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Webb SP, Ahmad I. Novel and Innovative Surgical Strategies for Recurrent Rectal Cancer: Uncommon Resections, Local Interventions for Pelvic Reoccurrence, and Intraoperative Radiation Therapy. Clin Colon Rectal Surg 2024; 37:66-70. [PMID: 38322600 PMCID: PMC10843878 DOI: 10.1055/s-0043-1761473] [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: 02/08/2024]
Abstract
The frequency of recurrent rectal cancer has dropped significantly with improved surgical approaches and adjunctive therapies. These recurrences have proven challenging to obtain R0 resection with salvage operations. Meticulous planning, clear understanding of anatomy with imaging, and multispecialty support have become essential in local control and long-term survival with pelvic recurrence of rectal cancer. Technical considerations and prognosis indicators along with role of intraoperative radiation or boost radiation are discussed within.
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Affiliation(s)
- Shawn Philip Webb
- Division of Colon and Rectal Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Imran Ahmad
- Division of Colon and Rectal Surgery, Henry Ford Hospital, Detroit, Michigan
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Shur JD, Qiu S, Johnston E, Tait D, Fotiadis N, Kontovounisios C, Rasheed S, Tekkis P, Riddell A, Koh DM. Multimodality Imaging to Direct Management of Primary and Recurrent Rectal Adenocarcinoma Beyond the Total Mesorectal Excision Plane. Radiol Imaging Cancer 2024; 6:e230077. [PMID: 38363197 PMCID: PMC10988347 DOI: 10.1148/rycan.230077] [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: 06/01/2023] [Revised: 10/11/2023] [Accepted: 01/10/2024] [Indexed: 02/17/2024]
Abstract
Rectal tumors extending beyond the total mesorectal excision (TME) plane (beyond-TME) require particular multidisciplinary expertise and oncologic considerations when planning treatment. Imaging is used at all stages of the pathway, such as local tumor staging/restaging, creating an imaging-based "roadmap" to plan surgery for optimal tumor clearance, identifying treatment-related complications, which may be suitable for radiology-guided intervention, and to detect recurrent or metastatic disease, which may be suitable for radiology-guided ablative therapies. Beyond-TME and exenterative surgery have gained acceptance as potentially curative procedures for advanced tumors. Understanding the role, techniques, and pitfalls of current imaging techniques is important for both radiologists involved in the treatment of these patients and general radiologists who may encounter patients undergoing surveillance or patients presenting with surgical complications or intercurrent abdominal pathology. This review aims to outline the current and emerging roles of imaging in patients with beyond-TME and recurrent rectal malignancy, focusing on practical tips for image interpretation and surgical planning in the beyond-TME setting. Keywords: Abdomen/GI, Rectum, Oncology © RSNA, 2024.
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Affiliation(s)
- Joshua D. Shur
- From the Royal Marsden Hospital NHS Foundation Trust, Downs Road,
Sutton SM2 5PT, England (J.D.S., S.Q., E.J., D.T., N.F., C.K., S.R.,
P.T., A.R., D.M.K.); and Institute of Cancer Research, Sutton, England (E.J.,
N.F., D.M.K.)
| | - Sheng Qiu
- From the Royal Marsden Hospital NHS Foundation Trust, Downs Road,
Sutton SM2 5PT, England (J.D.S., S.Q., E.J., D.T., N.F., C.K., S.R.,
P.T., A.R., D.M.K.); and Institute of Cancer Research, Sutton, England (E.J.,
N.F., D.M.K.)
| | - Edward Johnston
- From the Royal Marsden Hospital NHS Foundation Trust, Downs Road,
Sutton SM2 5PT, England (J.D.S., S.Q., E.J., D.T., N.F., C.K., S.R.,
P.T., A.R., D.M.K.); and Institute of Cancer Research, Sutton, England (E.J.,
N.F., D.M.K.)
| | - Diana Tait
- From the Royal Marsden Hospital NHS Foundation Trust, Downs Road,
Sutton SM2 5PT, England (J.D.S., S.Q., E.J., D.T., N.F., C.K., S.R.,
P.T., A.R., D.M.K.); and Institute of Cancer Research, Sutton, England (E.J.,
N.F., D.M.K.)
| | - Nicos Fotiadis
- From the Royal Marsden Hospital NHS Foundation Trust, Downs Road,
Sutton SM2 5PT, England (J.D.S., S.Q., E.J., D.T., N.F., C.K., S.R.,
P.T., A.R., D.M.K.); and Institute of Cancer Research, Sutton, England (E.J.,
N.F., D.M.K.)
| | - Christos Kontovounisios
- From the Royal Marsden Hospital NHS Foundation Trust, Downs Road,
Sutton SM2 5PT, England (J.D.S., S.Q., E.J., D.T., N.F., C.K., S.R.,
P.T., A.R., D.M.K.); and Institute of Cancer Research, Sutton, England (E.J.,
N.F., D.M.K.)
| | - Shahnawaz Rasheed
- From the Royal Marsden Hospital NHS Foundation Trust, Downs Road,
Sutton SM2 5PT, England (J.D.S., S.Q., E.J., D.T., N.F., C.K., S.R.,
P.T., A.R., D.M.K.); and Institute of Cancer Research, Sutton, England (E.J.,
N.F., D.M.K.)
| | - Paris Tekkis
- From the Royal Marsden Hospital NHS Foundation Trust, Downs Road,
Sutton SM2 5PT, England (J.D.S., S.Q., E.J., D.T., N.F., C.K., S.R.,
P.T., A.R., D.M.K.); and Institute of Cancer Research, Sutton, England (E.J.,
N.F., D.M.K.)
| | - Angela Riddell
- From the Royal Marsden Hospital NHS Foundation Trust, Downs Road,
Sutton SM2 5PT, England (J.D.S., S.Q., E.J., D.T., N.F., C.K., S.R.,
P.T., A.R., D.M.K.); and Institute of Cancer Research, Sutton, England (E.J.,
N.F., D.M.K.)
| | - Dow-Mu Koh
- From the Royal Marsden Hospital NHS Foundation Trust, Downs Road,
Sutton SM2 5PT, England (J.D.S., S.Q., E.J., D.T., N.F., C.K., S.R.,
P.T., A.R., D.M.K.); and Institute of Cancer Research, Sutton, England (E.J.,
N.F., D.M.K.)
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Sakata S, Karim SM, Martinez-Jorge J, Larson DW, Mathis KL, Kelley SR, Rose PS, Dozois EJ. Improving R0 Resection Rates With a Posterior-First, 2-Stage Approach for En Bloc Resection of Locally Advanced Primary and Recurrent Anorectal Cancers Involving the Deep Pelvic Sidewall. Dis Colon Rectum 2024; 67:90-96. [PMID: 38091415 DOI: 10.1097/dcr.0000000000003035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
BACKGROUND Using standard anterior approaches, consistent R0 resection of locally advanced primary and recurrent rectal and anal cancer involving the deep pelvic sidewall may be unattainable. Therefore, to improve R0 resection rates, we have used a posterior-first, then anterior 2-stage approach to resection of tumors in this location. OBJECTIVE To assess the R0 resection rate and surgical outcomes of the first 10 patients operated on using this approach. DESIGN We conducted a retrospective case series review of our prospectively maintained surgical pathology and tumor registries. SETTING This study was conducted at the Mayo Clinic in Rochester, Minnesota. PATIENTS Ten patients (6 female individuals, median age 53.5 years) with primary or recurrent anal or rectal cancer treated with a posterior-first, then anterior 2-stage approach were identified. MAIN OUTCOME MEASURES The primary outcome measures were the R0 resection rate and surgical outcomes. RESULTS An R0 resection was achieved in all 10 patients. Nine patients developed 1 or more 30-day Clavien-Dindo grade III complications. Nine patients developed gluteal wound complications ranging from superficial wound dehiscence to flap necrosis. During the follow-up period, 4 patients were found to have metastatic disease and 1 patient had local re-recurrence. LIMITATIONS Small cohort with heterogeneous tumors and a short follow-up duration. CONCLUSION A posterior-first, then anterior 2-stage approach has allowed us to achieve consistent R0 resection margins in locally advanced primary and recurrent rectal and anal cancers involving the deep pelvic sidewall. Poor wound healing of the posterior gluteal incision is a common complication. See Video Abstract. MEJORANDO LAS TASAS DE RESECCIN R CON UN ABORDAJE DE DOS ETAPAS PRIMERO POSTERIOR PARA LA RESECCIN EN BLOQUE DE CNCERES ANORRECTALES PRIMARIOS Y RECURRENTES LOCALMENTE AVANZADOS QUE AFECTAN LA PARED LATERAL PLVICA PROFUNDA ANTECEDENTES:Utilizando abordajes anteriores estándares, la resección R0 consistente del cáncer de recto y ano primario y recurrente localmente avanzado involucrando la pared lateral pélvica profunda puede ser inalcanzable. Por lo tanto, para mejorar las tasas de resección R0, hemos empleado un abordaje de 2 etapas primero posterior y luego anterior para la resección de tumores en esta ubicación.OBJETIVO:Este estudio tuvo como objetivo evaluar la tasa de resección R0 y los resultados quirúrgicos de los primeros 10 pacientes operados con este abordaje.DISEÑO:Realizamos una revisión retrospectiva de series de casos de nuestros registros de patología quirúrgica y tumores mantenidos prospectivamente.AJUSTE:Este estudio se realizó en la Clínica Mayo en Rochester, Minnesota, EE. UU.PACIENTES:Se identificaron diez pacientes (6 mujeres, mediana de edad 53.5 años) con cáncer anal o rectal primario o recurrente tratados con un abordaje de dos etapas, primero posterior y luego anterior.PRINCIPALES MEDIDAS DE RESULTADO:Las medidas de resultado primarias fueron la tasa de resección R0 y los resultados quirúrgicos.RESULTADOS:Se logró una resección R0 en los 10 pacientes. Nueve pacientes desarrollaron una o más complicaciones de grado III de Clavien-Dindo a los 30 días. Nueve pacientes desarrollaron complicaciones de la herida del glúteo que variaron desde dehiscencia superficial de la herida hasta necrosis del colgajo. Durante el período de seguimiento, se encontró que 4 pacientes tenían enfermedad metastásica y un paciente tuvo recurrencia local.LIMITACIONES:Cohorte pequeño con tumores heterogéneos y corta duración de seguimiento.CONCLUSIÓN:Un abordaje en 2 etapas, primero posterior y luego anterior, nos ha permitido lograr márgenes de resección R0 consistentes en cánceres de recto y anal primarios y recurrentes localmente avanzados que afectan la pared lateral pélvica profunda. La mala cicatrización de la incisión glútea posterior es una complicación común. (Traducción-Dr. Aurian Garcia Gonzalez).
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Affiliation(s)
- Shinichiro Sakata
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - S Mohammed Karim
- Division of Orthopedic Oncology, Mayo Clinic, Rochester, Minnesota
| | - Jorys Martinez-Jorge
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Scott R Kelley
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Peter S Rose
- Division of Orthopedic Oncology, Mayo Clinic, Rochester, Minnesota
| | - Eric J Dozois
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
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Pi F, Tang G, Xie C, Cao Y, Yang S, Wei Z. A retrospective study analyzing if lymph node ratio carbon nanoparticles predict stage III rectal cancer recurrence. Front Oncol 2023; 13:1238300. [PMID: 38023220 PMCID: PMC10643199 DOI: 10.3389/fonc.2023.1238300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 09/19/2023] [Indexed: 12/01/2023] Open
Abstract
Background Lymph node ratio has garnered increasing attention as a prognostic marker for rectal cancer; however, few studies have investigated the relationship between lymph node ratio and rectal cancer recurrence. Additionally, Carbon Nanoparticle tracking is a safe and effective strategy for locating tumors and tracking lymph nodes. However, no studies have reported the relationship between Carbon Nanoparticles and rectal cancer recurrence. Methods Patients with stage III rectal cancer who underwent radical resection between January 2016 and 2020 were analyzed. The primary outcome was tumor recurrence. 269 patients with stage III rectal cancer were included in this study. The effects of lymph node ratio, Carbon Nanoparticles, and other clinicopathological factors on rectal cancer recurrence were assessed using univariate, multivariate analyses and the t-test. Results Univariate analysis determined tumor recurrence using cytokeratin 19 fragment, CA-199, CEA, N-stage, positive lymph nodes, total lymph nodes, and lymph node ratio(positive/total); with the lymph node ratio being the most relevant. Receiver operating characteristic (ROC) analysis determined lymph node ratio =0.38 as the optimal cutoff value. The analysis of lymph node ratio ≥0.38 and <0.38 showed statistical differences in three indicators: tumor recurrence, CEA, and use of Carbon Nanoparticles. Conclusion Lymph node ratio is a strong predictor of stage III rectal cancer recurrence and may be considered for inclusion in future tumor-node-metastasis staging and stage III rectal cancer stratification. In addition, we found that Carbon Nanoparticles use significantly increased total lymph nodes and decreased lymph node ratio.
