Y, Leppaniemi AK, Loffredo A, Meschi T, Moore EE, Ortenzi M, Pata F, Parini D, Pisanu A, Poggioli G, Polistena A, Puzziello A, Rondelli F, Sartelli M, Smart N, Sugrue ME, Tejedor P, Vacante M, Coccolini F, Davies J, Catena F. Multidisciplinary management of elderly patients with rectal cancer: recommendations from the SICG (Italian Society of Geriatric Surgery), SIFIPAC (Italian Society of Surgical Pathophysiology), SICE (Italian Society of Endoscopic Surgery and new technologies), and the WSES (World Society of Emergency Surgery) International Consensus Project. World J Emerg Surg 2021; 16:35. [PMID: 34215310 PMCID: PMC8254305 DOI: 10.1186/s13017-021-00378-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 06/18/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND AIMS Although rectal cancer is predominantly a disease of older patients, current guidelines do not incorporate optimal treatment recommendations for the elderly and address only partially the associated specific challenges encountered in this population. This results in a wide variation and disparity in delivering a standard of care to this subset of patients. As the burden of rectal cancer in the elderly population continues to increase, it is crucial to assess whether current recommendations on treatment strategies for the general population can be adopted for the older adults, with the same beneficial oncological and functional outcomes. This multidisciplinary experts' consensus aims to refine current rectal cancer-specific guidelines for the elderly population in order to help to maximize rectal cancer therapeutic strategies while minimizing adverse impacts on functional outcomes and quality of life for these patients. METHODS The discussion among the steering group of clinical experts and methodologists from the societies' expert panel involved clinicians practicing in general surgery, colorectal surgery, surgical oncology, geriatric oncology, geriatrics, gastroenterologists, radiologists, oncologists, radiation oncologists, and endoscopists. Research topics and questions were formulated, revised, and unanimously approved by all experts in two subsequent modified Delphi rounds in December 2020-January 2021. The steering committee was divided into nine teams following the main research field of members. Each conducted their literature search and drafted statements and recommendations on their research question. Literature search has been updated up to 2020 and statements and recommendations have been developed according to the GRADE methodology. A modified Delphi methodology was implemented to reach agreement among the experts on all statements and recommendations. CONCLUSIONS The 2021 SICG-SIFIPAC-SICE-WSES consensus for the multidisciplinary management of elderly patients with rectal cancer aims to provide updated evidence-based statements and recommendations on each of the following topics: epidemiology, pre-intervention strategies, diagnosis and staging, neoadjuvant chemoradiation, surgery, watch and wait strategy, adjuvant chemotherapy, synchronous liver metastases, and emergency presentation of rectal cancer.
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Affiliation(s)
- Mauro Podda
- Department of Emergency Surgery, Cagliari University Hospital "D. Casula", Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy.
