Organ sparing to cure stage IV rectal cancer: A case report and review of literature

BACKGROUND

Rectal sparing is an option for some rectal cancers with complete or good response after chemoradiotherapy (CRT); however, it has never been evaluated in patients with metastases. We assessed long-term outcomes of a rectal-sparing approach in a liver-first strategy for patients with rectal cancer with resectable liver metastases.

CASE SUMMARY

We examined patients who underwent an organ-sparing approach for rectal cancer with synchronous liver metastases using a liver-first strategy during 2010-2015 (n = 8). Patients received primary chemotherapy and pelvic CRT. Liver surgery was performed during the interval between CRT completion and rectal tumor re-evaluation. Clinical and oncological characteristics and long-term outcomes were assessed.All patients underwent liver metastatic resection with curative intent. The R0 rate was 100%. Six and two patients underwent local excision and a watch-and-wait (WW) approach, respectively. All patients had T3N1 tumors at diagnosis and had good clinical response after CRT. The median survival time was 60 (range, 14-127) mo. Three patients were disease free for 5, 8, and 10 years after the procedure. Five patients developed metastatic recurrence in the liver (n = 5) and/or lungs (n = 2). Only one patient developed local recurrence concurrent with metastatic recurrence 24 mo after the WW approach. Two patients died during follow-up.

CONCLUSION

The results suggest good local control in patients undergoing organ-sparing strategies for rectal cancer with synchronous liver metastasis. Prospective trials are required to validate these data and identify good candidates for these strategies.

Intracorporeal Anastomosis and ERAS Program: The Winning Combination of Optimized Postoperative Outcomes After Laparoscopic Right Colectomy

BACKGROUND

Laparoscopic technique and the enhanced recovery after surgery (ERAS) protocol have become the standard of care in patients undergoing right colon cancer surgery, reducing hospital stay and postoperative morbidity. However, the optimal anastomosis technique [intracorporeal anastomosis (ICA) or extracorporeal anastomosis (ECA)] remains debated. This study aimed to determine the optimal perioperative approach (ICA vs. ECA combined with the ERAS program vs. standard care) for patients undergoing laparoscopic right colectomy for cancer.

MATERIALS AND METHODS

This single-center, retrospective study evaluated all consecutive patients who underwent laparoscopic right hemicolectomy for cancer between January 2012 and June 2021. Patient data were analyzed in 4 treatment groups according to the type of anastomosis and the care protocol. The primary endpoint was total postoperative hospital stay (THS). The secondary endpoints were recovery time and overall morbidity rate.

RESULTS

The baseline characteristics of the 373 included patients were comparable between the 4 groups. THS was significantly shorter in the ICA/ERAS group than in the ECA/standard and ICA/standard groups ( P <0.01), but there was no significant difference between the ICA/ERAS and ECA/ERAS groups (5.7 vs. 6.4 d; P =0.17). Recovery time was significantly shorter in the ICA/ERAS group ( P <0.01). The overall morbidity rate, including anastomotic morbidity, was comparable among the 4 groups. Regression analysis showed that ICA and the ERAS program were both predictive factors to reduce the THS and recovery time.

CONCLUSIONS

ICA combined with the ERAS program achieves the best outcomes and thus seems to be the optimal approach for the management of patients undergoing laparoscopic right colectomy for cancer.

Supine bottom-up extralevator abdominoperineal excision for anorectal adenocarcinoma is not inferior to standard approach and may be thus safely performed

BACKGROUND

Extralevator abdominoperineal excision (APE) for rectal carcinoma has been described in order to improve pathological and oncological results compared to standard APE. To obtain the same oncological advantages as extralevator APE, we have previously described a new procedure starting by a perineal approach: the supine bottom-up APE. Our objective is to compare oncological and surgical outcomes between the supine bottom-up APE and the standard APE.

METHODS

All patients with low rectal adenocarcinoma requiring APE were retrospectively included and divided into 2 groups: supine bottom-up APE (Group A) and standard APE (Group B).

