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Ota E, Nagasaki T, Akiyoshi T, Mukai T, Hiyoshi Y, Yamaguchi T, Fukunaga Y. Incidence and risk factors of bowel dysfunction after minimally invasive rectal cancer surgery and discrepancies between the Wexner score and the low anterior resection syndrome (LARS) score. Surg Today 2024:10.1007/s00595-023-02789-4. [PMID: 38170223 DOI: 10.1007/s00595-023-02789-4] [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: 09/13/2023] [Accepted: 11/14/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE Bowel dysfunction after sphincter-preserving-surgery (SPS) impacts quality of life. The Wexner score (WS) and the low anterior resection syndrome (LARS) score (LS) are instruments for assessing postoperative bowel dysfunction. We analyzed the incidence of and risk factors for each symptom and examined the discrepancies between the two scores. METHODS A total of 142 patients with rectal cancer, who underwent minimally invasive SPS between May, 2018 and July, 2019, were included. A questionnaire survey using the two scores was given to the patients 2 years after SPS. RESULTS Tumor location and preoperative radiotherapy were independent risk factors for major LARS. Intersphincteric resection with a hand-sewn anastomosis (HSA) was an independent risk factor for high WS. Among the patients who underwent HSA, 82% experienced incontinence for liquid stools, needed to wear pads, and suffered lifestyle alterations. Of the 35 patients with minor LARS, only 1 had a high WS, and 80.0% reported no lifestyle alterations. Among the 75 patients with major LARS, 58.7% had a low WS and 21.3% reported no lifestyle alterations. CONCLUSION The results of this study provide practical data to help patients understand potential bowel dysfunction after SPS. The discrepancies between the WS and LS were clarified, and further efforts are required to utilize these scores in clinical practice.
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Affiliation(s)
- Emi Ota
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Toshiya Nagasaki
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
| | - Takashi Akiyoshi
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Toshiki Mukai
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yukiharu Hiyoshi
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Tomohiro Yamaguchi
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yosuke Fukunaga
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
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Miura T, Morohashi H, Sakamoto Y, Kagiya T, Hasebe T, Nakayama Y, Fujita H, Hakamada K. Neoadjuvant S-1 and oxaliplatin plus bevacizumab therapy for high-risk locally advanced rectal cancer: A prospective multicenter phase II study. Ann Gastroenterol Surg 2024; 8:71-79. [PMID: 38250676 PMCID: PMC10797815 DOI: 10.1002/ags3.12720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 06/05/2023] [Accepted: 07/06/2023] [Indexed: 01/23/2024] Open
Abstract
Aim We report the short/mid-term results of surgery for high-risk locally advanced rectal cancer (LARC) after neoadjuvant chemotherapy (NAC, four courses of S-1 + oxaliplatin+ bevacizumab) without radiotherapy with the primary aim of ypT0-2. Methods High-risk LARC was defined as cT4b, mesorectal fascia (MRF) ≤1 mm (MRF+), or lateral lymph node metastasis (cLLN+) on high-resolution MRI. The planned 32 cases from April 2018 to December 2021 were all included. Results There were 10 patients at cT4b (31.2%), 26 MRF+ (81.3%), and 22 cLLN+ (68.8%). Thirteen (40.6%) underwent NAC after a colostomy for stenosis. NAC was completed in 26 (81.2%) cases. Grade 3 or higher adverse events occurred in six (18.7%). One patient developed progressive disease (3.2%). Eleven were ycT0-3MRF-LLN- (34.3%). Curative-intent surgery was performed on 31, with sphincter-preserving surgery in 20, abdominoperineal resection in nine, total pelvic exenteration in two, and lateral lymph node dissection in 24. Two had R1/2 resection (6.4%). A Grade 3 or higher postoperative complication rate occurred in 3.2%. Pathological complete response and ypT0-2 rates were 12.9% and 45.1%. Three-year disease-free survival rates (3yDFS) for ypT0-2 and ypT ≥3 were 81.2%, 46.6% (p = 0.061), and 3-year local recurrence rates (3yLR) were 0%, 48.8% (p = 0.015). 3yDFS for ycT0-3MRF-LLN- and ycT4/MRF+/LLN+ were 87.5%, 48.0% (p = 0.031) and 3yLR were 0%, 42.8% (p = 0.045). Conclusion NAC yielded a clinically significant effect in about half of high-risk LARC patients. If NAC alone is ineffective, radiotherapy should be added, even if extended surgery is intended.
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Affiliation(s)
- Takuya Miura
- Department of Gastroenterological SurgeryHirosaki University Graduate School of MedicineHirosakiJapan
| | - Hajime Morohashi
- Department of Gastroenterological SurgeryHirosaki University Graduate School of MedicineHirosakiJapan
| | - Yoshiyuki Sakamoto
- Department of Gastroenterological SurgeryHirosaki University Graduate School of MedicineHirosakiJapan
| | - Takuji Kagiya
- Department of Gastroenterological SurgeryHirosaki University Graduate School of MedicineHirosakiJapan
| | - Tatsuya Hasebe
- Department of SurgeryOdate Municipal General HospitalOdateJapan
| | | | - Hiromasa Fujita
- Department of RadiologyHirosaki University Graduate School of MedicineHirosakiJapan
| | - Kenichi Hakamada
- Department of Gastroenterological SurgeryHirosaki University Graduate School of MedicineHirosakiJapan
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Kubota S, Miura T, Hakamada K. ASO Author Reflections: One Step Closer to a Strong Definition of the Malignant Characteristics of Neoadjuvant Therapy-Resistant Rectal Cancer. Ann Surg Oncol 2023; 30:7635-7636. [PMID: 37543549 DOI: 10.1245/s10434-023-14055-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 07/18/2023] [Indexed: 08/07/2023]
Affiliation(s)
- Shunsuke Kubota
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Takuya Miura
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Kenichi Hakamada
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan.
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Kubota S, Miura T, Wakiya T, Yoshizawa T, Goto S, Morohashi H, Sakamoto Y, Tatara Y, Kijima H, Hakamada K. Exploration of Malignant Characteristics in Neoadjuvant Chemotherapy-Resistant Rectal Cancer, Focusing on Extramural Lesions. Ann Surg Oncol 2023; 30:7612-7623. [PMID: 37548833 PMCID: PMC10562322 DOI: 10.1245/s10434-023-13928-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 06/28/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Extramural vascular invasion (EMVI) and tumor deposits (TD) are poor prognostic factors in rectal cancer (RC), especially when resistant to neoadjuvant chemotherapy (NAC). We aimed to define differential expression in NAC responders and non-responders with concomitant EMVI and TD. METHODS From 52 RC surgical patients, post-NAC resected specimens were extracted, comprising two groups: cases with residual EMVI and TD (NAC-resistant) and cases without (NAC-effective). Proteomic analysis was conducted to define differential protein expression in the two groups. To validate the findings, immunohistochemistry was performed in another cohort that included 58 RC surgical patients. Based on the findings, chemosensitivity and prognosis were compared. RESULTS The NAC-resistant group was associated with a lower 3-year disease-free survival rate than the NAC-effective group (p = 0.041). Discriminative proteins in the NAC-resistant group were highly associated with the sulfur metabolism pathway. Among these pathway constituents, selenium-binding protein 1 (SELENBP1) expression in the NAC-resistant group decreased to less than one-third of that of the NAC-effective group. Immunohistochemistry in another RC cohort consistently validated the relationship between decreased SELENBP1 and poorer NAC sensitivity, in both pre-NAC biopsy and post-NAC surgery specimens. Furthermore, decrease in SELENBP1 was associated with a lower 3-year disease-free survival rate (p = 0.047). CONCLUSIONS We defined one of the differentially expressed proteins in NAC responders and non-responders, concomitant with EMVI and TD. SELENBP1 was suspected to contribute to NAC resistance and poor prognosis in RC.
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Affiliation(s)
- Shunsuke Kubota
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Takuya Miura
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Taiichi Wakiya
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Tadashi Yoshizawa
- Department of Pathology and Bioscience, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Shintaro Goto
- Department of Pathology and Bioscience, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Hajime Morohashi
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Yoshiyuki Sakamoto
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Yota Tatara
- Department of Stress Response Science, Center for Advanced Medical Research, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Hiroshi Kijima
- Department of Pathology and Bioscience, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Kenichi Hakamada
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan.
