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Cui Y, Song M, Tie J, Li S, Wang H, Zhang Y, Geng J, Liu Z, Teng H, Sui X, Zhu X, Cai Y, Li Y, Wang W. Clinicopathological factors predict residual lymph node metastasis in locally advanced rectal cancer with ypT0-2 after neoadjuvant chemoradiotherapy. J Cancer Res Clin Oncol 2024; 150:176. [PMID: 38575793 PMCID: PMC10995092 DOI: 10.1007/s00432-024-05662-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 02/21/2024] [Indexed: 04/06/2024]
Abstract
PURPOSE Residual lymph node metastases (RLNM) remained a great concern in the implementation of organ-preserving strategies and led to poor prognosis in locally advanced rectal cancer (LARC). In this study, we aimed to identify the clinicopathological factors correlated with RLNM in LARC patients with ypT0-2 after neoadjuvant chemoradiotherapy (NCRT). METHODS We retrospectively analyzed 417 patients histologically diagnosed middle-low LARC after NCRT and total mesorectal excision (TME), whose pathological staging was ypT0-2. All patients received pelvic magnetic resonance imaging (MRI) before NCRT. The radiation doses were 50-50.6 Gy for the planning gross tumor volume and 41.8-45 Gy for the planning target volume, respectively. A nomogram for predicting RLNM was constructed using a binary logistic regression. Nomogram performance was assessed by receiver operating characteristic (ROC) curve, calibration curve, decision curve analysis (DCA) and clinical impact curve (CIC). RESULTS After surgery, 191 patients (45.8%) were ypT0, 43 patients (10.3%) were ypT1 and 183 patients (43.9%) were ypT2, and a total of 49 patients (11.8%) were found the presence of RLNM. Multivariable analyses identified MRI-defined mesorectal fascia (MRF)-positive, high-grade histopathology at biopsy, advanced ypT-category, and the presence of perineural invasion (PNI) as the predictive factors. The nomogram, incorporating all these predictors, showed good discrimination and calibration efficacy, with the areas under the ROC curve of 0.690 (95% CI: 0.610-0.771). Both DCA and CIC demonstrated that this nomogram has good clinical usefulness. CONCLUSION The nomogram model can predict RLNM in patients with ypT0-2 tumors. It can help select suitable patients for performing organ-preserving strategies after NCRT.
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Affiliation(s)
- Yujun Cui
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Maxiaowei Song
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Jian Tie
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Shuai Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Hongzhi Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Yangzi Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Jianhao Geng
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Zhiyan Liu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Huajing Teng
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Xin Sui
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Xianggao Zhu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Yong Cai
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Yongheng Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China.
| | - Weihu Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China.
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Nors J, Iversen LH, Erichsen R, Gotschalck KA, Andersen CL. Incidence of Recurrence and Time to Recurrence in Stage I to III Colorectal Cancer: A Nationwide Danish Cohort Study. JAMA Oncol 2024; 10:54-62. [PMID: 37971197 PMCID: PMC10654928 DOI: 10.1001/jamaoncol.2023.5098] [Citation(s) in RCA: 44] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/21/2023] [Indexed: 11/19/2023]
Abstract
Importance Management of colorectal cancer (CRC) has been updated continuously over the past 2 decades. While the combination of these initiatives has had implications for improved survival, the implications for rates of recurrence remain unexplored. Objective To ascertain the rates of recurrence and describe time to recurrence within 5 years of surgery with curative intent for stages I to III CRC. Design, Setting, and Participants This cohort study used the Danish Colorectal Cancer Group Database to identify patients with Union for International Cancer Control (UICC) stages I to III CRC who underwent primary surgery between January 1, 2004, and December 31, 2019. They were followed up until recurrence (event), death (competing event), diagnosis of a second cancer (competing event), emigration (censoring event), 5 years postoperatively (censoring event), or January 1, 2023 (censoring event), whichever came first. Recurrence status was ascertained through individual-level linked data from the Danish Cancer Registry, Danish National Patient Registry, and Danish Pathology Registry using a validated algorithm. Data were analyzed from January 1 to August 8, 2023. Exposure Primary surgery performed during 3 calendar periods (2004-2008, 2009-2013, and 2014-2019) stratified by tumor site (colon or rectum) and UICC stage (I, II, and III). Main Outcomes and Measures Stage-specific 5-year recurrence reported as the cumulative incidence function (CIF) of recurrence, the association between calendar period of primary surgery and recurrence risk reported as subdistribution hazard ratios (sHRs), and the time from surgery to recurrence. Results Of the 34 166 patients with UICC stages I to III CRC (median [IQR] age, 70 [62-77] years); 18 552 males [54.3%]) included in the study, 7027 developed recurrence within 5 years after the primary surgery. For colon cancer, the 5-year CIF of recurrence decreased over the 3 calendar periods from 16.3% to 6.8% for UICC stage I, from 21.9% to 11.6% for UICC stage II, and from 35.3% to 24.6% for UICC stage III colon cancer. For rectal cancer, the 5-year CIF decreased over the 3 periods from 19.9% to 9.5% for stage I, from 25.8% to 18.4% for stage II, and from 38.7% to 28.8% for stage III disease. Patients with stage III disease had a shorter time from surgery to recurrence compared with those with stage I disease (time ratio stage III vs stage I = 0.30; 95% CI, 0.28-0.32). Cancers detected through screening were associated with lower stage-adjusted risks of recurrence (sHR, 0.81; 95% CI, 0.73-0.91) compared with cancers not detected through screening. Conclusions and Relevance In this cohort of patients with CRC, the risk of recurrence decreased in patients with stages I to III disease during the study period. Cancer detection by screening was associated with an even lower risk of recurrence. Time to recurrence differed according to UICC stage. Because the risk of recurrence was so low in selected patient groups, future research is warranted to explore risk-stratified surveillance protocols in patients with CRC.
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Affiliation(s)
- Jesper Nors
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Lene Hjerrild Iversen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Rune Erichsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Surgery, Randers Regional Hospital, Randers, Denmark
| | - Kåre Andersson Gotschalck
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Surgery, Horsens Regional Hospital, Horsens, Denmark
| | - Claus Lindbjerg Andersen
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Yellinek S, Krizzuk D, Gilshtein H, Freund MR, Wexner SD, Berho M. Distal Tumor Spread in Rectal Cancer-How Low Should We Go? Am Surg 2023; 89:5553-5558. [PMID: 36855994 DOI: 10.1177/00031348231157408] [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] [Indexed: 03/02/2023]
Abstract
BACKGROUND Distal tumor spread (DTS) is an adverse prognostic factor in rectal cancer correlating with advanced stage disease. We aimed to assess prevalence and location of distal tumor spread and impact of neoadjuvant chemoradiotherapy (NACRT) in patients who underwent proctectomy for rectal cancer. METHODS The pathology database at our institution was queried for all patients who underwent proctectomy with curative intent for rectal cancer from 1/2008 to 12/2016. Specimen slides were re-evaluated by a single expert rectal cancer pathologist to verify diagnosis and measure the distance to the distal resection margin. Main outcome measures were 3-year overall and disease-free survival. RESULTS 275 consecutive patients were identified. 109/111 patients with clinical stage 3 disease received preoperative neoadjuvant chemoradiotherapy. DTS was found in 13 (4.7%) specimens, 6 with intra-mural and 7 with extra-mural distal tumor spread. DTS was found only in patients with clinical stage 3 disease. Length of DTS from the distal end of the tumor ranged from 0 to 30 mm; in only 4 specimens DTS was >10 mm. A positive distal resection margin was found in 5/275 (1.8%) specimens. CONCLUSION A macroscopically tumor-free margin may suffice in patients with pre-treatment stage 1 or 2 disease. Furthermore, a 1 cm margin is adequate in most patients with stage 3 disease.
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Affiliation(s)
- Shlomo Yellinek
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Weston, FL, USA
- Department of General Surgery, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Dimitri Krizzuk
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Weston, FL, USA
- Department of General and Minimally-Invasive surgery, Aurelia Hospital, Rome, Italy
| | - Hayim Gilshtein
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Weston, FL, USA
| | - Michael R Freund
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Weston, FL, USA
- Department of General Surgery, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Weston, FL, USA
| | - Mariana Berho
- Department of Pathology, Cleveland Clinic Florida, Weston, FL, USA
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Barzola E, Cornejo L, Gómez N, Pigem A, Julià D, Ortega N, Delisau O, Bobb KA, Farrés R, Planellas P. Comparative analysis of short-term outcomes and oncological results between robotic-assisted and laparoscopic surgery for rectal cancer by multiple surgeon implementation: a propensity score-matched analysis. J Robot Surg 2023; 17:3013-3023. [PMID: 37924415 DOI: 10.1007/s11701-023-01736-2] [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: 07/27/2023] [Accepted: 09/26/2023] [Indexed: 11/06/2023]
Abstract
Robotic-assisted surgery (RAS) is becoming increasingly common for the surgical treatment of rectal cancer. However, the use and implementation of robotic surgery remains controversial. This study aimed to compare the short-term outcomes of robotic surgery, focusing on pathological results and disease-free survival (DFS), in our cohort with initial robotic experience by multiple surgeon implementation. This retrospective study enrolled 571 patients diagnosed with rectal cancer, who were treated with chemoradiotherapy and surgery between January 2015 and December 2021. Surgical outcomes after RAS and laparoscopic surgery (LS) were compared using a propensity score-matching (PSM) analysis. After matching, 200 patients (100 in each group) were included. The median operative time was significantly longer in the RAS group than in the LS group (p < 0.001). The conversion and morbidity rates were similar between the groups. A significantly higher rate of complete mesorectal excision (92% vs. 72%; p = 0.001) and number of lymph nodes harvested (p = 0.009) was observed in the RAS group. There were no statistically significant differences between the groups regarding circumferential and distal resection margin involvement. The 3-year overall and disease-free survival rate was similar between the two groups (p = 0.849 and p = 0.582, respectively). Two patients in the LS group developed local recurrence and 27 patients (15.4%) developed metastatic disease. Multivariate analysis showed that tumor stage III was the only factor associated with disease-free survival (HR, 9.34; (95% CI 1.13-77.1), p = 0.038). RAS and LS showed similar outcomes in terms of perioperative, anatomopathological, and disease-free survival, after multiple surgeon implementations.
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Affiliation(s)
- E Barzola
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - L Cornejo
- Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - N Gómez
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - A Pigem
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - D Julià
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - N Ortega
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - O Delisau
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - K A Bobb
- Department of Clinical Surgical Sciences, Faculty of Medical Sciences, University of the West Indies-St. Augustine, Eric Williams Medical Sciences Complex, Mount Hope, Trinidad, West Indies, Trinidad and Tobago
| | - R Farrés
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - P Planellas
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Girona, Spain.
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Rehné Jensen L, Dohrn N, Seiersen M, Bulut O, Bech-Knudsen F, Erik Jansen J, Gögenur I, Falk Klein M. Long-term outcomes after transanal total mesorectal excision for rectal cancer in Denmark: A prospective multicenter study from the late implementation phase. Surg Oncol 2023; 49:101967. [PMID: 37356316 DOI: 10.1016/j.suronc.2023.101967] [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: 05/23/2023] [Revised: 06/15/2023] [Accepted: 06/19/2023] [Indexed: 06/27/2023]
Abstract
PURPOSE The aim of this study was to evaluate the long-term surgical and oncological outcomes after transanal total mesorectal excision (TaTME) for rectal cancer during an implementation phase on a national level. METHOD This is a retrospective review of prospectively recorded data. Registration was initiated by the Danish Colorectal Cancer Group in order to assess the quality of care during the implementation of TaTME in Denmark. Data from four centers were pooled for simultaneous analysis. Short-term data was available from a prior study, and long-term data regarding recurrences, chemotherapy, and mortality was collected. RESULTS From August 2016 to April 2019, 115 TaTME procedures were registered. Patients were predominantly male (n = 85, 74%) with mid-rectal (n = 88, 77%) tumors. The overall local recurrence rate was 7.8% (n = 9) of which six patients also had systemic recurrence. Mean long-term follow-up was 59.4 months, and median time to local recurrence was 24.9 months. Local recurrences occurred predominantly among initial implementation cases. The overall mortality rate was 13% (n = 15). Of the 17 patients with recurrence, 35% (n = 6) died and developed either solely distant recurrence (n = 2, 12%) or in combination with local recurrence (n = 4, 24%). CONCLUSION We found acceptable long-term oncological results after TaTME during the implementation phase in Denmark. There was an accumulation of local recurrences in the early phase of the study which emphasizes the importance of thorough training and proctoring when starting the approach.
