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Fadel MG, Ahmed M, Shaw A, Fehervari M, Kontovounisios C, Brown G. Oncological outcomes of local excision versus radical surgery for early rectal cancer in the context of staging and surveillance: A systematic review and meta-analysis. Cancer Treat Rev 2024; 128:102753. [PMID: 38761791 DOI: 10.1016/j.ctrv.2024.102753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 05/09/2024] [Accepted: 05/11/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Local resection (LR) methods for rectal cancer are generally considered in the palliative setting or for patients deemed a high anaesthetic risk. This systematic review and meta-analysis aimed to compare oncological outcomes of LR and radical resection (RR) for early rectal cancer in the context of staging and surveillance assessment. METHODS A literature search of MEDLINE, Embase and Emcare databases was performed for studies that reported data on clinical outcomes for both LR and RR for early rectal cancer from January 1995 to April 2023. Meta-analysis was performed using random-effect models and between-study heterogeneity was assessed. The quality of assessment was assessed using the Newcastle-Ottawa Scale for observational studies and the Cochrane Risk of Bias 2.0 tool for randomised controlled trials. RESULTS Twenty studies with 12,022 patients were included: 6,476 patients had LR and 5,546 patients underwent RR. RR led to an improvement in 5-year overall survival (OR 1.84; 95 % CI 1.54-2.20; p < 0.0001; I2 20 %) and local recurrence (OR 3.06; 95 % CI 2.02-4.64; p < 0.0001; I2 39 %) when compared to LR. However, when staging and surveillance methods were clearly adopted in LR cases, there was an improvement in R0 rates (96.7 % vs 85.6 %), 5-year disease-free survival (93.0 % vs 77.9 %) and overall survival (81.6 % vs 79.0 %) compared to when staging and surveillance was not reported/performed. CONCLUSIONS LR may be appropriate for selected patients without poor prognostic factors in early rectal cancer. This study also highlights that there is currently no single standardised staging or surveillance approach being adopted in the management of early rectal cancer. A more specified and standardised preoperative staging for patient selection as well as clinical and image-based surveillance protocols is needed.
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Affiliation(s)
- Michael G Fadel
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom; Department of Colorectal and General Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Mosab Ahmed
- Department of Colorectal and General Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Annabel Shaw
- Department of Colorectal and General Surgery, Epsom and St. Helier University Hospitals NHS Trust, London, United Kingdom
| | - Matyas Fehervari
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom; Department of Gastrointestinal Surgery, Maidstone and Tunbridge Wells NHS Trust, Kent, United Kingdom
| | - Christos Kontovounisios
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom; Department of Colorectal and General Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom; Department of Colorectal Surgery, Royal Marsden NHS Foundation Trust, London, United Kingdom; 2nd Surgical Department Evaggelismos Athens General Hospital, Athens, Greece.
| | - Gina Brown
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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Xia W, Li D, He W, Pickhardt PJ, Jian J, Zhang R, Zhang J, Song R, Tong T, Yang X, Gao X, Cui Y. Multicenter Evaluation of a Weakly Supervised Deep Learning Model for Lymph Node Diagnosis in Rectal Cancer at MRI. Radiol Artif Intell 2024; 6:e230152. [PMID: 38353633 PMCID: PMC10982819 DOI: 10.1148/ryai.230152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 12/13/2023] [Accepted: 01/24/2024] [Indexed: 03/07/2024]
Abstract
Purpose To develop a Weakly supervISed model DevelOpment fraMework (WISDOM) model to construct a lymph node (LN) diagnosis model for patients with rectal cancer (RC) that uses preoperative MRI data coupled with postoperative patient-level pathologic information. Materials and Methods In this retrospective study, the WISDOM model was built using MRI (T2-weighted and diffusion-weighted imaging) and patient-level pathologic information (the number of postoperatively confirmed metastatic LNs and resected LNs) based on the data of patients with RC between January 2016 and November 2017. The incremental value of the model in assisting radiologists was investigated. The performances in binary and ternary N staging were evaluated using area under the receiver operating characteristic curve (AUC) and the concordance index (C index), respectively. Results A total of 1014 patients (median age, 62 years; IQR, 54-68 years; 590 male) were analyzed, including the training cohort (n = 589) and internal test cohort (n = 146) from center 1 and two external test cohorts (cohort 1: 117; cohort 2: 162) from centers 2 and 3. The WISDOM model yielded an overall AUC of 0.81 and C index of 0.765, significantly outperforming junior radiologists (AUC = 0.69, P < .001; C index = 0.689, P < .001) and performing comparably with senior radiologists (AUC = 0.79, P = .21; C index = 0.788, P = .22). Moreover, the model significantly improved the performance of junior radiologists (AUC = 0.80, P < .001; C index = 0.798, P < .001) and senior radiologists (AUC = 0.88, P < .001; C index = 0.869, P < .001). Conclusion This study demonstrates the potential of WISDOM as a useful LN diagnosis method using routine rectal MRI data. The improved radiologist performance observed with model assistance highlights the potential clinical utility of WISDOM in practice. Keywords: MR Imaging, Abdomen/GI, Rectum, Computer Applications-Detection/Diagnosis Supplemental material is available for this article. Published under a CC BY 4.0 license.