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Affiliation(s)
| | | | | | | | | | - Zhengqiang Wei
- Department Of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Rajendran S, Nguyen CL, Brown KGM, Solomon MJ. The evolution of oncovascular pelvic surgery: A historical perspective. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:1314-1316. [PMID: 36690534 DOI: 10.1016/j.ejso.2023.01.018] [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: 12/07/2022] [Revised: 01/08/2023] [Accepted: 01/16/2023] [Indexed: 01/19/2023]
Abstract
Pelvic exenteration surgery has evolved dramatically in recent decades and now represents the standard of care for many patients with advanced pelvic malignancy. Most recently the use of complex vascular resection and reconstructive techniques have been applied in advanced pelvic oncology surgery at specialist units and these oncovascular techniques are considered one of the frontiers in this field. This article summaries the historical evolution of oncovascular surgery in the pelvis and sets the scene for where this treatment is going. The role of vascular resection and reconstruction in curative treatment of advanced pelvic malignancy is an evolving area that is redefining the boundaries of what was historically thought possible.
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Affiliation(s)
- Saissan Rajendran
- Department of Vascular Surgery, Concord Repatriation General Hospital, Sydney, Australia; Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia; University of Sydney, New South Wales, Australia
| | - Chu Luan Nguyen
- Department of Vascular Surgery, Concord Repatriation General Hospital, Sydney, Australia; University of Sydney, New South Wales, Australia
| | - Kilian G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia; The Institute of Academic Surgery at RPA, Sydney, Australia; University of Sydney, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia; The Institute of Academic Surgery at RPA, Sydney, Australia; University of Sydney, New South Wales, Australia.
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Mantello G, Galofaro E, Caravatta L, Di Carlo C, Montrone S, Arpa D, Chiloiro G, De Paoli A, Donato V, Gambacorta MA, Genovesi D, Lupattelli M, Macchia G, Montesi G, Niespolo RM, Palazzari E, Pontoriero A, Scricciolo M, Valvo F, Franco P. Pattern of care for re-irradiation in locally recurrent rectal cancer: a national survey on behalf of the AIRO gastrointestinal tumors study group. LA RADIOLOGIA MEDICA 2023:10.1007/s11547-023-01652-3. [PMID: 37365381 DOI: 10.1007/s11547-023-01652-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 05/25/2023] [Indexed: 06/28/2023]
Abstract
PURPOSE Radical resection (R0) represents the best curative treatment for local recurrence (LR) rectal cancer. Re-irradiation (re-RT) can increase the rate of R0 resection. Currently, there is a lack of guidelines on Re-RT for LR rectal cancer. The Italian Association of Radiation and clinical oncology for gastrointestinal tumors (AIRO-GI) study group released a national survey to investigate the current clinical practice of external beam radiation therapy in these patients. MATERIAL AND METHODS In February 2021, the survey was designed and distributed to members of the GI working group. The questionnaire consisted of 40 questions regarding center characteristics, clinical indications, doses, and treatment techniques of re-RT for LR rectal cancer. RESULTS A total of 37 questionnaires were collected. Re-RT was reported as an option for neoadjuvant treatment in resectable and unresectable disease by 55% and 75% of respondents, respectively. Long-course treatment with 30-40 Gy (1.8-2 Gy/die, 1.2 Gy bid) and hypofractionated regimen of 30-35 Gy in 5 fractions were used in most centers. A total dose of 90-100 Gy as EqD2 dose (α/β = 5 Gy) was delivered by 46% of the respondents considering the previous treatment. Modern conformal techniques and daily image-guided radiation therapy protocols were used in 94% of centers. CONCLUSION Our survey showed that re-RT treatment is performed with advanced technology that allow a good management of LR rectal cancer. Significant variations were observed in terms of dose and fractionation, highlighting the need for a consensus on a common treatment strategy that could be validated in prospective studies.
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Affiliation(s)
- Giovanna Mantello
- Radiotherapy Department, Azienda Ospedaliero Universitaria delle Marche, Via Conca 71, 60126, Ancona, Italy
| | - Elena Galofaro
- Radiotherapy Department, Azienda Ospedaliero Universitaria delle Marche, Via Conca 71, 60126, Ancona, Italy.
| | - Luciana Caravatta
- Department of Radiation Oncology, SS Annunziata Hospital, Chieti, Italy
| | - Clelia Di Carlo
- Radiotherapy Department, Azienda Ospedaliero Universitaria delle Marche, Via Conca 71, 60126, Ancona, Italy
| | | | - Donatella Arpa
- IRCCS Istituto Scientifico Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Radiotherapy Unit, Meldola, Italy
| | - Giuditta Chiloiro
- Departments of Radiation Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Antonino De Paoli
- Division of Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Vittorio Donato
- Radiation Oncology Division, Oncology and Speciality Medicine Department, San Camillo-Forlanini Hospital, Rome, Italy
| | | | - Domenico Genovesi
- Department of Radiation Oncology, SS Annunziata Hospital, Chieti, Italy
| | - Marco Lupattelli
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, Perugia, Italy
| | - Gabriella Macchia
- Radiotherapy Unit, Gemelli Molise Hospital, Catholic University of Sacred Heart, Campobasso, Italy
| | | | | | - Elisa Palazzari
- Division of Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Antonio Pontoriero
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Melissa Scricciolo
- UOC di Radioterapia Oncologica Mestre, Ospedale dell'Angelo, Venice, Mestre, Italy
| | - Francesca Valvo
- Fondazione CNAO, National Center of Oncological Hadrontherapy, Pavia, Italy
| | - Pierfrancesco Franco
- Department of Translational Medicine, Department of Radiation Oncology, Maggiore Della Carità University Hospital, University of Eastern Piedmont, Novara, Italy
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Grazzini G, Danti G, Chiti G, Giannessi C, Pradella S, Miele V. Local Recurrences in Rectal Cancer: MRI vs. CT. Diagnostics (Basel) 2023; 13:2104. [PMID: 37370997 DOI: 10.3390/diagnostics13122104] [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: 04/25/2023] [Revised: 06/03/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Rectal cancers are often considered a distinct disease from colon cancers as their survival and management are different. Particularly, the risk for local recurrence (LR) is greater than in colon cancer. There are many factors predisposing to LR such as postoperative histopathological features or the mesorectal plane of surgical resection. In addition, the pattern of LR in rectal cancer has a prognostic significance and an important role in the choice of operative approach and. Therefore, an optimal follow up based on imaging is critical in rectal cancer. The aim of this review is to analyse the risk and the pattern of local recurrences in rectal cancer and to provide an overview of the role of imaging in early detection of LRs. We performed a literature review of studies published on Web of Science and MEDLINE up to January 2023. We also reviewed the current guidelines of National Comprehensive Cancer Network (NCCN) and the European Society for Medical Oncology (ESMO). Although the timing and the modality of follow-up is not yet established, the guidelines usually recommend a time frame of 5 years post surgical resection of the rectum. Computed Tomography (CT) scans and/or Magnetic Resonance Imaging (MRI) are the main imaging techniques recommended in the follow-up of these patients. PET-CT is not recommended by guidelines during post-operative surveillance and it is generally used for problem solving.
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Affiliation(s)
- Giulia Grazzini
- Department of Emergency Radiology, University Hospital Careggi, Largo Brambilla 3, 50134 Florence, Italy
| | - Ginevra Danti
- Department of Emergency Radiology, University Hospital Careggi, Largo Brambilla 3, 50134 Florence, Italy
| | - Giuditta Chiti
- Department of Emergency Radiology, University Hospital Careggi, Largo Brambilla 3, 50134 Florence, Italy
| | - Caterina Giannessi
- Department of Emergency Radiology, University Hospital Careggi, Largo Brambilla 3, 50134 Florence, Italy
| | - Silvia Pradella
- Department of Emergency Radiology, University Hospital Careggi, Largo Brambilla 3, 50134 Florence, Italy
| | - Vittorio Miele
- Department of Emergency Radiology, University Hospital Careggi, Largo Brambilla 3, 50134 Florence, Italy
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Post-Surgical Imaging Assessment in Rectal Cancer: Normal Findings and Complications. J Clin Med 2023; 12:jcm12041489. [PMID: 36836024 PMCID: PMC9966470 DOI: 10.3390/jcm12041489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 12/30/2022] [Accepted: 02/09/2023] [Indexed: 02/16/2023] Open
Abstract
Rectal cancer (RC) is one of the deadliest malignancies worldwide. Surgery is the most common treatment for RC, performed in 63.2% of patients. The type of surgical approach chosen aims to achieve maximum residual function with the lowest risk of recurrence. The selection is made by a multidisciplinary team that assesses the characteristics of the patient and the tumor. Total mesorectal excision (TME), including both low anterior resection (LAR) and abdominoperineal resection (APR), is still the standard of care for RC. Radical surgery is burdened by a 31% rate of major complications (Clavien-Dindo grade 3-4), such as anastomotic leaks and a risk of a permanent stoma. In recent years, less-invasive techniques, such as local excision, have been tested. These additional procedures could mitigate the morbidity of rectal resection, while providing acceptable oncologic results. The "watch and wait" approach is not a globally accepted model of care but encouraging results on selected groups of patients make it a promising strategy. In this plethora of treatments, the radiologist is called upon to distinguish a physiological from a pathological postoperative finding. The aim of this narrative review is to identify the main post-surgical complications and the most effective imaging techniques.
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9
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Harji DP, McKigney N, Koh C, Solomon MJ, Griffiths B, Evans M, Heriot A, Sagar PM, Velikova G, Brown JM. Short-term outcomes of health-related quality of life in patients with locally recurrent rectal cancer: multicentre, international, cross-sectional cohort study. BJS Open 2023; 7:zrac168. [PMID: 36787174 PMCID: PMC9927560 DOI: 10.1093/bjsopen/zrac168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 11/23/2022] [Accepted: 12/02/2022] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Overall survival rates for locally recurrent rectal cancer (LRRC) continue to improve but the evidence concerning health-related quality of life (HrQoL) remains limited. The aim of this study was to describe the short-term HrQoL differences between patients undergoing surgical and palliative treatments for LRRC. METHODS An international, cross-sectional, observational study was undertaken at five centres across the UK and Australia. HrQoL in LRRC patients was assessed using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-CR29 and functional assessment of cancer therapy - colorectal (FACT-C) questionnaires and subgroups (curative versus palliative) were compared. Secondary analyses included the comparison of HrQoL according to the margin status, location of disease and type of treatment. Scores were interpreted using minimal clinically important differences (MCID) and Cohen effect size (ES). RESULTS Out of 350 eligible patients, a total of 95 patients participated, 74.0 (78.0 per cent) treated with curative intent and 21.0 (22.0 per cent) with palliative intent. Median time between LRRC diagnosis and HrQoL assessments was 4 months. Higher overall FACT-C scores denoting better HrQoL were observed in patients undergoing curative treatment, demonstrating a MCID with a mean difference of 18.5 (P < 0.001) and an ES of 0.6. Patients undergoing surgery had higher scores denoting a higher burden of symptoms for the EORTC CR29 domains of urinary frequency (P < 0.001, ES 0.3) and frequency of defaecation (P < 0.001, ES 0.4). Higher overall FACT-C scores were observed in patients who underwent an R0 resection versus an R1 resection (P = 0.051, ES 0.6). EORTC CR29 scores identified worse body image in patients with posterior/central disease (P = 0.021). Patients undergoing palliative chemoradiation reported worse HrQoL scores with a higher symptom burden on the frequency of defaecation scale compared with palliative chemotherapy (P = 0.041). CONCLUSION Several differences in short-term HrQoL outcomes between patients undergoing curative and palliative treatment for LRRC were documented. Patients undergoing curative surgery reported better overall HrQoL and a higher burden of pelvic symptoms.