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Affiliation(s)
- Lasse Rehné Jensen
- Department of Surgery, Copenhagen University Hospital Herlev, Herlev, Denmark.
| | - Niclas Dohrn
- Department of Surgery, Copenhagen University Hospital Herlev, Herlev, Denmark
| | - Michael Seiersen
- Department of Surgery, Zealand University Hospital Koege, Koege, Denmark
| | - Orhan Bulut
- Department of Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Flemming Bech-Knudsen
- Department of Surgery, Colorectal Cancer Centre South, Vejle Hospital, University Hospital of Southern Denmark, Vejle, Denmark
| | - Jens Erik Jansen
- Department of Surgery, Copenhagen University Hospital North Zealand, Hillerød, Denmark
| | - Ismail Gögenur
- Department of Surgery, Centre for Surgical Science, Zealand University Hospital Koege, Koege, Denmark; Danish Colorectal Cancer Group (DCCG.dk), Copenhagen, Denmark
| | - Mads Falk Klein
- Department of Surgery, Copenhagen University Hospital Herlev, Herlev, Denmark; Danish Colorectal Cancer Group (DCCG.dk), Copenhagen, Denmark
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Angehrn FV, Schneider R, Wilhelm A, Daume D, Koechlin L, Fourie L, von Flüe M, Kern B, Steinemann DC, Bolli M. Robotic versus laparoscopic low anterior resection following neoadjuvant chemoradiation therapy for stage II-III locally advanced rectal cancer: a single-centre cohort study. J Robot Surg 2022; 16:1133-1141. [PMID: 35000106 DOI: 10.1007/s11701-021-01351-z] [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: 06/22/2021] [Accepted: 11/30/2021] [Indexed: 11/24/2022]
Abstract
Neoadjuvant chemo-radiotherapy (nCRT) of locally advanced rectal cancer is associated with challenging surgical treatment and increased postoperative morbidity. Robotic technology overcomes laparoscopy limitations by enlarged 3D view, improved anatomical transection accuracy, and physiologic tremor reduction. Patients with UICC stage II-III rectal cancer, consecutively referred to our institution between March 2015 and June 2020 (n = 102) were treated with robotic (Rob-G, n = 38) or laparoscopic (Lap-G, n = 64) low anterior resection (LAR) for total meso-rectal excision (TME) following highly standardized and successful nCRT treatment. Feasibility, conversion rates, stoma creation, morbidity and clinical/pathological outcome were comparatively analysed. Sex, age, BMI, ASA scores, cTN stages and tumour distance from dentate line were comparable in the two groups. Robotic resection was always feasible without conversion to open surgery, which was necessary in 11/64 (17%) Lap-G operations (p = 0.006). Primary or secondary stomata were created in 17/38 (45%) Rob-G and 52/64 (81%) Lap-G patients (p < 0.001). Major morbidity occurred in 7/38 (18.4%) Rob-G and 6/64 (9.3%) Lap-G patients (p = 0.225). Although median operation time was longer in Rob-G compared with Lap-G (376; IQR: 330-417 min vs. 300; IQR: 270-358 min; p < 0.001), the difference was not significant in patients (Rob-G, n = 6; Lap-G, n = 10) with ≥30 BMI (p = 0.106). Number of resected lymph nodes, ypTN staging and circumferential resection margins (CRM) were comparable. Resection was complete in 87% of Rob-G and 89% of Lap-G patients (p = 0.750). Robotic LAR is not inferior to laparoscopic LAR following nCRT. Larger, randomized studies are needed to confirm lower conversion in robotic, compared to laparoscopic resection.
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Affiliation(s)
- Fiorenzo V Angehrn
- Department of Surgery, Clarunis-University Center for Gastrointestinal and Liver Diseases, Postfach, 4002, Basel, Switzerland.
| | - Romano Schneider
- Department of Surgery, Clarunis-University Center for Gastrointestinal and Liver Diseases, Postfach, 4002, Basel, Switzerland
| | - Alexander Wilhelm
- Department of Surgery, Clarunis-University Center for Gastrointestinal and Liver Diseases, Postfach, 4002, Basel, Switzerland
| | - Diana Daume
- Department of Surgery, Clarunis-University Center for Gastrointestinal and Liver Diseases, Postfach, 4002, Basel, Switzerland
| | - Luca Koechlin
- Department of Surgery, Clarunis-University Center for Gastrointestinal and Liver Diseases, Postfach, 4002, Basel, Switzerland
| | - Lana Fourie
- Department of Surgery, Clarunis-University Center for Gastrointestinal and Liver Diseases, Postfach, 4002, Basel, Switzerland
| | - Markus von Flüe
- Department of Surgery, Clarunis-University Center for Gastrointestinal and Liver Diseases, Postfach, 4002, Basel, Switzerland
| | - Beatrice Kern
- Department of Surgery, Clarunis-University Center for Gastrointestinal and Liver Diseases, Postfach, 4002, Basel, Switzerland
| | - Daniel C Steinemann
- Department of Surgery, Clarunis-University Center for Gastrointestinal and Liver Diseases, Postfach, 4002, Basel, Switzerland
| | - Martin Bolli
- Department of Surgery, Clarunis-University Center for Gastrointestinal and Liver Diseases, Postfach, 4002, Basel, Switzerland
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Massa I, Ghignone F, Ugolini G, Ercolani G, Montroni I, Capelli P, Garulli G, Catena F, Lucchi A, Ansaloni L, Gentili N, Danesi V, Montella MT, Altini M. Emilia-Romagna Surgical Colorectal Cancer Audit (ESCA): a value-based healthcare retro-prospective study to measure and improve the quality of surgical care in colorectal cancer. Int J Colorectal Dis 2022; 37:1727-1738. [PMID: 35779080 PMCID: PMC9262771 DOI: 10.1007/s00384-022-04203-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/15/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Surgery is the main treatment for non-metastatic colorectal cancer. Despite huge improvements in perioperative care, colorectal surgery is still associated with a significant burden of postoperative complications and ultimately costs for healthcare organizations. Systematic clinical auditing activity has already proven to be effective in measuring and improving clinical outcomes, and for this reason, we decided to evaluate its impact in a large area of northern Italy. METHODS The Emilia-Romagna Surgical Colorectal Audit (ESCA) is an observational, multicentric, retro-prospective study, carried out by 7 hospitals located in the Emilia-Romagna region. All consecutive patients undergoing surgery for colorectal cancer during a 54-month study period will be enrolled. Data regarding baseline conditions, preoperative diagnostic work-up, surgery and postoperative course will be collected in a dedicated case report form. Primary outcomes regard postoperative complications and mortality. Secondary outcomes include each center's adherence to the auditing (enrolment rate) and evaluation of the systematic feedback activity on key performance indicators for the entire perioperative process. CONCLUSION This protocol describes the methodology of the Emilia-Romagna Surgical Colorectal Audit. The study will provide real-world clinical data essential for benchmarking and feedback activity, to positively impact outcomes and ultimately to improve the entire healthcare process of patients undergoing colorectal cancer surgery. CLINICAL TRIAL REGISTRATION The study ESCA is registered on the clinicaltrials.gov platform (Identifier: NCT03982641).
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Affiliation(s)
- Ilaria Massa
- Outcome Research, Healthcare Administration, IRCCS Istituto Romagnolo per lo studio dei tumori (IRST) " Dino Amadori", Meldola, Italy
| | - Federico Ghignone
- U.O. Chirurgia Generale, Hospital "Santa Maria delle Croci", AUSL, Ravenna, Romagna, Italy
| | - Giampaolo Ugolini
- U.O. Chirurgia Generale, Hospital "Santa Maria delle Croci", AUSL, Ravenna, Romagna, Italy
| | - Giorgio Ercolani
- U.O. Chirurgia Generale e Terapie Oncologiche avanzate, Hospital "GB. Morgagni-L.Pierantoni", AUSL, Forli, Romagna, Italy
| | - Isacco Montroni
- U.O Chirurgia Generale, Hospital "degli Infermi", AUSL, Faenza, Romagna, Italy
| | - Patrizio Capelli
- Department of Surgery, Hospital "G. Da Saliceto", Piacenza, AUSL, Piacenza, Italy
| | - Gianluca Garulli
- U.O. Chirurgia Generale, Hospital "Infermi", AUSL, Rimini, Romagna, Italy
| | - Fausto Catena
- General, Emergency and Trauma Surgery Dept., Bufalini Hospital, AUSL, Cesena, Romagna, Italy
| | - Andrea Lucchi
- U.O. Chirurgia Generale, Hospital "Ceccarini", AUSL, Riccione, Romagna, Italy
| | - Luca Ansaloni
- Department of Surgery, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Nicola Gentili
- Outcome Research, Healthcare Administration, IRCCS Istituto Romagnolo per lo studio dei tumori (IRST) " Dino Amadori", Meldola, Italy
| | - Valentina Danesi
- Outcome Research, Healthcare Administration, IRCCS Istituto Romagnolo per lo studio dei tumori (IRST) " Dino Amadori", Meldola, Italy.
| | - Maria Teresa Montella
- Outcome Research, Healthcare Administration, IRCCS Istituto Romagnolo per lo studio dei tumori (IRST) " Dino Amadori", Meldola, Italy
| | - Mattia Altini
- Healthcare Administration, AUSL of Romagna, Ravenna, Italy
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Kim JC, Park SH, Kim J, Kim CW, Park IJ, Yoon YS, Lee JL, Kim JH, Hong YS, Kim TW. Involvement of tissue changes induced by neoadjuvant treatment in total mesorectal excision (TME): novel suggestions for determining TME quality. Int J Colorectal Dis 2022; 37:1289-1300. [PMID: 35513539 DOI: 10.1007/s00384-022-04165-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/17/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Few studies to date have investigated morphological changes after neoadjuvant treatment (NAT) and their implications in total mesorectal excision (TME). This study was primarily designed to evaluate whether tissue changes associated with NAT affected the quality of TME and additionally to suggest a more objective method evaluating TME quality. METHODS This study enrolled 1322 consecutive patients who underwent curative robot-assisted surgery for rectal cancer. Patients who did and did not receive NAT were subjected to propensity-score matching, yielding 402 patients in each group. RESULTS NAT independently reduced complete achievement of TME [odds ratio (OR) = 2.056, p = 0.017]. Intraoperative evaluation identified seven tissue changes significantly associated with NAT, including tumor perforation, mucin pool, necrosis, fibrosis, fat degeneration, and rectal or perirectal edema NAT (p < 0.001-0.05). Tumor perforation (OR = 5.299, p = 0.001) and mucin pool (OR = 14.053, p = 0.002) were independently associated with inappropriate (near-complete + incomplete) TME. Complete TME resulted in significantly reduced local recurrence (4.3% vs 15.3%, p = 0.003) and increased 5-year DFS rate (80.6% vs 67.6%, p = 0.047) compared with inappropriate one. By contrast, two tiers of complete and near-complete TMEs vs incomplete TME did not. Notably, among patients with complete TME, those who received NAT had a lower 5-year DFS than those who did not (77.8% vs 83.3%, p = 0.048). CONCLUSIONS NAT-associated tissue changes, somewhat interrupting complete TME, may provide unsolved clue to the relative inability of NAT to improve overall survival. The conventional three-tier grading of TME seems to be simplified into two tiers as complete and inappropriate.
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Affiliation(s)
- Jin Cheon Kim
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea.
| | - Seong Ho Park
- Department of Radiology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Jihun Kim
- Department of Pathology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Chan Wook Kim
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - In Ja Park
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Yong Sik Yoon
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Jong Lyul Lee
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Jong Hoon Kim
- Department of Radiation Oncology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Yong Sang Hong
- Department of Oncology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Tae Won Kim
- Department of Oncology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
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Oerskov KM, Bondeven P, Laurberg S, Hagemann-Madsen RH, Christensen HK, Lauridsen H, Pedersen BG. Postoperative MRI Findings Following Conventional and Extralevator Abdominoperineal Excision in Low Rectal Cancer. Front Surg 2021; 8:771107. [PMID: 34869567 PMCID: PMC8635027 DOI: 10.3389/fsurg.2021.771107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 10/04/2021] [Indexed: 01/11/2023] Open
Abstract
Aim: The disparity in outcomes for low rectal cancer may reflect differences in operative approach and quality. The extralevator abdominoperineal excision (ELAPE) was developed to reduce margin involvement in low rectal cancers by widening the excision of the conventional abdominoperineal excision (c-APE) to include the posterior pelvic diaphragm. This study aimed to determine the prevalence and localization of inadvertent residual pelvic diaphragm on postoperative MRI after intended ELAPE and c-APE. Methods: A total of 147 patients treated with c-APE or ELAPE for rectal cancer were included. Postoperative MRI was performed on 51% of the cohort (n = 75) and evaluated with regard to the residual pelvic diaphragm by a radiologist trained in pelvic MRI. Patient records, histopathological reports, and standardized photographs were assessed. Pathology and MRI findings were evaluated independently in a blinded fashion. Additionally, preoperative MRIs were evaluated for possible risk factors for margin involvement. Results: Magnetic resonance imaging-detected residual pelvic diaphragm was identified in 45 (75.4%) of 61 patients who underwent ELAPE and in 14 (100%) of 14 patients who underwent c-APE. An increased risk of margin involvement was observed in anteriorly oriented tumors with 16 (22%) of 73 anteriorly oriented tumors presenting with margin involvement vs. 7 (9%) of 74 non-anteriorly oriented tumors (p = 0.038). Conclusion: Residual pelvic diaphragm following abdominoperineal excision can be depicted by postoperative MRI. Inadvertent residual pelvic diaphragm (RPD) was commonly found in the series of patients treated with the ELAPE technique. Anterior tumor orientation was a risk factor for circumferential resection margin (CRM) involvement regardless of surgical approach.