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Affiliation(s)
| | | | - Wenguang He
- From the Department of Medical Imaging, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, China (W.X., J.J., R.Z., X.G.); Department of Radiology, Shanxi Province Cancer Hospital/Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences/Cancer Hospital Affiliated to Shanxi Medical University, Taiyuan 030013, China (D.L., J.Z., R.S., X.Y., X.G., Y.C.); Department of Radiology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China (W.H.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Science Center, Madison, Wis (P.J.P.); Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China (T.T.); Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China (T.T.); and Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangzhou, China (Y.C.)
| | - Perry J. Pickhardt
- From the Department of Medical Imaging, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, China (W.X., J.J., R.Z., X.G.); Department of Radiology, Shanxi Province Cancer Hospital/Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences/Cancer Hospital Affiliated to Shanxi Medical University, Taiyuan 030013, China (D.L., J.Z., R.S., X.Y., X.G., Y.C.); Department of Radiology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China (W.H.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Science Center, Madison, Wis (P.J.P.); Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China (T.T.); Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China (T.T.); and Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangzhou, China (Y.C.)
| | - Junming Jian
- From the Department of Medical Imaging, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, China (W.X., J.J., R.Z., X.G.); Department of Radiology, Shanxi Province Cancer Hospital/Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences/Cancer Hospital Affiliated to Shanxi Medical University, Taiyuan 030013, China (D.L., J.Z., R.S., X.Y., X.G., Y.C.); Department of Radiology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China (W.H.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Science Center, Madison, Wis (P.J.P.); Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China (T.T.); Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China (T.T.); and Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangzhou, China (Y.C.)
| | - Rui Zhang
- From the Department of Medical Imaging, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, China (W.X., J.J., R.Z., X.G.); Department of Radiology, Shanxi Province Cancer Hospital/Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences/Cancer Hospital Affiliated to Shanxi Medical University, Taiyuan 030013, China (D.L., J.Z., R.S., X.Y., X.G., Y.C.); Department of Radiology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China (W.H.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Science Center, Madison, Wis (P.J.P.); Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China (T.T.); Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China (T.T.); and Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangzhou, China (Y.C.)
| | - Junjie Zhang
- From the Department of Medical Imaging, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, China (W.X., J.J., R.Z., X.G.); Department of Radiology, Shanxi Province Cancer Hospital/Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences/Cancer Hospital Affiliated to Shanxi Medical University, Taiyuan 030013, China (D.L., J.Z., R.S., X.Y., X.G., Y.C.); Department of Radiology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China (W.H.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Science Center, Madison, Wis (P.J.P.); Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China (T.T.); Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China (T.T.); and Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangzhou, China (Y.C.)
| | - Ruirui Song
- From the Department of Medical Imaging, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, China (W.X., J.J., R.Z., X.G.); Department of Radiology, Shanxi Province Cancer Hospital/Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences/Cancer Hospital Affiliated to Shanxi Medical University, Taiyuan 030013, China (D.L., J.Z., R.S., X.Y., X.G., Y.C.); Department of Radiology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China (W.H.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Science Center, Madison, Wis (P.J.P.); Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China (T.T.); Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China (T.T.); and Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangzhou, China (Y.C.)
| | - Tong Tong
- From the Department of Medical Imaging, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, China (W.X., J.J., R.Z., X.G.); Department of Radiology, Shanxi Province Cancer Hospital/Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences/Cancer Hospital Affiliated to Shanxi Medical University, Taiyuan 030013, China (D.L., J.Z., R.S., X.Y., X.G., Y.C.); Department of Radiology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China (W.H.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Science Center, Madison, Wis (P.J.P.); Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China (T.T.); Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China (T.T.); and Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangzhou, China (Y.C.)
| | - Xiaotang Yang
- From the Department of Medical Imaging, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, China (W.X., J.J., R.Z., X.G.); Department of Radiology, Shanxi Province Cancer Hospital/Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences/Cancer Hospital Affiliated to Shanxi Medical University, Taiyuan 030013, China (D.L., J.Z., R.S., X.Y., X.G., Y.C.); Department of Radiology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China (W.H.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Science Center, Madison, Wis (P.J.P.); Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China (T.T.); Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China (T.T.); and Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangzhou, China (Y.C.)
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Kwik C, El-Khoury T, Pathma-Nathan N, Toh JWT. Endoscopic and trans-anal local excision vs. radical resection in the treatment of early rectal cancer: A systematic review and network meta-analysis. Int J Colorectal Dis 2023; 39:13. [PMID: 38157077 DOI: 10.1007/s00384-023-04584-6] [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] [Accepted: 12/21/2023] [Indexed: 01/03/2024]
Abstract
PURPOSE The management of early-stage rectal cancer in clinical practice is controversial. The aim of this network meta-analysis was to compare oncological and postoperative outcomes for T1T2N0M0 rectal cancers managed with local excision in comparison to conventional radical resection. METHODS A systematic review of Medline, Embase and Cochrane electronic databases was performed. Relevant studies were selected using PRISMA guidelines. The primary outcomes measured were 5-year local recurrence and overall survival. Secondary outcomes included rates of postoperative complication, 30-day mortality, positive margin and permanent stoma formation. RESULTS Three randomized controlled trials and 27 observational studies contributed 8570 patients for analysis. Radical resection was associated with reduced 5-year local recurrence in comparison to local excision. This was statistically significant in comparison to trans-anal local excision (odds ratio (OR) 0.23; 95% confidence interval 0.16-0.30) and favourable in comparison to endoscopic techniques (OR 0.40; 95% confidence interval 0.13-1.23) although this did not reach clinical significance. Positive margin rates were lowest for radical resection. However, 30-day mortality rates, perioperative complications and permanent stoma rates all favoured local excision with no statistically significant difference between endoscopic and trans-anal techniques. CONCLUSION Radical resection of early rectal cancer is associated with the lowest 5-year local recurrence rates and the lowest rate of positive margins. However, this must be balanced with its higher 30-day mortality and complication rates as well as the increased risk of permanent stoma. The emerging potential role of neoadjuvant therapy prior to local resection, and the heterogeneity of its use, as an alternative treatment for early rectal cancer further complicates the treatment paradigm and adds to controversy in this field.