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Affiliation(s)
- Deena P Harji
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | - Niamh McKigney
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Cherry Koh
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
- Royal Prince Alfred Hospital, RPA Institute of Academic Surgery, Sydney, NSW, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Michael J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
- Royal Prince Alfred Hospital, RPA Institute of Academic Surgery, Sydney, NSW, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Ben Griffiths
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | - Martyn Evans
- Department of Colorectal Surgery, Heol Maes Eglwys, Morriston, Swansea, UK
| | - Alexander Heriot
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Peter M Sagar
- The John Goligher Department of Colorectal Surgery, St James’s University Hospital, Leeds, UK
| | - Galina Velikova
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
- St James’s Institute of Oncology, St James’s University Hospital, Leeds, UK
| | - Julia M Brown
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
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Harji DP, Houston F, Cutforth I, Hawthornthwaite E, McKigney N, Sharpe A, Coyne P, Griffiths B. The impact of multidisciplinary team decision-making in locally advanced and recurrent rectal cancer. Ann R Coll Surg Engl 2022; 104:611-617. [PMID: 35639482 PMCID: PMC9680687 DOI: 10.1308/rcsann.2022.0045] [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] [Accepted: 03/08/2022] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Appropriate patient selection within the context of a multidisciplinary team (MDT) is key to good clinical outcomes. The current evidence base for factors that guide the decision-making process in locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LRRC) is limited to anatomical factors. METHODS A registry-based, prospective cohort study was undertaken of patients referred to our specialist MDT between 2015 and 2019. Data were collected on patients and disease characteristics including performance status, Charlson Comorbidity Index, the English Index of Multiple Deprivation quintiles and MDT treatment decision. Curative treatment was defined as neoadjuvant treatment and surgical resection that would achieve a R0 resection, and/or complete treatment of distant metastatic disease. Palliative treatment was defined as non-surgical treatment. RESULTS In total, 325 patients were identified; 72.7% of patients with LARC and 63.6% of patients with LRRC were offered treatment with curative intent (p = 0.08). Patients with poor performance status (PS > 2; p < 0.001), severe comorbidity (p < 0.001), socio-economic deprivation (p = 0.004), a positive predictive circumferential resection margin (p = 0.005) and metastatic disease (p < 0.001) were associated with palliative treatment. Overall survival in the curative cohort was 49 months (95% confidence interval [CI] 32.4-65.5) compared with 12 months (95% CI 9.1-14.9) in the palliative cohort (p < 0.001). The presence of metastatic disease was identified as a prognostic factor for patients undergoing curative treatment (p = 0.05). The only prognostic factor identified in patients treated palliatively was performance status (p < 0.001). CONCLUSIONS Our study identifies a number of preoperative, prognostic factors that affect MDT decision-making and overall survival.
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Affiliation(s)
| | | | | | | | | | - A Sharpe
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - P Coyne
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - B Griffiths
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
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11
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Rokan Z, Simillis C, Kontovounisios C, Moran B, Tekkis P, Brown G. Locally Recurrent Rectal Cancer According to a Standardized MRI Classification System: A Systematic Review of the Literature. J Clin Med 2022; 11:jcm11123511. [PMID: 35743581 PMCID: PMC9224654 DOI: 10.3390/jcm11123511] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/11/2022] [Accepted: 06/16/2022] [Indexed: 12/15/2022] Open
Abstract
(1) Background: The classification of locally recurrent rectal cancer (LRRC) is not currently standardized. The aim of this review was to evaluate pelvic LRRC according to the Beyond TME (BTME) classification system and to consider commonly associated primary tumour characteristics. (2) Methods: A systematic review of the literature prior to April 2020 was performed through electronic searches of the Science Citation Index Expanded, EMBASE, MEDLINE, and CENTRAL databases. The primary outcome was to assess the location and frequency of previously classified pelvic LRRC and translate this information into the BTME system. Secondary outcomes were assessing primary tumour characteristics. (3) Results: A total of 58 eligible studies classified 4558 sites of LRRC, most commonly found in the central compartment (18%), following anterior resection (44%), in patients with an 'advanced' primary tumour (63%) and following neoadjuvant radiotherapy (29%). Most patients also classified had a low rectal primary tumour. The lymph node status of the primary tumour leading to LRRC was comparable, with 52% node positive versus 48% node negative tumours. (4) Conclusions: This review evaluates the largest number of LRRCs to date using a single classification system. It has also highlighted the need for standardized reporting in order to optimise perioperative treatment planning.
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Affiliation(s)
- Zena Rokan
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK; (C.S.); (P.T.); (G.B.)
- Pelican Cancer Foundation, Basingstoke RG24 9NN, UK;
- Correspondence: (Z.R.); (C.K.)
| | - Constantinos Simillis
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK; (C.S.); (P.T.); (G.B.)
- Cambridge Colorectal Unit, Addenbrookes Hospital, Cambridge CB2 0QQ, UK
| | - Christos Kontovounisios
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK; (C.S.); (P.T.); (G.B.)
- Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
- Chelsea & Westminster Hospital, London SW10 9NH, UK
- Correspondence: (Z.R.); (C.K.)
| | - Brendan Moran
- Pelican Cancer Foundation, Basingstoke RG24 9NN, UK;
- Basingstoke & North Hampshire Hospital, Basingstoke RG24 9NA, UK
| | - Paris Tekkis
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK; (C.S.); (P.T.); (G.B.)
- Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Gina Brown
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK; (C.S.); (P.T.); (G.B.)
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12
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Ng KS, Lee PJ. Pelvic exenteration: Pre-, intra-, and post-operative considerations. Surg Oncol 2022. [DOI: 10.1016/j.suronc.2022.101787] [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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13
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Shine RJ, Glyn T, Frizelle F. Pelvic exenteration: a review of current issues/controversies. ANZ J Surg 2022; 92:2822-2828. [PMID: 35490337 DOI: 10.1111/ans.17734] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 03/09/2022] [Accepted: 04/01/2022] [Indexed: 11/28/2022]
Abstract
Management of advanced or recurrent pelvic cancer has evolved dramatically over the past few decades. Patients who were previously considered inoperable are now candidates for potentially curative surgery and avoid suffering with intractable symptoms. Up to 10% of primary rectal cancers present with isolated advanced local disease and between 10% and 15% of patients develop localized recurrence following proctectomy. Advances in surgical technique, reconstruction and multidisciplinary involvement have led to a reduction in mortality and morbidity and culminated in higher R0 resection rates with superior longer-term survival outcomes. Recent studies boast over 50% 5-year survival for rectal with an R0 resection. Exenteration has cemented itself as an important treatment option for advanced primary/recurrent pelvic tumours, however, there are still a few controversies. This review will discuss some of these issues, including: limitations of resection and the approach to high/wide tumours; the role of acute exenteration; re-exenteration; exenteration in the setting of metastatic disease and palliation; the role of radiotherapy (including intra-operative and re-irradiation); management of the empty pelvis; and the impact on quality of life and function.
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Affiliation(s)
- Rebecca J Shine
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Tamara Glyn
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand.,Department of Surgery, University of Otago, Christchurch, New Zealand
| | - Frank Frizelle
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand.,Department of Surgery, University of Otago, Christchurch, New Zealand
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14
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Extended pelvic resection for gynecological malignancies: A review of out-of-the-box surgery. Gynecol Oncol 2022; 165:393-400. [PMID: 35331571 DOI: 10.1016/j.ygyno.2022.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/27/2022] [Accepted: 03/05/2022] [Indexed: 12/17/2022]
Abstract
The term 'out-of-the-box surgery' in gynecologic oncology was recently coined to describe the resection of tumor growing out of the endopelvic cavity. In the specific case of pelvic sidewall involvement, a laterally extended pelvic resection may be required. As previously defined by Höckel, this resection requires the en bloc removal of structures including the pelvic sidewall muscles, bones, nerves, and/or major vessels. This complex radical procedure leads to tumor-free margins in more than 75% of the patients, with reliable functional results. The rate of recurrence and overall survival are directly correlated with clear resection margins. Progress in imaging, surgical techniques, and perioperative care currently offer the opportunity to attempt surgical curative resection in selected patients for whom palliative therapy was the only alternative. However, the procedure is associated with a high rate of major postoperative complications affecting up to 60% of patients. Multidisciplinary expert centers are the most likely to achieve this complex surgery with favorable oncological outcomes. The aim of this review is to summarize the key issues of out-of-the-box surgery in gynecologic cancer.
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15
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Jin Z, Zhang P, Deng X, Wang Z. Long-term survival outcomes of laparoscopic extralevator abdominoperineal excision for low rectal cancer in a single center, high volume unit. Asian J Surg 2021; 45:773-774. [PMID: 34973858 DOI: 10.1016/j.asjsur.2021.09.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 08/24/2021] [Accepted: 09/20/2021] [Indexed: 02/08/2023] Open
Affiliation(s)
- Zechuan Jin
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China.
| | - Peilin Zhang
- Operations Management Department, West China Hospital, Sichuan University, Chengdu, 610041, China.
| | - Xiangbing Deng
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China.
| | - Ziqiang Wang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China.
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16
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Type of recurrence is associated with disease-free survival after salvage surgery for locally recurrent rectal cancer. Int J Colorectal Dis 2021; 36:2603-2611. [PMID: 34296325 PMCID: PMC8923354 DOI: 10.1007/s00384-021-03998-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/14/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE To compare the characteristics and outcomes of rectal cancer patients with local recurrence at a perianastomotic site (PA), a surgical field (SF) site, or in lateral lymph nodes (LLN). METHODS A total of 114 consecutive patients who underwent surgery for recurrent, non-metastatic rectal cancer at a single comprehensive cancer center between 1997 and 2012 were grouped on the basis of radiographic assessment of type of recurrence: PA, 76 (67%) patients; SF, 25 (22%) patients; LLN, 13 (11%) patients. Demographic, clinical, and pathological features were compared between the three groups, as were disease-free survival (DFS) and overall survival (OS). RESULTS Recurrence type was associated with positive circumferential margin in the primary resection (PA, 4 [6%]; SF, 4 [19%]; LLN, 3 [25%]; P = 0.027), prior neoadjuvant therapy for the primary tumor (PA, 57 [75%]; SF, 18 [72%]; LLN, 4 [31%]; P = 0.007), and location of the primary tumor in the upper rectum (PA, 33 [45%]; SF, 5 [23%]; LLN, 1 [8%]; P < 0.001). Patients with PA had longer median DFS (PA, 5.1 years; SF, 1.5 years; LLN, 1.2 years; P = 0.036). There was a non-significant trend toward longer OS and higher rates of R0 resection for PA. CONCLUSION Type of recurrence after salvage surgery for locally recurrent rectal cancer is associated with longer DFS in patients with PA recurrence.
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17
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Drami I, Lord AC, Sarmah P, Baker RP, Daniels IR, Boyle K, Griffiths B, Mohan HM, Jenkins JT. Preoperative assessment and optimisation for pelvic exenteration in locally advanced and recurrent rectal cancer: A review. Eur J Surg Oncol 2021; 48:2250-2257. [PMID: 34922810 DOI: 10.1016/j.ejso.2021.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 11/03/2021] [Indexed: 01/06/2023] Open
Abstract
The pre-operative phase in planning a pelvic exenteration or extended resections is critical to optimising patient outcomes. This review summarises the key components of preoperative assessment and planning in patients with locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LLRC) being considered for potential curative resection. The preoperative period can be considered in 5 key phases: 1) Multidisciplinary meeting (MDT) review and recommendation for neoadjuvant therapy and surgery, 2) Anaesthetic preoperative assessment of fitness for surgery and quantification of risk, 3) Shared decision making with the patient and the process of informed consent, 4) Prehabilitation and physiological optimisation 5) Technical aspects of surgical planning. This review will focus on patients who have been recommended for surgery by the MDT and have completed neoadjuvant therapy. Other important considerations beyond the scope of this review are the various neoadjuvant strategies employed which in this patient group include Total Neo-adjuvant Therapy and reirradiation. Critical to improving perioperative outcomes is the dual aim of achieving a negative resection margin in a patient fit enough for extended surgery. Advanced, realistic communication is required pre-operatively and should be maintained throughout recovery. Optimising patient's physiological and psychological reserve with a preoperative prehabilitation programme is important, with physiotherapy, psychological and nutritional input. From a surgical perspective, image based technical preoperative planning is important to identify risk points and ensure correct surgical strategy. Careful attention to the entire patient journey through these 5 preoperative phases can optimise outcomes with the accumulation of marginal gains at multiple timepoints.