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Affiliation(s)
| | - Peter Bondeven
- Department of Surgery, Randers Regional Hospital, Randers, Denmark
| | - Søren Laurberg
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | | | - Henrik Lauridsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Bodil Ginnerup Pedersen
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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10
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Kim JC, Yu CS, Lim SB, Park IJ, Yoon YS, Kim CW, Kim JH, Kim TW. Re-evaluation of controversial issues in the treatment of cT3N0-2 rectal cancer: a 10-year cohort analysis using propensity-score matching. Int J Colorectal Dis 2021; 36:2649-2659. [PMID: 34398263 DOI: 10.1007/s00384-021-04003-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/02/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Although neoadjuvant treatment is thought to provide optimal local control for stage II and III rectal cancers, many patients have been reported cured by total mesorectal excision (TME), alone or with additional chemotherapy (CTX). METHODS This study retrospectively evaluated outcomes in 2643 patients with cT3N0-2 rectal cancers undergoing curative TME during 2005-2015. Recurrence and survival outcomes were measured in three propensity-score matched groups, consisting of patients who underwent preoperative chemoradiotherapy (CRT) with postoperative CTX (NAPOC), postoperative CRT (POCRT), and exclusively postoperative CTX (EPOCT). RESULTS Near-complete or complete TME was conducted in more than 95.9% of patients and 80% of scheduled dose of postoperative CTX was completed in 99%. Except for higher SR rate in the POCRT group than the NAPOC group (p = 0.008), 5-year cumulative local and systemic recurrence (LR and SR) rates were 4.9% and 15.2% for cT3N0, and 4.2% and 21% for cT3N1-2 patients (LR, p = 0.703; SR, 0.065), respectively, with no significant differences associated with treatment exposure (p = 0.11-1). The 5-year cumulative disease-free (75.6% vs 65.7%, p = 0.018) and overall survival (87.1% vs 79.4%, p = 0.018 each) rates were higher in the NAPOC group than the POCRT group with cT3N1-2. However, any significant survival differences were not identified between the NAPOC and EPOCT groups according to tumor sub-stages or locations (p = 0.395-0.971). CONCLUSIONS We found any treatment modalities including competent TME and postoperative adjuvant CTX efficiently reducing LR generating robust survival outcome in the propensity-matched cohorts, demanding further randomized controlled trials by clinical sub-stages II-III.
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Affiliation(s)
- Jin Cheon Kim
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea.
- Institute of Innovative Cancer Research, Asan Institute for Life Sciences and Asan Medical Center, 88, Olympic-ro-43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
| | - Chang Sik Yu
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Seok-Byung Lim
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - In Ja Park
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Yong Sik Yoon
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Chan Wook Kim
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Jong Hun Kim
- Department of Radiation Oncology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Tae Won Kim
- Department of Oncology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
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11
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Kim JC, Han JS, Lee JL, Kim CW, Yoon YS, Park SH, Kim J. Re-evaluation of possible vulnerable sites in the lateral pelvic cavity to local recurrence during robot-assisted total mesorectal excision. Surg Endosc 2021; 35:5450-5460. [PMID: 32970206 DOI: 10.1007/s00464-020-08032-2] [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: 04/12/2020] [Accepted: 09/16/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Despite mechanical and technical improvements in laparoscopic and robot-assisted (LAR) rectal cancer procedures, the absence of prognostic disparities among various approaches cannot improve the quality of TME. The present study re-evaluated robot-assisted total mesorectal excision (TME) procedures to determine whether these procedures may reveal technical faults that may increase the rate of local recurrence (LR). METHODS This study enrolled 886 consecutive patients with rectal cancer, who underwent curative robot-assisted LAR at Asan Medical Center (Seoul, Korea) between July 2010 and August 2017 (the first vs second period; n = 399 vs 487). The quality of TME and lateral pelvic mesorectal excision (LPME) were analyzed, as were LR rates and survival outcomes. RESULTS Complete TME and LPME were achieved in 89.2% and 80.1% of these patients, respectively, with ≤ 1% having incomplete TME excluding intramesorectal excision. LR rates were 13.5 and 14.5 times higher in patients with incomplete TME and LPME, respectively, than in patients with complete TME and LPME (14.8% vs 1.1% and 8.7% vs 0.6%; p < 0.001 each by univariate analyses). Multivariate analyses showed that defective LPME was independently associated with incomplete TME and vice versa (p < 0.001). Cox regression analysis showed that defective LPME was independently correlated with reduced 5-year disease-free survival rate (hazard ratio, 1.563; 95% confidence interval, 1.052-2.323; p = 0.027). CONCLUSIONS LR in rectal cancer patients was largely due to incomplete LPME, which was significantly associated with incomplete TME. Complete LPME may enhance the likelihood of complete TME, reducing LR rates.
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Affiliation(s)
- Jin Cheon Kim
- Department of Surgery and Institute of Innovative Cancer Research, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro-43-gil, Songpa-gu, Seoul, 05505, Korea.
| | - Jin Su Han
- Department of Surgery and Institute of Innovative Cancer Research, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro-43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jong Lyul Lee
- Department of Surgery and Institute of Innovative Cancer Research, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro-43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Chan Wook Kim
- Department of Surgery and Institute of Innovative Cancer Research, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro-43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Yong Sik Yoon
- Department of Surgery and Institute of Innovative Cancer Research, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro-43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Sung Ho Park
- Department of Radiology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | - Jihun Kim
- Department of Pathology, University of Ulsan College of Medicine, Seoul, Korea
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12
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Chen PJ, Su WC, Chang TK, Chen YC, Li CC, Yin TC, Tsai HL, Ma CJ, Huang CW, Wang JY. Oncological outcomes of robotic-assisted total mesorectal excision after neoadjuvant concurrent chemoradiotherapy in patients with rectal cancer. Asian J Surg 2021; 44:957-963. [PMID: 33622595 DOI: 10.1016/j.asjsur.2021.01.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 12/06/2020] [Accepted: 01/19/2021] [Indexed: 12/30/2022] Open
Abstract
AIMS This study analyzed the oncological outcomes of robotic-assisted total mesorectal excision (TME) in patients with rectal cancer after neoadjuvant concurrent chemoradiotherapy (CCRT). METHODS We enrolled 109 consecutive patients with stage II-III rectal cancer who underwent robotic-assisted TME after neoadjuvant CCRT at one hospital between July 2013 and June 2018. RESULTS All 109 patients underwent preoperative CCRT. Of them, 37 (33.9%) achieved a pathologic complete response, and 29 (26.6%) experienced relapse, with local recurrence in 9 (8.3%) and distant metastasis in 20 (18.3%). R0 resection was performed in 104 (95.7%) patients; however, 7 (6.7%) of them developed local recurrence and 17 (16.3%) developed distant metastasis. Over a median follow-up of 42 months, the 3-year disease-free survival and overall survival rates were 73.4% and 87.2%, respectively. CONCLUSIONS Robotic-assisted TME after neoadjuvant CCRT is safe and effective for treating patients with stage II-III rectal cancer in one institution with acceptable short-term oncological outcomes. It may be a therapeutic alternative to salvage surgery for T4 tumors invading adjacent organs, such as the bladder, prostate, and uterus.
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Affiliation(s)
- Po-Jung Chen
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Municipal Hsiaokang Hospital, Kaohsiung, Taiwan; Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wei-Chih Su
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tsung-Kun Chang
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yen-Cheng Chen
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ching-Chun Li
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tzu-Chieh Yin
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Division of General and Digestive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Surgery, Kaohsiung Municipal Tatung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsiang-Lin Tsai
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Cheng-Jen Ma
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Division of General and Digestive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ching-Wen Huang
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.
| | - Jaw-Yuan Wang
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Medical Research, Kaohsiung Medical University, Kaohsiung, Taiwan; Cohort Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan.
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13
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Kim JC, Kim CW, Lee JL, Yoon YS, Park IJ, Kim JR, Kim J, Park SH. Complete intersphincteric longitudinal muscle excision May Be key to reducing local recurrence during intersphincteric resection. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2021; 47:1629-1636. [PMID: 33642088 DOI: 10.1016/j.ejso.2020.12.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 11/26/2020] [Accepted: 12/28/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Although total mesorectal excision (TME) is regarded as a standard procedure for rectal cancer, technical definition and evaluation method have not yet been investigated for intersphincteric resection (ISR). This study was performed to introduce a complete ISR procedure, and to assess whether total intersphincteric longitudinal muscle excision (TILME) facilitated the completeness of ISR and reduced recurrence. METHODS A total of 1080 patients with rectal adenocarcinoma who underwent robot-assisted low anterior resection (LAR) over 10 years were consecutively enrolled. Propensity-score matching of the two LAR groups (ISR vs LAR group, 1:1) and three ISR subgroups (partial vs subtotal vs total ISR subgroup, 2:2:1) was performed by strict adjustment of baseline characteristics. Archived specimens and video-/photo-records were reevaluated to examine completeness of TILME. RESULTS Complete-TILME was performed in 84.5% of patients who underwent ISR. Multivariate analysis showed that incomplete-TILME was the only parameter independently associated with increased 5-year cumulative local recurrence (odds ratio = 23.385; 95% confidence interval = 1.492-366.421; p = 0.03), and that incomplete-TILME was independently associated with adipose tissue surrounding the intersphincteric longitudinal muscle, coloanal anastomosis, and total ISR (p < 0.001-0.05). Although mean incontinence scores and anorectal manometry deteriorated to some degree 12-24 months after surgery in all patients, they remained acceptable. The 5-year cumulative DFS (74.1% vs 60%, p = 0.18) and OS (85.9% vs 70%, p = 0.10) rates tended to be higher in patients with complete than incomplete-TILME. CONCLUSIONS The completeness of TILME appears to be an independent indicator of complete ISR, reducing local recurrence following lower rectal cancer surgery.
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Affiliation(s)
- Jin Cheon Kim
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea; Institute of Innovative Cancer Research, Asan Medical Center, Seoul, 05505, Republic of Korea.
| | - Chan Wook Kim
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea; Institute of Innovative Cancer Research, Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Jong Lyul Lee
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea; Institute of Innovative Cancer Research, Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Yong Sik Yoon
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea; Institute of Innovative Cancer Research, Asan Medical Center, Seoul, 05505, Republic of Korea
| | - In Ja Park
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Jung Rang Kim
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Jihun Kim
- Department of Pathology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Seong Ho Park
- Department of Radiology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
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14
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Stringfield SB, Fleshman JW. Specialization improves outcomes in rectal cancer surgery. Surg Oncol 2021; 37:101568. [PMID: 33848763 DOI: 10.1016/j.suronc.2021.101568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/24/2021] [Accepted: 03/28/2021] [Indexed: 01/23/2023]
Affiliation(s)
- Sarah B Stringfield
- Baylor University Medical Center, Department of Surgery, 3500 Gaston Ave, Dallas, TX, 75246, USA.
| | - James W Fleshman
- Baylor University Medical Center, Department of Surgery, 3500 Gaston Ave, Dallas, TX, 75246, USA
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15
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Klein MF, Seiersen M, Bulut O, Bech-Knudsen F, Jansen JE, Gögenur I. Short-term outcomes after transanal total mesorectal excision for rectal cancer in Denmark - a prospective multicentre study. Colorectal Dis 2021; 23:834-842. [PMID: 33226722 DOI: 10.1111/codi.15454] [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: 07/03/2020] [Revised: 10/23/2020] [Accepted: 10/27/2020] [Indexed: 12/12/2022]
Abstract
AIM The aim of this study was to evaluate the short-term surgical and oncological outcomes after transanal total mesorectal excision (TaTME) for rectal cancer during the implementation phase of this procedure in Denmark. METHOD This is a retrospective review of prospectively recorded data. Registration was initiated by the Scientific Council of the Danish Colorectal Cancer Group (DCCG.dk) in order to assess the quality of care during the implementation of TaTME. Pre-, intra- and postoperative data including early recurrences were recorded at the operating centres. RESULTS From August 2016 to April 2019, 115 TaTME procedures were registered. Patients were predominantly male (74%) with mid-rectal (88%) tumours. The level of surgical complications was comparable to previous nationwide results. Anastomotic leakage occurred in 6/109 (5.5%). One urethral injury occurred. The plane of dissection was mesorectal in 60% of cases, intramesorectal in 28% and muscularis in 12%. Nonmicroradicality was seen in 8% (R1, 6%; R2, 2%). Four local recurrences occurred after a median of 23 months of follow-up. One of these was multifocal. CONCLUSION In an implementation phase where patient selection is expected, surgical and oncological results after TaTME were comparable to those of other approaches reported in the literature.
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Affiliation(s)
- Mads Falk Klein
- Department of Surgery, Copenhagen University Hospital Herlev, Herlev, Denmark.,Danish Colorectal Cancer Group (DCCG.dk, Copenhagen, Denmark
| | - Michael Seiersen
- Department of Surgery, Zealand University Hospital Koege, Koege, Denmark
| | - Orhan Bulut
- Department of Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Flemming Bech-Knudsen
- Department of Surgery, Colorectal Cancer Centre South, Vejle Hospital, University Hospital of Southern Denmark, Vejle, Denmark
| | - Jens Erik Jansen
- Department of Surgery, Copenhagen University Hospital North Zealand, Hillerød, Denmark
| | - Ismail Gögenur
- Danish Colorectal Cancer Group (DCCG.dk, Copenhagen, Denmark.,Department of Surgery, Centre for Surgical Science, Zealand University Hospital Koege, Koege, Denmark
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16
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Su WC, Huang CW, Ma CJ, Chen PJ, Tsai HL, Chang TK, Chen YC, Li CC, Yeh YS, Wang JY. Feasibility of robot-assisted surgery in elderly patients with rectal cancer. J Minim Access Surg 2021; 17:165-174. [PMID: 33723180 PMCID: PMC8083738 DOI: 10.4103/jmas.jmas_154_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 01/27/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Although surgical resection is the main treatment for rectal cancer, the optimal surgical protocol for elderly patients with rectal cancer remains controversial. This study evaluated the feasibility of robot-assisted surgery in elderly patients with rectal cancer. PATIENTS AND METHODS This retrospective study enrolled 156 patients aged 28-93 years diagnosed with Stage I-III rectal cancer, who underwent robot-assisted surgery between May 2013 and December 2018 at a single institution. RESULTS In total, 156 patients with rectal cancer, including 126 non-elderly (aged < 70 years) and 30 elderly (aged ≥70 years) patients, who underwent robot-assisted surgery were recruited. Between the patient groups, the post-operative length of hospital stay did not differ statistically significantly (P = 0.084). The incidence of overall post-operative complications was statistically significantly lower in the elderly group (P = 0.002). The disease-free and overall survival did not differ statistically significantly between the two groups (P = 0.719 and 0.390, respectively). CONCLUSIONS Robot-assisted surgery for rectal cancer was well tolerated by elderly patients, with similar results to the non-elderly patients. Oncological outcomes and survival did not depend on patient age, suggesting that robot-assisted surgery is a feasible surgical modality for treating operable rectal cancer and leads to age-independent post-operative outcomes in elderly patients.