| | - Patricia Sylla
- Division of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY, USA
| | - Gianluca Baiocchi
- ASST Cremona, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Michel Adamina
- Department of Colorectal Surgery, Cantonal Hospital of Winterthur, Winterthur - University of Basel, Basel, Switzerland
| | | | - Ferdinando Agresta
- Department of General Surgery, Vittorio Veneto Hospital, AULSS2 Trevigiana del Veneto, Vittorio Veneto, Italy
| | - Luca Ansaloni
- 1st General Surgery Unit, University of Pavia, Pavia, Italy
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Nicola Avenia
- SC Chirurgia Generale e Specialità Chirurgiche Azienda Ospedaliera Santa Maria, Università degli Studi di Perugia, Terni, Italy
| | - Walter Biffl
- Trauma and Acute Care Surgery, Scripps Memorial Hospital, La Jolla, CA, USA
| | - Antonio Biondi
- Department of General Surgery and Medical - Surgical Specialties, University of Catania, Catania, Italy
| | - Simona Bui
- Department of Medical Oncology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Fabio C Campanile
- Department of Surgery, ASL VT - Ospedale "San Giovanni Decollato - Andosilla", Civita Castellana, Italy
| | - Paolo Carcoforo
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara, University of Ferrara, Ferrara, Italy
| | - Claudia Commisso
- Department of Radiology, University Hospital of Parma, Parma, Italy
| | - Antonio Crucitti
- General and Minimally Invasive Surgery Unit, Cristo Re Hospital and Catholic University, Rome, Italy
| | - Nicola De'Angelis
- Unit of Minimally Invasive and Robotic Digestive Surgery, Regional General Hospital F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Gian Luigi De'Angelis
- Department of Medicine and Surgery, Gastroenterology and Endoscopy Unit, University of Parma, Parma, Italy
| | | | - Belinda De Simone
- Department of General and Metabolic Surgery, Poissy and Saint Germain en Laye Hospitals, Poissy, France
| | | | - Giorgio Ercolani
- General and Oncologic Surgery, Morgagni-Pierantoni Hospital, AUSL Romagna, Forlì, Italy
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, SP, Brazil
| | | | - Federica Gaiani
- Department of Medicine and Surgery, Gastroenterology and Endoscopy Unit, University of Parma, Parma, Italy
| | | | | | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ari K Leppaniemi
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Andrea Loffredo
- UOC Chirurgia Generale - AOU san Giovanni di Dio e Ruggi d'Aragona, Università di Salerno, Salerno, Italy
| | - Tiziana Meschi
- Department of Medicine and Surgery, University of Parma Geriatric-Rehabilitation Department, Parma University Hospital, Parma, Italy
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, Denver, USA
| | | | | | - Dario Parini
- Santa Maria della Misericordia Hospital, Rovigo, Italy
| | - Adolfo Pisanu
- Department of Emergency Surgery, Cagliari University Hospital "D. Casula", Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy
| | - Gilberto Poggioli
- Surgery of the Alimentary Tract, Sant'Orsola Hospital, Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Andrea Polistena
- Dipartimento di Chirurgia Pietro Valdoni Policlinico Umberto I, Sapienza Università degli Studi di Roma, Rome, Italy
| | - Alessandro Puzziello
- UOC Chirurgia Generale - AOU san Giovanni di Dio e Ruggi d'Aragona, Università di Salerno, Salerno, Italy
| | - Fabio Rondelli
- SC Chirurgia Generale e Specialità Chirurgiche Azienda Ospedaliera Santa Maria, Università degli Studi di Perugia, Terni, Italy
| | | | | | - Michael E Sugrue
- Letterkenny University Hospital and CPM sEUBP Interreg Project, Letterkenny, Ireland
| | | | - Marco Vacante
- Department of General Surgery and Medical - Surgical Specialties, University of Catania, Catania, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Fausto Catena
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
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47
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Teste B, Rouanet P, Tuech JJ, Valverde A, Lelong B, Rivoire M, Faucheron JL, Jafari M, Portier G, Meunier B, Sielezneff I, Prudhomme M, Marchal F, Dubois A, Capdepont M, Denost Q, Rullier E. Early and late morbidity of local excision after chemoradiotherapy for rectal cancer. BJS Open 2021; 5:6294246. [PMID: 34097005 PMCID: PMC8183183 DOI: 10.1093/bjsopen/zrab043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 04/08/2021] [Indexed: 12/17/2022] Open
Abstract
Background Local excision (LE) after chemoradiotherapy is a new option in low rectal cancer, but morbidity has never been compared prospectively with total mesorectal excision (TME). Early and late morbidity were compared in patients treated either by LE or TME after neoadjuvant chemoradiotherapy for rectal cancer. Method This was a post-hoc analysis from a randomized trial. Patients with clinical T2/T3 low rectal cancer with good response to the chemoradiotherapy and having either LE, LE with eventual completion TME, or TME were considered. Early (1 month) and late (2 years) morbidities were compared between the three groups. Results There were no deaths following surgery in any of the three groups. Early surgical morbidity (20 per cent LE versus 36 per cent TME versus 43 per cent completion TME, P = 0.025) and late surgical morbidity (4 per cent versus 33 per cent versus 57 per cent, P < 0.001) were significantly lower in the LE group than in the TME or the completion TME group. of LE, was associated with the lowest rate of early (10 versus 18 versus 21 per cent, P = 0.217) and late medical morbidities (0 versus 7 versus 7 per cent, P = 0.154), although this did not represent a significant difference between the groups. The severity of overall morbidity was significantly lower at 2 years after LE compared with TME or completion TME (4 versus 28 versus 43 per cent grade 3–5, P < 0.001). Conclusion The rate of surgical complications after neoadjuvant chemoradiotherapy in the LE group was half that of TME group at 1 month and 10 times lower at 2 years. LE is a safe approach for organ preservation and should be considered as an alternative to watch-and-wait in complete clinical responders and to TME in subcomplete responders.