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Affiliation(s)
- I Drami
- Dukes' Club, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK.
| | - A C Lord
- Dukes' Club, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - P Sarmah
- Dukes' Club, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - R P Baker
- Advanced Malignancy Subcommittee, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - I R Daniels
- Advanced Malignancy Subcommittee, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - K Boyle
- Advanced Malignancy Subcommittee, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - B Griffiths
- Advanced Malignancy Subcommittee, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - H M Mohan
- Dukes' Club, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - J T Jenkins
- Advanced Malignancy Subcommittee, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
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18
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Jankowski M, Wysocki WM, Las-Jankowska M, Tkaczyński K, Wiśniewski D, Bała D, Zegarski W. Efficacy of endoscopic surveillance in the detection of local recurrence after radical rectal cancer surgery is limited? A retrospective study. World J Surg Oncol 2021; 19:308. [PMID: 34670554 PMCID: PMC8529797 DOI: 10.1186/s12957-021-02413-0] [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: 01/23/2021] [Accepted: 09/30/2021] [Indexed: 01/19/2023] Open
Abstract
Background Rectal cancer, one of most common neoplasms, is characterized by an overall survival rate exceeding 60%. Nonetheless, local recurrence (LR) following surgery for rectal cancer remains a formidable clinical problem. The aim of this study was to assess the value of postoperative endoscopic surveillance (PES) for the early detection of LR in rectal cancer after radical anterior resection with sigmoid-rectal anastomosis. Methods We performed an anterior resection in 228 patients with stages I‑III rectal cancer who had undergone surgery from 2001 to 2008 in the Oncology Center in Bydgoszcz, Poland. Of these patients, 169 had perioperative radiotherapy or radiochemotherapy. All patients underwent PES with abdominal and pelvic imaging (abdominal ultrasound, computed tomography, magnetic resonance) and clinical examination. Sensitivities, specificities, positive likelihood ratios, negative likelihood ratios, and receiver operating characteristic curves were calculated to compare the value of colonoscopy versus imaging techniques for the diagnosis of LR. Results During the 5-year follow-up, recurrences occurred in 49 (21%) patients; of these, 15 (6%) had LR, which was most often located outside the intestinal lumen (n = 10, 4%). Anastomotic LR occurred in 5 (2%) patients. The mean time to anastomotic LR was 30 months after initial surgery, similar to that of other locations (29 months). Both imaging and endoscopy were shown to be efficient techniques for the diagnosis of LR in anastomotic sites. In the study group, endoscopy did not provide any additional benefit in patients who were receiving radiation therapy. Conclusions The benefit of PES for the detection of LR after curative treatment of rectal cancer is limited and not superior to imaging techniques. It remains a useful method, however, for the histopathological confirmation of suspected or confirmed recurrence. Supplementary Information The online version contains supplementary material available at 10.1186/s12957-021-02413-0.
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Affiliation(s)
- Michal Jankowski
- Chair of Surgical Oncology, Ludwik Rydygier's Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland. .,Department of Surgical Oncology, Oncology Center-Prof Franciszek Łukaszczyk Memorial Hospital, Romanowskiej 2 Street, 85-796, Bydgoszcz, Poland.
| | - Wojciech M Wysocki
- Department of Surgery, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, Gustawa Herlinga-Grudzińskiego 1 Street, 30-705, Kraków, Poland.,Department of General, Oncological and Vascular Surgery, 5th Military Clinical Hospital in Kraków, Wrocławska 1-3 Street, 30-901, Kraków, Poland.,National Institute of Oncology, Maria Skłodowska-Curie Memorial, Scientific Editorial Office, W.K. Roentgena 5 Street, 02-781, Warszawa, Poland
| | - Manuela Las-Jankowska
- Chair of Surgical Oncology, Ludwik Rydygier's Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland.,Department of Clinical Oncology, Oncology Center-Prof Franciszek Łukaszczyk Memorial Hospital, Romanowskiej 2 Street, 85-796, Bydgoszcz, Poland
| | - Karol Tkaczyński
- Chair of Surgical Oncology, Ludwik Rydygier's Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland.,Department of Surgical Oncology, Oncology Center-Prof Franciszek Łukaszczyk Memorial Hospital, Romanowskiej 2 Street, 85-796, Bydgoszcz, Poland
| | - Dorian Wiśniewski
- Chair of Surgical Oncology, Ludwik Rydygier's Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland.,Department of Surgical Oncology, Oncology Center-Prof Franciszek Łukaszczyk Memorial Hospital, Romanowskiej 2 Street, 85-796, Bydgoszcz, Poland
| | - Dariusz Bała
- Chair of Surgical Oncology, Ludwik Rydygier's Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland.,Department of Surgical Oncology, Oncology Center-Prof Franciszek Łukaszczyk Memorial Hospital, Romanowskiej 2 Street, 85-796, Bydgoszcz, Poland
| | - Wojciech Zegarski
- Chair of Surgical Oncology, Ludwik Rydygier's Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland.,Department of Surgical Oncology, Oncology Center-Prof Franciszek Łukaszczyk Memorial Hospital, Romanowskiej 2 Street, 85-796, Bydgoszcz, Poland
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19
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Kazi M, Sukumar V, Desouza A, Saklani A. State-of-the-art surgery for recurrent and locally advanced rectal cancers. Langenbecks Arch Surg 2021; 406:1763-1774. [PMID: 34341869 DOI: 10.1007/s00423-021-02285-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 07/19/2021] [Indexed: 02/07/2023]
Abstract
Extended and beyond total mesorectal excisions (TME) for advanced and recurrent rectal cancers are increasingly performed with acceptable oncological and functional outcomes. These are undoubtedly due to better understanding of tumor biology and improved patient selection rather than surgical valor and technical refinements alone. In the present review, we attempt to present the current surgical standards for advanced and recurrent cancers requiring surgery outside the TME planes based on involved pelvic compartments. The available procedures, their indications, and extent of resection and reconstruction are highlighted. Emphasis is on formation of dedicated exenteration teams, structured training, and referral systems that increase hospital and surgeon volume to improve patient outcomes and reduce morbidity. Areas of deficiencies in literature were recognized with regards to factors influencing recurrences, patient selection, and quality of life. Finally, the most appropriate preoperative therapy for these tumors is unclear in both the primary and recurrent settings.
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Affiliation(s)
- Mufaddal Kazi
- Division of Colorectal Surgical Oncology, Department of Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, 400012, India
| | - Vivek Sukumar
- Division of Colorectal Surgical Oncology, Department of Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, 400012, India
| | - Ashwin Desouza
- Division of Colorectal Surgical Oncology, Department of Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, 400012, India
| | - Avanish Saklani
- Division of Colorectal Surgical Oncology, Department of Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, 400012, India.
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20
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Rokan Z, Simillis C, Kontovounisios C, Moran BJ, Tekkis P, Brown G. Systematic review of classification systems for locally recurrent rectal cancer. BJS Open 2021; 5:6272170. [PMID: 33963369 PMCID: PMC8105621 DOI: 10.1093/bjsopen/zrab024] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 02/13/2021] [Indexed: 01/08/2023] Open
Abstract
Background Classification of pelvic local recurrence (LR) after surgery for primary rectal cancer is not currently standardized and optimal imaging is required to categorize anatomical site and plan treatment in patients with LR. The aim of this review was to evaluate the systems used to classify locally recurrent rectal cancer (LRRC) and the relevant published outcomes. Methods A systematic review of the literature prior to April 2020 was performed through electronic searches of the Science Citation Index Expanded, EMBASE, MEDLINE and CENTRAL databases. The primary outcome was to review the classifications currently in use; the secondary outcome was the extraction of relevant information provided by these classification systems including prognosis, anatomy and prediction of R0 after surgery. Results A total of 21 out of 58 eligible studies, classifying LR in 2086 patients, were reviewed. Studies used at least one of the following eight classification systems proposed by institutions or institutional groups (Mayo Clinic, Memorial Sloan-Kettering – original and modified, Royal Marsden and Leeds) or authors (Yamada, Hruby and Kusters). Negative survival outcomes were associated with increased pelvic fixity, associated symptoms of LR, lateral compared with central LR and involvement of three or more pelvic compartments. A total of seven studies used MRI with specifically defined anatomical compartments to classify LR. Conclusion This review highlights the various imaging systems in use to classify LRRC and some of the prognostic indicators for survival and oncological clearance based on these systems. Implementation of an agreed classification system to document pelvic LR consistently should provide more detailed information on anatomical site of recurrence, burden of disease and standards for comparative outcome assessment.
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Affiliation(s)
- Z Rokan
- Department of Radiology, Royal Marsden Hospital, London, UK.,Pelican Cancer Foundation, Basingstoke, UK.,Cambridge Colorectal Unit, Addenbrookes Hospital, Cambridge, UK
| | - C Simillis
- Cambridge Colorectal Unit, Addenbrookes Hospital, Cambridge, UK.,Department of Surgery & Cancer, Imperial College, London, UK
| | - C Kontovounisios
- Department of Surgery & Cancer, Imperial College, London, UK.,Department of Colorectal Surgery, Royal Marsden Hospital, London, UK.,Department of Colorectal Surgery, Chelsea & Westminster Hospital, London, UK
| | - B J Moran
- Pelican Cancer Foundation, Basingstoke, UK.,Department of Peritoneal Malignancy, Basingstoke & North Hampshire Hospital, Basingstoke, UK
| | - P Tekkis
- Department of Surgery & Cancer, Imperial College, London, UK.,Department of Colorectal Surgery, Royal Marsden Hospital, London, UK.,Department of Colorectal Surgery, Chelsea & Westminster Hospital, London, UK
| | - G Brown
- Department of Radiology, Royal Marsden Hospital, London, UK.,Department of Surgery & Cancer, Imperial College, London, UK
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21
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Westberg K, Othman B, Suzuki C, Blomqvist L, Martling A, Iversen H. Magnetic resonance imaging as a predictor of surgical outcome in patients with local pelvic recurrence of colorectal cancer. Eur J Surg Oncol 2021; 47:2119-2124. [PMID: 33926780 DOI: 10.1016/j.ejso.2021.04.021] [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: 02/09/2021] [Revised: 03/29/2021] [Accepted: 04/16/2021] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Pelvic local recurrence of colorectal cancer (PRCRC) may be cured if radical surgery is performed. Preoperative assessment normally includes magnetic resonance imaging (MRI). The aim of this study was to evaluate the influence of specific MRI-related findings on outcome of surgery of PRCRC. MATERIALS AND METHODS Clinical data from 95 consecutive patients, operated with a curative intent for PRCRC at Karolinska University Hospital during 2003-2013, were collected from medical records. Preoperative MRI examinations of the PRCRC were re-evaluated. The potential influence of clinical factors and specific MRI-findings (location, solid/mucinous, size, volume and border) on surgical resection margins (R0-R1) and survival were calculated with logistic and cox regression. RESULTS Eighty-seven patients had available MRI scans and were included in the study. Sixty-five patients (75%) had a R0 resection and 22 patients (25%) had a R1 resection of their PRCRC. In all, 47 patients (54%) had an involved lateral compartment. Lateral location was the only MRI finding associated with both an increased risk of R1 resection (OR 3.97, 95%CI: 1.31-12.04) and death (HR 1.94, 95%CI: 1.07-3.51). Lateral location entailed an increased risk of death also after R0 resection (HR2.09, 95%CI: 1.07-4.10). Five-year survival was 35% for all patients, 44% after R0 resection and 7% after R1 resection. CONCLUSION Tumour involvement of the lateral and posterior compartments on MRI was a predictor for R1 resection, but only lateral involvement was associated with an increased risk of death. An increased risk of death associated with lateral involvement was still present after R0 resection.
