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van Gijn W, Marijnen CAM, Nagtegaal ID, Kranenbarg EMK, Putter H, Wiggers T, Rutten HJT, Påhlman L, Glimelius B, van de Velde CJH. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer: 12-year follow-up of the multicentre, randomised controlled TME trial. Lancet Oncol 2011. [PMID: 21596621 DOI: 10.1016/s1470-] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The TME trial investigated the value of preoperative short-term radiotherapy in combination with total mesorectal excision (TME). Long-term results are reported after a median follow-up of 12 years. METHODS Between Jan 12, 1996, and Dec 31, 1999, 1861 patients with resectable rectal cancer without evidence of distant disease were randomly assigned to TME preceded by 5 × 5 Gy radiotherapy or TME alone (ratio 1:1). Randomisation was based on permuted blocks of six with stratification according to centre and expected type of surgery. The primary endpoint was local recurrence, analysed for all eligible patients who underwent a macroscopically complete local resection. FINDINGS 10-year cumulative incidence of local recurrence was 5% in the group assigned to radiotherapy and surgery and 11% in the surgery-alone group (p<0·0001). The effect of radiotherapy became stronger as the distance from the anal verge increased. However, when patients with a positive circumferential resection margin were excluded, the relation between distance from the anal verge and the effect of radiotherapy disappeared. Patients assigned to radiotherapy had a lower overall recurrence and when operated with a negative circumferential resection margin, cancer-specific survival was higher. Overall survival did not differ between groups. For patients with TNM stage III cancer with a negative circumferential resection margin, 10-year survival was 50% in the preoperative radiotherapy group versus 40% in the surgery-alone group (p=0·032). INTERPRETATION For all eligible patients, preoperative short-term radiotherapy reduced 10-year local recurrence by more than 50% relative to surgery alone without an overall survival benefit. For patients with a negative resection margin, the effect of radiotherapy was irrespective of the distance from the anal verge and led to an improved cancer-specific survival, which was nullified by an increase in other causes of death, resulting in an equal overall survival. Nevertheless, preoperative short-term radiotherapy significantly improved 10-year survival in patients with a negative circumferential margin and TNM stage III. Future staging techniques should offer possibilities to select patient groups for which the balance between benefits and side-effects will result in sufficiently large gains. FUNDING The Dutch Cancer Society, the Dutch National Health Council, and the Swedish Cancer Society.
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Thong MSY, Mols F, Lemmens VEPP, Rutten HJT, Roukema JA, Martijn H, van de Poll-Franse LV. Impact of preoperative radiotherapy on general and disease-specific health status of rectal cancer survivors: a population-based study. Int J Radiat Oncol Biol Phys 2011; 81:e49-58. [PMID: 21362582 DOI: 10.1016/j.ijrobp.2010.12.030] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2010] [Revised: 12/10/2010] [Accepted: 12/15/2010] [Indexed: 01/11/2023]
Abstract
PURPOSE To date, few studies have evaluated the impact of preoperative radiotherapy (pRT) on long-term health status of rectal cancer survivors. Using a population-based sample, we assessed the impact of pRT on general and disease-specific health status of rectal cancer survivors up to 10 years post diagnosis. The health status of older (≥75 years old at diagnosis) pRT survivors was also compared with that of younger survivors. METHODS AND MATERIALS Survivors identified from the Eindhoven Cancer Registry treated with surgery only (SU) or with pRT between 1998 and 2007 were included. Survivors completed the Short Form-36 (SF-36) health survey questionnaire and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Colorectal 38 (EORTC QLQ-CR38) questionnaire. The SF-36 and EORTC QLQ-CR38 (sexuality subscale) scores of the survivors were compared to an age- and sex-matched Dutch normal population. RESULTS A total of 340 survivors (response, 85%; pRT survivors, 71%) were analyzed. Overall, survivors had similar general health status. Both short-term (<5 years) and long-term (≥5 years) pRT survivors had significantly poorer body image and more problems with gastrointestinal function, male sexual dysfunction, and defecation than SU survivors. Survivors had comparable general health status but greater sexual dysfunction than the normal population. Older pRT survivors had general and disease-specific health status comparable to that of younger pRT survivors. CONCLUSIONS For better survivorship care, rectal cancer survivors could benefit from increased clinical and psychological focus on the possible long-term morbidity of treatment and its effects on health status.
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Fariña-Sarasqueta A, Gosens MJEM, Moerland E, van Lijnschoten I, Lemmens VEPP, Slooter GD, Rutten HJT, van den Brule AJC. TS gene polymorphisms are not good markers of response to 5-FU therapy in stage III colon cancer patients. ANALYTICAL CELLULAR PATHOLOGY (AMSTERDAM) 2011; 33:1-11. [PMID: 20966539 PMCID: PMC4605551 DOI: 10.3233/acp-clo-2010-0526] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Aim: Although the predictive and prognostic value of thymidylate synthase (TS) expression and gene polymorphism in colon cancer has been widely studied, the results are inconclusive probably because of methodological differences. With this study, we aimed to elucidate the role of TS gene polymorphisms genotyping in therapy response in stage III colon carcinoma patients treated with 5-FU adjuvant chemotherapy. Patients and Methods: 251 patients diagnosed with stage III colon carcinoma treated with surgery followed by 5-FU based adjuvant therapy were selected. The variable number of tandem repeats (VNTR) and the single nucleotide polymorphism (SNP) in the 5′-untranslated region of the TS gene were genotyped. Results: There was a positive association between tumor T stage and the VNTR genotypes (p=0.05). In both univariate and multivariate survival analysis no effects of the studied polymorphisms on survival were found. However, there was an association between both polymorphisms and age. Among patients younger than 60 years, the patients homozygous for 2R seemed to have a better overall survival, whereas among the patients older than 67 this longer survival was seen by the carriers of other genotypes. Conclusion: We conclude that the TS VNTR and SNP do not predict response to 5-FU therapy in patients with stage III colon carcinoma. However, age appears to modify the effects of TS polymorphisms on survival.
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de Bruin AFJ, Gosselink MP, van der Harst E, Rutten HJT. Local application of gentamicin collagen implants in the prophylaxis of surgical site infections following gastrointestinal surgery: a review of clinical experience. Tech Coloproctol 2010; 14:301-10. [PMID: 20585822 PMCID: PMC2988990 DOI: 10.1007/s10151-010-0593-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Accepted: 06/10/2010] [Indexed: 01/15/2023]
Abstract
BACKGROUND Surgical site infection (SSI) is a common type of healthcare-associated infection in gastrointestinal (GI) surgical procedures, which often has major consequences for patient recovery and increased healthcare costs due to prolonged hospital stay. This article provides an overview of the efficacy and safety of prophylactic application of resorbable gentamicin-containing collagen implants (GCI) in the prevention of SSI following high-risk GI surgical procedures. METHOD Nine publications were identified using the PubMed online database and search terms 'gentamicin collagen implant' plus 'surgical site infection', 'wound infection' and 'gastrointestinal surgery'. RESULTS Data from 483 patients treated prophylactically have demonstrated that GCI can reduce the wound infection rate in high-risk GI surgical procedures and improve wound healing after pilonidal sinus excision. In a study of 221 patients who underwent colorectal surgery, the wound infection rate was reduced to 5.6% in the GCI group compared to 18.4% in the control group (P < 0.01). GCI also positively influences the post-operative course for patients undergoing particularly risky procedures e.g. abdominoperineal resection (APR) combined with neoadjuvant radiotherapy. In one such patient series, GCI reduced the wound infection rate by over 70% and the length of hospital stay by 40%. Few side effects of GCI were noted in the 9 clinical studies. CONCLUSIONS This review demonstrates that GCI can have a positive effect on wound infection rates in high-risk GI surgery and can also improve wound healing after pilonidal sinus excision.
