Multidisciplinary treatment of rectal cancer in 2014: Where are we going?

Endoluminal vacuum-assisted therapy as a treatment for anastomotic leakage in colorectal surgery

Anastomotic leakage (AL) has a wide range of clinical features ranging from radiological only findings to peritonitis and sepsis with multiorgan failure. An early diagnosis of AL is essential in order to establish the most appropriate treatment for this complication. Despite AL continues to be a dreadful compli-cation after colorectal surgery, there has been no consensus on its management. However, based on patient's presentation and timing of the AL, there has been a gradual shift to a more conservative management, keeping surgery as the last option Reoperation for sepsis control is rarely necessary especially in those patients who already have a diverting stoma at the time of the leak. A nonoperative management is usually preferred in these patients. There are several treatment options, also for patients without a stoma who do not require a reoperation for a contained pelvic leak, including recently developed endoscopic procedures, such as clip placement or endoluminal vacuum-assisted therapy. More conservative treatments could be an option in patients who are clinically stable or in presence of a small defect.

Prognostic Significance of Lymphocyte-to-Monocyte and Platelet-to-Lymphocyte Ratio in Rectal Cancer: A Systematic Review, Meta-analysis, and Meta-regression

BACKGROUND

The low lymphocyte-to-monocyte ratio and high platelet-to-lymphocyte ratio have been reported to be poor prognostic indicators in various solid tumors, but the prognostic significance in rectal cancer remains controversial.

OBJECTIVES

We sought to determine the prognostic value of the lymphocyte-to-monocyte ratio and the platelet-to-lymphocyte ratio following curative-intent surgery for rectal cancer.

DATA SOURCES

Following PRISMA guidelines (PROSPERO, ID: CRD42020190880), PubMed and Embase databases were searched through January 2021 including 3 other registered medical databases.

STUDY SELECTION

Studies evaluating the impact of pretreatment lymphocyte-to-monocyte ratio and platelet-to-lymphocyte ratio on overall or disease-free survival in patients undergoing curative rectal cancer resection were selected.

MAIN OUTCOMES MEASURES

The main outcome measures were overall and disease-free survival.

RESULTS

A total of 23 studies (6683 patients) were included; lymphocyte-to-monocyte ratio and platelet-to-lymphocyte ratio were evaluated in 14 and 16 studies. A low lymphocyte-to-monocyte ratio was associated with poorer overall survival (HR, 1.57; 95% CI, 1.29-1.90; p < 0.001) and disease-free survival (HR, 1.29; 95% CI, 1.13-1.46; p < 0.001). However, when the analysis was limited to patients treated with surgery alone or to those with stage I to III tumors, lymphocyte-to-monocyte ratio was not a predictor of overall survival and disease-free survival. The platelet-to-lymphocyte ratio did not predict for overall or disease-free survival, regardless of the treatment modality, studied population, tumor stage, or cutoff value. Finally, a low lymphocyte-to-monocyte ratio, but not a high platelet-to-lymphocyte ratio, was inversely correlated with complete pathologic response rate.

LIMITATIONS

The retrospective nature of most included studies was a limitation.

CONCLUSIONS

Pretreatment lymphocyte-to-monocyte ratio, but not platelet-to-lymphocyte ratio, correlates with tumor response to neoadjuvant chemoradiotherapy and poorer prognosis after curative-intent surgery for rectal cancer, and it potentially represents a simple and reliable biomarker that could help optimize individualized clinical decision-making in high-risk patients.

REGISTRATION

https://www.crd.york.ac.uk/prospero/; ID: CRD42020190880.

A multicentre cohort study assessing the utility of routine blood tests as adjuncts to identify complete responders in rectal cancer following neoadjuvant chemoradiotherapy

PURPOSE

Management of rectal cancer with a complete clinical response (cCR) to neoadjuvant chemoradiotherapy (NACRT) is controversial. Some advocate "watch and wait" programmes and organ-preserving surgery. Central to these strategies is the ability to accurately preoperatively distinguish cCR from residual disease (RD). We sought to identify if post-NACRT (preoperative) inflammatory markers act as an adjunct to MRI and endoscopy findings for distinguishing cCR from RD in rectal cancer.