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Affiliation(s)
- Karin Westberg
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Division of Surgery, Danderyd Hospital, Stockholm, Sweden.
| | - Barwar Othman
- Department of Diagnostic Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Chikako Suzuki
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Diagnostic Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Lennart Blomqvist
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Diagnostic Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Martling
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Pelvic Cancer, GI Oncology and Colorectal Surgery Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Iversen
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Pelvic Cancer, GI Oncology and Colorectal Surgery Unit, Karolinska University Hospital, Stockholm, Sweden
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Jankowski M, Las-Jankowska M, Rutkowski A, Bała D, Wiśniewski D, Tkaczyński K, Kowalski W, Głowacka-Mrotek I, Zegarski W. Clinical Reality and Treatment for Local Recurrence of Rectal Cancer: A Single-Center Retrospective Study. ACTA ACUST UNITED AC 2021; 57:medicina57030286. [PMID: 33808603 PMCID: PMC8003449 DOI: 10.3390/medicina57030286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/11/2021] [Accepted: 03/15/2021] [Indexed: 01/31/2023]
Abstract
Background and Objectives: Despite advances in treatment, local recurrence remains a great concern in patients with rectal cancer. The aim of this study was to investigate the incidence and risk factors of local recurrence of rectal cancer in our single center over a 7-year-period. Materials and Methods: Patients with stage I-III rectal cancer were treated with curative intent. The necessity for radiotherapy and chemotherapy was determined before surgery and/or postoperative histopathological results. Results: Of 365 rectal cancer patients, 76 (20.8%) developed recurrent disease. In total, 27 (7.4%) patients presented with a local tumor recurrence (isolated in 40.7% of cases). Radiotherapy was performed in 296 (81.1%) patients. The most often used schema was 5 × 5 Gy followed by immediate surgery (n = 214, 58.6%). Local recurrence occurred less frequently in patients treated with 5 × 5 Gy radiotherapy followed by surgery (n = 9, 4%). Surgical procedures of relapses were performed in 12 patients, six of whom were operated with radical intent. Only two (7.4%) patients lived more than 5 years after local recurrence treatment. The incidence of local recurrence was associated with primary tumor distal location and worse prognosis. The median overall survival of patients after local recurrence treatment was 19 months. Conclusions: Individualized rectal cancer patient selection and systematic treatment algorithms should be used clinical practice to minimize likelihood of relapse. 5 × 5 Gy radiotherapy followed by immediate surgery allows good local control in resectable cT2N+/cT3N0 patients. Radical resection of isolated local recurrence offers the best chances of cure.
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Affiliation(s)
- Michał Jankowski
- Department of Surgical Oncology, Ludwik Rydygier’s Collegium Medicum, Bydgoszcz, Nicolaus Copernicus University, 85-067 Torun, Poland; (M.L.-J.); (D.B.); (W.K.); (W.Z.)
- Department of Surgical Oncology, Oncology Center—Prof Franciszek Łukaszczyk Memorial Hospital, 85-796 Bydgoszcz, Poland; (D.W.); (K.T.)
- Correspondence: or
| | - Manuela Las-Jankowska
- Department of Surgical Oncology, Ludwik Rydygier’s Collegium Medicum, Bydgoszcz, Nicolaus Copernicus University, 85-067 Torun, Poland; (M.L.-J.); (D.B.); (W.K.); (W.Z.)
- Department of Clinical Oncology, Oncology Center—Prof Franciszek Łukaszczyk Memorial Hospital, 85-796 Bydgoszcz, Poland
| | - Andrzej Rutkowski
- Department of Gastroenterological Oncology, M. Skłodowska-Curie Memorial Cancer Centre, 02-781 Warsaw, Poland;
| | - Dariusz Bała
- Department of Surgical Oncology, Ludwik Rydygier’s Collegium Medicum, Bydgoszcz, Nicolaus Copernicus University, 85-067 Torun, Poland; (M.L.-J.); (D.B.); (W.K.); (W.Z.)
- Department of Surgical Oncology, Oncology Center—Prof Franciszek Łukaszczyk Memorial Hospital, 85-796 Bydgoszcz, Poland; (D.W.); (K.T.)
| | - Dorian Wiśniewski
- Department of Surgical Oncology, Oncology Center—Prof Franciszek Łukaszczyk Memorial Hospital, 85-796 Bydgoszcz, Poland; (D.W.); (K.T.)
| | - Karol Tkaczyński
- Department of Surgical Oncology, Oncology Center—Prof Franciszek Łukaszczyk Memorial Hospital, 85-796 Bydgoszcz, Poland; (D.W.); (K.T.)
| | - Witold Kowalski
- Department of Surgical Oncology, Ludwik Rydygier’s Collegium Medicum, Bydgoszcz, Nicolaus Copernicus University, 85-067 Torun, Poland; (M.L.-J.); (D.B.); (W.K.); (W.Z.)
| | - Iwona Głowacka-Mrotek
- Department of Rehabilitation, Ludwik Rydygier’s Collegium Medicum, Bydgoszcz, Nicolaus Copernicus University, 85-067 Torun, Poland;
| | - Wojciech Zegarski
- Department of Surgical Oncology, Ludwik Rydygier’s Collegium Medicum, Bydgoszcz, Nicolaus Copernicus University, 85-067 Torun, Poland; (M.L.-J.); (D.B.); (W.K.); (W.Z.)
- Department of Surgical Oncology, Oncology Center—Prof Franciszek Łukaszczyk Memorial Hospital, 85-796 Bydgoszcz, Poland; (D.W.); (K.T.)
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Ng KS, Lee PJM. Pelvic exenteration: Pre-, intra-, and post-operative considerations. Surg Oncol 2021; 37:101546. [PMID: 33799076 DOI: 10.1016/j.suronc.2021.101546] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 03/02/2021] [Indexed: 01/18/2023]
Abstract
This review outlines the role of pelvic exenteration (PE) in the management of certain locally-advanced primary and recurrent rectal cancers. PE has undergone significant evolution over the past decades. Advances in pre-, intra-, and post-operative care have been directed towards achieving the 'holy grail' of an R0 resection, which remains the most important predictor of survival, quality of life, morbidity, and cost effectiveness following PE. Patient selection for surgery is largely determined by assessment of resectability. Pelvic magnetic resonance imaging determines the extent of local disease, while positron emission tomography remains the most accurate tool for exclusion of distant metastases. PE in the setting of metastatic disease or with palliative intent remains controversial. The intra-operative approach is based on the anatomical division of the pelvis into five compartments (anterior, central, posterior, and two lateral). Within each compartment are various possible dissection planes which are elected depending on the extent of tumour involvement. Innovations in surgical technique have allowed 'higher and wider' dissection planes with resultant en bloc excision of major vessels, major nerves, and bone. Evidence of improved R0 resection and survival rates with these techniques justifies the radicality of these novel approaches. Post-operative care for PE patients is technically demanding with a substantial hospital resource burden. Unique considerations for PE patients include the 'empty pelvis syndrome', urological complications, and management of post-operative malnutrition. While undeniably a morbid procedure, quality of life largely returns to baseline at six months, and for long-term survivors is sustained for up to five years.
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Affiliation(s)
- Kheng-Seong Ng
- Royal Prince Alfred Hospital, Department of Colorectal Surgery, Sydney, Australia; Surgical Outcomes Research Centre, Royal Prince Alfred Hospital, Sydney, Australia
| | - Peter J M Lee
- Royal Prince Alfred Hospital, Department of Colorectal Surgery, Sydney, Australia; Surgical Outcomes Research Centre, Royal Prince Alfred Hospital, Sydney, Australia.
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Masaki T, Matsuoka H, Kishiki T, Kojima K, Tonari A, Aso N, Beniya A, Iioka A, Wakamatsu T, Sunami E. Site-specific risk factors for local recurrence after rectal cancer surgery. Surg Oncol 2021; 37:101540. [PMID: 33714843 DOI: 10.1016/j.suronc.2021.101540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 02/16/2021] [Accepted: 03/02/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Quite few studies examined risk factors for local recurrence after rectal cancer surgery with respect to local recurrence sites. METHODS Local recurrence sites were categorized into axial, anterior, posterior, and lateral (pelvic sidewall), and axial, anterior, and posterior type were combined as the "other" type of local recurrence. Among 76 patients enrolled into our prospective randomized controlled trial to determine the indication for pelvic autonomic nerve preservation (PANP) in patients with advanced lower rectal cancer (UMIN000021353), multivariate analyses were conducted to elucidate risk factors for either lateral or the "other" type of local recurrence. RESULTS Univariate analyses showed that tumor distance from the anal verge was significantly (p = 0.017), and type of operation (sphincter preserving operation (SPO) vs. abdominoperineal resection (APR)) was marginally (p = 0.065) associated with pelvic sidewall recurrence. Multivariate analysis using these two parameters showed that tumor distance from the anal verge was significantly and independently correlated with pelvic sidewall recurrence (p = 0.017). As for the "other" type of local recurrence, univariate analyses showed that depth of tumor invasion (p = 0.011), radial margin status (p < 0.001), and adjuvant chemotherapy (p = 0.037) were significantly associated, and multivariate analysis using these three parameters revealed that depth of tumor invasion (p = 0.004) and radial margin status (p < 0.001) were significantly and independently correlated with the "other" type of local recurrence. CONCLUSION Risk factors for local recurrence after rectal cancer surgery were totally different with respect to the intra-pelvic recurrent sites. Site-specific probability of local recurrence can be inferred using these risk factors. TRIAL REGISTRATION NUMBER UMIN000021353.
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Affiliation(s)
| | | | | | | | | | | | | | - Aiko Iioka
- Department of Surgery, Kyorin University, Japan
| | | | - Eiji Sunami
- Department of Surgery, Kyorin University, Japan
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25
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Sorrentino L, Belli F, Guaglio M, Daveri E, Cosimelli M. Prediction of R0/R+ surgery by different classifications for locally recurrent rectal cancer. Updates Surg 2021; 73:539-545. [PMID: 33555570 DOI: 10.1007/s13304-020-00941-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 12/07/2020] [Indexed: 11/28/2022]
Abstract
A widely adopted classification system for locally recurrent rectal cancer (LRRC) is currently missing, and the indication for surgery is not standardized. To evaluate all the published classification systems in a large monocentric cohort of LRRC patients, assessing their capability to predict a radical (R0) resection. A total of 152 consecutive LRRC patients treated at the National Cancer Institute of Milan (NCIM) from 2009 to 2017 were classified according to Pilipshen, Mayo Clinic, Memorial Sloan-Kettering Cancer Center (MSKCC), Wanebo, Yamada, Boyle, Dutch TME Trial, Royal Marsden and National Cancer Institute of Milan (NCIM) classification systems. Central location of LRRC was significantly predictive of R0 resection across all classification systems. R + resection was predicted by the "anterior" category of MSKCC (OR 2.66, p = 0.007), the "S2b" (OR 3.50, p = 0.04) and the "S3" (OR 2.70, p = 0.01) categories of NCIM, "pelvic disease through anastomosis" of Pilipshen (OR 2.89, p = 0.002), "fixed at 2 sites" of Mayo Clinic (OR 2.68, p = 0.019), and "TR4" of Wanebo (OR 3.39, p = 0.002). The NCIM was the most predictive classification for R0 surgery. The NCIM classification seems to be superior among the others in predicting R0 surgery. Generally, lateral invasive and high sacral invasive relapses are associated with reduced probability of R0 surgery and unfavorable outcomes.
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Affiliation(s)
- Luca Sorrentino
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Filiberto Belli
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Marcello Guaglio
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy.
| | - Elena Daveri
- Unit of Immunotherapy of Human Tumors, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Maurizio Cosimelli
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
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Transanal total mesorectal excision for stage II or III rectal cancer: pattern of local recurrence in a tertiary referral center. Surg Endosc 2021; 35:7191-7199. [PMID: 33398553 DOI: 10.1007/s00464-020-08200-4] [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: 03/20/2020] [Accepted: 11/19/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND For mid and low rectal cancer, transanal total mesorectal excision (TaTME) has been established as an alternative approach to laparoscopic surgery. However, there are concerns about an unexpected pattern of local recurrence. This study aimed to analyze the pattern of local recurrence for patients treated with TaTME in a tertiary referral center. METHODS A retrospective single-center analysis was performed. Since 2011, all patients with rectal cancer undergoing TaTME with curative intent were prospectively included in a standardized database. Patients with tumors within 12 cm, clinical stage II or III were included. The primary endpoint of the study was the overall local recurrence rate, together with a critical analysis of the patterns of local failures. RESULTS Two hundred and five patients were included in this analysis. At the time of surgery, patients had a mean age of 67.1 years (SD 12.3), and 66.8% were male. Neoadjuvant therapy was administered in 73.7%. Mesorectal specimen quality was complete or near-complete in 98.5%, while circumferential resection margin was ≤ 1 mm (including T4 tumors) in 11.8%. After a median follow-up of 34.3 months (95% CI 30.1-38.5), 3.4% (n = 7) presented with local recurrent disease. Six out of the seven patients were also diagnosed with hematogenous metastases. Of the seven patients, three presented with at least one of the following risk factors: T4 tumor, N2 disease, incomplete mesorectal specimen, or positive CRM. Local failure was noted posteriorly (n = 3), laterally (n = 2), anteriorly (n = 1), and in the axial compartment (n = 1). Median time to relapse was 31.5 months (10.3-40.9). The median follow-up after local recurrence was 7.9 (95% CI 6.7-9.1) months, with an overall survival of 85.7%. CONCLUSIONS TaTME provided satisfactory local recurrence outcomes, and the most common patterns of failure were in the central pelvis.