RESULTS

From 2008 to 2016, 61 patients were divided into Groups A (n = 30) and B (n = 31). Postoperative outcomes and median length of stay were similar between groups. Patients from Group A had a significantly longer distal margin (30 [8-120] vs. 20 [1.5-60] mm, p = 0.04) and higher number of harvested lymph nodes (14.5 [0-33] vs. 11 [5-25], p = 0.03) than those from Group B. Circumferential resection margin involvement was similar between groups (28 vs. 22%, p = 0.6), whereas tumors from Group A were significantly larger and more frequently classified as T4 than those from Group B. Operative time was significantly shorter in Group A (437.5 [285-655] minutes) than in Group B (537.5 [361-721] minutes, p = 0.0009). At the end of follow-up, local recurrence occurred in 7 and 16% of patients from Groups A and B (p = 0.68). Three-year overall and disease-free survival rates were similar between groups (87 vs. 90%, p = 0.62 and 61 vs. 63%, p = 0.88, respectively).

CONCLUSION

Our findings suggest that supine bottom-up APE doesn't impair surgical outcomes, pathological results, overall and disease-free survivals in comparison with standard APE. This new procedure may be thus safely performed and decrease the operative time. Further randomized multicentric studies are required to confirm these results.

Nomogram to predict disease recurrence in patients with locally advanced rectal cancer undergoing rectal surgery after neoadjuvant therapy: retrospective cohort study

INTRODUCTION

Prognostic models can be used for predicting survival outcomes and guiding patient management. TNM staging alone is insufficient for predicting recurrence after chemoradiotherapy (CRT) and surgery for locally advanced rectal cancer. This study aimed to develop a nomogram to better predict cancer recurrence after CRT followed by total mesorectal excision (TME) and tailor postoperative management and follow-up.

MATERIALS AND METHODS

Between 2002 and 2019, data were retrospectively collected on patients with rectal adenocarcinoma. Data on sex, age, carcinoembryonic antigen (CEA) level, tumour location, induction chemotherapy, adjuvant chemotherapy, tumour downsizing, perineural invasion, lymphovascular invasion, pathological stage, resection margins (R0 versus R1), and pelvic septic complications were analysed. The variables significantly associated with cancer recurrence were used to build a nomogram that was validated in both the training and validation cohorts. Model performance was evaluated by receiver operating characteristic curve and area under the curve (AUC) analyses.

RESULTS

After applying exclusion criteria, 634 patients with rectal adenocarcinoma were included in this study. Eight factors (CEA level, adjuvant chemotherapy, tumour downsizing, perineural invasion, lymphovascular invasion, pathological stage, resection margins (R0 versus R1), and pelvic septic complications) were identified as nomogram variables. Our nomogram showed good performance with an AUC of 0.74 and 0.75 in the training and validation cohorts respectively.

CONCLUSION

Our nomogram is a simple tool for predicting cancer recurrence in patients with locally advanced rectal cancer after neoadjuvant CRT followed by TME. It provides an individual risk prediction of recurrence to tailor surveillance.

Systematic Early Urinary Catheter Removal Integrated in the Full Enhanced Recovery After Surgery (ERAS) Protocol After Laparoscopic Mid to Lower Rectal Cancer Excision: A Feasibility Study

Purpose

Enhanced Recovery After Surgery (ERAS) programs advocate early urinary catheter removal after rectal cancer surgery; however, the optimal duration remains unclear. This study assessed the feasibility of the early urinary catheter removal protocol after rectal cancer surgery within an ERAS pathway and identified predictive factors for failure of this strategy.

Methods

Between March 2017 and October 2018, all unselected and consecutive patients who underwent rectal cancer resection and benefited from our ERAS program were included. Urinary complications (infection and retention) were prospectively recorded. Success was defined as catheter removal on postoperative day (POD) 3 without urinary complications.