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Affiliation(s)
- Charlotte Kwik
- Department of Colorectal Surgery, Westmead Hospital, Cnr Hawkesbury Road and Darcy Road, Westmead, NSW, Australia.
| | - Toufic El-Khoury
- Department of Colorectal Surgery, Westmead Hospital, Cnr Hawkesbury Road and Darcy Road, Westmead, NSW, Australia
| | - Nimalan Pathma-Nathan
- Department of Colorectal Surgery, Westmead Hospital, Cnr Hawkesbury Road and Darcy Road, Westmead, NSW, Australia
| | - James Wei Tatt Toh
- Department of Colorectal Surgery, Westmead Hospital, Cnr Hawkesbury Road and Darcy Road, Westmead, NSW, Australia.
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
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Lynch P, Ryan OK, Donnelly M, Ryan ÉJ, Davey MG, Reynolds IS, Creavin B, Hanly A, Kennelly R, Martin ST, Winter DC. Comparing neoadjuvant therapy followed by local excision to total mesorectal excision in the treatment of early stage rectal cancer: a systematic review and meta-analysis of randomised clinical trials. Int J Colorectal Dis 2023; 38:263. [PMID: 37924372 DOI: 10.1007/s00384-023-04558-8] [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] [Accepted: 10/26/2023] [Indexed: 11/06/2023]
Abstract
INTRODUCTION Total mesorectal excision (TME) is the standard-of-care in early, clinical stage (cT2-3 N0 M0) rectal cancer. Local excision (LE) may be an alternative after adequate response to neoadjuvant therapy (NAT), with either long-course chemoradiotherapy (nCRT) or short-course radiotherapy (SCRT), as a means of preserving the rectum and potentially obviating the morbidity of TME. METHODS A systematic review was performed according to PRISMA guidelines for studies that randomly assigned patients with cT2-3 N0 M0 rectal cancer to either NAT + LE or TME that reported radiologic, oncologic, surgical, and morbidity outcomes. RESULTS A total of 4 RCTs comprise 462 patients (232 patients receiving NAT + LE; nCRT n = 205; SCRT n = 27) and 230 undergoing TME, respectively. NAT compliance was 98.86%. The rate of early completion TME in the NAT + LE group was 22.3%, while the proportion of patients achieving durable organ preservation was 75.4% at mean follow-up of 5.6 years. There was no difference in disease-free survival (DFS) (HR [hazard ratio] 1.19; 95% CI 0.95, 1.49; p = 0.13) or overall survival (OS) (HR 0.94; 95% CI 0.72, 1.23; p = 0.63]) according to the assigned treatment arm. The local recurrence rate (LRR) (HR 1.22; 95% CI 0.5-3.02; p = 0.66) and distant metastases (HR 0.92; 95% CI 0.45, 1.90; p = 0.82) were also comparable between the groups. There was a significant reduction in major (OR 0.45; 95% CI 0.21, 0.95; p = 0.04) and minor morbidity (OR 0.45; 95% CI 0.24, 0.85; p = 0.01) for patients undergoing NAT + LE. Overall stoma formation was decreased in the NAT + LE group (OR 0.03; 95% CI 0.0, 0.23; p ≤ 0.00001). CONCLUSION NAT + LE reduces adverse effects of TME, without any compromise in oncological outcomes, and the potential for an organ preserving strategy should be discussed with patients with T2-3N0 rectal cancers prior to treatment.
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Affiliation(s)
- Paul Lynch
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Odhrán K Ryan
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Mark Donnelly
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Éanna J Ryan
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland.
| | - Matthew G Davey
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Ian S Reynolds
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Ben Creavin
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Ann Hanly
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Rory Kennelly
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Seán T Martin
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Des C Winter
- Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
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Gao Y, Wu A. Organ Preservation in MSS Rectal Cancer. Clin Colon Rectal Surg 2023; 36:430-440. [PMID: 37795468 PMCID: PMC10547535 DOI: 10.1055/s-0043-1767710] [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: 10/06/2023]
Abstract
Rectal cancer is a heterogeneous disease with complex genetic and molecular subtypes. Emerging progress of neoadjuvant therapy has led to increased pathological and clinical complete response (cCR) rates for microsatellite stable (MSS) rectal cancer, which responds poorly to immune checkpoint inhibitor alone. As a result, organ preservation of MSS rectal cancer as an alternative to radical surgery has gradually become a feasible option. For patients with cCR or near-cCR after neoadjuvant treatment, organ preservation can be implemented safely with less morbidity. Patient selection can be done either before the neoadjuvant treatment for higher probability or after with careful assessment for a favorable outcome. Those patients who achieved a good clinical response are managed with nonoperative management, organ preservation surgery, or radiation therapy alone followed by strict surveillance. The oncological outcomes of patients with careful selection and organ preservation seem to be noninferior compared with those of radical surgery, with lower postoperative morbidity. However, more studies should be done to seek better regression of tumor and maximize the possibility of organ preservation in MSS rectal cancer.