METHODS

Patients from three specialist rectal cancer centres were screened for inclusion (2010-2015). For inclusion, patients were required to have completed NACRT, had a post-NACRT MRI (to assess mrTRG) and proceeded to total mesorectal excision (TME). Endoluminal response was assessed on endoscopy at 6-8 weeks post-NACRT. Pathological response to therapy was calculated using a three-point tumour regression grade system (TRG1-3). Neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), serum albumin (SAL), CEA and CA19-9 levels post-NACRT (preoperatively) were recorded. Variables were compared between those who had RD on post-operative pathology and those with ypCR. Statistical analysis was performed using SPSS (version 21).

RESULTS

Six hundred forty-six patients were screened, of which 422 were suitable for inclusion. A cCR rate of 25.5% (n = 123) was observed. Sixty patients who achieved cCR were excluded from final analysis as they underwent organ-preserving surgery (local excision) leaving 63 ypCR patients compared to 359 with RD. On multivariate analysis, combining cCR on MRI and endoscopy with NLR < 5 demonstrated the greatest odds of ypCR on final histological assessment [OR 6.503 (1.594-11.652]) p < 0.001]. This method had the best diagnostic accuracy (AUC = 0.962 95% CI 0.936-0.987), compared to MRI (AUC = 0.711 95% CI 0.650-0.773) or endoscopy (AUC = 0.857 95% CI 0.811-0.902) alone or used together (AUC = 0.926 95% CI 0.892-0.961).

CONCLUSION

Combining post-NACRT inflammatory markers with restaging MRI and endoscopy findings adds another avenue to aid distinguishing RD from cCR in rectal cancer.

Variation in the volume-outcome relationship after rectal cancer surgery in the United States: Retrospective study with implications for regionalization

BACKGROUND

Previous studies have demonstrated improved outcomes for patients with rectal cancer treated at higher-volume hospitals. However, little is known whether heterogeneity in this effect exists. The objective was to test whether the effect of increased annual rectal cancer resection volume on outcomes is consistent across all hospitals treating rectal cancer.

METHODS

Adult stage I to III patients who underwent surgical resection for rectal adenocarcinoma from 2004 to 2016 were identified in the National Cancer Database.

RESULTS

We included 120,522 patients treated at 763 hospitals in this retrospective cohort study. Higher volume was linearly and incrementally related to outcomes in unadjusted analyses. In adjusted models, for an average patient at the average hospital, the effect of increasing the annual caseload of rectal cancer resections by 20 resections per year was associated with 8%, (hazard ratio = 0.92, 95% confidence interval = 0.87, 0.97), 18% (odds ratio = 0.82, 95% confidence interval = 0.70, 0.98), and 16% (odds ratio = 0.84, 95% confidence interval = 0.73, 0.95) relative reductions in 5-year overall survival, 30-, and 90-day mortality, respectively, and with a 19% (odds ratio = 1.19, 95% confidence interval = 1.04, 1.36) relative increase in the rate of neoadjuvant chemoradiation. These effects varied by individual hospitals such that 39% of hospitals do not see any benefit in 5-year overall survival associated with higher volumes. Increased volume was associated with lower positive circumferential resection margin rates at 19% of the hospitals.

CONCLUSION

This study confirms that higher-volume hospitals have improved outcomes after rectal cancer surgery. However, there exists significant variation in these effects induced by individual within-hospital effects. Regionalization policies may need to be flexible in identifying the hospitals that would achieve enhanced benefits from treating a larger volume of patients.

Current status of surgical treatment of rectal cancer in China

With the changing lifestyle and the acceleration of aging in the Chinese population, the incidence and mortality of colorectal cancer (CRC) have risen in the last decades. On the contrary, the incidence and mortality of CRC have continued to decline in the USA since the 1980s, which is mainly attributed to early screening and standardized diagnosis and treatment. Rectal cancer accounts for the largest proportion of CRC in China, and its treatment regimens are complex. At present, surgical treatment is still the most important treatment for rectal cancer. Since the first Chinese guideline for diagnosis and treatment of CRC was issued in 2010, the fourth version has been revised in 2020. These guidelines have greatly promoted the standardization and internationalization of CRC diagnosis and treatment in China. And with the development of comprehensive treatment methods such as neoadjuvant chemoradiotherapy, targeted therapy, and immunotherapy, the post-operative quality of life and prognosis of patients with rectal cancer have improved. We believe that the inflection point of the rising incidence and mortality of rectal cancer will appear in the near future in China. This article reviewed the current status and research progress on surgical therapy of rectal cancer in China.

