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Giner F, Frasson M, Cholewa H, Sancho-Muriel J, García-Gómez E, Hernández JA, Flor-Lorente B, García-Granero E. A comparison of whole-mount and conventional sections for pathological mesorectal extension and circumferential resection margin assessment after total mesorectal excision. Cir Esp 2024:S2173-5077(24)00049-8. [PMID: 38373616 DOI: 10.1016/j.cireng.2024.01.008] [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: 10/13/2023] [Accepted: 01/24/2024] [Indexed: 02/21/2024]
Abstract
INTRODUCTION The objective of the study is to compare 2 techniques for histological handling of rectal cancer specimens, namely whole-mount in a large block vs conventional sampling using small blocks, for mesorectal pathological assessment of circumferential resection margin status and depth of tumor invasion into the mesorectal fat. METHODS This is a prospective study including 27 total mesorectal excision specimens of rectal cancer from patients treated for primary rectal carcinoma between 2020 and 2022 in a specialized multidisciplinary Colorectal Unit. For each total mesorectal excision specimen, 2 contiguous representative tumoral slices were selected and comparatively analyzed with whole-mount and small blocks macroscopic dissection techniques, enabling comparison between them in the same surgical specimen. The agreement between the 2 techniques to assess the distance of the tumor from the circumferential resection margin as well as the depth of tumor invasion was evaluated with the Student's t-test for paired samples, Pearson's correlation coefficient, and the Bland-Altman method comparison analysis. RESULTS Complete mesorectal excision was observed in 8% of cases. Circumferential resection margin involvement was observed in only one case (4 %). The whole-mount and small block techniques obtained similar results when we assessed the distance to the circumferential resection margin (t-test P = 0.8, r = 0.92) and the depth of mesorectal infiltration (t-test P = 0.6, r = 0.95). CONCLUSIONS Both gross dissection techniques (whole-mount vs multiple small cassettes) are equivalent and reliable to assess the distance to circumferential resection margin and the depth of mesorectal infiltration in the mesorectal fat in rectal cancer staging.
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Affiliation(s)
- Francisco Giner
- Pathology Department, University of Valencia, Valencia, Spain; Pathology Department, Hospital Universitari I Politècnic La Fe, Valencia, Spain
| | - Matteo Frasson
- Coloproctology Unit, Hospital Universitari I Politècnic La Fe, University of Valencia, Valencia, Spain; Surgery Department. University of Valencia, Spain.
| | - Hanna Cholewa
- Coloproctology Unit, Hospital Universitari I Politècnic La Fe, University of Valencia, Valencia, Spain
| | - Jorge Sancho-Muriel
- Coloproctology Unit, Hospital Universitari I Politècnic La Fe, University of Valencia, Valencia, Spain
| | | | | | - Blas Flor-Lorente
- Coloproctology Unit, Hospital Universitari I Politècnic La Fe, University of Valencia, Valencia, Spain; Surgery Department. University of Valencia, Spain
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Sylla P, Sands D, Ricardo A, Bonaccorso A, Polydorides A, Berho M, Marks J, Maykel J, Alavi K, Zaghiyan K, Whiteford M, Mclemore E, Chadi S, Shawki SF, Steele S, Pigazzi A, Albert M, DeBeche-Adams T, Moshier E, Wexner SD. Multicenter phase II trial of transanal total mesorectal excision for rectal cancer: preliminary results. Surg Endosc 2023; 37:9483-9508. [PMID: 37700015 PMCID: PMC10709232 DOI: 10.1007/s00464-023-10266-9] [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: 04/15/2023] [Accepted: 06/27/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND Transanal TME (taTME) combines abdominal and transanal dissection to facilitate sphincter preservation in patients with low rectal tumors. Few phase II/III trials report long-term oncologic and functional results. We report early results from a North American prospective multicenter phase II trial of taTME (NCT03144765). METHODS 100 patients with stage I-III rectal adenocarcinoma located ≤ 10 cm from the anal verge (AV) were enrolled across 11 centers. Primary and secondary endpoints were TME quality, pathologic outcomes, 30-day and 90-day outcomes, and stoma closure rate. Univariable regression analysis was performed to assess risk factors for incomplete TME and anastomotic complications. RESULTS Between September 2017 and April 2022, 70 males and 30 females with median age of 58 (IQR 49-62) years and BMI 27.8 (IQR 23.9-31.8) kg/m2 underwent 2-team taTME for tumors located a median 5.8 (IQR 4.5-7.0) cm from the AV. Neoadjuvant radiotherapy was completed in 69%. Intersphincteric resection was performed in 36% and all patients were diverted. Intraoperative complications occurred in 8% including 3 organ injuries, 2 abdominal and 1 transanal conversion. The 30-day and 90-day morbidity rates were 49% (Clavien-Dindo (CD) ≥ 3 in 28.6%) and 56% (CD ≥ 3 in 30.4% including 1 mortality), respectively. Anastomotic complications were reported in 18% including 10% diagnosed within 30 days. Higher anastomotic risk was noted among males (p = 0.05). At a median follow-up of 5 (IQR 3.1-7.4) months, 98% of stomas were closed. TME grade was complete or near complete in 90%, with positive margins in 2 cases (3%). Risk factors for incomplete TME were ASA ≥ 3 (p = 0.01), increased time between NRT and surgery (p = 0.03), and higher operative blood loss (p = 0.003). CONCLUSION When performed at expert centers, 2-team taTME in patients with low rectal tumors is safe with low conversion rates and high stoma closure rate. Mid-term results will further evaluate oncologic and functional outcomes.
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Affiliation(s)
- Patricia Sylla
- Division of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY, USA.
- Division of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY, USA.
| | - Dana Sands
- Department of Colon and Rectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Alison Ricardo
- Division of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY, USA
| | | | | | - Mariana Berho
- Executive Administration Florida, Cleveland Clinic Florida, Weston, FL, USA
| | - John Marks
- Department of Colorectal Surgery, Lankenau Medical Center, Wynnewood, PA, USA
| | - Justin Maykel
- Division of Colon and Rectal Surgery, UMass Memorial Medical Center, Worcester, MA, USA
| | - Karim Alavi
- Division of Colon and Rectal Surgery, UMass Memorial Medical Center, Worcester, MA, USA
| | - Karen Zaghiyan
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Mark Whiteford
- Gastrointestinal and Minimally Invasive Surgical Division, The Oregon Clinic, Providence Cancer Center, Portland, OR, USA
| | - Elisabeth Mclemore
- Division of Colorectal Surgery, Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | - Sami Chadi
- Division of Surgical Oncology, Department of Surgery, Princess Margaret Cancer Centre and University Health Network, Toronto, ON, Canada
| | - Sherief F Shawki
- Department of Colorectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Scott Steele
- Department of Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Alessio Pigazzi
- Division of Colorectal Surgery, Department of Surgery, New York-Presbyterian Weill Cornell Medical Center, New York, NY, USA
| | - Matthew Albert
- Department of Colon and Rectal Surgery, Advent Health Orlando, Orlando, FL, USA
| | | | - Erin Moshier
- Department of Population Health Sciences and Policy, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Steven D Wexner
- Department of Colorectal Surgery, Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, USA
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Kang MK, Park SY, Park JS, Kim HJ, Kim JG, Kang BW, Baek JH, Cho SH, Seo AN, Kim DW, Kim J, Baek SJ, Kim JH, Kim JY, Ha GW, Park EJ, Park IJ, Kim CH, Kang H, Choi GS. Preoperative sequential short-course radiation therapy and FOLFOX chemotherapy versus long-course chemoradiotherapy for locally advanced rectal cancer: a multicenter, randomized controlled trial (SOLAR trial). BMC Cancer 2023; 23:1059. [PMID: 37923987 PMCID: PMC10623855 DOI: 10.1186/s12885-023-11363-7] [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: 07/16/2023] [Accepted: 09/04/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND Preoperative (chemo)radiotherapy has been widely used as an effective treatment for locally advanced rectal cancer (LARC), leading to a significant reduction in pelvic recurrence rates. Because early administration of intensive chemotherapy for LARC has more advantages than adjuvant chemotherapy, total neoadjuvant therapy (TNT) has been introduced and evaluated to determine whether it can improve tumor response or treatment outcomes. This study aims to investigate whether short-course radiotherapy (SCRT) followed by intensive chemotherapy improves oncologic outcomes compared with traditional preoperative long-course chemoradiotherapy (CRT). METHODS A multicenter randomized phase II trial involving 364 patients with LARC (cT3-4, cN+, or presence of extramural vascular invasion) will be conducted. Patients will be randomly assigned to the experimental or control arm at a ratio of 1:1. Participants in the experimental arm will receive SCRT (25 Gy in 5 fractions, daily) followed by four cycles of FOLFOX (oxaliplatin, 5-fluorouracil, and folinic acid) as a neoadjuvant treatment, and those in the control arm will receive conventional radiotherapy (45-50.4 Gy in 25-28 fractions, 5 times a week) concurrently with capecitabine or 5-fluorouracil. As a mandatory surgical procedure, total mesorectal excision will be performed 2-5 weeks from the last cycle of chemotherapy in the experimental arm and 6-8 weeks after the last day of radiotherapy in the control arm. The primary endpoint is 3-year disease-free survival, and the secondary endpoints are tumor response, overall survival, toxicities, quality of life, and cost-effectiveness. DISCUSSION This is the first Korean randomized controlled study comparing SCRT-based TNT with traditional preoperative LC-CRT for LARC. The involvement of experienced colorectal surgeons ensures high-quality surgical resection. SCRT followed by FOLFOX chemotherapy is expected to improve disease-free survival compared with CRT, with potential advantages in tumor response, quality of life, and cost-effectiveness. TRIAL REGISTRATION This trial is registered at Clinical Research Information under the identifier Service KCT0004874 on April 02, 2020, and at Clinicaltrial.gov under the identifier NCT05673772 on January 06, 2023.