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Affiliation(s)
- Yuye Gao
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Unit III, Gastrointestinal Cancer Center, Peking University Cancer Hospital and Institute, Beijing, China
| | - Aiwen Wu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Unit III, Gastrointestinal Cancer Center, Peking University Cancer Hospital and Institute, Beijing, China
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Kelly KJ. Editorial: Updating the Operative Standards for Cancer Surgery Key Questions. Ann Surg Oncol 2022; 29:6511-6514. [PMID: 35980552 DOI: 10.1245/s10434-022-12417-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 08/03/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Kaitlyn J Kelly
- Division of Surgical Oncology, University of Wisconsin Hospital and Clinics, Madison, WI, USA.
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Peltrini R, Imperatore N, Di Nuzzo MM, Pellino G. Towards personalized treatment of T2N0 rectal cancer: A systematic review of long-term oncological outcomes of neoadjuvant therapy followed by local excision. J Gastroenterol Hepatol 2022; 37:1426-1433. [PMID: 35614027 PMCID: PMC9545053 DOI: 10.1111/jgh.15898] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 05/17/2022] [Accepted: 05/19/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIM Total mesorectal excision (TME) remains the treatment of choice in T2N0 tumors. However, evidence suggest that one-size-fits-all approach is not always beneficial for this group of patients. The aim of this study is to synthesize data on long-term outcomes after neoadjuvant therapy (NAT) followed by local excision (LE) in T2N0 rectal cancer patients in the perspective of a rectal-preserving strategy. METHODS A systematic search of PubMed/MEDLINE, SCOPUS, and Web of Science databases was conducted until October 2021 to identify studies comparing LE after NAT and TME or reporting oncologic outcomes after conservative approach. A pooled analysis was conducted using a fixed-effect model in the case of non-significant heterogeneity (P > 0.1), and a random effect model (DerSimonian-Laird method) when significant heterogeneity was present (P < 0.1) CRD42022300344. RESULTS Nine studies were included in the analysis. Three of them were comparative studies. The pooled 3-year DFS, 5-year DFS, 3-year OS, 5-year OS, local and distant recurrence rates were 92.8% (95% CI 81.6-99.5%), 91.3% (95% CI 88.3-94.3%), 96.1% (95% CI 90.5-100%), 72.6% (95% CI 57.5-87.7%), 4% (95% CI 18-63%), and 4.9% (95% CI 2-7.8%), respectively, in subjects treated with NAT followed by LE. No heterogeneity was found for all these analyses, except for the 5-year OS sub-analysis (I2 95.5%, P < 0.001). Complete pathological response (ypT0) rate after NAT and LE ranges from 26.7% to 59%. CONCLUSION LE following neoadjuvant CRT may provide comparable survival benefit to radical surgery for patients with clinical stage T2N0 in selected patients although the evidence is still limited to provide solid recommendations. A personalized therapeutic approach taking into account tumor and patient-related factors should be considered.
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Affiliation(s)
- Roberto Peltrini
- Department of Public Health, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Nicola Imperatore
- Gastroenterology and Endoscopy Unit, AORN Antonio Cardarelli, Naples, Italy
| | - Maria Michela Di Nuzzo
- Department of Public Health, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitell", Naples, Italy.,Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
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Zhang M, Zhang Y, Jing H, Zhao L, Xu M, Xu H, Zhu S, Zhang X. Prognosis of Patients Over 60 Years Old With Early Rectal Cancer Undergoing Transanal Endoscopic Microsurgery – A Single-Center Experience. Front Oncol 2022; 12:888739. [PMID: 35774121 PMCID: PMC9239430 DOI: 10.3389/fonc.2022.888739] [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: 03/03/2022] [Accepted: 05/12/2022] [Indexed: 11/13/2022] Open
Abstract
AimTransanal endoscopic microsurgery (TEM) is widely performed in early rectal cancer. This technique offers greater organ preservation and decreases the risk of subsequent surgery. However, postoperative local recurrence and distant metastasis remain challenges for patients with high-risk pathological factors. This single-center study reports the prognosis of early rectal cancer patients over 60 years old after TEM.MethodsThe data of the patients over 60 years old who underwent local anal resection were collected retrospectively. Moreover, the 5-year follow-up data were analyzed to determine the 5-year DFS and OS.Results47 early rectal cancer patients over 60 years old underwent TEM. There were 27 patients with high-risk factors and 20 patients without high-risk factors. Two patients underwent radical surgery after TEM and ten patients received adjuvant treatment. Local recurrence occurred in 7 patients, of which 4 underwent salvage surgery. The 5-year progression-free survival rate was 75.6%, which was lower in the high-risk patients group (69.6%) than in the non-high-risk patients group (83.3%) (P>0.05). The 5-year OS was 90.2%, but there was no statistically significant difference between the two groups (high-risk patients 87.0%, non-high-risk patients 94.4%). Furthermore, there was no significant difference in DFS and OS between people over and under 70 years old.ConclusionSome high-risk factor patients over 60 years old do not have inferior 5-year DFS and OS to the non-high-risk patients. TEM is an option for old patients with high surgical risks. Even if postoperative pathology revealed high-risk factors, timely surgical treatment after local recurrence would be beneficial to improve the 5-year DFS and OS.