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Affiliation(s)
- Wei-Chih Su
- Department of Surgery, Division of Colorectal Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ching-Wen Huang
- Department of Surgery, Division of Colorectal Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Cheng-Jen Ma
- Department of Surgery, Division of Colorectal Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Surgery, Division of General and Digestive Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Po-Jung Chen
- Department of Surgery, Division of Colorectal Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Surgery, Division of Colorectal Surgery, Kaohsiung Municipal Hsiaokang Hospital, Kaohsiung, Taiwan
| | - Hsiang-Lin Tsai
- Department of Surgery, Division of Colorectal Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tsung-Kun Chang
- Department of Surgery, Division of Colorectal Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yen-Cheng Chen
- Department of Surgery, Division of Colorectal Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ching-Chun Li
- Department of Surgery, Division of Colorectal Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yung-Sung Yeh
- Department of Surgery, Division of Colorectal Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jaw-Yuan Wang
- Department of Surgery, Division of Colorectal Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Center for Cancer Research, Kaohsiung Medical University, Kaohsiung, Taiwan
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Yin TC, Su WC, Chen PJ, Chang TK, Chen YC, Li CC, Hsieh YC, Tsai HL, Huang CW, Wang JY. Oncological Outcomes of Robotic-Assisted Surgery With High Dissection and Selective Ligation Technique for Sigmoid Colon and Rectal Cancer. Front Oncol 2020; 10:570376. [PMID: 33194663 PMCID: PMC7641631 DOI: 10.3389/fonc.2020.570376] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 09/15/2020] [Indexed: 12/18/2022] Open
Abstract
Background: Curative resection of sigmoid colon and rectal cancer includes "high tie" of the inferior mesenteric artery (IMA). However, IMA ligation compromises blood flow to the anastomosis, which may increase the complication rate. We present preliminary experiences of operative and oncologic outcomes of patients with rectal or sigmoid colon cancer who underwent robotic surgery employing the high dissection and selective ligation technique. Methods: Over May 2013 to April 2017, 113 stage I-III rectal or sigmoid colon cancer patients underwent robotic surgery with the single-docking technique at one institution. We performed D3 lymph node dissection and low-tie ligation of the IMA (i.e., high dissection and selective ligation technique). Clinicopathological features, perioperative parameters, and postoperative outcomes were retrospectively analyzed. Overall survival (OS) and disease-free survival (DFS) were calculated using the Kaplan-Meier method. Results: Sphincter preservation rate was 96.3% in rectal cancer patients. Median number of harvested lymph nodes was 12. Apical nodes were pathologically harvested in 84 (82.4%) patients. R0 resection was performed in 108 (95.6%) patients. Overall complication rate was 17.7%; but most complications were mild and the patients recovered uneventfully. Estimated 5-year OS was 86.1% and 3-year DFS was 79.6% after median follow-up periods of 49.1 months (range, 5.3-85.3). Conclusions: High dissection of the IMA and selective ligation of the major feeding vessel to the sigmoid colon or rectum can be safely performed using da Vinci Surgical System,yielding favorable clinical, and oncologic outcomes in rectal or sigmoid colon cancer treatment.
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Affiliation(s)
- Tzu-Chieh Yin
- Division of General and Digestive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Surgery, Kaohsiung Municipal Tatung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wei-Chih Su
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Po-Jung Chen
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Municipal Hsiaokang Hospital, Kaohsiung, Taiwan
| | - Tsung-Kun Chang
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yen-Cheng Chen
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ching-Chun Li
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Chien Hsieh
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsiang-Lin Tsai
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ching-Wen Huang
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jaw-Yuan Wang
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Center for Cancer Research, Kaohsiung Medical University, Kaohsiung, Taiwan
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Circumferential Resection Margin as a Hospital Quality Assessment Tool for Rectal Cancer Surgery. J Am Coll Surg 2020; 230:1008-1018.e5. [PMID: 32142927 DOI: 10.1016/j.jamcollsurg.2020.02.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 02/05/2020] [Accepted: 02/05/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Circumferential resection margin (CRM) status is an important predictor of outcomes after rectal cancer operation, and is influenced not only by operative technique, but also by incorporation of a multidisciplinary treatment strategy. This study sought to develop a risk-adjusted quality metric based on CRM status to assess hospital-level performance for rectal cancer operation. STUDY DESIGN We conducted a retrospective observational cohort study of 58,374 patients with resected stage I to III rectal cancer within 1,303 hospitals who were identified from the National Cancer Database (2010 to 2015). The number of observed cases with a positive CRM (≤ 1 mm) was divided by the risk-adjusted expected number of cases with positive CRM to form the observed-to-expected (O/E) ratio. Secondary endpoint was overall survival. RESULTS The overall rate of CRM positivity was 15.9%. Based on the O/E ratio for 1,139 hospitals, 147 (12.9%) and 103 (9.0%) were significantly worse and better performers, respectively. The majority of hospitals (n = 570) performed as expected. Positive CRMs using criteria of 0 mm and 0.1 to 1 mm were associated with a significantly shorter 5-year overall survival of 49% and 63.5% (hazard ratio 1.67; 95% CI, 1.57 to 1.76 and hazard ratio 1.19; 95% CI, 1.12 to 1.26) than negative CRM > 1 mm of 74.1% (all p < 0.001). CONCLUSIONS CRM-based O/E ratio is a robust hospital-based quality measure for rectal cancer operation. It allows facilities to compare their performance with that of centers of similar characteristics and helps identify underperforming, at-risk, and high-performing centers. National quality-improvement initiatives for rectal cancer should focus on ensuring high-quality data collection and providing ready access to risk-adjusted comparative metrics.
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Sun RJ, Wang L, Li XT, Lu QY, Zhang XY, Guan Z, Sun YS. Baseline MRI detected lateral lymph node as a prognostic factor: a cohort study in pN0 low-risk rectal cancer. J Cancer Res Clin Oncol 2020; 146:739-748. [PMID: 31832762 DOI: 10.1007/s00432-019-03100-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 11/25/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND It is highly controversial that how to deal with the lateral lymph-node metastasis in patients with rectal cancer. Although lateral lymph node can be detected by preoperative MRI, the metastasis status cannot be accurately determined following standard total mesorectal excision (TME) in low-risk patients. This study was to assess the correlation between preoperative MRI detected lateral lymph-node (LLN) features and prognosis in patients with non-preradiated low recurrence risk rectal cancers. MATERIALS AND METHODS This retrospective study included 593 low-risk rectal cancers underwent TME without neoadjuvant chemo-radiotherapy from January 2013 to December 2015. The features of the largest LLN were retrospectively reviewed on preoperative MRI. The relationship of MR-LLN features with overall survival, metastasis-free survival, and local relapse-free survival was analyzed. RESULTS A total of 593 patients including 415 cases of pN0, 86 cases of pN1, and 92 cases of pN2 were enrolled in this study. In pN0 patients, at least one visible LLN was detected in 104 patients on primary MRI. The MR-T staging, postoperative therapy status, the presence of MR-LLN, and short axis (SA) of MR-LLN were significantly correlated with the recurrence in pN0 patients (all p < 0.05). The OS and MFS were significantly lower in patients with MR-LLN SA ≥ 8 mm than SA < 8 mm (p < 0.01, HR = 4.35, 95% CI = 1.48-12.77). The OS and MFS of patients with pN0-LLN(+) and SA ≥ 8 mm were similar to pN2-LLN(-) patients. The location of MR-LLN showed no significant impact on prognosis. CONCLUSION For low-risk rectal cancers without neoadjuvant chemo-radiotherapy, the presence of MR-LLN is associated with poor prognosis. The pN0-LLN(+) SA ≥ 8 mm patients might be concerned as pN2 patients and receive more intensive neoadjuvant or adjuvant treatment.
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Affiliation(s)
- Rui-Jia Sun
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiology, Peking University Cancer Hospital and Institute, No. 52 Fu Cheng Road Hai Dian District, Beijing, 100142, China
| | - Lin Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Surgery, Peking University Cancer Hospital and Institute, Hai Dian District, Beijing, 100142, China
| | - Xiao-Ting Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiology, Peking University Cancer Hospital and Institute, No. 52 Fu Cheng Road Hai Dian District, Beijing, 100142, China
| | - Qiao-Yuan Lu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiology, Peking University Cancer Hospital and Institute, No. 52 Fu Cheng Road Hai Dian District, Beijing, 100142, China
| | - Xiao-Yan Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiology, Peking University Cancer Hospital and Institute, No. 52 Fu Cheng Road Hai Dian District, Beijing, 100142, China
| | - Zhen Guan
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiology, Peking University Cancer Hospital and Institute, No. 52 Fu Cheng Road Hai Dian District, Beijing, 100142, China
| | - Ying-Shi Sun
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiology, Peking University Cancer Hospital and Institute, No. 52 Fu Cheng Road Hai Dian District, Beijing, 100142, China.
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Chang W, Wei Y, Ren L, Jian M, Chen Y, Chen J, Liu T, Huang W, Peng S, Xu J. Short-term and long-term outcomes of robotic rectal surgery-from the real word data of 1145 consecutive cases in China. Surg Endosc 2019; 34:4079-4088. [PMID: 31602514 PMCID: PMC7395014 DOI: 10.1007/s00464-019-07170-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 09/26/2019] [Indexed: 12/16/2022]
Abstract
Background Due to a limited patient sample size, substantial data on robotic rectal resection (RRR) is lacking. Here, we reported a large consecutive cases from the real word data to assess the safety and efficacy of RRR. Methods From September 2010 to June 2017, a total of 1145 consecutive RRR procedures were performed in patients with stage I–IV disease. We conducted an analysis based on information from a prospectively designed database to evaluate surgical outcomes, urogenital function, and long-term oncological outcomes. Results Of three types of RRR performed, 227 (24.2%) were abdominoperineal resections, 865 (75.5%) were anterior resections, and 3 (0.3%) were Hartmann. Conversion to an open procedure occurred in 5.9% of patients. The overall positive circumferential margin rate was 1.3%. Surgical complication rate and mortality were 16.2% and 0.8% within 30 days of surgery, respectively. Mean hospital stay after surgery and hospital cost were 6.3 ± 2.9 days and 10442.5 ± 3321.5 US dollars, respectively. Risk factors for surgical complications included male gender, tumor location (mid-low rectum), combined organ resection, and clinical T category (cT3–4). Urinary function and general sexual satisfaction decreased significantly 1 month after surgery for both sexes. Subsequently, both parameters increased progressively, and the values 1 year after surgery were comparable to those measured before surgery. At a median follow-up of 34.6 months, local recurrence and distant metastases occurred in 2.3% and 21.1% of patients, respectively. Conclusions Robotic rectal resection was safe with preserved urogenital function and arrived equivalent oncological outcomes in a nonselected group of patients with rectal cancer.
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Affiliation(s)
- Wenju Chang
- Colorectal Cancer Center; Department of General Surgery; Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, China.,Shanghai Engineering Research Cancer of Colorectal Cancer Minimally Invasive (17DZ2252600), Shanghai, China
| | - Ye Wei
- Colorectal Cancer Center; Department of General Surgery; Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, China.,Shanghai Engineering Research Cancer of Colorectal Cancer Minimally Invasive (17DZ2252600), Shanghai, China
| | - Li Ren
- Colorectal Cancer Center; Department of General Surgery; Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, China.,Shanghai Engineering Research Cancer of Colorectal Cancer Minimally Invasive (17DZ2252600), Shanghai, China
| | - Mi Jian
- Colorectal Cancer Center; Department of General Surgery; Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, China
| | - Yijiao Chen
- Colorectal Cancer Center; Department of General Surgery; Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, China
| | - Jingwen Chen
- Colorectal Cancer Center; Department of General Surgery; Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, China
| | - Tianyu Liu
- Colorectal Cancer Center; Department of General Surgery; Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, China
| | - Wenbai Huang
- Colorectal Cancer Center; Department of General Surgery; Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, China.,Shanghai Engineering Research Cancer of Colorectal Cancer Minimally Invasive (17DZ2252600), Shanghai, China
| | - Shangjin Peng
- Department of General Surgery, Jinshan Hospital, Fudan University, Shanghai, China
| | - Jianmin Xu
- Colorectal Cancer Center; Department of General Surgery; Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, China. .,Shanghai Engineering Research Cancer of Colorectal Cancer Minimally Invasive (17DZ2252600), Shanghai, China.