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Yamaguchi T, Akiyoshi T, Fukunaga Y, Sakamoto T, Mukai T, Hiyoshi Y, Nagasaki T, Taguchi S, Chino A, Shinozaki E, Yamaguchi K, Konishi T. Adding Induction Chemotherapy Before Chemoradiotherapy with Total Mesorectal Excision and Selective Lateral Lymph Node Dissection for Patients with Poor-Risk, Locally Advanced, Mid-to-Low Rectal Cancer May Improve Oncologic Outcomes: A Propensity Score-Matched Analysis. Ann Surg Oncol 2023; 30:4716-4724. [PMID: 37032405 DOI: 10.1245/s10434-023-13458-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 03/08/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND This study aimed to investigate whether the addition of induction chemotherapy before chemoradiotherapy (CRT) and total mesorectal excision (TME) with selective lateral lymph node dissection improves disease-free survival for patients with poor-risk, mid-to-low rectal cancer. METHODS The authors' institutional prospective database was queried for consecutive patients with clinical stage II or III, primary, poor-risk, mid-to-low rectal cancer who received neoadjuvant treatment followed by TME from 2004 to 2019. The outcomes for the patients who received induction chemotherapy before neoadjuvant CRT (induction-CRT group) were compared (via log-rank tests) with those for a propensity score-matched cohort of patients who received neoadjuvant CRT without induction chemotherapy (CRT group). RESULTS From 715 eligible patients, the study selected two matched cohorts with 130 patients each. The median follow-up duration was 5.4 years for the CRT group and 4.1 years for the induction-CRT group. The induction-CRT group had significantly higher rates of 3-year disease-free survival (83.5 % vs 71.4 %; p = 0.015), distant metastasis-free survival (84.3 % vs 75.2 %; p = 0.049), and local recurrence-free survival (98.4 % vs 94.4 %; p = 0.048) than the CRT group. The pathologically complete response rate also was higher in the induction-CRT group than in the CRT group (26.2 % vs 10.0 %; p < 0.001). Postoperative major complications (Clavien-Dindo classification ≥III) did not differ significantly between the two groups (12.3 % vs 10.8 %; p = 0.698). CONCLUSIONS The addition of induction chemotherapy to neoadjuvant CRT appeared to improve oncologic outcomes significantly, including disease-free survival, for the patients with poor-risk, mid-to-low rectal cancer who underwent TME using selective lateral lymph node dissection.
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Affiliation(s)
- Tomohiro Yamaguchi
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Takashi Akiyoshi
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yosuke Fukunaga
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takashi Sakamoto
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Toshiki Mukai
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yukiharu Hiyoshi
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Toshiya Nagasaki
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Senzo Taguchi
- Department of Radiation Oncology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Akiko Chino
- Department of Gastroenterology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Eiji Shinozaki
- Department of Gastroenterological Chemotherapy, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Kensei Yamaguchi
- Department of Gastroenterological Chemotherapy, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tsuyoshi Konishi
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
- Department of Colon and Rectal Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
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Amano T, Akiyoshi T, Furuta M, Saino Y, Mukai T, Hiyoshi Y, Nagasaki T, Yamaguchi T, Kawachi H, Fukunaga Y. Geriatric nutritional risk index after neoadjuvant chemoradiotherapy and survival in older patients with advanced rectal cancer. Int J Colorectal Dis 2023; 38:119. [PMID: 37157019 DOI: 10.1007/s00384-023-04425-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/01/2023] [Indexed: 05/10/2023]
Abstract
PURPOSE To investigate the clinical impact of malnutrition on the survival of older patients with advanced rectal cancer who underwent neoadjuvant chemoradiotherapy. METHODS We investigated the clinical significance of the geriatric nutritional risk index (GNRI) in 237 patients aged over 60 years with clinical stage II/III rectal adenocarcinoma who were treated with neoadjuvant long-course chemoradiotherapy or total neoadjuvant therapy followed by radical resection from 2004 to 2017. Pre-treatment and post-treatment GNRI were evaluated, with patients split into low (< 98) and high (≥ 98) GNRI groups. The prognostic impact of pre-treatment and post-treatment GNRI levels on overall survival (OS), post-recurrence survival (PRS), and disease-free survival (DFS) was evaluated using univariate and multivariate analyses. RESULTS Fifty-seven patients (24.1%) before neoadjuvant treatment and 94 patients (39.7%) after neoadjuvant treatment were categorized with low GNRI. Pre-treatment GNRI levels were not associated with OS (p = 0.80) or DFS (p = 0.70). Patients in the post-treatment low GNRI group had significantly poorer OS than those in the post-treatment high GNRI group (p = 0.0005). The multivariate analysis showed that post-treatment low GNRI levels were independently associated with poorer OS (hazard ratio, 3.06; 95% confidence interval, 1.55-6.05; p = 0.001). Although post-treatment GNRI levels were not associated with DFS (p = 0.24), among the 50 patients with recurrence, post-treatment low GNRI levels were associated with poorer PRS (p = 0.02). CONCLUSION Post-treatment GNRI is a promising nutritional score associated with OS and PRS in patients over 60 years with advanced rectal cancer treated with neoadjuvant chemoradiotherapy.
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Affiliation(s)
- Takahiro Amano
- Department of Colorectal Surgery, Gastroenterology Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Takashi Akiyoshi
- Department of Colorectal Surgery, Gastroenterology Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
| | - Momoko Furuta
- Department of Clinical Nutrition, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yoko Saino
- Department of Clinical Nutrition, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Toshiki Mukai
- Department of Colorectal Surgery, Gastroenterology Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yukiharu Hiyoshi
- Department of Colorectal Surgery, Gastroenterology Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Toshiya Nagasaki
- Department of Colorectal Surgery, Gastroenterology Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Tomohiro Yamaguchi
- Department of Colorectal Surgery, Gastroenterology Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Hiroshi Kawachi
- Division of Pathology, Cancer Institute, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yosuke Fukunaga
- Department of Colorectal Surgery, Gastroenterology Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
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Beppu N, Ikeda M, Kataoka K, Kimura K, Ikeuchi H, Uchino M, Nakamoto Y, Okamoto R, Yanagi H. Total Neoadjuvant Chemotherapy in Rectal Cancer: Current Facts and Future Strategies. J Anus Rectum Colon 2023; 7:1-7. [PMID: 36743465 PMCID: PMC9876605 DOI: 10.23922/jarc.2022-060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 10/22/2022] [Indexed: 01/25/2023] Open
Abstract
Despite preoperative chemoradiotherapy (CRT) and total mesorectal excision improving the local control for locally advanced rectal cancer (LARC), oncologic outcomes and survival were not significantly improved because the main prognostic factor is distant metastasis. Thus, total neoadjuvant chemotherapy (TNT) as a novel approach has been proposed to improve chemotolerance. Since the first randomized phase II trial of TNT versus standard CRT demonstrated in 2012, many prospective and retrospective studies have been published. The initial consensus from TNT studies was that pathological complete response, pathological response of the main tumor, and local control are more favorable at TNT than at CRT. Furthermore, recent studies such as the PAPIDO trial and PRODIGE 23 trial made a major breakthrough of the treatment of TNT, showing that TNT improves the disease-free survival compared to standard treatment with long-course CRT. In addition, several innovative findings of TNT were clarified by prospective phase II trial. In this review, we summarize the most recent advances in TNT based on the findings of pivotal clinical trials for patients with LARC.