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Grants
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- HA22C0042 National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
- National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea
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Affiliation(s)
- Min Kyu Kang
- Department of Radiation Oncology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Soo Yeun Park
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, 807 Hogukro, Buk-gu, Daegu, 41404, South Korea
| | - Jun Seok Park
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, 807 Hogukro, Buk-gu, Daegu, 41404, South Korea
| | - Hye Jin Kim
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, 807 Hogukro, Buk-gu, Daegu, 41404, South Korea
| | - Jong Gwang Kim
- Department of Oncology/Hematology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Byung Woog Kang
- Department of Oncology/Hematology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Jin Ho Baek
- Department of Oncology/Hematology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Seung Hyun Cho
- Department of Radiology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - An Na Seo
- Department of Pathology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Duck-Woo Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jin Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University College of Medicine, Seoul, South Korea
| | - Se Jin Baek
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University College of Medicine, Seoul, South Korea
| | - Ji Hoon Kim
- Division of Colorectal Surgery, Department of Surgery, Incheon St. Mary's Hospital, the Catholic University of Korea, Incheon, South Korea
| | - Ji Yeon Kim
- Division of Colorectal Surgery, Department of Surgery, Chungnam National University Hospital, Daejeon, South Korea
| | - Gi Won Ha
- Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Jeonbuk, South Korea
| | - Eun Jung Park
- Division of Colon and Rectal Surgery, Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - In Ja Park
- Division of Colon and Rectal Surgery, Department of surgery, , University of Ulsan College of Medicine and Asan Medical Center, Seoul, South Korea
| | - Chang Hyun Kim
- Department of Surgery, Chonnam National University Hwasun Hospital and Medical School, Hwasun, South Korea
| | - Hyun Kang
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, South Korea
| | - Gyu-Seog Choi
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, 807 Hogukro, Buk-gu, Daegu, 41404, South Korea.
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Baloyiannis I, Perivoliotis K, Mamaloudis I, Bompou E, Sarakatsianou C, Tzovaras G. Determination of Factors Related to the Reversal and Perioperative Outcomes of Defunctioning Ileostomies in Patients Undergoing Rectal Cancer Surgery: A Regression Analysis Model. J Gastrointest Cancer 2023; 54:782-790. [PMID: 36063314 DOI: 10.1007/s12029-022-00862-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE Defunctioning ileostomies are often performed during rectal cancer surgery. However, stomas are sometimes associated with complications, while 20-30% of them are never reversed. Additionally, ileostomy closure can have associated morbidity, with rates as high as 45%, with the respective literature evidence being scarce and conflicting. Thus, we evaluated the stoma reversal outcomes and the risk factors for non-closure after rectal cancer surgery. METHODS This is a retrospective analysis of a prospectively collected database of all patients who had a defunctioning ileostomy at the time of resection for rectal cancer. All operations were performed by the same surgical team. A multivariable regression model was implemented. RESULTS In this study, 129 patients (male: 68.2%, female: 31.8%) were included. Ileostomy formation was associated with a total of 31% complication rate. Eventually 73.6% of the stomas were reversed at a mean time to closure of 26.6 weeks, with a morbidity of 13.7%. Non-reversal of ileostomy was correlated with neoadjuvant CRT (OR: 0.093, 95% CI: 0.012-0.735), anastomotic leakage (OR: 0.107, 95% CI: 0.019-0.610), and lymph node yield (OR: 0.946, 95% CI: 0.897-0.998). Time to reversal was affected by the N status, the LNR, the need for adjuvant chemotherapy, and the histologic grade. CONCLUSION In patients with rectal cancer resections, defunctioning stoma closure rate and time to closure were associated with several perioperative and pathological outcomes.
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Affiliation(s)
- Ioannis Baloyiannis
- Department of Surgery, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
| | - Konstantinos Perivoliotis
- Department of Surgery, General Hospital of Volos, Polymeri 134, 38222, Volos, Greece.
- University of Thessaly, Viopolis, 41500, Larissa, Greece.
- Department of Surgery, University Hospital of Larissa, Viopolis, 41110, Larissa, Greece.
| | - Ioannis Mamaloudis
- Department of Surgery, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
| | - Effrosyni Bompou
- Department of Surgery, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
| | - Chamaidi Sarakatsianou
- Department of Anesthesiology, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
| | - George Tzovaras
- Department of Surgery, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
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Sylla P, Berho M, Sands D, Ricardo A, Bonaccorso A, Moshier E, Hain E, Letchinger R, Marks J, Whiteford M, Mclemore E, Maykel J, Alavi K, Zaghiyan K, Chadi S, Shawki SF, Steele S, Pigazzi A, Albert M, DeBeche-Adams T, Polydorides A, Wexner S. Discordance in Total Mesorectal Excision Specimen Grading in a Prospective Phase 2 Multicenter Rectal Cancer Trial: Are We Overestimating the Quality of Our Resections? Ann Surg 2023; 278:452-463. [PMID: 37450694 DOI: 10.1097/sla.0000000000005948] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
OBJECTIVES To report the results of a rigorous quality control (QC) process in the grading of total mesorectal excision (TME) specimens during a multicenter prospective phase 2 trial of transanal TME. BACKGROUND Grading of TME specimens is based on the macroscopic assessment of the mesorectum and standardized through synoptic pathology reporting. TME grade is a strong predictor of outcomes with incomplete (IC) TME associated with increased rates of local recurrence relative to complete or near complete (NC) TME. Although TME grade serves as an endpoint in most rectal cancer trials, in protocols incorporating centralized review of TME specimens for quality assurance, discordance in grading and the management thereof has not been previously described. METHODS A phase 2 prospective transanal TME trial was conducted from 2017 to 2022 across 11 North American centers with TME quality as the primary study endpoint. QC measures included (1) training of site pathologists in TME protocols, (2) blinded grading of de-identified TME specimen photographs by central pathologists, and (3) reconciliation of major discordance before trial reporting. Cohen Kappa statistic was used to assess agreement in grading. RESULTS Overall agreement in grading of 100 TME specimens between site and central reviewer was rated as fair, (κ = 0.35; 95% CI: 0.10-0.61; P < 0.0001). Concordance was noted in 54%, with minor and major discordance in 32% and 14% of cases, respectively. Upon reconciliation, 13/14 (93%) major discordances were resolved. Pre versus postreconciliation rates of complete or NC and IC TME are 77%/16% and 7% versus 69%/21% and 10%. Reconciliation resulted in a major upgrade (IC-NC; N = 1) or major downgrade (NC/C-IC, N = 4) in 5 cases overall (5%). CONCLUSIONS A 14% rate of major discordance was observed in TME grading between the site and central reviewers. The resolution resulted in a major change in final TME grade in 5% of cases, which suggests that reported rates or TME completeness are likely overestimated in trials. QC through a central review of TME photographs and reconciliation of major discordances is strongly recommended.