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Circumferential Resection Margin After Laparoscopic and Open Rectal Resection: A Nationwide Propensity Score Matched Cohort Study. Dis Colon Rectum 2019; 62:1177-1185. [PMID: 31490826 DOI: 10.1097/dcr.0000000000001460] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Recent studies suggest better oncological results after open versus laparoscopic rectal resection for cancer. The external validity of these results has not been tested on a nationwide basis. OBJECTIVE This study aimed to identify risk factors for positive circumferential resection margin in patients undergoing surgery for rectal cancer with special emphasis on surgical approach. DESIGN This database study was based on the Danish nationwide colorectal cancer database. To identify risk factors for positive circumferential resection margin, we performed uni- and multivariate logistic regression analyses. To assess the role of surgical approach, a propensity score-matched analysis was performed. SETTINGS This study was conducted at public hospitals across Denmark. PATIENTS Patients undergoing elective rectal resection from October 2009 through December 2013 were included. MAIN OUTCOME MEASURES The primary outcome measured was the risk of a positive circumferential resection margin. RESULTS Included in the final analyses were 2721 cases (745 operated on by an open approach; 1976 by laparoscopy). On direct comparison, positive circumferential resection margin occurred more often after open resection (6.3% vs 4.7%; p = 0.047). After multivariate analyses, tumors located low in the rectum, neoadjuvant chemoradiation therapy, increasing T and N stage, tumor fixated in the pelvis, and dissection in the muscularis plane increased the risk of a positive circumferential resection margin. In the propensity score-matched sample (541 exact matched pairs), the laparoscopic approach did not influence the risk of a positive circumferential resection margin (OR, 0.9; 95% CI, 0.6-1.5; p = 0.77). LIMITATIONS This was a retrospective review of prospectively collected data, and thereby contained possible selection bias. CONCLUSIONS Based on this nationwide database study, and after multivariate and propensity score-matched analyses, there was no increased risk of positive circumferential resection margin after laparoscopic vs open rectal resection. See Video Abstract at http://links.lww.com/DCR/A996. MARGEN DE RESECCIÓN CIRCUNFERENCIAL DESPUÉS DE LA RESECCIÓN RECTAL LAPAROSCÓPICA Y ABIERTA: UN ESTUDIO DE COHORTE DE PUNTUACIÓN DE PROPENSIÓN A NIVEL NACIONAL: Estudios recientes sugieren mejores resultados oncológicos después de la resección rectal abierta versus laparoscópica. La validez de estos resultados no se ha probado a nivel nacional. OBJETIVO Identificar los factores de riesgo del margen de resección circunferencial positivo en pacientes sometidos a cirugía por cáncer de recto con especial énfasis en el abordaje quirúrgico. DISEÑO:: Estudio de la base de datos nacional de Dinamarca de cáncer colorrectal. Para identificar los factores de riesgo del margen de resección circunferencial positivo, realizamos análisis de regresión logística uni y multivariable. Para evaluar el papel del abordaje quirúrgico, se realizó un análisis emparejado de puntuación de propensión. AJUSTES Hospitales públicos en toda Dinamarca. PACIENTES Pacientes sometidos a resección rectal electiva en el período comprendido entre octubre de 2009 y diciembre de 2013. PRINCIPALES MEDIDAS DE RESULTADOS Riesgo del margen de resección circunferencial positivo. RESULTADOS 2721 casos (745 operados por abordaje abierto; 1976 por laparoscopia) se incluyeron en el análisis final. En la comparación directa, el margen de resección circunferencial positivo ocurrió más a frecuentemente, después de la resección abierta (6.3 vs 4.7%; p = 0.047). Posterior a los análisis multivariados, tumores localizados en el recto bajo, quimioterapia con radioterapia neoadyuvante, incremento de etapas T y la N, tumor fijo en pelvis y la disección en el plano muscular, aumentaron el riesgo del margen de resección circunferencial positivo. En la muestra emparejada del puntaje de propensión (541 pares coincidentes exactos), el abordaje laparoscópico no influyó en el riesgo del margen de resección circunferencial positivo (razón de probabilidades (IC 95%) 0.9 (0.6-1.5); p = 0.77). LIMITACIONES Revisión retrospectiva de los datos recopilados prospectivamente y por lo tanto, posible sesgo de selección. CONCLUSIONES El estudio de la base de datos a nivel nacional y después de los análisis emparejados multivariados y de puntuación de propensión, no hubo un mayor riesgo del margen de resección circunferencial positivo después de la resección laparoscópica versus resección abierta. Vea el Resumen del video en http://links.lww.com/DCR/A996.
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Rouanet P, Gourgou S, Gogenur I, Jayne D, Ulrich A, Rautio T, Spinoglio G, Bouazza N, Moussion A, Gomez Ruiz M. Rectal Surgery Evaluation Trial: protocol for a parallel cohort trial of outcomes using surgical techniques for total mesorectal excision with low anterior resection in high-risk rectal cancer patients. Colorectal Dis 2019; 21:516-522. [PMID: 30740878 DOI: 10.1111/codi.14581] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 02/02/2019] [Indexed: 12/18/2022]
Abstract
AIM Total mesorectal excision (TME) is the standard of care for rectal cancer, which can be combined with low anterior resection (LAR) in patients with mid-to-low rectal cancer. The narrow pelvic space and difficulties in obtaining adequate exposure make surgery technically challenging. Four techniques are used to perform the surgery: open laparotomy, laparoscopy, robot-assisted surgery and transanal surgery. Comparative data for these techniques are required to provide clinical data on the surgical management of rectal cancers. METHODS The Rectal Surgery Evaluation Trial will be a prospective, observational, case-matched, four-cohort, multicentre trial designed to study TME with LAR using open laparotomy, laparoscopy, robot-assisted surgery or transanal surgery in high-surgical-risk patients with mid-to-low non-metastatic rectal cancer. All surgeries will be performed by surgeons experienced in at least one of the techniques. Oncological, morbidity and functional outcomes will be assessed in a composite primary outcome, with success defined as circumferential resection margin ≥ 1 mm, TME Grade III and minimal postoperative morbidity (absence of Clavien-Dindo Grade III-IV complications within 30 days after surgery). Secondary end-points will include the co-primary end-points over the long term (2 years), quality of surgery, quality of life, length of hospital stay, operative time and rate of unplanned conversions. DISCUSSION This will be the first trial to study all four surgical techniques currently used for TME with LAR in a specific group of high-risk patients. The knowledge obtained will contribute towards helping physicians determine the advantages of each technique and which may be the most appropriate for their patients.
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Affiliation(s)
- P Rouanet
- Surgery Department, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
| | - S Gourgou
- Biometrics Unit, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
| | - I Gogenur
- Zealand University Hospital, Roskilde, Denmark
| | - D Jayne
- St James University Hospital, Leeds, UK
| | - A Ulrich
- Department of Surgery, Lukaskrankenhaus Neuss, Neuss, Germany
| | - T Rautio
- Oulu University Hospital, Oulu, Finland
| | - G Spinoglio
- IEO European Institute of Oncology, Milan, Italy
| | - N Bouazza
- Clinical Research Department, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
| | - A Moussion
- Clinical Research Department, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
| | - M Gomez Ruiz
- Cirugía Colorrectal - Cirugía General y del Aparato Digestivo, Hospital Universitario Marqués de Valdecilla, Santander, Spain
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National multicentric evaluation of quality of pathology reports for rectal cancer in France in 2016. Virchows Arch 2019; 474:561-568. [PMID: 30729335 DOI: 10.1007/s00428-019-02534-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 01/07/2019] [Accepted: 01/28/2019] [Indexed: 12/12/2022]
Abstract
The quality of pathologic assessment of rectal cancer specimens is crucial for treatment efficiency and survival. The Royal College of Pathologists (RCP) recommends evaluating the quality of the pathology report in routine practice using three quality indicators (QIs): the number of lymph nodes (LNs) analyzed (≥ 12), the rate of venous invasion (VI ≥ 30%), and peritoneal involvement (pT4a ≥ 10%). In this study, we evaluated the three QIs of the French national pathology reports and compared them with British guidelines and assessed the influence of neoadjuvant radiochemotherapy on QIs. From January 1 to December 31, 2016, all pathology reports for rectal adenocarcinoma were collected from French departments. Neoadjuvant radiochemotherapy included long-course radiotherapy with concomitant 5-FU-based chemotherapy. A total of 983 rectal cancer pathology reports were evaluated. A median of 15 LNs were analyzed and 81% of centers had ≥ 12 LNs. The rate of VI was 30% and 41% of centers had ≥ 30% VI. The rate of pT4a was 4% and 18% of centers reported ≥ 10% pT4a. None of the centers reached the threshold for the three QIs. All three QIs were lower after radiochemotherapy compared to surgery alone. In conclusion, in French routine practice, the values of two of the three QIs (LNs analyzed and VI) were globally in line with RCP guidelines. However, the rate of pT4a was very low, particularly after radiochemotherapy, suggesting its low value in rectal cancer.
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Shao H, Ma X, Gao Y, Wang J, Wu J, Wang B, Li J, Tian J. Comparison of the diagnostic efficiency for local recurrence of rectal cancer using CT, MRI, PET and PET-CT: A systematic review protocol. Medicine (Baltimore) 2018; 97:e12900. [PMID: 30508883 PMCID: PMC6283203 DOI: 10.1097/md.0000000000012900] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 09/27/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The risk of local recurrence (LR) continues to threat patients with rectal cancer after surgery or chemoradiotherapy. The main reason is that there is frequently extensive scarring and reactive changes after radiotherapy and resection. Thus, the diagnosis of LR can be challenging. There are different imaging modalities that have been used in the follow-up of rectal cancer, including computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), and positron emission tomography-computed tomography (PET-CT) in clinical practice. METHODS We will systematically search PubMed, EMBASE, the Cochrane Library, and Chinese Biomedical Literature Database for diagnostic trials using CT, MRI, PET, and PET-CT to detect LR of rectal cancer in April, 2018. Two review authors will independently screen titles and abstracts for relevance, assess full texts for inclusion, and carry out data extraction and methodological quality assessment using the QUADAS-2 tool. We will use bivariate meta-analysis to estimate summary sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio of CT, MRI, PET, and PET-CT, as well as different sequences of MRI. For each index test, estimates of sensitivity and specificity from each study will be plotted in summary receive operating curve space and forest plots will be constructed for visual examination of variation in test accuracy. We will perform meta-analyses using the hierarchical summary receiver-operating characteristic model to produce summary estimates of sensitivity and specificity. Then, head-to-head and indirect comparison meta-analyses will be carried out. DISCUSSION This review will help determine the diagnostic accuracy of CT, MRI, PET, and PET-CT for the diagnosis of patients with LR of rectal cancer. ETHICS AND DISSEMINATION Ethics approval and patient consent are not required, as this study is a systematic review. PROSPERO REGISTRATION NUMBER CRD42018104918.
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Affiliation(s)
- Hongsheng Shao
- Radiology Department, Rehabilitation Center Hospital of Gansu Province
| | - Xueni Ma
- The Second Clinical Medical College of Lanzhou University
| | - Ya Gao
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University
| | | | - Jiarui Wu
- Department of Clinical Pharmacology of Traditional Chinese Medicine, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing
| | - Bo Wang
- Department of Nursing, Rehabilitation Center Hospital of Gansu Province, Lanzhou, China
| | - Jipin Li
- The Second Clinical Medical College of Lanzhou University
| | - Jinhui Tian
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University
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Canbey Göret C, Göret NE. Histopathological Analysis of 173 Consecutive Patients with Colorectal Carcinoma: A Pathologist's View. Med Sci Monit 2018; 24:6809-6815. [PMID: 30255856 PMCID: PMC6178881 DOI: 10.12659/msm.911012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Worldwide, colorectal carcinomas are the third most common carcinomas in men and the second most common carcinomas in women. Pathological examination of rectum specimens requires special attention for correctly evaluating many prognostically important factors. In this study, we present pathological results of 173 lower anterior resection (LAR) and abdominoperineal resection (APR) specimens retrospectively evaluated. Material/Methods We included 173 LAR and APR specimens in this study. Patients were evaluated in the Istanbul Ekin Private Pathology Laboratory and underwent surgery at Çanakkale State Hospital, General Surgery Clinic. Results Of the 173 specimens, 15 (8.7%) were APR and 158 (91.3%) were LAR specimens. Ninety-four patients (54.3%) were males and 79 patients (45.7%) were females. The mean age of the patients was 63.5 years (range 26–90 years). In the histopathological examination, malignant neoplasm was detected in 172 of the cases (99.4%) and benign endometriosis was detected in 1 of the cases (0.6%). There were 151 (87.2%), 8 (4.6%), 5 (2.9%), 1 (0.6%), 1 (0.6%), 1 (0.6%), 1 (0.6%), 1 (0.6%), and 4 (2.3%) patients with adenocarcinoma, mucinous adenocarcinoma, intramucosal adenocarcinoma in the setting of a high-grade tubulovillous adenoma, synchronous colon/prostate adenocarcinoma, malignant melanoma, signet ring cell carcinoma, gastrointestinal stromal tumor, endometriosis, and adenocarcinoma diagnosed by the examination of colonoscopic biopsy specimens that showed complete regression with neoadjuvant therapy, respectively. Conclusions When evaluating specimens from patients with colorectal carcinoma, pathological evaluation, which is one of the most fundamental pillars in managing patients with cancer, must be performed carefully and meticulously. Each pathological parameter should be evaluated carefully and clinicians and pathologists should evaluate these cases together.