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Affiliation(s)
- Mingqing Zhang
- Nankai University School of Medicine, Nankai University, Tianjin, China
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
- Colorectal Cancer Screening Office, Tianjin Institute of Coloproctology, Tianjin, China
- The Institute of Translational Medicine, Tianjin Union Medical Center of Nankai University, Tianjin, China
| | - Yongdan Zhang
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
- Colorectal Cancer Screening Office, Tianjin Institute of Coloproctology, Tianjin, China
| | - Haoren Jing
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
- Colorectal Cancer Screening Office, Tianjin Institute of Coloproctology, Tianjin, China
| | - Lizhong Zhao
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
- Colorectal Cancer Screening Office, Tianjin Institute of Coloproctology, Tianjin, China
| | - Mingyue Xu
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
- Colorectal Cancer Screening Office, Tianjin Institute of Coloproctology, Tianjin, China
| | - Hui Xu
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
- Colorectal Cancer Screening Office, Tianjin Institute of Coloproctology, Tianjin, China
| | - Siwei Zhu
- Nankai University School of Medicine, Nankai University, Tianjin, China
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
- Colorectal Cancer Screening Office, Tianjin Institute of Coloproctology, Tianjin, China
- The Institute of Translational Medicine, Tianjin Union Medical Center of Nankai University, Tianjin, China
- *Correspondence: Siwei Zhu, ; Xipeng Zhang,
| | - Xipeng Zhang
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China
- Colorectal Cancer Screening Office, Tianjin Institute of Coloproctology, Tianjin, China
- The Institute of Translational Medicine, Tianjin Union Medical Center of Nankai University, Tianjin, China
- *Correspondence: Siwei Zhu, ; Xipeng Zhang,
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Read M, Felder S. Transanal Approaches to Rectal Neoplasia. SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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10
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Post-Operative Functional Outcomes in Early Age Onset Rectal Cancer. Front Oncol 2022; 12:868359. [PMID: 35707361 PMCID: PMC9190512 DOI: 10.3389/fonc.2022.868359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/18/2022] [Indexed: 12/17/2022] Open
Abstract
Background Impairment of bowel, urogenital and fertility-related function in patients treated for rectal cancer is common. While the rate of rectal cancer in the young (<50 years) is rising, there is little data on functional outcomes in this group. Methods The REACCT international collaborative database was reviewed and data on eligible patients analysed. Inclusion criteria comprised patients with a histologically confirmed rectal cancer, <50 years of age at time of diagnosis and with documented follow-up including functional outcomes. Results A total of 1428 (n=1428) patients met the eligibility criteria and were included in the final analysis. Metastatic disease was present at diagnosis in 13%. Of these, 40% received neoadjuvant therapy and 50% adjuvant chemotherapy. The incidence of post-operative major morbidity was 10%. A defunctioning stoma was placed for 621 patients (43%); 534 of these proceeded to elective restoration of bowel continuity. The median follow-up time was 42 months. Of this cohort, a total of 415 (29%) reported persistent impairment of functional outcomes, the most frequent of which was bowel dysfunction (16%), followed by bladder dysfunction (7%), sexual dysfunction (4.5%) and infertility (1%). Conclusion A substantial proportion of patients with early-onset rectal cancer who undergo surgery report persistent impairment of functional status. Patients should be involved in the discussion regarding their treatment options and potential impact on quality of life. Functional outcomes should be routinely recorded as part of follow up alongside oncological parameters.
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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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12
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Perez RO, Julião GPS, Vailati BB. Transanal Local Excision of Rectal Cancer after Neoadjuvant Chemoradiation: Is There a Place for It or Should Be Avoided at All Costs? Clin Colon Rectal Surg 2022; 35:122-128. [PMID: 35237107 PMCID: PMC8885162 DOI: 10.1055/s-0041-1742112] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Tumor response to neoadjuvant chemoradiation (nCRT) with tumor downsizing and downstaging has significantly impacted the number of patients considered to be appropriate candidates for transanal local excision (TLE). Some patients may harbor small residual lesions, restricted to the bowel wall. These patients, who exhibit major response ("near-complete") by digital rectal examination, endoscopic assessment, and radiological assessment may be considered for this approach. Although TLE is associated with minimal postoperative morbidity, a few clinical consequences and oncological outcomes must be evaluated in advance and with caution. In the setting of nCRT, a higher risk for clinically relevant wound dehiscences leading to a considerable risk for readmission for pain management has been observed. Worse anorectal function (still better than after total mesorectal excision [TME]), worsening in the quality of TME specimen, and higher rates of abdominal resections (in cases requiring completion TME) have been reported. The exuberant scar observed in the area of TLE also represents a challenging finding during follow-up of these patients. Local excision should be probably restricted for patients with primary tumors located at or below the level of the anorectal ring (magnetic resonance defined). These patients are otherwise candidates for abdominal perineal resections or ultra-low anterior resections with coloanal anastomosis frequently requiring definitive stomas or considerably poor anorectal function.
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Affiliation(s)
- Rodrigo Oliva Perez
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil,Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil,Address for correspondence Rodrigo Oliva Perez, MD, PhD Department of Surgical Oncology, Hospital Beneficencia PortuguesaSão Paulo 01323-001Brazil
| | - Guilherme Pagin São Julião
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil,Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Bruna Borba Vailati
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil,Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
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Wlodarczyk JR, Lee SW. New Frontiers in Management of Early and Advanced Rectal Cancer. Cancers (Basel) 2022; 14:938. [PMID: 35205685 PMCID: PMC8870151 DOI: 10.3390/cancers14040938] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 01/29/2022] [Accepted: 02/08/2022] [Indexed: 02/04/2023] Open
Abstract
It is important to understand advances in treatment options for rectal cancer. We attempt to highlight advances in rectal cancer treatment in the form of a systematic review. Early-stage rectal cancer focuses on minimally invasive endoluminal surgery, with importance placed on patient selection as the driving factor for improved outcomes. To achieve a complete pathologic response, various neoadjuvant chemoradiation regimens have been employed. Short-course radiation therapy, total neoadjuvant chemotherapy, and others provide unique advantages with select patient populations best suited for each. With a clinical complete response, a "watch and wait" non-operative surveillance has been introduced with preliminary equivalency to radical resection. Various modalities for total mesorectal excision, such as robotic or transanal, have advantages and can be utilized in select patient populations. Tumors demonstrating solid organ or peritoneal spread, traditionally defined as unresectable lesions conveying a terminal diagnosis, have recently undergone advances in hepatic and pulmonary metastasectomy. Hepatic and pulmonary metastasectomy has demonstrated clear advantages in 5-year survival over standard chemotherapy. With the peritoneal spread of colorectal cancer, HIPEC with cytoreductive therapy has emerged as the preferred treatment. Understanding the various therapeutic interventions will pave the way for improved patient outcomes.