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Affiliation(s)
- Patricia Sylla
- Division of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY
| | - Mariana Berho
- Executive Administration Florida, Cleveland Clinic Florida, Weston, FL
| | - Dana Sands
- Department of Colon and Rectal Surgery, Cleveland Clinic Florida, Weston, FL
| | - Alison Ricardo
- Division of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY
| | | | - Erin Moshier
- Department of Population Health Sciences and Policy, Icahn School of Medicine at Mount Sinai Hospital, New York, NY
| | - Elisabeth Hain
- Department of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY
| | - Riva Letchinger
- Icahn School of Medicine at Mount Sinai Hospital, New York, NY
| | - John Marks
- Department of Colorectal Surgery, Lankenau Medical Center, Wynnewood, PA
| | - Mark Whiteford
- Gastrointestinal and Minimally Invasive Surgical Division, the Oregon Clinic Providence Cancer Center, Portland, OR
| | - Elisabeth Mclemore
- Department of Surgery, Division of Colorectal Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Justin Maykel
- Division of Colon and Rectal Surgery, UMass Memorial Medical Center, Worcester, MA
| | - Karim Alavi
- Division of Colon and Rectal Surgery, UMass Memorial Medical Center, Worcester, MA
| | - Karen Zaghiyan
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Sami Chadi
- Department of Surgery, Division of Surgical Oncology, Princess Margaret Cancer Centre and University Health Network, Toronto, Ontario, Canada
| | | | - Scott Steele
- Department of Surgery, Cleveland Clinic, Cleveland, OH
| | - Alessio Pigazzi
- Department of Surgery, Division of Colorectal Surgery, New York-Presbyterian Weill Cornell Medical Center, New York, NY
| | - Matthew Albert
- Department of Colon and Rectal Surgery, Advent Health Orlando, Orlando, FL
| | | | | | - Steven Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL
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Svoboda M, Procházka V, Grolich T, Pavlík T, Mazalová M, Kala Z. Does Pathological Complete Response after Neoadjuvant Therapy Influence Postoperative Morbidity in Rectal Cancer after Transanal Total Mesorectal Excision? J Gastrointest Cancer 2023; 54:528-535. [PMID: 35524090 DOI: 10.1007/s12029-022-00826-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE It is still unclear if pathological complete response (pCR) after neoadjuvant chemoradiotherapy (CRT) in patients treated for rectal cancer causes worse postoperative outcomes, especially after transanal total mesorectal excision (TaTME). Worse postoperative outcomes might be an argument for an organ preserving watch and wait strategy in fragile patients and patients with comorbidities. The aim of this study is to evaluate whether patients treated for rectal cancer who had pCR to neoadjuvant therapy develop worse postoperative outcomes after TaTME than patients without complete response. METHODS Comparative retrospective analysis (with nearest neighbor matching algorithm) of postoperative outcomes in two groups of patients, with pCR, n = 15 and without pCR (non-pCR), n = 57. All patients were operated on only by one surgical approach, TaTME, for middle and distal rectal tumors. All procedures were performed by one surgical team between 2014 and 2020 at the University Hospital Brno in Czech Republic. RESULTS Overall morbidity was comparable between the groups (pCR group - 53.8% vs. non-pCR - 38.6%, p = 0.381). Anastomotic leak (AL) was observed in 33.3% of patients with pCR and in 17.5% of patients in the non-pCR group without statistical significance (p = 0.281). CONCLUSION In conclusion, pathological complete response after neoadjuvant therapy does not appear to affect postoperative morbidity in rectal cancer after TaTME. Therefore, in patients with complete response who are not adherent to W&W surveillance, surgical resection can be perform without increased postoperative complications.
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Affiliation(s)
- Martin Svoboda
- Department of Surgery, Faculty of Medicine, University Hospital Brno Bohunice, Masaryk University, Brno, Czech Republic
| | - Vladimír Procházka
- Department of Surgery, Faculty of Medicine, University Hospital Brno Bohunice, Masaryk University, Brno, Czech Republic.
| | - Tomáš Grolich
- Department of Surgery, Faculty of Medicine, University Hospital Brno Bohunice, Masaryk University, Brno, Czech Republic
| | - Tomáš Pavlík
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Monika Mazalová
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Zdeněk Kala
- Department of Surgery, Faculty of Medicine, University Hospital Brno Bohunice, Masaryk University, Brno, Czech Republic
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7
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Ando M, Matsuda T, Sawada R, Hasegawa H, Yamashita K, Harada H, Urakawa N, Goto H, Kanaji S, Oshikiri T, Kakeji Y. Feasibility and safety of robotic surgery for low rectal cancer combined with transanal total mesorectal excision. Langenbecks Arch Surg 2023; 408:129. [PMID: 36991217 PMCID: PMC10060269 DOI: 10.1007/s00423-023-02870-z] [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: 11/10/2022] [Accepted: 03/24/2023] [Indexed: 03/31/2023]
Abstract
PURPOSE Laparoscopic surgery for low rectal cancer is often challenging. Transanal total mesorectal excision (TaTME) and robotic surgery have been introduced to overcome the technical difficulties in laparoscopic surgery and achieve more favorable outcomes. Hybrid robotic surgery, which combines TaTME with the abdominal robotic approach, incorporates the advantages of each of these surgical techniques and might achieve less invasive and safer surgery. This study evaluated the safety and feasibility of hybrid robotic surgery with TaTME (hybrid TaTME). METHODS We retrospectively reviewed 162 TaTME cases performed at our department from September 2016 to May 2022. Among them, 92 cases of conventional TaTME and 30 of hybrid TaTME were eligible. We used propensity score matching analysis (PSM) to adjust for patients' characteristics and compared the short-term outcomes of the two treatment groups. RESULTS Twenty-seven cases in each group were extracted using PSM. The operation time in hybrid TaTME was comparable to that in conventional TaTME. There was no significant difference in the postoperative hospital stay between the two groups. Other intra- and post-operative outcomes were also comparable between the two groups. Furthermore, no significant differences were observed between the two groups in the curative resection and recurrence rates. CONCLUSION Hybrid TaTME for low rectal cancer was as favorable as conventional TaTME in producing satisfactory short-term outcomes. However, furthermore, larger-scale studies conducted over longer study periods are needed to evaluate the validity of the findings.
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Affiliation(s)
- Masayuki Ando
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takeru Matsuda
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan.
- Division of Minimally Invasive Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-Chou, Chuo-Ku, Kobe, 650-0017, Japan.