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Affiliation(s)
- Ceren Canbey Göret
- Department of Surgical Pathology, Health Sciences University, Sancaktepe Research and Education Hospital, Istanbul, Turkey
| | - Nuri Emrah Göret
- Department of General Surgery, Health Sciences University, Kartal Research and Education Hospital, Istanbul, Turkey
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Kitz J, Fokas E, Beissbarth T, Ströbel P, Wittekind C, Hartmann A, Rüschoff J, Papadopoulos T, Rösler E, Ortloff-Kittredge P, Kania U, Schlitt H, Link KH, Bechstein W, Raab HR, Staib L, Germer CT, Liersch T, Sauer R, Rödel C, Ghadimi M, Hohenberger W. Association of Plane of Total Mesorectal Excision With Prognosis of Rectal Cancer: Secondary Analysis of the CAO/ARO/AIO-04 Phase 3 Randomized Clinical Trial. JAMA Surg 2018; 153:e181607. [PMID: 29874375 PMCID: PMC6142959 DOI: 10.1001/jamasurg.2018.1607] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 03/04/2018] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Previous retrospective studies have shown that surgical quality affects local control in rectal cancer.. OBJECTIVE In this secondary end point analysis, we evaluated the prognostic effect of the total mesorectal excision (TME) plane in the CAO/ARO/AIO-04 phase 3 randomized clinical trial. DESIGN, SETTING, AND PARTICIPANTS The CAO/ARO/AIO-04 trial enrolled 1236 patients with cT3-4 and/or node-positive rectal adenocarcinoma from 88 centers in Germany between July 25, 2006, and February 26, 2010. INTERVENTIONS Patients were randomized to receive treatment with standard fluorouracil-based preoperative chemoradiotherapy (CRT) alone (control arm) or oxaliplatin (experimental arm) followed by TME and adjuvant chemotherapy. MAIN OUTCOMES AND MEASURES The TME quality (mesorectal, intramesorectal, and muscularis propria plane) was prospectively assessed in 1152 operation specimens. An assessment was performed independently by pathologists and surgeons. The results were correlated with clinicopathologic data and the clinical outcome was tested, including multivariable analysis with the Cox regression model. RESULTS Of 1152 German Caucasian participants, 332 (28.8) were women and the mean age was 63 years. The plane of TME was mesorectal in 930 patients (80.7%), intramesorectal in 169 (14.7%), and muscularis propria in 53 (4.6%). In a univariable analysis, the TME plane was significantly associated with 3-year disease-free survival (mesorectal vs intramesorectal vs muscularis propria, 95% CI, 73.1-78.8 vs 61.6-76.0 vs 55.6-81.3, respectively; P = .01), cumulative incidence of local and distant recurrences (mesorectal vs intramesorectal vs muscularis propria, 95% CI, 2.0-4.5 vs 1.2-8.1 vs 2.5-20.5, respectively; P < .001; and mesorectal vs intramesorectal vs muscularis propria, 95% CI, 17.0-22.4 vs 18.3-32.0 vs 14.2-39.0, respectively; P = .03, respectively), and overall survival (mesorectal vs intramesorectal vs muscularis propria, 95% CI, 88.3-92.3 vs 79.7-91.0 vs 81.6-98.7, respectively; P = .02). In contrast to the pathologist-based evaluation, the assessment of TME plane by the operating surgeon failed to demonstrate prognostic significance for any of these clinical end points. In a multivariable analysis, the plane of surgery (mesorectal vs muscularis propria TME) constituted an independent factor for local recurrence (P = .002). CONCLUSIONS AND RELEVANCE This phase 3 randomized clinical trial confirms the long-term clinical effect of TME plane quality on local recurrence, as initially reported in the MRC CR07 study. The data highlight the key role of pathologists and surgeons in the multidisciplinary management of rectal cancer. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00349076.
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Affiliation(s)
- Julia Kitz
- Institute of Pathology, University Medical Center Göttingen, Göttingen, Germany
| | - Emmanouil Fokas
- Department of Radiotherapy and Oncology, University of Frankfurt, Frankfurt, Germany
| | - Tim Beissbarth
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Philipp Ströbel
- Institute of Pathology, University Medical Center Göttingen, Göttingen, Germany
| | | | - Arndt Hartmann
- Institute of Pathology, University Medical Center Erlangen, Erlangen, Germany
| | | | | | | | | | - Ulrich Kania
- Department of General and Visceral Surgery, Krankenhaus Maria Hilf, Mönchengladbach, Germany
| | - Hans Schlitt
- Department of Visceral Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Karl-Heinrich Link
- Department of Visceral Surgery, Asklepios Paulinen Klinik Wiesbaden, Wiesbaden, Germany
| | - Wolf Bechstein
- Department of General and Visceral Surgery, University Medical Center Frankfurt, Frankfurt, Germany
| | - Hans-Rudolf Raab
- Department of General and Visceral Surgery, University Medical Center Oldenburg, Oldenburg, Germany
| | - Ludger Staib
- Department of General and Visceral Surgery, Klinikum Esslingen, Esslingen, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Vascular and Pediatric Surgery, University Hospital Würzburg, Würzburg, Germany
| | - Torsten Liersch
- Department of General and Visceral Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - Rolf Sauer
- Department of Radiation Therapy, University of Erlangen, Erlangen, Germany
| | - Claus Rödel
- Department of Radiotherapy and Oncology, University of Frankfurt, Frankfurt, Germany
| | - Michael Ghadimi
- Department of General and Visceral Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - Werner Hohenberger
- Department of General and Visceral Surgery, University of Erlangen, Erlangen, Germany
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von den Grün JM, Hartmann A, Fietkau R, Ghadimi M, Liersch T, Hohenberger W, Weitz J, Sauer R, Wittekind C, Ströbel P, Rödel C, Fokas E. Can clinicopathological parameters predict for lymph node metastases in ypT0-2 rectal carcinoma? Results of the CAO/ARO/AIO-94 and CAO/ARO/AIO-04 phase 3 trials. Radiother Oncol 2018; 128:557-563. [PMID: 29929861 DOI: 10.1016/j.radonc.2018.06.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 05/29/2018] [Accepted: 06/04/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The advent of less radical surgical approaches has generated concern about leaving locoregional lymph node metastases (LNM) unresected that could lead to adverse outcome. We examined the prognostic role of clinicopathological factors for ypN-positivity in patients with ypT0-2 rectal carcinoma treated within the CAO/ARO/AIO-94 and CAO/ARO/AIO-04 randomized phase 3 trials. METHODS The correlation of clinicopathological factors with ypN-status (ypN0 vs ypN1/2) was examined in n = 776 patients with ypT0-2 rectal carcinoma after preoperative CRT and total mesorectal excision surgery using Pearson's Chi-squared test for categorical variables and Kruskal-Wallis' test for continuous variables. Multivariable analysis was performed using binary logistic regression to identify independent prognosticators for ypN-positivity. RESULTS Residual LNM (ypN+) were found in 6%, 20.8% and 21.4% of patients with ypT0, ypT1 and ypT2 carcinomas, respectively. Independent prognosticators for LNM were advanced ypT category (p = 0.002) and lymphatic invasion (p = 0.020). In a separate multivariable analysis performed upon exclusion of ypT-category due to multicollinearity with residual tumor diameter (RTD), lymphatic invasion (p = 0.015) and RTD ≥10 mm (p = 0.005) demonstrated strong correlation with LNM. CONCLUSION Advanced ypT-stage, lymphatic invasion and RTD ≥10 mm were prognostic factors for LNM in patients ypT0-2 rectal carcinoma treated with CRT and surgery within both phase 3 trials. The high incidence of LNM in the ypT1-2 group needs to be taken into consideration in the context of oncological safety and indicate that LE should be advocated with great caution in this patient subgroup. The prognostic pathological factor identified here could help guide decision of LE vs TME after standard CRT.
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Affiliation(s)
| | - Arndt Hartmann
- Institute of Pathology, University of Erlangen, Nürnberg, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology and Radiotherapy, University of Erlangen, Nürnberg, Germany
| | - Michael Ghadimi
- Department of General, Visceral and Pediatric Surgery, University Medical Center, Göttingen, Germany
| | - Torsten Liersch
- Department of General, Visceral and Pediatric Surgery, University Medical Center, Göttingen, Germany
| | - Werner Hohenberger
- Department of General and Visceral and Pediatric Surgery, University of Erlangen, Nürnberg, Germany
| | - Jürgen Weitz
- Department of General and Visceral and Pediatric Surgery, University of Dresden, Germany
| | - Rolf Sauer
- Department of Radiation Oncology and Radiotherapy, University of Erlangen, Nürnberg, Germany
| | | | - Philipp Ströbel
- Institute of Pathology, University Medical Center Göttingen, Germany
| | - Claus Rödel
- Department of Radiotherapy and Oncology, University of Frankfurt, Germany
| | - Emmanouil Fokas
- Department of Radiotherapy and Oncology, University of Frankfurt, Germany.
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Wu AW, Cai Y, Li YH, Wang L, Li ZW, Sun YS, Ji JF. Pattern and Management of Recurrence of Mid-Low Rectal Cancer After Neoadjuvant Intensity-Modulated Radiotherapy: Single-Center Results of 687 Cases. Clin Colorectal Cancer 2018. [DOI: 10.1016/j.clcc.2018.01.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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29
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Bowden DL, Sutton PA, Wall MA, Jithesh PV, Jenkins RE, Palmer DH, Goldring CE, Parsons JL, Park BK, Kitteringham NR, Vimalachandran D. Proteomic profiling of rectal cancer reveals acid ceramidase is implicated in radiation response. J Proteomics 2018. [PMID: 29518574 DOI: 10.1016/j.jprot.2018.02.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy (CRT) is used in locally advanced rectal cancer when tumours threaten the circumferential resection margin, with varying response to treatment. This experimental study aimed to identify significantly differentially expressed proteins between patients responding and not responding to CRT, and to validate any proteins of interest. METHODS Mass spectrometry (with isobaric tagging for relative quantification) analysis of rectal cancers pre- and post-CRT, and at resection. Validation of proteins of interest was performed by assessing tissue microarray (TMA) immunohistochemistry expression in a further 111 patients with rectal cancer. RESULTS Proteomic data are available via ProteomeXchange with identifier PXD008436. Reduced abundance of contributing peptide ions for acid ceramidase (AC) (log fold change -1.526, p = 1.17E-02) was observed in CRT responders. Differential expression of AC was confirmed upon analysis of the TMAs. Cancer site expression of AC in stromal cells from post-CRT resection specimens was observed to be relatively low in pathological complete response (p = 0.003), and relatively high with no response to CRT (p = 0.017). CONCLUSION AC may be implicated in the response of rectal cancer to CRT. We propose its further assessment as a novel potential biomarker and therapeutic target. SIGNIFICANCE There is a need for biomarkers to guide the use of chemoradiotherapy in rectal cancer, as none are in routine clinical use. We have determined acid ceramidase may have a role in radiation response, based on novel proteomic profiling and validation in a wider dataset using tissue microarrays. The ability to predict or improve response would positively select those patients who will derive benefit, prevent delays in the local and systemic management of disease in non-responders, and reduce morbidity associated with chemoradiotherapy.
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Affiliation(s)
- D L Bowden
- The University of Liverpool, Department of Molecular and Clinical Pharmacology, Ashton Street, Liverpool L69 3GE, United Kingdom.
| | - P A Sutton
- The University of Liverpool, Department of Molecular and Clinical Pharmacology, Ashton Street, Liverpool L69 3GE, United Kingdom
| | - M A Wall
- The Countess of Chester Hospital, Liverpool Road, Chester CH2 1UL, United Kingdom
| | - P V Jithesh
- Sidra Medical and Research Centre, PO Box 26999, Doha, Qatar
| | - R E Jenkins
- The University of Liverpool, Department of Molecular and Clinical Pharmacology, Ashton Street, Liverpool L69 3GE, United Kingdom
| | - D H Palmer
- The University of Liverpool, Department of Molecular and Clinical Cancer Medicine, London Road, Liverpool L3 9TA, United Kingdom
| | - C E Goldring
- The University of Liverpool, Department of Molecular and Clinical Pharmacology, Ashton Street, Liverpool L69 3GE, United Kingdom
| | - J L Parsons
- The University of Liverpool, Department of Molecular and Clinical Cancer Medicine, London Road, Liverpool L3 9TA, United Kingdom
| | - B K Park
- The University of Liverpool, Department of Molecular and Clinical Pharmacology, Ashton Street, Liverpool L69 3GE, United Kingdom
| | - N R Kitteringham
- The University of Liverpool, Department of Molecular and Clinical Pharmacology, Ashton Street, Liverpool L69 3GE, United Kingdom
| | - D Vimalachandran
- The Countess of Chester Hospital, Liverpool Road, Chester CH2 1UL, United Kingdom; The University of Liverpool, Department of Molecular and Clinical Cancer Medicine, London Road, Liverpool L3 9TA, United Kingdom
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30
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Pai RK, Pai RK. Pathologic assessment of gastrointestinal tract and pancreatic carcinoma after neoadjuvant therapy. Mod Pathol 2018; 31:4-23. [PMID: 28776577 DOI: 10.1038/modpathol.2017.87] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 05/31/2017] [Accepted: 06/18/2017] [Indexed: 12/17/2022]
Abstract
Neoadjuvant therapy is increasingly used to treat patients with a wide variety of malignancies. Histologic evaluation of treated specimens provides important prognostic information and may guide subsequent chemotherapy. Neoadjuvant therapy is commonly employed in the treatment of locally advanced rectal adenocarcinoma, hepatic colorectal metastases, esophageal/esophagogastric junction carcinoma, and pancreatic ductal adenocarcinoma. Numerous tumor regression schemes have been used in these tumors and standardized approaches to evaluate these specimens are needed. In this review, the various tumor regression scoring systems that have been used in these organs are described and their associations with clinical outcomes are discussed. Recommendations regarding how to handle and report the histologic findings in these resections specimens are provided.
