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Milanzi E, Pelly RM, Hayes IP, Gibbs P, Faragher I, Reece JC. Accuracy of Baseline Magnetic Resonance Imaging for Staging Rectal Cancer Patients Proceeding Directly to Surgery. J Surg Oncol 2024. [PMID: 39233560 DOI: 10.1002/jso.27852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 08/08/2024] [Accepted: 08/19/2024] [Indexed: 09/06/2024]
Abstract
BACKGROUND AND OBJECTIVES High-resolution magnetic resonance imaging (MRI) accuracy for staging preoperative rectal cancer varies across studies. We examined MRI accuracy for T- and N-staging of rectal cancer compared with final histopathology of the resected specimen in a large Australian cohort who did not receive neoadjuvant therapy or radiation. METHODS Retrospective analysis of prospectively-collected clinical data from 153 rectal adenocarcinomas locally staged by high-resolution MRI between January 2012 and December 2019 that did not undergo chemoradiotherapy or radiation before surgery. T- and N-stage agreement between MRI and final histopathology was assessed using Kappa statistic. Agreement at each T-stage was evaluated using log-linear modeling. N-staging accuracy was examined using positive and negative predictive values. RESULTS Overall agreement between MRI and final histopathology for T-stage and N-stage was 55% and 65%, respectively. Kappa statistic found higher agreement between MRI and final histopathology for T-staging (κ = 0.33) versus N-staging (κ = 0.18). MRI correctly assessed 91% of T1 tumors, 43% of T2 tumors, 65% of T3 tumors, and 80% of T4 tumors. MRI accuracy was higher for N-negative tumors (74.1%) than for N-positive tumors (44.4%). CONCLUSION MRI is moderately accurate at staging T1, T3, and T4 rectal tumors but caution when staging tumors as T2 is advised. Greater accuracy for staging N-negative versus N-positive tumors is indicated.
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Affiliation(s)
- Elasma Milanzi
- Neuroepidemiology Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Victoria, Australia
| | - Rachel M Pelly
- Neuroepidemiology Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Victoria, Australia
| | - Ian P Hayes
- Colorectal Surgery Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Surgery, The University of Melbourne, Parkville, Victoria, Australia
| | - Peter Gibbs
- Personalised Oncology Division, Walter and Eliza Hall Institute, Parkville, Victoria, Australia
| | - Ian Faragher
- Colorectal Surgery Unit, Western Health, Melbourne, Victoria, Australia
| | - Jeanette C Reece
- Neuroepidemiology Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Victoria, Australia
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Wang Y, Wang X, Chen J, Huang S, Huang Y. Comparative analysis of preoperative chemoradiotherapy and upfront surgery in the treatment of upper-half rectal cancer: oncological benefits, surgical outcomes, and cost implications. Updates Surg 2024; 76:949-962. [PMID: 38240957 DOI: 10.1007/s13304-023-01744-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 12/24/2023] [Indexed: 05/28/2024]
Abstract
The value of neoadjuvant chemoradiotherapy (CRT) is not absolutely clear for upper-half (> 7-15 cm) rectal cancer. This study aimed to compare the efficacy and safety of radical surgery with preoperative CRT vs. upfront surgery (US) in Chinese patients with stage II and III upper-half rectal cancer. A total of 809 patients with locally advanced upper-half rectal cancer between 2017 and 2021 were enrolled retrospectively (280 treated with CRT and 529 treated with US). Through 1:1 propensity score matching, the CRT (172 patients) and US (172 patients) groups were compared for short-term postoperative results and long-term oncological and functional outcomes. In the entire cohort, patients in the CRT group had a younger age, lower distance from the anal verge (DAV), and higher rates of cT4 stage, cN2 stage, mrCRM positivity, EMVI positivity, CEA elevation, and CA-199 elevation than those in the US group. The 5-year disease-free survival (DFS) was lower in the CRT group than in the US group (76% vs. 84%, p = 0.022), while the 5-year overall survival (OS) was comparable between the two groups (85% and 88%, p = 0.084). The distant metastasis rate was higher in the CRT group than in the US group (12.5% vs. 7.8%, p = 0.028), though the local recurrence rate was similar between the two groups (1.1% and 1.3%, p = 1.000). After performing PSM, the 5-year OS (86% vs. 88% p = 0.312), the 5-year DFS (79% vs. 80%, p = 0.435), the local recurrence rate (1.2% vs. 1.7%, p = 1.000), and the distant metastasis rate (11.0% vs. 9.3%, p = 0.593) were comparable