| | - Ryuichiro Sawada
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroshi Hasegawa
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kimihiro Yamashita
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hitoshi Harada
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Naoki Urakawa
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hironobu Goto
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shingo Kanaji
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Taro Oshikiri
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yoshihiro Kakeji
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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Advanced Lymph Node Staging With Ex Vivo Intra-arterial Indigo Carmine Injection After Transanal Total Mesorectal Excision for Rectal Cancer: A Retrospective Cohort Study. Dis Colon Rectum 2022; 65:1015-1024. [PMID: 34856584 DOI: 10.1097/dcr.0000000000002058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Exact lymph node staging is essential in rectal cancer therapy. OBJECTIVE The aim of the study was to assess the impact of intra-arterial indigo carmine injection after transanal total mesorectal excision on the number of retrieved lymph nodes. DESIGN This was a retrospective, nonrandomized study. SETTINGS The study was conducted at a tertiary hospital by a multidisciplinary team. PATIENTS Patients who underwent transanal total mesorectal excision for suspected rectal cancer between 2013 and 2019 were included. INTERVENTIONS Rectal cancer specimens received ex vivo intra-arterial indigo carmine injection to stain lymph nodes. MAIN OUTCOME MEASURES Outcome measures included the number of retrieved lymph nodes with or without staining. RESULTS Specimens of 189 patients were analyzed, of which 108 (57.1%) were stained with indigo carmine. A mean of 19.8 ± 6.1 lymph nodes was identified in stained samples compared to 16.0 ± 4.9 without staining ( p < 0.001). Multivariable analysis showed that 3.2 additional lymph nodes were found in stained specimens (95% CI: 1.0 to 5.3; p = 0.02). In stained specimens the adequate lymph node count (≥12) was increased in univariable (odds ratio: 3.24, 95% CI: 1.13 to 10.65; p = 0.03) but not in multivariable analysis. Indigo carmine injection had no effect on the number of positive lymph nodes or the nodal stage. Chemoradiotherapy reduced the lymph node count by 2.5 ( p = 0.008). After staining, 95.0% of patients with chemoradiotherapy had ≥12 lymph nodes retrieved. The median follow-up of patients was 24.2 months with a local recurrence rate of 3.3%. LIMITATIONS The study is limited by its retrospective design and the nonrandomized allocation. CONCLUSIONS Ex vivo intra-arterial indigo carmine injection increases the number of isolated lymph nodes after transanal total mesorectal excision regardless of neoadjuvant chemoradiotherapy. Indigo carmine injection is not associated with nodal upstaging or an increased number of tumor-positive lymph nodes. See Video Abstract at http://links.lww.com/DCR/B839 . ESTADIFICACIN AVANZADA DE LOS GANGLIOS LINFTICOS CON INYECCIN INTRAARTERIAL EX VIVO,DE NDIGO CARMN,DESPUS DE LA ESCISIN TOTAL DEL MESORRECTO POR VA TRANSANAL PARA CNCER DE RECTO UN ESTUDIO DE COHORTE RETROSPECTIVO ANTECEDENTES:La estadificación exacta de los ganglios linfáticos es esencial en la tratamiento del cáncer de recto.OBJETIVO:El objetivo del estudio fue evaluar el impacto de la inyección intraarterial de índigo carmín después de la escisión total del mesorrecto por vía transanal con relación al número de ganglios linfáticos recuperados en el espécimen quirúrgico..DISEÑO:Estudio retrospectivo no aleatorizado.AJUSTE:El estudio se llevó a cabo en un hospital de tercer nivel por un equipo multidisciplinario.PACIENTES:Pacientes a quienes se les practicó escisión total del mesorrecto por vía transanal por sospecha de cáncer de recto entre 2013 y 2019.INTERVENCIONES:Al espécimen quirúrgico que se obtuvo, se le practicó inyección intraarterial ex vivo, de índigo carmín para teñir los ganglios linfáticos.PRINCIPALES MEDIDAS DE RESULTADO:El número de ganglios linfáticos recuperados con o sin tinción.RESULTADOS:Se analizaron muestras de 189 pacientes, de los cuales 108 (57,1%) fueron teñidos con índigo carmín. Se identificó una media de 19,8 ± 6,1 ganglios linfáticos en las muestras teñidas en comparación con 16,0 ± 4,9 sin tinción ( p < 0,001). El análisis multivariado mostró que se encontraron 3.2 ganglios linfáticos adicionales en las muestras teñidas (intervalo de confianza del 95%: 1,0 a 5,3; p = 0,02). En las muestras teñidas, el recuento adecuado de ganglios linfáticos (≥12) aumentó en el análisis univariado (razón de posibilidades: 3,24, intervalo de confianza del 95%: 1,13 a 10,65; p = 0,03) pero no en el multivariado. La inyección de índigo carmín no tuvo ningún efecto sobre el número de ganglios linfáticos positivos o el estadio ganglionar. La quimiorradioterapia redujo el recuento de ganglios linfáticos en 2,5 ( p = 0,008). Después de la tinción, en el 95,0% de los pacientes con quimiorradioterapia se recuperaron ≥12 ganglios linfáticos. La mediana de seguimiento de los pacientes fue de 24,2 meses con una tasa de recurrencia local del 3,3%.LIMITACIONES:El estudio está limitado por su diseño retrospectivo y la asignación no aleatoria.CONCLUSIONES:La inyección ex vivo de índigo carmín intraarterial aumenta el número de ganglios linfáticos aislados después de la escisión total del mesorrectal por vía transanal a pesar de la quimiorradioterapia neoadyuvante. La inyección de índigo carmín no se asocia con un aumento del estadio de los ganglios ni con un mayor número de ganglios linfáticos positivos para tumor. Consulte Video Resumen en http://links.lww.com/DCR/B839 . (Traducción-Eduardo Londoño-Schimmer ).
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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: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [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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Diefenhardt M, Ludmir EB, Hofheinz RD, Ghadimi M, Minsky BD, Fleischmann M, Fokas E, Rödel C. Impact of body-mass index on treatment and outcome in locally advanced rectal cancer: A secondary, post-hoc analysis of the CAO/ARO/AIO-04 randomized phase III trial. Radiother Oncol 2021; 164:223-231. [PMID: 34619239 DOI: 10.1016/j.radonc.2021.09.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 09/15/2021] [Accepted: 09/26/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND A better understanding of the impact of body-mass index (BMI) on the course of multimodal therapy and oncologic outcome in locally advanced rectal cancer could provide new insights for optimization of treatment and supportive strategies. PATIENTS AND METHODS Correlations of BMI with pretreatment clinical, surgical, and pathological characteristics, toxicity and treatment adherence using the Pearson's Chi-squared test or logistic regression were analyzed in the CAO/ARO/AIO-04 III trial cohort (n = 1236). One-way ANOVA or Welch test were used to analyze correlations of baseline blood-parameters and BMI. The prognostic role of BMI was examined with log-rank test and multivariate cox regression. RESULTS Obese had a better ECOG performance status (P = 0.027) but were less likely to undergo sphincter preserving surgery (P = 0.01). Post-surgical complications did not differ significantly between BMI classes, whereas underweight was associated with increased neutrophil (P = 0.025) and platelet counts (P < 0.001), poorer TME quality (P = 0.007) and increased incidence of acute organ toxicity (P < 0.001). After a median follow-up of 50 months, underweight [HR 1.896, P = 0.014] and overweight [HR 1.392, P = 0.042] were associated with worse DFS. Obese patients had an increased risk of death [HR 1.653, P = 0.032]. Normalweight men showed superior OS compared to underweight [HR 4.070, P = 0.002], overweight [HR 2.077, P = 0.010], severe overweight [HR 1.886, P = 0.026] and obese [HR 2.046, P = 0.015] men. Adding oxaliplatin to standard CRT significantly improved DFS in obese patients (P = 0.034). CONCLUSION In our study, underweight and overweight correlated with inferior DFS, underweight experienced more organ toxicity and obesity was associated with an increased risk of abdominoperineal resection and poorer overall survival.
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Affiliation(s)
- Markus Diefenhardt
- Department of Radiotherapy and Oncology, University of Frankfurt, Germany; Frankfurt Cancer Institute, Frankfurt, Germany.
| | - Ethan B Ludmir
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Ralf-Dieter Hofheinz
- Department of Medical Oncology, University Hospital Mannheim, University Heidelberg, Germany
| | - Michael Ghadimi
- Department of General, Visceral and Pediatric Surgery, University Medical Center, Göttingen, Germany
| | - Bruce D Minsky
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Max Fleischmann
- Department of Radiotherapy and Oncology, University of Frankfurt, Germany
| | - Emmanouil Fokas
- Department of Radiotherapy and Oncology, University of Frankfurt, Germany; German Cancer Research Center (DKFZ), Heidelberg, German Cancer Consortium (DKTK), Partner Site Frankfurt am Main, Frankfurt, Germany; Frankfurt Cancer Institute, Frankfurt, Germany
| | - Claus Rödel
- Department of Radiotherapy and Oncology, University of Frankfurt, Germany; German Cancer Research Center (DKFZ), Heidelberg, German Cancer Consortium (DKTK), Partner Site Frankfurt am Main, Frankfurt, Germany; Frankfurt Cancer Institute, Frankfurt, Germany
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Piozzi GN, Baek SJ, Kwak JM, Kim J, Kim SH. Anus-Preserving Surgery in Advanced Low-Lying Rectal Cancer: A Perspective on Oncological Safety of Intersphincteric Resection. Cancers (Basel) 2021; 13:4793. [PMID: 34638278 PMCID: PMC8507715 DOI: 10.3390/cancers13194793] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/17/2021] [Accepted: 09/21/2021] [Indexed: 12/15/2022] Open
Abstract
The surgical management of low-lying rectal cancer, within 5 cm from the anal verge (AV), is challenging due to the possibility, or not, to preserve the anus with its sphincter muscles maintaining oncological safety. The standardization of total mesorectal excision, the adoption of neoadjuvant chemoradiotherapy, the implementation of rectal magnetic resonance imaging, and the evolution of mechanical staplers have increased the rate of anus-preserving surgeries. Moreover, extensive anatomy and physiology studies have increased the understanding of the complexity of the deep pelvis. Intersphincteric resection (ISR) was introduced nearly three decades ago as the ultimate anus-preserving surgery. The definition and indication of ISR have changed over time. The adoption of the robotic platform provides excellent perioperative results with no differences in oncological outcomes. Pushing the boundaries of anus-preserving surgeries has risen doubts on oncological safety in order to preserve function. This review critically discusses the oncological safety of ISR by evaluating the anatomical characteristics of the deep pelvis, the clinical indications, the role of distal and circumferential resection margins, the role of the neoadjuvant chemoradiotherapy, the outcomes between surgical approaches (open, laparoscopic, and robotic), the comparison with abdominoperineal resection, the risk factors for oncological outcomes and local recurrence, the patterns of local recurrences after ISR, considerations on functional outcomes after ISR, and learning curve and surgical education on ISR.
