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Tanaka H, Yamashita K, Urabe Y, Kuwai T, Oka S. Management of T1 Colorectal Cancer. Digestion 2024:1-9. [PMID: 39097960 DOI: 10.1159/000540594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Accepted: 07/24/2024] [Indexed: 08/06/2024]
Abstract
BACKGROUND Approximately 10% of patients with submucosal invasive (T1) colorectal cancer (CRC) have lymph node metastasis (LNM). The risk of LNM can be stratified according to various histopathological factors, such as invasion depth, lymphovascular invasion, histological grade, and tumor budding. SUMMARY T1 CRC with a low risk of LNM can be cured by local excision via endoscopic resection (ER), whereas surgical resection (SR) with lymph node dissection is required for high-risk T1 CRC. Current guidelines raise concern that many patients receive unnecessary SR, even though most patients achieve a radical cure. Novel diagnostic techniques for LNM, such as nomograms, artificial intelligence systems, and genomic analysis, have been recently developed to identify more low-risk T1 CRC cases. Assessing the curability and the necessity of additional treatment, including SR with lymph node dissection and chemoradiotherapy, according to histopathological findings of the specimens resected using ER, is becoming an acceptable strategy for T1 CRC, particularly for rectal cancer. Therefore, complete resection with negative vertical and horizontal margins is necessary for this strategy. Advanced ER methods for resecting the muscle layer or full thickness, which may guarantee complete resection with negative vertical margins, have been developed. KEY MESSAGE Although a necessary SR should not be delayed for T1 CRC given its unfavorable prognosis when SR with lymph node dissection is performed, the optimal treatment method should be chosen based on the risk of LNM and the patient's life expectancy, physical condition, social characteristics, and wishes.
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Affiliation(s)
- Hidenori Tanaka
- Department of Gastroenterology, Hiroshima University Hospital, Hiroshima, Japan,
| | - Ken Yamashita
- Department of Gastroenterology, Hiroshima University Hospital, Hiroshima, Japan
| | - Yuji Urabe
- Department of Gastroenterology, Hiroshima University Hospital, Hiroshima, Japan
| | - Toshio Kuwai
- Department of Gastroenterology, Hiroshima University Hospital, Hiroshima, Japan
| | - Shiro Oka
- Department of Gastroenterology, Hiroshima University Hospital, Hiroshima, Japan
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Labiad C, Alric H, Barret M, Cazelles A, Rahmi G, Karoui M, Manceau G. Management after local excision of small rectal cancers. Indications for completion total mesorectal excision and possible alternatives. J Visc Surg 2024; 161:173-181. [PMID: 38448362 DOI: 10.1016/j.jviscsurg.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
The treatment of superficial rectal cancers (local excision, or proctectomy with total mesorectal excision (TME) remains controversial. Endoscopy and endorectal ultrasonography are essential for the precise initial definition of these small cancers. During endoscopy, the depth of the lesion can be estimated using virtual chromoendoscopy with magnification, thereby aiding the assessment of the possibilities of local excision. Current international recommendations indicate completion proctectomy after wide local excision for cases where the pathologic examination reveals poorly-differentiated lesions, lymphovascular invasion, grade 2 or 3 tumor budding, and incomplete resection. But debate persists regarding whether the depth of submucosal invasion can accurately predict the risk of lymph node spread. Recent data from the literature suggest that the depth of submucosal invasion should no longer, by itself, be an indication for additional oncological surgery. Adjuvant radio-chemotherapy could be an alternative to completion proctectomy in patients with pT1 rectal cancer and unfavorable histopathological criteria. A Dutch randomized controlled trial is underway to validate this strategy.
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Affiliation(s)
- Camélia Labiad
- Digestive and Oncological Surgery Department, Assistance publique-Hôpitaux de Paris, hôpital européen Georges-Pompidou, université Paris Cité, 20, rue Leblanc, 75015 Paris, France
| | - Hadrien Alric
- Gastroenterology Department, Assistance publique-Hôpitaux de Paris, hôpital européen Georges-Pompidou, université Paris Cité, Paris, France
| | - Maximilien Barret
- Gastroenterology Department, Assistance publique-Hôpitaux de Paris, hôpital Cochin, université Paris Cité, Paris, France
| | - Antoine Cazelles
- Digestive and Oncological Surgery Department, Assistance publique-Hôpitaux de Paris, hôpital européen Georges-Pompidou, université Paris Cité, 20, rue Leblanc, 75015 Paris, France
| | - Gabriel Rahmi
- Gastroenterology Department, Assistance publique-Hôpitaux de Paris, hôpital européen Georges-Pompidou, université Paris Cité, Paris, France
| | - Mehdi Karoui
- Digestive and Oncological Surgery Department, Assistance publique-Hôpitaux de Paris, hôpital européen Georges-Pompidou, université Paris Cité, 20, rue Leblanc, 75015 Paris, France
| | - Gilles Manceau
- Digestive and Oncological Surgery Department, Assistance publique-Hôpitaux de Paris, hôpital européen Georges-Pompidou, université Paris Cité, 20, rue Leblanc, 75015 Paris, France.
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Wang C, Liu X, Wang W, Miao Z, Li X, Liu D, Hu K. Treatment Options for Distal Rectal Cancer in the Era of Organ Preservation. Curr Treat Options Oncol 2024; 25:434-452. [PMID: 38517596 PMCID: PMC10997725 DOI: 10.1007/s11864-024-01194-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2024] [Indexed: 03/24/2024]
Abstract
OPINION STATEMENT The introduction of total mesorectal excision into the radical surgery of rectal cancer has significantly improved the oncological outcome with longer survival and lower local recurrence. Traditional treatment modalities of distal rectal cancer, relying on radical surgery, while effective, take their own set of risks, including surgical complications, potential damage to the anus, and surrounding structure owing to the pursuit of thorough resection. The progress of operating methods as well as the integration of systemic therapies and radiotherapy into the peri-operative period, particularly the exciting clinical complete response of patients after neoadjuvant treatment, have paved the way for organ preservation strategy. The non-inferiority oncological outcome of "watch and wait" compared with radical surgery underscores the potential of organ preservation not only to control local recurrence but also to reduce the need for treatments followed by structure destruction, hopefully improving the long-term quality of life. Radical radiotherapy provides another treatment option for patients unwilling or unable to undergo surgery. Organ preservation points out the direction of treatment for distal rectal cancer, while additional researches are needed to answer remaining questions about its optimal use.
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Affiliation(s)
- Chen Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Xiaoliang Liu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Weiping Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Zheng Miao
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Xiaoyan Li
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Dingchao Liu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Ke Hu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, 100730, China.