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27
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Möglichkeiten der Magnetresonanztomographie beim Rezidiv des Rektumkarzinoms. COLOPROCTOLOGY 2020. [DOI: 10.1007/s00053-020-00491-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Brown KG, Solomon MJ. Decision making, treatment planning and technical considerations in patients undergoing surgery for locally recurrent rectal cancer. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100764] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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29
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Peacock O, Smith N, Waters PS, Cheung F, McCormick JJ, Warrier SK, Wagner T, Heriot AG. Outcomes of extended radical resections for locally advanced and recurrent pelvic malignancy involving the aortoiliac axis. Colorectal Dis 2020; 22:818-823. [PMID: 31961476 DOI: 10.1111/codi.14969] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 12/15/2019] [Indexed: 02/08/2023]
Abstract
AIM Currently, there is no clear consensus on the role of extended pelvic resections for locally advanced or recurrent disease involving major vascular structures. The aims of this study were to report the outcomes of consecutive patients undergoing extended resections for pelvic malignancy involving the aortoiliac axis. METHODS Prospective data were collected on patients having extended radical resections for locally advanced or recurrent pelvic malignancies, with aortoiliac axis involvement, requiring en bloc vascular resection and reconstruction, at a single institution between 2014 and 2018. RESULTS Eleven patients were included (median age 60 years; range 31-69 years; seven women). The majority required resection of both arterial and venous systems (n = 8), and the technique for vascular reconstruction was either interposition grafts or femoral-femoral crossover grafts. The median operative time was 510 min (range 330-960 min). Clear resection margins (R0) were achieved in nine patients. The median length of stay was 25 days (range 7-83 days). Seven patients did not suffer an early complication. There was one serious complication (Clavien-Dindo ≥ 3), an arterial graft occlusion secondary to thrombus in the immediate postoperative period, requiring a return to theatre and thrombectomy. The median length of follow-up in this study was 22 months (range 4-58 months). CONCLUSION This series demonstrates that en bloc major vascular resection and reconstruction can be performed safely and can achieve clear resection margins in selected patients with locally advanced or recurrent pelvic malignancy at specialist surgery centres.
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Affiliation(s)
- O Peacock
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - N Smith
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - P S Waters
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - F Cheung
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - J J McCormick
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - S K Warrier
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - T Wagner
- Vascular Surgery Unit, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - A G Heriot
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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30
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Wong JSM, Tan GHC, Chia CS, Ong CAJ, Teo MCC. Management of synchronous lateral pelvic nodal metastasis in rectal cancer in the era of neoadjuvant chemoradiation: A systemic review. World J Gastrointest Surg 2020; 12:247-258. [PMID: 32551030 PMCID: PMC7289645 DOI: 10.4240/wjgs.v12.i5.247] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 03/03/2020] [Accepted: 04/28/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Lateral pelvic lymph node (LLN) metastasis (LLNM) occur in up to 28% of patients with low rectal tumours. While prophylactic lateral pelvic lymph node dissection (LLND) has been abandoned by most western institutions in the era of neoadjuvant chemoradiation therapy (CRT), the role of selective LLND in patients with enlarged LLN on pre-CRT imaging remains unclear. Some studies have shown improved survival and recurrence outcomes when LLNs show “response” to CRT. However, no management algorithm exists to differentiate treatment for “responders” vs “non-responders”.
AIM To determine if selective LLND in patients with enlarged LLNs results in improved survival and recurrence outcomes.
METHODS A systemic search of PubMed and Embase databases for studies reporting on patients with synchronous radiologically suspicious LLNM (s-LLNM) in rectal cancer receiving preoperative-CRT was performed.
RESULTS Fifteen retrospective, single-centre studies were included. 793 patients with s-LLNM were evaluated: 456 underwent TME while 337 underwent TME with LLND post-CRT. In the TME group, local recurrence (LR) rates range from 12.5% to 36%. Five-year disease free survival (DFS) was 42% to 75%. In the TME with LLND group, LR rates were 0% to 6%. Five years DFS was 41.2% to 100%. Radiological response was seen in 58%. Pathologically positive LLN was found in up to 94% of non-responders vs 0% to 20% in responders. Young age, low tumour location and radiological non-response were associated with final positive LLNM and lowered DFS.
CONCLUSION LLND is associated with local control in patients with s-LLNM. It can be performed in radiological non-responders given a large majority represent true LLNM. Its role in radiological responders should be considered in selected high risk patients.
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Affiliation(s)
- Jolene Si Min Wong
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore 169610, Singapore
| | - Grace Hwei Ching Tan
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore 169610, Singapore
- Duke-NUS Medical School, 8 College Road, Singapore 169857, Singapore
| | - Claramae Shulyn Chia
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore 169610, Singapore
- Duke-NUS Medical School, 8 College Road, Singapore 169857, Singapore
| | - Chin-Ann Johnny Ong
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore 169610, Singapore
- Duke-NUS Medical School, 8 College Road, Singapore 169857, Singapore
- Laboratory of Applied Human Genetics, Division of Medical Sciences, National Cancer Centre Singapore, Singapore 169610, Singapore
- Institute of Molecular and Cell Biology, A*STAR Research Entities, 61 Biopolis Drive, Singapore 138673, Singapore
| | - Melissa Ching Ching Teo
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore 169610, Singapore
- Duke-NUS Medical School, 8 College Road, Singapore 169857, Singapore
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Belli F, Sorrentino L, Gallino G, Gronchi A, Scaramuzza D, Valvo F, Cattaneo L, Cosimelli M. A proposal of an updated classification for pelvic relapses of rectal cancer to guide surgical decision-making. J Surg Oncol 2020; 122:350-359. [PMID: 32424824 DOI: 10.1002/jso.25938] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 04/05/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND OBJECTIVES Selection of patients affected by pelvic recurrence of rectal cancer (PRRC) who are likely to achieve a R0 resection is mandatory. The aim of this study was to propose a classification for PRRC to predict both radical surgery and disease-free survival (DFS). METHODS PRRC patients treated at the National Cancer Institute of Milan (Italy) were included in the study. PRRC were classified as S1, if located centrally (S1a-S1b) or anteriorly (S1c) within the pelvis; S2, in case of sacral involvement below (S2a) or above (S2b) the second sacral vertebra; S3, in case of lateral pelvic involvement. RESULTS Of 280 reviewed PRRC patients, 152 (54.3%) were evaluated for curative surgery. The strongest predictor of R+ resection was the S3 category (OR, 6.37; P = .011). Abdominosacral resection (P = .012), anterior exenteration (P = .012) and extended rectal re-excision (P = .003) were predictive of R0 resection. S3 category was highly predictive of poor DFS (HR 2.53; P = .038). DFS was significantly improved after R0 surgery for S1 (P < .0001) and S2 (P = .015) patients but not for S3 cases (P = .525). CONCLUSIONS The proposed classification allows selection of subjects candidates to curative surgery, emphasizing that lateral pelvic involvement is the main predictor of R+ resection and independently affects the DFS.
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Affiliation(s)
- Filiberto Belli
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Luca Sorrentino
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Gianfrancesco Gallino
- Melanoma and Sarcoma Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Alessandro Gronchi
- Melanoma and Sarcoma Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Davide Scaramuzza
- Department of Radiology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Francesca Valvo
- Radiotherapy Unit, Clinical Department, CNAO National Center for Oncological Hadrontherapy, Pavia, Italy
| | - Laura Cattaneo
- Pathology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Maurizio Cosimelli
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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The added value of pelvic surveillance by MRI during postoperative follow-up of rectal cancer, with a focus on abbreviated MRI. Eur Radiol 2020; 30:3113-3124. [PMID: 32072254 DOI: 10.1007/s00330-020-06711-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 01/17/2020] [Accepted: 02/04/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To assess the added value of MRI over CT for the detection of pelvic recurrence during postoperative surveillance after rectal cancer surgery and to compare the diagnostic accuracy for pelvic recurrence achieved with abbreviated MRI (aMRI) with that of conventional enhanced MRI (cMRI). METHODS Patients who underwent rectal cancer surgery followed by MRI in addition to the standard CT follow-up protocol were evaluated retrospectively. Two readers independently scored images from CT, cMRI, and aMRI, which consisted of T2-weighted and diffusion-weighted imaging, to rate the likelihood of recurrence. Diagnostic accuracy and ROC curves were calculated. The patients were divided into two groups for risk-adapted surveillance according to risk of recurrence: high-risk (n = 157) and low-risk (n = 169) groups. RESULTS In total, 579 MRIs from 326 patients were assessed. A total of 48 pelvic recurrences occurred in 33 patients. The AUC in cMRI, aMRI, and CT were 0.98, 0.99, and 0.84, respectively. The difference in performance between CT and cMRI or aMRI for identifying recurrence was statistically significant (p < 0.001). Both cMRI and aMRI showed superior performance compared with CT in the high-risk group (p < 0.001), but this was not the case in the low-risk group (p = 0.13). Furthermore, the diagnostic accuracy of aMRI was similar to that of cMRI. CONCLUSIONS The addition of MRI to the postoperative surveillance protocol may result in an improvement in the detection of pelvic recurrence after rectal cancer surgery. For patients at high risk of recurrence, an aMRI surveillance may be justified to improve the diagnostic yield. KEY POINTS • The addition of MRI to the postoperative surveillance protocol improved the diagnostic yield in patients at a high risk of recurrence. • Abbreviated non-enhanced MRI with DWI allows detection of pelvic recurrence with a diagnostic accuracy that is similar to that of contrast-enhanced MRI (AUC, 0.99 and 0.98, respectively; p = 0.12). • Abbreviated MRI that is restricted to high spatial resolution structural imaging and diffusion-weighted imaging takes less time and can be carried out without the need for injection of a contrast agent.
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Hamilton JM, Larach TJ, Heriot AG, Warrier SK, McCormick JJ. Delayed Haemorrhage Following Pelvic Side Wall Excision With Internal Iliac Vessel Resection in Locally Recurrent Rectal Cancer. ANZ J Surg 2020; 90:2125-2127. [PMID: 31994350 DOI: 10.1111/ans.15734] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 01/09/2020] [Accepted: 01/20/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Jordan M Hamilton
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia
| | - Tomas J Larach
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia
| | - Alexander G Heriot
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia
| | - Satish K Warrier
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia
| | - Jacob J McCormick
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia
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Denost Q, Bousser V, Morin-Porchet C, Vincent C, Pinon E, Collin F, Martin A, Colombani F, Digue L, Ravaud A, Harji DP, Saillour-Glénisson F. The development of a regional referral pathway for locally recurrent rectal cancer: A Delphi consensus study. Eur J Surg Oncol 2019; 46:470-475. [PMID: 31866109 DOI: 10.1016/j.ejso.2019.12.001] [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: 07/18/2019] [Revised: 11/18/2019] [Accepted: 12/01/2019] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The management of patients with locally recurrent rectal cancer (LRRC) is often complex and requires multidisciplinary input whereas only few patients are referred to a specialist centre. The aim of this study was to design a regional referral pathway for LRRC, in Nouvelle Aquitaine (South-West, France). METHODS In 2016, we conducted with a Study Steering Committee (SC) a three phase mixed-methods study including identification of key factors, identification of key stakeholders and Delphi voting consensus. During three rounds of Delphi voting, a consensus was defined as favorable, if at least 80% of participating experts rate the factor, below or equal to 3/10 using a Likert scale, or consider it as "useful" using a binary scale (third round only). Finally, the SC drafted guidelines. RESULTS Among the 423 physicians involved in 29 regional digestive Multi-Disciplinary Team (MDT) meeting, 59 participants (from 26 MDT meeting) completed all three rounds of Delphi voting. Thirteen out of twenty initially selected factors reached a favorable consensus. All patients with a LRRC need to be included into a referral pathway. Patients with a central pelvic recurrence offered curative treatment in their local hospital and patients with unresectable metastatic disease were excluded of the referral. Key performance indicators were also agreed including the time to referral and completion of pelvic MRI-, CT-, PET-scan prior to MDT referral. CONCLUSION The development of this referral pathway represents an innovative health service, which will improve the management of patients with LRRC in France.
