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Motamedi MAK, Mak NT, Brown CJ, Raval MJ, Karimuddin AA, Giustini D, Phang PT. Local versus radical surgery for early rectal cancer with or without neoadjuvant or adjuvant therapy. Cochrane Database Syst Rev 2023; 6:CD002198. [PMID: 37310167 PMCID: PMC10264720 DOI: 10.1002/14651858.cd002198.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Total mesorectal excision is the standard of care for stage I rectal cancer. Despite major advances and increasing enthusiasm for modern endoscopic local excision (LE), uncertainty remains regarding its oncologic equivalence and safety relative to radical resection (RR). OBJECTIVES To assess the oncologic, operative, and functional outcomes of modern endoscopic LE compared to RR surgery in adults with stage I rectal cancer. SEARCH METHODS We searched CENTRAL, Ovid MEDLINE, Ovid Embase, Web of Science - Science Citation Index Expanded (1900 to present), four trial registers (ClinicalTrials.gov, ISRCTN registry, the WHO International Clinical Trials Registry Platform, and the National Cancer Institute Clinical Trials database), two thesis and proceedings databases, and relevant scientific societies' publications in February 2022. We performed handsearching and reference checking and contacted study authors of ongoing trials to identify additional studies. SELECTION CRITERIA We searched for randomized controlled trials (RCTs) in people with stage I rectal cancer comparing any modern LE techniques to any RR techniques with or without the use of neo/adjuvant chemoradiotherapy (CRT). DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. We calculated hazard ratios (HR) and standard errors for time-to-event data and risk ratios for dichotomous outcomes, using generic inverse variance and random-effects methods. We regrouped surgical complications from the included studies into major and minor according to the standard Clavien-Dindo classification. We assessed the certainty of evidence using the GRADE framework. MAIN RESULTS Four RCTs were included in data synthesis with a combined total of 266 participants with stage I rectal cancer (T1-2N0M0), if not stated otherwise. Surgery was performed in university hospital settings. The mean age of participants was above 60, and median follow-up ranged from 17.5 months to 9.6 years. Regarding the use of co-interventions, one study used neoadjuvant CRT in all participants (T2 cancers); one study used short-course radiotherapy in the LE group (T1-T2 cancers); one study used adjuvant CRT selectively in high-risk patients undergoing RR (T1-T2 cancers); and the fourth study did not use any CRT (T1 cancers). We assessed the overall risk of bias as high for oncologic and morbidity outcomes across studies. All studies had at least one key domain with a high risk of bias. None of the studies reported separate outcomes for T1 versus T2 or for high-risk features. Low-certainty evidence suggests that RR may result in an improvement in disease-free survival compared to LE (3 trials, 212 participants; HR 1.96, 95% confidence interval (CI) 0.91 to 4.24). This would translate into a three-year disease-recurrence risk of 27% (95% CI 14 to 50%) versus 15% after LE and RR, respectively. Regarding sphincter function, only one study provided objective results and reported short-term deterioration in stool frequency, flatulence, incontinence, abdominal pain, and embarrassment about bowel function in the RR group. At three years, the LE group had superiority in overall stool frequency, embarrassment about bowel function, and diarrhea. Local excision may have little to no effect on cancer-related survival compared to RR (3 trials, 207 participants; HR 1.42, 95% CI 0.60 to 3.33; very low-certainty evidence). We did not pool studies for local recurrence, but the included studies individually reported comparable local recurrence rates for LE and RR (low-certainty evidence). It is unclear if the risk of major postoperative complications may be lower with LE compared with RR (risk ratio 0.53, 95% CI 0.22 to 1.28; low-certainty evidence; corresponding to 5.8% (95% CI 2.4% to 14.1%) risk for LE versus 11% for RR). Moderate-certainty evidence shows that the risk of minor postoperative complications is probably lower after LE (risk ratio 0.48, 95% CI 0.27 to 0.85); corresponding to an absolute risk of 14% (95% CI 8% to 26%) for LE compared to 30.1% for RR. One study reported an 11% rate of temporary stoma after LE versus 82% in the RR group. Another study reported a 46% rate of temporary or permanent stomas after RR and none after LE. The evidence is uncertain about the effect of LE compared with RR on quality of life. Only one study reported standard quality of life function, in favor of LE, with a 90% or greater probability of superiority in overall quality of life, role, social, and emotional functions, body image, and health anxiety. Other studies reported a significantly shorter postoperative period to oral intake, bowel movement, and off-bed activities in the LE group. AUTHORS' CONCLUSIONS Based on low-certainty evidence, LE may decrease disease-free survival in early rectal cancer. Very low-certainty evidence suggests that LE may have little to no effect on cancer-related survival compared to RR for the treatment of stage I rectal cancer. Based on low-certainty evidence, it is unclear if LE may have a lower major complication rate, but probably causes a large reduction in minor complication rate. Limited data based on one study suggest better sphincter function, quality of life, or genitourinary function after LE. Limitations exist with respect to the applicability of these findings. We identified only four eligible studies with a low number of total participants, subjecting the results to imprecision. Risk of bias had a serious impact on the quality of evidence. More RCTs are needed to answer our review question with greater certainty and to compare local and distant metastasis rates. Data on important patient outcomes such as sphincter function and quality of life are very limited. Results of currently ongoing trials will likely impact the results of this review. Future trials should accurately report and compare outcomes according to the stage and high-risk features of rectal tumors, and evaluate quality of life, sphincter, and genitourinary outcomes. The role of neoadjuvant or adjuvant therapy as an emerging co-intervention for improving oncologic outcomes after LE needs to be further defined.
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Affiliation(s)
| | - Nicole T Mak
- Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Carl J Brown
- Head, Division of General Surgery, St. Paul's Hospital, Vancouver, Canada
| | - Manoj J Raval
- Department of Surgery, St. Paul's Hospital, University of British Columbia, Vancouver, Canada
| | - Ahmer A Karimuddin
- Department of Surgery, St. Paul's Hospital, University of British Columbia, Vancouver, Canada
| | - Dean Giustini
- Faculty of Medicine, University of British Columbia Library, Vancouver, Canada
| | - Paul Terry Phang
- Department of Surgery, St. Paul's Hospital, University of British Columbia, Vancouver, Canada
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Freund MR, Horesh N, Emile SH, Garoufalia Z, Gefen R, Wexner SD. Predictors and outcomes of positive surgical margins after local excision of clinical T1 rectal cancer: A National Cancer Database analysis. Surgery 2023; 173:1359-1366. [PMID: 36959073 DOI: 10.1016/j.surg.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 02/09/2023] [Accepted: 02/11/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Transanal local excision and the use of specialized platforms has become increasingly popular for early-stage rectal cancer. Predictors and outcomes of positive resection margins following transanal local excision for early-stage rectal cancer have yet to be explored. METHODS This was a retrospective analysis of the National Cancer Database of all patients with clinical nonmetastatic node negative T1 rectal adenocarcinoma who underwent transanal local excision from 2004 to 2017. Patients with positive surgical margins were compared to those with negative resection margins to determine factors associated with predictors and outcomes of positive surgical margins after transanal local excision. The main outcome measure was overall survival. RESULTS Of 318,548 patients with rectal adenocarcinoma in the National Cancer Database, 9,078 (2.8%) met the inclusion criteria. The positive surgical margins rate was 7.4%. Predictors of positive surgical margins were older age (odds ratio, 1.03; P < .001), higher Charlson comorbidity index (odds ratio, 1.24; P = .004), poorly differentiated carcinomas (odds ratio, 1.89; P < .001), mucinous (odds ratio, 2.36; P = .003) and signet-ring cell carcinomas (odds ratio, 4.7; P = .048). Independent predictors of reduced survival were older age (hazard ratio, 1.062; P < .001), male sex (hazard ratio, 1.214; P = .011), Charlson comorbidity index 3 (hazard ratio, 1.94; P < .001), pathologic T2 (hazard ratio, 1.27; P = .036) and T3 stages (hazard ratio, 1.77; P = .006), poorly differentiated carcinomas (hazard ratio, 1.47; P = .008), and positive surgical margins (hazard ratio, 1.374; P = .018). The positive surgical margins group's median overall survival was significantly shorter (88 vs 159.3 months, P < .001). CONCLUSION Positive surgical margins after transanal local excision for early-stage node-negative rectal cancer adversely affects prognosis. Older male patients with higher Charlson comorbidity index scores and poorly differentiated mucinous or signet cell histology tumors are at risk for positive surgical margins. Patient selection according to these suggested criteria may help avoid positive surgical margins.
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Affiliation(s)
- Michael R Freund
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Department of General Surgery, Shaare Zedek Medical Center, the Hebrew University Faculty of Medicine, Jerusalem, Israel. https://twitter.com/mikifreund
| | - Nir Horesh
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Department of Surgery and Transplantations, Sheba Medical Center, Ramat Gan, Israel. https://twitter.com/Nirhoresh1
| | - Sameh Hany Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Colorectal Surgery Unit, Mansoura University, Faculty of Medicine, Egypt. https://twitter.com/dr_samehhany81
| | - Zoe Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL. https://twitter.com/ZGaroufalia
| | - Rachel Gefen
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Department of General Surgery, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Israel. https://twitter.com/RachellGefen
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL.
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Verrijssen AE, Ketelaers SHJ, Rutten HJT, Theuws J, Burger JWA, Cnossen JS. Organ Preservation in Rectal Cancer: An Overview of the Dutch Perspective and Recent Developments. Clin Oncol (R Coll Radiol) 2023; 35:107-16. [PMID: 36253320 DOI: 10.1016/j.clon.2022.09.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 08/17/2022] [Accepted: 09/22/2022] [Indexed: 01/20/2023]
Abstract
Although current guidelines on rectal cancer treatment often recommend rectal resection with or without neoadjuvant (chemo)radiotherapy, there is growing interest in organ-preserving treatment approaches among patients and clinicians in the Netherlands. Currently, multiple ongoing studies are investigating the value of different non-operative treatment modalities to improve tumour response rates and increase the chance of successful organ preservation. Papillon contact X-ray brachytherapy is a promising treatment modality to improve the chance of organ preservation, which seems especially relevant for elderly and frail patients unable or refusing to undergo total mesorectal excision surgery. The elderly and frail patient with rectal cancer poses a significant challenge and warrants a thorough multidisciplinary approach to provide the most optimal organ-preserving treatment. In this overview, an insight into the Dutch perspectives and developments within the field of organ preservation and the set-up of a Papillon facility to complete the spectrum of organ-preserving treatment options in a tertiary referral centre for rectal cancer treatment has been provided.
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Ketelaers SHJ, Jacobs A, Verrijssen ASE, Cnossen JS, van Hellemond IEG, Creemers GJM, Schreuder RM, Scholten HJ, Tolenaar JL, Bloemen JG, Rutten HJT, Burger JWA. A Multidisciplinary Approach for the Personalised Non-Operative Management of Elderly and Frail Rectal Cancer Patients Unable to Undergo TME Surgery. Cancers (Basel) 2022; 14:2368. [PMID: 35625976 PMCID: PMC9139821 DOI: 10.3390/cancers14102368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/05/2022] [Accepted: 05/09/2022] [Indexed: 02/07/2023] Open
Abstract
Despite it being the optimal curative approach, elderly and frail rectal cancer patients may not be able to undergo a total mesorectal excision. Frequently, no treatment is offered at all and the natural course of the disease is allowed to unfold. These patients are at risk for developing debilitating symptoms that impair quality of life and require palliative treatment. Recent advancements in non-operative treatment modalities have enhanced the toolbox of alternative treatment strategies in patients unable to undergo surgery. Therefore, a proposed strategy is to aim for the maximal non-operative treatment, in an effort to avoid the onset of debilitating symptoms, improve quality of life, and prolong survival. The complexity of treating elderly and frail patients requires a patient-centred approach to personalise treatment. The main challenge is to optimise the balance between local control of disease, patient preferences, and the burden of treatment. A comprehensive geriatric assessment is a crucial element within the multidisciplinary dialogue. Since limited knowledge is available on the optimal non-operative treatment strategy, these patients should be treated by dedicated multidisciplinary rectal cancer experts with special interest in the elderly and frail. The aim of this narrative review was to discuss a multidisciplinary patient-centred treatment approach and provide a practical suggestion of a successfully implemented clinical care pathway.