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Affiliation(s)
| | - Sang W. Lee
- Division of Colorectal Surgery, Norris Cancer Center, Keck School of Medicine, University of Southern California, 1441 Eastlake Avenue, Suite NTT-7418, Los Angeles, CA 90033, USA;
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Son GM, Lee IY, Cho SH, Park BS, Kim HS, Park SB, Kim HW, Oh SB, Kim TU, Shin DH. Multidisciplinary treatment strategy for early rectal cancer A review. PRECISION AND FUTURE MEDICINE 2021. [DOI: 10.23838/pfm.2021.00163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2022] Open
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15
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Zhou H, Qiao XF, Chen X. Stromal composition predicts relapse of early rectal cancer after local resection: several methodological concerns. Histopathology 2021; 80:609-610. [PMID: 34496072 DOI: 10.1111/his.14561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Hong Zhou
- Department of General Surgery, The First Affiliated Hospital of University of Science and Technology of China, Hefei, People's Republic of China
| | - Xiao-Fei Qiao
- Department of General Surgery, The First Affiliated Hospital of University of Science and Technology of China, Hefei, People's Republic of China
| | - Xia Chen
- Department of General Surgery, The First Affiliated Hospital of University of Science and Technology of China, Hefei, People's Republic of China
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16
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Wang Y, Zhang Y, Lin H, Xu M, Zhou X, Zhuang J, Yang Y, Chen B, Liu X, Guan G. Risk factors for lymph node metastasis in rectal neuroendocrine tumors: A recursive partitioning analysis based on multicenter data. J Surg Oncol 2021; 124:1098-1105. [PMID: 34291822 DOI: 10.1002/jso.26615] [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: 04/15/2021] [Revised: 05/22/2021] [Accepted: 07/11/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND The well-differentiated rectal neuroendocrine tumors (RNETs) can also have lymph node metastasis (LNM). Large multicenter data were reviewed to explore the risk factors for LNM in RNETs. Further, we developed a model to predict the risk of LNM in RNETs. METHODS In total, 223 patients with RNETs from the Fujian Medical University Union Hospital, the First Affiliated Hospital of Fujian Medical University, and the First Affiliated Hospital of Xiamen University were retrospectively enrolled. Logistic regression analysis was performed to study the factors affecting LNM, and recursive partitioning analysis (RPA) was performed to stratify the risk of LNM. RESULTS Among the 223 patients diagnosed with RNETs, the incidence of LNM was 10.8%. Univariate and multivariate regression analyses revealed that tumor size, World Health Organization (WHO) grade, and depth of tumor invasion were independent risk factors for LNM (p < 0.05). The area under the curve was 0.948 (95% confidence interval: 0.890-1.000). Furthermore, the incidence of LNM in patients divided into low- and high-risk groups according to RPA was 1.1% and 56.4%, respectively. CONCLUSION Compared with tumor size, the depth of tumor invasion and WHO grade are more important factors in predicting LNM. Then, we developed a model based on RPA to predict the risk of LNM in RNETs and identify patients who are suitable for local resection.
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Affiliation(s)
- Ye Wang
- Department of Colorectal Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Yiyi Zhang
- Department of Colorectal Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Hexin Lin
- Department of Colorectal Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Meifang Xu
- Department of Pathology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Xin Zhou
- Departments of Colorectal Cancer Surgery, The First Affiliated Hospital of Xiamen University, Teaching Hospital of Fujian Medical University, Xiamen, China
| | - Jinfu Zhuang
- Department of Colorectal Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Yuanfeng Yang
- Department of Colorectal Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Bin Chen
- Department of Colorectal Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Xing Liu
- Department of Colorectal Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Guoxian Guan
- Department of Colorectal Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China
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Lai IL, You JF, Chern YJ, Tsai WS, Chiang JM, Hsieh PS, Hung HY, Hsu YJ. The risk factors of local recurrence and distant metastasis on pT1/T2N0 mid-low rectal cancer after total mesorectal excision. World J Surg Oncol 2021; 19:116. [PMID: 33849564 PMCID: PMC8045195 DOI: 10.1186/s12957-021-02223-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 04/01/2021] [Indexed: 01/04/2023] Open
Abstract
Background Radical resection is associated with good prognosis among patients with cT1/T2Nx rectal cancer. However, still some of the patients experienced cancer recurrence following radical resection. This study tried to identify the postoperative risk factors of local recurrence and distant metastasis separately. Methods This retrospective, single-center study comprised of 279 consecutive patients from Linkou branch of Chang Gung Memorial Hospital in 2005–2016 with rectal adenocarcinoma, pT1/T2N0M0 at distance from anal verge ≤ 8cm, who received curative radical resection. Results The study included 279 patients with pT1/pT2N0 mid-low rectal cancer with median follow-up of 73.5 months. Nineteen (6.8%) patients had disease recurrence in total. Nine (3.2%) of them had local recurrence, and fourteen (5.0%) of them had distant metastasis. Distal resection margin < 0.9 (cm) (hazard ratio = 4.9, p = 0.050) was the risk factor of local recurrence. Preoperative carcinoembryonic antigen (CEA) ≥ 5 ng/mL (hazard ratio = 9.3, p = 0.0003), lymph node yield (LNY) < 14 (hazard ratio = 5.0, p = 0.006), and distal resection margin < 1.4cm (hazard ratio = 4.0, p = 0.035) were the risk factors of distant metastasis. Conclusion For patients with pT1/pT2N0 mid-low rectal cancer, current multidisciplinary treatment brings acceptable survival outcome. Insufficient distal resection margin attracted the awareness of risk factors for local recurrence and distant metastasis as a foundation for future research. Supplementary Information The online version contains supplementary material available at 10.1186/s12957-021-02223-4.