Accuracy of Magnetic Resonance Imaging in Staging Rectal Cancer with Multidisciplinary Team: A Single-Center Experience

Purpose: To investigate the accuracy of magnetic resonance imaging (MRI) in preoperative staging diagnosis for rectal cancer with multidisciplinary team (MDT) discussion. Methods: The retrospective study included 377 patients of rectal cancer with preoperative MRI staging from February 2015 to April 2018, in which 137 patients (36 received MDT discussion) received neoadjuvant therapy, 240 did not (97 received MDT discussion) and direct surgery was given. With postoperative pathological stage as the standard, the accuracy of MRI in preoperative staging for rectal cancer with MDT discussion was compared with non-MDT. Results: For direct surgery group, 21 out 97 (21.6%) patients changed their therapy strategy due to the change of the stage assessment after MDT. The accuracy of MRI for the diagnosis of preoperative N stage with MDT was significantly higher than those without MDT (56.2% vs. 42.1%, P=0.021). And for those without lymph node metastasis, the accuracy of MRI was higher after MDT (61.2% vs. 37.8%, P=0.009). For neoadjuvant therapy group, 7 out of 36 (19.4%) patients altered their therapy after MDT because of the changed stage. MDT improved the accuracy of restaging N stage with MRI (70.0% vs. 33.3%, P=0.003). The accuracy of MRI in staging T stage seemed not improved after MDT in both groups. Conclusions: In conclusion, MDT discussion increased the accuracy of MRI in preoperative staging diagnosis for rectal cancer. This mode could give a more accurate clinical stage of patients, which was in favor of choosing a preferable therapy strategy.

Survival benefit of statins in older patients with rectal cancer: A Swedish population-based cohort study

OBJECTIVES

Increasing evidence suggests that statins may have antitumor effects but their role in rectal cancer appears inconclusive. The aim of this study was to investigate whether statins may have an impact on survival of older and younger patients with rectal cancer.

MATERIALS AND METHODS

This study included 238 patients ≥70 years and 227 patients <70 years old, from the Southeast Health Care Region of Sweden, who were diagnosed with rectal adenocarcinoma between 2004 and 2013.

RESULTS

In the older group (n = 238), statin use at the time of diagnosis was related to better cancer-specific survival (CSS) and overall survival (OS), compared to non-use (CSS: Hazard Ratio (HR), 0.37; 95% CI, 0.19-0.72; P = .003; OS: HR, 0.62; 95% CI, 0.39-0.96; P = .032). In the older group with stages I-III disease (n = 199), statin use was associated with better disease-free survival (DFS) compared to non use (HR, 0.18; 95% CI, 0.06-0.59; P = .005). The improvement of CSS, OS and DFS remained significant after adjusting for potential confounders. In the older group with stage III disease, statin users had better CSS and DFS compared to non-users (log rank P = .043; log-rank P = .028, respectively). In the older group with short course radiotherapy, statin use was related to better CSS (log-rank P = .032). No such association was present in the younger group.

CONCLUSION

Statin use was related to improved survival in older patients with rectal cancer. This observation is important given the low cost and safety of statins as a drug.

Variations of the renal function parameters in rectal cancer patients with a defunctioning loop ileostomy

PURPOSE

The objective of this study is to investigate the impact of the temporary loop ileostomy on renal function and also to assess the factors associated with the change in renal function observed between the index surgery (the moment of the radical surgical procedure) and the closure of the ileostomy (the moment of the secondary surgical act of suppression of the ileostomy).

METHODS

A total of 69 rectal cancer patients from a single referral surgical unit who had a loop ileostomy during low anterior resection of the rectum were included in this study. Serum creatinine levels were evaluated, and estimated glomerular filtration rate (eGFR) was calculated prior to index surgery and closure of the ileostomy.

RESULTS

During this time interval, there was a significant decrease in eGFR levels (mean difference - 4.5 mL/min/1.73 m², 95% CI - 7.8 to - 1.3 mL/min/1.73 m²), and also a significant increase in the serum creatinine values (mean difference 0.07, 95% CI 0.02-0.12 mg/dL). The eGFR decrease was more pronounced in diabetic patients, in those with a baseline Charlson Comorbidity Index score ≥ 1 or in those that received chemotherapy. In a multivariable regression analysis, the use of neoadjuvant chemotherapy was the only variable significantly associated with the change in eGFR levels between the two surgical interventions.