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Klaver YLB, Hendriks T, Lomme RMLM, Rutten HJT, Bleichrodt RP, de Hingh IHJT. Intraoperative hyperthermic intraperitoneal chemotherapy after cytoreductive surgery for peritoneal carcinomatosis in an experimental model. Br J Surg 2010; 97:1874-80. [PMID: 20806291 DOI: 10.1002/bjs.7249] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2010] [Indexed: 12/22/2022]
Abstract
BACKGROUND The combination of cytoreductive surgery (CS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is the treatment of choice for selected patients with peritoneal carcinomatosis (PC) of colorectal origin. However, it remains to be proven whether the addition of HIPEC to CS is essential for the reported survival benefit. METHODS Sixty WAG/Rij rats were inoculated intraperitoneally with the rat colonic carcinoma cell line CC-531. Animals were randomized into three treatment groups: CS alone, CS followed by HIPEC (mitomycin 15 mg/m(2) ) and CS followed by HIPEC (mitomycin 35 mg/m(2) ). Survival was the primary outcome parameter. RESULTS The median survival of rats treated with CS alone was 43 days. Rats receiving HIPEC 15 mg/m(2) and HIPEC 35 mg/m(2) both had a significantly longer median survival of 75 days (P = 0·003) and 97 days (P < 0·001) respectively. Rats receiving HIPEC showed a significantly lower tumour load at autopsy compared with rats treated with CS alone. CONCLUSION A combination of CS and HIPEC results in longer survival than CS alone in rats with PC of colorectal origin.
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Fariña-Sarasqueta A, van Lijnschoten G, Rutten HJT, van den Brule AJC. Value of gene polymorphisms as markers of 5-FU therapy response in stage III colon carcinoma: a pilot study. Cancer Chemother Pharmacol 2010; 66:1167-71. [PMID: 20665215 DOI: 10.1007/s00280-010-1403-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2010] [Accepted: 07/11/2010] [Indexed: 01/31/2023]
Abstract
PURPOSE The role of pharmacogenetics in chemotherapy response in colon carcinoma is controversial. We studied the value of known SNPs in genes involved in 5-FU metabolism as biomarkers of chemotherapy response in patients with stage III colon carcinoma. METHODS DNA was isolated from normal colonic tissue of 60 patients with stage III colon carcinoma treated adjuvantly with 5-FU combined with leucovorin. The tested SNPs were validated SNPs on the OPRT, TYMS and DPYD genes and a synonymous SNP on the TYMP gene. Real-time PCR, sequencing and RFLP were used for genotyping. RESULTS None of the studied genotypes was associated with any of the tumor or patient characteristics. Moreover, none of the genotypes studied had effect on patient survival. CONCLUSION In conclusion, the tested SNPs are not biomarkers of chemotherapy response in our stage III colon cancer patients group.
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Kusters M, Wallner C, Lange MM, DeRuiter MC, van de Velde CJH, Moriya Y, Rutten HJT. Origin of presacral local recurrence after rectal cancer treatment. Br J Surg 2010; 97:1582-7. [DOI: 10.1002/bjs.7180] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Abstract
Background
The objective of this study was to obtain detailed anatomical information about the lateral lymph nodes, in order to determine whether they might play a role in presacral local recurrence of rectal cancer after total mesorectal excision without lateral lymph node dissection.
Methods
Ten serially sectioned human fetal pelvises were studied at high magnification and a three-dimensional reconstruction of the fetal pelvis was made.
Results
Examination of the histological sections and the three-dimensional reconstruction showed that lateral lymph node tissue comprises a major proportion of the pelvic tissue volume. There were no lymph nodes located in the presacral area. Connections between the mesorectal and extramesorectal lymph node system were found in all fetal pelvises, located below the peritoneal reflection on the anterolateral side of the fetal rectum. At this site middle rectal vessels passed to and from the mesorectum, and branches of the autonomic nervous system bridge to innervate the rectal wall.
Conclusion
The findings of this study support the hypothesis that tumour recurrence might arise from lateral lymph nodes.
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Dresen RC, Kusters M, Daniels-Gooszen AW, Cappendijk VC, Nieuwenhuijzen GAP, Kessels AGH, de Bruïne AP, Beets GL, Rutten HJT, Beets-Tan RGH. Absence of tumor invasion into pelvic structures in locally recurrent rectal cancer: prediction with preoperative MR imaging. Radiology 2010; 256:143-50. [PMID: 20574091 DOI: 10.1148/radiol.10090725] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE To retrospectively assess the accuracy of preoperative magnetic resonance (MR) imaging for identification of tumor invasion into pelvic structures in patients with locally recurrent rectal cancer scheduled to undergo curative resection. MATERIALS AND METHODS The institutional review board approved this study, and informed consent was waived because of the retrospective nature of the study. Preoperative MR images in 40 consecutive patients with locally recurrent rectal cancer scheduled to undergo curative treatment between October 2003 and November 2006 were analyzed retrospectively. Four observers with different levels of experience in reading pelvic MR images assessed tumor invasion into the following structures: bladder, uterus or seminal vesicles, vagina or prostate, left and right pelvic walls, and sacrum. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated, and a receiver operating characteristic curve was constructed. Surgical and/or histopathologic findings were used as the reference standard. Interobserver agreement was measured by using kappa statistics. RESULTS Preoperative MR imaging was accurate for the prediction of tumor invasion into structures with negative predictive values of 93%-100% and areas under receiver operating characteristic curves of 0.79-1.00 for all structures and observers. Positive predictive values were 53%-100%. Disease was overstaged in 11 (observer 1), 22 (observer 2), 10 (observer 3), and nine (observer 4) structures and was understaged in nine (observer 3) and two (observer 4) structures. Assessment failures were mainly because of misinterpretation of diffuse fibrosis, especially at the pelvic side walls. Interobserver agreement ranged between 0.64 and 0.99 for experienced observers. CONCLUSION Preoperative MR imaging is accurate for the prediction of absence of tumor invasion into pelvic structures. MR imaging may be useful as a preoperative road map for surgical procedure and may thus increase chances of complete resection. Interpretation of diffuse fibrosis remains difficult.
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MacDonald CM, Boursier L, D'Cruz DP, Dunn-Walters DK, Spencer J, Rutten HJT, van den Brule AJC. Mathematical analysis of antigen selection in somatically mutated immunoglobulin genes associated with autoimmunity. Lupus 2010; 21:2396-2402. [PMID: 20501503 DOI: 10.1093/annonc/mdq258] [Citation(s) in RCA: 199] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Affinity maturation is a process by which low-affinity antibodies are transformed into highly specific antibodies in germinal centres. This process occurs by hypermutation of immunoglobulin heavy chain variable (IgH V) region genes followed by selection for high-affinity variants. It has been proposed that statistical tests can identify affinity maturation and antigen selection by analysing the frequency of replacement and silent mutations in the complementarity determining regions (CDRs) that contact antigen and the framework regions (FRs) that encode structural integrity. In this study three different methods that have been proposed for detecting selection: the binomial test, the multinomial test and the focused binomial test, have been assessed for their reliability and ability to detect selection in human IgH V genes. We observe first that no statistical test is able to identify selection in the CDR antigen-binding sites, second that tests can reliably detect selection in the FR and third that antibodies from nasal biopsies from patients with Wegener's granulomatosis and pathogenic antibodies from systemic lupus erythematosus do not appear to be as stringently selected for structural integrity as other groups of functional sequences.
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van Riet YEA, Jansen FH, van Beek M, van de Velde CJH, Rutten HJT, Nieuwenhuijzen GAP. Localization of non-palpable breast cancer using a radiolabelled titanium seed. Br J Surg 2010; 97:1240-5. [DOI: 10.1002/bjs.7097] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Abstract
Background
Resection guided by a radiologically placed hookwire is the most common surgical technique for non-palpable breast cancer. This technique has several well described disadvantages such as incidental migration, kinking or fracture of the wire, and difficult logistics between the radiology, surgical and nuclear medicine departments. Use of an iodine-125-radiolabelled (I-125) seed for localization of non-palpable breast tumours could potentially prevent these problems.
Methods
Data on use of the I-125 seed localization technique in 325 consecutive women were collected prospectively between October 2003 and June 2009. All patients with screen-detected, histologically proven malignancy were included. Patients with a preoperative core biopsy showing either ductal carcinoma in situ or unclear pathology were excluded from this study.