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Affiliation(s)
- Naohito Beppu
- Division of Lower G.I., Department of Gastroenterological Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Masataka Ikeda
- Division of Lower G.I., Department of Gastroenterological Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kozo Kataoka
- Division of Lower G.I., Department of Gastroenterological Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kei Kimura
- Division of Lower G.I., Department of Gastroenterological Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hiroki Ikeuchi
- Division of Inflammatory Bowel Disease Surgery, Department of Gastroenterological Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Motoi Uchino
- Division of Inflammatory Bowel Disease Surgery, Department of Gastroenterological Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | | | - Ryou Okamoto
- Department of Surgery, Meiwa Hospital, Nishinomiya, Japan
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Yoo GS, Park HC, Yu JI. Clinical implication and management of rectal cancer with clinically suspicious lateral pelvic lymph node metastasis: A radiation oncologist's perspective. Front Oncol 2022; 12:960527. [PMID: 36568216 PMCID: PMC9768025 DOI: 10.3389/fonc.2022.960527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 10/31/2022] [Indexed: 12/12/2022] Open
Abstract
Rectal cancer is the eighth most common malignancy worldwide. With the introduction of total mesorectal excision (TME) and neoadjuvant chemoradiation (NCRT), intrapelvic local control has been remarkably improved. However, lateral pelvic recurrence remains problematic, especially in patients with clinically suspicious lateral pelvic lymph node (LPLN). LPLN dissection has been applied for the management of LPLN metastasis, mainly in Japan and other Eastern countries, while the role of NCRT is more emphasized and LPLN dissection is performed in very limited cases in Western countries. However, the optimal management strategy for patients with rectal cancer with suspicious LPLN metastasis has not been determined. Herein, we review the latest studies on the optimal management of LPLN metastasis to suggest the most appropriate treatment policies according to current evidence and discuss future research directions.
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Affiliation(s)
| | | | - Jeong Il Yu
- *Correspondence: Jeong Il Yu, ; Hee Chul Park,
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9
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The evaluation of postoperative bowel dysfunction in Japanese patients with rectal cancer. Surg Today 2022; 53:596-604. [PMID: 36197503 DOI: 10.1007/s00595-022-02598-1] [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: 05/30/2022] [Accepted: 09/13/2022] [Indexed: 10/10/2022]
Abstract
PURPOSE The present study assessed postoperative bowel dysfunction in Japanese patients with rectal cancer, including patients who underwent preoperative radiotherapy (RT). METHODS A total of 277 rectal cancer patients who underwent primary resection were included in the analyses. A questionnaire survey was administered using the low anterior resection syndrome (LARS) score and Wexner score. Scores were determined one year after rectal surgery or diverting ileostomy closure. The LARS score was categorized as minor LARS (21-29) and major LARS (30-42). RESULTS The proportions of patients with minor and major LARS were significantly larger and Wexner scores significantly higher in patients with distal tumors and a lower anastomosis level than in those with proximal tumors and a higher anastomosis level. Among the patients with lower rectal cancer, the proportions with minor and major LARS were similar between those with and without preoperative RT. The Wexner scores in patients with preoperative RT were significantly higher than in patients without RT. A distal tumor location and lower anastomosis level were independent risk factors of major LARS in multivariate analyses. CONCLUSION A distal tumor location, low anastomosis level, and preoperative RT might be associated with postoperative bowel dysfunction in rectal cancer patients.
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10
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Sakamoto K, Okabayashi K, Matsui S, Seishima R, Shigeta K, Kitagawa Y. Association of Tumor Pathological Response with the Use of Metformin During Neoadjuvant Chemoradiotherapy in Rectal and Esophageal/Gastroesophageal Cancer Patients: a Systematic Review and Meta-analysis. J Gastrointest Surg 2022; 26:2227-2236. [PMID: 35829868 DOI: 10.1007/s11605-022-05354-5] [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: 02/28/2022] [Accepted: 04/30/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE Metformin has been reported to be associated with improved cancer prognosis when used in combination with chemotherapy and/or radiotherapy. In this study, we present a systematic review and meta-analyses of studies evaluating the association of tumor pathological response with the use of metformin during neoadjuvant chemoradiotherapy (NACRT) in rectal and esophageal/gastroesophageal cancer patients. METHODS We systematically searched databases for articles that compared concurrent metformin use with no metformin use in cancer patients treated with NACRT following the PRISMA 2020. The design and quality of the collected studies were reviewed, and meta-analyses were performed on the pathologic complete response (pCR) rate, tumor regression grade (TRG), T factor downstaging, and N factor downstaging. RESULTS Three databases were searched, and 220 papers were screened. Five retrospective cohort study papers were eligible for the meta-analysis, with a total of 2041 patients. The included papers contained only rectal and esophageal/gastroesophageal cancers. In the metformin group, the pCR rate was 26% [20-32%], and metformin was associated with the pCR rate (odds ratio [OR] = 0.51 [0.34-0.76], p < 0.01). Meta-regression analysis of the pCR rate showed a positive correlation with adenocarcinoma (coefficient = 0.13 [0.02-0.25], p = 0.03) and fluoropyrimidine anticancer drug use (coefficient = 0.01 [0.001-0.02], p = 0.03). CONCLUSIONS The results suggest that metformin is associated with pCR rate when used in combination with NACRT. The association of metformin and pCR rate in combination with fluoropyrimidine anticancer drugs was observed mostly for adenocarcinoma patients.
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Affiliation(s)
- Kyoko Sakamoto
- Department of Surgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 1608582, Japan
| | - Koji Okabayashi
- Department of Surgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 1608582, Japan
| | - Shimpei Matsui
- Department of Surgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 1608582, Japan
| | - Ryo Seishima
- Department of Surgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 1608582, Japan
| | - Kohei Shigeta
- Department of Surgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 1608582, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 1608582, Japan
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Identification of patient subgroups with low risk of postoperative local recurrence for whom total mesorectal excision surgery alone is sufficient: a multicenter retrospective analysis. Int J Colorectal Dis 2022; 37:2207-2218. [PMID: 36156129 DOI: 10.1007/s00384-022-04255-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE For rectal cancer, a multimodality approach is mandatory including neoadjuvant chemoradiotherapy, neoadjuvant chemotherapy, and lateral pelvic lymph node (LPLN) dissection, in addition to the total mesorectal excision (TME). However, these treatments are associated with adverse events. It is important to select patients who do or do not need these treatments. METHODS We retrospectively analyzed patients with cStage II and III rectal cancer who underwent curative resection at three hospitals. Recurrence patterns were classified into three types; pelvic cavity, LPLN, and distant recurrences, and the risk factors for each pattern of recurrence were compared. We then analyzed the risk of recurrence in the patients who underwent TME alone. RESULTS In total, 506 patients were enrolled in this study. Pelvic cavity recurrence was significantly associated with clinical assumption of circumferential resection margin involvement (cCRM) (p < 0.001), distant recurrence was associated with cN positivity (p < 0.001), and LPLN recurrence was associated with pretreatment LPLN swelling ≥ 5 mm (p < 0.001), lower tumor location (p = 0.016), and serum CEA level > 5 ng/mL (p = 0.008). In patients without cCRM and swollen LPLN, the local recurrence rate was extremely low even if they underwent TME alone; the 5-year recurrence rates of pelvic cavity and LPLN were 2.2% and 1.9%, respectively. CONCLUSION Additional treatments to TME for rectal cancer need to be performed based on the risk factors for each recurrence pattern.
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Efficacy of Laparoscopic Radical Resection Combined with Neoadjuvant Chemotherapy and Its Impact on Long-Term Prognosis of Patients with Colorectal Cancer. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:4774531. [PMID: 35983001 PMCID: PMC9381182 DOI: 10.1155/2022/4774531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/09/2022] [Accepted: 07/13/2022] [Indexed: 12/04/2022]
Abstract
Objective The aim of the study is to examine the efficacy of laparoscopic radical resection of colorectal cancer combined with neoadjuvant chemotherapy and its impact on the overall prognosis of patients with colorectal cancer (CC). Methods A total of 80 CC patients hospitalized and treated at our hospital between November 2019 and June 2021 were selected at random as research subjects and divided equally into two groups: the surgical group (n = 40) and the combination group (n = 40). Patients in the surgical group were treated with laparoscopic radical resection, while patients in the combination group received laparoscopic radical resection combined with neoadjuvant chemotherapy. The two groups were compared in terms of surgery-related indicators, tumor markers (serum carcinoembryonic antigen (CEA), glycoprotein 199 (CA199), vascular endothelial growth factor (VEGF), and matrix metalloproteinase 9 (MMP9)), postoperative complications, and 1–3 years postoperative survival rate and recurrence rate. Results The surgical duration of the combination group was significantly shorter than the surgical group (P < 0.05). No significant differences were found in intraoperative blood loss, time to get out of bed, exhaust time, or hospital stay between the two groups (P < 0.05). In the combination group, serum tumor markers (carcinoembryonic antigen (CEA), carbohydrate antigen 199 (CA199), vascular endothelial growth factor (VEGF), and matrix metalloproteinase 9 (MMP9)) were markedly lower than those in the surgical group (P < 0.05). The combination group exhibited fewer postoperative complications than those in the operation group (P < 0.05). In the combination group, the 1–3 years postoperative survival rate was higher, while the 1–3 years postoperative recurrence rate was considerably lower than that in the surgical group (P < 0.05). Conclusion CC patients benefit well from laparoscopic radical resection coupled with neoadjuvant chemotherapy. The approach is efficient in lowering blood tumor markers in patients and lowering the risk of surgery-related complications. It has the potential to enhance patients' long-term prognoses, allowing them to live longer and lower their chance of recurrence.