Results

Of 135 patients (male, 63.7%; neoadjuvant chemoradiation, 57.0%; urology history, 17.8%), 120 had early urinary catheter removal with no complications (success rate, 88.9%), 8 did not have urinary catheter removal on POD 3 due to clinical judgment or prescription error, 5 experienced a urinary tract infection, and 2 had acute urinary retention. Obesity (odds ratio [OR], 0.16; P = 0.003), American Society of Anesthesiologists physical status classification > II (OR, 0.28; P = 0.048), antiaggregant platelet medication (OR, 0.12; P < 0.001), absence of anastomosis (OR, 0.1; P = 0.003), and prolonged operative time (OR, 0.21; P = 0.020) were predictive factors for failure. Conversely, optimal compliance with the ERAS program (OR, 7.68; P < 0.001), postoperative nonsteroidal anti-inflammatory drug use (OR, 21.71; P < 0.001), and balanced intravenous fluid therapy (OR, 7.87; P = 0.001) were associated with increased strategy success.

Conclusion

Withdrawal of the urinary catheter on POD 3 was successfully achieved after laparoscopic rectal resection and can be safely implemented in the ERAS program.

Well-Differentiated Papillary Mesothelioma of the Peritoneum: A Retrospective Study from the RENAPE Observational Registry

BACKGROUND

Well-differentiated papillary mesothelioma of the peritoneum (WDPMP) is a rare entity. Questions regarding management are still being debated as no more than 50 cases have been reported in the literature.

OBJECTIVE

We aimed to analyze the clinical, therapeutic, and prognostic data of patients with WDPMP from the RENAPE observational registry.

PATIENTS AND METHODS

All patients diagnosed with WDPMP and prospectively included in the RENAPE national registry between 2010 and 2018 were also included in our study. Expert pathologists from the RENA-PATH group confirmed all cases. All clinical, therapeutic, postoperative, and prognostic data were extracted and analyzed.

RESULTS

We report on 56 patients with a mean age of 52 years (range 21-74). WDPMP was incidentally diagnosed during imaging or surgery in 16% and 36% of patients, respectively, and an association with synchronous malignancy was found in 18% of patients. Nine lesions showed discrete signs of fatty invasion. The median Peritoneal Cancer Index was 11 (range 0-33). Eleven patients were treated with definitive excision, 4 were treated with cytoreductive surgery (CRS) only, 37 were treated with CRS and hyperthermic intraperitoneal chemotherapy (HIPEC), and 2 were treated with CRS plus HIPEC plus early postoperative intraperitoneal chemotherapy. CRS was considered to be complete in 90% of cases. One patient died postoperatively and 16 patients (31%) faced postoperative complications. The median disease-free survival was 144 months; Four patients relapsed, with a median period of 27 months. No prognostic factors could be identified.

CONCLUSIONS

Our analysis confirms the favorable prognosis of WDPMP. CRS and HIPEC could be a therapeutic option for diffuse, symptomatic, and/or recurrent disease.

Effect of Interval (7 or 11 weeks) Between Neoadjuvant Radiochemotherapy and Surgery on Complete Pathologic Response in Rectal Cancer: A Multicenter, Randomized, Controlled Trial (GRECCAR-6)

Purpose A pathologic complete response (pCR; ypT0N0) of a rectal tumor after neoadjuvant radiochemotherapy (RCT) is associated with an excellent prognosis. Several retrospective studies have investigated the effect of increasing the delay after RCT. The aim of this study was to evaluate the effect of increasing the interval between the end of RCT and surgery on the pCR rate. Methods GRECCAR6 was a phase III, multicenter, randomized, open-label, parallel-group controlled trial. Patients with cT3/T4 or Tx N+ tumors of the mid or lower rectum who had received RCT (45 to 50 Gy with fluorouracil or capecitabine) were included. Patients were randomly included in the 7-week or the 11-week (11w) group. Primary end point was the pCR rate defined as a ypT0N0 specimen (NCT01648894). Results A total of 265 patients from 24 centers were enrolled between October 2012 and February 2015. The majority of the tumors were cT3 (82%). After RCT, surgery was not performed in nine patients (3.4%) because of the occurrence of distant metastasis (n = 5) or other reasons. Two patients underwent local resection of the tumor scar. A total of 47 (18.6%) specimens were classified as ypT0 (four had invaded lymph nodes [8.5%]). The primary end point (ypT0N0) was not different (7 weeks: 20 of 133, 15.0% v 11w: 23 of 132, 17.4%; P = .5983). Morbidity was significantly increased in the 11w group (44.5% v 32%; P = .0404) as a result of increased medical complications (32.8% v 19.2%; P = .0137). The 11w group had a worse quality of mesorectal resection (complete mesorectum [I] 78.7% v 90%; P = .0156). Conclusion Waiting 11 weeks after RCT did not increase the rate of pCR after surgical resection. A longer waiting period may be associated with higher morbidity and more difficult surgical resection.