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Affiliation(s)
- Stijn H. J. Ketelaers
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
| | - Anne Jacobs
- Department of Gerontology and Geriatrics, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands;
| | - An-Sofie E. Verrijssen
- Department of Radiation Oncology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (A.-S.E.V.); (J.S.C.)
| | - Jeltsje S. Cnossen
- Department of Radiation Oncology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (A.-S.E.V.); (J.S.C.)
| | - Irene E. G. van Hellemond
- Department of Medical Oncology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (I.E.G.v.H.); (G.-J.M.C.)
| | - Geert-Jan M. Creemers
- Department of Medical Oncology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (I.E.G.v.H.); (G.-J.M.C.)
| | - Ramon-Michel Schreuder
- Department of Gastroenterology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands;
| | - Harm J. Scholten
- Department of Anaesthesiology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands;
| | - Jip L. Tolenaar
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
| | - Johanne G. Bloemen
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
| | - Harm J. T. Rutten
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
- GROW, School for Oncology and Reproduction, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Jacobus W. A. Burger
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
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Ozgur I, Gorgun E. Local Excision and Endoscopic Strategies for the Treatment of Colorectal Cancer. Surg Oncol Clin N Am 2022; 31:219-237. [DOI: 10.1016/j.soc.2021.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Perez RO, Julião GPS, Vailati BB. Transanal Local Excision of Rectal Cancer after Neoadjuvant Chemoradiation: Is There a Place for It or Should Be Avoided at All Costs? Clin Colon Rectal Surg 2022; 35:122-128. [PMID: 35237107 PMCID: PMC8885162 DOI: 10.1055/s-0041-1742112] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Tumor response to neoadjuvant chemoradiation (nCRT) with tumor downsizing and downstaging has significantly impacted the number of patients considered to be appropriate candidates for transanal local excision (TLE). Some patients may harbor small residual lesions, restricted to the bowel wall. These patients, who exhibit major response ("near-complete") by digital rectal examination, endoscopic assessment, and radiological assessment may be considered for this approach. Although TLE is associated with minimal postoperative morbidity, a few clinical consequences and oncological outcomes must be evaluated in advance and with caution. In the setting of nCRT, a higher risk for clinically relevant wound dehiscences leading to a considerable risk for readmission for pain management has been observed. Worse anorectal function (still better than after total mesorectal excision [TME]), worsening in the quality of TME specimen, and higher rates of abdominal resections (in cases requiring completion TME) have been reported. The exuberant scar observed in the area of TLE also represents a challenging finding during follow-up of these patients. Local excision should be probably restricted for patients with primary tumors located at or below the level of the anorectal ring (magnetic resonance defined). These patients are otherwise candidates for abdominal perineal resections or ultra-low anterior resections with coloanal anastomosis frequently requiring definitive stomas or considerably poor anorectal function.
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Affiliation(s)
- Rodrigo Oliva Perez
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil,Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil,Address for correspondence Rodrigo Oliva Perez, MD, PhD Department of Surgical Oncology, Hospital Beneficencia PortuguesaSão Paulo 01323-001Brazil
| | - Guilherme Pagin São Julião
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil,Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Bruna Borba Vailati
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil,Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
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Naiderman D, Tufare AL, Trinchero LB, Rossi F, Dolan M, Cano DM, Fagalde RL, Jury GL. Transanal Minimally-Invasive Surgery (TAMIS): Experience with No Closure of the Rectal Defect. Journal of Coloproctology 2021. [DOI: 10.1055/s-0041-1735642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Abstract
Background In transanal minimally-invasive surgery (TAMIS), the closure of the rectal defect is controversial, and endoluminal suture is one of the most challenging aspects. The goal of the present study is to evaluate the short- and medium-term complications of a consecutive series of patients with extraperitoneal rectal injuries who underwent TAMIS without closure of the rectal defect.
Materials and Methods A prospective, longitudinal, descriptive study conducted between August 2013 and July 2019 in which all patients with extraperitoneal rectal lesions, who were operated on using the TAMIS technique, were consecutively included. The lesions were: benign lesions ≥ 3 cm; neuroendocrine tumors ≤ 2 cm; adenocarcinomas in stage T1N0; and adenocarcinomas in stage T2N0, with high surgical risk, or with the patients reluctant to undergo radical surgery, and others with doubts about complete remission after the neoadjuvant therapy. Bleeding, infectious complications, rectal stenosis, perforations, and death were evaluated.
Results A total of 35 patients were treated using TAMIS without closure of the defect. The average size of the lesions was of 3.68 ± 2.1 cm (95% confidence interval [95%CI]: 0.7 cm to 9 cm), their average distance from the anal margin was of 5.7 ± 1.48 cm, and the average operative time was of 39.2 ± 20.5 minutes, with a minimum postoperative follow-up of 1 year. As for the pathologies, they were: 15 adenomas; 3 carcinoid tumors; and 17 adenocarcinomas. In all cases, the rectal defect was left open.The overall morbidity was of 14.2%. Two patients (grade II in the Clavien-Dindo classification) were readmitted for pain treatment, and three patients (grade III in the Clavien-Dindo classification) were assisted due to postoperative bleeding, one of whom required reoperation.
Conclusion The TAMIS technique without closure of the rectal defect yields good results, and present a high feasibility and low complication rate.
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Affiliation(s)
- Diego Naiderman
- Coloproctology Sector, Hospital Interzonal General de Agudos “Dr. Oscar E. Alende” (HIGA), Mar del Plata, Buenos Aires, Argentina
- Centro de Estudios Digestivos, Mar del Plata, Buenos Aires, Argentina
- Clínica Pueyrredón, Mar del Plata, Buenos Aires, Argentina
| | - Ana Laura Tufare
- Universidad Nacional de Mar del Plata, Mar del Plata, Buenos Aires, Argentina
| | | | - Fernando Rossi
- Clínica Pueyrredón, Mar del Plata, Buenos Aires, Argentina
| | - Martín Dolan
- Centro de Estudios Digestivos, Mar del Plata, Buenos Aires, Argentina
| | - Diego Martín Cano
- Coloproctology Sector, Hospital Interzonal General de Agudos “Dr. Oscar E. Alende” (HIGA), Mar del Plata, Buenos Aires, Argentina
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Verseveld M, Verver D, Noordman BJ, Pouwels S, Elferink MAG, de Graaf EJR, Verhoef C, Doornebosch PG, de Wilt JHW. Treatment of clinical T1 rectal cancer in the Netherlands; a population-based overview of clinical practice. Eur J Surg Oncol 2021; 48:1153-1160. [PMID: 34799230 DOI: 10.1016/j.ejso.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 10/22/2021] [Accepted: 11/01/2021] [Indexed: 10/19/2022] Open
Abstract
INTRODUCTION Local excision is increasingly used as an alternative treatment for radical surgery in patients with early stage clinical T1 (cT1) rectal cancer. This study provides an overview of incidence, staging accuracy and treatment strategies in patients with cT1 rectal cancer in the Netherlands. MATERIALS AND METHODS Patients with cT1 rectal cancer diagnosed between 2005 and 2018 were included from the Netherlands Cancer Registry. An overview per time period (2005-2009, 2010-2014 and 2015-2018) of the incidence and various treatment strategies used, e.g. local excision (LE) or major resection, with/without neoadjuvant treatment (NAT), were given and trends over time were analysed using the Chi Square for Trend test. In addition, accuracy of tumour staging was described, compared and analysed over time. RESULTS In total, 3033 patients with cT1 rectal cancer were diagnosed. The incidence of cT1 increased from 540 patients in 2005-2009 to 1643 patients in 2015-2018. There was a significant increased use of LE. In cT1N0/X patients, 9.2% received NAT, 25.5% were treated by total mesorectal excision (TME) and 11.4% received a completion TME (cTME) following prior LE. Overall accuracy in tumour staging (cT1 = pT1) was 77.3%, yet significantly worse in cN1/2 patients, as compared to cN0 patients (44.8% vs 77.9%, respectively, p < 0.001). CONCLUSION Over time, there was an increase in the incidence of cT1 tumours. Both the use of neoadjuvant therapy and TME surgery in clinically node negative patients decreased significantly. Clinical accuracy in T1 tumour staging improved over time, but remained significantly worse in clinical node positive patients.
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Affiliation(s)
- M Verseveld
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, Schiedam, the Netherlands; Department of Surgery, division of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands.
| | - D Verver
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, Schiedam, the Netherlands
| | - B J Noordman
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, Schiedam, the Netherlands; Department of Surgery, division of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - S Pouwels
- Department of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, the Netherlands
| | - M A G Elferink
- Department of Research & Development, Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands
| | - E J R de Graaf
- Department of Surgery, IJsselland Hospital, Capelle aan den IJssel, the Netherlands
| | - C Verhoef
- Department of Surgery, division of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - P G Doornebosch
- Department of Surgery, IJsselland Hospital, Capelle aan den IJssel, the Netherlands
| | - J H W de Wilt
- Department of Surgery, division of Surgical Oncology, Radboud University Medical Centre, Nijmegen, the Netherlands
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Sato K, Shimoda H, Miura T, Sakamoto Y, Morohashi H, Watanabe S, Narita H, Mitsuhashi Y, Umemura K, Hakamada K. Widespread anorectal lymphovascular networks and tissue drainage: analyses from submucosal India ink injection and indocyanine green fluorescence imaging. Colorectal Dis 2021; 23:1334-1345. [PMID: 33570769 PMCID: PMC8248146 DOI: 10.1111/codi.15582] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 01/12/2021] [Accepted: 02/04/2021] [Indexed: 01/11/2023]
Abstract
AIM Abdominoperineal resection is associated with poor prognosis in patients with advanced lower rectal cancer. This study aimed to analyse the functional lymphovascular network and tissue drainage in the anorectal region. METHODS In this descriptive study, we performed microanatomical evaluations and intra-operative imaging analysis in a cadaver and patients with rectal cancer. Specimens with India ink injection were collected from a cadaver and from six patients who underwent abdominoperineal resection. Intra-operative indocyanine green fluorescence imaging was performed on four patients who underwent surgery for lower rectal cancer. India ink was injected into the submucosa at the dentate line of specimens. Tissue sections were examined by immunohistochemistry for D2-40 and CD31. Intra-operative indocyanine green was injected into the submucosa at the dentate line. Lymph flow was traced using a near-infrared camera system. RESULTS Fascia branching from the rectal longitudinal muscle layer extended to the posterior hiatal ligament and lateral endopelvic fascia connective tissue lamina on the surface of the levator ani muscle. The fascia contained veins labelled with ink in their lumina and initial lymphatics. Intra-operative indocyanine green fluorescence imaging revealed extensive lymph flow from the muscle layer of the anal canal to the hiatal ligament and endopelvic fascia along the longitudinal muscle layer fibres. CONCLUSIONS The anorectal region contained widespread venous and lymphatic networks in proportion to its specific connective tissue framework around the longitudinal-muscle-layer-extending muscle bundles, which provides extensive networks for tissue fluid and cells.