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Abstract
BACKGROUND Lavage cytology is a method to detect cancer cells released within the abdominal cavity. It has been widely utilized, in particular, for gastric cancer. However, its clinical significance has not yet been determined in colorectal cancer. OBJECTIVE This study aimed to investigate the frequency of lavage cytology positivity and its influence on the prognosis of patients with colorectal cancer. DESIGN This is a single-institution retrospective observational study. SETTING This study was conducted at a comprehensive cancer center. PATIENTS We retrospectively analyzed 3135 colorectal cancer cases from 2007 to 2013 at our institution. Intraoperative peritoneal washing cytology was performed just after the start of the operation. Fluids were centrifuged for 5 minutes at 2500 rotations per minute, cell pellets were smeared on microscope glass slides, and Papanicolaou staining was performed. MAIN OUTCOME MEASURES The primary outcome was the 5-year overall survival rate. The secondary outcome was the 5-year recurrence rate. RESULTS Lavage cytology positivity was detected in 19 (2.0%) and 86 (16.9%) cases of stage III and IV colorectal cancer; however, no positive cases were found in stage I and II colorectal cancer. Lavage cytology positivity was an independent prognostic factor in stage III and IV colorectal cancer in the multivariate analysis (5-year mortality HR 3.59 [1.69-7.64] in stage III, 2.23 [1.15-4.31] in stage IV). The prognosis of the 5-year survival rate was significantly worse in the lavage cytology-positive group in stages III and IV. In terms of recurrence, the results of the lavage cytology-positive group in stage III were similar to those of the lavage cytology-positive/negative group in stage IV (73.7%, 70.0%, and 75.0%). LIMITATIONS This study was limited by its retrospective study design. CONCLUSIONS Lavage cytology positivity is an independent prognostic and regulatory factor of stage IV colorectal cancer. See Video Abstract at http://links.lww.com/DCR/B770.INCIDENCIA Y VALOR PRONÓSTICO EN LA CITOLOGÍA DEL LAVADO PERITONEAL EN CÁNCER COLORECTALANTECEDENTES:La citología del lavado peritoneal es un método para detectar células cancerosas liberadas dentro de la cavidad abdominal. Se ha utilizado ampliamente, en particular para el cáncer gástrico. Sin embargo, aún no se ha determinado su importancia clínica en el cáncer colorrectal.OBJETIVO:Este estudio tuvo como objetivo investigar la frecuencia de positividad de la citología del lavado y su influencia en el pronóstico de los pacientes con cáncer colorrectal.DISEÑO:Este fue un estudio observacional retrospectivo de una sola institución.DISENTORNO CLÍNICO:El estudio se llevó a cabo en un centro oncológico integral.PACIENTES:Analizamos retrospectivamente 3.135 casos de cáncer colorrectal desde 2007 hasta 2013 en nuestra institución. La citología de lavado peritoneal intraoperatorio se realizó inmediatamente después del inicio de la operación. Los fluidos se centrifugaron durante 5 min a 2.500 rpm, los sedimentos celulares se extendieron sobre portaobjetos de vidrio de microscopio y se realizó la tinción con Papanicolaou.DISPRINCIPALES MEDIDAS DE VALORACIÓN:El primer resultado fueron las tasas de supervivencia general a 5 años. El segundo resultado las tasas de recurrencia a los 5 años.RESULTADOS:Se detectó positividad en la citología de lavado en 19 (2,0%) y 86 (16,9%) casos de cáncer colorrectal en estadio III y IV, respectivamente; sin embargo, no se encontraron casos positivos en el cáncer colorrectal en estadio I y II. La positividad de la citología de lavado fue un factor pronóstico independiente en el cáncer colorrectal en estadio III y IV en el análisis multivariado [cociente de riesgo de mortalidad a 5 años 3,59 (1,69-7,64), en estadio III, 2,23 (1,15-4,31), en estadio IV]. El pronóstico de la tasa de supervivencia a 5 años fue significativamente peor en el grupo con citología de lavado positiva en los estadios III y IV. En cuanto a la recurrencia, los resultados del grupo de lavado con citología positiva en el estadio III fueron similares a los del grupo de lavado con citología positiva / negativa en el estadio IV (73,7%, 70,0% y 75,0%).LIMITACIONES:Este estudio estuvo limitado por su diseño de estudio retrospectivo.CONCLUSIONES:La positividad de la citología de lavado es un factor pronóstico y regulador independiente del cáncer colorrectal en estadio IV. Consulte Video Resumen en http://links.lww.com/DCR/B770. (Traducción- Dr. Ingrid Melo).
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Akiyoshi T, Shinozaki E, Taguchi S, Chino A, Hiratsuka M, Tominaga T, Nonaka T, Toda S, Matoba S, Matsui S, Okabayashi K, Mukai T, Hiyoshi Y, Yamaguchi T, Nagasaki T, Yamaguchi K, Ueno M, Kuroyanagi H, Fukunaga Y, Ishizuka N, Konishi T. Non-operative management after chemoradiotherapy plus consolidation or sandwich (induction with bevacizumab and consolidation) chemotherapy in patients with locally advanced rectal cancer: a multicentre, randomised phase II trial (NOMINATE trial). BMJ Open 2022; 12:e055140. [PMID: 35304396 PMCID: PMC8935173 DOI: 10.1136/bmjopen-2021-055140] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Total mesorectal excision (TME) and postoperative adjuvant chemotherapy following neoadjuvant chemoradiotherapy (CRT) is the standard treatment for locally advanced rectal cancer (LARC). However, neoadjuvant CRT has no recognised impact on reducing distant recurrence, and patients suffer from a long-lasting impairment in quality of life (QOL) associated with TME. Total neoadjuvant therapy (TNT) is an alternative approach that could reduce distant metastases and increase the proportion of patients who could safely undergo non-operative management (NOM). This study is designed to compare two TNT regimens in the context of NOM for selecting a more optimal regimen for patients with LARC. METHODS AND ANALYSIS NOMINATE trial is a prospective, multicentre, randomised phase II selection design study. Patients must have clinical stage II or III (T3-T4Nany) LARC with distal location (≤5 cm from the anal verge or for those who are candidates for abdominoperineal resection or intersphincteric resection). Patients will be randomised to either arm A consisting of CRT (50.4 Gy with capecitabine) followed by consolidation chemotherapy (six cycles of CapeOx), or arm B consisting of induction chemotherapy (three cycles of CapeOx plus bevacizumab) followed by CRT and consolidation chemotherapy (three cycles of CapeOx). In the case of clinical complete response (cCR) or near cCR, patients will progress to NOM. Response assessment involves a combination of digital rectal examination, endoscopy and MRI. The primary endpoint is the proportion of patients achieving pathological CR or cCR≥2 years, defined as the absence of local regrowth within 2 years after the start of NOM among eligible patients. Secondary endpoints include the cCR rate, near cCR rate, rate of NOM, overall survival, distant metastasis-free survival, locoregional failure-free survival, time to disease-related treatment failure, TME-free survival, permanent stoma-free survival, safety of the treatment, completion rate of the treatment and QOL. Allowing for a drop-out rate of 10%, 66 patients (33 per arm) from five institutions will be accrued. ETHICS AND DISSEMINATION The study protocol was approved by Wakayama Medical University Certified Review Board in December 2020. Trial results will be published in peer-reviewed international journals and on the jRCT website. TRIAL REGISTRATION NUMBER jRCTs051200121.