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Affiliation(s)
- I-Li Lai
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Linkou, No.5, Fu-Hsing Street, Guei-Shan, Tao-Yuan, Taiwan
| | - Jeng-Fu You
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Linkou, No.5, Fu-Hsing Street, Guei-Shan, Tao-Yuan, Taiwan
| | - Yih-Jong Chern
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Linkou, No.5, Fu-Hsing Street, Guei-Shan, Tao-Yuan, Taiwan
| | - Wen-Sy Tsai
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Linkou, No.5, Fu-Hsing Street, Guei-Shan, Tao-Yuan, Taiwan
| | - Jy-Ming Chiang
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Linkou, No.5, Fu-Hsing Street, Guei-Shan, Tao-Yuan, Taiwan
| | - Pao-Shiu Hsieh
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Linkou, No.5, Fu-Hsing Street, Guei-Shan, Tao-Yuan, Taiwan
| | - Hsin-Yuan Hung
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Linkou, No.5, Fu-Hsing Street, Guei-Shan, Tao-Yuan, Taiwan
| | - Yu-Jen Hsu
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Linkou, No.5, Fu-Hsing Street, Guei-Shan, Tao-Yuan, Taiwan.
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18
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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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Atallah C, Taylor JP, Lo BD, Stem M, Brocke T, Efron JE, Safar B. Local excision for T1 rectal tumours: are we getting better? Colorectal Dis 2020; 22:2038-2048. [PMID: 32886836 DOI: 10.1111/codi.15344] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 08/17/2020] [Indexed: 12/13/2022]
Abstract
AIM The objective was to assess the effect of three different surgical treatments for T1 rectal tumours, radical resection (RR), open local excision (open LE) and laparoscopic local excision (laparoscopic LE), on overall survival (OS). METHODS Adults from the National Cancer Database (2008-2016) with a diagnosis of T1 rectal cancer were stratified by treatment type (LE vs RR). We assumed that laparoscopic LE equates to transanal minimally invasive surgery (TAMIS) or transanal endoscopic microsurgery. The primary outcome was 5-year OS. Subgroup analyses of the LE group stratified by time period [2008-2010 (before TAMIS) vs 2011-2016 (after TAMIS)] and approach (laparoscopic vs open) were performed. RESULTS Among 10 053 patients, 6623 (65.88%) underwent LE (74.33% laparoscopic LE vs 25.67% open LE) and 3430 (34.12%) RR. The use of LE increased from 52.69% in 2008 to 69.47% in 2016, whereas RR decreased (P < 0.001). In unadjusted analysis, there was no significant difference in 5-year OS between the LE and RR groups (P = 0.639) and between the two LE time periods (P = 0.509), which was consistent with the adjusted analysis (LE vs RR, hazard ratio 1.05, 95% CI 0.92-1.20, P = 0.468; 2008-2010 LE vs 2011-2016 LE, hazard ratio 1.09, 95% CI 0.92-1.29, P = 0.321). Laparoscopic LE was associated with improved OS in the unadjusted analysis only (P = 0.006), compared to the open LE group (hazard ratio 0.94, 95% CI 0.78-1.12, P = 0.495). CONCLUSIONS This study supports the use of a LE approach for T1 rectal tumours as a strategy to reduce surgical morbidity without compromising survival.