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Affiliation(s)
- Reetesh K Pai
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Rish K Pai
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Scottsdale, AZ, USA
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31
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Huang CW, Tsai HL, Yeh YS, Su WC, Huang MY, Huang CM, Chang YT, Wang JY. Robotic-assisted total mesorectal excision with the single-docking technique for patients with rectal cancer. BMC Surg 2017; 17:126. [PMID: 29208050 PMCID: PMC5716256 DOI: 10.1186/s12893-017-0315-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 11/20/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The robotic system has advantages of high-definition three-dimensional vision and articular instruments with high dexterity, allowing more precise dissection in the deep and narrow pelvic cavity. METHODS We enrolled 95 patients with stage I-III rectal cancer (adenocarcinoma) who underwent totally robotic-assisted total mesorectal excision (TME) with single-docking technique at a single institution between September 2013 and December 2016. RESULTS Of the 95 patients, 48 (50.5%) and 30 (31.6%) patients had lower and middle rectal cancers, respectively. Of the 75 (78.9%) patients undergoing preoperative concurrent chemoradiotherapy (CCRT), 27 (28.4%) exhibited pathologic complete response (pCR). Only four (4.2%) patients underwent abdominoperineal resection and the sphincter preservation rate was 95.8%. R0 resection was performed in 92 (96.8%) patients. Circumferential resection margin (CRM) and distal resection margin (DRM) were positive in 2 (2.1%) and 1 (1.1%) patients, respectively. The anastomotic leakage rate was 5.4% (5/95 patients). The overall complication rate was 17.9% (17/95 patients); most of them were mild. No 30-day hospital mortality occurred, and no patients required conversion to open surgery. In 92 patients undergoing R0 resection, 2-year overall survival was 94% and 2-year disease-free survival was 83%. CONCLUSIONS The results demonstrated that totally robotic-assisted TME with the single-docking technique is safe and feasible for patients with rectal cancer, with or without preoperative CCRT. Moreover, favorable pCR rate, R0 resection rate, CRM, DRM, sphincter preservation rate, and short-term oncological outcomes can be achieved by combining this approach with appropriate preoperative CCRT.
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Affiliation(s)
- Ching-Wen Huang
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsiang-Lin Tsai
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Division of General Surgery Medicine, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yung-Sung Yeh
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Division of Trauma, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wei-Chih Su
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ming-Yii Huang
- Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chun-Ming Huang
- Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yu-Tang Chang
- Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Division of Pediatric Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jaw-Yuan Wang
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Center for Biomarkers and Biotech Drugs, Kaohsiung Medical University, Kaohsiung, Taiwan
- Center for Environmental Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Research Center for Natural products & Drug Development, Kaohsiung Medical University, Kaohsiung, Taiwan
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32
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Kusters M, Uehara K, Velde CJHVD, Moriya Y. Is There Any Reason to Still Consider Lateral Lymph Node Dissection in Rectal Cancer? Rationale and Technique. Clin Colon Rectal Surg 2017; 30:346-356. [PMID: 29184470 DOI: 10.1055/s-0037-1606112] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Nodal dissemination in locally advanced rectal cancer occurs mainly in two directions: upward and lateral. Lateral node involvement has been demonstrated; however, lateral lymph node dissection (LLND) is not routinely performed in Western countries and the focus is more on neoadjuvant treatment regimens. The main reasons for this are the high morbidity associated with the operation and the uncertain oncological benefit. There is, however, recent evidence that in selected cases, neoadjuvant treatment combined with total mesorectal excision only might not be sufficient. In this article, the historical developments in the East and the West, the current evidence regarding lateral nodal disease, and the surgical steps in the LLND are discussed.
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Affiliation(s)
- Miranda Kusters
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands.,Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Keisuke Uehara
- Division of Surgical Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Fan WH, Xiao J, An X, Jiang W, Li LR, Gao YH, Chen G, Kong LH, Lin JZ, Wang JP, Pan ZZ, Ding PR. Patterns of recurrence in patients achieving pathologic complete response after neoadjuvant chemoradiotherapy for rectal cancer. J Cancer Res Clin Oncol 2017; 143:1461-1467. [PMID: 28386648 PMCID: PMC5504135 DOI: 10.1007/s00432-017-2383-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 02/21/2017] [Indexed: 12/20/2022]
Abstract
PURPOSE The aim of this study was to characterize the patterns of recurrence in patients achieving pathologic complete response (pCR) after neoadjuvant chemoradiotherapy (CRT) for locally advanced rectal cancer. METHODS Patients with locally advanced rectal cancer treated with neoadjuvant CRT and who achieved pCR from January 2004 to December 2012 were collected. The primary outcome measurement was the patterns of recurrence. RESULTS Among 195 patients who achieved pCR, 18 developed recurrence. Furthermore, local recurrence occurred in 1.5% of patients (3/195), while distant metastases occurred in 7.7% of patients (15/195), which included 7 lung metastases, 1 liver metastasis, and 8 metastases in other locations. CONCLUSIONS Our study indicated that patients achieving pCR following neoadjuvant CRT have a favorable prognosis, with distant metastases predominating in all recurrences. Among patients with distant metastases, non-liver metastases were the predominant pattern.
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Affiliation(s)
- Wen-Hua Fan
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road East, Guangzhou, 510060, People's Republic of China.,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Jian Xiao
- Department of Medical Oncology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Xin An
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road East, Guangzhou, 510060, People's Republic of China.,Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Wu Jiang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road East, Guangzhou, 510060, People's Republic of China.,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Li-Ren Li
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road East, Guangzhou, 510060, People's Republic of China.,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Yuan-Hong Gao
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road East, Guangzhou, 510060, People's Republic of China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Gong Chen
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road East, Guangzhou, 510060, People's Republic of China.,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Ling-Heng Kong
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road East, Guangzhou, 510060, People's Republic of China.,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Jun-Zhong Lin
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road East, Guangzhou, 510060, People's Republic of China.,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Jian-Ping Wang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China.
| | - Zhi-Zhong Pan
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road East, Guangzhou, 510060, People's Republic of China. .,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China.
| | - Pei-Rong Ding
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road East, Guangzhou, 510060, People's Republic of China. .,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China.
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Abdul Rahim MR, James ML, Hickey BE. Intervention quality is not routinely assessed in Cochrane systematic reviews of radiation therapy interventions. J Med Imaging Radiat Oncol 2017; 61:662-665. [PMID: 28102003 DOI: 10.1111/1754-9485.12589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 12/17/2016] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The aim of this study was to maximise the benefits from clinical trials involving technological interventions such as radiation therapy. High compliance to the quality assurance protocols is crucial. We assessed whether the quality of radiation therapy intervention was evaluated in Cochrane systematic reviews. METHODS We searched 416 published Cochrane systematic reviews and identified 67 Cochrane systematic reviews that investigated radiation therapy or radiotherapy as an intervention. For each systematic review, either quality assurance or quality control for the intervention was identified by a description of such processes in the published systematic reviews. RESULTS Of the 67 Cochrane systematic reviews studied, only two mentioned quality assurance or quality control. CONCLUSIONS Our findings revealed that 65 of 67 (97%) Cochrane systematic reviews of radiation therapy interventions failed to consider the quality of the intervention. We suggest that advice about the evaluation of intervention quality be added to author support materials.
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Affiliation(s)
- Mohamad R Abdul Rahim
- Christchurch Regional Cancer and Blood Service, Canterbury District Health Board, Christchurch, New Zealand
| | - Melissa L James
- Christchurch Regional Cancer and Blood Service, Canterbury District Health Board, Christchurch, New Zealand
| | - Brigid E Hickey
- Radiation Oncology Unit, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
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35
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Debove C, Lefèvre JH, Parc Y. [Mesocolic excision for colonic adenocarcinoma]. Bull Cancer 2016; 104:177-181. [PMID: 27912892 DOI: 10.1016/j.bulcan.2016.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 11/09/2016] [Accepted: 11/09/2016] [Indexed: 01/14/2023]
Abstract
On the same principle than total mesorectal excision in rectal cancer, the effect of complete mesocolic excision on short and long-term outcomes is actually evaluated for colonic adenocarcinoma. This method, usually performed for left colectomy, offers a surgical specimen of higher quality, with a larger number of lymph nodes harvested. For right colectomy, surgical specifications make it less common complete mesocolic excision and conventional surgery offer comparable outcomes, as regards to postoperative morbidity and mortality rates. No differences are identified between laparoscopic and open surgery. On oncologic outcomes, only two studies report a higher free-disease survival after complete mesocolic excision. Then, there is evidence that complete mesocolic excision offers a higher rate of specimen with extensive lymph node resection, without increased morbidity rate. However, there is limited evidence that it leads to improve long-term oncological outcomes.
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Affiliation(s)
- Clotilde Debove
- Hôpital Saint-Antoine, service de chirurgie générale et digestive, 184, rue du Faubourg-Saint-Antoine, 75571 Paris cedex 12, France; Pierre & Marie Curie, université Paris VI, faculté de médecine, Paris, France
| | - Jérémie H Lefèvre
- Hôpital Saint-Antoine, service de chirurgie générale et digestive, 184, rue du Faubourg-Saint-Antoine, 75571 Paris cedex 12, France; Pierre & Marie Curie, université Paris VI, faculté de médecine, Paris, France.
| | - Yann Parc
- Hôpital Saint-Antoine, service de chirurgie générale et digestive, 184, rue du Faubourg-Saint-Antoine, 75571 Paris cedex 12, France; Pierre & Marie Curie, université Paris VI, faculté de médecine, Paris, France
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Dreyer SB, Powell AGMT, McSorley ST, Waterston A, Going JJ, Edwards J, McMillan DC, Horgan PG. The Pretreatment Systemic Inflammatory Response is an Important Determinant of Poor Pathologic Response for Patients Undergoing Neoadjuvant Therapy for Rectal Cancer. Ann Surg Oncol 2016; 24:1295-1303. [PMID: 27873100 PMCID: PMC5374176 DOI: 10.1245/s10434-016-5684-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Indexed: 12/14/2022]
Abstract
Background Not all patients respond equally to neoadjuvant chemoradiotherapy (nCRT), with subsequent effects on survival. The systemic inflammatory response has been shown to predict long-term outcomes in colorectal cancer. The current study examined the association between systemic inflammation and nCRT in patients with rectal cancer. Methods Between 1999 and 2010, patients who underwent nCRT were identified. Serum measurements of hemoglobin, C-reactive protein, albumin, modified Glasgow prognostic score (mGPS), and differential white cell counts were obtained before and after nCRT. The Rödel scoring system measured pathologic tumor regression, and magnetic resonance imaging and computed tomography determined radiologic staging. Results The study included 79 patients. Of these patients, 37% were radiologically downstaged, and 44% were categorized as showing a good pathologic response (Rödel scores 3 and 4). As a validated measure of the systemic inflammatory response, mGPS (P = 0.022) was associated with a poor pathologic response to nCRT. A radiologic response was associated with a good pathologic response to treatment (P = 0.003). A binary logistic regression model identified mGPS (odds ratio [OR] 0.27; 95% confidence interval [CI] 0.07–0.96; P = 0.043) and radiologic response (OR 0.43; 95% CI 0.18–0.99; P = 0.048) as strong independent predictors of a pathologic response to treatment. Conclusion The current study showed that a systemic inflammatory response before nCRT is associated with a poor pathologic response. Further study in a prospective controlled trial setting is warranted.
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Affiliation(s)
- Stephan B Dreyer
- Institute of Cancer Science, University of Glasgow, Glasgow, UK.
| | | | - Stephen T McSorley
- Academic Unit of Surgery, School of Medicine, University of Glasgow, Glasgow, UK
| | - Ashita Waterston
- Department of Oncology, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - James J Going
- Section of Pathology, University of Glasgow, Glasgow, UK
| | - Joanne Edwards
- Institute of Cancer Science, University of Glasgow, Glasgow, UK
| | - Donald C McMillan
- Academic Unit of Surgery, School of Medicine, University of Glasgow, Glasgow, UK
| | - Paul G Horgan
- Academic Unit of Surgery, School of Medicine, University of Glasgow, Glasgow, UK
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Cahill RA, Hompes R. Transanal total mesorectal excision. Br J Surg 2016; 102:1591-3. [PMID: 26694990 DOI: 10.1002/bjs.9933] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 08/04/2015] [Indexed: 01/23/2023]
Affiliation(s)
- R A Cahill
- Department of Surgery, Mater Misericordiae University Hospital, 47 Eccles Street, Dublin 7, and University College Dublin, Dublin, Ireland.
| | - R Hompes
- Department of Colorectal Surgery, Oxford University Hospitals, Oxford, UK
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38
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Routine endoscopic surveillance for local recurrence of rectal cancer is futile. Am J Surg 2015; 210:996-1001; discussion 1001-2. [DOI: 10.1016/j.amjsurg.2015.06.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 06/24/2015] [Accepted: 06/27/2015] [Indexed: 11/19/2022]
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Wang L, Li YH, Cai Y, Zhan TC, Gu J. Intermediate Neoadjuvant Radiotherapy Combined With Total Mesorectal Excision for Locally Advanced Rectal Cancer: Outcomes After a Median Follow-Up of 5 Years. Clin Colorectal Cancer 2015; 15:152-7. [PMID: 26508595 DOI: 10.1016/j.clcc.2015.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 09/25/2015] [Accepted: 10/05/2015] [Indexed: 01/03/2023]
Abstract
BACKGROUND We previously reported the oncologic results for intermediate neoadjuvant radiotherapy (nRT) plus total mesorectal excision (TME) for locally advanced rectal cancer in a retrospective study. The objective of the present study was to further investigate the efficacy and long-term outcomes after this nRT regimen. PATIENTS AND METHODS From 2002 to 2011, 382 patients with resectable locally advanced rectal cancer were treated at the Peking University Cancer Hospital with 30 Gy of intermediate nRT in 10 fractions (biologic equivalent dose, 36 Gy) plus TME. Surgery, RT, and pathologic examination were standardized. The primary endpoints were local recurrence-free survival (LRFS), cancer-specific survival (CSS), and overall survival (OS). RESULTS The median patient age at the initial treatment was 58 years (range, 22-85 years). The median patient follow-up time was 5.5 years. The estimated 5-year LRFS, CSS, and OS were 93.6%, 79.0%, and 73.6%, respectively. Of the 382 patients, 4 (1%), 4 (1%), 4 (1%), and 11 (2.9%) patients died of postoperative complications, secondary malignancies, cardiovascular and/or neurologic events, or other causes, respectively. Seven patients (1.8%) developed late-onset ileus and died after conservative treatment in peripheral hospitals. CONCLUSION The 10-fraction intermediate nRT regimen reported in the present study is efficient and safe. The long-term outcome is acceptable. This treatment schedule is useful as an alternative that provides efficiency, patient convenience, and low medical costs.