Results
The mean(s.d.) age of the women was 59·5(11·9) years. Localization was guided ultrasonographically in 275 procedures, stereotactically in 45 and by both techniques in five. The I-125 seed was removed by surgery after a mean of 4(5) days. The mean duration of operation was 62·9(21·2) min. Complete tumour removal was achieved in 310 procedures (95·4 per cent).
Conclusion
Localization of impalpable breast cancer using a I-125 seed was safe and led to a high proportion of radical lumpectomies.
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van Steenbergen LN, Elferink MAG, Krijnen P, Lemmens VEPP, Siesling S, Rutten HJT, Richel DJ, Karim-Kos HE, Coebergh JWW. Improved survival of colon cancer due to improved treatment and detection: a nationwide population-based study in The Netherlands 1989-2006. Ann Oncol 2010; 21:2206-2212. [PMID: 20439339 DOI: 10.1093/annonc/mdq227] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND We described changes in treatment of colon cancer over time and the impact on survival in The Netherlands in the period 1989-2006. PATIENTS AND METHODS All 103,744 patients with invasive colon cancer during 1989-2006 in The Netherlands were included. Data were extracted from The Netherlands Cancer Registry. Trends in treatment over time were analysed and multivariable relative survival analysis was carried out. RESULTS The administration of adjuvant chemotherapy in stage III patients <75 years increased from 19% in 1989-1993 to 79% in 2004-2006 and from 1% to 19% in stage III patients ≥75 years. Among stage IV patients, resection rates of the primary tumour decreased from 72% to 63%, while chemotherapy administration increased from 23% to 64% in those <75 years. Survival increased from 52% to 58% in males and from 55% to 58% among females. Stage III patients with adjuvant chemotherapy exhibited a relative excess risk of 0.4 (95% confidence interval 0.4-0.4) compared with those without. Among stage IV patients, resection of primary tumour, palliative chemotherapy, and metastasectomy were important prognostic factors. CONCLUSIONS There were substantial improvements in management and survival of colon cancer from 1989 to 2006. Stage III disease patients with colon cancer experienced the largest improvement in survival, most likely related to the increased administration of adjuvant chemotherapy.
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van Steenbergen LN, Lemmens VEPP, Rutten HJT, Martijn H, Coebergh JWW. Was there shortening of the interval between diagnosis and treatment of colorectal cancer in southern Netherlands between 2005 and 2008? World J Surg 2010; 34:1071-9. [PMID: 20182722 PMCID: PMC2848725 DOI: 10.1007/s00268-010-0480-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Dutch Cancer Society proposed that the interval between diagnosis and start of treatment should be less than 15 working days. The purpose of this study was to determine whether the interval from diagnosis to treatment for patients with colorectal cancer (CRC) shortened between 2005 and 2008 in hospitals in southern Netherlands. METHODS Patients with CRC diagnosed in six hospitals in southern Netherlands during January to December in 2005 (n = 445) and January to July in 2008 (n = 353) were included. The time between diagnosis and start of treatment was assessed, and the proportion of patients treated within the recommended time (<15 working days) was calculated. RESULTS The time to treatment for colon cancer patients was 13 working days in 2005 and 17 working days in 2008. For rectal cancer patients, the median time to preoperative radiotherapy was 28 working days in 2005 and 30 working days in 2008, and the median time to surgical treatment for rectal cancer patients was 26 working days in 2005 and 18 working days in 2008. Time to treatment did not shorten between 2005 and 2008 for colon and rectal cancer patients, except for rectal cancer patients who underwent surgery as initial treatment in patients aged >70 years and those with stage I disease. Substantial variation was seen among hospitals. CONCLUSIONS Time to treatment for patients with CRC in southern Netherlands did not shorten between 2005 and 2008. The time to treatment should be reduced to meet the advice of the Dutch Cancer Society.
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van Steenbergen LN, van Lijnschoten G, Rutten HJT, Lemmens VEPP, Coebergh JWW. Improving lymph node detection in colon cancer in community hospitals and their pathology department in southern Netherlands. Eur J Surg Oncol 2009; 36:135-40. [PMID: 19576723 DOI: 10.1016/j.ejso.2009.05.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2009] [Revised: 05/20/2009] [Accepted: 05/28/2009] [Indexed: 12/12/2022] Open
Abstract
AIM The aim was to investigate whether a set of measures directed at increasing lymph node (LN) detection among colon cancer patients led to clinically relevant changes in LN detection rate. METHODS Data of all patients with curative colon cancer (pT(any) N(any) M0) diagnosed in 1999-2007 whose resection specimens were evaluated by the Institute for Pathology and Medical Microbiology in Eindhoven (n=1501) were included. Feedback to specialists, increased fixation time, and ex-vivo injection of the specimen with Patent blue V dye were used to increase LN detection rate. Trends in the proportion of patients with insufficient LNs examined were investigated; moreover, the Patent blue-stained patients (n=86) were compared with a group of unstained patients (n=84). Based on the decrease in the proportion of high-risk node-negative patients, a calculation of chemotherapy-related costs saved was made. RESULTS The proportion of patients with <12 LNs examined decreased from 87% in 1999 to 48% in 2007 (p(trend)<0.0001). In the stained group this was 37%, versus 56% for the unstained group (p=0.010). In 1999, 79% of stage II patients were high-risk compared to 55% in 2007, which translates to a saving of almost 1,000,000 euro based on 92 stage II patients diagnosed in 2007. CONCLUSION A diverse set of measures increased the number of examined lymph nodes among patients with colon cancer. Large savings can be made due to the reduced proportion of high-risk node-negative patients who would otherwise have received adjuvant chemotherapy.
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Dresen RC, Beets GL, Rutten HJT, Engelen SME, Lahaye MJ, Vliegen RFA, de Bruïne AP, Kessels AGH, Lammering G, Beets-Tan RGH. Locally advanced rectal cancer: MR imaging for restaging after neoadjuvant radiation therapy with concomitant chemotherapy. Part I. Are we able to predict tumor confined to the rectal wall? Radiology 2009; 252:71-80. [PMID: 19403847 DOI: 10.1148/radiol.2521081200] [Citation(s) in RCA: 114] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE To retrospectively assess accuracy of magnetic resonance (MR) imaging after radiation therapy with concomitant chemotherapy for downsizing of the primary lesion to ypT0-2 tumor confined to rectal wall in locally advanced rectal cancer, with histopathologic findings as reference standard, and to evaluate additional value of volumetric analysis. MATERIALS AND METHODS The institutional review board approved the study and waived informed consent. Sixty-seven patients met criteria of the study. T2-weighted MR images obtained before and after radiation therapy with concomitant chemotherapy were assessed for tumor stage by expert abdominal radiologist, colorectal surgeon, and general radiologist. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated; tumor volume was measured (compared with Mann-Whitney U test). Findings were correlated with histopathologic findings. RESULTS Sixty-seven patients (38 men, 29 women; mean age, 63 years) who underwent radiation therapy with concomitant chemotherapy and surgery (all but one) were evaluated. The PPV for prediction of tumor confined to rectal wall (ypT0-2) was 91% (10 of 11), 86% (six of seven), and 88% (seven of eight) for expert abdominal radiologist, surgeon, and general radiologist, respectively. In 24 patients, sensitivity was 42% (10), 25% (six), and 29% (seven). ypT0-2 tumors had significantly smaller volumes than did ypT3-4 tumors before radiation therapy with concomitant chemotherapy (55 vs 92 cm(3), P = .038). Volume reduction rates were significantly higher in ypT0-2 than in ypT3-4 tumors (89% vs 61%, P < .001). If volume before radiation therapy with concomitant chemotherapy was 50 cm(3) or smaller and volume reduction rate was 75% or higher, excised tumor was always confined to rectal wall (ypT0-2). By using these criteria, 43% (six of 14) of cases with overstaging could have been predicted to be ypT0-2 tumors correctly. CONCLUSION Downsizing to ypT0-2 tumors can be accurately predicted by combining morphologic tumor staging predictions with results from volumetric analyses. MR images obtained after radiation therapy with concomitant chemotherapy might be helpful in more individualized treatment planning.