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Affiliation(s)
- Kentaro Sato
- Department of Gastroenterological SurgeryGraduate School of MedicineHirosaki UniversityHirosakiAomoriJapan,Department of Anatomical ScienceGraduate School of MedicineHirosaki UniversityHirosakiAomoriJapan
| | - Hiroshi Shimoda
- Department of Anatomical ScienceGraduate School of MedicineHirosaki UniversityHirosakiAomoriJapan,Department of Neuroanatomy, Cell Biology, HistologyGraduate School of MedicineHirosaki UniversityHirosakiAomoriJapan
| | - Takuya Miura
- Department of Gastroenterological SurgeryGraduate School of MedicineHirosaki UniversityHirosakiAomoriJapan
| | - Yoshiyuki Sakamoto
- Department of Gastroenterological SurgeryGraduate School of MedicineHirosaki UniversityHirosakiAomoriJapan
| | - Hajime Morohashi
- Department of Gastroenterological SurgeryGraduate School of MedicineHirosaki UniversityHirosakiAomoriJapan
| | - Seiji Watanabe
- Department of Anatomical ScienceGraduate School of MedicineHirosaki UniversityHirosakiAomoriJapan
| | - Hirokazu Narita
- Department of Anatomical ScienceGraduate School of MedicineHirosaki UniversityHirosakiAomoriJapan
| | - Yuto Mitsuhashi
- Department of Gastroenterological SurgeryGraduate School of MedicineHirosaki UniversityHirosakiAomoriJapan,Department of Anatomical ScienceGraduate School of MedicineHirosaki UniversityHirosakiAomoriJapan
| | - Kotaro Umemura
- Department of Gastroenterological SurgeryGraduate School of MedicineHirosaki UniversityHirosakiAomoriJapan,Department of Anatomical ScienceGraduate School of MedicineHirosaki UniversityHirosakiAomoriJapan
| | - Kenichi Hakamada
- Department of Gastroenterological SurgeryGraduate School of MedicineHirosaki UniversityHirosakiAomoriJapan
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10
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Kimura CMS, Kawaguti FS, Nahas CSR, Marques CFS, Segatelli V, Martins BC, de Paulo GA, Cecconello I, Ribeiro-Junior U, Nahas SC, Maluf-Filho F. Long-term outcomes of endoscopic submucosal dissection and transanal endoscopic microsurgery for the treatment of rectal tumors. J Gastroenterol Hepatol 2021; 36:1634-1641. [PMID: 33091219 DOI: 10.1111/jgh.15309] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 09/28/2020] [Accepted: 10/11/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIM Endoscopic submucosal dissection and transanal endoscopic microsurgery are good options for the treatment of rectal adenomas and early rectal carcinomas, but whether long-term outcomes of these procedures are comparable is not known. The aim of this study was to address this question. METHODS A retrospective single-center study evaluating 98 consecutive procedures between June 2008 and December 2017 was performed in a tertiary cancer center. Consecutive patients who had undergone either endoscopic submucosal resection or transanal endoscopic microsurgery for rectal adenomas and early rectal carcinomas were evaluated, and long-term recurrence and complication rates were compared. RESULTS Both groups were similar regarding sex, age, preoperative surgical risk, and en bloc resection rate (95.7% in the endoscopic and 100% in the surgical group, P = 0.81). Mean follow-up period was 37.6 months. Lesions resected endoscopically were significantly larger (68.5 mm) than those resected by transanal resection (44.5 mm), P = 0.003. Curative resections occurred in 97.2% of endoscopic resections and 85.2% of the surgical ones (P = 0.04). Comparing resections that fulfilled histologic curative criteria, there were no recurrences in the endoscopic group (out of 69 cases) and two recurrences in the transanal group (8.3% of 24 cases), P = 0.06. Late complications occurred in 12.7% of endoscopic procedures and 25.9% of surgical procedures (P = 0.13). CONCLUSIONS In our experience, endoscopic submucosal resection seems to have advantages over transanal endoscopic microsurgery, with similar en bloc resection rate and lower rate of late complications and recurrences. Multicenter randomized controlled trials are needed to support our findings.
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Affiliation(s)
| | | | | | | | | | | | | | - Ivan Cecconello
- Division of Gastrointestinal Surgery, Institute of Cancer of São Paulo, São Paulo, Brazil
| | - Ulysses Ribeiro-Junior
- Division of Gastrointestinal Surgery, Institute of Cancer of São Paulo, São Paulo, Brazil
| | - Sergio Carlos Nahas
- Division of Gastrointestinal Surgery, Institute of Cancer of São Paulo, São Paulo, Brazil
| | - Fauze Maluf-Filho
- Division of Endoscopy, Institute of Cancer of São Paulo, São Paulo, Brazil
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11
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Luo D, Shan Z, Liu Q, Cai S, Ma Y, Li Q, Li X. The correlation between tumor size, lymph node status, distant metastases and mortality in rectal cancer patients without neoadjuvant therapy. J Cancer 2021; 12:1616-1622. [PMID: 33613748 PMCID: PMC7890314 DOI: 10.7150/jca.52165] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 12/15/2020] [Indexed: 12/24/2022] Open
Abstract
Tumor size has an effect on decision making for the treatment rectal cancer. Transanal local excision can be selected to remove rectal cancer with favorable histopathological features. It is generally recognized that the risk of lymph node involvement and distant metastases increases as the tumor enlarges. However, the majority of the studies classified patients into two groups using concrete value as a cutoff point. The coarse classification was not sufficient to reveal a correlation between the tumor size and lymph node status or distant metastases across the full range of sizes examined. Between 1988 and 2015, a total of 77,746 patients were diagnosed with first primary rectal cancer who had not received neoadjuvant therapy. These subjects were identified using the Surveillance, Epidemiology and End Results (SEER) database. The association between tumor size, lymph node status, distant metastases and cancer-specific mortality was investigated. Tumor size was examined as a continuous (1-30 mm) and categorical variable (11 size groups; 10-mm intervals). A non-linear correlation between increasing tumor size and the prevalence of lymph node involvement was observed, while a near-positive correlation between tumor size and distant metastases was presented. In addition, the 5-year and 10-year rates of rectal cancer-specific mortality were increased as the tumor enlarged. For small tumors (under 30 mm), a positive correlation was noted between tumor size and lymph node involvement. The clinical value of the tumor size should be reevaluated by exact classification.
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Affiliation(s)
- Dakui Luo
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Zezhi Shan
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Qi Liu
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Sanjun Cai
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Yanlei Ma
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Qingguo Li
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Xinxiang Li
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
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12
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van Oostendorp SE, Smits LJH, Vroom Y, Detering R, Heymans MW, Moons LMG, Tanis PJ, de Graaf EJR, Cunningham C, Denost Q, Kusters M, Tuynman JB. Local recurrence after local excision of early rectal cancer: a meta-analysis of completion TME, adjuvant (chemo)radiation, or no additional treatment. Br J Surg 2020; 107:1719-1730. [PMID: 32936943 PMCID: PMC7692925 DOI: 10.1002/bjs.12040] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 07/13/2020] [Accepted: 08/10/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The risks of local recurrence and treatment-related morbidity need to be balanced after local excision of early rectal cancer. The aim of this meta-analysis was to determine oncological outcomes after local excision of pT1-2 rectal cancer followed by no additional treatment (NAT), completion total mesorectal excision (cTME) or adjuvant (chemo)radiotherapy (aCRT). METHODS A systematic search was conducted in PubMed, Embase and the Cochrane Library. The primary outcome was local recurrence. Statistical analysis included calculation of the weighted average of proportions. RESULTS Some 73 studies comprising 4674 patients were included in the analysis. Sixty-two evaluated NAT, 13 cTME and 28 aCRT. The local recurrence rate for NAT among low-risk pT1 tumours was 6·7 (95 per cent c.i. 4·8 to 9·3) per cent. There were no local recurrences of low-risk pT1 tumours after cTME or aCRT. The local recurrence rate for high-risk pT1 tumours was 13·6 (8·0 to 22·0) per cent for local excision only, 4·1 (1·7 to 9·4) per cent for cTME and 3·9 (2·0 to 7·5) per cent for aCRT. Local recurrence rates for pT2 tumours were 28·9 (22·3 to 36·4) per cent with NAT, 4 (1 to 13) per cent after cTME and 14·7 (11·2 to 19·0) per cent after aCRT. CONCLUSION There is a substantial risk of local recurrence in patients who receive no additional treatment after local excision, especially those with high-risk pT1 and pT2 rectal cancer. The lowest recurrence risk is provided by cTME; aCRT has outcomes comparable to those of cTME for high-risk pT1 tumours, but shows a higher risk for pT2 tumours.
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Affiliation(s)
- S E van Oostendorp
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - L J H Smits
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - Y Vroom
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - R Detering
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - M W Heymans
- Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - L M G Moons
- Department of Gastroenterology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - P J Tanis
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - E J R de Graaf
- Department of Surgery, IJsselland Ziekenhuis, Capelle aan den Ijssel, the Netherlands
| | - C Cunningham
- Department of Surgery, Oxford University Hospitals, Oxford, UK
| | - Q Denost
- Department of Surgery, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - M Kusters
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - J B Tuynman
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
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13
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Samalavicius NE, Kavaliauskas P, Dulskas A. Transanal excision of a giant rectal polyp - a video vignette. Colorectal Dis 2020; 22:726-727. [PMID: 31965708 DOI: 10.1111/codi.14976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 12/21/2019] [Indexed: 02/08/2023]
Affiliation(s)
- N E Samalavicius
- Department of Surgery, Klaipeda University Hospital, Klaipeda, Lithuania.,Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - P Kavaliauskas
- Vilnius City Clinical Hospital, Vilnius, Lithuania.,Departament of General and Abdominal Surgery and Oncology, National Cancer Institute, Vilnius, Lithuania
| | - A Dulskas
- Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Departament of General and Abdominal Surgery and Oncology, National Cancer Institute, Vilnius, Lithuania.,Faculty of Health Care, University of Applied Sciences, Vilnius, Lithuania
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14
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Cohen R, Platell C. Primary local excision of stage 1 rectal cancer is not associated with worse oncological outcomes when compared with major resection. Int J Colorectal Dis 2020; 35:607-14. [PMID: 31974752 DOI: 10.1007/s00384-020-03512-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Primary local excision (PLE) for early rectal cancers is associated with decreased surgical morbidity and mortality compared with major resection (MR). However, it is thought to be associated with poorer oncological outcomes. There is a paucity of data regarding PLE within the Australasian population. We present comparative post-operative and survival outcomes for stage 1 rectal cancers treated with PLE or MR from three Western Australian hospitals. METHODS A retrospective analysis was performed on a prospectively maintained database of patients undergoing PLE or MR for stage 1 rectal cancers between February 1996 and May 2019. RESULTS Of the 533 patients, 81 underwent PLE. Median post-operative admission was shorter for those undergoing PLE, with no significant difference in post-operative complication rate. Five-year overall survival was greater following MR (89.6% CI 86.1-92.3) compared with PLE (84.6% CI 73.8-91.2; p = 0.0003). There was no significant difference in 5-year cancer-specific survival (MR, 94.4% CI 91.5-96.3; PLE, 95.3% CI 86.0-98.5; p = 0.98) or 5-year disease-free survival (MR, 92.3% CI 89.1-94.7; PLE, 89.1% CI 78.5-94.7; p = 0.36). Local excision provided poorer local tumour control with an inferior 5-year local recurrence rate (MR, 2.16% CI 1.08-4.28; PLE, 10.9% CI 5.30-21.6; p = 0.0002). After controlling for confounders, PLE was significantly associated with worse local recurrence but did not significantly impact overall survival, cancer-specific survival, overall recurrence, or metastatic recurrence. CONCLUSION Local excision of early rectal cancer remains a viable alternative, in those unwilling or unable to undergo MR. Patients should be informed that while PLE is associated with poorer local pelvic control, this does not translate to worse survival.
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15
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Ushigome H, Ohue M, Kitamura M, Nakatsuka S, Haraguchi N, Nishimura J, Yasui M, Wada H, Takahashi H, Omori T, Miyata H, Yano M, Takiguchi S. Evaluation of risk factors for lymph node metastasis in T2 lower rectal cancer to perform chemoradiotherapy after local resection. Mol Clin Oncol 2020; 12:390-394. [PMID: 32190324 DOI: 10.3892/mco.2020.1993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 01/16/2020] [Indexed: 11/05/2022] Open
Abstract
The oncological outcome of chemoradiotherapy (CRT) after local excision (LE) for T2 lower rectal cancer has demonstrated a high local recurrence (LR) rate. The aim of the present study was to determine the risk factors for lymph node metastasis (LNM) in order to reduce LR in T2 lower rectal cancer after LE and CRT. Specimens were collected from 95 consecutive patients with T2 lower rectal adenocarcinoma who underwent R0 resection by total mesenteric excision or tumor-specific mesenteric excision between January 2008 and December 2018 at Osaka International Cancer Institute. All specimens were checked and evaluated to determine the risk factors for LNM. LNM was observed in 26 patients (27%), including 2 patients (2%) with lateral pelvic lymph node metastasis. Univariate analysis indicated lymphovascular invasion (LVI; P=0.008), tumor budding (P=0.012) and histology other than well-differentiated adenocarcinoma (P=0.08) were associated with LNM; multivariate analysis revealed that LVI (P=0.03) was the only independent risk factor for LNM. LNM was confirmed in 0% (0/8) of patients without LVI, tumor budding and histological type. LVI, tumor budding and histological type can be risk factors for LNM in lower rectal cancer. The present study may be helpful to select patients for performing LE and CRT with good oncological outcome.