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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] [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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Pimentel-Nunes P, Libânio D, Bastiaansen BAJ, Bhandari P, Bisschops R, Bourke MJ, Esposito G, Lemmers A, Maselli R, Messmann H, Pech O, Pioche M, Vieth M, Weusten BLAM, van Hooft JE, Deprez PH, Dinis-Ribeiro M. Endoscopic submucosal dissection for superficial gastrointestinal lesions: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2022. Endoscopy 2022; 54:591-622. [PMID: 35523224 DOI: 10.1055/a-1811-7025] [Citation(s) in RCA: 219] [Impact Index Per Article: 109.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
ESGE recommends that the evaluation of superficial gastrointestinal (GI) lesions should be made by an experienced endoscopist, using high definition white-light and chromoendoscopy (virtual or dye-based).ESGE does not recommend routine performance of endoscopic ultrasonography (EUS), computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET)-CT prior to endoscopic resection.ESGE recommends endoscopic submucosal dissection (ESD) as the treatment of choice for most superficial esophageal squamous cell and superficial gastric lesions.For Barrett's esophagus (BE)-associated lesions, ESGE suggests the use of ESD for lesions suspicious of submucosal invasion (Paris type 0-Is, 0-IIc), for malignant lesions > 20 mm, and for lesions in scarred/fibrotic areas.ESGE does not recommend routine use of ESD for duodenal or small-bowel lesions.ESGE suggests that ESD should be considered for en bloc resection of colorectal (but particularly rectal) lesions with suspicion of limited submucosal invasion (demarcated depressed area with irregular surface pattern or a large protruding or bulky component, particularly if the lesions are larger than 20 mm) or for lesions that otherwise cannot be completely removed by snare-based techniques.ESGE recommends that an en bloc R0 resection of a superficial GI lesion with histology no more advanced than intramucosal cancer (no more than m2 in esophageal squamous cell carcinoma), well to moderately differentiated, with no lymphovascular invasion or ulceration, should be considered a very low risk (curative) resection, and no further staging procedure or treatment is generally recommended.ESGE recommends that the following should be considered to be a low risk (curative) resection and no further treatment is generally recommended: an en bloc R0 resection of a superficial GI lesion with superficial submucosal invasion (sm1), that is well to moderately differentiated, with no lymphovascular invasion, of size ≤ 20 mm for an esophageal squamous cell carcinoma or ≤ 30 mm for a stomach lesion or of any size for a BE-related or colorectal lesion, and with no lymphovascular invasion, and no budding grade 2 or 3 for colorectal lesions.ESGE recommends that, after an endoscopically complete resection, if there is a positive horizontal margin or if resection is piecemeal, but there is no submucosal invasion and no other high risk criteria are met, this should be considered a local-risk resection and endoscopic surveillance or re-treatment is recommended rather than surgery or other additional treatment.ESGE recommends that when there is a diagnosis of lymphovascular invasion, or deeper infiltration than sm1, or positive vertical margins, or undifferentiated tumor, or, for colorectal lesions, budding grade 2 or 3, this should be considered a high risk (noncurative) resection, and complete staging and strong consideration for additional treatments should be considered on an individual basis in a multidisciplinary discussion.ESGE recommends scheduled endoscopic surveillance with high definition white-light and chromoendoscopy (virtual or dye-based) with biopsies of only the suspicious areas after a curative ESD.
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Affiliation(s)
- Pedro Pimentel-Nunes
- Department of Gastroenterology, Porto Comprehensive Cancer Center, and RISE@CI-IPOP (Health Research Network), Porto, Portugal
- Department of Surgery and Physiology, Porto Faculty of Medicine, Portugal
| | - Diogo Libânio
- Department of Gastroenterology, Porto Comprehensive Cancer Center, and RISE@CI-IPOP (Health Research Network), Porto, Portugal
- MEDCIDS, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Barbara A J Bastiaansen
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology & Metabolism, Amsterdam University Medical Center, The Netherlands
| | - Pradeep Bhandari
- Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth, UK
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, TARGID, Leuven, Belgium
| | - Michael J Bourke
- Department of Gastroenterology, Westmead Hospital, Sydney, Australia and Western Clinical School, University of Sydney, Sydney, Australia
| | - Gianluca Esposito
- Department of Medical-Surgical Sciences and Translational Medicine, Sant' Andrea Hospital, Sapienza University of Rome, Italy
| | - Arnaud Lemmers
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Roberta Maselli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Helmut Messmann
- Department of Gastroenterology, Universitätsklinikum Augsburg, Augsburg, Bayern, Germany
| | - Oliver Pech
- Department of Gastroenterology and Interventional Endoscopy, St. John of God Hospital, Regensburg, Germany
| | - Mathieu Pioche
- Endoscopy and Gastroenterology Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Michael Vieth
- Institute of Pathology, Friedrich-Alexander University Erlangen-Nuremberg, Klinikum Bayreuth, Bayreuth, Germany
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital Nieuwegein and University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Pierre H Deprez
- Department of Hepatogastroenterology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Mario Dinis-Ribeiro
- Department of Gastroenterology, Porto Comprehensive Cancer Center, and RISE@CI-IPOP (Health Research Network), Porto, Portugal
- MEDCIDS, Faculty of Medicine, University of Porto, Porto, Portugal
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Kim S, Huh JW, Lee WY, Yun SH, Kim HC, Cho YB, Park YA, Shin JK. Can CCRT/RT Achieve Favorable Oncologic Outcome in Rectal Cancer Patients With High Risk Feature After Local Excision? Front Oncol 2022; 12:767838. [PMID: 35402222 PMCID: PMC8986033 DOI: 10.3389/fonc.2022.767838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 02/18/2022] [Indexed: 12/08/2022] Open
Abstract
PurposeThe oncologic outcome of concurrent chemoradiotherapy (CCRT) after local excision in patients with high-risk early rectal cancer as compared with radical operation has not been reported. The aim of this study is to compare the oncologic outcome between radical operation and adjuvant CCRT after local excision for high-risk early rectal cancer.Materials and MethodsFrom January 2005 to December 2015, 266 patients diagnosed with early rectal cancer and treated with local excision who showed high-risk characteristics were retrospectively analyzed. Propensity score matching was applied in a ratio of 1:4, comparing the CCRT/radiotherapy (RT) (n = 34) and radical operation (n = 91) groups. Univariate and multivariate analyses were performed to identify prognostic factors for survival.ResultsThe median follow-up period was 112 months. The 5-year disease-free survival rate and the 5-year overall survival of the radical operation group were significantly higher than those of the CCRT/RT group after propensity score matching (96.7% vs. 70.6%, p <0.001; 100% vs. 91.2%, p = 0.005, respectively). In a multivariate analysis, salvage therapy type and preoperative carcinoembryonic antigen (CEA) were prognostic factors for 5-year disease-free survival (p <0.001 and p = 0.021, respectively). The type of salvage therapy, the preoperative CEA, and the pT were prognostic factors for 5-year overall survival (p = 0.009, p = 0.024, and p = 0.046, respectively).ConclusionsPatients who undergo radical operations after local excision with a high-risk early rectal cancer had better survival than those treated with adjuvant CCRT/RT. Therefore, radical surgery may be recommended to high-risk early rectal cancer patients who have undergone local excision for more favorable oncologic outcomes.
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Tang J, Zhang Y, Zhang D, Zhang C, Jin K, Ji D, Peng W, Feng Y, Sun Y. Total Mesorectal Excision vs. Transanal Endoscopic Microsurgery Followed by Radiotherapy for T2N0M0 Distal Rectal Cancer: A Multicenter Randomized Trial. Front Surg 2022; 9:812343. [PMID: 35178428 PMCID: PMC8844472 DOI: 10.3389/fsurg.2022.812343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 01/10/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction Transanal endoscopic microsurgery (TEM) is an organ-preserving treatment alternative for patients with early rectal cancer. However, TEM alone is associated with greater risk of local recurrence and inferior survival in comparison with total meso-rectal excision (TME). As an important adjuvant therapy, radiotherapy can effectively reduce the local recurrence rate of rectal cancer. This study aimed to investigate whether TEM followed by radiotherapy can be a valid alternative to TME in T2N0M0 distal rectal cancer treatment. Methods We plan to recruit 168 participants meeting established inclusion criteria. Following informed consent, participants will randomly receive treatment protocols of TEM followed by radiotherapy (a total dose of 45–50.4 Gy given in 25–28 factions) or TME. Depending on post-operative pathology, the participants will receive either long-term follow-up or further treatment. The primary endpoint of this trial is 3-year local recurrence rate. The secondary end points include 3-year disease-free survival rate, 3-year overall survival rate, 3-year mortality rate, post-operative quality of life, post-operative safety index, intraoperative evaluation index and post-operative short-term evaluation index. Discussion This trial is the first prospective randomized trial to investigate the rectum preserving treatment by using transanal local excision followed by radiotherapy. Clinical trial registration The trial was prospectively registered at ClinicalTrials.gov NCT04098471 on September 20, 2019.