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Kusters M, Holman FA, Martijn H, Nieuwenhuijzen GA, Creemers GJ, Daniels-Gooszen AW, van den Berg HA, van den Brule AJ, van de Velde CJH, Rutten HJT. Patterns of local recurrence in locally advanced rectal cancer after intra-operative radiotherapy containing multimodality treatment. Radiother Oncol 2009; 92:221-5. [PMID: 19339070 DOI: 10.1016/j.radonc.2009.03.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2009] [Revised: 03/07/2009] [Accepted: 03/07/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND PURPOSE The purpose of this study is to analyze the patterns of local recurrence (LR) after intra-operative radiotherapy (IORT) containing multimodality treatment of locally advanced rectal carcinoma (LARC). METHODS AND MATERIALS Two hundred and ninety patients with LARC who underwent multimodality treatment between 1994 and 2006 were studied. For patients who developed LR, the subsite was classified into presacral, postero-lateral, lateral, anterior, anastomotic or perineal. Patient and treatment characteristics were related to subsite of LR. RESULTS After 5years, 34 patients (13.2%) developed LR. The most prominent subsite of LR was the presacral subsite. 47% of the local recurrences occurred outside the IORT field. Most recurrences developed when IORT was given dorsally, while least occurred when IORT was given ventrally. Especially after dorsal IORT a high amount of infield recurrences were observed (6 of 8; 75%). In multi-variate analysis tumor distance of more than 5cm from the anal verge and a positive circumferential margin were associated with presacral local recurrence. CONCLUSIONS Multimodality treatment is effective in the prevention of local recurrence in LARC. IORT application to the area most at risk is feasible and seems effective in the prevention of local recurrence. Dorsal tumor location results in unfavourable oncologic results.
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Gosens MJEM, Dresen RC, Rutten HJT, Nieuwenhuijzen GAP, van der Laak JAWM, Martijn H, Tan-Go I, Nagtegaal ID, van den Brule AJC, van Krieken JHJM. Preoperative radiochemotherapy is successful also in patients with locally advanced rectal cancer who have intrinsically high apoptotic tumours. Ann Oncol 2008; 19:2026-32. [PMID: 18664561 DOI: 10.1093/annonc/mdn428] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Not all patients with locally advanced rectal cancer (LARC) respond equally to neo-adjuvant radiochemotherapy (RCT). Patients with highly apoptotic less advanced rectal cancers do not benefit from short-term radiotherapy. This study investigates whether this is also the case in the setting of RCT for LARC. PATIENTS AND METHODS Tissue microarrays were constructed of biopsy and resection specimens of 201 LARC patients. Apoptosis (M30) and several apoptosis-regulating proteins [p53, Bcl-2, Bax, cyclooxygenase-2 (Cox-2) and mamma serine protease inhibitor (maspin)] were studied with immunohistochemistry. Subsequently, predictive values for local recurrence (LR), overall survival (OS) and histological tumour regression were analysed. RESULTS Apoptotic levels, quantified as the number of apoptotic cells/mm(2) tumour epithelium, were higher in posttherapy tissues compared with biopsies (P < 0.001). Biopsies from clinical T4 stage tumours demonstrated significantly higher levels of apoptosis than clinical T3 stage tumours (P = 0.020). Therapy-induced apoptosis was higher when the interval between the last day of irradiation and surgery increased (P < 0.001, correlation coefficient = 0.355). Pre- and posttherapy apoptosis, p53, Bcl-2, Bax and Cox-2 were not associated with LR, OS or tumour regression. Intense pretherapy cytoplasmatic staining of maspin indicated a higher risk on LR (P = 0.009) only. CONCLUSION Combined RCT is also successful in highly apoptotic tumours and is therefore independent of intrinsic apoptosis.
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Faneyte IF, Dresen RC, Edelbroek MAL, Nieuwenhuijzen GAP, Rutten HJT. Pre-operative staging with positron emission tomography in patients with pelvic recurrence of rectal cancer. Dig Surg 2008; 25:202-7. [PMID: 18577865 DOI: 10.1159/000140690] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2007] [Accepted: 01/26/2008] [Indexed: 12/16/2022]
Abstract
BACKGROUND/AIM The treatment of pelvic recurrences of rectal cancer is primarily surgical. The substantial morbidity and mortality of such resections warrant stringent patient selection. Recent literature reports PET to be of additional value to CT for the detection of metastases in colorectal cancer patients. We studied the clinical impact of PET in pelvic rectal cancer recurrence. METHODS PET findings in 37 pelvic recurrences of rectal cancer were evaluated retrospectively. Comparison was made to CT and MRI findings. It was analyzed whether PET had been decisive in clinical decision making or could have been so. RESULTS Thirty-two patients had 37 rectal cancer recurrences. PET differed from conventional imaging in 13 cases (35%): seven PET scans showed lesions that were not seen with CT or MRI. PET scans were negative in six lesions detected by CT or MRI. PET alone changed management in five recurrences (14%). Four PET scans were false-positive; this had clinical implications in 2 patients. CONCLUSION In a selected population with pelvic rectal cancer recurrences, PET had additional value to conventional imaging, mainly in detecting lymph node metastases. PET findings thus had a significant impact on selection of patients for curative surgery.
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Rutten HJT, den Dulk M, Lemmens VEPP, van de Velde CJH, Marijnen CAM. Controversies of total mesorectal excision for rectal cancer in elderly patients. Lancet Oncol 2008; 9:494-501. [PMID: 18452860 DOI: 10.1016/s1470-2045(08)70129-3] [Citation(s) in RCA: 219] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The cornerstone of treatment for rectal cancer is resectional treatment according to the principles of total mesorectal excision (TME). However, population-based registries show that improvements in outcome after resectional treatment occur mainly in younger patients. Furthermore, 6-month postoperative mortality is significantly increased in elderly patients (> or = 75 years of age) compared with younger patients (< 75 years of age). Several confounding factors, such as treatment-related complications and comorbidity, are thought to be responsible for these disappointing findings. Thus, major resectional treatment is not advantageous for all older patients with rectal cancer. However, the Dutch TME trial showed a good response to a short course of neoadjuvant radiotherapy in elderly patients. Biological responses to cancer treatment seem to change with age, and, therefore, individualised cancer treatments should be used that take into account the heterogeneity of ageing. For elderly patients who retain a good physical and mental condition, treatment that is given to younger patients is deemed appropriate, whereas for those with diminished physiological reserves and comorbid conditions, alternative treatments that keep surgical trauma to a minimum and optimise the use of radiotherapy might be more suitable.
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Gosens MJEM, Klaassen RA, Tan-Go I, Rutten HJT, Martijn H, van den Brule AJC, Nieuwenhuijzen GAP, van Krieken JHJM, Nagtegaal ID. Circumferential margin involvement is the crucial prognostic factor after multimodality treatment in patients with locally advanced rectal carcinoma. Clin Cancer Res 2008; 13:6617-23. [PMID: 18006762 DOI: 10.1158/1078-0432.ccr-07-1197] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE After preoperative (radio)chemotherapy, histologic determinants for prognostication have changed. It is unclear which variables, including assessment of tumor regression, are the best indicators for local recurrence and survival. EXPERIMENTAL DESIGN A series of 201 patients with locally advanced rectal cancer (cT3/T4, M0) presenting with an involved or at least threatened circumferential margin (CRM) on preoperative imaging (<2 mm) were evaluated using standard histopathologic variables and four different histologic regression systems. All patients received neoadjuvant radiochemotherapy or radiotherapy. The prognostic value of all factors was tested with univariate survival analysis of time to local recurrence and overall survival. RESULTS Local recurrence occurred in only 8% of the patients with a free CRM compared with 43% in case of CRM involvement (P < 0.0001). None of the four regression systems were associated with prognosis, not even when corrected for CRM status. However, we did observe a higher degree of tumor regression after radiochemotherapy compared with radiotherapy (P < 0.001). Absence of tumor regression was associated with increasing invasion depth and a positive CRM (P = 0.02 and 0.03, respectively). CONCLUSIONS Assessment of CRM involvement is the most important pathologic variable after radiochemotherapy. Although tumor regression increases the chance on a free CRM, in cases with positive resection margins prognosis is poor irrespective of the degree of therapy-induced regression.