A multicentre randomised controlled trial to evaluate the efficacy, morbidity and functional outcome of endoscopic transanal proctectomy versus laparoscopic proctectomy for low-lying rectal cancer (ETAP-GRECCAR 11 TRIAL): rationale and design

BACKGROUND

Total mesorectal excision is the standard surgical treatment for mid- and low-rectal cancer. Laparoscopy represents a clear leap forward in the management of rectal cancer patients, offering significant improvements in post-operative measures such as pain, first bowel movement, and hospital length of stay. However, there are still some limits to its applications, especially in difficult cases. Such cases may entail either conversion to an open procedure or positive resection margins. Transanal endoscopic proctectomy (ETAP) was recently described and could address the difficulties of approaching the lower third of the rectum. Early series and case-control studies have shown favourable short-term results, such as a low conversion rate, reduced hospital length of stay and oncological outcomes comparable to laparoscopic surgery. The aim of the proposed study is to compare the rate of positive resection margins (R1 resection) with ETAP versus laparoscopic proctectomy (LAP), with patients randomly assigned to each arm.

METHODS/DESIGN

The proposed study is a multicentre randomised trial using two parallel groups to compare ETAP and LAP. Patients with T3 lower-third rectal adenocarcinomas for whom conservative surgery with manual coloanal anastomosis is planned will be recruited. Randomisation will be performed immediately prior to surgery after ensuring that the patient meets the inclusion criteria and completing the baseline functional and quality of life tests. The study is designed as a non-inferiority trial with a main criterion of R0/R1 resection. Secondary endpoints will include the conversion rate, the minimal invasiveness of the abdominal approach, postoperative morbidity, the length of hospital stay, mesorectal macroscopic assessment, functional urologic and sexual results, faecal continence, global quality of life, stoma-free survival, and disease-free survival at 3 years. The inclusion period will be 3 years, and every patient will be followed for 3 years. The number of patients needed is 226.

DISCUSSION

There is a strong need for optimal evaluation of the ETAP because of substancial changes in the operative technique. Assessment of oncological safety and septic risk, as well as digestive and urological functional results, is particularily mandatory. Moreover, benefits of the ETAP technique could be demonstrated  in post-operative outcome.

TRIAL REGISTRATION

ClinicalTrial.gov: NCT02584985 . Date and version identifier: Version n°2 - 2015 July 6.

Short- and Mid-Term Outcomes after Endoscopic Transanal or Laparoscopic Transabdominal Total Mesorectal Excision for Low Rectal Cancer: A Single Institutional Case-Control Study

BACKGROUND

Transabdominal laparoscopic proctectomy (LAP) for rectal cancer was associated with postoperative recovery improvement. Early studies showed favorable short-term results of endoscopic transanal proctectomy (ETAP), with low conversion rates to open procedures. We aimed to compare efficacy, morbidity, and functional outcomes of ETAP to standard LAP for low rectal cancer.

STUDY DESIGN

From 2008 to 2013, 72 consecutive patients received proctectomy and coloanal manual anastomosis for low rectal adenocarcinoma. Thirty-four patients had transanal endoscopic proctectomy, and 38 patients underwent the standard laparoscopic procedure.