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Affiliation(s)
- Takashi Akiyoshi
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Eiji Shinozaki
- Department of Gastroenterological Chemotherapy, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Senzo Taguchi
- Department of Radiation Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Akiko Chino
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Makiko Hiratsuka
- Department of Diagnostic Imaging, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tetsuro Tominaga
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Nagasaki, Japan
| | - Takashi Nonaka
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Nagasaki, Japan
| | - Shigeo Toda
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
| | - Shuichiro Matoba
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
| | - Shimpei Matsui
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Koji Okabayashi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Toshiki Mukai
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yukiharu Hiyoshi
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tomohiro Yamaguchi
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Toshiya Nagasaki
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Kensei Yamaguchi
- Department of Gastroenterological Chemotherapy, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masashi Ueno
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
| | - Hiroya Kuroyanagi
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
| | - Yosuke Fukunaga
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Naoki Ishizuka
- Department of Clinical Trial Planning and Management, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tsuyoshi Konishi
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Hazen SM, Sluckin T, Beets G, Hompes R, Tanis P, Kusters M. Current practices concerning the assessment and treatment of lateral lymph nodes in low rectal cancer: a survey among colorectal surgeons in The Netherlands. Acta Chir Belg 2021:1-9. [PMID: 34898363 DOI: 10.1080/00015458.2021.2016204] [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: 10/19/2022]
Abstract
PURPOSE The presence of lateral lymph nodes (LLNs) in patients with rectal cancer is not always acknowledged by the multidisciplinary team or treated in a standardized manner, and (inter)national guidelines concerning this topic are lacking. This study aimed to evaluate current practices regarding the assessment and treatment of LLNs in rectal cancer patients based on a survey among Dutch colorectal surgeons. METHODS An online survey was sent to members of the Dutch Association of Coloproctology. The survey consisted of 16 questions addressing their views on diagnosis, restaging, and treatment approaches for suspicious LLNs. RESULTS A total of 62 surgeons from 50 Dutch hospitals responded. For patients with a distal cT3/T4 rectal tumor; lateral lymph node compartments were routinely discussed during multidisciplinary meetings in only nine hospitals (18%). When defining what makes an LLN suspicious; the size threshold varied from >3 to >10 mm (median 7, SD 2), and MRI-based malignant features were mentioned by 29 surgeons (47%). Surgeons stated eight different treatment strategies as their designated treatment of suspicious LLNs. A total of 33 surgeons (53%) would add a radiotherapy boost to the neoadjuvant treatment. In cases of surgical resection; 12 surgeons (19%) would remove the suspicious LLN by 'node-picking' and 44 surgeons (71%) would perform a lateral lymph node dissection. The variation was not influenced by hospital type or surgeon's experience. CONCLUSION These results highlight the vast variation in the awareness, definition of suspicious LLNs in rectal cancer, and different treatment approaches. International guidelines based on further research are warranted.
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Affiliation(s)
- Sanne-Marije Hazen
- Department of Surgery, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Tania Sluckin
- Department of Surgery, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Geerard Beets
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, Netherlands
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Pieter Tanis
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Miranda Kusters
- Department of Surgery, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, Netherlands
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Feng W, Yu B, Zhang Z, Li J, Wang Y. Current status of total neoadjuvant therapy for locally advanced rectal cancer. Asia Pac J Clin Oncol 2021; 18:546-559. [PMID: 34818447 DOI: 10.1111/ajco.13640] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 07/05/2021] [Indexed: 12/21/2022]
Abstract
Neoadjuvant chemoradiotherapy (nCRT) plus total mesorectal excision (TME) has been the standard regimen for treatment of patients with locally advanced rectal cancer (LARC), because it significantly reduces the rate of local recurrence and enables sphincter preservation. However, distant metastasis remains the major reason for treatment failure, and the value of postoperative chemotherapy is still controversial. Recent studies have examined the use of total neoadjuvant therapy (TNT), defined as induction and/or consolidation chemotherapy (CONCT) with radiotherapy (RT) or nCRT prior to surgery. The results indicated that TNT may increase the rates of chemotherapy compliance and pathological complete response (pCR), and probably improve the success rate of sphincter preservation surgery. TNT may also improve disease-free survival and overall survival, and even reduce the rate of relapse. Here, we critically appraise the existing literature on three different TNT schemes used for LARC patients.
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Affiliation(s)
- Wei Feng
- Department of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Sciences, Hangzhou, China.,Department of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou, China
| | - Bin Yu
- The Second Department of Surgery, Hebei Medical University Fourth Affiliated Hospital and Hebei Provincial Tumor Hospital, Shijiazhuang, China
| | - Zhenya Zhang
- The Second Department of Surgery, Hebei Medical University Fourth Affiliated Hospital and Hebei Provincial Tumor Hospital, Shijiazhuang, China
| | - Juan Li
- Department of Radiation Oncology, Hebei Medical University Fourth Affiliated Hospital and Hebei Provincial Tumor Hospital & Hebei Clinical Research Center for Radiation Oncology, Shijiazhuang, China
| | - Yuxiang Wang
- Department of Radiation Oncology, Hebei Medical University Fourth Affiliated Hospital and Hebei Provincial Tumor Hospital & Hebei Clinical Research Center for Radiation Oncology, Shijiazhuang, China
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Nagaoka T, Fukunaga Y, Mukai T, Yamaguchi T, Nagasaki T, Akiyoshi T, Konishi T, Nagayama S. Risk factors for anastomotic leakage after laparoscopic low anterior resection: A single-center retrospective study. Asian J Endosc Surg 2021; 14:478-488. [PMID: 33205524 DOI: 10.1111/ases.12900] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 10/19/2020] [Accepted: 11/03/2020] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Anastomotic leakage (AL) is a serious complication affecting short-term and long-term outcomes in rectal cancer surgery. While laparoscopic low anterior resection is a widespread procedure, the risk factors for AL are not well established. This study aimed to evaluate risk factors for AL after laparoscopic low anterior resection with double stapling technique (DST) anastomosis. METHODS We performed a retrospective cohort study of laparoscopic low anterior resection with DST anastomosis for rectal cancer between January 2010 and February 2019. Finally, a total of 1197 patients were eligible for the study. Twenty-five variables were collected for univariate and multivariate analyses. RESULTS AL occurred in 49 patients (4.1%). In multivariate analysis, blood loss (≥70 mL) and no defunctioning stoma were independent risk factors (odds ratio [OR] 2.23; 95% confidence interval [CI] 1.08-4.34; P = .030 and OR 3.15; 95% CI 1.66-6.37; P = .0003, respectively). In addition, risk factors for AL were analyzed in 601 patients without defunctioning stoma. As a result, AL occurred in 36 patients (6.0%) and multivariate analysis demonstrated that blood loss (≥70 mL) and anastomotic level from anal verge (<5 cm) were independent risk factors (OR 3.11; 95% CI 1.24-7.44; P = .016 and OR 2.33; 95% CI 1.14-4.69; P = .020, respectively). CONCLUSION Laparoscopic low anterior resection is feasible and safe with a low AL rate. Important factors associated with AL were blood loss and defunctioning stoma. Without defunctioning stoma, blood loss and distal anastomosis are also important factors.