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Vulto JCM, Louwman WJ, Lybeert MLM, Poortmans PMP, Rutten HJT, Brenninkmeijer SJ, Coebergh JWW. A population-based study of radiotherapy in a cohort of patients with rectal cancer diagnosed between 1996 and 2000. Eur J Surg Oncol 2007; 33:993-7. [PMID: 17400420 DOI: 10.1016/j.ejso.2007.02.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2006] [Accepted: 02/12/2007] [Indexed: 10/23/2022] Open
Abstract
AIMS To study, in a population-based setting, the use of delayed radiotherapy (RT) in a cohort of 2008 unselected rectal cancer patients diagnosed between 1996 and 2000. PATIENTS AND METHODS Radiation within 6 months of diagnosis was considered part of the primary treatment (PRT). RT given 6 months or later after diagnosis or after PRT was considered as delayed or secondary RT (SRT). Number, percentage and cumulative proportion of patients receiving SRT were calculated. The odds for receiving SRT (total and for recurrent rectal cancer only) were studied by logistic regression analysis, taking into account age, gender, co-morbidity, socio-economic status, stage, prior PRT and RT department (2 departments, each serving general hospitals only). RESULTS Forty-six percent of all newly diagnosed patients received RT. Ten percent (n=203) received at least once SRT, either after PRT or as first RT, of which 96 patients for a relapsed rectal tumour (31 after PRT on the rectal tumour, 65 as a first radiation treatment). In a multivariate analysis of patients with rectal recurrence secondary pelvic irradiation was less often given after primary irradiation (OR: 0.7, 95% CI: 0.4-1.1). Patients with a stage III significantly more often received SRT on a recurrence (OR=2.5, 95% CI=1.4-4.5). Generally, patients in the eastern department received more often PRT and less often SRT for recurrence (OR: 0.5, 95% CI: 0.3-0.8). CONCLUSIONS Five percent of all patients with rectal cancer received SRT on a recurrent tumour, with a large variation between the two RT departments in the region.
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van de Schoot L, Romme EAPM, van der Sangen MJ, Creemers GJ, van Lijnschoten G, van Driel OJR, Rutten HJT, Nieuwenhuijzen GAP. A highly active and tolerable neoadjuvant regimen combining paclitaxel, carboplatin, 5-FU, and radiation therapy in patients with stage II and III esophageal cancer. Ann Surg Oncol 2007; 15:88-95. [PMID: 17896144 PMCID: PMC2190342 DOI: 10.1245/s10434-007-9582-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2007] [Revised: 07/26/2007] [Accepted: 07/27/2007] [Indexed: 12/13/2022]
Abstract
Background The present phase II study aimed to assess the feasibility and efficacy of a new paclitaxel-based neoadjuvant chemoradiation regimen followed by surgery in patients with stage II–III esophageal cancer. Methods From January 2002 to November 2004, 50 patients with a potentially resectable stage II–III esophageal cancer received chemotherapy with paclitaxel, carboplatin, and 5-FU in combination with radiotherapy 45 Gy in 25 fractions. Surgery followed 6–8 weeks after completion of neoadjuvant treatment. Results Patient characteristics: male/female: 44/6, median age 60 years (34–75), median WHO 1 (0–2), adenocarcinoma (n = 42), squamous cell carcinoma (n = 8). Toxicity was mild, and 84 % of the patients completed the whole regimen. Forty-seven patients underwent surgery with a curative intention (transhiatal n = 44, transthoracic n = 3). Pathologic complete tumor regression was achieved in 18 of 47 operated patients (38%). R0 resection was achieved in 45 of 47 operated patients (96%). There were four postoperative deaths (8.5). Postoperative complications were comparable with other studies. After a median follow-up of 41.5 months (21–59) estimated 3- and 5-year survival on an intention-to-treat basis was 56 and 48%. Estimated 3-year survival in responders was 61%, in nonresponders 33%. Conclusion This novel neoadjuvant chemoradiation regimen for treatment of patients with stage II–III esophageal cancer is feasible. Results are encouraging with a high pathologic complete tumor regression and R0 resection rate and an acceptable morbidity and mortality. Preliminary survival data are very promising.
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Vulto JCM, Louwman WJ, Poortmans PMP, Lybeert LM, Rutten HJT, Coebergh JWW. A population based study of radiotherapy in a cohort of patients with breast cancer diagnosed between 1996 and 2000. Eur J Cancer 2007; 43:1976-82. [PMID: 17618112 DOI: 10.1016/j.ejca.2007.05.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2007] [Revised: 05/16/2007] [Accepted: 05/25/2007] [Indexed: 11/30/2022]
Abstract
We studied the use of radiotherapy (RT) (especially secondary RT) in a cohort of 6561 patients in southern Netherlands with invasive breast cancer diagnosed between 1996 and 2000 (median follow-up: 66 months, range 0-107 months). Radiation within 6 months of diagnosis was considered primary RT (PRT). RT given 6 months or later after diagnosis or after PRT was considered secondary RT (SRT). Of all patients, 67% received RT, 3554 only PRT, 323 only SRT and 503 both. The cumulative use of SRT at 100 months was 17%. The 826 patients receiving SRT underwent 1846 courses 0-105 months (median 36) after diagnosis; the retreat rate was 35%. Elderly patients received SRT significantly less often (OR(age50-69)=0.7, 95%CI=0.6-0.8, OR(age> or 70)=0.4, 95%CI=0.3-0.5). The following factors increased the chance for SRT: patients from the eastern region (OR=1.3, 95%CI=1.1-1.6); patients who received PRT (OR=1.3, 95%CI=1.0-1.5) and patients who underwent mastectomy including axillary node dissection as well as unresected patients (OR=1.9, 95%CI=1.5-2.4, OR=2.6, 95%CI=1.7-3.9, respectively). Thirteen percent of all patients with breast cancer received SRT, with a large variation in age and between the 2 RT departments in the region.
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de Heer P, Gosens MJEM, de Bruin EC, Dekker-Ensink NG, Putter H, Marijnen CAM, van den Brule AJC, van Krieken JHJM, Rutten HJT, Kuppen PJK, van de Velde CJH. Cyclooxygenase 2 expression in rectal cancer is of prognostic significance in patients receiving preoperative radiotherapy. Clin Cancer Res 2007. [PMID: 17504996 DOI: 10.1158/1078-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE To determine the effect of cyclooxygenase (COX)-2 expression on clinical behavior in irradiated and nonirradiated rectal carcinomas. EXPERIMENTAL DESIGN Tumor samples were collected from 1,231 patients of the Dutch TME trial, in which rectal cancer patients were treated with standardized surgery and randomized for preoperative short-term (5 x 5 Gy) radiotherapy or no preoperative radiotherapy. Tissue microarrays were constructed from primary tumor material, and COX-2 expression was assessed by immunohistochemistry. Tumor cell apoptosis was determined by M30 immunostaining. RESULTS A high level of COX-2 expression after radiotherapy was associated with low levels of tumor cell apoptosis (P=0.001). COX-2 expression had no significant effect on patient survival or tumor recurrence in nonirradiated tumors. However, in patients receiving preoperative radiotherapy, high level of COX-2 expression was associated with higher incidence of distant recurrences [P=0.003; hazard ratio (HR), 1.7; 95% confidence interval (95% CI), 1.2-2.5] and shorter disease-free survival (P=0.002; HR, 1.8; 95% CI, 1.2-2.5) and overall survival (P=0.009; HR, 1.5; 95% CI, 1.1-2.0), independent of patient age, tumor stage, tumor location, or the presence of tumor cells in the circumferential resection margin. CONCLUSIONS A high level of COX-2 expression after preoperative radiotherapy in resection specimens is associated with apoptosis resistance, high distant recurrence rates, and a poor prognosis in rectal cancer.