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Affiliation(s)
| | | | | | | | - Seon Hahn Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul 02841, Korea; (G.N.P.); (S.-J.B.); (J.-M.K.); (J.K.)
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12
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Orel VE, Ashykhmin A, Golovko T, Rykhalskyi O, Orel VB. Texture Analysis of Tumor and Peritumoral Tissues Based on 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography Hybrid Imaging in Patients With Rectal Cancer. J Comput Assist Tomogr 2021; 45:820-828. [PMID: 34469907 DOI: 10.1097/rct.0000000000001218] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE This study aimed to determine whether texture parameters could be used in differentiation between the tumor and the peritumoral tissues based on hybrid 18F-Fluorodeoxyglucose positron emission tomography/computed tomography imaging for patients with rectal cancer. METHODS Seven parameters, including heterogeneity, entropy, energy, skewness, kurtosis, standard deviation, and average brightness, were extracted from positron emission tomography/computed tomography scans of 22 patients (12 male and 10 female; mean age, 61 ± 2 years). RESULTS The peritumoral tissue had a significantly lower value of the heterogeneity parameter (23%) than the tumor. Tumor size (r = -0.48, P < 0.05) and extramural venous invasion scores (r = 0.64, P < 0.05) correlated with heterogeneity in the peritumoral tissue. There were significant differences (P < 0.05) in the correlation coefficients between men and women. CONCLUSIONS Therefore, we provided additional quantitative information to differentiate the tumor from the peritumoral tissue and indicated possible application for extramural venous invasion evaluation in rectal cancer.
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Tilney HS, Huddy JR, Nizar AS, Smith R, Gudgeon AM. Minimal access rectal cancer surgery: an observational study of patient outcomes from a district general hospital with over a decade of experience with robotic rectal cancer surgery. Colorectal Dis 2021; 23:1961-1970. [PMID: 34157214 DOI: 10.1111/codi.15776] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 05/26/2021] [Accepted: 05/31/2021] [Indexed: 12/12/2022]
Abstract
AIM Robotic surgery for colorectal cancer has become established more slowly than in other specialities. The aim of this study was to assess the risks and benefits of the use of robotic rectal cancer surgery in comparison with laparoscopic surgery within the confines of a subspecialist rectal cancer service in a district general hospital. METHOD Outcomes from consecutive patients undergoing minimal access rectal cancer surgery between July 2008 and January 2020 were analysed. Comparisons were made between short-term outcomes including conversion rates, anastomotic leakage and pathological outcomes as well as long-term survival and cancer recurrence. RESULTS A total of 337 patients were included in the analysis, 204 (60.5%) of whom underwent robotic surgery. Demographic characteristics and use of neoadjuvant chemoradiotherapy were similar between groups. However, patients having robotic surgery had significantly lower tumours than in the laparoscopic group (7.6 cm vs. 9.8 cm, p = 0.003). Conversion to open surgery in the robotic group was significantly less likely (9.8% vs. 22.6%, p = 0.001). Operative mortality, clinical leakage and major complications were similar between groups. While asymptomatic 'radiological' leaks were significantly more common following robotic surgery (13.7% vs. 5.3%, p = 0.017) this did not affect the long-term stoma closure rate. Pathological outcomes were similar with the exception of shorter mean distal resection margins (25.9 mm vs. 32.8 mm, p = 0.001) for the robotic group of patients. There was no statistical difference in 5-year survival between groups (78.7% robotic vs. 85.4% laparoscopic, p = 0.263) nor local recurrence (2.0% robotic vs. 3.8% laparoscopic, p = 0.253). CONCLUSIONS These results illustrate how the selective use of robotic surgery by a dedicated rectal cancer team can achieve low rates of cancer recurrence and low permanent stoma rates.
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Affiliation(s)
- Henry S Tilney
- Department of Colorectal Surgery, Frimley Park Hospital, Camberley, Surrey, UK
| | - Jeremy R Huddy
- Department of Colorectal Surgery, Frimley Park Hospital, Camberley, Surrey, UK
| | - A Shiyam Nizar
- Department of Colorectal Surgery, Frimley Park Hospital, Camberley, Surrey, UK
| | - Ralph Smith
- Department of Colorectal Surgery, Frimley Park Hospital, Camberley, Surrey, UK
| | - A Mark Gudgeon
- Department of Colorectal Surgery, Frimley Park Hospital, Camberley, Surrey, UK
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14
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Teneva T, Zlatarov A, Grigorov R. Role of Magnetic Resonance Imaging in Patients with Rectal Cancer. COLORECTAL CANCER 2021. [DOI: 10.5772/intechopen.94868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In a chapter about rectal cancer there is content about rectal anatomy in relation to magnet-resonanse imaging and TME- surgery (total mesorectal excision). Secondly there is content about imaging methods used in diagnosis and follow-up of rectal cancer. Very important topic is concerning the novel imaging strategies in surgical and radiotherapy planning in the era of individual oncologic approach to the patient. At last there is detailed desctiption and metaanalysis of imaging strategies concerning neoadjuvant and adjuvant radiotherapy and chemotherapy for rectal cancer patients. All imaging markers correspond to substantial oncologic parameters such as survival rates. The connecting bridge is magnet-resonance imaging.
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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 2020; 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] [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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16
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Clermonts SHEM, Köeter T, Pottel H, Stassen LPS, Wasowicz DK, Zimmerman DDE. Outcomes of completion total mesorectal excision are not compromised by prior transanal minimally invasive surgery. Colorectal Dis 2020; 22:790-798. [PMID: 31943682 PMCID: PMC7497048 DOI: 10.1111/codi.14962] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 12/15/2019] [Indexed: 01/08/2023]
Abstract
AIM Transanal minimally invasive surgery (TAMIS) is used increasingly often as an organ-preserving treatment for early rectal cancer. If final pathology reveals unfavourable histological prognostic features, completion total mesorectal excision (cTME) is recommended. This study is the first to investigate the results of cTME after TAMIS. METHOD Data were retrieved from the prospective database of the Elisabeth-TweeSteden Hospital. Completion TME patients were case matched with a control group of patients undergoing primary TME (pTME). Primary and secondary outcomes were surgical outcomes and oncological outcomes, respectively. RESULTS From 2011 to 2017, 20 patients underwent cTME and were compared with 40 patients undergoing pTME. There were no significant differences in operating time (238 min vs 226 min, P = 0.53), blood loss (137 ml vs. 158 ml, P = 0.88) or complications (45% vs 55%, P = 0.07) between both groups. There was no 90-day mortality in the cTME group. The mesorectal fascia was incomplete in three patients (15%) in the cTME group compared with no breaches in the pTME group (P = 0.083). There were no local recurrences in either group. In three patients (15%), distant metastases were detected after cTME compared with one patient (2.5%) in the pTME group (P = 0.069). After cTME patients had a 1- and 5-year disease-free survival of 85% compared with 97.5% for the pTME group (P = 0.062). CONCLUSION Completion TME surgery after TAMIS is not associated with increased peri- or postoperative morbidity or mortality compared with pTME surgery. After cTME surgery patients have a similar disease-free and overall survival when compared with patients undergoing pTME.