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Varela C, Kim NK. Surgical Treatment of Low-Lying Rectal Cancer: Updates. Ann Coloproctol 2021; 37:395-424. [PMID: 34961303 PMCID: PMC8717072 DOI: 10.3393/ac.2021.00927.0132] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 11/17/2021] [Indexed: 02/07/2023] Open
Abstract
Despite innovative advancements, distally located rectal cancer remains a critical disease of challenging management. The crucial location of the tumor predisposes it to a circumferential resection margin (CRM) that tends to involve the anal sphincter complex and surrounding organs, with a high incidence of delayed anastomotic complications and the risk of the pelvic sidewall or rarely inguinal lymph node metastases. In this regard, colorectal surgeons should be aware of other issues beyond total mesorectal excision (TME) performance. For decades, the concept of extralevator abdominoperineal resection to avoid compromised CRM has been introduced. However, the complexity of deep pelvic dissection with poor visualization in low-lying rectal cancer has led to transanal TME. In contrast, neoadjuvant chemoradiotherapy (NCRT) has allowed for the execution of more sphincter-saving procedures without oncologic compromise. Significant tumor regression after NCRT and complete pathologic response also permit applying the watch-and-wait protocol in some cases, now with more solid evidence. This review article will introduce the current surgical treatment options, their indication and technical details, and recent oncologic and functional outcomes. Lastly, the novel characteristics of distal rectal cancer, such as pelvic sidewall and inguinal lymph node metastases, will be discussed along with its tailored and individualized treatment approach.
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Affiliation(s)
- Cristopher Varela
- Coloproctology Unit, Department of General Surgery, Hospital Dr. Domingo Luciani, Caracas, Venezuela
| | - Nam Kyu Kim
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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9
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Mehraj A, Saqib N, Wani R, Chowdri N, Parray F, Khan M. Transanal minimal invasive surgery (TAMIS): safety and feasibility for the resection of benign and malignant lesions of the rectum. Turk J Surg 2021; 37:6-12. [PMID: 34585088 DOI: 10.47717/turkjsurg.2021.5057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 01/27/2021] [Indexed: 12/23/2022]
Abstract
Objectives Radical surgery for rectal tumours has high morbidity. Local excision of such tumours can be achieved without compromising oncologic safety. However tumours that are not accessible to local excision can be approached using Transanal Minimal Invasive Surgery (TAMIS). The aim of our study was to assess feasibility of TAMIS procedure in terms of complications, operating time, resection margin positivity, hospital stay and local recurrence rate. Material and Methods Forty eight patients with benign adenomas or early stage adenocarcinoma, within 4 to 12 cm from anal verge who were subjected to TAMIS over a period of 3 years were included in the study. Short and long term outcomes were assessed. Results TAMIS was performed for 36 benign adenomas and 12 adenocarcinomas, which were located at an average distance of 6.2 cm from anal verge. The mean operating time was 72 minutes. There were no intraoperative complications.1 (2.08%) patient suffered post operative bleeding, which was managed conservatively. 2 (4.16%) patients developed acute urinary retention who required indwelling catheterisation. Resection margin was positive in 3 (6.25%) benign cases. Average hospital stay was 2.7 days. Local recurrence occurred in 2 (4.16%) villous adenoma patients (after 11 and 13 months), whereas in malignant patients there was no recurrence at a follow up period ranging between 12 to 36 months. Conclusion TAMIS is a safe and feasible procedure for benign tumours and early rectal cancers, located in low and middle rectum.
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Affiliation(s)
- Asif Mehraj
- Department Colorectal Surgery, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Najmus Saqib
- Department Colorectal Surgery, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Rauf Wani
- Department Colorectal Surgery, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Nisar Chowdri
- Department Colorectal Surgery, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Fazl Parray
- Department Colorectal Surgery, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Mudassir Khan
- Department Colorectal Surgery, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
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Javed MA, Shamim S, Slawik S, Andrews T, Montazeri A, Ahmed S. Long-term outcomes of patients with poor prognostic factors following transanal endoscopic microsurgery for early rectal cancer. Colorectal Dis 2021; 23:1953-1960. [PMID: 33900004 DOI: 10.1111/codi.15693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 02/24/2021] [Accepted: 03/23/2021] [Indexed: 12/11/2022]
Abstract
AIM Management of early rectal cancer following transanal microscopic anal surgery poses a management dilemma when the histopathology reveals poor prognostic features, due to high risk of local recurrence. The aim of this study is to evaluate the oncological outcomes of such patients who undergo surgery with total mesorectal excision (TME), receive adjuvant chemo/radiotherapy (CRDT/RT) or receive close surveillance only (no further treatment). METHODS We identified patients with poor prognostic factors-pT2 adenocarcinoma, poor differentiation, deep submucosal invasion (Kikuchi SM3), lymphovascular invasion, tumour budding or R1 resection margin-between 1 September 2012 and 31 January 2020 and report their oncological outcomes. RESULTS Of the 53 patients, 18 had TME, 14 had CRDT and 14 had RT; seven patients did not have any further treatment. The median follow-up was 48 months, 12 developed recurrence and six died. Overall, 5-year survival (OS) was 88.9% and disease-free survival (DFS) was 79.2%. Compared to the surgical group, in which there were eight recurrences and two deaths, there were zero recurrences or deaths in the CRDT group, log-rank test P = 0.206 for OS and P = 0.005 for DFS. The 5-year survival rates in the RT and surveillance only groups were OS 78.6%, DFS 85.7% and OS 71.5%, DFS 71% respectively. TME assessment in the surgical group revealed Grade 3 quality in seven of the 16 available reports. CONCLUSION These findings support the strategy of adjuvant CRDT as first line treatment for patients undergoing transanal endoscopic microsurgery for early rectal cancer with poor prognostic factors on initial histological assessment.
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Affiliation(s)
- Muhammad A Javed
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Sarah Shamim
- Health Education England-North West, Manchester, UK
| | - Simone Slawik
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Timothy Andrews
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Amir Montazeri
- Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK
| | - Shakil Ahmed
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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11
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Tei M, Noura S, Ohue M, Kitakaze M, Takahashi H, Miyoshi N, Uemura M, Mizushima T, Murata K, Doki Y, Eguchi H. Tolerability and safety of adjuvant chemoradiotherapy with S-1 after limited surgery for T1 or T2 lower rectal cancer. Int J Clin Oncol 2021; 26:2046-2052. [PMID: 34318389 DOI: 10.1007/s10147-021-01998-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 07/19/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Chemo-radiotherapy (CRT) after local excision for pT1 with high-risk features or pT2 rectal cancer is recommended as an optional treatment to achieve both curability and maintenance of quality of life. The aim of this study was to evaluate the short-term safety of combining limited surgery with adjuvant CRT for T1 or T2 lower rectal cancer. METHODS This was a multicenter, single-arm, prospective phase II trial. Patients diagnosed with lower rectal or anal canal cancer (clinical T1 or T2 with a maximum diameter of 30 mm and N0 and M0) underwent local excision or endoscopic resection. Patients received CRT with S-1 (tegafur/gimeracil/oteracil) after confirmation of well- or moderately differentiated adenocarcinoma, and negative margins, and/or depth of submucosal invasion ≥ 1000 µm or muscularis propria, and/or positive lymphovascular invasion, and/or tumor budding grade of 2/3. The primary endpoint was relapse-free survival. Secondary endpoints included overall and local relapse-free survival, safety, anal sphincter preservation rate, and anal function. RESULTS Pathological diagnosis was T1 in 36 patients and T2 in 16 patients. Serious complications after surgery were not reported. The CRT completion rate per protocol was 86.5% (45/52). Thirty-two patients developed 54 events of CRT-related adverse events, including only one patient with a grade 3 event (stomatitis). The most common CRT-related adverse event was diarrhea (n = 14). No patients showed deterioration of anal function at 3 years postoperatively. CONCLUSION CRT with S-1 after limited surgery for T1 or T2 lower rectal cancer resulted in a low incidence of toxicities and maintenance of anal function.