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de Heer P, Gosens MJEM, de Bruin EC, Dekker-Ensink NG, Putter H, Marijnen CAM, van den Brule AJC, van Krieken JHJM, Rutten HJT, Kuppen PJK, van de Velde CJH. Cyclooxygenase 2 expression in rectal cancer is of prognostic significance in patients receiving preoperative radiotherapy. Clin Cancer Res 2007; 13:2955-60. [PMID: 17504996 DOI: 10.1158/1078-0432.ccr-06-2042] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To determine the effect of cyclooxygenase (COX)-2 expression on clinical behavior in irradiated and nonirradiated rectal carcinomas. EXPERIMENTAL DESIGN Tumor samples were collected from 1,231 patients of the Dutch TME trial, in which rectal cancer patients were treated with standardized surgery and randomized for preoperative short-term (5 x 5 Gy) radiotherapy or no preoperative radiotherapy. Tissue microarrays were constructed from primary tumor material, and COX-2 expression was assessed by immunohistochemistry. Tumor cell apoptosis was determined by M30 immunostaining. RESULTS A high level of COX-2 expression after radiotherapy was associated with low levels of tumor cell apoptosis (P=0.001). COX-2 expression had no significant effect on patient survival or tumor recurrence in nonirradiated tumors. However, in patients receiving preoperative radiotherapy, high level of COX-2 expression was associated with higher incidence of distant recurrences [P=0.003; hazard ratio (HR), 1.7; 95% confidence interval (95% CI), 1.2-2.5] and shorter disease-free survival (P=0.002; HR, 1.8; 95% CI, 1.2-2.5) and overall survival (P=0.009; HR, 1.5; 95% CI, 1.1-2.0), independent of patient age, tumor stage, tumor location, or the presence of tumor cells in the circumferential resection margin. CONCLUSIONS A high level of COX-2 expression after preoperative radiotherapy in resection specimens is associated with apoptosis resistance, high distant recurrence rates, and a poor prognosis in rectal cancer.
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den Dulk M, Marijnen CAM, Putter H, Rutten HJT, Beets GL, Wiggers T, Nagtegaal ID, van de Velde CJH. Risk factors for adverse outcome in patients with rectal cancer treated with an abdominoperineal resection in the total mesorectal excision trial. Ann Surg 2007; 246:83-90. [PMID: 17592295 PMCID: PMC1899206 DOI: 10.1097/01.sla.0000259432.29056.9d] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE This study was performed to identify tumor- and patient-related risk factors for distal rectal cancer in patients treated with an abdominoperineal resection (APR) associated with positive circumferential resection margin (CRM), local recurrence (LR), and overall survival (OS). BACKGROUND The introduction of total mesorectal excision (TME) has improved the outcome of patients with rectal cancer. However, survival of patients treated with an APR improved less than of those treated with low anterior resections (LAR). Besides, an APR is associated with a higher LR rate. METHODS Patients were selected from the TME trial, which is a randomized, multicenter trial, studying the effects of preoperative radiotherapy (RT) in 1861 patients. Of the Dutch patients, 455 underwent an APR. Location of the bulk of the tumor was scored with surgery, pathology, or other reports. CRM was available from pathology reports. RESULT A positive CRM was found in 29.6% of all patients, 44% for anterior, 21% for lateral, 23% for posterior, and 17% for (semi)circular tumor location (P < 0.0001). In a multivariate analysis, T-stage, N-stage, and tumor location were independent risk factors for CRM. If a (partial) resection of the vaginal wall was performed in women, 47.8% of patients still had a positive CRM. T-stage, N-stage, and CRM were risk factors for LR and age, T-stage, N-stage, CRM, and distance of the inferior tumor margin to the anal verge for OS. CONCLUSION Age, T-stage, N-stage, CRM, distance of the tumor to the anal verge, and tumor location were independent risk factors for adverse outcome in patients treated with an APR for low rectal cancer. Anterior location, specifically in women, more often requires downstaging and/or more extended resection to obtain free margins.
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den Dulk M, Smit M, Peeters KCMJ, Kranenbarg EMK, Rutten HJT, Wiggers T, Putter H, van de Velde CJH. A multivariate analysis of limiting factors for stoma reversal in patients with rectal cancer entered into the total mesorectal excision (TME) trial: a retrospective study. Lancet Oncol 2007; 8:297-303. [PMID: 17395102 DOI: 10.1016/s1470-2045(07)70047-5] [Citation(s) in RCA: 219] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND In many patients with rectal cancer, defunctioning stomas are created to limit the consequences of anastomotic leakage. Although intended to be temporary, a substantial proportion of these stomas might never be reversed for various reasons. We aimed to describe stoma policy by use of data from the total mesorectal excision (TME) trial in patients with rectal cancer and to identify factors that limit stoma reversal. METHODS 924 Dutch patients with rectal cancer who underwent a low anterior resection were selected from the TME trial, a prospective, randomised multicentre trial studying the effects of short-term preoperative radiotherapy in 1861 patients who underwent TME. Creation of stomas and time to stoma reversal were analysed retrospectively by use of multivariate analysis. FINDINGS In 523 of 924 (57%) patients, a primary stoma (defined as a stoma created at the time of TME) was constructed after a low anterior resection. Geographical differences in the number of primary stomas constructed were reported throughout the Netherlands. 19% of stomas that were created were never reversed. Postoperative complications and secondary constructed stomas (defined as a stoma created during a second or subsequent procedure after TME) were associated with a high likelihood of a permanent stoma. However, perioperative complications were not a limiting factor for stoma closure. INTERPRETATION Postoperative complications are an important limiting factor for stoma reversal because, after occurrence of these complications, patients and surgeons might be reluctant to reverse the stoma, so a substantial proportion of these stomas are never closed. Future guidelines for stoma creation and closure should consider these factors.
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Lemmens VEPP, Verheij CDGW, Janssen-Heijnen MLG, Rutten HJT, Coebergh JWW. Mixed adherence to clinical practice guidelines for colorectal cancer in the Southern Netherlands in 2002. Eur J Surg Oncol 2006; 32:168-73. [PMID: 16387468 DOI: 10.1016/j.ejso.2005.11.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2005] [Accepted: 11/21/2005] [Indexed: 12/14/2022] Open
Abstract
AIMS Population-based cancer registries can provide excellent data for insight in disease management practice. This study examines the extent to which the consensus-based national clinical guidelines (version 2000-2001) for colorectal cancer (CRC) had been implemented in the diagnostic and treatment approach in the Southern Netherlands in 2002. METHODS Data were gathered from the medical records for a random sample from the Eindhoven Cancer Registry of 308 patients with colorectal cancer. Adherence to clinical guidelines was determined for diagnostic assessment, pathology, and treatment during the first year after diagnosis. RESULTS Surgical procedures and referral for pre-operative radiotherapy were carried out largely conform the recommendations. The number of performed colonoscopies among colon cancer patients amounted to 60%; contrast enemas after incomplete colonoscopy were performed in only 27% of patients. The median number of examined lymph nodes was only six for patients with colon and five for patients with rectal cancer; the administration of adjuvant chemotherapy for patients with stage III colon cancer decreased from 95% of patients younger than 70 years to 48% of patients over 70. CONCLUSIONS Adherence to clinical guidelines was not optimal. Feedback to surgeons and pathologists should improve adherence, especially with respect to nodal retrieval and assessment.