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Affiliation(s)
- Tomoyuki Nagaoka
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yosuke Fukunaga
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Toshiki Mukai
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tomohiro Yamaguchi
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Toshiya Nagasaki
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takashi Akiyoshi
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tsuyoshi Konishi
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Satoshi Nagayama
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
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Sakamoto W, Ohki S, Onozawa H, Okayama H, Endo H, Fujita S, Saito M, Saze Z, Momma T, Takenoshita S, Kono K. Long-term Outcomes of Lower Rectal Cancer Patients Treated with Total Mesorectal Excision and Lateral Pelvic Lymph Node Dissection after Preoperative Radiotherapy or Chemoradiotherapy. JOURNAL OF THE ANUS RECTUM AND COLON 2021; 5:129-136. [PMID: 33937552 PMCID: PMC8084532 DOI: 10.23922/jarc.2020-054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 11/27/2020] [Indexed: 11/30/2022]
Abstract
Objectives: The standard strategy for advanced rectal cancer (RC) is preoperative short-course radiotherapy (SCRT)/chemoradiotherapy (CRT) plus total mesorectal excision (TME) in Western countries; however, the survival benefit of adding chemotherapy to radiotherapy remains unclear. There is accumulating evidence that either SCRT/CRT or lateral pelvic lymph node dissection (LPND) alone may not be sufficient for local control of advanced RC. We herein retrospectively evaluated the clinical outcomes of patients who were treated by SCRT/CRT+TME+LPND, particularly focusing on the prognostic impact of lateral pelvic lymph node metastasis (LPNM). Methods: Patients diagnosed as having clinical Stage II and III lower RC who received SCRT/CRT+TME+LPND between 1999 and 2012 at our hospital were enrolled. Adverse events (AEs), surgery-related complications (SRC), and therapeutic effects were retrospectively analyzed. Results: Fifty cases (SCRT:25, CRT:25) were analyzed. No significant differences were observed in overall survival (OS), relapse-free survival (RFS), local recurrence (LR), AE, and SRC between the SCRT and CRT groups, although the pathological therapeutic effect was higher in the CRT group. The patients with LPNM showed significantly inferior 5-year OS and 5-year RFS than those without LPNM. Conclusions: There were no significant differences in OS, RFS, or LR between SCRT and CRT, although CRT had a significantly greater histological therapeutic effect. The prognosis of the pathological LPNM-positive cases was significantly poorer than that of pathological LPNM-negative cases.
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Affiliation(s)
- Wataru Sakamoto
- Department of Gastrointestinal Tract Surgery, School of Medicine Fukushima Medical University, Fukushima, Japan
| | - Shinji Ohki
- Department of Gastrointestinal Tract Surgery, School of Medicine Fukushima Medical University, Fukushima, Japan
| | - Hisashi Onozawa
- Department of Gastrointestinal Tract Surgery, School of Medicine Fukushima Medical University, Fukushima, Japan
| | - Hirokazu Okayama
- Department of Gastrointestinal Tract Surgery, School of Medicine Fukushima Medical University, Fukushima, Japan
| | - Hisahito Endo
- Department of Gastrointestinal Tract Surgery, School of Medicine Fukushima Medical University, Fukushima, Japan
| | - Shotaro Fujita
- Department of Gastrointestinal Tract Surgery, School of Medicine Fukushima Medical University, Fukushima, Japan
| | - Motonobu Saito
- Department of Gastrointestinal Tract Surgery, School of Medicine Fukushima Medical University, Fukushima, Japan
| | - Zenichiro Saze
- Department of Gastrointestinal Tract Surgery, School of Medicine Fukushima Medical University, Fukushima, Japan
| | - Tomoyuki Momma
- Department of Gastrointestinal Tract Surgery, School of Medicine Fukushima Medical University, Fukushima, Japan
| | - Seiichi Takenoshita
- Department of Gastrointestinal Tract Surgery, School of Medicine Fukushima Medical University, Fukushima, Japan
| | - Koji Kono
- Department of Gastrointestinal Tract Surgery, School of Medicine Fukushima Medical University, Fukushima, Japan
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Tuta M, Boc N, Brecelj E, Peternel M, Velenik V. Total neoadjuvant therapy vs standard therapy of locally advanced rectal cancer with high-risk factors for failure. World J Gastrointest Oncol 2021; 13:119-130. [PMID: 33643528 PMCID: PMC7896420 DOI: 10.4251/wjgo.v13.i2.119] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 12/22/2020] [Accepted: 01/07/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND For locally advanced rectal cancer (LARC), standard therapy [consisting of neoadjuvant chemoradiotherapy (CRT), surgery, and adjuvant chemotherapy (ChT)] achieves excellent local control. Unfortunately, survival is still poor due to distant metastases, which remains the leading cause of death among these patients. In recent years, the concept of total neoadjuvant treatment (TNT) has been developed, whereby all systemic ChT-mainly affecting micrometastases-is applied prior to surgery. AIM To compare standard therapy and total neoadjuvant therapy for LARC patients with high-risk factors for failure. METHODS In a retrospective study, we compared LARC patients with high-risk factors for failure who were treated with standard therapy or with TNT. High-risk for failure was defined according to the presence of at least one of the following factors: T4 stage; N2 stage; positive mesorectal fascia; extramural vascular invasion; positive lateral lymph node. TNT consisted of 12 wk of induction ChT with capecitabine and oxaliplatin or folinic acid, fluorouracil and oxaliplatin, CRT with capecitabine, and 6-8 wk of consolidation ChT with capecitabine and oxaliplatin or folinic acid, fluorouracil and oxaliplatin prior to surgery. The primary endpoint was pathological complete response (pCR). In total, 72 patients treated with standard therapy and 89 patients treated with TNT were included in the analysis. RESULTS Compared to standard therapy, TNT showed a higher proportion of pCR (23% vs 7%; P = 0.01), a lower neoadjuvant rectal score (median: 8.43 vs 14.98; P < 0.05), higher T-and N-downstaging (70% and 94% vs 51% and 86%), equivalent R0 resection (95% vs 93%), shorter time to stoma closure (mean: 20 vs 33 wk; P < 0.05), higher compliance during systemic ChT (completed all cycles 87% vs 76%; P < 0.05), lower proportion of acute toxicity grade ≥ 3 during ChT (3% vs 14%, P < 0.05), and equivalent acute toxicity and compliance during CRT and in the postoperative period. The pCR rate in patients treated with TNT was significantly higher in patients irradiated with intensity-modulated radiotherapy/volumetric-modulated arc radiotherapy than with 3D conformal radiotherapy (32% vs 9%; P < 0.05). CONCLUSION Compared to standard therapy, TNT provides better outcome for LARC patients with high-risk factors for failure, in terms of pCR and neoadjuvant rectal score.