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Affiliation(s)
- Quentin Denost
- Department of Digestive Surgery, Haut-leveque Hospital, Bordeaux University Hospital, Pessac, France.
| | | | | | - Cecile Vincent
- Limousin Oncology-Hematology Network (ROHLim), 87000, Limoges, France.
| | - Elodie Pinon
- Aquitaine Regional Cancer Network, 33076, Bordeaux, France.
| | - Fideline Collin
- Department of Digestive Surgery, Haut-leveque Hospital, Bordeaux University Hospital, Pessac, France.
| | - Aurelie Martin
- INSERM, ISPED, Centre INSERM U1219-Bordeaux Population Health, Team EMOS, F-33000, Bordeaux, France.
| | | | - Laurence Digue
- Department of Medical Oncology, Saint-André Hospital, Bordeaux University Hospital-CHU Bordeaux, France; Aquitaine Regional Cancer Network, 33076, Bordeaux, France.
| | - Alain Ravaud
- Department of Medical Oncology, Saint-André Hospital, Bordeaux University Hospital-CHU, Bordeaux, France, University of Bordeaux, Bordeaux, France.
| | - Deena Pravin Harji
- Department of Digestive Surgery, Haut-leveque Hospital, Bordeaux University Hospital, Pessac, France.
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Lau YC, Brown KGM, Lee P. Pelvic exenteration for locally advanced and recurrent rectal cancer-how much more? J Gastrointest Oncol 2019; 10:1207-1214. [PMID: 31949941 DOI: 10.21037/jgo.2019.01.21] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
There have been significant advances in the surgical management of locally advanced and recurrent rectal cancer in recent decades. Patient with advanced pelvic tumours involving adjacent organs and neurovascular structures, beyond the traditional mesorectal planes, who would have traditionally been considered irresectable at many centres, now undergo surgery routinely at specialised units. While high rates of morbidity and mortality were reported by the pioneers of pelvic exenteration (PE) in early literature, this is now considered historical data. In 2019, patients who undergo PE for advanced or recurrent rectal cancer can expect reasonable rates of long-term survival (up to 60% at 5 years) and acceptable morbidity and quality of life. This article describes the surgical techniques that have been developed for radical multivisceral pelvic resections and reviews contemporary outcomes.
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Affiliation(s)
- Yee Chen Lau
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia
| | - Kilian G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia.,The Institute of Academic Surgery at RPA, Sydney, Australia
| | - Peter Lee
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia.,The Institute of Academic Surgery at RPA, Sydney, Australia
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Local Therapy Options for Recurrent Rectal and Anal Cancer: Current Strategies and New Directions. CURRENT COLORECTAL CANCER REPORTS 2019. [DOI: 10.1007/s11888-019-00445-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Ganeshan D, Nougaret S, Korngold E, Rauch GM, Moreno CC. Locally recurrent rectal cancer: what the radiologist should know. Abdom Radiol (NY) 2019; 44:3709-3725. [PMID: 30953096 DOI: 10.1007/s00261-019-02003-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Despite advances in surgical techniques and chemoradiation therapy, recurrent rectal cancer remains a cause of morbidity and mortality. After successful treatment of rectal cancer, patients are typically enrolled in a surveillance strategy that includes imaging as studies have shown improved prognosis when recurrent rectal cancer is detected during imaging surveillance versus based on development of symptoms. Additionally, patients who experience a complete clinical response with chemoradiation therapy may elect to enroll in a "watch-and-wait" strategy that includes imaging surveillance rather than surgical resection. Factors that increase the likelihood of recurrence, patterns of recurrence, and the imaging appearances of recurrent rectal cancer are reviewed with a focus on CT, PET CT, and MR imaging.
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Affiliation(s)
- Dhakshinamoorthy Ganeshan
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX, 77030, USA
| | - Stephanie Nougaret
- Montpellier Cancer Research Institute, IRCM, Montpellier Cancer Research Institute, 208 Ave des Apothicaires, 34295, Montpellier, France
- Department of Radiology, Montpellier Cancer Institute, INSERM, U1194, University of Montpellier, 208 Ave des Apothicaires, 34295, Montpellier, France
| | - Elena Korngold
- Department of Radiology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Gaiane M Rauch
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX, 77030, USA
| | - Courtney C Moreno
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Road, NE, Atlanta, GA, 30322, USA.
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Lee J, Kim CY, Koom WS, Rim CH. Practical effectiveness of re-irradiation with or without surgery for locoregional recurrence of rectal cancer: A meta-analysis and systematic review. Radiother Oncol 2019; 140:10-19. [PMID: 31176204 DOI: 10.1016/j.radonc.2019.05.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 05/13/2019] [Accepted: 05/20/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE Re-irradiation might yield local control (LC) or palliation for locoregionally recurrent rectal cancer (LRRC), but iatrogenic complications are a possible hindrance. We aimed to evaluate the efficacy of re-irradiation to determine optimal treatment of LRRC. METHODS We performed a systematic review of PubMed, MEDLINE, Cochrane Library, and Embase. RESULTS A total of 17 studies involving 744 patients with LRRC were included; median OS ranging from 10 to 45 months (median: 24.5 months). Pooled 1-, 2-, and 3-year OS rates for all patients were 76.1%, 49.1%, and 38.3%, respectively. For patients who underwent re-irradiation and surgery (OP group), these pooled rates were 85.9%, 71.8%, and 51.7%, respectively. For patients who underwent re-irradiation but not surgery (non-OP group), pooled 1-, 2-, and 3-year OS rates were 63.5%, 34.2%, and 23.8%, respectively. The OS difference between both groups was significant for all 3 years (P < 0.05). Pooled 1-, 2-, and 3-year LC rates for the OP group were 84.4%, 63.8%, and 46.9%, and for the non-OP group were 72.0%, 54.8%, and 44.6%, respectively, without significant differences. Pooled grade ≥3 acute and late complication rates were 11.7% and 25.5% in the OP and non-OP groups, respectively. Patients who underwent surgery had a higher risk of grade ≥3 late complications (odds ratio: 6.39). Pooled symptomatic palliation rate was 75.2%. CONCLUSIONS Re-irradiation with or without surgery for LRRC showed oncologic and palliative efficacy. Salvage treatment including re-irradiation and surgery showed higher survival, but the late complication was significantly increased with concomitant surgery.
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Affiliation(s)
- Jeongshim Lee
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Republic of Korea; Department of Radiation Oncology, Inha University Hospital, Inha University College of Medicine, Incheon, Republic of Korea
| | - Chul Yong Kim
- Department of Radiation Oncology, Anam Hospital, Korea University Medical College, Seoul, Republic of Korea
| | - Woong Sub Koom
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chai Hong Rim
- Department of Radiation Oncology, Ansan Hospital, Korea University Medical College, Ansan, Republic of Korea.
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Davis BR, Schlosser KA. Management of locally recurrent rectal cancer. SEMINARS IN COLON AND RECTAL SURGERY 2019. [DOI: 10.1053/j.scrs.2019.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Westberg K, Palmer G, Hjern F, Holm T, Martling A. Population-based study of surgical treatment with and without tumour resection in patients with locally recurrent rectal cancer. Br J Surg 2019; 106:790-798. [PMID: 30776087 DOI: 10.1002/bjs.11098] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 10/26/2018] [Accepted: 11/23/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND Population-based studies of treatment of locally recurrent rectal cancer (LRRC) are lacking. The aim was to investigate the surgical treatment of patients with LRRC at a national population-based level. METHODS All patients undergoing abdominal resection for primary rectal cancer between 1995 and 2002 in Sweden with LRRC as a first event were included. Detailed information about treatment, complications and outcomes was collected from the medical records. The patients were analysed in three groups: patients who had resection of the LRRC, those treated without tumour resection and patients who received best supportive care only. RESULTS In all, 426 patients were included in the study. Of these, 149 (35·0 per cent) underwent tumour resection, 193 (45·3 per cent) had treatment without tumour resection and 84 (19·7 per cent) received best supportive care. Abdominoperineal resection was the most frequent surgical procedure, performed in 65 patients (43·6 per cent of those who had tumour resection). Thirteen patients had total pelvic exenteration. In total, 63·8 per cent of those whose tumour was resected had potentially curative surgery. After tumour resection, 62 patients (41·6 per cent) had a complication within 30 days. Patients who received surgical treatment without tumour resection had a lower complication rate but a significantly higher 30-day mortality rate than those who underwent tumour resection (10 versus 1·3 per cent respectively; P = 0·002). Of all patients included in the study, 22·3 per cent had potentially curative treatment and the 3-year survival rate for these patients was 56 per cent. CONCLUSION LRRC is a serious condition with overall poor outcome. Patients undergoing curative surgery have an acceptable survival rate but substantial morbidity. There is room for improvement in the management of patients with LRRC.
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Affiliation(s)
- K Westberg
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Division of Surgery, Danderyd Hospital, Stockholm, Sweden
| | - G Palmer
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Center of Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - F Hjern
- Department of Clinical Sciences, Karolinska Institutet and Center of Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - T Holm
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Center of Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - A Martling
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Center of Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
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Horvat N, Carlos Tavares Rocha C, Clemente Oliveira B, Petkovska I, Gollub MJ. MRI of Rectal Cancer: Tumor Staging, Imaging Techniques, and Management. Radiographics 2019; 39:367-387. [PMID: 30768361 DOI: 10.1148/rg.2019180114] [Citation(s) in RCA: 218] [Impact Index Per Article: 43.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Rectal cancer is prone to local recurrence and systemic metastasis. However, owing to improvements in TNM staging and treatment, including a more widespread use of rectal MRI and increased radiologist awareness of the key rectal cancer TNM staging features, the mortality rate of rectal cancer has been declining over the past few decades in adults over 50 years of age. Currently, rectal MRI plays a key role in the pre- and posttreatment evaluation of rectal cancer, assisting the multidisciplinary team in tailoring the most appropriate treatment option. The benefits achieved with rectal MRI are strictly dependent on obtaining good-quality images, which is important for the characterization of the main anatomic structures and their relationship with the tumor. In primary staging, rectal MRI helps the radiologist (a) describe the tumor location and morphology, (b) provide its T and N categories, (c) detect the presence of extramural vascular invasion, and (d) identify its relationship with surrounding structures, including the sphincter complex and involvement of the mesorectal fascia. These features help diagnose locally advanced rectal tumors (categories T3c-d, T4, N1, and N2), for which neoadjuvant chemoradiotherapy (CRT) is indicated. In restaging after neoadjuvant CRT, in addition to reassessing the features noted during primary staging, rectal MRI can help in the assessment of treatment response, especially with the emergence of nonsurgical approaches such as "watch and wait." ©RSNA, 2019.
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Affiliation(s)
- Natally Horvat
- From the Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY (N.H., I.P., M.J.G.); Department of Radiology, Hospital Sírio-Libanês, Adma Jafet 91, 01308-050 Bela Vista, São Paulo, Brazil (N.H., B.C.O.); and Department of Radiology, University of São Paulo, São Paulo, Brazil (N.H., C.C.T.R., B.C.O.)
| | - Camila Carlos Tavares Rocha
- From the Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY (N.H., I.P., M.J.G.); Department of Radiology, Hospital Sírio-Libanês, Adma Jafet 91, 01308-050 Bela Vista, São Paulo, Brazil (N.H., B.C.O.); and Department of Radiology, University of São Paulo, São Paulo, Brazil (N.H., C.C.T.R., B.C.O.)
| | - Brunna Clemente Oliveira
- From the Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY (N.H., I.P., M.J.G.); Department of Radiology, Hospital Sírio-Libanês, Adma Jafet 91, 01308-050 Bela Vista, São Paulo, Brazil (N.H., B.C.O.); and Department of Radiology, University of São Paulo, São Paulo, Brazil (N.H., C.C.T.R., B.C.O.)
| | - Iva Petkovska
- From the Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY (N.H., I.P., M.J.G.); Department of Radiology, Hospital Sírio-Libanês, Adma Jafet 91, 01308-050 Bela Vista, São Paulo, Brazil (N.H., B.C.O.); and Department of Radiology, University of São Paulo, São Paulo, Brazil (N.H., C.C.T.R., B.C.O.)
| | - Marc J Gollub
- From the Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY (N.H., I.P., M.J.G.); Department of Radiology, Hospital Sírio-Libanês, Adma Jafet 91, 01308-050 Bela Vista, São Paulo, Brazil (N.H., B.C.O.); and Department of Radiology, University of São Paulo, São Paulo, Brazil (N.H., C.C.T.R., B.C.O.)