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van der Sangen MJC, van de Poll-Franse LV, Roumen RMH, Rutten HJT, Coebergh JWW, Vreugdenhil G, Voogd AC. The prognosis of patients with local recurrence more than five years after breast conservation therapy for invasive breast carcinoma. Eur J Surg Oncol 2005; 32:34-8. [PMID: 16305821 DOI: 10.1016/j.ejso.2005.10.005] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2005] [Accepted: 10/20/2005] [Indexed: 11/22/2022] Open
Abstract
AIMS The increasing use of breast-conserving therapy (BCT) and the rising incidence and improved prognosis of early breast are causing a substantial increase in the absolute number of patients with a late local recurrence following BCT. This study examined the characteristics and the prognosis of patients with a local recurrence occurring more than 5 years after BCT. METHODS In the period 1982-1997, 3280 patients with invasive breast cancer underwent breast-conserving therapy in one of the eight community hospitals in the South-eastern part of The Netherlands. Of these patients, 98 developed a local recurrence in the breast more than 5 years after BCT. RESULTS Eighty-five of the 98 recurrences were invasive, 12 were purely in situ and for one patient this information was not available. The 5 years distant recurrence-free survival rate of 85 patients with a late invasive local recurrence was 68% (95% confidence interval [CI], 56-80) and significantly better than the rate of 41% (95% CI, 33-48) in an existing cohort of 173 patients with invasive recurrence within 5 years after BCT (p=0.007). Local excision of the recurrence was followed by a significantly lower local control rate than salvage mastectomy (50 vs 89%; p=0.004). CONCLUSION The prognosis of patients with a local recurrence more than 5 years after BCT is significantly better than of patients with local recurrence within 5 years after BCT.
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Voogd AC, Cranenbroek S, de Boer R, Roumen RMH, Rutten HJT, van der Sangen MJC. Long-term prognosis of patients with axillary recurrence after axillary dissection for invasive breast cancer. Eur J Surg Oncol 2005; 31:485-9. [PMID: 15922883 DOI: 10.1016/j.ejso.2004.12.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2004] [Revised: 12/23/2004] [Accepted: 12/23/2004] [Indexed: 11/24/2022] Open
Abstract
AIM To investigate the long-term prognosis of patients with axillary recurrence after axillary dissection for invasive breast cancer and describe the long-term survivors. METHODS Between 1984 and 1994, 4669 patients with invasive breast cancer underwent axillary dissection in eight community hospitals in the south-eastern part of The Netherlands. Using follow-up data of the population-based Eindhoven Cancer Registry, 59 patients with axillary recurrence were identified. RESULTS The median interval between treatment of the primary tumour and diagnosis of axillary recurrence was 2.6 years (range 0.3-10.7). The median length of follow-up after diagnosis of axillary recurrence was 11.1 years (5.7-15.6). Distant metastases occurred in 38 of the 59 patients. The 5- and 10-year distant recurrence-free survival rates were 39% (95% CI: 25-52%) and 29% (95% CI: 16-42%). CONCLUSIONS Axillary recurrence following axillary dissection is associated with a high rate of subsequent distant metastasis and poor overall prognosis but is not always a fatal event. Our results show that it is possible to cure about one-third of the patients.
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van den Brink M, Stiggelbout AM, van den Hout WB, Kievit J, Klein Kranenbarg E, Marijnen CAM, Nagtegaal ID, Rutten HJT, Wiggers T, van de Velde CJH. Clinical nature and prognosis of locally recurrent rectal cancer after total mesorectal excision with or without preoperative radiotherapy. J Clin Oncol 2004; 22:3958-64. [PMID: 15459218 DOI: 10.1200/jco.2004.01.023] [Citation(s) in RCA: 119] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE To document the clinical nature and prognosis of locally recurrent rectal cancer after total mesorectal excision (TME) with or without 5 x 5 Gy preoperative radiotherapy (PRT) and to identify patient-, disease-, and treatment-related factors associated with differences in prognosis after local recurrence. PATIENTS AND METHODS For 96 Dutch patients with a local recurrence who participated in a multicenter randomized clinical trial, data on treatments and follow-up were gathered from surgeons and radiation and medical oncologists. Twenty-three patients (24%) had previously been treated with PRT plus TME, and 73 patients (76%) had been treated with TME alone. Eighty-one patients (84%) were followed until death; median follow-up time of the alive patients after local recurrence was 21 months (range, 5 to 48 months). RESULTS Survival after local recurrence in the PRT + TME group was significantly shorter than in the TME group (median survival, 6.1 v 15.9 months; hazard ratio for death, 2.1; P =.008). Patients with a local recurrence in the PRT + TME group had distant metastases more often (74% v 40%; P =.004), underwent surgical resection of local recurrence less often (17% v 35%; P =.11), and received radiotherapy for local recurrence at a total dose >/= 45 Gy less often (4% v 42%; P =.001) than patients without PRT. In a multivariate analysis, the difference in survival after local recurrence between randomization groups was no longer statistically significant (hazard ratio for death of PRT, 1.53; P =.16). CONCLUSION The clinical nature and prognosis of patients with locally recurrent rectal cancer has changed since the introduction of PRT. The majority of patients who present with a local recurrence after previous PRT have simultaneous distant metastases, and median survival has decreased to 6 months.
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Klaassen RA, Nieuwenhuijzen GAP, Martijn H, Rutten HJT, Hospers GAP, Wiggers T. Treatment of locally advanced rectal cancer. Surg Oncol 2004; 13:137-47. [PMID: 15572096 DOI: 10.1016/j.suronc.2004.08.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Historically, locally advanced rectal cancer is known for its dismal prognosis. The treatment of locally advanced rectal cancer is subject to continuous change due to development of new and better diagnostic tools, radiotherapeutic techniques, chemotherapeutic agents and understanding of the subject. It is clear, that a multimodality approach is the only way to achieve satisfactory local recurrence and survival rates in this type of cancer. However, which multimodality strategy is to be used still remains a point of controversy. This review summarises recent developments in imaging, (neo-) adjuvant therapy and surgical techniques in the treatment of primary locally advanced rectal cancer.
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Martijn H, Voogd AC, van de Poll-Franse LV, Repelaer van Driel OJ, Rutten HJT, Coebergh JWW. Improved survival of patients with rectal cancer since 1980: a population-based study. Eur J Cancer 2003; 39:2073-9. [PMID: 12957462 DOI: 10.1016/s0959-8049(03)00493-3] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The treatment of rectal cancer has changed over the last two decades as far as surgical techniques and radiotherapy are concerned. We studied the changes in patterns of care for patients with rectal cancer and the effect on prognosis. All patients with cancer of the rectum or rectosigmoid in South-east Netherlands, diagnosed in the period of 1980-2000, were included in our analyses (n=3635). The use of surgery as the only treatment decreased from 62% in the period of 1980-1989 to 42% in the period of 1995-2000, whereas the combination of surgery and radiotherapy increased from 26 to 40%. The use of postoperative radiotherapy decreased from 25 to 4%, while preoperative radiotherapy increased from 1 to 35%. Patients aged 75 years or older were less likely to receive radiotherapy. After adjustment for age, gender, tumour stage and tumour site, significant improvements in the relative risk of death were observed between the periods of 1995-2000 and 1980-1989 for patients under 60 years of age (Relative Risk (RR)=0.45; 95% Confidence Interval (CI)=0.35-0.58) and those 60-74 years old (RR=0.62; 95% CI 0.53-0.72). No improvement in the risk of death was found for patients aged 75 years and over. No improvements in the distribution of tumour stage were observed, making it very likely that the continuing increase in population-based survival among patients aged <75 years results from the shift from postoperative to preoperative radiotherapy, the development of the total mesorectal excision technique and the related tendency to subspecialisation of surgeons in colorectal cancer surgery.
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Abstract
After the diagnosis of a locally recurrent rectal cancer, imaging is the first step to estimate the extent and location of the local tumour growth and the presence or absence of distant metastases. The aim of the treatment is a R0 resection (microscopically tumour free circumferential margin) by multimodality treatment consisting of pre-operative radiation, extended resection and intra-operative radiotherapy by either electron beam irradiation or with high dose rate brachytherapy. Filling the pelvic cavity with vital tissue such as an omentoplasty should considered carefully. With this treatment the overall three-year survival rate of a group of 33 patients was 60% with a local control rate of 73%. The combination of chemotherapy as a radiosensitizer resulted in an increase of R0 resections by 20%. Introduction of TME surgery and pre-operative radiotherapy has created a new situation with limited possibilities due to dose-accumulation toxicity of the radiotherapy and extensive scarring of the tissues making estimation of the extent of the tumour growth more difficult. The prevention of local recurrence by proper selection of primary cases, the training of experienced surgeons and the optimal use of pre-operative radiotherapy is the way forward to improve results.