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Affiliation(s)
- Mojca Tuta
- Division of Radiology, Institute of Oncology, Ljubljana 1000, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana 1000, Slovenia
| | - Nina Boc
- Division of Radiology, Institute of Oncology, Ljubljana 1000, Slovenia
| | - Erik Brecelj
- Division of Surgery, Institute of Oncology, Ljubljana 1000, Slovenia
| | - Monika Peternel
- Division of Radiotherapy, Institute of Oncology, Ljubljana 1000, Slovenia
| | - Vaneja Velenik
- Faculty of Medicine, University of Ljubljana, Ljubljana 1000, Slovenia
- Division of Radiotherapy, Institute of Oncology, Ljubljana 1000, Slovenia
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Adding Narrow-Band Imaging to Chromoendoscopy for the Evaluation of Tumor Response to Neoadjuvant Therapy in Rectal Cancer. Dis Colon Rectum 2021; 64:53-59. [PMID: 32639283 DOI: 10.1097/dcr.0000000000001699] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Endoscopic assessment is crucial in diagnosing clinical complete response after neoadjuvant therapy in rectal cancer. OBJECTIVE The purpose of this research was to evaluate the benefits of adding narrow-band imaging endoscopy to conventional chromoendoscopy in predicting pathologic complete response in the surgical specimen. DESIGN This was a prospective nonrandomized study. SETTINGS This was an ad hoc study of a prospective phase II trial at a single comprehensive cancer center that evaluated oncologic outcomes of a neoadjuvant therapy for rectal cancer. PATIENTS Patients with high-risk stage II to III low rectal cancer who received neoadjuvant modified folinic acid, fluorouracil, and oxaliplatin plus bevacizumab followed by chemoradiotherapy and surgery were included. INTERVENTION Tumor response after neoadjuvant therapy was evaluated using conventional white light endoscopy plus chromoendoscopy then followed by using narrow-band imaging based on a predefined diagnostic protocol. MAIN OUTCOME MEASURES Diagnostic accuracy for predicting pathologic complete response and inter-rater agreement between an expert and trainee endoscopists were compared between the assessments using conventional white light endoscopy plus chromoendoscopy and the assessment adding narrow-band imaging. RESULTS In total, 61 patients were eligible for the study, and 19 had pathologic complete response (31.1%). Although the addition of narrow-band imaging correctly converted the diagnosis in 3 patients, overall diagnostic improvement in predicting pathologic complete response was limited (conventional chromoendoscopy vs adding narrow-band imaging: accuracy, 70.5% vs 75.4%; sensitivity, 63.2% vs 73.7%; specificity, 73.8% vs 76.2%; positive predictive value, 52.2% vs 58.3%; and negative predictive value, 81.6% vs 86.5%). A κ value for the inter-rater agreement improved from 0.599 to 0.756 by adding narrow-band imaging. LIMITATIONS This was a single-center study with a relatively small sample size. CONCLUSIONS Despite the limited improvement in diagnostic accuracy, adding narrow-band imaging to chromoendoscopy improved inter-rater agreement between the expert and nonexpert endoscopists. Narrow-band imaging is a reliable and promising modality for universal standardization of the diagnosis of clinical complete response. See Video Abstract at http://links.lww.com/DCR/B275. ADICIÓN DE IMÁGENES DE BANDA ESTRECHA A LA CROMOENDOSCOPÍA PARA LA EVALUACIÓN DE LA RESPUESTA TUMORAL A LA TERAPIA NEOADYUVANTE EN EL CÁNCER DE RECTO: La evaluación endoscópica es fundamental para valorar la respuesta clínica completa después de la terapia neoadyuvante en el cáncer de recto.Evaluar los beneficios de agregar endoscopia de imagen de banda estrecha a la cromoendoscopía convencional para predecir la respuesta patológica completa en la muestra quirúrgica.Estudio prospectivo no aleatorizado.Un estudio ad hoc de un ensayo prospectivo de fase II en un solo centro integral de cáncer que evaluó los resultados oncológicos de una terapia neoadyuvante para el cáncer rectal.Pacientes con cáncer rectal bajo de alto riesgo en estadio II-III que recibieron ácido folínico neoadyuvante modificado, fluorouracilo y oxaliplatino más bevacizumab seguido de quimiorradioterapia y cirugía.La respuesta tumoral después de la terapia neoadyuvante se evaluó mediante endoscopia de luz blanca convencional más cromoendoscopía, seguido de imágenes de banda estrecha basadas en un protocolo de diagnóstico predefinido.La precisión diagnóstica para predecir la respuesta patológica completa y el acuerdo entre evaluadores entre un experto y un endoscopista en entrenamiento se compararon entre las evaluaciones utilizando endoscopia de luz blanca convencional más cromoendoscopía y la evaluación agregando imágenes de banda estrecha.En total, 61 pacientes fueron elegibles para el estudio, y 19 tuvieron una respuesta patológica completa (31.1%). Aunque la adición de imágenes de banda estrecha convirtió correctamente el diagnóstico en 3 pacientes, la mejora diagnóstica general en la predicción de la respuesta patológica completa fue limitada (cromoendoscopía convencional versus adición de imágenes de banda estrecha: precisión, 70.5% versus 75.4%; sensibilidad, 63.2% versus 73.7%; especificidad, 73.8% versus 76.2%; valor predictivo positivo, 52.2% versus 58.3%; y valor predictivo negativo, 81.6% versus 86.5%). Un valor de kappa para el acuerdo entre evaluadores mejoró de 0.599 a 0.756 al agregar imágenes de banda estrecha.Un estudio de centro único con un tamaño de muestra relativamente pequeño.A pesar de la mejora limitada en la precisión diagnóstica, agregar imágenes de banda estrecha a la cromoendoscopía mejoró el acuerdo entre evaluadores entre los endoscopistas expertos y no expertos. La imagenología de banda estrecha es una modalidad confiable y prometedora para la estandarización universal del diagnóstico de respuesta clínica completa. Consulte Video Resumen en http://links.lww.com/DCR/B275.
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Zhou Y, Guo Z, Wu Z, Shi J, Zhou C, Sun J, Hidasa I, Lu X, Lu C. The efficacy and safety of adding bevacizumab in neoadjuvant therapy for locally advanced rectal cancer patients: A systematic review and meta-analysis. Transl Oncol 2020; 14:100964. [PMID: 33248411 PMCID: PMC7704460 DOI: 10.1016/j.tranon.2020.100964] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 11/15/2020] [Accepted: 11/16/2020] [Indexed: 01/11/2023] Open
Abstract
Background Patients with locally advanced rectal cancer (LARC) are more likely to suffer local recurrence and distant metastases, contributing to worse prognoses. Considering the provided dramatic reduction of local recurrences, neoadjuvant CRT (nCRT) followed by curative resection with total mesorectal excision (TME) and adjuvant chemotherapy has been established as standard therapy for LARC patients. However, the efficacy of adding bevacizumab in neoadjuvant therapy, especially in induction therapy-containing nCRT for LARC patients remains uncertain. Materials PubMed, Embase, and Web of Science were searched to retrieve records on the application of bevacizumab in a neoadjuvant setting for LARC patients. The endpoints of interest were pCR and the rates of patients suffering Grade 3/4 bevacizumab-specific adverse events, namely bleeding, wound healing complications, and gastrointestinal perforation. Results 29 cohorts covering 1134 subjects were included in this systematic review. The pooled pCR rate for bevacizumab-relevant cohorts was 21% (95% confidence interval (95% CI), 17–25%; I2 = 61.8%), the pooled estimates of Grade 3/4 bleeding, Grade 3/4 wound healing complication, Grade 3/4 gastrointestinal perforation were 1% (95% CI, 0–3%; I2 = 0%), 2% (95% CI, 1–5%; I2 = 4.7%), and 2% (95% CI, 0–5%; I2 = 0%), respectively. Conclusion The addition of bevacizumab in the nCRT, especially in the TNT, for LARC patients provides promising efficacy and acceptable safety. However, the results should be interpreted cautiously due to the small amount of relevant data and need further confirmation by future studies.
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Affiliation(s)
- Yue Zhou
- Department of Medical Oncology, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang 110001, China
| | - Zhexu Guo
- Department of Surgical Oncology and General Surgery, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, China
| | - Zhonghua Wu
- Department of Surgical Oncology and General Surgery, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, China
| | - Jinxin Shi
- Department of Surgical Oncology and General Surgery, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, China
| | - Cen Zhou
- Department of Surgical Oncology and General Surgery, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, China
| | - Jie Sun
- Department of Surgical Oncology and General Surgery, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, China
| | - Iko Hidasa
- Department of Surgical Oncology and General Surgery, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, China
| | - Xuefei Lu
- Department of Pediatrics, People's Hospital of Yifeng County, 24 Chengnanmen Road, Yifeng County, Yichun 336300, China
| | - Chong Lu
- Department of Surgical Oncology and General Surgery, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Heping District, Shenyang City, 110001, China.
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Effects of needlescopic surgery on postoperative pain in intersphincteric or abdominoperineal resection. Langenbecks Arch Surg 2020; 406:301-307. [PMID: 33221943 DOI: 10.1007/s00423-020-02035-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 11/15/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Laparoscopic surgery allows minimally invasive treatment of rectal cancer, and needlescopic surgery (NS) offers even more minimally invasive operations beyond the scope of conventional laparoscopic surgery (CS). The aim of this study was to compare short-term outcomes of NS for intersphincteric resection (ISR) or abdominoperineal resection (APR) to treat anal or rectal cancer without an abdominal incision for specimen extraction and to measure abdominal wound pain compared to CS. METHODS Between September 2014 and December 2016, a total of 134 patients underwent laparoscopic ISR or APR. Of these, 26 patients underwent NS, and 108 patients underwent CS. Postoperative abdominal wound pain was estimated using the numerical rating scale. Short-term outcomes were compared between NS and CS. RESULTS No conversion to CS or open surgery was required. Median operation time was significantly shorter with NS (295 min) than with CS (331.5 min; p = 0.020). Median estimated blood loss was significantly lower with NS (30 ml) than with CS (50 ml; p = 0.011). Postoperative pain score on postoperative day (POD)5 was significantly lower with NS than with CS (p = 0.025), and frequencies of analgesic use were significantly lower with NS than with CS on POD0, POD2, and POD3 (p = 0.032, p = 0.017, p = 0.045, respectively). The postoperative complications occurred at similar frequencies between groups (p = 0.655). CONCLUSION NS for ISR or APR offers comparable short-term outcomes to CS, with better pain outcomes.