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Affiliation(s)
- S. H. E. M. Clermonts
- Department of SurgeryETZ (Elisabeth‐TweeSteden) HospitalTilburgThe Netherlands,Department of SurgeryMaastricht University Medical CentreMaastrichtThe Netherlands
| | - T. Köeter
- Department of SurgeryETZ (Elisabeth‐TweeSteden) HospitalTilburgThe Netherlands
| | - H. Pottel
- Department of Public Health and Primary CareCatholic University LeuvenKortrijkBelgium
| | - L. P. S. Stassen
- Department of SurgeryMaastricht University Medical CentreMaastrichtThe Netherlands
| | - D. K. Wasowicz
- Department of SurgeryETZ (Elisabeth‐TweeSteden) HospitalTilburgThe Netherlands
| | - D. D. E. Zimmerman
- Department of SurgeryETZ (Elisabeth‐TweeSteden) HospitalTilburgThe Netherlands
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Tey HTV, Foo SMJ, Fong SS, Chong CS. Short Term Postoperative and Oncological Outcomes of Two-Dimensional Versus Three-Dimensional Laparoscopic Transanal Total Mesorectal Excision of Rectal Cancer. J Laparoendosc Adv Surg Tech A 2020; 30:1350-1353. [PMID: 32522084 DOI: 10.1089/lap.2020.0093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Transanal total mesorectal excision (TaTME) carried out synchronously with laparoscopy is a useful surgical technique in rectal cancer patients who are overweight or who have a narrow pelvis. This retrospective study aims to compare the safety and efficacy of two-dimensional (2D) and three-dimensional (3D) laparoscopic TaTME of rectal cancer based on the short-term postoperative and oncological outcomes of 40 patients in Singapore who underwent laparoscopic TaTME. Materials and Methods: Forty patients underwent laparoscopic TaTME for rectal cancer in one of three centers in Singapore from October 2015 to August 2018. Out of these patients, 23 underwent 3D laparoscopic TaTME with the Olympus Flexible Tip™ 10 mm scope. Data on patient demographics, operative details, and postoperative and oncological outcomes were collected retrospectively by going through soft copy patient records, analyzed and compared. Results: The operative time for 3D group was significantly shorter (340 versus 419 minutes, P = .04). Complete TME grade and R0 resection was achieved in a higher percentage of patients in the 3D group although this was not statistically significant. There were no other significant differences between the two groups in terms of oncological outcomes and other short-term postoperative outcomes. Discussion and Conclusion: TaTME is overall a safe technique. Three-dimensional TaTME for rectal cancers is as safe and feasible as 2D TaTME, with the advantage of a shorter operative time.
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Affiliation(s)
- Hwee Ting Vanessa Tey
- Division of Colorectal Surgery, University Surgical Cluster, National University Health System, National University Hospital, Singapore, Singapore
| | - Shuo Min Jonathan Foo
- Division of General Surgery, National University Health System, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Sau Shung Fong
- Division of Colorectal Surgery, National Healthcare Group, Tan Tock Seng Hospital, Singapore, Singapore
| | - Choon Seng Chong
- Division of Colorectal Surgery, University Surgical Cluster, National University Health System, National University Hospital, Singapore, Singapore
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Kok END, Eppenga R, Kuhlmann KFD, Groen HC, van Veen R, van Dieren JM, de Wijkerslooth TR, van Leerdam M, Lambregts DMJ, Heerink WJ, Hoetjes NJ, Ivashchenko O, Beets GL, Aalbers AGJ, Nijkamp J, Ruers TJM. Accurate surgical navigation with real-time tumor tracking in cancer surgery. NPJ Precis Oncol 2020; 4:8. [PMID: 32285009 PMCID: PMC7142120 DOI: 10.1038/s41698-020-0115-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/12/2020] [Indexed: 12/11/2022] Open
Abstract
In the past decades, image-guided surgery has evolved rapidly. In procedures with a relatively fixed target area, like neurosurgery and orthopedics, this has led to improved patient outcomes. In cancer surgery, intraoperative guidance could be of great benefit to secure radical resection margins since residual disease is associated with local recurrence and poor survival. However, most tumor lesions are mobile with a constantly changing position. Here, we present an innovative technique for real-time tumor tracking in cancer surgery. In this study, we evaluated the feasibility of real-time tumor tracking during rectal cancer surgery. The application of real-time tumor tracking using an intraoperative navigation system is feasible and safe with a high median target registration accuracy of 3 mm. This technique allows oncological surgeons to obtain real-time accurate information on tumor location, as well as critical anatomical information. This study demonstrates that real-time tumor tracking is feasible and could potentially decrease positive resection margins and improve patient outcome.
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Affiliation(s)
- Esther N D Kok
- 1Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Roeland Eppenga
- 1Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Koert F D Kuhlmann
- 1Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Harald C Groen
- 1Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Ruben van Veen
- 1Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jolanda M van Dieren
- 2Department of Gastrointestinal Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Thomas R de Wijkerslooth
- 2Department of Gastrointestinal Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Monique van Leerdam
- 2Department of Gastrointestinal Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Doenja M J Lambregts
- 3Department of Radiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Wouter J Heerink
- 1Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Nikie J Hoetjes
- 1Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Oleksandra Ivashchenko
- 1Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Geerard L Beets
- 1Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Arend G J Aalbers
- 1Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jasper Nijkamp
- 1Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Theo J M Ruers
- 1Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,4Faculty TNW, Group Nanobiophysics, Twente University, Enschede, 7522 NB The Netherlands
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Manceau G, Margot N, Augustin J, Bardier A, Simon JM, Bachet JB, Spano JP, Maingon P, Vaillant JC, Karoui M. YpN0 rectal cancer patients with sterilized lymph nodes after neoadjuvant chemoradiotherapy are of greater risk of recurrence. Dig Liver Dis 2020; 52:214-220. [PMID: 31427089 DOI: 10.1016/j.dld.2019.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 07/13/2019] [Accepted: 07/17/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Indication for adjuvant chemotherapy in ypN0 rectal cancer patients after chemoradiotherapy (CRT) is debated. The clinical significance of the presence of sterilized lymph nodes (LNS) in ypN0 patients remains to be determined. AIMS To assess the prognostic value of LNS in ypN0 rectal cancers after neoadjuvant CRT. METHODS From 2006-2016, 235 patients underwent TME surgery for non-metastatic mid-low rectal cancer after CRT. A lymph node was considered sterilized if there were signs of treatment response (fibrosis, necrosis or mucus) without residual tumor cells. RESULTS 180 patients (77%) were classified ypN0 and 55 (23%) ypN+. LNS was present in 20 patients (9%). In ypN0 patients, 5-year OS was similar between patients with and without LNS. In contrast, 5-year DFS was significantly lower in ypN0/LNS + patients (58% vs. 78%, p = 0.043) and was similar to those staged ypN+. In multivariate analysis, two factors were independent predictors of DFS: mesorectal grading (OR = 3.14; 95%CI: 1.10-8.34; p = 0.033) and the presence of LNS (OR = 3.93, 95% CI: 1.06-11.81, p = 0.042) CONCLUSION: The presence of LNS in ypN0 rectal cancer after neoadjuvant CRT is associated with an increased risk of recurrence and may be taken into account for the discussion of adjuvant chemotherapy.
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Affiliation(s)
- Gilles Manceau
- Department of Digestive and Hepato-Pancreato-Biliary Surgery, Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière University Hospital, Paris, France
| | - Nicolas Margot
- Department of Digestive and Hepato-Pancreato-Biliary Surgery, Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière University Hospital, Paris, France
| | - Jeremy Augustin
- Department of Pathology, Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière University Hospital, Paris, France
| | - Armelle Bardier
- Department of Pathology, Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière University Hospital, Paris, France
| | - Jean-Marc Simon
- Department of Radiotherapy, Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière University Hospital, Paris, France
| | - Jean-Baptiste Bachet
- Department of Hepato-Gastroenterology and Digestive Oncology, Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière University Hospital, Paris, France
| | - Jean-Philippe Spano
- Department of Medical Oncology, Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière University Hospital, Paris, France
| | - Philippe Maingon
- Department of Radiotherapy, Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière University Hospital, Paris, France
| | - Jean-Christophe Vaillant
- Department of Digestive and Hepato-Pancreato-Biliary Surgery, Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière University Hospital, Paris, France
| | - Mehdi Karoui
- Department of Digestive and Hepato-Pancreato-Biliary Surgery, Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière University Hospital, Paris, France.