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Affiliation(s)
- Hajime Ushigome
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Masayuki Ohue
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Masaki Kitamura
- Department of Pathology, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Shinichi Nakatsuka
- Department of Pathology, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Naoaki Haraguchi
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Junichi Nishimura
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Masayoshi Yasui
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Hiroshi Wada
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Hidenori Takahashi
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Takeshi Omori
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Hiroshi Miyata
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Masahiko Yano
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Shuji Takiguchi
- Department of Gastroenterological Surgery, Nagoya City University, Nagoya, Aichi 467-8602, Japan
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16
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Skowron KB, Hurst RD, Umanskiy K, Hyman NH, Shogan BD. Caring for Patients with Rectal Cancer During the COVID-19 Pandemic. J Gastrointest Surg 2020; 24:1698-703. [PMID: 32415658 DOI: 10.1007/s11605-020-04645-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 05/05/2020] [Indexed: 02/07/2023]
Abstract
The extraordinary spread of the novel coronavirus (COVID-19) has dramatically and rapidly changed the way in which we provide medical care for patients with all diagnoses. Conservation of resources, social distancing, and the risk of poor outcomes in COVID-19-positive cancer patients have forced practitioners and surgeons to completely rethink routine care. The treatment of patients with rectal cancer requires both a multidisciplinary approach and a significant amount of resources. It is therefore imperative to rethink how rectal cancer treatment can be aligned with the current COVID-19 pandemic paradigms. In this review, we discuss evidence-based recommendations to optimize oncological outcomes during the COVID-19 pandemic.
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17
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Russo S, Anker CJ, Abdel-Wahab M, Azad N, Das P, Dragovic J, Goodman KA, Herman JM, Jones W, Kennedy T, Konski A, Kumar R, Lee P, Patel NM, Sharma N, Small W, Suh WW, Jabbour SK. Executive Summary of the American Radium Society Appropriate Use Criteria for Local Excision in Rectal Cancer. Int J Radiat Oncol Biol Phys 2019; 105:977-993. [PMID: 31445109 PMCID: PMC11101014 DOI: 10.1016/j.ijrobp.2019.08.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 08/02/2019] [Accepted: 08/11/2019] [Indexed: 02/07/2023]
Abstract
The goal of treatment for early stage rectal cancer is to optimize oncologic outcome while minimizing effect of treatment on quality of life. The standard of care treatment for most early rectal cancers is radical surgery alone. Given the morbidity associated with radical surgery, local excision for early rectal cancers has been explored as an alternative approach associated with lower rates of morbidity. The American Radium Society Appropriate Use Criteria presented in this manuscript are evidence-based guidelines for the use of local excision in early stage rectal cancer that include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) used by a multidisciplinary expert panel to rate the appropriateness of imaging and treatment procedures. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. These guidelines are intended for the use of all practitioners and patients who desire information regarding the use of local excision in rectal cancer.
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Affiliation(s)
- Suzanne Russo
- Case Western Reserve University School of Medicine and University Hospitals, Cleveland, Ohio.
| | | | - May Abdel-Wahab
- International Atomic Energy Agency, Division of Human Health, New York, New York
| | - Nilofer Azad
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Prajnan Das
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | | | - Joseph M Herman
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - William Jones
- UT Health Cancer Center, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | | | - Andre Konski
- University of Pennsylvania Perelman School of Medicine, Chester County Hospital, West Chester, Pennsylvania
| | - Rachit Kumar
- Banner MD Anderson Cancer Center, Gilbert, Arizona
| | - Percy Lee
- University of California, Los Angeles, Jonsson Comprehensive Cancer Center, Los Angeles, California
| | | | - Navesh Sharma
- Milton S. Hershey Cancer Institute, Hershey, Pennsylvania
| | | | - W Warren Suh
- Ridley-Tree Cancer Center Santa Barbara @ Sansum Clinic, Santa Barbara California
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18
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Abstract
Background Total mesorectal excision (tme) is the current standard of care for the treatment of rectal cancer. However, that surgery is associated with significant morbidity and mortality. Clinicians and patients are seeking alternatives to radical resection. Currently, prevalent organ-sparing strategies under investigation include local excision and nonoperative management (nom). Methods We reviewed the current evidence in the literature to create an overview of the use of transanal endoscopic surgery and watch-and-wait strategies in the modern management of rectal cancer. Results Compared with radical resection, transanal endoscopic surgery in patients with early rectal cancer (cT1) having favourable histopathologic features is associated with an increased risk of local recurrence, but no difference in 5-year survival. In patients with T2 or early T3 cancer, strategies that use neoadjuvant or adjuvant therapy as adjuncts to local excision are under evaluation. Nonoperative management is a new option for patients who experience a complete clinical response after neoadjuvant chemoradiotherapy (ncrt). The selection criteria that will appropriately identify patients for whom nom will succeed are not established. Conclusions Local excision is appropriate for early rectal cancer with favourable histopathologic features. Although organ-preserving strategies are promising, the quality of the evidence to date is insufficient to replace the current standard care in most patients. Patients should be offered nom in the safe setting of a clinical trial or registry. Rigorous follow-up, including endoscopy and imaging at frequent intervals is recommended when radical resection is forgone.
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Affiliation(s)
- F Rouleau-Fournier
- Department of Surgery, St. Paul's Hospital, Providence Health Care, Vancouver, BC
| | - C J Brown
- Department of Surgery, St. Paul's Hospital, Providence Health Care, Vancouver, BC
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19
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Kitaguchi D, Sasaki T, Nishizawa Y, Tsukada Y, Ito M. Long-Term Outcomes and Lymph Node Metastasis in Patients Receiving Radical Surgery for Pathological T1 Lower Rectal Cancer. World J Surg 2019; 43:649-656. [PMID: 30353404 DOI: 10.1007/s00268-018-4824-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Few reports have evaluated the long-term outcomes of pathological T1 (pT1) lower rectal cancer (LRC), perhaps because pT1 LRC is classified as TNM stage I if lymph node metastasis (LNM) is absent and stage IIIA if LNM is present. Moreover, it is difficult to diagnose regional LNM preoperatively. This study aimed to clarify the long-term outcomes of radical surgery for pT1 LRC and risk factor(s) for LNM. Additionally, we examined whether preoperative computed tomography (CT) and magnetic resonance imaging (MRI) findings were predictive of LNM in pT1 LRC. METHODS This was a retrospective analysis of the clinical characteristics, short-term operative outcomes, and long-term survival rates of 155 patients who received radical surgery and were diagnosed with pT1 LRC at our hospital between January 1993 and February 2017. RESULTS Among patients with pT1 LRC, 5-year recurrence-free and overall survival rates were 94.0% and 95.8%, respectively. LNM status was not associated with statistically significant differences in recurrence-free or overall survival. Even in patients with LNM, the recurrence rate was only 9%. Among patients who lacked visible mesorectal lymph nodes on preoperative CT and MRI, LNM rates were 3.5% and 4.3%, respectively. CONCLUSION The long-term outcomes after radical surgery for pT1 LRC are satisfactory or good, regardless of the presence or absence of LNM. In patients with pT1 LRC, the absence of visible mesorectal lymph nodes on preoperative CT and MRI is associated with a reduced likelihood of LNM and has a high negative predictive value for LNM.
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Affiliation(s)
- Daichi Kitaguchi
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa-City, Chiba, 277-8577, Japan
| | - Takeshi Sasaki
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa-City, Chiba, 277-8577, Japan.
| | - Yuji Nishizawa
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa-City, Chiba, 277-8577, Japan
| | - Yuichiro Tsukada
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa-City, Chiba, 277-8577, Japan
| | - Masaaki Ito
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa-City, Chiba, 277-8577, Japan.
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20
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Abstract
BACKROUND A common consensus for the definition for early rectal cancer does not exist. This item is used in cases of histological findings including pTis, pT1 or pT2 tumors. The term early rectal cancer is not mentioned in the German S3 guidelines on colorectal cancer. The pTis tumors are located at the mucosa level of the intestinal wall and they have nearly no tendency to develop metastases but pT2 tumors have a high risk of local metastases; therefore, the term early rectal cancer is not adequate for pT2 tumors. OBJECTIVE This focus of this article is exclusively on pT1 rectal cancer. Following the histological definition, pT1 tumors of the rectum are located at the level of the mucosa and submucosa of the intestinal wall. CONCLUSION With respect to the nature of the tumor (e.g. size, grading, invasion of lymphatic and/or blood vessels, Kikuchi classification) local methods (endoscopic procedure, surgical techniques) or radical resections are recommended. Tumor budding is of increasing interest and importance. Depending on the severity of the tumor budding classification (bd1-bd3) there is an association with a more frequent occurrence of lymph node metastases and should therefore be taken into consideration in treatment decisions in the future.
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21
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Halverson AL, Morris AM, Cleary RK, Chang GJ. For Patients with Early Rectal Cancer, Does Local Excision Have an Impact on Recurrence, Survival, and Quality of Life Relative to Radical Resection? Ann Surg Oncol 2019; 26:2497-2506. [PMID: 31025228 DOI: 10.1245/s10434-019-07328-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND The most appropriate treatment for early-stage rectal cancers is controversial. The advantages of local excision regarding morbidity and function must be weighed against poorer oncologic efficacy. This study aimed to clarify further the role for local excision in the treatment of rectal cancer. METHODS A systematic review of Medline, SCOPUS, and Cochrane databases was conducted. Relevant studies were selected using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data addressing five key questions about outcomes of local versus radical resection of rectal cancer were analyzed. RESULTS The 16 studies identified by this study were mostly retrospective, and none were randomized. Local excision was associated with fewer complications and better functional outcome than radical resection. Of 12 studies evaluating local recurrence, 6 showed a higher local recurrence rate among patients who underwent local excision. Two additional studies showed no increase in local recurrence rate among patients who underwent local excision of T1 lesions but a significantly higher local recurrence rate among those who underwent local excision of T2 lesions. High histologic grade, angiolymphatic invasion, perineural invasion, and depth within submucosa were features associated with a higher risk of local recurrence. In 7 of 15 studies, long-term survival was reduced compared with that of patients who underwent radical resection. CONCLUSIONS Although local excision for early-stage rectal cancer is associated with increased local recurrence and decreased overall survival compared with radical resection, local excision may be appropriate for select individuals who have T1 tumors with no adverse pathologic features.