between the two groups. Notable pathological downstaging was observed in the CRT group, with a pathological complete response (PCR) rate of 14.5%. In addition, patients in the CRT group had a lower proportion of pT3 (61.6% vs. 77.9%, p < 0.001), pN + (pN1, 15.1% vs. 30.2%, pN2, 9.3% vs. 20.3%, p < 0.001), stage III (24.4% vs. 50.6%, p < 0.001), perineural invasion (19.8% vs. 32.0%, p = 0.014), and lymphovascular invasion (9.3% vs. 25.6%, p < 0.001) than those in the US group. Postoperative complications and long-term functional results were similar, yet there was a trend toward a higher conversion to laparotomy rate (5 (2.9%) vs. 0 (0.0%), p = 0.061) and higher rates of robotic surgery (11.6% vs. 4.7%, p < 0.001), open surgery (7.0% vs. 0.6%, p < 0.001), diverting stoma (47.1% vs. 25.6%, p < 0.001), and surgery costs (1473.6 ± 106.5 vs. 1140.3 ± 54.3$, p = 0.006) in the CRT group. In addition, EMVI (OR = 2.516, p = 0.001) was the only independent risk factor associated with poor response to CRT, and in subgroup analysis of EMVI + , CRT group patients presented a lower 5-year DFS (72.9% vs. 80.5%, p = 0.025) compared to US group patients. CRT prior to surgery has no additional oncological benefits over US in the treatment of upper-half rectal cancer. In contrast, CRT is associated with increased rates of conversion to laparotomy, stoma creation and higher surgery costs. Surgeons tend to favor robotic surgery in the treatment of complex cases such as radiated upper-half rectal cancers. Notably, EMVI + patients with upper-half rectal cancer should be encouraged to undergo upfront surgery, as preoperative CRT may not provide benefits and may lead to delayed treatment effects.
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Affiliation(s)
- Yangyang Wang
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, 29 Xin-Quan Road, Fuzhou, Fujian, 350001, People's Republic of China
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Shandong First Medical University, Tai'an, People's Republic of China
| | - Xiaojie Wang
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, 29 Xin-Quan Road, Fuzhou, Fujian, 350001, People's Republic of China
| | - Jinhua Chen
- Follow-Up Center, Union Hospital, Fujian Medical University, Fuzhou, People's Republic of China
| | - Shenghui Huang
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, 29 Xin-Quan Road, Fuzhou, Fujian, 350001, People's Republic of China
| | - Ying Huang
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, 29 Xin-Quan Road, Fuzhou, Fujian, 350001, People's Republic of China.
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Mahmood AS, Ahmed Abbas M, Gany Yassin A, Ahmed HA, Sabri S, Shakir AA, Abbas H, Ismail M. Evaluating Postoperative Prognosis: A Single Surgeon's Experience With Total Mesorectal Excision in Middle and Lower Rectal Cancer Cases in Iraq. Cureus 2024; 16:e62174. [PMID: 38993431 PMCID: PMC11238923 DOI: 10.7759/cureus.62174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2024] [Indexed: 07/13/2024] Open
Abstract
INTRODUCTION Surgical intervention for rectal cancer is widely recognized for its potential to significantly impact quality of life, chiefly due to the high probability of permanent colostomy and the associated postoperative complications. OBJECTIVE This study aimed to evaluate the short-term outcomes and morbidity associated with total mesorectal excision for middle and lower rectal cancer within an Iraqi cohort, in a prospective setting. METHODS This study prospectively collected and analyzed data from 89 patients who underwent a standardized radical rectal resection, with a follow-up period extending to one month post-surgery. RESULTS The mean age of patients was 54.4 ± 12.9 years, with a gender distribution of 46 males and 43 females. A total of 33 patients presented with preoperative comorbidities, which heightened the risk of adverse short-term outcomes by a factor of 7.51. The most prevalent comorbidities were hypertension and diabetes mellitus, affecting 22 and 20 patients, respectively. Patients aged 60 years and above were at a 3.97 times greater risk of developing complications. The overall complication rate was 21.35%, with wound infections (9.0%) and cardiovascular events (3.4%) being the most common. Mortality during the follow-up was 1.1%. CONCLUSION The findings indicate that increased age and the presence of comorbidities are significant risk factors for morbidity and mortality post-surgery. Neoadjuvant chemoradiotherapy or radiotherapy was shown to reduce morbidity and mortality rates while improving survival. The morbidity and mortality rates observed in this study concur with existing literature.