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Affiliation(s)
- Mitsuyoshi Tei
- Department of Surgery, Osaka Rosai Hospital, 1179-3 Nagasonecho, Kita-ku, Sakai, 591-8025, Japan.
| | - Shingo Noura
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Masayuki Ohue
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Masatoshi Kitakaze
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Hidekazu Takahashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Norikatsu Miyoshi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Mamoru Uemura
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Tsunekazu Mizushima
- Department of Surgery, Osaka Rosai Hospital, 1179-3 Nagasonecho, Kita-ku, Sakai, 591-8025, Japan
| | - Kohei Murata
- Department of Surgery, Kansai Rosai Hospital, Amagasaki, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
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12
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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] [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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13
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Chang LC, Shun CT, Lin BR, Sanduleanu S, Hsu WF, Wu MS, Chiu HM. Recurrence Outcomes Less Favorable in T1 Rectal Cancer than in T1 Colon Cancer. Oncologist 2021; 26:e1548-e1554. [PMID: 33955121 DOI: 10.1002/onco.13815] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 04/23/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND With the implementation of screening programs worldwide, diagnosis of early-stage colorectal cancer steadily increased, including T1 cancer. Current T1 cancer treatment does not differ according to anatomic location. We therefore compared the disease-free survival of T1 cancer arising from the rectum versus the colon. METHODS The hospital-based study included subjects with T1 cancer at National Taiwan University Hospital from 2005 to 2014. Clinical, colonoscopy, and histopathology were reviewed for patients with a mean follow-up time of 7.1 (0.7-12.9) years. We conducted Kaplan-Meier analysis to compare the risk of recurrence by cancer location and Cox regression analysis to identify risk factors for T1 cancer recurrence. RESULTS The final cohort included a total of 343 subjects with T1 cancer (mean age, 64.9 ± 11.7 years; 56.1% male), of whom 25 underwent endoscopic resection alone. Of the subjects who underwent surgery, 50 had lymph node metastasis and 268 did not. Kaplan-Meier analysis showed that the risk of recurrence was higher in T1 rectal cancer than T1 colon cancer (p = .022). Rectal location and larger neoplasm size were independent risk factors for recurrence, with hazard ratios of 4.84 (95% confidence interval, 1.18-19.92), and 1.32 (95% confidence interval, 1.06-1.65), respectively. The occurrence of advanced histology did not differ between T1 rectal and colon cancers (p = .58). CONCLUSION T1 cancers arising from the rectum had less favorable recurrence outcomes than those arising from the colon. Further studies are needed to examine whether adjuvant radiotherapy or chemotherapy can reduce the risk of recurrence in T1 rectal cancer. IMPLICATIONS FOR PRACTICE Current T1 colorectal cancer treatment and surveillance do not differ according to anatomic location. Clinical, colonoscopy, and histopathology were reviewed for 343 patients with T1 cancer with a mean follow-up time of 7.1 years. Kaplan-Meier analysis showed that the risk of recurrence was higher in T1 rectal cancer than T1 colon cancer. Moreover, the rectal location was an independent risk factor for recurrence. T1 cancers from the rectum had less favorable recurrence outcomes than those arising from the colon. It is critical to clarify whether adjuvant therapy or more close surveillance can reduce recurrence risk in T1 rectal cancer.
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Affiliation(s)
- Li-Chun Chang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Health Management Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Chia-Tung Shun
- Department of Pathology, National Taiwan University Hospital, Taipei, Taiwan
| | - Been-Ren Lin
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Silvia Sanduleanu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht, The Netherlands.,GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Weng-Feng Hsu
- Department of Internal Medicine, National Taiwan University Cancer Center, Taipei, Taiwan
| | - Ming-Shiang Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Han-Mo Chiu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Health Management Center, National Taiwan University Hospital, Taipei, Taiwan
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14
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Noguchi M, Shitara K, Kawazoe A, Yamamoto D, Takii Y, Saito Y, Sato T, Horimatsu T, Ishikawa H, Ito Y, Ito M, Ikematsu H. Short-term safety of adjuvant chemoradiotherapy after local resection for patients with high-risk submucosal invasive rectal cancer: a single-arm, multicenter phase II trial. Jpn J Clin Oncol 2021; 51:707-712. [PMID: 33558891 PMCID: PMC8086053 DOI: 10.1093/jjco/hyaa260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 12/17/2020] [Indexed: 11/17/2022] Open
Abstract
Background Surgery is recommended for patients with high-risk submucosal invasive rectal cancer (SM-RC) after local resection but affects the quality of life due to stoma placement or impaired anal function; therefore, alternative treatment approaches are needed to prevent local metastasis. The purpose of this study was to assess the short-term safety of adjuvant chemoradiotherapy with capecitabine in patients with high-risk submucosal invasive rectal cancer after local resection. Methods This single-arm, multicenter, phase II trial included patients undergoing local resection for high-risk submucosal invasive rectal cancer within 12 weeks prior to enrollment. High-risk submucosal invasive rectal cancer was defined as the presence of at least one of the following factors: poor differentiation of adenocarcinoma, submucosal invasion depth > 1 mm, presence of lymphovascular invasion and grade-2 or -3 tumour budding. Protocol treatment comprised 45.0 Gy radiotherapy with conventional fractionation and 1650 mg/m2 capecitabine given twice daily until radiotherapy completion. The primary endpoint was treatment completion rate with an expected rate of 95% and a threshold of 80%. Results Twenty-nine patients from six institutions were enrolled between May 2015 and February 2018. One patient was ineligible. Twenty-three patients completed treatment, with a completion rate of 82% (80% confidence interval, 69–91%); the remaining five patients completed treatment with protocol deviation. The median relative dose intensity of capecitabine was 100% (range, 58–100%). Common adverse events included radiation dermatitis (54%), anal pain (39%) and anal mucositis (29%). No grade-3 or higher adverse events were reported. Conclusions Adjuvant chemoradiotherapy using capecitabine demonstrated acceptable short-term safety profiles in patients with high-risk submucosal invasive rectal cancer after local resection.
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Affiliation(s)
- Masaaki Noguchi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Kohei Shitara
- Department of Gastroenterology and Gastrointestinal Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - Akihito Kawazoe
- Department of Gastroenterology and Gastrointestinal Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - Daisuke Yamamoto
- Department of Gastroenterological Surgery, Ishikawa Prefectural Central Hospital, Ishikawa, Japan
| | - Yasumasa Takii
- Department of Gastroenterological Surgery, Niigata Cancer Centre Hospital, Niigata, Japan
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Toshihiko Sato
- Department of Surgery, Yamagata Prefectural Central Hospital, Yamagata, Japan
| | - Takahiro Horimatsu
- Department of Therapeutic Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hideki Ishikawa
- Department of Molecular-Targeting Cancer Prevention, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yoshinori Ito
- Department of Radiation Oncology, Showa University School of Medicine, Tokyo, Japan
| | - Masaaki Ito
- Department of Colorectal Surgery, National Cancer Center Hospital East, Chiba, Japan
| | - Hiroaki Ikematsu
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Chiba, Japan
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15
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Local excision and chemoradiation for clinical node-negative anal adenocarcinoma. Surg Oncol 2021; 37:101551. [PMID: 33819849 DOI: 10.1016/j.suronc.2021.101551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 03/04/2021] [Accepted: 03/26/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Given the lack of consensus in the surgical treatment of anal adenocarcinoma, practice-patterns demonstrate utilization of organ-preserving techniques. The adequacy of local excision compared to abdominoperineal resection (APR) as a surgical approach for stage II disease is unknown. Our study examines the utilization of local excision in the treatment of stage II anal adenocarcinoma, rates of R0 resection, and differences in overall survival compared to APR. MATERIALS AND METHODS Using the National Cancer Database (2004-2016), we retrospectively analyzed patients diagnosed with clinical stage II anal adenocarcinoma who received chemoradiation and surgery. Patient cohorts were assigned based on the surgical procedure they received. Propensity score matching was used to offset selection bias and confounding factors. Treatment approach, pathologic margin status, and overall survival were assessed. RESULTS Overall, 359 patients underwent resection of clinical stage II anal adenocarcinoma and received chemoradiation therapy. Of these patients, 87 (24%) underwent local excision, whereas 272 (76%) received an abdominoperineal resection. In a propensity score-matched cohort, patients who underwent local excision were less likely to achieve an R0 resection (40% vs 90%), and more likely to receive adjuvant instead of neoadjuvant chemoradiation. Overall survival was not significantly different between the propensity-matched groups. Surgical approach and pathologic margin status were not independently associated with overall survival. CONCLUSIONS Among patients with clinical stage II anal adenocarcinoma who received chemotherapy and radiation, complete resection was significantly less likely with local excision compared to abdominoperineal resection, however, overall survival was not affected. Prospective studies of neoadjuvant chemoradiation followed by local excision are warranted.