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Affiliation(s)
- Amy L Halverson
- Division of Colon and Rectal Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Arden M Morris
- Section of Colon and Rectal Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Robert K Cleary
- Division of Colon and Rectal Surgery, St Joseph Mercy Hospital, Ann Arbor, MI, USA
| | - George J Chang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Mangas-Sanjuan C, Jover R, Cubiella J, Marzo-Castillejo M, Balaguer F, Bessa X, Bujanda L, Bustamante M, Castells A, Diaz-Tasende J, Díez-Redondo P, Herráiz M, Mascort-Roca JJ, Pellisé M, Quintero E. Vigilancia tras resección de pólipos de colon y de cáncer colorrectal. Actualización 2018. Gastroenterología y Hepatología 2019; 42:188-201. [PMID: 30621911 DOI: 10.1016/j.gastrohep.2018.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 11/08/2018] [Accepted: 11/12/2018] [Indexed: 02/07/2023]
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Coton C, Lefevre JH, Debove C, Creavin B, Chafai N, Tiret E, Parc Y. Does transanal local resection increase morbidity for subsequent total mesorectal excision for early rectal cancer? Colorectal Dis 2019; 21:15-22. [PMID: 30300969 DOI: 10.1111/codi.14445] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 07/30/2018] [Indexed: 02/06/2023]
Abstract
AIM Local excision is recommended for early rectal cancer (pT1). Complementary total mesorectal excision (cTME) is warranted when bad pathological features are present. The impact of a prior local resection on the outcome remains unclear. The aim of this study was to assess if prior local excision increases the morbidity of a subsequent cTME compared with primary TME. METHODS From 2001 to 2016 all patients who underwent TME after local excision for rectal adenocarcinoma were studied. All were matched (1:1) with patients who underwent primary TME, without neoadjuvant radiochemotherapy. The matching factors included age, sex, body mass index, American Society of Anesthesiologists score and type of surgery. Short-term morbidity and pathological examination of the resected specimen were compared. RESULTS Forty-one patients were included (14 women, 34%, mean age 65 ± 11 years), comprising classic transanal excision (66%) and transanal endoscopic microsurgery (34%), and were matched to 41 patients who had primary TME. cTME was significantly longer (315 min ± 87 vs 275 min ± 58, P = 0.03). The overall morbidity was 48.8% in the local excision group vs 31.7% in the control group (P = 0.18). Surgical morbidity was 31.7% vs 26.8% (P = 0.8). Anastomotic related morbidity was similar (local excision 17% vs TME 14.6%, P = 0.84) and the mean length of stay was similar (14 days) in both groups. There was a tendency to a worse quality of mesorectal excision in the cTME group (17% vs 5%, P = 0.15). CONCLUSION Local excision prior to TME for early rectal cancer tends to increase overall morbidity and may worsen the quality of the mesorectal plane but should be considered as a surgical approach in select cases.
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Affiliation(s)
- C Coton
- Department of Digestive and General Surgery, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - J H Lefevre
- Department of Digestive and General Surgery, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - C Debove
- Department of Digestive and General Surgery, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - B Creavin
- Department of Colorectal Surgery, St Vincent's University Hospital, Dublin 4, Ireland
| | - N Chafai
- Department of Digestive and General Surgery, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - E Tiret
- Department of Digestive and General Surgery, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - Y Parc
- Department of Digestive and General Surgery, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
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Dehal A, Graff-Baker AN, Vuong B, Nelson D, Chang SC, Goldfarb M, Bilchik AJ. Current Imaging Modalities Understage One-Third of Patients with Stage I Rectal Cancer: Implications for Treatment Selection. Am Surg 2018. [DOI: 10.1177/000313481808401010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Accurate preoperative clinical staging is essential to optimize the treatment of rectal cancer. Primary surgical resection is typically indicated for stage I disease, whereas neoadjuvant therapy is recommended for stages II and III. The objective of this study is to examine the accuracy of clinical staging using current imaging modalities in predicting pathologic stage and, thus, selecting appropriate treatment. Adult patients with nonmetastatic rectal cancer who underwent primary surgical resection were identified from the National Cancer Database between 2006 and 2014. Data on clinical and pathologic staging was obtained. Kappa index was used to determine the correlation between clinical and pathologic staging. A total of 13,175 patients were identified. The correlation between clinical and pathologic staging was 69 per cent for stage I (31% upstaged) (Kappa 0.54, P < 0.001). One-third of patients who were clinically staged as stage I, and were therefore treated with primary surgical resection, had pathologic stage II or III disease. Based on their clinical staging, those patients did not receive the neoadjuvant therapy recommended by present guidelines. Where accurate clinical staging is in doubt, oncologists should carefully examine the quality of staging modality and perhaps consider multimodal imaging using both endorectal ultrasound and MRI.
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Affiliation(s)
- Ahmed Dehal
- John Wayne Cancer Institute at Providence St John's Health Center, Santa Monica, California
| | - Amanda N. Graff-Baker
- John Wayne Cancer Institute at Providence St John's Health Center, Santa Monica, California
| | - Brooke Vuong
- John Wayne Cancer Institute at Providence St John's Health Center, Santa Monica, California
| | - Daniel Nelson
- John Wayne Cancer Institute at Providence St John's Health Center, Santa Monica, California
| | - Shu-Ching Chang
- Medical Data Research Center, Providence Health & Services, Portland, Oregon
| | - Melanie Goldfarb
- John Wayne Cancer Institute at Providence St John's Health Center, Santa Monica, California
| | - Anton J. Bilchik
- John Wayne Cancer Institute at Providence St John's Health Center, Santa Monica, California
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Suzuki T, Sadahiro S, Tanaka A, Okada K, Saito G, Miyakita H, Akiba T, Yamamuro H. Outcomes of Local Excision plus Chemoradiotherapy in Patients with T1 Rectal Cancer. Oncology 2018; 95:246-250. [PMID: 29909419 DOI: 10.1159/000489930] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 05/08/2018] [Indexed: 01/03/2023]
Abstract
OBJECTIVE The National Comprehensive Cancer Network (NCCN) guidelines recommend local excision and observation as standard treatment for selected patients with clinical T1N0M0 rectal cancer. In patients with pathological T1 (pT1) rectal cancer who received local excision, the local recurrence rate is at least 10%. We studied oncological outcomes in patients with pT1 rectal cancer who received chemoradiotherapy (CRT) after local excision. METHODS Local excision was performed in 65 patients with clinical T1N0M0 rectal cancer (≤8 cm from the anal verge, tumor size < 30 mm, well or moderately differentiated adenocarcinoma). The patients received CRT (40 or 45 Gy in 1.8-2.0 fractions with concurrent oral UFT [tegafur/uracil] or S-1 [tegafur/gimeracil/ote-racil]) after confirmation of pT1 and negative margins. RESULTS Patients who had pT2 cancer or who did not provide informed consent were excluded. The remaining 50 patients additionally received CRT. The CRT was completed in 48 patients (96%). The median follow-up period was 71 months. Local recurrence occurred in 1 patient (2%). Distant metastases occurred in 3 patients (6%). The 5-year disease-free survival rate was 86%, and the 5-year overall survival rate was 92%. CONCLUSIONS Our study suggested that multidisciplinary treatment with local excision plus CRT can be used as a treatment option in selected patients with clinical T1N0M0 rectal cancer.
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Affiliation(s)
- Toshiyuki Suzuki
- Department of Surgery, Tokai University School of Medicine, Kanagawa, Japan
| | - Sotaro Sadahiro
- Department of Surgery, Tokai University School of Medicine, Kanagawa, Japan
| | - Akira Tanaka
- Department of Surgery, Tokai University School of Medicine, Kanagawa, Japan
| | - Kazutake Okada
- Department of Surgery, Tokai University School of Medicine, Kanagawa, Japan
| | - Gota Saito
- Department of Surgery, Tokai University School of Medicine, Kanagawa, Japan
| | - Hiroshi Miyakita
- Department of Surgery, Tokai University School of Medicine, Kanagawa, Japan
| | - Takeshi Akiba
- Department of Radiology, Tokai University School of Medicine, Kanagawa, Japan
| | - Hiroshi Yamamuro
- Department of Radiology, Tokai University School of Medicine, Kanagawa, Japan
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Read J, Tekkis P, Rullier E, Nicholls J, Mortensen N, Marks J, Steele RJC, Brown G. Session 3: Many ways to organ preserve the rectum but which is correct? Colorectal Dis 2018; 20 Suppl 1:82-87. [PMID: 29878680 DOI: 10.1111/codi.14085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
From the patient's perspective, cancer cure with full preservation of function is a crucial goal. There are many advances that have emerged which may make this possible in a greater proportion of patients without compromising oncological outcomes. Professor Tekkis reviews the options and evidence to date for 'organ preservation' and the expert panel discuss the implications for current and future patient care.
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Affiliation(s)
- J Read
- The Royal Marsden NHS Foundation Trust, London, UK
| | - P Tekkis
- The Royal Marsden NHS Foundation Trust, London, UK
| | - E Rullier
- Saint-Andre Hospital, University of Bordeaux, Bordeaux, France
| | | | | | - J Marks
- Lankenau Hospital, Wynnewood, Pennsylvania, USA
| | - R J C Steele
- Prevention, Early Detection and Treatment of Colorectal Cancer, University of Dundee, Dundee, UK
| | - G Brown
- The Royal Marsden NHS Foundation Trust, London, UK.,Imperial College London, London, UK
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Rombouts AJM, Al-Najami I, Abbott NL, Appelt A, Baatrup G, Bach S, Bhangu A, Garm Spindler KL, Gray R, Handley K, Kaur M, Kerkhof E, Kronborg CJ, Magill L, Marijnen CAM, Nagtegaal ID, Nyvang L, Peters FP, Pfeiffer P, Punt C, Quirke P, Sebag-Montefiore D, Teo M, West N, de Wilt JHW. Can we Save the rectum by watchful waiting or Trans Anal microsurgery following (chemo) Radiotherapy versus Total mesorectal excision for early REctal Cancer (STAR-TREC study)?: protocol for a multicentre, randomised feasibility study. BMJ Open 2017; 7:e019474. [PMID: 29288190 PMCID: PMC5770914 DOI: 10.1136/bmjopen-2017-019474] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 10/20/2017] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Total mesorectal excision (TME) is the highly effective standard treatment for rectal cancer but is associated with significant morbidity and may be overtreatment for low-risk cancers. This study is designed to determine the feasibility of international recruitment in a study comparing organ-saving approaches versus standard TME surgery. METHODS AND ANALYSIS STAR-TREC trial is a multicentre international randomised, three-arm parallel, phase II feasibility study in patients with biopsy-proven adenocarcinoma of the rectum. The trial is coordinated from Birmingham, UK with national hubs in Radboudumc (the Netherlands) and Odense University Hospital Svendborg UMC (Denmark). Patients with rectal cancer, staged by CT and MRI as ≤cT3b (up to 5 mm of extramural spread) N0 M0 can be included. Patients will be randomised to either standard TME surgery (control), organ-saving treatment using long-course concurrent chemoradiation or organ-saving treatment using short-course radiotherapy. For patients treated with an organ-saving strategy, clinical response to (chemo)radiotherapy determines the next treatment step. An active surveillance regime will be performed in the case of a complete clinical regression. In the case of incomplete clinical regression, patients will proceed to local excision using an optimised platform such as transanal endoscopic microsurgery or other transanal techniques (eg, transanal endoscopic operation or transanal minimally invasive surgery). The primary endpoint of this phase II study is to demonstrate sufficient international recruitment in order to sustain a phase III study incorporating pelvic failure as the primary endpoint. Success in phase II is defined as randomisation of at least four cases per month internationally in year 1, rising to at least six cases per month internationally during year 2. ETHICS AND DISSEMINATION The medical ethical committees of all the participating countries have approved the study protocol. Results of the primary and secondary endpoints will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER ISRCTN14240288, 20 October 2016. NCT02945566; Pre-results, October 2016.