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Affiliation(s)
- Aqeel S Mahmood
- Department of Surgery, College of Medicine, University of Baghdad, Baghdad, IRQ
| | | | - Ammar Gany Yassin
- Department of Biochemistry, College of Medicine, University of Karbala, Karbala, IRQ
| | - Haider A Ahmed
- Department of Surgery, Iraqi Board of Medical Specializations, Baghdad, IRQ
| | - Samer Sabri
- Department of Surgery, Baghdad Teaching Hospital, Baghdad, IRQ
| | - Ahmed A Shakir
- Department of Surgery, Baghdad Teaching Hospital, Baghdad, IRQ
| | - Hussein Abbas
- Department of Surgery, College of Medicine, University of Baghdad, Baghdad, IRQ
| | - Mustafa Ismail
- Department of Surgery, College of Medicine, University of Baghdad, Baghdad, IRQ
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Jabbour SK, Hochster HS. Evolving paradigms in locally advanced rectal cancer: the means justify the ends. J Natl Cancer Inst 2023; 115:1439-1441. [PMID: 37851864 DOI: 10.1093/jnci/djad196] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 09/11/2023] [Indexed: 10/20/2023] Open
Affiliation(s)
- Salma K Jabbour
- Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Howard S Hochster
- Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
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Grazzini G, Danti G, Chiti G, Giannessi C, Pradella S, Miele V. Local Recurrences in Rectal Cancer: MRI vs. CT. Diagnostics (Basel) 2023; 13:2104. [PMID: 37370997 DOI: 10.3390/diagnostics13122104] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/03/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Rectal cancers are often considered a distinct disease from colon cancers as their survival and management are different. Particularly, the risk for local recurrence (LR) is greater than in colon cancer. There are many factors predisposing to LR such as postoperative histopathological features or the mesorectal plane of surgical resection. In addition, the pattern of LR in rectal cancer has a prognostic significance and an important role in the choice of operative approach and. Therefore, an optimal follow up based on imaging is critical in rectal cancer. The aim of this review is to analyse the risk and the pattern of local recurrences in rectal cancer and to provide an overview of the role of imaging in early detection of LRs. We performed a literature review of studies published on Web of Science and MEDLINE up to January 2023. We also reviewed the current guidelines of National Comprehensive Cancer Network (NCCN) and the European Society for Medical Oncology (ESMO). Although the timing and the modality of follow-up is not yet established, the guidelines usually recommend a time frame of 5 years post surgical resection of the rectum. Computed Tomography (CT) scans and/or Magnetic Resonance Imaging (MRI) are the main imaging techniques recommended in the follow-up of these patients. PET-CT is not recommended by guidelines during post-operative surveillance and it is generally used for problem solving.
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Affiliation(s)
- Giulia Grazzini
- Department of Emergency Radiology, University Hospital Careggi, Largo Brambilla 3, 50134 Florence, Italy
| | - Ginevra Danti
- Department of Emergency Radiology, University Hospital Careggi, Largo Brambilla 3, 50134 Florence, Italy
| | - Giuditta Chiti
- Department of Emergency Radiology, University Hospital Careggi, Largo Brambilla 3, 50134 Florence, Italy
| | - Caterina Giannessi
- Department of Emergency Radiology, University Hospital Careggi, Largo Brambilla 3, 50134 Florence, Italy
| | - Silvia Pradella
- Department of Emergency Radiology, University Hospital Careggi, Largo Brambilla 3, 50134 Florence, Italy
| | - Vittorio Miele
- Department of Emergency Radiology, University Hospital Careggi, Largo Brambilla 3, 50134 Florence, Italy
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The pattern and treatment outcomes for rectal cancer with concurrent locoregional recurrence and distant metastases after total mesorectal excision. BMC Cancer 2022; 22:1088. [PMID: 36280830 PMCID: PMC9590188 DOI: 10.1186/s12885-022-10212-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 10/21/2022] [Indexed: 11/29/2022] Open
Abstract