CONCLUSION

Renal function impairment is an important event that the surgeon has to take into consideration when deciding upon opting for a loop ileostomy to temporarily defunction a colorectal anastomosis.

Impact of Adjuvant Therapy Type on Survival in Stage II/III Rectal Cancer Without Preoperative Chemoradiation: A Korean Multicenter Retrospective Study

PURPOSE

This study compared the oncologic impact of postoperative chemotherapy and chemoradiotherapy on patients with rectal cancer without preoperative chemoradiation.

METHODS

This retrospective study analyzed 713 patients with a mean follow-up of 58 months who had undergone radical resection for stage II/III rectal cancer without preoperative treatment in nine hospitals from January 2004 to December 2009. The study population was categorized a chemotherapy group (CG, n = 460) and a chemoradiotherapy group (CRG, n = 253). Five-year overall survival (OS) and disease-free survival (DFS) were analyzed, and independent factors predicting survival were identified.

RESULTS

The patients in the CRG were significantly younger (P < 0.001) and had greater incidences of low rectal cancer (P < 0.001) and stage III disease (P < 0.001). Five-year OS (P = 0.024) and DFS (P = 0.012) were significantly higher in the CG for stage II disease; however, they were not significantly different for stage III disease. In the multivariate analysis, independent predictive factors were male sex, low rectal cancer and stage III disease for OS and male sex, abdominoperineal resection, stage III disease and tumor-positive circumferential margin for DFS. However, adjuvant therapy type did not independently affect OS (hazard ratio [HR], 1.243; 95% confidence interval [CI], 0.794-1.945; P = 0.341) and DFS (HR, 1.091; 95% CI, 0.810-1.470; P = 0.566).

CONCLUSION

Adjuvant therapy type did not affect survival of stage II/III rectal cancer patients without neoadjuvant chemoradiotherapy. These results suggest that adjuvant therapy can be chosen based on the patient's condition and the policies of the surgeons and hospital facilities.

Adjuvant Second-Dose Chemotherapy before Surgery for Patients with Locally Advanced Rectal Malignancy Is Not Beneficial: A Systematic Review and Meta-Analysis

BACKGROUND

Preoperative chemoradiotherapy is the standard treatment for patients with locally advanced rectal cancer, although tumor responses vary widely; some patients may achieve a pathologic complete response rate (pCR) after chemoradiotherapy. Controversy exists with regard to the efficacy of different preoperative combination chemotherapy regimens and neoadjuvant chemoradiotherapy, compared with chemoradiotherapy alone.

METHODS

PubMed, the Cochrane Library, and Embase databases were searched for comparative studies of patients with locally advanced rectal cancer that were published between January 1991 and January 2016. Efficacies of different preoperative combination chemotherapy regimens and neoadjuvant chemoradiotherapy (group A) were compared with chemoradiotherapy alone (group B) in a meta-analysis using Review Manager v5.2.

RESULTS

Three prospective randomized controlled trials and two prospective nonrandomized controlled trials comprising 444 cases were eligible for analysis. No significant difference was detected in the rate of pCR (50/223, 22.4% versus 35/223, 15.7%; relative risk, RR: 1.42 [95% confidence interval, CI: 0.97-2.09], p = 0.07) between the two groups. The rate of tumor regression was similar for both groups (122/203, 60.1% versus 111/203, 54.7%; RR: 1.11 [95% CI: 0.94-1.29], p = 0.22).

CONCLUSIONS

Adjuvant chemotherapy with preoperative chemoradiotherapy did not significantly improve the rate of pCR nor the rate of T and N downstaging.

Re-Staging Following Long-Course Chemoradiotherapy For Rectal Cancer: Does It Influence Management?

BACKGROUND

In patients with locally advanced or low rectal cancers, long-course chemoradiotherapy (LCCRT) is recommended prior to surgical management.¹ The need for restaging afterwards has been questioned as it may be difficult to interpret imaging due to local tissue effects of chemoradiotherapy. The purpose of this study was to determine if restaging affected the management of patients receiving long-course chemoradiotherapy for rectal cancer.

METHODS

A retrospective review of patients with rectal cancer discussed at the South Eastern Health and Social Care Trust Lower Gastrointestinal Multi-Disciplinary Team Meeting (LGIMDT) in 2013 who had received long-course chemoradiotherapy was performed. Patients were identified from the Trust Audit Department, LGIMDT notes and patient records. Imaging results and outcomes from meetings were obtained through the Northern Ireland Picture Archiving and Communications System^® (NIPACS) and Electronic Care Record^® (ECR). Data including patient demographics, initial radiological staging and LGIMDT discussion, restaging modality and result, outcome from post-treatment LGIMDT discussion and recorded changes in management plans were documented using a proforma.