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Affiliation(s)
- Anouk J M Rombouts
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Issam Al-Najami
- Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Natalie L Abbott
- Radiotheraphy Trials Quality Assurance Group, Velindre Cancer Centre, Cardiff, UK
| | - Ane Appelt
- Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
- Leeds Cancer Centre, St. James' University Hospital, Leeds, UK
| | - Gunnar Baatrup
- Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Simon Bach
- Department of Surgery, University Hospitals Birmingham, Birmingham, UK
| | - Aneel Bhangu
- Department of Surgery, University Hospitals Birmingham, Birmingham, UK
| | - Karen-Lise Garm Spindler
- Department of Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Richard Gray
- Clinical Trial Services Unit, University of Oxford, Oxford, UK
| | - Kelly Handley
- Institue of Applied Health Research, University of Birmingham Clinical Trials Unit, Birmingham, UK
| | - Manjinder Kaur
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Ellen Kerkhof
- Department of Radiotherapy, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Laura Magill
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Corrie A M Marijnen
- Department of Radiotherapy, Leiden University Medical Center, Leiden, The Netherlands
| | - Iris D Nagtegaal
- Department of Pathology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Lars Nyvang
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Femke P Peters
- Department of Radiotherapy, Leiden University Medical Center, Leiden, The Netherlands
| | - Per Pfeiffer
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Cornelis Punt
- Department of Medical Oncology, Academic Medical Center, Amsterdam, The Netherlands
| | - Philip Quirke
- Department of Pathology, School of Medicine, University of Leeds, Leeds, UK
| | - David Sebag-Montefiore
- Department of Clinical Oncology, Leeds Radiotherapy Research Group, University of Leeds, Leeds, UK
| | - Mark Teo
- Department of Clinical Oncology, Leeds Radiotherapy Research Group, University of Leeds, Leeds, UK
- Department of Clinical Oncology, Leeds Cancer Centre, St James University Hospital, Leeds, UK
| | - Nick West
- Department of Pathology, School of Medicine, University of Leeds, Leeds, UK
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
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Lee L, Kelly J, Nassif GJ, Atallah SB, Albert MR, Shridhar R, Monson JRT. Chemoradiation and Local Excision for T2N0 Rectal Cancer Offers Equivalent Overall Survival Compared to Standard Resection: a National Cancer Database Analysis. J Gastrointest Surg 2017; 21:1666-1674. [PMID: 28819913 DOI: 10.1007/s11605-017-3536-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 08/04/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Local excision (LE) alone is associated with worse survival compared to radical surgery (RS) for T2 rectal cancer, but LE with additional chemoradiation (CRT) may improve outcomes. The objective of this study was to compare combined CRT and LE versus RS for T2 rectal cancer. METHODS The 2004-2014 National Cancer Database was queried for patients with T2N0M0 rectal cancer undergoing LE with neoadjuvant(NA-CRT + LE) or adjuvant(LE + Adj-CRT) CRT, or RS. The main outcome was 5-year overall survival (OS). Cox proportional hazards was used to determine the independent effect of treatment on OS. RESULTS A total of 4822 patients were included (4367 RS, 242 CRT + LE, 213 LE + Adj-CRT). Mean follow-up was 48.6 (SD28.5) months. There were no differences in patient characteristics, but more high-risk features in the LE + Adj-CRT group. There were no differences in 90-day mortality. Five-year OS was similar (RS 77.4% vs. CRT + LE 76.1% vs. LE + Adj-CRT 79.7%, p = 0.786). Older age, male gender, and higher Charlson score were independently associated with worse OS, whereas treatment type was not. If 90-day mortality was excluded, LE + Adj-CRT was independently associated with worse OS compared to RS. CONCLUSIONS CRT with LE for T2N0M0 rectal cancer was not associated with worse OS compared to RS, and may be a viable treatment modality.
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Affiliation(s)
- Lawrence Lee
- Center for Colon and Rectal Surgery, Florida Hospital, 2401 North Orange Ave, Suite 240, Orlando, FL, 32804, USA.
| | - Justin Kelly
- Center for Colon and Rectal Surgery, Florida Hospital, 2401 North Orange Ave, Suite 240, Orlando, FL, 32804, USA
| | - George J Nassif
- Center for Colon and Rectal Surgery, Florida Hospital, 2401 North Orange Ave, Suite 240, Orlando, FL, 32804, USA
| | - Sam B Atallah
- Center for Colon and Rectal Surgery, Florida Hospital, 2401 North Orange Ave, Suite 240, Orlando, FL, 32804, USA
| | - Matthew R Albert
- Center for Colon and Rectal Surgery, Florida Hospital, 2401 North Orange Ave, Suite 240, Orlando, FL, 32804, USA
| | - Ravi Shridhar
- Department of Radiation Oncology, Florida Hospital, Orlando, FL, USA
| | - John R T Monson
- Center for Colon and Rectal Surgery, Florida Hospital, 2401 North Orange Ave, Suite 240, Orlando, FL, 32804, USA
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Sasaki T, Ito Y, Ohue M, Kanemitsu Y, Kobatake T, Ito M, Moriya Y, Saito N. Postoperative Chemoradiotherapy After Local Resection for High-Risk T1 to T2 Low Rectal Cancer: Results of a Single-Arm, Multi-Institutional, Phase II Clinical Trial. Dis Colon Rectum 2017; 60:914-21. [PMID: 28796729 DOI: 10.1097/DCR.0000000000000870] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND After treatment with local excision for TNM stage I low rectal cancer, the risk of local recurrence is not only high for T2 lesions but also for T1 lesions with features of massive invasion to the submucosal layer and/or lymphovascular invasion. OBJECTIVE The purpose of this study was to determine the efficacy of chemoradiotherapy combined with local excision in the treatment of T1 to T2 low rectal cancer. DESIGN We conducted a prospective, single-arm, phase II trial. SETTINGS This was a multicenter study. PATIENTS From April 2003 to October 2010, 57 patients were treated with local excision after additional external beam irradiation (45 Gy) plus continuous 5-week intravenous injection of 5-fluorouracil (250 mg/m per day) at 10 domestic hospitals. Fifty-three patients had clinical T1N0 lesions, and 4 had T2N0 lesions in the low rectum, located below the peritoneal reflection. MAIN OUTCOMES MEASURES The primary end point was disease-free survival at 5 years. RESULTS The completion rate for full-dose chemoradiotherapy was 86% (49/57). Serious, nontransient treatment-related complications were not reported. With a median follow-up of 7.3 years after local excision, the 5-year disease-free survival rate was 94% for the 53 patients with T1 lesions and 75% for the 4 patients with T2 lesions. There were 2 local recurrences during the entire observation period. Anal function after local excision and chemoradiation were kept at almost the same levels as observed before treatment. LIMITATIONS The study was limited by the small number of registered T2 rectal cancers, retrospective evaluations of quality of life, and the exclusion of poorly differentiated adenocarcinoma (a high-risk feature of T1 lesions). CONCLUSIONS The addition of chemoradiotherapy to local excision of T1 rectal adenocarcinomas with poor prognostic features including deep submucosal invasion and lymphovascular invasion could improve on less favorable historic oncologic outcomes of local excision alone in this high-risk group for lymph node metastasis. See Video Abstract at http://links.lww.com/DCR/A421.
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Abstract
Imaging determines the optimal treatment for rectal cancer patients. High-resolution magnetic resonance imaging (MRI) overcomes many of the known limitations of previous methods. When performed in accordance with the recommended standards, MRI enables accurate staging of both early and advanced rectal cancer, accurate response assessment, the delineation of recurrent disease and planning surgical treatment in a safe and effective manner. Tumour-related high-risk features with known adverse outcomes can be preoperatively identified and treated with neoadjuvant chemoradiotherapy. Further, MRI post-treatment tumour response assessment using TRG grading system also predicts the likely survival outcomes and in the future will be used to modify treatment further by stratification into good and poor responders. There is a paucity of literature with validated outcome data concerning use of diffusion-weighted imaging and positron emission tomography (PET)/computed tomography (CT), and in the absence of any validated methods and outcome data, their use in the initial assessment and restaging after treatment is limited to research protocols. Combination MRI and CT is essential for distant spread assessment and recurrent disease, and currently PET-CT is sometimes used in the workup of patients with recurrent and metastatic disease.
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Gollins S, Moran B, Adams R, Cunningham C, Bach S, Myint AS, Renehan A, Karandikar S, Goh V, Prezzi D, Langman G, Ahmedzai S, Geh I. Association of Coloproctology of Great Britain & Ireland (ACPGBI): Guidelines for the Management of Cancer of the Colon, Rectum and Anus (2017) - Multidisciplinary Management. Colorectal Dis 2017; 19 Suppl 1:37-66. [PMID: 28632307 DOI: 10.1111/codi.13705] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
| | - Brendan Moran
- Basingstoke & North Hampshire Hospital, Basingstoke, UK
| | - Richard Adams
- Cardiff University and Velindre Cancer Centre, Cardiff, UK
| | | | - Simon Bach
- University of Birmingham and Queen Elizabeth Hospital, Birmingham, UK
| | | | - Andrew Renehan
- University of Manchester and Christie Hospital, Manchester, UK
| | | | - Vicky Goh
- King's College and Guy's & St Thomas' Hospital, London, UK
| | | | | | | | - Ian Geh
- Queen Elizabeth Hospital, Birmingham, UK
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Han J, Noh GT, Cheong C, Cho MS, Hur H, Min BS, Lee KY, Kim NK. Transanal Endoscopic Operation Versus Conventional Transanal Excision for Rectal Tumors: Case-Matched Study with Propensity Score Matching. World J Surg 2017; 41:2387-2394. [PMID: 28421262 DOI: 10.1007/s00268-017-4017-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUNDS Although transanal endoscopic surgery is practiced worldwide, there is no consensus on comparative outcomes between transanal endoscopic operation (TEO) and transanal excision (TAE). In this study, we reviewed our experiences with these techniques and compared patients who underwent TEO and TAE using propensity score matching (PSM). METHODS A total of 207 patients underwent local rectal tumor excision between January 2008 and November 2015. To overcome selection bias, we used PSM to achieve a one-to-one TEO: TAE ratio. We included baseline characteristics, age, sex, surgeon, American Society of Anesthesiologists score, tumor location (clockwise direction), involved circumference quadrants, tumor size, and pathology. RESULTS After PSM, 72 patients were included in each group. The tumor distance from the anal verge was higher in the TEO group (8.0 [5-10] vs. TAE: 4.0 [3-5], p < 0.001). Complication rates did not differ between the groups (TEO: 8.3% vs. TAE: 11.1%, p = 0.39). TEO was associated with a shorter hospital stay (3.01 vs. 4.68 days, p = 0.001), higher negative margin rate (95.8 vs. 86.1%, p = 0.039), and non-fragmented specimen rate vs. TAE (98.6 vs. 90.3%, p = 0.029). CONCLUSIONS TEO was more beneficial for patients with higher rectal tumors. Regardless of tumor location, involved circumference quadrants, and tumor size, TEO may more effectively achieve negative resection margins and non-fragmented specimens. Consequently, although local excision method according to tumor distance may be important, TEO will become the standard for rectal tumors.
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Affiliation(s)
- Jeonghee Han
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Gyoung Tae Noh
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Chinock Cheong
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Min Soo Cho
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Hyuk Hur
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Soh Min
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Kang Young Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Nam Kyu Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea. .,Division of Colon and Rectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Korea.
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Junginger T, Goenner U, Hitzler M, Trinh TT, Heintz A, Roth W, Blettner M, Wollschlaeger D. Analysis of local recurrences after transanal endoscopic microsurgery for low risk rectal carcinoma. Int J Colorectal Dis 2017; 32:265-271. [PMID: 27888300 DOI: 10.1007/s00384-016-2715-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/18/2016] [Indexed: 02/04/2023]
Abstract
AIM Rates of local recurrence (LR) after transanal endoscopic microsurgery (TEM) for rectal carcinoma vary; the reasons remain unclear. We analyzed LR after TEM for low-risk pT1 (G1/2/X, L0/X) rectal carcinoma to investigate the influence of completeness of resection and occult lymph node metastasis on risk of LR. METHOD LR location and stage, completeness of resection of primary carcinoma (minimal distance between tumor and resection line ≤1 mm vs >1 mm), and incidence of involved lymph nodes in resected LR specimens were collected, and tumor characteristics of LR were compared with primary carcinoma. Distant metastasis and overall and cancer-specific survival were determined. RESULTS LR developed in 14 patients; in 2/4 with R1/X resection, in 3/8 (38%) with clear margins (R0) but a minimal distance of ≤1 mm, and in 9/88 (10%) with formally complete resection. Six of nine patients with formally complete resection underwent radical surgery for LR; in five out of these six, lymph nodes were not involved. In 5/14 patients, LR was poorly differentiated compared to primary carcinoma. Main LR causes were incomplete tumor resection or tumor persistence after formally complete resection. Overall (p = 0.008) and cancer-specific (p < 0.001) survival was lower in LR patients compared to non-LR patients, even if lymph nodes were uninvolved. CONCLUSIONS The results suggest that most LRs after TEM for low-risk rectal cancer were caused by residual tumor at the previous excision site and not by undetected lymph node metastases. By improved standardization of surgical techniques to ensure complete resection of carcinomas and thorough pathological assessments, most LRs seem to be avoidable.