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Affiliation(s)
- B Teste
- Department of Colorectal Surgery, Magellan Centre, Haut-Leveque Hospital, University of Bordeaux, 33604 Pessac, France
| | - P Rouanet
- Département de Chirurgie Oncologique, ICM Val d'Aurelle, Montpellier, France
| | - J-J Tuech
- Service de Chirurgie Digestive, CHU Charles Nicolle, Rouen, France
| | - A Valverde
- Service de Chirurgie Digestive, Groupe Hospitalier Diaconesses Croix Saint-Simon, Paris, France
| | - B Lelong
- Département de Chirurgie Oncologique, Institut Paoli Calmette, Marseille, France
| | - M Rivoire
- Département de Chirurgie Oncologique, Centre Léon Bérard, Lyon, France
| | - J-L Faucheron
- Service de Chirurgie Digestive, Hôpital A. Michallon, La Tronche, France
| | - M Jafari
- Département de Chirurgie Oncologique, Centre Oscar Lambret, Lille, France
| | - G Portier
- Service de Chirurgie Digestive, Hôpital Purpan, Toulouse, France
| | - B Meunier
- Service de Chirurgie Viscérale, CHU Pontchaillou, Rennes, France
| | - I Sielezneff
- Service de Chirurgie Digestive, CHU Timone, Marseille, France
| | - M Prudhomme
- Département de Chirurgie Digestive et de Cancérologie Digestive, Hôpital Universitaire Carémeau, Nimes, France
| | - F Marchal
- Département de Chirurgie Oncologique, Institut de Cancérologie de Lorraine, Vandoeuvre les Nancy, France
| | - A Dubois
- Service de Chirurgie Générale et Digestive, Hôtel Dieu, Clermont-Ferrand, France
| | - M Capdepont
- Department of Colorectal Surgery, Magellan Centre, Haut-Leveque Hospital, University of Bordeaux, 33604 Pessac, France
| | - Q Denost
- Department of Colorectal Surgery, Magellan Centre, Haut-Leveque Hospital, University of Bordeaux, 33604 Pessac, France
| | - E Rullier
- Department of Colorectal Surgery, Magellan Centre, Haut-Leveque Hospital, University of Bordeaux, 33604 Pessac, France
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Anker CJ, Akselrod D, Ades S, Bianchi NA, Lester-Coll NH, Cataldo PA. Non-operative Management (NOM) of Rectal Cancer: Literature Review and Translation of Evidence into Practice. CURRENT COLORECTAL CANCER REPORTS 2021. [DOI: 10.1007/s11888-020-00463-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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49
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Xiong X, Wang C, Wang B, Shen Z, Jiang K, Gao Z, Ye Y. Can transanal endoscopic microsurgery effectively treat T1 or T2 rectal cancer?A systematic review and meta-analysis. Surg Oncol 2021; 37:101561. [PMID: 33848762 DOI: 10.1016/j.suronc.2021.101561] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 03/03/2021] [Accepted: 03/28/2021] [Indexed: 02/07/2023]
Abstract
AIM We aimed to compare the safety and oncological outcomes of transanal endoscopic microsurgery (TEM) and radical surgery (RS) for patients with T1 or T2 rectal cancer. METHOD We searched Pubmed, Embase, Cochrane Library databases for relevant studies comparing TEM with RS in rectal cancer published until April 2020. We focused on safety and oncological outcomes. RESULTS This meta-analysis included 3526 patients from 12 studies. Compared with RS, TEM had a shorter operative time (weighted mean difference [WMD] -110.02, 95% confidence interval [CI]: 143.98, -76.06), less intraoperative blood loss (WMD -493.63, 95% CI: 772.66, -214.59), lower perioperative morality (risk ratio [RR] 0.25, 95% CI: 0.06, 0.99), and fewer postoperative surgical complications (RR 0.23, 95% CI: 