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Beyond total mesorectal excision in locally advanced rectal cancer with organ or pelvic side-wall involvement. Eur J Surg Oncol 2018; 44:1226-1232. [DOI: 10.1016/j.ejso.2018.03.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 02/28/2018] [Accepted: 03/31/2018] [Indexed: 01/07/2023] Open
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Iversen H, Martling A, Johansson H, Nilsson PJ, Holm T. Pelvic local recurrence from colorectal cancer: surgical challenge with changing preconditions. Colorectal Dis 2018; 20:399-406. [PMID: 29161761 DOI: 10.1111/codi.13966] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 10/03/2017] [Indexed: 02/08/2023]
Abstract
AIM Although the rate of local recurrence (LR) after colorectal cancer surgery has decreased, it still poses major surgical and oncological challenges. The aims of this study, based on an audit from a tertiary referral centre, was to evaluate determinants associated with outcomes after surgery for pelvic LR and how these have changed over time. METHOD Retrospective analysis of all resections for pelvic LR of colorectal cancer performed at the Karolinska University Hospital from January 2003 until August 2009 (period 1) and from September 2009 until November 2013 (period 2) . RESULTS Ninety-five patients with pelvic LR were operated on with a curative intent. An R0 resection was achieved in 77% and an R1 resection in 23%. Lateral compartments were invaded in 48% and this proportion increased in resections performed in period 2 (37% vs 60%, P = 0.05). R1 resections were associated with a higher risk of local re-recurrence than R0 resections (64% vs 16%; OR = 8.90, 95% CI: 2.71-29.78). Lateral recurrences were associated with a lower R0-resection rate than nonlateral recurrences (63% vs 90%; OR = 0.20, 95% CI: 0.05-0.64) and a higher risk of treatment failure in terms of local re-recurrence or distant metastases, or death, as first event (hazard ratio [HR] = 1.75, 95% CI: 1.06-2.75). However, in a multivariate analysis only R1 resections remained a significant prognostic factor for treatment failure (HR = 2.37, 95% CI: 1.32-4.27). CONCLUSION The proportion of lateral pelvic recurrences has increased over time. In comparison with non-lateral LRs, lateral LRs are more difficult to resect radically and are associated with worse overall and disease-free survival. However, with radical surgery many patients with pelvic locally recurrent colorectal cancer may be offered curative treatment.
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Affiliation(s)
- H Iversen
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - A Martling
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - H Johansson
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - P J Nilsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - T Holm
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
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Dickfos M, Tan SBM, Stevenson ARL, Harris CA, Esler R, Peters M, Taylor DG. Development of a pelvic exenteration service at a tertiary referral centre. ANZ J Surg 2018; 88. [PMID: 29510462 DOI: 10.1111/ans.14427] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 01/07/2018] [Accepted: 01/13/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Over one-third of primary rectal cancers are locally advanced at diagnosis, and local recurrence of rectal cancer occurs at a rate of 3-10% following primary curative resection. Extended resectional surgery, including pelvic exenteration, is the only proven therapy with curative potential in the treatment of these cancers along with many other pelvic malignancies. A microscopically clear resection margin (R0 resection) is the predominant prognostic factor affecting overall and disease-free survival. The extent and complexity of surgery required to achieve an R0 resection is associated with significant risk of morbidity and mortality. The aim of this paper is to show that pelvic exenterations can be performed with acceptable oncological and safe perioperative results in an appropriately resourced specialist centre. METHODS Data was collected retrospectively for 61 consecutive patients treated between June 2012 and February 2017. This included patient demographics, tumour characteristics, operative, clinical and histological data, length of hospital stay, morbidity and mortality data. RESULTS A total of 61 patients underwent surgery. Median age was 57 years (range 27-78 years). Median length of stay was 41 days (range 6-288 days). Median operative time was 624 min (range 239-1035 min); 30-day mortality was 3.3% (n = 2). Resection rates were 91.5% - R0, 6.8% - R1 and 1.7% - R2 resections. Histologically, 86.9% - adenocarcinomas, 3.3% - squamous cell carcinomas and 9.8% - represented by leiomyosarcoma, melanoma, myxoid chondrosarcoma, non-neoplastic processes and undifferentiated carcinoma. CONCLUSION Our experience confirms that radical resectional pelvic surgery can be safely performed with acceptable results during the establishment phase of a dedicated tertiary service.
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Affiliation(s)
- Marilla Dickfos
- General Surgery Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- School of Medicine, Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Stephanie B M Tan
- General Surgery Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- School of Medicine, Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Andrew R L Stevenson
- General Surgery Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Craig A Harris
- General Surgery Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Department of Colorectal Surgery, Mater Hospital, Brisbane, Queensland, Australia
| | - Rachel Esler
- General Surgery Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Department of Urology, Wesley Hospital, Brisbane, Queensland, Australia
| | - Matthew Peters
- General Surgery Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - David G Taylor
- General Surgery Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Department of Urology, Wesley Hospital, Brisbane, Queensland, Australia
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Management and prognosis of locally recurrent rectal cancer - A national population-based study. Eur J Surg Oncol 2017; 44:100-107. [PMID: 29224985 DOI: 10.1016/j.ejso.2017.11.013] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 10/27/2017] [Accepted: 11/16/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The rate of local recurrence of rectal cancer (LRRC) has decreased but the condition remains a therapeutic challenge. This study aimed to examine treatment and prognosis in patients with LRRC in Sweden. Special focus was directed towards potential differences between geographical regions and time periods. METHOD All patients with LRRC as first event, following primary surgery for rectal cancer performed during the period 1995-2002, were included in this national population-based cohort-study. Data were collected from the Swedish Colorectal Cancer Registry and from medical records. The cohort was divided into three time periods, based on the date of diagnosis of the LRRC. RESULTS In total, 426 patients fulfilled the inclusion criteria. Treatment with curative intent was performed in 149 patients (35%), including 121 patients who had a surgical resection of the LRRC. R0-resection was achieved in 64 patients (53%). Patients with a non-centrally located tumour were more likely to have positive resection margins (R1/R2) (OR 5.02, 95% CI:2.25-11.21). Five-year survival for patients resected with curative intent was 43% after R0-resection and 14% after R1-resection. There were no significant differences in treatment intention or R0-resection rate between time periods or regions. The risk of any failure was significantly higher in R1-resected patients compared with R0-resected patients (HR 2.04, 95% CI:1.22-3.40). CONCLUSION A complete resection of the LRRC is essential for potentially curative treatment. Time period and region had no influence on either margin status or prognosis.
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Westberg K, Palmer G, Hjern F, Nordenvall C, Johansson H, Holm T, Martling A. Population-based study of factors predicting treatment intention in patients with locally recurrent rectal cancer. Br J Surg 2017; 104:1866-1873. [DOI: 10.1002/bjs.10645] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 06/08/2017] [Accepted: 06/15/2017] [Indexed: 11/09/2022]
Abstract
Abstract
Background
Local recurrence of rectal cancer (LRRC) is associated with poor survival unless curative treatment is performed. The aim of this study was to investigate predictive factors for treatment with curative intent in patients with LRRC.
Methods
Population-based data for patients treated for primary rectal cancer between 1995 and 2002, and with LRRC reported as first event were collected from the Swedish Colorectal Cancer Registry and medical records. The associations between patient-, primary tumour- and LRRC-related factors and intention of the treatment for LRRC were determined. The impact of the identified predictive factors on prognosis after treatment with curative intent was also assessed.
Results
A total of 426 patients were included in the study, of whom 149 (35·0 per cent) received treatment with curative intent. Factors significantly associated with treatment of the LRRC with palliative intent were primary surgery with abdominoperineal resection (odds ratio (OR) 5·16, 95 per cent c.i. 2·97 to 8·97), age at diagnosis of LRRC at least 80 years (OR 4·82, 2·37 to 9·80), symptoms at diagnosis (OR 2·79, 1·56 to 5·01) and non-central location of the LRRC (OR 1·79, 1·15 to 2·79). The overall 5-year survival rate was 8·9 per cent for all patients and 23·1 per cent among those treated with curative intent. In patients treated with curative intent, factors associated with increased risk of death were age 80 years or more (hazard ratio (HR) 2·44, 95 per cent c.i. 1·55 to 3·86), presence of symptoms (HR 1·92, 1·20 to 3·05), non-central tumour location (HR 1·51, 1·01 to 2·26) and presence of hydronephrosis (HR 2·02, 1·18 to 3·44).
Conclusion
Non-central location of the LRRC, presence of symptoms and age at least 80 years at diagnosis of the LRRC were associated with treatment with palliative intent.
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Affiliation(s)
- K Westberg
- Department of Molecular Medicine and Surgery, Karolinska Institute and Division of Surgery, Danderyd Hospital, Stockholm, Sweden
| | - G Palmer
- Department of Molecular Medicine and Surgery, Karolinska Institute and Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - F Hjern
- Department of Clinical Sciences, Karolinska Institute and Division of Surgery, Danderyd Hospital, Stockholm, Sweden
| | - C Nordenvall
- Department of Molecular Medicine and Surgery, Karolinska Institute and Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - H Johansson
- Department of Oncology–Pathology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - T Holm
- Department of Molecular Medicine and Surgery, Karolinska Institute and Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - A Martling
- Department of Molecular Medicine and Surgery, Karolinska Institute and Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
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Abstract
Imaging determines the optimal treatment for rectal cancer patients. High-resolution magnetic resonance imaging (MRI) overcomes many of the known limitations of previous methods. When performed in accordance with the recommended standards, MRI enables accurate staging of both early and advanced rectal cancer, accurate response assessment, the delineation of recurrent disease and planning surgical treatment in a safe and effective manner. Tumour-related high-risk features with known adverse outcomes can be preoperatively identified and treated with neoadjuvant chemoradiotherapy. Further, MRI post-treatment tumour response assessment using TRG grading system also predicts the likely survival outcomes and in the future will be used to modify treatment further by stratification into good and poor responders. There is a paucity of literature with validated outcome data concerning use of diffusion-weighted imaging and positron emission tomography (PET)/computed tomography (CT), and in the absence of any validated methods and outcome data, their use in the initial assessment and restaging after treatment is limited to research protocols. Combination MRI and CT is essential for distant spread assessment and recurrent disease, and currently PET-CT is sometimes used in the workup of patients with recurrent and metastatic disease.
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Pelvic Exenteration Surgery: The Evolution of Radical Surgical Techniques for Advanced and Recurrent Pelvic Malignancy. Dis Colon Rectum 2017; 60:745-754. [PMID: 28594725 DOI: 10.1097/dcr.0000000000000839] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Pelvic exenteration was first described by Alexander Brunschwig in 1948 in New York as a palliative procedure for recurrent carcinoma of the cervix. Because of initially high rates of morbidity and mortality, the practice of this ultraradical operation was largely confined to a small number of American centers for most of the 20 century. The post-World War II era saw advances in anaesthesia, blood transfusion, and intensive care medicine that would facilitate the evolution of more radical and heroic abdominal and pelvic surgery. In the last 3 decades, pelvic exenteration has continued to evolve into one of the most important treatments for locally advanced and recurrent rectal cancer. This review aimed to explore the evolution of pelvic exenteration surgery and to identify the pioneering surgeons, seminal articles, and novel techniques that have led to its current status as the procedure of choice for locally advanced and recurrent rectal cancer.
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Lee DJK, Sagar PM, Sadadcharam G, Tan KY. Advances in surgical management for locally recurrent rectal cancer: How far have we come? World J Gastroenterol 2017; 23:4170-4180. [PMID: 28694657 PMCID: PMC5483491 DOI: 10.3748/wjg.v23.i23.4170] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 03/31/2017] [Accepted: 05/09/2017] [Indexed: 02/06/2023] Open
Abstract
Locally recurrent rectal cancer (LRRC) is a complex disease with far-reaching implications for the patient. Until recently, research was limited regarding surgical techniques that can increase the ability to perform an en bloc resection with negative margins. This has changed in recent years and therefore outcomes for these patients have improved. Novel radical techniques and adjuncts allow for more radical resections thereby improving the chance of negative resection margins and outcomes. In the past contraindications to surgery included anterior involvement of the pubic bone, sacral invasions above the level of S2/S3 and lateral pelvic wall involvement. However, current data suggests that previously unresectable cases may now be feasible with novel techniques, surgical approaches and reconstructive surgery. The publications to date have only reported small patient pools with the research conducted by highly specialised units. Moreover, the short and long-term oncological outcomes are currently under review. Therefore although surgical options for LRRC have expanded significantly, one should balance the treatment choices available against the morbidity associated with the procedure and select the right patient for it.
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