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Affiliation(s)
- Theodor Junginger
- Department of General and Abdominal Surgery, University Medical Centre of the Johannes Gutenberg-University, Langenbeckstr. 1, 55131, Mainz, Germany.
| | - Ursula Goenner
- Department of General and Abdominal Surgery, University Medical Centre of the Johannes Gutenberg-University, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Mirjam Hitzler
- Department of General, Visceral and Vascular Surgery, Catholic Hospital Mainz, Mainz, Germany
| | - Tong T Trinh
- Department of Heart, Chest and Vascular Surgery, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Achim Heintz
- Department of General, Visceral and Vascular Surgery, Catholic Hospital Mainz, Mainz, Germany
| | - Wilfried Roth
- Institute of Pathology, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Maria Blettner
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Daniel Wollschlaeger
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
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Riansuwan W, Lohsiriwat V. Local Excision Versus Total Mesorectal Excision for Clinical Stage I (cT1–cT2) Rectal Cancer. Curr Colorectal Cancer Rep 2017. [DOI: 10.1007/s11888-017-0350-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Sekiguchi M, Matsuda T, Saito Y. Surveillance after endoscopic and surgical resection of colorectal cancer. Best Pract Res Clin Gastroenterol 2016; 30:959-970. [PMID: 27938790 DOI: 10.1016/j.bpg.2016.09.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Revised: 08/05/2016] [Accepted: 09/06/2016] [Indexed: 01/31/2023]
Abstract
With the increase in colorectal cancer burden, surveillance following endoscopic and surgical resection is an essential issue. The aim of surveillance programs is improvement of patient survival by early detection of residual tumor tissue or local recurrence, metachronous colorectal tumors, and metastases. Appropriate surveillance should be determined according to this risk of factors. In current guidelines, only surveillance colonoscopy is recommended after endoscopic resection of polyps with high-grade dysplasia, whereas intensive, multimodality surveillance using colonoscopy, radiological imaging and tumor marker measurements is recommended following surgical resection of invasive colorectal cancer. Detailed recommendations, including the timing of surveillance, are described based on high-quality evidence. However, there are still many unresolved issues for which more high-quality evidence is required.
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Affiliation(s)
- Masau Sekiguchi
- Cancer Screening Center, National Cancer Center Hospital, Tokyo, Japan; Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan; Division of Screening Technology, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan
| | - Takahisa Matsuda
- Cancer Screening Center, National Cancer Center Hospital, Tokyo, Japan; Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan; Division of Screening Technology, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan.
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
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Ramirez JM, Elia M, Cordoba E, Gracia JA, Aguilella V. Current Controversies in Transanal Surgery for Rectal Cancer. Surg Laparosc Endosc Percutan Tech 2016; 26:431-8. [DOI: 10.1097/sle.0000000000000357] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Abstract
Colorectal cancer is one of the most common causes of cancer and cancer morbidity in the United States. In comparison to colon polyps, rectal polyps pose a unique challenge. Advances in endoscopic techniques have allowed for more thorough rectal adenoma detection and removal; however, there remains a concern over piecemeal resection and negative resection margins. Advances in transanal excision techniques, such as transanal endoscopic microsurgery, have been proposed for the removal of benign polyps as well as some early stage rectal cancers, with emphasis on proper patient selection. This review will discuss the current endoscopic and surgical considerations of both benign and malignant rectal polyps.
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Affiliation(s)
- Michelle L Cowan
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Matthew L Silviera
- Section of Colon and Rectal Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
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Jeong JU, Nam TK, Kim HR, Shim HJ, Kim YH, Yoon MS, Song JY, Ahn SJ, Chung WK. Adjuvant chemoradiotherapy instead of revision radical resection after local excision for high-risk early rectal cancer. Radiat Oncol 2016; 11:114. [PMID: 27595767 PMCID: PMC5011790 DOI: 10.1186/s13014-016-0692-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Accepted: 08/31/2016] [Indexed: 01/30/2023] Open
Abstract
Background After local excision of early rectal cancer, revision radical resection is recommended for patients with high-risk pathologic stage T1 (pT1) or pT2 cancer, but the revision procedure has high morbidity rates. We evaluated the efficacy of adjuvant concurrent chemoradiotherapy (CCRT) for reducing recurrence after local excision in these patients. Methods Eighty-three patients with high-risk pT1 or pT2 rectal cancer underwent postoperative adjuvant CCRT after local excision. We defined high-risk features as pT1 having tumor size ≤3 cm, and/or resection margin (RM) ≤3 mm, and/or lymphovascular invasion (LVI), and/or non-full thickness excision such as endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD), or unknown records regarding those features, or pT2 cancer. Radiotherapy was administered with a median dose of 50.4 Gy in 1.8 Gy fraction size over 5–7 weeks. Concurrent 5-fluorouracil and leucovorin were administered for 4 days in the first and fifth weeks of radiotherapy. Results The median interval between local excision and radiotherapy was 34 (range, 11–104) days. Fifteen patients (18.1 %) had stage pT2 tumors, 22 (26.5 %) had RM of ≥3 mm, and 21 (25.3 %) had tumors of ≥3 cm in size. Thirteen patients (15.7 %) had LVI. Transanal excision was performed in 58 patients (69.9 %) and 25 patients (30.1 %) underwent EMR or ESD. The median follow-up was 61 months. The 5-year overall survival (OS), locoregional relapse-free survival (LRFS), and disease-free survival (DFS) rates for all patients were 94.9, 91.0, and 89.8 %, respectively. Multivariate analysis did not identify any significant factors for OS or LRFS, but the only significant factor affecting DFS was the pT stage (p = 0.027). Conclusions In patients with high-risk pT1 rectal cancer, adjuvant CCRT after local excision could be an effective alternative treatment instead of revision radical resection. However, patients with pT2 stage showed inferior DFS compared to pT1.
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Affiliation(s)
- Jae-Uk Jeong
- Department of Radiation Oncology, Chonnam National University Medical School, Hwasun-eup, Hwasun-gun, Jeonnam, South Korea
| | - Taek-Keun Nam
- Department of Radiation Oncology, Chonnam National University Medical School, Hwasun-eup, Hwasun-gun, Jeonnam, South Korea.
| | - Hyeong-Rok Kim
- Department of Surgery, Chonnam National University Medical School, Hwasun-eup, Hwasun-gun, Jeonnam, South Korea
| | - Hyun-Jeong Shim
- Department of Hemato-Oncology, Chonnam National University Medical School, Hwasun-eup, Hwasun-gun, Jeonnam, South Korea
| | - Yong-Hyub Kim
- Department of Radiation Oncology, Chonnam National University Medical School, Hwasun-eup, Hwasun-gun, Jeonnam, South Korea
| | - Mee Sun Yoon
- Department of Radiation Oncology, Chonnam National University Medical School, Hwasun-eup, Hwasun-gun, Jeonnam, South Korea
| | - Ju-Young Song
- Department of Radiation Oncology, Chonnam National University Medical School, Hwasun-eup, Hwasun-gun, Jeonnam, South Korea
| | - Sung-Ja Ahn
- Department of Radiation Oncology, Chonnam National University Medical School, Hwasun-eup, Hwasun-gun, Jeonnam, South Korea
| | - Woong-Ki Chung
- Department of Radiation Oncology, Chonnam National University Medical School, Hwasun-eup, Hwasun-gun, Jeonnam, South Korea
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Apisarnthanarax S, Chia-Hsien Cheng J, Jabbour SK, Liauw SL, Murphy JD, Chang DT. Gastrointestinal Cancers-Changing the Standard for Rectal Cancer and Establishing a New Standard for Liver Tumors. Int J Radiat Oncol Biol Phys 2016; 95:930-6. [PMID: 27302509 PMCID: PMC10905611 DOI: 10.1016/j.ijrobp.2016.02.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 02/05/2016] [Indexed: 01/04/2023]
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Hur H, Bae SU, Han YD, Kang J, Min BS, Baik SH, Lee KY, Kim NK. Transanal Endoscopic Operation for Rectal Tumor: Short-term Outcomes and Learning Curve Analysis. Surg Laparosc Endosc Percutan Tech 2016; 26:236-43. [DOI: 10.1097/sle.0000000000000258] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
The optimal management of rectal cancer is achieved through a shared multidisciplinary decision making process with accurate staging by imaging being critical for treatment planning. Good quality, high-resolution MRI has become the imaging gold standard as it allows consistent staging and stratification of patients into distinct prognostic groups according to MR-findings. Imaging features other than T and N have been proven to influence patient outcomes, and increasingly these features are taken into consideration when determining treatment options: distance of tumour to the potential circumferential margin (CRM), presence of tumour within the extramural rectal vessels (EMVI), discontinuous tumour deposits (N1c), relationship to the intersphincteric plane in low rectal tumours and to pelvic compartments in advanced disease. The presence or absence of proven adverse MR features should be included in the MRI report and shared with the patient when treatment choices are offered. MRI enables the identification of high risk tumours where the use of neoadjuvant therapy is justified and is a robust method of identifying patients with a strong likelihood of complete response after preoperative treatment.
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Xynos E, Tekkis P, Gouvas N, Vini L, Chrysou E, Tzardi M, Vassiliou V, Boukovinas I, Agalianos C, Androulakis N, Athanasiadis A, Christodoulou C, Dervenis C, Emmanouilidis C, Georgiou P, Katopodi O, Kountourakis P, Makatsoris T, Papakostas P, Papamichael D, Pechlivanides G, Pentheroudakis G, Pilpilidis I, Sgouros J, Triantopoulou C, Xynogalos S, Karachaliou N, Ziras N, Zoras O, Souglakos J. Clinical practice guidelines for the surgical treatment of rectal cancer: a consensus statement of the Hellenic Society of Medical Oncologists (HeSMO). Ann Gastroenterol 2016; 29:103-26. [PMID: 27064746 PMCID: PMC4805730 DOI: 10.20524/aog.2016.0003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
In rectal cancer management, accurate staging by magnetic resonance imaging, neo-adjuvant treatment with the use of radiotherapy, and total mesorectal excision have resulted in remarkable improvement in the oncological outcomes. However, there is substantial discrepancy in the therapeutic approach and failure to adhere to international guidelines among different Greek-Cypriot hospitals. The present guidelines aim to aid the multidisciplinary management of rectal cancer, considering both the local special characteristics of our healthcare system and the international relevant agreements (ESMO, EURECCA). Following background discussion and online communication sessions for feedback among the members of an executive team, a consensus rectal cancer management was obtained. Statements were subjected to the Delphi methodology voting system on two rounds to achieve further consensus by invited multidisciplinary international experts on colorectal cancer. Statements were considered of high, moderate or low consensus if they were voted by ≥80%, 60-80%, or <60%, respectively; those obtaining a low consensus level after both voting rounds were rejected. One hundred and two statements were developed and voted by 100 experts. The mean rate of abstention per statement was 12.5% (range: 2-45%). In the end of the process, all statements achieved a high consensus. Guidelines and algorithms of diagnosis and treatment were proposed. The importance of centralization, care by a multidisciplinary team, adherence to guidelines, and personalization is emphasized.