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Kanters AE, Cleary RK, Obi SH, Asgeirsson T, Evilsizer SK, Fasbinder LG, Campbell DA, Hendren SK. Uptake of Total Mesorectal Excision and Total Mesorectal Excision Grading for Rectal Cancer: A Statewide Study. Dis Colon Rectum 2020; 63:53-59. [PMID: 31633602 PMCID: PMC6895431 DOI: 10.1097/dcr.0000000000001526] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Total mesorectal excision is associated with decreased local recurrence and improved disease-free survival following rectal cancer resection. The extent to which total mesorectal excision has been adopted in the United States is unknown. OBJECTIVE We sought to assess trends in total mesorectal excision performance and grading in Michigan hospitals. DESIGN This is a retrospective cohort study from the Michigan Surgical Quality Collaborative. Trends in total mesorectal excision performance and grade assignment were analyzed by using χ tests and linear regression. SETTINGS Participating hospitals (initially 14 hospitals, now 38) abstracted medical records data for rectal cancer cases from 2007 to 2016. PATIENTS Patients who underwent rectal cancer resection were included. MAIN OUTCOME MEASURE The main outcome measures were surgeon-documented total mesorectal excision performance and pathologist-reported total mesorectal excision grade. RESULTS Of 510 rectal cancer cases, 367 (72.0%) had surgeon-reported total mesorectal excision performance and 78 (15.3%) had pathologist-reported total mesorectal excision grade. Between-hospital variability in total mesorectal excision performance ranged from 0% to 97% and total mesorectal excision grading ranged from 0% to 90%. Total mesorectal excision grading was associated with a higher likelihood of also having adequate lymph node assessment (88.5% versus 71.9%, p = 0.002). There has been a statistically significant trend toward an increase in total mesorectal excision grading in the original 14 hospitals (p = 0.001), but not in the complete cohort of all hospitals (p = 0.057). LIMITATIONS This is a retrospective cohort design with sampled rectal cancer cases. In addition, there is insufficient granularity to capture all factors associated with total mesorectal excision performance or grade assignment. CONCLUSIONS The rates of total mesorectal excision performance and grade assignment are widely variable throughout the state of Michigan. Overall, grade assignment remains very low. This suggests an opportunity for quality improvement projects to increase total mesorectal excision performance and grading, involving both the surgeons and pathologists for effective implementation. See Video Abstract at http://links.lww.com/DCR/B53. IMPLEMENTACIÓN DE LA ESCISIÓN MESORRECTAL TOTAL Y LA CLASIFICACIÓN POR ESCISIÓN MESORRECTAL TOTAL PARA EL CÁNCER RECTAL: UN ESTUDIO A NIVEL ESTATAL.: La escisión mesorrectal total se asocia con una menor recurrencia local y una mejor supervivencia libre de enfermedad después de la resección del cáncer rectal. Se desconoce hasta que punto se ha adoptado la escisión mesorrectal total en los Estados Unidos.Se intento evaluar las tendencias en el rendimiento y la clasificación de la escisión mesorrectal total en los hospitales de Michigan.Este es un estudio de cohorte retrospectivo de la "Michigan Surgical Quality Collaborative". Las tendencias en el rendimiento de la escisión mesorrectal total y la asignación de grado se analizaron mediante pruebas de chi-cuadrada y regresión lineal.Los hospitales participantes (inicialmente 14 hospitales, ahora 38) extrajeron datos de registros médicos de los casos de cáncer rectal desde 2007 hasta 2016.Pacientes que se sometieron a resección de cáncer rectal.Las principales medidas de resultado fueron el rendimiento de la escisión mesorrectal total documentado por el cirujano y el grado de escisión mesorrectal total informada por el patólogo.De 510 casos de cáncer rectal, 367 (72.0%) tenían un rendimiento de escisión mesorrectal total reportado por el cirujano y 78 (15.3%) tenían un grado de escisión mesorrectal total reportado por el patólogo. La variabilidad entre hospitales en el rendimiento de la escisión mesorrectal total varió del 0 al 97% y la clasificación de la escisión mesorrectal total varió del 0 al 90%. La clasificación de la escisión mesorrectal total se asoció con una mayor probabilidad de tener también una evaluación adecuada de los ganglios linfáticos (88.5% versus 71.9%, p = 0.002). Ha habido una tendencia estadísticamente significativa hacia un aumento en la clasificación de la escisión mesorrectal total en los 14 hospitales originales (p = 0.001), pero no en la cohorte completa de todos los hospitales (p = 0.057).Diseño de cohorte retrospectivo con casos de cáncer rectal muestreados. Además, no hay suficiente granularidad para capturar todos los factores asociados con el rendimiento de la escisión mesorrectal total o la asignación de grados.Las tasas de rendimiento de escisión mesorrectal total y asignación de grado son muy variables en todo el estado de Michigan. En general, la asignación de calificaciones sigue siendo muy baja. Esto sugiere una oportunidad para que los proyectos de mejora de la calidad aumenten el rendimiento y la clasificación de la escisión mesorrectal total, involucrando tanto a los cirujanos como a los patólogos para una implementación efectiva. Vea el resumen del video en http://links.lww.com/DCR/B53.
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Affiliation(s)
- Arielle E. Kanters
- Department of Surgery, Michigan Medicine, Ann Arbor, MI,Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI,Correspondence: Arielle Kanters, MD, Center for Healthcare Outcomes and Policy, 2800 Plymouth Road Building 16, Office 016-168C, Ann Arbor, MI 48105. . Twitter: arikanters, Presentation of work, Telephone: 734-998-7470, Fax: 734-998-7473
| | - Robert K. Cleary
- Department of Surgery, St. Joseph Mercy Ann Arbor, Ann Arbor, MI
| | - Shawn H. Obi
- Department of Surgery, Henry Ford Allegiance, Jackson, MI
| | | | | | | | - Darrell A. Campbell
- Department of Surgery, Michigan Medicine, Ann Arbor, MI,Michigan Surgical Quality Collaborative, Ann Arbor, MI
| | - Samantha K. Hendren
- Department of Surgery, Michigan Medicine, Ann Arbor, MI,Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI
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Matsunaga R, Kojima M, Nishizawa Y, Yokota M, Hasegawa H, Saito N, Ito M, Ochiai A. The utility of longitudinal slicing method for rectal specimen: pathological analysis of circumferential resection margin of intersphincteric resection for low‐lying rectal cancer. Pathol Int 2019; 69:272-281. [DOI: 10.1111/pin.12797] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 03/03/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Rie Matsunaga
- Colorectal and Pelvic Surgery DivisionNational Cancer Center Hospital EastChiba Japan
| | - Motohiro Kojima
- Pathology DivisionResearch Center for Innovative Oncology, National Cancer Center Hospital EastChiba Japan
| | - Yuji Nishizawa
- Colorectal and Pelvic Surgery DivisionNational Cancer Center Hospital EastChiba Japan
| | - Mitsuru Yokota
- Colorectal and Pelvic Surgery DivisionNational Cancer Center Hospital EastChiba Japan
| | - Hiro Hasegawa
- Colorectal and Pelvic Surgery DivisionNational Cancer Center Hospital EastChiba Japan
| | - Norio Saito
- Colorectal and Pelvic Surgery DivisionNational Cancer Center Hospital EastChiba Japan
| | - Masaaki Ito
- Colorectal and Pelvic Surgery DivisionNational Cancer Center Hospital EastChiba Japan
| | - Atsushi Ochiai
- Pathology DivisionResearch Center for Innovative Oncology, National Cancer Center Hospital EastChiba Japan
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22
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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 DOI: 10.1001/jamasurg.2018.1607] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [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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Unger LW, Muckenhuber M, Riss S, Argeny S, Stift J, Mesteri I, Stift A. Effect of pathologist's dedication on lymph node detection rate and postoperative survival in colorectal cancer. Colorectal Dis 2018; 20:O173-O180. [PMID: 29706021 DOI: 10.1111/codi.14241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 04/16/2018] [Indexed: 12/13/2022]
Abstract
AIM As adjuvant chemotherapy in colorectal cancer relies on the identification of lymph node metastases, the pathologist's dedication may have a considerable influence on postoperative survival. METHOD The aim of this retrospective study was to assess the impact of the pathologist's dedication on lymph node detection rate and postoperative survival in patients operated on by a single experienced colorectal surgeon within a 5-year period. We assessed 229 patients undergoing total mesorectal excision or complete mesocolic excision by the senior author between 1 January 2009 and 31 December 2013. Pathologists were grouped as 'general pathologist' or 'dedicated pathologist' depending on their dedication/specialization. RESULTS Dedicated pathologists found statistically significantly more lymph nodes in colorectal specimens than general pathologists [23 (interquartile range 24) vs 14 (interquartile range 11), respectively; P < 0.001]. The detection rate of ≥ 12 lymph nodes per specimen was significantly higher in the dedicated pathologist group [65/74 (87.8%) vs 105/155 (67.7%); P = 0.016]. However, postoperative survival did not differ in the respective subgroups. In the multivariable analysis by Cox proportional hazard model, International Union against Cancer Stage IV was the only factor associated with decreased disease-specific survival (hazard ratio 28.257; 95% CI 3.850-207.386; P = 0.001). CONCLUSION In our centre, the pathologist's dedication has an impact on lymph node detection rate but does not influence postoperative disease-specific survival.