RESULTS

When compared with the LAP group, the ETAP group demonstrated a lower conversion rate to open procedures (23.7% vs 2.9%, respectively; p = 0.015), shorter in-hospital stays (9 vs 8 days, respectively; p = 0.04), and a lower readmission rate (13.2% vs 0%; p = 0.03). Overall postoperative morbidity rates for the LAP and the ETAP groups (36.8% vs 32.4%, respectively; p = 0.69) and functional results (Kirwan score 1/2, 73.7% vs 73.5%, respectively; p = 0.85) were comparable; additionally, we found similar oncologic quality criteria (R1 resection 10.5% vs 5.9%, respectively; p = 0.68; grade 3 mesorectal integrity 52.6% vs 55.9%, respectively; p = 0.66). Disease-free survival of 24 months (Kaplan-Meier estimation) was comparable in the 2 groups: 86% in the ETAP group vs 88% in the LAP group; p = 0.91. At the date of last follow-up, 91.2% of ETAP patients and 92.1% of LAP patients were free of stoma.

CONCLUSIONS

The endoscopic transanal approach could facilitate mesorectal excision and improve short-term outcomes without impairing the oncologic quality of the resection or mid-term functional and oncologic results.

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis in the Elderly: A Case-Controlled, Multicenter Study

OBJECTIVE

This study was designed to identify factors associated with morbidity and mortality in patients older than 70 years who underwent cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis (PC).

BACKGROUND

Major surgery is associated with higher morbidity and mortality in elderly patients. For PC, CRS and HIPEC is the only current potential curative therapy, but the risks inherent to this patient population have called its benefits into question.

METHODS

We retrospectively analyzed a multi-center database from 1989 to 2015. All patients who underwent CRS and HIPEC for PC were selected and patients older than 70 years were matched 1:4 with a younger cohort according to cancer origin, peritoneal cancer index (PCI), and completeness of cytoreduction. Major morbidity and mortality were analyzed.

RESULTS

Of 2328 patients, 188 patients older than aged 70 years were matched with 704 younger patients. Patients older than aged 70 years demonstrated a higher American Society of Anesthesiologist score (≥ASA III 10.8 vs. 6.6 %, p = 0.008). There was no difference in overall 90-day morbidity (≥70: 45.7 % vs. <70: 44.5 %; p = 0.171); however, patients older than 70 years had significantly more cardiovascular complications (13.8 vs. 9.2 %, p = 0.044). Differences between the older and younger cohorts failed to reach significance for 90-day mortality (5.4 and 2.7 %, respectively; p = 0.052), and failure-to-rescue (11.6 and 6.1 %, respectively; p = 0.078). In multivariate analysis, PCI > 7 (95 % CI 1.051-5.798, p = 0.038) and HIPEC duration (95 % CI 1.106-6.235, p = 0.028) were independent factors associated with morbidity in elderly patients.

CONCLUSIONS

CRS and HIPEC appear feasible for selected patients older than aged 70 years, albeit with a higher risk of medical complications associated with increased mortality.

Overexpression of the Promigratory and Prometastatic PTK7 Receptor Is Associated with an Adverse Clinical Outcome in Colorectal Cancer