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Ogura A, Uehara K, Aiba T, Hattori N, Nakayama G, Maeda O, Ando Y, Kodera Y, Ebata T, Nagino M. What is the impact of systemic chemotherapy for lateral lymph nodes in patients with locally advanced low rectal cancer? Int J Colorectal Dis 2020; 35:2073-2080. [PMID: 32676686 DOI: 10.1007/s00384-020-03690-z] [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] [Accepted: 07/06/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Systemic chemotherapy (SC) before surgery is a potential treatment to improve survival in patients with advanced rectal cancer. However, the impact of SC on lateral lymph nodes (LLNs) remains unclear. METHODS A total of 78 patients with stage II/III low rectal cancer, who received 3-month oxaliplatin-based SC followed by LLN dissection (LLND) in principle, were analysed retrospectively. "Total lateral lymph node metastases (tLLNMs)" was defined as having either pathological LLNMs (pLLNMs) or lateral local recurrences (LLRs). Patients with the maximum short-axis size of LLNs ≥ 7 mm were classified into the swollen group (n = 21). RESULTS In the total cohort, tLLNMs included 6 pLLNMs (7.7%) and 2 LLRs (2.6%). In the non-swollen group, no patients had pLLNMs, but one had LLR (1.8%). In the swollen group, pLLNMs and LLRs were detected in 6 (28.6%) and 1 (4.8%), respectively. The swollen group was an independent risk factor for tLLNMs (P < 0.001), leading to the significantly worse 5-year relapse-free survival (RFS) of 52.4% than the others. CONCLUSION For patients without swollen LLNs, SC could allow for omission both of lateral irradiation and LLND. For patients with swollen LLNs, the lateral local control was favourable after SC and LLND without chemoradiotherapy (CRT); however, oxaliplatin-based SC might be insufficient to improve survival, requiring more intensive chemotherapy. CRT should be indicated according to the other risk factors of central local recurrence, although the swollen LLNs should be removed.
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Affiliation(s)
- Atsushi Ogura
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
| | - Kay Uehara
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan.
| | - Toshisada Aiba
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
| | - Norifumi Hattori
- Division of Gastrointestinal Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Goro Nakayama
- Division of Gastrointestinal Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Osamu Maeda
- Department of Clinical Oncology and Chemotherapy, Nagoya University Hospital, Nagoya, Japan
| | - Yuichi Ando
- Department of Clinical Oncology and Chemotherapy, Nagoya University Hospital, Nagoya, Japan
| | - Yasuhiro Kodera
- Division of Gastrointestinal Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tomoki Ebata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
| | - Masato Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
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Nakanishi R, Akiyoshi T, Toda S, Murakami Y, Taguchi S, Oba K, Hanaoka Y, Nagasaki T, Yamaguchi T, Konishi T, Matoba S, Ueno M, Fukunaga Y, Kuroyanagi H. Radiomics Approach Outperforms Diameter Criteria for Predicting Pathological Lateral Lymph Node Metastasis After Neoadjuvant (Chemo)Radiotherapy in Advanced Low Rectal Cancer. Ann Surg Oncol 2020; 27:4273-4283. [PMID: 32767224 DOI: 10.1245/s10434-020-08974-w] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 06/19/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Advanced low rectal cancer has a non-negligible risk of lateral pelvic lymph node (LPLN) metastasis (LPLNM) and lateral local recurrence (LR) after neoadjuvant (chemo)radiotherapy and total mesorectal excision. LPLN dissection (LPLND) reduces LR but increases postoperative complications and sexual/urinary dysfunction. OBJECTIVE The aim of this study was to develop a new radiomics-based prediction model for LPLNM in patients with rectal cancer. METHODS A total of 247 patients with rectal cancer and enlarged LPLNs treated by (chemo)radiotherapy and LPLND were enrolled in this retrospective, multicenter study. LPLN radiomic features were extracted from pretreatment portal venous-phase computed tomography images. A radiomics score of LPLN was constructed based on the least absolute shrinkage and selection operator regression in a primary cohort of 175 patients. Model performance was assessed in terms of discrimination, calibration, and decision curve analysis, and was externally validated in 72 patients. RESULTS The radiomics score showed significantly better discrimination compared with pretreatment short-axis diameter measurements in both the primary (area under the curve [AUC] 0.91 vs. 0.83, p = 0.0015) and validation (AUC 0.90 vs. 0.80, p = 0.0298) cohorts. Decision curve analysis also indicated the superiority of the radiomics score. In a subanalysis of patients with a short-axis diameter ≥ 7 mm, the radiomics nomogram, incorporating the radiomics score and LPLN shrinkage to ≤ 4 mm, had better discrimination compared with a model incorporating only LPLN shrinkage in both cohorts. CONCLUSIONS Radiomics-based prediction modeling provides individualized risk estimation of LPLNM in rectal cancer patients treated with (chemo)radiotherapy, and outperforms measurements of pretreatment LPLN diameter.
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Affiliation(s)
- Ryota Nakanishi
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takashi Akiyoshi
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Shigeo Toda
- Department of Colorectal Surgery, Toranomon Hospital, Tokyo, Japan
| | - Yu Murakami
- Department of Radiation Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Senzo Taguchi
- Department of Radiation Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Koji Oba
- Department of Biostatistics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yutaka Hanaoka
- Department of Colorectal Surgery, Toranomon Hospital, Tokyo, Japan
| | - Toshiya Nagasaki
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tomohiro Yamaguchi
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tsuyoshi Konishi
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Shuichiro Matoba
- Department of Colorectal Surgery, Toranomon Hospital, Tokyo, Japan
| | - Masashi Ueno
- Department of Colorectal Surgery, Toranomon Hospital, Tokyo, Japan
| | - Yosuke Fukunaga
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
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Risk factors for outlet obstruction after laparoscopic surgery and diverting ileostomy for rectal cancer. Surg Today 2020; 51:366-373. [PMID: 32754842 DOI: 10.1007/s00595-020-02096-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 07/20/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE Outlet obstruction is defined as bowel obstruction at the stoma opening. The aim of this study was to evaluate the risk factors for outlet obstruction in patients with rectal cancer who underwent laparoscopic surgery and diverting ileostomy. METHODS Among consecutive patients who underwent laparoscopic curative resection for primary rectal cancer between 2013 and 2015, 261 patients with diverting ileostomy were included in the analysis. The thickness of the abdominal wall, including the thickness of the rectus abdominis muscle, was measured using preoperative computed tomography. The clinicopathological factors were compared between the patients with and without outlet obstruction. RESULTS Fourteen (5.4%) patients were diagnosed with outlet obstruction, but reoperation was not required. The rectus abdominis muscle was significantly thicker in male patients with outlet obstruction compared to those without outlet obstruction, but not in females. In a multivariate analysis, a rectus abdominis muscle thickness of 10 mm or more was determined to be an independent risk factor for outlet obstruction (odds ratio, 7.0482; p = 0.0061). CONCLUSIONS The thickness of the rectus abdominis muscle may be used to predict the occurrence of outlet obstruction in male patients with rectal cancer who undergo laparoscopic surgery and diverting ileostomy.
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Prognostic value of metastatic lymph node regression grade after neoadjuvant chemoradiotherapy in patients with locally advanced rectal cancer. Surgery 2019; 166:1061-1067. [DOI: 10.1016/j.surg.2019.06.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/29/2019] [Accepted: 06/08/2019] [Indexed: 12/13/2022]
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Konishi T, Shinozaki E. ASO Author Reflections: Combining Intensive Neoadjuvant Therapy with Minimally Invasive Surgery: A Promising Future Strategy for Rectal Cancer with High-Risk Features. Ann Surg Oncol 2019; 26:753-754. [PMID: 31571051 DOI: 10.1245/s10434-019-07882-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Tsuyoshi Konishi
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Eiji Shinozaki
- Department of Gastroenterological Oncology, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
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