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Affiliation(s)
- Lin Wang
- Department of Gastrointestinal Surgery, Peking University Cancer Hospital and Institute, Beijing, People's Republic of China
| | - Yong-Heng Li
- Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, People's Republic of China
| | - Yong Cai
- Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, People's Republic of China
| | - Tian-Cheng Zhan
- Department of Gastrointestinal Surgery, Peking University Cancer Hospital and Institute, Beijing, People's Republic of China
| | - Jin Gu
- Department of Gastrointestinal Surgery, Peking University Cancer Hospital and Institute, Beijing, People's Republic of China.
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40
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Lux P, Weber K, Hohenberger W. Laparoskopische Chirurgie des Kolonkarzinoms. COLOPROCTOLOGY 2015; 37:325-331. [DOI: 10.1007/s00053-015-0022-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
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Surgeon perspectives on the use and effects of neoadjuvant chemoradiation in the treatment of rectal cancer: a comprehensive review of the literature. Langenbecks Arch Surg 2015; 400:661-73. [PMID: 26250144 DOI: 10.1007/s00423-015-1328-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 07/27/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite screening initiatives, rectal cancer remains one of the most prevalent malignancies diagnosed in patients worldwide with a high mortality. The introduction of neoadjuvant therapy has resulted in a paradigm shift in the treatment and outcomes of rectal cancer. Surgeons play an intricate role in the pre-operative, operative, and post-operative management of these patients. PURPOSE The purpose of this comprehensive literature review was to summarize the evolution of the use chemotherapy and radiation and the process of differentiation into specific neoadjuvant chemoradiation protocols in the treatment of locally advanced rectal cancer. This will provide a concise summary for practicing surgeons of the current evidence for neoadjuvant chemoradiation as well as the various implications of therapy on operative outcomes. CONCLUSION The initial benefit of adjuvant therapy in the treatment of rectal cancer patients became evident with prospective studies demonstrating improvements in various oncologic survival outcomes. Due to the improved compliance and reduced toxicity, as well as the potential for tumor down-staging and sphincter preservation, neoadjuvant approaches became the preferred method of administering chemotherapy and radiation. Furthermore, a subgroup of patients has been shown to present with complete clinical response to neoadjuvant therapy. This has resulted in the development of the non-operative "watch and wait" approach, which has initiated discussions on changing the interval from the completion of neoadjuvant therapy to surgical resection. The continued development of the multidisciplinary approach will only further improve our ability to provide patients with the best possible oncologic outcomes.
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Abstract
Advances in the surgical management of rectal cancer have placed the quality of total mesorectal excision (TME) as the major predictor in overall survival. A standardized TME technique along with quality increases the percentage of patients undergoing a complete TME. Quality measurements of TME will place increasing demands on surgeons maintaining competence with present and future techniques. These efforts will improve the outcome of the rectal cancer patients.
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Affiliation(s)
- Warren E Lichliter
- Division of Colon and Rectal Surgery, Baylor University Medical Center, Dallas, Texas
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43
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Efficacy and safety of neoadjuvant intensity-modulated radiotherapy with concurrent capecitabine for locally advanced rectal cancer. Dis Colon Rectum 2015; 58:186-92. [PMID: 25585076 DOI: 10.1097/dcr.0000000000000294] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND We previously conducted a prospective phase II clinical trial studying a unique 22-fraction neoadjuvant intensity-modulated radiotherapy with concurrent capecitabine treatment followed by total mesorectal excision for locally advanced rectal cancer. OBJECTIVE The objective of this study was to retrospectively review the efficacy, toxicity, and surgical complications following intensity-modulated radiotherapy in patients who have rectal cancer. DESIGN This was a retrospective study. SETTING Data were gathered from a surgical database. PATIENTS This study included patients who underwent intensity-modulated radiotherapy with gross tumor volume/clinical target volume of 50.6/41.8 Gy in 22 fractions with concurrent capecitabine treatment over a period of 30 days, after which the patients underwent surgery for rectal cancer in Peking University Cancer Hospital (2007-2013). MAIN OUTCOME MEASURES The primary end points were acute toxicity, postoperative complications, and complete response rate. RESULTS A total of 260 patients were included in our analysis. The median age was 55 years (range, 21-87 years), and 68.5% of the patients were male. The yield complete response rate was 18.5% (48/260). There were no grade 4 toxicity and perioperative mortality. The grade 3 toxicity rate was 5.8%, which included diarrhea (4.2%), neutropenia (1.2%), and radiation dermatitis (0.4%). The 30-day postoperative and severe complication (≥grade 3) rates were 23.1% and 2.7%. The anastomotic leakage rate was 3.3% (5/152). Perineal wound complications (29.2%, 28/96) represented the most common problem following abdominoperineal resection. The estimated 3-year local recurrence-free survival, cancer-specific survival, and disease-free survival rates were 94.2% (95% CI, 90.1%-98.3%), 92.2% (95% CI, 87.5%-97.0%), and 81.4% (95% CI, 75.4%-87.4%). LIMITATION The retrospective nature and the single-arm design was the limitation of the study. CONCLUSION The 22-fraction neoadjuvant intensity-modulated radiotherapy regimen used to treat rectal cancer in this study has a high efficacy rate and a low toxicity rate. Further studies are needed to better define the role of intensity-modulated radiotherapy for rectal cancer treatment in a neoadjuvant setting.
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Affiliation(s)
- Phil Quirke
- Pathology and Tumour Biology, St James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK.
| | - Nick West
- Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, School of Medicine, University of Leeds, Leeds, UK
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Wilhelmsen M, Kring T, Jorgensen LN, Madsen MR, Jess P, Bulut O, Nielsen KT, Andersen CL, Nielsen HJ. Determinants of recurrence after intended curative resection for colorectal cancer. Scand J Gastroenterol 2014; 49:1399-408. [PMID: 25370351 DOI: 10.3109/00365521.2014.926981] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Despite intended curative resection, colorectal cancer will recur in ∼45% of the patients. Results of meta-analyses conclude that frequent follow-up does not lead to early detection of recurrence, but improves overall survival. The present literature shows that several factors play important roles in development of recurrence. It is well established that emergency surgery is a major determinant of recurrence. Moreover, anastomotic leakages, postoperative bacterial infections, and blood transfusions increase the recurrence rates although the exact mechanisms still remain obscure. From pathology studies it has been shown that tumors behave differently depending on their location and recur more often when micrometastases are present in lymph nodes and around vessels and nerves. K-ras mutations, microsatellite instability, and mismatch repair genes have also been shown to be important in relation with recurrences, and tumors appear to have different mutations depending on their location. Patients with stage II or III disease are often treated with adjuvant chemotherapy despite the fact that the treatments are far from efficient among all patients, who are at risk of recurrence. Studies are now being presented identifying subgroups, in which the therapy is inefficient. Unfortunately, only few of these facts are implemented in the present follow-up programs. Therefore, further research is urgently needed to verify which of the well-known parameters as well as new parameters that must be added to the current follow-up programs to identify patients at risk of recurrence.
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Affiliation(s)
- Michael Wilhelmsen
- Department of Surgical Gastroenterology 360, Hvidovre Hospital , Hvidovre , Denmark
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46
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Extralevator versus standard abdominoperineal excision for rectal cancer. Tech Coloproctol 2014; 19:145-52. [DOI: 10.1007/s10151-014-1243-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 10/28/2014] [Indexed: 12/13/2022]
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47
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Lux P, Weber K, Hohenberger W. [Laparoscopic surgery for colon cancer: quality requirements for (extended) right hemicolectomy]. Chirurg 2014; 85:593-8. [PMID: 24928372 DOI: 10.1007/s00104-014-2741-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The current S3 guidelines on the surgical treatment of colorectal cancer note that with a suitable patient selection and expertise of the surgeon the same oncological results can be achieved laparoscopically as with the open procedure. This requires that the same quality requirements have to be provided for both methods. The most important quality parameters of right sided (extended) hemicolectomy are central ligation of the supplying arteries (ileocolic artery, right branch of the middle colic artery and middle colic artery) flush to the central origin of the vessel (superior mesenteric artery or middle colic artery) and the sharp dissection of the mesocolon without any preparation tears. The photographic documentation of the fresh surgical specimens for categorizing the preparation quality as well as to determine the pedicle of the vessel can capture this quality well and is also currently the best surrogate parameter to evaluate the oncological quality of the operation. At present, there are still considerable widespread deficits not only with the laparoscopic approach but also in open surgery which must be urgently fixed.
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Affiliation(s)
- P Lux
- Kinderchirurgische Abteilung, Universitätsklinikum Erlangen, Krankenhausstr. 12, 91054, Erlangen, Deutschland,
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Madbouly KM, Hussein AM, Abdelzaher E. Long-term prognostic value of mesorectal grading after neoadjuvant chemoradiotherapy for rectal cancer. Am J Surg 2014; 208:332-41. [PMID: 24581995 DOI: 10.1016/j.amjsurg.2013.10.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Revised: 09/22/2013] [Accepted: 10/03/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Mesorectal grading was reported to be a valuable prognostic factor in rectal cancer surgery. Previous studies were retrospective, and had short follow-up. OBJECTIVE To assess the long-term influence of total mesorectal excision quality on disease recurrence in mid and low rectal cancer patients who received preoperative neoadjuvant chemoradiotherapy (CRT) and postoperative chemotherapy. METHODS One hundred twenty-one patients with rectal cancer had either low anterior resection or abdominoperineal resection. All patients received neoadjuvant CRT and postoperative chemotherapy. Main outcome measures included TNM staging, involvement of the circumferential resection margin (ICRM), mesorectal grading, local and systemic recurrences were recorded. RESULTS Follow-up was done for at least 5 years or up to disease recurrence whatever comes first. Mean follow-up time was 59.4 months. Twenty-nine patients had abdominoperineal resection and 92 had low anterior resection. About 7.5% had positive CRM which was significantly correlated with mesorectal grading. Grade 3 mesorectal specimens were obtained in approximately 60% of patients, 27% had grade 2, and only 13% had grade 1 (poor) mesorectal specimens. Poorer mesorectal grading increased with APR and lower rectal tumors. Recurrences occurred in 20% of patients (40% in the first 2 years, 32% in the 3rd year, and 28% in the 4th and 5th years); factors affecting recurrence included lymphovascular invasion, ICRM, and N stage. Mesorectal grading was not a valuable prognostic factor for recurrence unless it resulted in ICRM. Recurrences occurred earlier with poorer mesorectal grade, yet this was not statistically significant. CONCLUSIONS Mesorectal grading is a pathologic description that reflects the quality of surgery. However, in patients who received neoadjuvant CRT and postoperative chemotherapy, grading had no long-term prognostic value regarding recurrences unless it resulted in ICRM.
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Affiliation(s)
- Khaled M Madbouly
- Department of Surgery, University of Alexandria, El Raml Station, Alexandria, Egypt.
| | - Ahmed M Hussein
- Department of Surgery, University of Alexandria, El Raml Station, Alexandria, Egypt
| | - Eman Abdelzaher
- Department of Pathology, University of Alexandria, El Raml Station, Alexandria, Egypt
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Wang L, Zhong XG, Peng YF, Li ZW, Gu J. Prognostic value of pretreatment level of carcinoembryonic antigen on tumour downstaging and early occurring metastasis in locally advanced rectal cancer following neoadjuvant radiotherapy (30 Gy in 10 fractions). Colorectal Dis 2014; 16:33-9. [PMID: 23848511 DOI: 10.1111/codi.12354] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Accepted: 02/13/2013] [Indexed: 12/13/2022]
Abstract
AIM To evaluate the role of carcinoembryonic antigen (CEA) in predicting the response to and prognosis for locally advanced rectal cancer treated with 30 Gy neoadjuvant radiotherapy (nRT) in 10 fractions (30 Gy/10 f). METHOD This retrospective study involved 240 patients with locally advanced rectal cancer who underwent 30 Gy/10 f nRT (biologically equivalent dose 36 Gy) followed by total mesorectal excision between August 2003 and 2009. Serum CEA level was determined before administration of nRT. The prognostic value of serum CEA level on tumour downstaging and 3-year disease-free survival was analysed. RESULTS Ninety out of 240 (37.5%) patients had elevated CEA levels before nRT. The incidence of T downstaging in patients decreased significantly as the pretreatment CEA levels became more elevated (< 5 ng/ml, 50.7%; 5-10 ng/ml, 39.5%; > 10 ng/ml, 17.3%; P = 0.00014). Downstaging to ypCR or ypStage I occurred in 46.7% (66/150) of patients with a CEA level of < 5 ng/ml and 34.2% (13/38) of patients with a CEA level of 5-10 ng/ml. In contrast, just 13.5% (7/52) of those with a CEA level > 10 ng/ml downstaged to ypStage I and none of them achieved ypCR, with statistical difference (P = 0.001). A significantly higher incidence of early metastasis (within 6 postoperative months) was observed with increasing CEA level: 2.0% (3/150), 5.4% (2/38) and 11.5% (6/52) in patients with CEA level < 5 ng/ml, 5-10 ng/ml or > 10 ng/ml, respectively (P = 0.018). CONCLUSION Pretreatment CEA level cannot only predict tumour downstaging and ypTNM stage for rectal cancer following 30 Gy/10 f nRT, but also promisingly suggests a high incidence of early occurring distant metastasis. These findings may be used to select patients with nRT resistance and occult metastasis and make alternative treatment strategies.
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Affiliation(s)
- L Wang
- Department of Colorectal Surgery, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, Beijing, China
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