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Affiliation(s)
- L W Unger
- Division of General Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - M Muckenhuber
- Division of General Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - S Riss
- Division of General Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - S Argeny
- Division of General Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - J Stift
- Department of Pathology, Clinical, Institute of Pathology, Medical University of Vienna, Vienna, Austria
| | - I Mesteri
- Department of Pathology, Clinical, Institute of Pathology, Medical University of Vienna, Vienna, Austria
| | - A Stift
- Division of General Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
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Distribution of metastases in mesorectum is unpredictable: Metastases do not respect tumor localization even in small non-circumferential rectal cancers. Eur J Surg Oncol 2018; 44:87-92. [DOI: 10.1016/j.ejso.2017.11.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 10/09/2017] [Accepted: 11/16/2017] [Indexed: 01/01/2023] Open
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Kamali D, Sharpe A, Musbahi A, Reddy A. Oncological and quality of life outcomes following extralevator versus standard abdominoperineal excision for rectal cancer. Ann R Coll Surg Engl 2017; 99:402-409. [PMID: 28462642 DOI: 10.1308/rcsann.2017.0038] [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] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION There is increasing and conflicting research debating the oncological benefits of extralevator abdominoperineal excision (ELAPE) compared with standard abdominoperineal excision (SAPE). However, there is very little in the literature on the long-term effects on patients' wellbeing following the two procedures. The aim of this study was to determine the oncological outcomes and long-term quality of life (QoL) of patients at two hospitals having undergone ELAPE or SAPE. METHODS Consecutive patients with rectal cancer who underwent either ELAPE or SAPE between January 2009 and June 2015 at a single centre were analysed. Oncological outcomes were determined by histology and follow-up imaging. QoL data were obtained prospectively using the QLQ-C30 and QLQ-CR29 questionnaires. RESULTS A total of 48 patients (36 male, 12 female; 27 ELAPE, 21 SAPE) were reviewed. The mean age was 67.4 years and the median follow-up duration was 44 months (range: 6-79 months). Four patients (2 ELAPE, 2 SAPE) developed local recurrence. Rates of distant metastasis were similar (ELAPE: 11%, SAPE: 14%). There was no significant difference in mean global health status score (ELAPE: 77.3, SAPE: 65.3). Impotence was the most frequently reported problem (mean symptom scores of 89.7 and 78.8 for ELAPE and SAPE respectively). CONCLUSIONS This is the largest study with the longest follow-up period that compares QoL after ELAPE with that after SAPE. Although more radical in nature, ELAPE did not demonstrate any significant impact on QoL compared with SAPE. There was no significant difference in long-term oncological outcome between the groups. Impotence remains a significant problem for all patients and they should be well informed of this risk prior to surgery.
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Affiliation(s)
- D Kamali
- South Tees Hospitals NHS Foundation Trust, UK
| | - A Sharpe
- South Tees Hospitals NHS Foundation Trust, UK
| | - A Musbahi
- South Tees Hospitals NHS Foundation Trust, UK
| | - A Reddy
- South Tees Hospitals NHS Foundation Trust, UK
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Richardson B, Preskitt J, Lichliter W, Peschka S, Carmack S, de Prisco G, Fleshman J. The effect of multidisciplinary teams for rectal cancer on delivery of care and patient outcome: has the use of multidisciplinary teams for rectal cancer affected the utilization of available resources, proportion of patients meeting the standard of care, and does this translate into changes in patient outcome? Am J Surg 2015; 211:46-52. [PMID: 26601650 DOI: 10.1016/j.amjsurg.2015.08.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 07/27/2015] [Accepted: 08/02/2015] [Indexed: 02/09/2023]
Abstract
BACKGROUND We hypothesized that mandatory multidisciplinary team (MDT) participation improves process evaluation, outcomes, and technical aspects of surgery for rectal cancer in a stable practice of colorectal surgery. METHODS A retrospective review of MDT data was conducted of all patients with colorectal cancer since 2010. Demographic, clinical stage, process evaluation, quality of surgery, and outcome data were collected. Total mesorectal excision and MDT required participation started 2013. RESULTS One hundred thirty patients were included in this study: 47 patients in 2014; 41 patients in 2013; and 42 patients pre-MDT. Improvements were seen in 12 of the 14 preoperative process variables, 6 significantly. Improvement in the completeness of total mesorectal excision (0% to 76%) was significant. Local recurrence occurred in 10% of the pre-MDT group, and follow-up is ongoing in the MDT groups. CONCLUSIONS MDT participation improves care of patients with rectal cancer. Preoperative clinical staging, multimodality treatment, pathologic staging, and technical aspects of surgery have improved.
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Affiliation(s)
- Bradford Richardson
- Department of Surgery, Baylor University Medical Center, 3500 Gaston Avenue, Dallas, TX, 75246, USA
| | - John Preskitt
- Department of Surgery, Baylor University Medical Center, 3500 Gaston Avenue, Dallas, TX, 75246, USA
| | - Warren Lichliter
- Department of Surgery, Baylor University Medical Center, 3500 Gaston Avenue, Dallas, TX, 75246, USA
| | - Stephanie Peschka
- Department of Surgery, Baylor University Medical Center, 3500 Gaston Avenue, Dallas, TX, 75246, USA
| | - Susanne Carmack
- Department of Pathology, Baylor University Medical Center, Dallas, TX, USA
| | - Gregory de Prisco
- Department of Radiology, Baylor University Medical Center, Dallas, TX, USA
| | - James Fleshman
- Department of Surgery, Baylor University Medical Center, 3500 Gaston Avenue, Dallas, TX, 75246, USA.
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27
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Lino-Silva LS, García-Gómez MA, Aguilar-Romero JM, Domínguez-Rodríguez JA, Salcedo-Hernández RA, Loaeza-Belmont R, Ruiz-García EB, Herrera-Gómez Á. Mesorectal pathologic assessment in two grades predicts accurately recurrence, positive circumferential margin, and correlates with survival. J Surg Oncol 2015; 112:900-6. [PMID: 26487289 DOI: 10.1002/jso.24076] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 10/10/2015] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVES We aimed to determine the prognostic value of the mesorectum quality assessed in a two-grade system compared with a classic system. METHODS Consecutive patients undergoing surgery for rectal cancer were included (n = 103). Mesorectum was assessed into three grades (classic system: complete, nearly complete, incomplete) and compared with a two-grade system (adequate, inadequate). RESULTS Mesorectum was complete in 62 (60.25%) patients, nearly complete in 21, and incomplete in 20. Reassessment showed adequate mesorectum in 83 (80.5%) patients and inadequate in 20. A R0 resection was achieved in 90.4% of adequate mesorectum and in 65% of inadequate mesorectum (P = 0.006). Recurrence was present in 18% of adequate mesorectum patients as compared with 50% of inadequate mesorectum (P = 0.003). The classic system failed to accurately predict the 5-year survival rate between complete (78.9%) and nearly complete (86.2%) categories (P = 0.235); whereas a two grading system showed a 5-year survival rate of 80.8% for adequate versus 39.3% for inadequate (P = 0.034). CONCLUSION High recurrence occurred in inadecuate mesorectum patients and was correlated with R1/R2 resections, positive margins, and decreased survival. We propose a simplified classification of mesorectum that correlates with survival and overall recurrence.
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Affiliation(s)
- Leonardo S Lino-Silva
- Department of Gastrointestinal Pathology, Instituto Nacional de Cancerología, Mexico City, Mexico
| | - Miguel A García-Gómez
- Department of Surgical Oncology, Instituto Nacional de Cancerología, Mexico City, Mexico
| | | | | | | | - Reynaldo Loaeza-Belmont
- Department of Gastrointestinal Pathology, Instituto Nacional de Cancerología, Mexico City, Mexico
| | - Erika B Ruiz-García
- Department of Translational Oncology, Instituto Nacional de Cancerología, Mexico City, Mexico
| | - Ángel Herrera-Gómez
- Department of Surgical Oncology, Instituto Nacional de Cancerología, Mexico City, Mexico
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