Biomarkers and novel therapeutic targets are urgently needed in colorectal cancer (CRC). The pseudo tyrosine kinase receptor 7 (PTK7) is involved in planar cell polarity and it is deregulated in various malignancies, including CRC. Yet, little is known about its protein expression in human CRC, or about a possible correlation of its expression with clinical endpoints. Using a clinically annotated Tissue MicroArray (TMA) produced from from 192 consecutive CRC patients treated by initial surgery, we examined PTK7 expression by immunohistochemistry in tumoral tissue and matched normal mucosae, and correlated its expression with clinico-pathological features and patient outcome. PTK7 depletion by specific shRNA in HCT116 and HCT15 CRC cell lines was found to affect cell proliferation, resistance to drugs and cell migration. Tumor growth and metastatic phenotype were investigated in vivo using a xenograft mouse model of CRC cells with modulated expression of PTK7 levels. PTK7 was significantly up-regulated in CRC tissue as compared to matched healthy mucosae, and significant overexpression was found in 34% of patients. PTK7 overexpression was significantly associated with a reduced metastasis-free survival in non-metastatic patients. In HCT116 and HCT15 cells, shRNA PTK7 reduced migration but did not affect cell proliferation and resistance to drugs. In a xenograft mouse of HCT15 cells, downregulation of PTK7 led to reduced tumor growth, whereas its overexpression in PTK7-negative cancer cells led to increased metastatic events. PTK7 expression thus represents a potential prognostic biomarker and a novel therapeutic target in CRC.

Caustic injuries of the upper digestive tract: a population observational study

BACKGROUND

Both observational and aggressive surgical strategies have been advocated for the treatment of corrosive injuries of the upper gastrointestinal tract (UGT) but the optimal management is still a dilemma. The aim of this study was to report our experience with caustic UGT injuries in adult patients treated with a surgically aggressive, endoscopy-based therapeutic protocol over a 6-year period.

PATIENTS AND METHODS

Between January 2002 and December 2007, 315 patients (138 men, mean age = 40 ± 15.5 years) were referred for corrosive UGT injuries. Emergency endoscopy was performed in all patients at admission. Patients with mild injuries (grades I-IIIa) were offered nonoperative management, whereas emergency surgery was performed for severe injuries (grades IIIb and IV). Esophageal reconstruction was offered to psychologically stable patients after emergency esophageal resection and for esophageal strictures that failed endoscopic dilation. Functional failure was defined as the impossibility to remove the jejunostomy or/and the tracheotomy tube.

RESULTS

At endoscopy 73 (23%) patients did not have UGT injuries, 158 (50%) patients had mild injuries eligible for nonoperative management and 84 (27%) patients had severe injuries. Nonoperative management was successful in 93% of patients with mild injuries. Surgical exploration was eventually performed in 88 (28%) patients and resection was undertaken in 76 of them. Emergency mortality was 7% and all fatalities were patients with initial severe injuries. After a median follow-up of 6 days (range = 1 day-8.5 years), functional failure was recorded in 9 (3%) patients, all of whom had initial severe injuries.

CONCLUSION

Emergency endoscopic grading of caustic injuries is the main factor that conditions outcome after caustic ingestion.

Neoadjuvant 5 fluorouracil-cisplatin chemoradiation effect on survival in patients with resectable pancreatic head adenocarcinoma: a ten-year single institution experience

OBJECTIVES

It is the aim of this study to assess the outcome of patients who received neoadjuvant 5-fluorouracil-cisplatin chemoradiation (CRT) for stage I/III pancreatic adenocarcinoma.

METHODS

Eligible patients (n = 101) received radiation therapy (45 Gy) associated with continuous infusion of 5-fluorouracil accompanied by a cisplatin bolus.

RESULTS

Of the 102 patients enrolled in the study, 26 patients had progression of cancer during treatment and were deemed unresectable; 1 patient died during CRT of septic shock. Sixty-two of 75 remaining patients underwent pancreaticoduodenectomy. The overall median survival of all 102 patients in the study was 17 months, with a 5-year survival of 10%. For patients who underwent resection, the median survival was 23 months. Correspondingly, the median survival was 11 months for the 40 unresected patients (p = 0.002). The 5-year survivals for resected and unresected patients were 18 and 0% (p = 0.01), respectively. A complete pathological response to neoadjuvant CRT was noted for 8 patients (13%). Margin and lymph node positivity was present in 5 (8%) and 15 (24%) patients, respectively. There was documented local recurrence in 8 (13%) and distant recurrence in 36 (58%) patients, with the liver being the most common site.

CONCLUSION

Neoadjuvant 5-fluorouracil-based CRT had a limited impact on survival but appeared to be associated with improved local control.