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16
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Wan LJ, Liu Y, Peng WJ, Zou SM, Ye F, Ouyang H, Zhao XM, Zhou CW, Zhang HM. Submucosal Enhancing Stripe as a Contrast Material-enhanced MRI-based Imaging Feature for the Differentiation of Stage T0-T1 from Early T2 Rectal Cancers. Radiology 2020; 298:93-101. [PMID: 33170102 DOI: 10.1148/radiol.2020201416] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Accurate differentiation of stage T0-T1 rectal tumors from stage T2 rectal tumors facilitates the selection of appropriate surgical treatment. MRI is a recommended technique for local staging, but its ability to distinguish T1 from T2 tumors is poor. Purpose To explore the value of a submucosal enhancing stripe (SES), an uninterrupted enhancing band between the rectal tumor and the muscular layer on contrast material-enhanced T1-weighted images, as a potential imaging feature to differentiate T0-T1 from T2 rectal tumors. Materials and Methods This retrospective study included patients with pT0-T1 and pT2 rectal tumors who underwent pretreatment MRI and rectal tumor resection between January 2012 and November 2019. Two radiologists independently evaluated tumor characteristics (SES; status of muscularis propria [SMP]; and tumor shape, location, and size) at MRI. The associations of clinical and imaging characteristics with stage T0-T1 or T2 tumors were assessed, β values were calculated, and predictive models were built. The diagnostic accuracies for the differentiation of T0-T1 tumors from T2 tumors with SES and SMP were compared. Results Data from 431 patients (mean age, 60 years ± 10 [standard deviation]; 261 men) were evaluated. SES (β = 3.9; 95% CI: 3.1, 4.7; P < .001), SMP (β = 1.3; 95% CI: 0.7, 1.9; P < .001), and carpetlike shape (β = 1.6; 95% CI: 0.5, 2.8; P = .01) were independent factors distinguishing T0-T1 tumors from T2 tumors. The diagnostic accuracy was 87% (95% CI: 84, 90; 376 of 431) for SES and 67% (95% CI: 63, 72; 290 of 431) for SMP (P < .001). Conclusion Submucosal enhancing stripe (SES) at contrasted-enhanced MRI, status of muscularis propria (SMP) on T2-weighted images, and tumor shape can serve as independent imaging features to differentiate stage T0-T1 rectal tumors from stage T2 rectal tumors. Moreover, SES is a more accurate feature than is SMP. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Turkbey in this issue.
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Affiliation(s)
- Li-Juan Wan
- From the Departments of Radiology (L.J.W., Y.L., W.J.P., F.Y., H.O., X.M.Z., C.W.Z., H.M.Z.) and Pathology (S.M.Z.), National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuan Nanli, Chaoyang District, Beijing 100021, China
| | - Yuan Liu
- From the Departments of Radiology (L.J.W., Y.L., W.J.P., F.Y., H.O., X.M.Z., C.W.Z., H.M.Z.) and Pathology (S.M.Z.), National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuan Nanli, Chaoyang District, Beijing 100021, China
| | - Wen-Jing Peng
- From the Departments of Radiology (L.J.W., Y.L., W.J.P., F.Y., H.O., X.M.Z., C.W.Z., H.M.Z.) and Pathology (S.M.Z.), National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuan Nanli, Chaoyang District, Beijing 100021, China
| | - Shuang-Mei Zou
- From the Departments of Radiology (L.J.W., Y.L., W.J.P., F.Y., H.O., X.M.Z., C.W.Z., H.M.Z.) and Pathology (S.M.Z.), National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuan Nanli, Chaoyang District, Beijing 100021, China
| | - Feng Ye
- From the Departments of Radiology (L.J.W., Y.L., W.J.P., F.Y., H.O., X.M.Z., C.W.Z., H.M.Z.) and Pathology (S.M.Z.), National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuan Nanli, Chaoyang District, Beijing 100021, China
| | - Han Ouyang
- From the Departments of Radiology (L.J.W., Y.L., W.J.P., F.Y., H.O., X.M.Z., C.W.Z., H.M.Z.) and Pathology (S.M.Z.), National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuan Nanli, Chaoyang District, Beijing 100021, China
| | - Xin-Ming Zhao
- From the Departments of Radiology (L.J.W., Y.L., W.J.P., F.Y., H.O., X.M.Z., C.W.Z., H.M.Z.) and Pathology (S.M.Z.), National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuan Nanli, Chaoyang District, Beijing 100021, China
| | - Chun-Wu Zhou
- From the Departments of Radiology (L.J.W., Y.L., W.J.P., F.Y., H.O., X.M.Z., C.W.Z., H.M.Z.) and Pathology (S.M.Z.), National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuan Nanli, Chaoyang District, Beijing 100021, China
| | - Hong-Mei Zhang
- From the Departments of Radiology (L.J.W., Y.L., W.J.P., F.Y., H.O., X.M.Z., C.W.Z., H.M.Z.) and Pathology (S.M.Z.), National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuan Nanli, Chaoyang District, Beijing 100021, China
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17
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Nishizaki D, Hoshino N, Hida K, Nishikawa Y, Horimatsu T, Minamiguchi S, Sakanaka K, Sakai Y. Nonsurgical Management Following Local Resection for Early Rectal Cancer in Patients with High-risk Factors: A Single-institute Experience. JOURNAL OF THE ANUS RECTUM AND COLON 2020; 4:174-180. [PMID: 33134598 PMCID: PMC7595679 DOI: 10.23922/jarc.2020-019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/05/2020] [Indexed: 11/30/2022]
Abstract
Objective Additional surgery is considered for patients at high risk for lymph node metastasis (LNM) after local resection for early rectal cancer. Several factors are considered as indications for additional surgery, although there are currently no definitive criteria. This study aimed to clarify the need for additional surgery based on the number of risk factors for LNM and to evaluate the significance of submucosal invasion on recurrence. Methods Patients with early rectal cancer harboring risk factors for LNM who underwent local resection between March 2005 and December 2016 were retrospectively analyzed. Associations among the number of risk factors, prognosis, and additional treatment after local resection were investigated. Results A total of 29 eligible patients were classified into the surgery (n = 10), chemoradiotherapy (n = 7), and no-additional-treatment (NAT, n = 12) groups. Among the 29 patients, 15 patients (52%) with only one risk factor did not relapse. The NAT group harbored fewer risk factors for LNM, and 8 of the 12 patients (67%) had only deep submucosal invasion. Local recurrence occurred in one patient in the chemoradiotherapy group. The estimated 5-year overall survival rates were 88.9%, 75.0%, and 81.5% in the surgery, chemoradiotherapy, and NAT groups, respectively. There were no disease-specific deaths in the overall cohort. Conclusions In the present study, no recurrence occurred in patients who did not receive additional surgery with deep submucosal invasion as the only risk factor. A multicenter investigation is necessary to confirm the safety of nonsurgical options.