RESULTS

Seventy-one patients with rectal cancer were identified as having LCCRT in 2013 (M:F 36:35; age range 31 - 85 years). Fifty-nine patients were restaged following long-course treatment with computed tomography (CT) and magnetic resonance imaging (MRI). Twelve patients did not undergo restaging. Data was not available for 6 patients, one patient underwent emergency surgery, two patients were not fit for treatment, one failed to attend for restaging and two patients died prior to completion of treatment. Of the 59 patients restaged, 19 patients (32%) had their management plan altered from that which had been proposed at the initial LGIMDT discussion. The most common change in plan was not to operate. Ten patients had a complete clinical and radiological response to treatment and have undergone intensive follow-up. Nine patients had disease progression, with 3 requiring palliative surgery and 6 referred for palliative care.

CONCLUSION

Of those patients who were restaged, 32% had their management plan altered from that recorded at the initial LGIMDT discussion. Seventeen per cent of patients in this group had a complete clinical and radiological response to treatment. Fifteen percent demonstrated disease progression. We recommend, therefore, that patients with rectal cancer be restaged with CT and MRI following long-course chemoradiotherapy as surgery may be avoided in up to 27% of cases.

Clinical application of precise radiotherapy in rectal cancer

Precise radiotherapy plays an important role in the comprehensive multidisciplinary therapy of rectal cancer. The mainstream technology is the intensity modulated radiation therapy (IMRT). The technique of repetitive body positioning and the filling of the bladder and rectum are the important factors influencing the accuracy and efficacy of radiotherapy for rectal cancer. The quality of life for patients with rectal cancer is highly affected by side effects associated with radiotherapy. The application of precise positioning technique and image guided radiotherapy (IGRT) can significantly contribute to the accurate delivery of radiotherapy to the region of rectal cancer to improve the local tumor control and reduce unnecessary exposure of normal tissues to irradiation. In this paper, the clinical application of precise positioning technique and the improvement of accurate delivery of radiotherapy are comprehensively reviewed.

Current Role of Endoscopic Ultrasonography in Rectal Cancer Evaluation During Multidisciplinary Therapy

We report the case of a patient presenting in the Gastroenterology Department with intermittent rectal bleeding during the past year. A diagnosis of a low rectal adenocarcinoma was based on colonoscopy examination with biopsies, and staging procedures included transrectal endoscopic ultrasonography and magnetic resonance imaging of the abdomen and pelvis (cT2N0M0). Consequently the patient was referred for pre-operative chemoradiotherapy, achieving a complete clinical response as documented by repeated EUS and MRI examinations. Transanal endoscopic microsurgery with pathological assessment of the resected specimen revealed residual adenocarcinoma, highlighting the limitations of current imaging methods, and the constant need of technological improvements.

Prognostic Significance of Microvessel Density Determining by Endoglin in Stage II Rectal Carcinoma: A Retrospective Analysis

Background. The role of endoglin in the Dukes B rectal cancer is still unexplored. The aim of this study was to examine the expression of endoglin (CD105) in resected rectal cancer and to evaluate the relationship between microvessels density (MVD), clinicopathological factors, and survival rates. Methods. The study included 95 primary rectal adenocarcinomas, corresponding to 67 adjacent and 73 distant normal mucosa specimens from surgical resection samples. Tumor specimens were paraffin-embedded and immunohistochemical staining for the CD105 endothelial antigen was performed to count CD105-MVD. For exact measurement of the CD105-MVD used a computer-integrated system Alphelys Spot Browser 2 was used. Results. The intratumoral CD105-MVD was significantly higher compared with corresponding adjacent mucosa (P < 0.0001) and distant mucosa specimens (P < 0.0001). There was no significant difference in the CD105-MVD according to patients age, gender, tumor location, grade of differentiation, histological type, depth of tumor invasion, and tumor size. The overall survival rate was significantly higher in the low CD105-MVD group of patients than in the high CD105-MVD group of patients (log-rank test, P = 0.0406). Conclusion. CD105-assessed MVD could help to identify patients with possibility of poor survival in the group of stage II RC.