The impact of surgical quality on prognosis in patients undergoing rectal carcinoma surgery after preoperative chemoradiation

Prognostic importance of circumferential resection margin in the era of evolving surgical and multidisciplinary treatment of rectal cancer: A systematic review and meta-analysis

BACKGROUND

Circumferential resection margin is considered an important prognostic parameter after rectal cancer surgery, but its impact might have changed because of improved surgical quality and tailored multimodality treatment. The aim of this systematic review was to determine the prognostic importance of circumferential resection margin involvement based on the most recent literature.

METHODS

A systematic literature search of MEDLINE, Embase, and the Cochrane Library was performed for studies published between January 2006 and May 2019. Studies were included if 3- or 5-year oncological outcomes were reported depending on circumferential resection margin status. Outcome parameters were local recurrence, overall survival, disease-free survival, and distant metastasis rate. The Newcastle Ottawa Scale and Jadad score were used for quality assessment of the studies. Meta-analysis was performed using a random effects model and reported as a pooled odds ratio or hazard ratio with 95% confidence interval.

RESULTS

Seventy-five studies were included, comprising a total of 85,048 rectal cancer patients. Significant associations between circumferential resection margin involvement and all long-term outcome parameters were uniformly found, with varying odds ratios and hazard ratios depending on circumferential resection margin definition (<1 mm, ≤1 mm, otherwise), neoadjuvant treatment, study period, and geographical origin of the studies.

CONCLUSION

Circumferential resection margin involvement has remained an independent, poor prognostic factor for local recurrence and survival in most recent literature, indicating that circumferential resection margin status can still be used as a short-term surrogate endpoint.

Prognostic Impact of Ventral Versus Dorsal Tumor Location After Total Mesorectal Excision of Rectal Cancer

BACKGROUND

Multidisciplinary treatment of rectal cancer, including neoadjuvant treatment, total mesorectal excision, and adjuvant chemotherapy, have improved oncological outcome. Preoperative radiation therapy is advocated by national and international guidelines in all patients with AJCC stage II and III rectal cancer. Although this treatment reduces local recurrence rates with no effect on overall survival, there are possible short- and long-term side effects of radiation exposure, so patients should be carefully selected for neoadjuvant radiation therapy.

METHODS

We analyzed whether ventral or dorsal tumor location affects local recurrence rates following radical rectal resection. Patients who underwent radical rectal resection for mid or low rectal cancer in our department between October 2001 and December 2013 were included. Prognostic indicators for local recurrence were analyzed using univariate and multivariate analyses.

RESULTS

Overall, 480 patients met the inclusion criteria. Univariate analysis identified surgical procedure (hazard ratio [HR] 1.9, p = 0.006), ventral tumor location (HR 3.8, p < 0.001), and a pathologic circumferential resection margin (pCRM) (HR 9.3, p < 0.001) as prognostic factors of local recurrence. Multivariate analysis revealed tumor location (HR 3.5, p < 0.001) and pCRM (HR 6.0, p = 0.002) as independent factors for local recurrence. Neoadjuvant treatment of AJCC stage II and III tumors reduced the local recurrence rate at ventral but not at dorsal tumor locations (p < 0.001).

CONCLUSIONS

Ventral versus dorsal tumor location is an independent prognostic factor for local recurrence. Tumor location may aid in patient selection for neoadjuvant treatment.

The quality of total mesorectal excision specimen: A review of its macroscopic assessment and prognostic significance

As a surgical procedure which could significantly lower the recurrence rate of cancers, total mesorectal excision (TME) has been the gold standard for middle and lower rectal cancer treatment. However, previous studies have shown that the procedure did not achieve the ideal theoretical local recurrence rates of rectal cancers. Some researchers pointed out it was very likely that not all so-called TME treatments completely removed the mesorectum, implying that some of these TME surgical treatments failed to meet oncological quality standards. Therefore, a suitable assessment tool for the surgical quality of TME is necessary. The notion of “macroscopic assessment of mesorectal excision (MAME)” was put forward by some researchers as a better assessment tool for the surgical quality of TME and has been confirmed by a series of studies. Besides providing rapid and accurate surgical quality feedbacks for surgeons, MAME also effectively assesses the prognosis of patients with rectal cancer. However, as a new assessment tool used for TME surgical quality, MAME has an only limited influence on the current guidelines and is yet to be widely applied in most countries. The aims of this review are to provide a detailed introduction to MAME for clinical practice and to summarize the current prognostic significance of MAME.

Salvage Surgery after Radiation Failure in T1/T2 Larynx Cancer: Outcomes following Total versus Conservation Surgery

Objective

After radiation failure for early T-stage larynx cancer, national guidelines recommend salvage surgery. Total laryngectomy and conservation laryngeal surgery with an open or endoscopic approach are both used. Beyond single-institution studies, there is a lack of evidence concerning the outcomes of these procedures. We aim to study whether treatment with conservation laryngeal surgery is associated with poorer outcomes than treatment with total laryngectomy as salvage surgery after radiation failure for T1/T2 larynx cancers.

Study Design

A retrospective study was conducted of adult squamous cell larynx cancer cases in the National Cancer Database diagnosed from 2004 to 2012.

Setting

Commission on Cancer cancer programs in the United States.

Methods

Demographic, facility, tumor, and survival variables were included in the analyses. Multivariate survival regressions as well as univariate Kaplan-Meier analyses were conducted.

Results

Slightly more than 7% of patients receiving radiotherapy for T1/T2 larynx cancers later received salvage surgery. Salvage with partial laryngectomy was not associated with diminished survival as compared with total laryngectomy. However, positive surgical margins were associated with worse outcomes (hazard ratio, 1.782; P = .001), and a larger percentage of patients receiving partial laryngectomy had positive margins than those receiving total laryngectomy. Facility characteristics were not associated with differences in salvage surgery type or outcomes.

Conclusion

In recognition of the inherent selection bias, patients who experienced recurrences after radiation for T1/T2 larynx cancer and underwent conservation salvage laryngeal surgery demonstrated clinical outcomes similar to those of patients undergoing salvage total laryngectomy. Increased rates of positive surgical margins were observed among patients undergoing salvage conservation surgery.

Surgery for Colorectal Cancer - Trends, Developments, and Future Perspectives

BACKGROUND

Although colorectal surgery is long established as the mainstay treatment for colon cancer, certain topics regarding technical fine-tuning to increase postsurgical recurrence-free survival have remained a matter of debate throughout the past years. These include complete mesocolic excision (CME), treatment strategies for metastatic disease, significance of hyperthermic intraperitoneal chemotherapy (HIPEC), and surgical techniques for the treatment of colorectal cancer recurrence. In addition, new surgical techniques have been introduced in oncologic colorectal surgery, and their potential to provide sufficiently radical resection has yet to be proven.

METHODS

A structured review of the literature was performed to identify the current state of the art with regard to the mentioned key issues in colorectal surgery.

RESULTS

This article provides a comprehensive review of the current literature addressing the above-mentioned current challenges in colorectal surgery. The focus lies on the impact of CME and, in relation to this, on lymph node dissection, as well as on treatment of metastatic disease including peritoneal spread, and finally on the treatment of recurrent disease.

CONCLUSION

Uniformly, the current literature reveals that surgery aiming at complete malignancy elimination within multimodal treatment approaches represents the fundamental quantum leap for the achievement of long-term tumor-free survival.