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Affiliation(s)
- Daisuke Nishizaki
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Nobuaki Hoshino
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan.,Department of Health Informatics, School of Public Health, Kyoto University, Kyoto, Japan
| | - Koya Hida
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yoshitaka Nishikawa
- Department of Health Informatics, School of Public Health, Kyoto University, Kyoto, Japan.,Department of Therapeutic Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takahiro Horimatsu
- Department of Therapeutic Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | | | - Katsuyuki Sakanaka
- Department of Radiation Oncology and Image-Applied Therapy, Kyoto University Hospital, Kyoto, Japan
| | - Yoshiharu Sakai
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
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18
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Xu K, Liu Y, Yu P, Shang W, Zhang Y, Jiao M, Cui Z, Xia L, Chen J. Oncological Outcomes of Transanal Endoscopic Microsurgery Plus Adjuvant Chemoradiotherapy for Patients with High-Risk T1 and T2 Rectal Cancer. J Laparoendosc Adv Surg Tech A 2020; 31:1006-1013. [PMID: 33026943 DOI: 10.1089/lap.2020.0706] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: Radical surgery is recommended for high-risk pathological stage T1 (pT1) or pT2 rectal cancer after transanal endoscopic microsurgery (TEM). However, in clinical practice, many patients may unfit or decline radical surgery. In recent years, adjuvant chemoradiotherapy (CRT) after TEM was considered as an alternative to radical surgery for these patients. This study aimed to assess oncological outcomes of adjuvant CRT after TEM for high-risk early rectal cancer. Materials and Methods: We collected retrospectively data of 97 patients who underwent TEM with pT1 and pT2 between January 2008 and December 2018. Of these, 35 patients were excluded. Of the remaining 62 patients, 42 were managed by TEM alone and 20 by TEM plus adjuvant CRT. Demographics, recurrence, and survival were analyzed between the two groups. Results: At a median follow-up of 52.5 months, the 3-year local recurrence-free survival and disease-free survival (DFS) in TEM alone group were significantly lower than those in TEM+CRT group (66.6% versus 93.3%, P = .035; 63.7% versus 93.3%, P = .022). Although the 3-year overall survival in TEM+CRT group was higher than TEM alone group (100% versus 83.3%), the difference was not statistically significant (P = .13). The local recurrence rate in TEM alone was 31%, compared with 5% in TEM+CRT group (P = .025). Multivariate analysis showed that adjuvant CRT was an independent prognostic factor for DFS (hazard ratio: 0.094; 95% confidence interval: 0.001-0.764; P = .027). Conclusions: Our study suggests that adjuvant CRT after TEM may be an alternative for pT1 high-risk and T2 rectal cancer who are not suitable or unwilling to undergo salvage radical surgery.
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Affiliation(s)
- Kang Xu
- Department of General Surgery, Weifang Medical University, Weifang, China.,Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Yulin Liu
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Peng Yu
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Wei Shang
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Yongbo Zhang
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Mingwen Jiao
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Zhonghui Cui
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Lijian Xia
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Jingbo Chen
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
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19
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Aguirre-Allende I, Enriquez-Navascues JM, Elorza-Echaniz G, Etxart-Lopetegui A, Borda-Arrizabalaga N, Saralegui Ansorena Y, Placer-Galan C. Early-rectal Cancer Treatment: A Decision-tree Making Based on Systematic Review and Meta-analysis. Cir Esp 2020; 99:89-107. [PMID: 32993858 DOI: 10.1016/j.ciresp.2020.05.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 05/27/2020] [Accepted: 05/30/2020] [Indexed: 02/07/2023]
Abstract
Local excision (LE) has arisen as an alternative to total mesorectal excision for the treatment of early rectal cancer. Despite a decreased morbidity, there are still concerns about LE outcomes. This systematic-review and meta-analysis design is based on the "PICO" process, aiming to answer to three questions related to LE as primary treatment for early-rectal cancer, the optimal method for LE, and the potential role for completion treatment in high-risk histology tumors and outcomes of salvage surgery. The results revealed that reported overall survival (OS) and disease-specific survival (DSS) were 71%-91.7% and 80%-94% for LE, in contrast to 92.3%-94.3% and 94.4%-97% for radical surgery. Additional analysis of National Database studies revealed lower OS with LE (HR: 1.26; 95%CI, 1.09-1.45) and DSS (HR: 1.19; 95%CI, 1.01-1.41) after LE. Furthermore, patients receiving LE were significantly more prone develop local recurrence (RR: 3.44, 95%CI, 2.50-4.74). Analysis of available transanal surgical platforms was performed, finding no significant differences among them but reduced local recurrence compared to traditional transanal LE (OR:0.24;95%CI, 0.15-0.4). Finally, we found poor survival outcomes for patients undergoing salvage surgery, favoring completion treatment (chemoradiotherapy or surgery) when high-risk histology is present. In conclusion, LE could be considered adequate provided a full-thickness specimen can be achieved that the patient is informed about risk for potential requirement of completion treatment. Early-rectal cancer cases should be discussed in a multidisciplinary team, and patient's preferences must be considered in the decision-making process.
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Affiliation(s)
- Ignacio Aguirre-Allende
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain.
| | - Jose Maria Enriquez-Navascues
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain
| | - Garazi Elorza-Echaniz
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain
| | - Ane Etxart-Lopetegui
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain
| | - Nerea Borda-Arrizabalaga
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain
| | - Yolanda Saralegui Ansorena
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain
| | - Carlos Placer-Galan
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain
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20
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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: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [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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21
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Kadota T, Ikematsu H, Sasaki T, Saito Y, Ito M, Mizutani T, Ogawa G, Shitara K, Ito Y, Kushima R, Kanemitsu Y, Muto M. Protocol for a single-arm confirmatory trial of adjuvant chemoradiation for patients with high-risk rectal submucosal invasive cancer after local resection: Japan Clinical Oncology Group Study JCOG1612 (RESCUE study). BMJ Open 2020; 10:e034947. [PMID: 32665384 PMCID: PMC7365419 DOI: 10.1136/bmjopen-2019-034947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Intestinal resection with lymph node dissection is the current standard treatment for high-risk lower rectal submucosal invasive cancer after local resection; however, surgery affects patients' quality of life due to stoma placement or impaired anal sphincter function. A recent study demonstrated that adjuvant chemoradiation yields promising results. METHODS AND ANALYSIS This study aims to confirm the non-inferiority of adjuvant chemoradiation, consisting of capecitabine and concurrent radiotherapy (45 Gy in 25 fractions), measured by 5-year relapse-free survival (RFS), over standard surgery in patients with high-risk lower rectal submucosal invasive cancer after local resection. The primary endpoint is 5 year RFS. The secondary endpoints are 10 years RFS, 5-year and 10-year overall survival, 5-year and 10-year local RFS, 5-year and 10-year proportion of anus-preservation without stoma, Wexner score, low anterior resection syndrome score, adverse events and serious adverse events. During the 5-year trial period, 210 patients will be accrued from 65 Japanese institutions. ETHICS AND DISSEMINATION The National Cancer Center Hospital East Certified Review Board approved this study protocol in October 2018. The study is conducted in accordance with the precepts established in the Declaration of Helsinki and Clinical Trials Act. Written informed consent will be obtained from all eligible patients prior to registration. The primary results of this study will be published in an English article. In addition, the main results will be published on the websites of Japan Clinical Oncology Group (www.jcog.jp) and jRCT (https://jrct.niph.go.jp/). As to data curation, it has not been prepared yet. TRIAL REGISTRATION NUMBER jRCT1031180076.
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Affiliation(s)
- Tomohiro Kadota
- JCOG Data Center/Operations Office, National Cancer Center Hospital, Chuo-ku, Japan
- Department of Gastroenterology and Endoscopy, National Cancer Center-Hospital East, Kashiwa, Chiba, Japan
| | - Hiroaki Ikematsu
- Department of Gastroenterology and Endoscopy, National Cancer Center-Hospital East, Kashiwa, Chiba, Japan
| | - Takeshi Sasaki
- Department of Colorectal Surgery, National Cancer Center-Hospital East, Kashiwa, Chiba, Japan
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Masaaki Ito
- Department of Colorectal Surgery, National Cancer Center-Hospital East, Kashiwa, Chiba, Japan
| | - Tomonori Mizutani
- JCOG Data Center/Operations Office, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Gakuto Ogawa
- JCOG Data Center/Operations Office, National Cancer Center Hospital, Chuo-ku, Japan
| | - Kohei Shitara
- Department of Gastroenterology and Endoscopy, National Cancer Center-Hospital East, Kashiwa, Chiba, Japan
| | - Yoshinori Ito
- Department of Radiation Oncology, Showa University Graduate School of Medicine, Shinagawa-ku, Tokyo, Japan
| | - Ryoji Kushima
- Department of Clinical Laboratory Medicine (Diagnostic Pathology), Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Yukihide Kanemitsu
- Department of Colorectal Surgery, National Cancer Center Hospital, Chuo-ku, Japan
| | - Manabu Muto
- Department of Therapeutic Oncology, Kyoto University Graduate School of Medicine, Kyoto, Japan
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22
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Balibegloo M, Rezaei N. Development and clinical application of bispecific antibody in the treatment of colorectal cancer. Expert Rev Clin Immunol 2020; 16:689-709. [PMID: 32536227 DOI: 10.1080/1744666x.2020.1783249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Treatment of colorectal cancer as one of the most commonly diagnosed and a frequent cause of cancer-related deaths is of great challenges in health-related issues. AREAS COVERED Immunotherapy is the fourth pillar of cancer treatment which provides more novel therapeutic options with expanding investigational potentials. One of the modalities in immunotherapy is the use of bispecific antibodies. Despite demonstrating many promising roles, it still needs more advanced studies to identify the actual pros and cons. In this review, the application of bispecific antibody in the treatment of colorectal cancer has been explained, based on preclinical and clinical studies. The literature search was conducted mainly through PubMed in June and September 2019. EXPERT OPINION Bispecific antibody is in its early stages in colorectal cancer treatment, requiring modern technologies in manufacturing, better biomarkers and more specific target antigens, more studies on individual genetic variations, and conducting later phase clinical trials and systematic reviews to achieve better survival benefits.