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Affiliation(s)
- Evaghelos Xynos
- General Surgery, InterClinic Hospital of Heraklion, Greece (Evangelos Xynos)
| | - Paris Tekkis
- Colorectal Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK (Paris Tekkis, Panagiotis Georgiou)
| | - Nikolaos Gouvas
- General Surgery, Metropolitan Hospital of Piraeus, Greece (Nikolaos Gouvas)
| | - Louiza Vini
- Radiation Oncology, Iatriko Center of Athens, Greece (Louza Vini)
| | - Evangelia Chrysou
- Radiology, University Hospital of Heraklion, Greece (Evangelia Chrysou)
| | - Maria Tzardi
- Pathology, University Hospital of Heraklion, Greece (Maria Tzardi)
| | - Vassilis Vassiliou
- Radiation Oncology, Oncology Center of Bank of Cyprus, Nicosia, Cyprus (Vassilis Vassiliou)
| | - Ioannis Boukovinas
- Medical Oncology, Bioclinic of Thessaloniki, Greece (Ioannis Boukovinas)
| | - Christos Agalianos
- General Surgery, Athens Naval & Veterans Hospital, Greece (Christos Agalianos, George Pechlivanides)
| | - Nikolaos Androulakis
- Medical Oncology, Venizeleion Hospital of Heraklion, Greece (Nikolaos Androulakis)
| | | | | | - Christos Dervenis
- General Surgery, Konstantopouleio Hospital of Athens, Greece (Christos Dervenis)
| | - Christos Emmanouilidis
- Medical Oncology, Interbalkan Medical Center, Thessaloniki, Greece (Christos Emmanouilidis)
| | - Panagiotis Georgiou
- Colorectal Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK (Paris Tekkis, Panagiotis Georgiou)
| | - Ourania Katopodi
- Medical Oncology, Iaso General Hospital, Athens, Greece (Ourania Katopodi)
| | - Panteleimon Kountourakis
- Medical Oncology, Oncology Center of Bank of Cyprus, Nicosia, Cyprus (Panteleimon Kountourakis, Demetris Papamichael)
| | - Thomas Makatsoris
- Medical Oncology, University Hospital of Patras, Greece (Thomas Makatsoris)
| | - Pavlos Papakostas
- Medical Oncology, Ippokrateion Hospital of Athens, Greece (Pavlos Papakostas)
| | - Demetris Papamichael
- Medical Oncology, Oncology Center of Bank of Cyprus, Nicosia, Cyprus (Panteleimon Kountourakis, Demetris Papamichael)
| | - George Pechlivanides
- General Surgery, Athens Naval & Veterans Hospital, Greece (Christos Agalianos, George Pechlivanides)
| | | | - Ioannis Pilpilidis
- Gastroenterology, Theageneion Cancer Hospital, Thessaloniki, Greece (Ioannis Pilpilidis)
| | - Joseph Sgouros
- Medical Oncology, Agioi Anargyroi Hospital of Athens, Greece (Joseph Sgouros)
| | | | - Spyridon Xynogalos
- Medical Oncology, George Gennimatas General Hospital, Athens, Greece (Spyridon Xynogalos)
| | - Niki Karachaliou
- Medical Oncology, Dexeus University Institute, Barcelona, Spain (Niki Karachaliou)
| | - Nikolaos Ziras
- Medical Oncology, Metaxas Cancer Hospital, Piraeus, Greece (Nikolaos Ziras)
| | - Odysseas Zoras
- General Surgery, University Hospital of Heraklion, Greece (Odysseas Zoras)
| | - John Souglakos
- Medical Oncology, University Hospital of Heraklion, Greece (John Souglakos)
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Kahi CJ, Boland CR, Dominitz JA, Giardiello FM, Johnson DA, Kaltenbach T, Lieberman D, Levin TR, Robertson DJ, Rex DK. Colonoscopy surveillance after colorectal cancer resection: recommendations of the US multi-society task force on colorectal cancer. Gastrointest Endosc 2016; 83:489-98.e10. [PMID: 26802191 DOI: 10.1016/j.gie.2016.01.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Charles J Kahi
- Richard L. Roudebush VA Medical Center, Indianapolis, IN; Indiana University School of Medicine, Indianapolis, Indiana.
| | | | - Jason A Dominitz
- VA Puget Sound Health Care System, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington
| | | | | | - Tonya Kaltenbach
- Veterans Affairs Palo Alto, Palo Alto, California; Stanford University School of Medicine, Palo Alto, California
| | | | | | - Douglas J Robertson
- VA Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana
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Rackley TP, Ma RM, Brown CJ, Hay JH. Transanal Local Excision for Patients With Rectal Cancer: Can Radiation Compensate for What Is Perceived as a Nondefinitive Surgical Approach? Dis Colon Rectum 2016; 59:173-8. [PMID: 26855390 DOI: 10.1097/DCR.0000000000000544] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Total mesorectal excision has long been the standard of care for patients with rectal cancer. However, in select patients, local excision is an appropriate alternative option. The role of adjuvant radiation therapy in patients treated with local excision is controversial and evidence is lacking. OBJECTIVE The purpose of this study was to report oncological outcomes of patients with rectal cancer treated with local excision and adjuvant radiation. DESIGN This study was a retrospective chart review. SETTINGS The study was conducted at the BC Cancer Agency, a tertiary referral hospital. PATIENTS A total of 93 patients with node-negative rectal cancer treated with local excision and adjuvant radiotherapy between 2001 and 2010 were included in the study. MAIN OUTCOME MEASURES Patient and tumor characteristics are reported. Five-year local control, progression-free survival, and overall survival were analyzed using Kaplan-Meier methods. RESULTS Five-year overall survival, local control, and progression-free survival for patients treated with local excision and adjuvant radiotherapy were 78.5%, 86.1%, and 83.8%. In T1 disease, local control was 92.5%. LIMITATIONS Referral bias, selection bias, lack of uniform surveillance, and retrospective analysis are the study limitations. CONCLUSIONS Local excision with adjuvant radiotherapy provides a good level of local control in T1 disease and remains a good treatment option for patients who are either medically not suitable for a more radical surgical approach or who refuse this procedure. Local excision and radiotherapy should not be advocated in T2/T3 disease; however, it can provide a good alternative in those patients who are not fit enough for a more radical operation.
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45
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Kahi CJ, Boland CR, Dominitz JA, Giardiello FM, Johnson DA, Kaltenbach T, Lieberman D, Levin TR, Robertson DJ, Rex DK. Colonoscopy Surveillance After Colorectal Cancer Resection: Recommendations of the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2016; 150:758-768.e11. [PMID: 26892199 DOI: 10.1053/j.gastro.2016.01.001] [Citation(s) in RCA: 124] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The US Multi-Society Task Force has developed updated recommendations to guide health care providers with the surveillance of patients after colorectal cancer (CRC) resection with curative intent. This document is based on a critical review of the literature regarding the role of colonoscopy, flexible sigmoidoscopy, endoscopic ultrasound, fecal testing and CT colonography in this setting. The document addresses the effect of surveillance, with focus on colonoscopy, on patient survival after CRC resection, the appropriate use and timing of colonoscopy for perioperative clearing and for postoperative prevention of metachronous CRC, specific considerations for the detection of local recurrence in the case of rectal cancer, as well as the place of CT colonography and fecal tests in post-CRC surveillance.
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Affiliation(s)
- Charles J Kahi
- Richard L. Roudebush VA Medical Center, Indianapolis, IN; Indiana University School of Medicine, Indianapolis, Indiana.
| | | | - Jason A Dominitz
- VA Puget Sound Health Care System, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington
| | | | | | - Tonya Kaltenbach
- Veterans Affairs Palo Alto, Palo Alto, California; Stanford University School of Medicine, Palo Alto, California
| | | | | | - Douglas J Robertson
- VA Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana
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Abstract
A transanal approach to rectal polyp and cancer excision is often an appropriate alternative to conventional rectal resection, and has a lower associated morbidity. There has been a steady evolution in the techniques of transanal surgery over the past 30 years. It started with traditional transanal excision and was revolutionized by introduction of transanal endoscopic microsurgery in early 1980s. Introduction of transanal minimally invasive surgery made it more accessible to surgeons around the world. Now robotic platforms are being tried in certain institutions. Concerns have been raised about recurrence rates of cancers with transanal approach and success of subsequent salvage operations.
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Affiliation(s)
- Vinay Rai
- Colon and Rectum Surgery, University of New Mexico, New Mexico
| | - Nitin Mishra
- Colon and Rectum Surgery, Mayo Clinic College of Medicine, Arizona
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47
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Kahi CJ, Boland CR, Dominitz JA, Giardiello FM, Johnson DA, Kaltenbach T, Lieberman D, Levin TR, Robertson DJ, Rex DK. Colonoscopy Surveillance after Colorectal Cancer Resection: Recommendations of the US Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2016; 111:337-46; quiz 347. [PMID: 26871541 DOI: 10.1038/ajg.2016.22] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 12/07/2015] [Indexed: 12/11/2022]
Abstract
The US Multi-Society Task Force has developed updated recommendations to guide health care providers with the surveillance of patients after colorectal cancer (CRC) resection with curative intent. This document is based on a critical review of the literature regarding the role of colonoscopy, flexible sigmoidoscopy, endoscopic ultrasound, fecal testing and CT colonography in this setting. The document addresses the effect of surveillance, with focus on colonoscopy, on patient survival after CRC resection, the appropriate use and timing of colonoscopy for perioperative clearing and for postoperative prevention of metachronous CRC, specific considerations for the detection of local recurrence in the case of rectal cancer, as well as the place of CT colonography and fecal tests in post-CRC surveillance.
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Affiliation(s)
- Charles J Kahi
- Richard L. Roudebush VA Medical Center, Indianapolis, IN.,Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Jason A Dominitz
- VA Puget Sound Health Care System, Seattle, Washington.,University of Washington School of Medicine, Seattle, Washington
| | | | | | - Tonya Kaltenbach
- Veterans Affairs Palo Alto, Palo Alto, California.,Stanford University School of Medicine, Palo Alto, California
| | | | | | - Douglas J Robertson
- VA Medical Center, White River Junction, Vermont.,Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana
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Martin BM, Cardona K, Sullivan PS. Management of Early (T1 or T2) Rectal Cancer. Curr Colorectal Cancer Rep 2016. [DOI: 10.1007/s11888-016-0315-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Junginger T, Goenner U, Hitzler M, Trinh TT, Heintz A, Wollschlaeger D, Blettner M. Long-term Oncologic Outcome After Transanal Endoscopic Microsurgery for Rectal Carcinoma. Dis Colon Rectum 2016; 59:8-15. [PMID: 26651106 DOI: 10.1097/DCR.0000000000000509] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Transanal endoscopic microsurgery is superior to other methods of local excision of rectal cancer, but few studies report long-term follow-up data. OBJECTIVE This study investigated the use of transanal endoscopic microsurgery alone as curative and compromise therapy based on long-term disease recurrence and mortality. DESIGN This was a retrospective review of prospectively collected data. SETTINGS The study was conducted at a tertiary care university medical center. PATIENTS The study included 133 patients treated between 1985 and 2007. There were 3 groups, including transanal endoscopic microsurgery in curative intent (low-risk rectal carcinoma, including pT1, G1/2, L0, and LX with clear margins and a minimal distance between tumor and resection margin of >1 mm (N = 64) or clear margins only (N = 18 ))) and as compromise therapy (high-risk or incompletely resected rectal carcinoma; N = 51). MAIN OUTCOME MEASURES Log-rank tests were used to compare overall and cancer-specific survival. RESULTS The median follow-up time was 8.6 years (range, 0.2-25.1 years), and a total of 131 of 133 patients (98.5%) were followed >5 years or until death. The preoperative diagnosis of carcinoma was not associated with belonging into 1 of the 3 categories. In patients with low-risk completely (>1 mm) resected carcinoma, the 5- and 10-year local recurrence rates were 6.6% and 11.6%. In patients with high-risk or incompletely resected carcinoma, the rates were 32.5% and 35.0% (p = 0.006). The 5- and 10-year cancer-specific survival rates for low-risk patients were 98.0% and 91.0% and 84.3% and 74.3% for high-risk patients (p = 0.05). LIMITATIONS The study was limited by its retrospective design and small subgroups. CONCLUSIONS The high cancer-specific survival justifies transanal endoscopic microsurgery alone as curative treatment in low-risk rectal carcinoma. Complete resection is essential to lower the risk of local recurrence. The high local recurrence rate in patients with high-risk rectal carcinoma restricts the use of TEM alone as compromise therapy.
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50
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Pucciarelli S, Barina A, Rella A. Local Failure After Conservative Treatment of Rectal Cancer. Updates Surg 2016. [DOI: 10.1007/978-88-470-5767-8_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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