0.11,0.45). TEM was associated with more patients with a positive margin or a doubtfully complete margin than RS (RR 7.36, 95% CI: 3.66, 14.78). TEM was associated with higher local recurrence (RR 2.63, 95% CI: 1.60, 4.31) and overall recurrence (RR 1.60, 95% CI: 1.09, 2.36). TEM had a negative effect on 5-year overall survival (hazard ratio [HR] 1.51, 95% CI: 1.16, 1.96), especially in the T2 without neoadjuvant therapy (NAT) subgroup (HR 2.02, 95% CI: 1.32, 3.09), but in the subgroups of T1 or T2 with NAT before TEM, TEM did not yield a significantly lower overall survival than RS. CONCLUSION TEM seems appropriate for T1 rectal cancer with favourable histopathology. For patients with T2 rectal cancer, NAT before TEM may contribute to achieving oncological outcomes equivalent to that achieved with RS.
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Affiliation(s)
- Xiaoyu Xiong
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, 100044, PR China
| | - Chao Wang
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, 100044, PR China; Laboratory of Surgical Oncology, Peking University People's Hospital, Beijing, 100044, PR China
| | - Bo Wang
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, 100044, PR China; Laboratory of Surgical Oncology, Peking University People's Hospital, Beijing, 100044, PR China
| | - Zhanlong Shen
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, 100044, PR China; Laboratory of Surgical Oncology, Peking University People's Hospital, Beijing, 100044, PR China
| | - Kewei Jiang
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, 100044, PR China; Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Peking University People's Hospital, Beijing, 100044, PR China
| | - Zhidong Gao
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, 100044, PR China; Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Peking University People's Hospital, Beijing, 100044, PR China.
| | - Yingjiang Ye
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, 100044, PR China; Laboratory of Surgical Oncology, Peking University People's Hospital, Beijing, 100044, PR China.
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50
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Devane LA, Burke JP, Kelly JJ, Albert MR. Transanal minimally invasive surgery for rectal cancer. Ann Gastroenterol Surg 2021; 5:39-45. [PMID: 33532679 PMCID: PMC7832961 DOI: 10.1002/ags3.12402] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 08/24/2020] [Accepted: 09/08/2020] [Indexed: 11/08/2022] Open
Abstract
Due to the increased uptake of rectal cancer screening and the increasing rates of complete clinical response to chemoradiotherapy, more early-stage and down-staged rectal cancers are being treated. This has triggered surgeons to question the necessity for proctectomy and its associated morbidity and consider local excision and organ preservation in selected cases. Transanal minimally invasive surgery (TAMIS) has evolved as an oncologically safe yet cost-effective platform for local excision of rectal tumors using traditional laparoscopic instruments. This review highlights the recent advances and current role of TAMIS in the treatment of rectal cancer.
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Affiliation(s)
- Liam A. Devane
- Department of Colorectal SurgeryBeaumont HospitalDublinIreland
| | - John P. Burke
- Department of Colorectal SurgeryBeaumont HospitalDublinIreland
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