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Affiliation(s)
- Maryam Balibegloo
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences , Tehran, Iran.,Cancer Immunology Project (CIP), Universal Scientific Education & Research Network (USERN) , Tehran, Iran
| | - Nima Rezaei
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences , Tehran, Iran.,Department of Immunology, School of Medicine, Tehran University of Medical Sciences , Tehran, Iran.,Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education & Research Network (USERN) , Tehran, Iran
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23
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Samalavicius NE, Kavaliauskas P, Klimasauskiene V, Dulskas A. Transanal endoscopic microsurgery for a T2 rectal cancer in a high-risk patient - a compromised treatment - a video vignette. Colorectal Dis 2020; 22:472-473. [PMID: 31868955 DOI: 10.1111/codi.14931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 11/26/2019] [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
- Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Departament of General and Abdominal Surgery and Oncology, National Cancer Institute, Vilnius, Lithuania
| | - V Klimasauskiene
- Department of Surgery, Klaipeda University Hospital, Klaipeda, 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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24
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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] [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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25
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Lai IL, You JF, Chern YJ, Tsai WS, Chiang JM, Hsieh PS, Hung HY, Yeh CY, Chiang SF, Lai CC, Tang RP, Chen JS, Hsu YJ. Survival analysis of local excision vs total mesorectal excision for middle and low rectal cancer in pT1/pT2 stage and intermediate pathological risk. World J Surg Oncol 2019; 17:212. [PMID: 31818295 PMCID: PMC6902326 DOI: 10.1186/s12957-019-1763-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 11/28/2019] [Indexed: 02/08/2023] Open
Abstract
Background Local excision (LE) is a feasible treatment approach for rectal cancers in stage pT1 and presents low pathological risk, whereas total mesorectal excision (TME) is a reasonable treatment for more advanced cancers. On the basis of the pathology findings, surgeons may suggest TME for patients receiving LE. This study compared the survival outcomes between LE with/without chemoradiation and TME in mid and low rectal cancer patients in stage pT1/pT2, with highly selective intermediate pathological risk. Methods This retrospective study included 134 patients who received TME and 39 patients who underwent LE for the treatment of intermediate risk (pT1 with poor differentiation, lymphovascular invasion, perineural invasion, relatively large tumor, or small-sized pT2 tumor) rectal cancer between 1998 and 2016. Results Overall survival (OS), disease-free survival (DFS), and cumulative recurrence rate (CRR) were similar between the LE (3-year DFS 92%) and TME (3-year DFS 91%) groups. Following subgrouping into an LE with adjuvant therapy group and a TME without adjuvant therapy group, the compared survival outcomes (OS, DFS, and CRR) were found not to be statistically different. The temporary and permanent ostomy rates were higher in the TME group than in the LE group (p < 0.001). Rates of early and late morbidity following surgery were higher in the TME group (p = 0.005), and LE had similar survival compared with TME. Conclusion For patients who had mid and low rectal cancer in stage pT1/pT2 and intermediate pathological risk, LE with chemoradiation presents an alternative treatment option for selected patients.
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Affiliation(s)
- I-Li Lai
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, 5, Fu-Hsing Street, Guei-Shan, Tao-Yuan, Taiwan
| | - Jeng-Fu You
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, 5, Fu-Hsing Street, Guei-Shan, Tao-Yuan, Taiwan
| | - Yih-Jong Chern
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, 5, Fu-Hsing Street, Guei-Shan, Tao-Yuan, Taiwan
| | - Wen-Sy Tsai
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, 5, Fu-Hsing Street, Guei-Shan, Tao-Yuan, Taiwan
| | - Jy-Ming Chiang
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, 5, Fu-Hsing Street, Guei-Shan, Tao-Yuan, Taiwan
| | - Pao-Shiu Hsieh
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, 5, Fu-Hsing Street, Guei-Shan, Tao-Yuan, Taiwan
| | - Hsin-Yuan Hung
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, 5, Fu-Hsing Street, Guei-Shan, Tao-Yuan, Taiwan
| | - Chien-Yuh Yeh
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, 5, Fu-Hsing Street, Guei-Shan, Tao-Yuan, Taiwan
| | - Sum-Fu Chiang
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, 5, Fu-Hsing Street, Guei-Shan, Tao-Yuan, Taiwan
| | - Cheng-Chou Lai
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, 5, Fu-Hsing Street, Guei-Shan, Tao-Yuan, Taiwan
| | - Rei-Ping Tang
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, 5, Fu-Hsing Street, Guei-Shan, Tao-Yuan, Taiwan
| | - Jinn-Shiun Chen
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, 5, Fu-Hsing Street, Guei-Shan, Tao-Yuan, Taiwan
| | - Yu-Jen Hsu
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, 5, Fu-Hsing Street, Guei-Shan, Tao-Yuan, Taiwan.
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26
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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] [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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Jones HJS, Goodbrand S, Hompes R, Mortensen N, Cunningham C. Radiotherapy after local excision of rectal cancer may offer reduced local recurrence rates. Colorectal Dis 2019; 21:451-459. [PMID: 30585677 DOI: 10.1111/codi.14546] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 11/26/2018] [Indexed: 02/08/2023]
Abstract
AIM Early rectal cancer can be managed effectively with local excision, which is now the standard of care for many T1 lesions. However, the presence of unexpected adverse histopathological factors may indicate an increased risk of local recurrence, prompting consideration of completion radical surgery. Many patients are unfit or prefer to avoid radical surgery, relying instead on surveillance and early detection of recurrent disease. Recently, radiotherapy has shown promise as an adjuvant therapy in this group. This study assesses local recurrence rates after local excision with adjuvant radiotherapy at a single centre. METHOD This was a retrospective review of a prospective database of all patients undergoing transanal endoscopic microsurgery (TEM) in a single institution. Data covering a 10-year period were analysed. RESULTS Of 197 patients undergoing TEM for rectal cancer, 33 (17%) had adjuvant radiotherapy because of adverse histopathological features. At 3.2 years' median follow-up, there were three instances of local recurrence (9.1%). Estimated local recurrence at 1 and 3 years was 0% and 6.9%, compared to 16.8% and 21.2% in a propensity-score-matched group who were followed by surveillance alone. Local recurrence was diagnosed at a median of 23 months post-TEM in the radiotherapy group, compared to 8 months in the matched group. CONCLUSION Radiotherapy after TEM is associated with a trend towards a reduced rate of local recurrence, even for high-risk disease. Radiotherapy would appear to offer a viable alternative to radical completion surgery in the presence of unforeseen adverse histopathological features, as long as a meticulous surveillance programme is in place.