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van der Sangen MJC, Coebergh JWW, Roumen RMH, Rutten HJT, Vreugdenhil G, Voogd AC. Detection, treatment, and outcome of isolated supraclavicular recurrence in 42 patients with invasive breast carcinoma. Cancer 2003; 98:11-7. [PMID: 12833449 DOI: 10.1002/cncr.11469] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND There still is debate as to whether breast carcinoma patients with isolated supraclavicular recurrence should be considered to be patients with disseminated disease or patients for whom aggressive treatment with curative intent is justified. METHODS In the period 1984-1994, 4669 patients with invasive breast carcinoma underwent axillary dissection in 1 of 8 community hospitals in the southeastern part of the Netherlands. During follow-up, 42 patients with isolated supraclavicular recurrence, without other sites of distant disease, were identified. RESULTS The median interval between treatment of the primary tumor and diagnosis of the supraclavicular recurrence was 2.5 years (range, 0.2-11.5 years). Radiotherapy was administered to 25 patients (60%), 5 of whom also underwent surgery and 16 of whom also received chemotherapy or hormonal therapy. Eleven patients received hormonal therapy only, and four received chemotherapy only. One patient received surgical treatment only, and one patient remained untreated. Complete remission was achieved in 35 patients (83%), but a second supraclavicular recurrence occurred in 12 (34% of patients who achieved complete remission). Overall, 6 patients (14%) were alive without evidence of disease after a follow-up period of 4.4-8.3 years. The 5-year actuarial overall survival and distant disease-free survival rates, based on the date of diagnosis of supraclavicular recurrence, were 38% (95% confidence interval [CI], 23-53%) and 22% (95% CI, 8-35%), respectively. The distant disease-free survival rate was somewhat better for the 25 patients who underwent radiotherapy as part of the treatment for supraclavicular recurrence than it was for the 17 patients who did not receive radiotherapy (P = 0.06); the difference became more pronounced after the exclusion of 8 patients who had received axillary and supraclavicular radiotherapy as part of treatment for the primary tumor (P = 0.002). CONCLUSIONS Although complete remission can be obtained in most patients with isolated supraclavicular recurrence, the prognosis for these patients is poor. Involved field radiotherapy appears to play an important role in the treatment of supraclavicular recurrence and may improve the distant recurrence-free survival rate.
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Schijven MP, Vingerhoets AJJM, Rutten HJT, Nieuwenhuijzen GAP, Roumen RMH, van Bussel ME, Voogd AC. Comparison of morbidity between axillary lymph node dissection and sentinel node biopsy. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2003; 29:341-50. [PMID: 12711287 DOI: 10.1053/ejso.2002.1385] [Citation(s) in RCA: 220] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIMS The use of axillary lymph node dissection (ALND) in women with breast cancer is associated with considerable morbidity. Sentinel node biopsy (SNB) removes the lymph node in the axillary basin indicative for receiving first lymphatic drainage from the breast. This study compares the nature and severity of physical morbidity among breast cancer patients who underwent primary surgery for breast cancer combined with either ALND or SNB. Also, it assesses influence of subsequent radiotherapy on morbidity. METHOD Two hundred and thirteen ALND patients were compared with 180 SNB patients retrospectively. Morbidity was measured using a disease-specific quality-of-life questionnaire. RESULTS Patients' demographic characteristics were alike. The axillary procedure is the strongest and most consistent factor in explaining differences in a variety of self-reported complaints. Patients having had SNB have a 3.2-fold lower risk of experiencing pain, a 5-fold lower risk of lymph oedema, a 7.7-fold lower risk of numbness, a 3.7-fold lower risk of tingling sensations, a 7.1-fold lower risk of loss of strength in arm/hand, a 3.6-fold lower risk of loss of active motion range of the arm and a 2.9-fold lower risk of impaired use of the arm. Axillary radiation therapy adds to complaints next to the axillary surgical procedure by increasing the risk of lymph oedema 2.4-fold and enhancing the risk of impaired use of the arm by 2.6-fold. Axillary radiation therapy does not explain lymph oedema by itself. CONCLUSION SNB is associated with less morbidity compared to ALND in patients with primary breast cancer.
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Mannaerts GHH, Rutten HJT, Martijn H, Hanssens PEJ, Wiggers T. Effects on functional outcome after IORT-containing multimodality treatment for locally advanced primary and locally recurrent rectal cancer. Int J Radiat Oncol Biol Phys 2002; 54:1082-8. [PMID: 12419435 DOI: 10.1016/s0360-3016(02)03012-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE In the treatment of patients with locally advanced primary or locally recurrent rectal cancer, much attention is focused on the oncologic outcome. Little is known about the functional outcome. In this study, the functional outcome after a multimodality treatment for locally advanced primary and locally recurrent rectal cancer is analyzed. METHODS AND MATERIALS Between 1994 and 1999, 55 patients with locally advanced primary and 66 patients with locally recurrent rectal cancer were treated with high-dose preoperative external beam irradiation, followed by extended surgery and intraoperative radiotherapy. To assess long-term functional outcome, all patients still alive (n = 97) were asked to complete a questionnaire regarding ongoing morbidity, as well as functional and social impairment. Seventy-six of the 79 patients (96%) returned the questionnaire. The median follow-up was 14 months (range: 4-60 months). RESULTS The questionnaire revealed fatigue in 44%, perineal pain in 42%, radiating pain in the leg(s) in 21%, walking difficulties in 36%, and voiding dysfunction in 42% of the patients as symptoms of ongoing morbidity. Functional impairment consisted of requiring help with basic activities in 15% and sexual inactivity in 56% of the respondents. Social handicap was demonstrated by loss of former lifestyle in 44% and loss of professional occupation in 40% of patients. CONCLUSIONS As a result of multimodality treatment, the majority of these patients have to deal with long-term physical morbidity, the need for help with daily care, and considerable social impairment. These consequences must be weighed against the chance of cure if the patient is treated and the disability eventually caused by uncontrolled tumor progression if the patient is not treated. These potential drawbacks should be discussed with the patient preoperatively and taken into account when designing a treatment strategy.
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Mannaerts GHH, Van Zundert AAJ, Meeusen VCH, Martijn H, Rutten HJT. Anaesthesia for advanced rectal cancer patients treated with combined major resections and intraoperative radiotherapy. Eur J Anaesthesiol 2002; 19:742-8. [PMID: 12463386 DOI: 10.1017/s0265021502001205] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVE Multimodality treatment for patients with locally advanced primary or locally recurrent rectal cancer, including high-dose preoperative external beam radiotherapy, extensive surgery and intraoperative radiation therapy, decreases the local recurrence rates and improves survival. During this aggressive operation, the anaesthesiologist is faced with potential problems such as major transfusion requirements, hypothermia, intraoperative position changes, the need to transport the patient to the intraoperative radiation therapy applicator, and the risks associated with remote monitoring of the patient during the 10 min intraoperative radiation therapy application. The anaesthetic management and perioperative results were evaluated for the anaesthetic results and the complications. METHODS One-hundred-and-six patients undergoing the multimodality treatment between February 1994 and March 2000 for locally advanced primary (n = 50) and locally recurrent rectal cancer (n = 56) were retrospectively evaluated for their anaesthetic results and complications. RESULTS All patients were operated upon using a combination of general and epidural anaesthesia. The average duration of anaesthesia was 6 (range 3-10.5) h and the mean blood loss 3.6 (range 0.4-14) L. All patients recovered well from anaesthesia. Two patients (2%) died in the intensive care unit (34 and 48 days postoperatively) because of adult respiratory distress syndrome following postoperative haemorrhage. Severe haemorrhage during or after the operation was significantly related with the development of adult respiratory distress syndrome (P < 0.0001). CONCLUSION With adequate preoperative assessment and optimalization of the patient's condition, maintaining peroperative haemodynamic stability with the help of adequate remote monitoring, early and fast transfusion, and multidisciplinary communication, anaesthetic complications can be minimized.
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