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Affiliation(s)
- C Atallah
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - J P Taylor
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - B D Lo
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - M Stem
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - T Brocke
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - J E Efron
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - B Safar
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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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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Jones HJ, Al-Najami I, Cunningham C. Quality of life after rectal-preserving treatment of rectal cancer. Eur J Surg Oncol 2020; 46:2050-2056. [DOI: 10.1016/j.ejso.2020.07.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/25/2020] [Accepted: 07/15/2020] [Indexed: 12/21/2022] Open
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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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23
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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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24
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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Rectal Cancer. Dis Colon Rectum 2020; 63:1191-1222. [PMID: 33216491 DOI: 10.1097/dcr.0000000000001762] [Citation(s) in RCA: 152] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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26
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Primary local excision of stage 1 rectal cancer is not associated with worse oncological outcomes when compared with major resection. Int J Colorectal Dis 2020; 35:607-614. [PMID: 31974752 DOI: 10.1007/s00384-020-03512-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Primary local excision (PLE) for early rectal cancers is associated with decreased surgical morbidity and mortality compared with major resection (MR). However, it is thought to be associated with poorer oncological outcomes. There is a paucity of data regarding PLE within the Australasian population. We present comparative post-operative and survival outcomes for stage 1 rectal cancers treated with PLE or MR from three Western Australian hospitals. METHODS A retrospective analysis was performed on a prospectively maintained database of patients undergoing PLE or MR for stage 1 rectal cancers between February 1996 and May 2019. RESULTS Of the 533 patients, 81 underwent PLE. Median post-operative admission was shorter for those undergoing PLE, with no significant difference in post-operative complication rate. Five-year overall survival was greater following MR (89.6% CI 86.1-92.3) compared with PLE (84.6% CI 73.8-91.2; p = 0.0003). There was no significant difference in 5-year cancer-specific survival (MR, 94.4% CI 91.5-96.3; PLE, 95.3% CI 86.0-98.5; p = 0.98) or 5-year disease-free survival (MR, 92.3% CI 89.1-94.7; PLE, 89.1% CI 78.5-94.7; p = 0.36). Local excision provided poorer local tumour control with an inferior 5-year local recurrence rate (MR, 2.16% CI 1.08-4.28; PLE, 10.9% CI 5.30-21.6; p = 0.0002). After controlling for confounders, PLE was significantly associated with worse local recurrence but did not significantly impact overall survival, cancer-specific survival, overall recurrence, or metastatic recurrence. CONCLUSION Local excision of early rectal cancer remains a viable alternative, in those unwilling or unable to undergo MR. Patients should be informed that while PLE is associated with poorer local pelvic control, this does not translate to worse survival.
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Mason S, Manoli E, Poynter L, Alexander J, Paizs P, Adebesin A, Goldin R, Darzi A, Takats Z, Kinross J. Mass spectrometry transanal minimally invasive surgery (MS-TAMIS) to promote organ preservation in rectal cancer. Surg Endosc 2019; 34:3618-3625. [PMID: 31617102 PMCID: PMC7326832 DOI: 10.1007/s00464-019-07140-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 09/19/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Transanal minimally invasive surgery (TAMIS) is deployed for organ preservation in early rectal cancer and significant rectal polyps. Rapid evaporative ionisation mass spectrometry (REIMS) provides biochemical tissue analysis, which could be applied intraoperatively to give real-time tissue feedback to the surgeon and decrease the risk of an involved margin. However, the accuracy and feasibility of this approach have not been established. METHODS In this prospective observational study, patients undergoing resection of rectal adenomas or carcinomas were recruited. An electrosurgical handpiece analysed tissues ex vivo using diathermy, with the aerosol aspirated into a Xevo G2-S ToF mass spectrometer. The relative abundance of lipids underwent predictive statistical modelling and leave-one-patient-out cross-validation. The outcomes of interest were the ability of REIMS to differentiate normal, adenomatous and cancerous tissue, or any disease subtype from normal. REIMS was coupled with TAMIS for in vivo sampling, assessing the accuracy of tissue recognition and distinguishing bowel wall layers. RESULTS Forty-seven patients were included, yielding 266 spectra (121 normal, 109 tumour and 36 adenoma). REIMS differentiates normal, adenomatous and cancerous rectal tissues with 86.8% accuracy, and normal and adenomatous tissue with 92.4% accuracy and 91.4% accuracy when differentiating disease from normal. We have performed the first five in-man mass spectrometry augmented TAMIS (MS-TAMIS). In real time, MS-TAMIS can differentiate rectal mucosa and submucosa based on their relative abundance of triglycerides and glycerophospholipids. The ex vivo accuracy distinguishing diseased and normal tissues is maintained in vivo at 90%, with negative predictive value of 95%. The system identified a deep and lateral involved tumour margin during TAMIS. CONCLUSIONS REIMS distinguishes rectal tissue types based on underlying lipid biology, and this can be translated in vivo by coupling it to TAMIS. There is a role for this technology in improving the efficacy of resection of early rectal cancers.
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Affiliation(s)
- Sam Mason
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, 10th Floor QEQM Building, Paddington, London, W2 1NY, UK.
| | - Eftychios Manoli
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, 10th Floor QEQM Building, Paddington, London, W2 1NY, UK
| | - Liam Poynter
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, 10th Floor QEQM Building, Paddington, London, W2 1NY, UK
| | - James Alexander
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, 10th Floor QEQM Building, Paddington, London, W2 1NY, UK
| | - Petra Paizs
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, 10th Floor QEQM Building, Paddington, London, W2 1NY, UK
| | - Afeez Adebesin
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, 10th Floor QEQM Building, Paddington, London, W2 1NY, UK
| | - Robert Goldin
- Department of Histopathology, Imperial College London, South Kensington, UK
| | - Ara Darzi
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, 10th Floor QEQM Building, Paddington, London, W2 1NY, UK
| | - Zoltan Takats
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, 10th Floor QEQM Building, Paddington, London, W2 1NY, UK
| | - James Kinross
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, 10th Floor QEQM Building, Paddington, London, W2 1NY, UK
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28
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Lawson EH, Melvin JC, Geltzeiler CB, Heise CP, Foley EF, King RS, Harms BA, Carchman EH. Advances in the management of rectal cancer. Curr Probl Surg 2019; 56:100648. [PMID: 31779779 DOI: 10.1016/j.cpsurg.2019.100648] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 07/01/2019] [Indexed: 01/05/2023]
Affiliation(s)
| | | | - Cristina B Geltzeiler
- University of Wisconsin-Madison, Madison, WI; University of Wisconsin-Madison, William S. Middleton Memorial Veterans Hospital, Madison, WI
| | | | | | - Ray S King
- University of Wisconsin-Madison, Madison, WI
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