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Affiliation(s)
- H J S Jones
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - S Goodbrand
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R Hompes
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - N Mortensen
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - C Cunningham
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Abstract
BACKGROUND Local excision is now accepted as a standard treatment option for certain patients with early rectal cancer. However, there is a higher risk of local recurrence than after radical surgery with total mesorectal excision. Adjuvant radiotherapy after local excision may reduce this excess risk, and yet retain the benefits of local excision, with rectal preservation. METHODS A review of the literature pertaining to the use of adjuvant radiotherapy after local excision of rectal cancer and a discussion of current practice. RESULTS We first considered local excision as a treatment option for early rectal cancer, looking at technical developments and the risks and benefits of organ preservation, in particular, the advantages for quality of life and the risk of leaving residual disease which may result in local recurrence. We then looked at reported outcomes for studies using adjuvant radiotherapy after local excision. Few of the studies routinely used modern endoscopic methods of local excision and only the recent used chemoradiation. Local recurrence rates after adjuvant radiotherapy have improved over time, with rates of around 3.5% in the recent studies. Adverse effects of adjuvant radiotherapy are not commonly described, but generally, they are relatively mild when described. We then discussed current practice regarding adjuvant radiotherapy, including pathological criteria, discussion of local recurrence risk with the patient and the importance of a surveillance regime to detect any recurrence at an early stage. CONCLUSION We conclude that the current state of knowledge regarding adjuvant radiotherapy after local excision suggests a potential role in decreasing the risk of local recurrence but further studies are required to better define this effect, clarify which patients will gain the most benefit from this pathway, and identify those who should avoid exposure to the risks of radiotherapy.
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Affiliation(s)
- H. J. S. Jones
- Department of Colorectal Surgery, Oxford University Hospitals, Oxford, UK
| | - C. Cunningham
- Department of Colorectal Surgery, Oxford University Hospitals, Oxford, UK
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Wang XJ, Chi P, Zhang YY, Lin HM, Lu XR, Huang Y, Xu ZB, Ghareeb WM, Huang SH, Sun YW, Ye DX. Survival outcome of adjuvant radiotherapy after local excision for T2 early rectal cancer: An analysis based on the surveillance, epidemiology, and end result registry database. Eur J Surg Oncol 2018; 44:1865-1872. [PMID: 30262325 DOI: 10.1016/j.ejso.2018.08.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 06/15/2018] [Accepted: 08/28/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Major resection (MR) is recommended for cases with T2 finding after local excision (LE) of early rectal cancer, but the revision procedure is accompanied with high morbidity. We evaluated the oncological safety of LE followed by adjuvant radiotherapy as a rectum-preserving alternative to MR for T2 early rectal cancer. METHODS A total of 3786 patients with T2N0M0 rectal adenocarcinoma between 1998 and 2013 were included from the SEER database. Survival rates were compared using the Kaplan-Meier method with a log-rank test, and multivariate analyses were performed using Cox proportional regression models. RESULTS Of these patients included, 429 (11.3%) treated with LE alone (LE group), 3067 (81.0%) treated with MR (MR group), and 290 (7.7%) treated with LE followed by adjuvant radiotherapy (LE + adjuvant RT group). The 5-year cancer specific survival (CSS) rate and 5-year overall survival (OS) rate were significantly lower in LE patients group than those in MR patients group (70.5% vs. 81.8%, P < 0.001; 57.3% vs. 72.3%, P < 0.001). The 5-year CSS rate and 5-year OS rate were similar between LE + adjuvant RT and MR groups (78.4% vs. 81.8%, P = 0.975, and 70.7% vs. 72.3%, P = 0.311, respectively). Multivariate Cox regression revealed that treatment strategies, age and CEA status were independently associated with CSS and OS. After age adjustment, LE was associated with reduced CSS (using MR as a reference, HR, 1.784; P < 0.001) and reduced OS (HR, 1.739; P < 0.001). However, CSS and OS related to LE + adjuvant RT of T2 rectal cancer group weren't be affected (HR, 0.994; P = 0.962 and HR, 0.904; P = 0.302, respectively). CONCLUSIONS When MR is inappropriate for T2 early rectal cancer patients because of patients refusal or co-morbidities, LE + adjuvant RT can provide acceptable levels of long-term survival.
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Affiliation(s)
- Xiao-Jie Wang
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, PR China
| | - Pan Chi
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, PR China.
| | - Yue-Yi Zhang
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, PR China
| | - Hui-Ming Lin
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, PR China
| | - Xing-Rong Lu
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, PR China
| | - Ying Huang
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, PR China
| | - Zong-Bin Xu
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, PR China
| | - Waleed M Ghareeb
- Department of General and Gastrointestinal Surgery, Suez Canal University, Egypt
| | - Sheng-Hui Huang
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, PR China
| | - Yan-Wu Sun
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, PR China
| | - Dao-Xiong Ye
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, PR China
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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] [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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Polamraju P, Haque W, Verma V, Wiederhold L, Hatch S, Butler EB, Teh BS. Adjuvant Management of Pathologic Node-Positive Disease After Definitive Surgery for Clinical T1-2 N0 Rectal Cancer. Clin Colorectal Cancer 2018; 17:e519-e530. [PMID: 29753642 DOI: 10.1016/j.clcc.2018.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 04/14/2018] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Patients with cT1-2N0M0 rectal cancer are often treated with up-front surgical resection, with adjuvant treatment reserved for patients upstaged with pathologic node-positive (pN+) disease at surgery. This study evaluates practice patterns and clinical outcomes when comparing different forms of adjuvant treatment for this patient population. METHODS The National Cancer Data Base was queried for cT1-2N0M0 rectal cancer patients between 2004 and 2015 with postoperative pN+ disease treated without neoadjuvant treatment. Patients were divided into groups receiving observation, chemotherapy, or chemoradiotherapy (CRT). Multivariable logistic regression determined factors associated with receipt of adjuvant treatment. Kaplan-Meier curves compared overall survival (OS), and Cox regression determined patient factors associated with OS. RESULTS Altogether, 1466 patients met the inclusion criteria; 536 patients (36.6%) received adjuvant chemotherapy, 413 (28.2%) received adjuvant CRT, and 517 (35.3%) were observed postoperatively. Use of adjuvant treatment was associated with superior median OS (124.1 vs. 51.1 months, P < .001), persisting after propensity score matching (124.0 vs. 61.9 months, P < .001), but not between adjuvant CRT versus chemotherapy on subset analysis. Patients with positive surgical margins receiving adjuvant CRT showed a trend toward OS improvement compared to patients managed with chemotherapy (54.9 vs. 47.4 months, P = .10). Increased age, pN2 status, positive margin status, and observation were associated with poorer OS. CONCLUSION Most patients found to have pN+ disease after up-front surgery for cT1-2N0 rectal cancer receive adjuvant treatment, which is associated with improved OS. Chemotherapy or CRT are appropriate options, although there was a trend toward higher OS for patients with positive surgical margins receiving CRT.
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Affiliation(s)
- Praveen Polamraju
- Department of Radiation Oncology, University of Texas Medical Branch, Galveston, TX
| | - Waqar Haque
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX.
| | - Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA
| | - Lee Wiederhold
- Department of Radiation Oncology, University of Texas Medical Branch, Galveston, TX
| | - Sandra Hatch
- Department of Radiation Oncology, University of Texas Medical Branch, Galveston, TX
| | - E Brian Butler
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX
| | - Bin S Teh
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX
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32
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Motamedi MAK, Mak NT, Brown CJ, Raval MJ, Karimuddin AA, Phang PT. Local versus radical surgery for early rectal cancer with or without neoadjuvant or adjuvant therapy. Hippokratia 2011. [DOI: 10.1002/14651858.cd002198.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- M Ali K Motamedi
- Surgery; St. Paul's Hospital, University of British Columbia; Vancouver Canada
| | - Nicole T Mak
- Surgery; University of British Columbia; Vancouver Canada
| | - Carl J Brown
- Head Division of General Surgery; St. Paul's Hospital; Vancouver Canada
| | - Manoj J Raval
- General Surgery; Providence Health Care - St. Paul's Hospital; Vancouver Canada
| | | | - Paul Terry Phang
- Surgery; St. Paul's Hospital, University of British Columbia; Vancouver Canada
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