Background To study the pattern and treatment outcome of rectal cancer (RC) with concurrent locoregional recurrence (LR) and distant metastasis (DM) after total mesorectal excision (TME) and to identify patient-, disease-, and treatment-related factors associated with differences in prognosis after concurrent LR and DM. Methods RC patients who were diagnosed with concurrent LR and DM after TME from May 2015 to June 2019 were included in our study. All patients received single or multiple treatment modalities under the guidance of multidisciplinary team (MDT) of colorectal cancer in Fudan University Shanghai Cancer Center. The prognostic value of various clinicopathological factors for survival were calculated by Kaplan–Meier curves and Cox regression analyses. Results A total of 74 RC patients with concurrent LR and DM who had undergone TME with a median follow-up of 27 months were eligible for analysis. The median survival of the included patients was 34 months, and 30 patients (41%) died. Fifty-nine patients (80%) underwent comprehensive treatments. Patients with oligometastatic disease (OMD) achieved no evidence of disease (NED) status more frequently than those with multiple metastases (P = 0.003). In the univariate analysis, patients achieving NED, diagnosed with OMD and five or less peritoneal metastases tended to have longer survival after LR and DM diagnosis (P < 0.05). In the multivariate analysis, attaining NED status was the only independent factor for survival (hazard ratio (HR), 2.419; P = 0.032). Survival after concurrent LR and DM in the non-NED group was significantly shorter than that in the NED group (median survival, 32 vs. 46 months; HR, 2.7; P = 0.014). Conclusions The pattern and treatment outcome of RC with concurrent LR and DM after TME has changed with the development of multiple treatment modalities. Although the prognosis remains poor, pursuing NED status through comprehensive treatments may improve the survival of RC patients with concurrent LR and DM after TME.
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7
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Hui C, Baclay R, Liu K, Sandhu N, Loo P, von Eyben R, Chen C, Sheth V, Vitzthum L, Chang D, Pollom E. Rectosigmoid Cancer-Rectal Cancer or Sigmoid Cancer? Am J Clin Oncol 2022; 45:333-337. [PMID: 35848736 PMCID: PMC9311454 DOI: 10.1097/coc.0000000000000931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We aimed to determine the optimal treatment for patients with locally advanced rectosigmoid cancers, and to determine whether this can be guided by distance from anal verge (AV) and/or anatomic landmarks such as the sacral promontory and peritoneal reflection (PR). MATERIALS AND METHODS We retrospectively reviewed patients with T3-T4 and/or node-positive rectosigmoid cancers who underwent surgery from 2006 to 2018 with available pelvic imaging. We included tumors at 9 to 20 cm from the AV on either staging imaging, or colonoscopy. Patients were stratified into those who received neoadjuvant therapy, and those who underwent upfront surgery. Comparisons of characteristics were performed using χ 2 test and Fischer exact test. Locoregional failure (LRF) and overall survival were compared using Cox regressions and Kaplan-Meier analysis. RESULTS One hundred sixty-one patients were included. Ninety-seven patients had neoadjuvant therapy, and 64 patients had upfront surgery. Median follow-up time was 45.1 months. Patients who had neoadjuvant therapy had tumors that were higher cT stage ( P <0.01) with more positive/close circumferential resection margins seen on imaging by radiologists (28.9% vs. 1.6% , P =0.015). The 2-year rate of LRF, distant metastases, or overall survival was not significantly different between the 2 groups. None of 15 patients with tumors below the PR treated with neoadjuvant therapy had LRF, but 1 (25%) of 4 patients with tumors below the PR treated with adjuvant therapy experienced LRF ( P =0.05). CONCLUSIONS Patients with tumors below the PR may benefit more from neoadjuvant therapy. The PR on imaging may be a reliable landmark in addition to the distance from the AV to determine the most appropriate treatment option.
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Affiliation(s)
| | | | | | | | | | | | | | - Vipul Sheth
- Radiology, Stanford University, Stanford, CA
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8
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Rokan Z, Simillis C, Kontovounisios C, Moran B, Tekkis P, Brown G. Locally Recurrent Rectal Cancer According to a Standardized MRI Classification System: A Systematic Review of the Literature. J Clin Med 2022; 11:jcm11123511. [PMID: 35743581 PMCID: PMC9224654 DOI: 10.3390/jcm11123511] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/11/2022] [Accepted: 06/16/2022] [Indexed: 12/15/2022] Open
Abstract
(1) Background: The classification of locally recurrent rectal cancer (LRRC) is not currently standardized. The aim of this review was to evaluate pelvic LRRC according to the Beyond TME (BTME) classification system and to consider commonly associated primary tumour characteristics. (2) Methods: A systematic review of the literature prior to April 2020 was performed through electronic searches of the Science Citation Index Expanded, EMBASE, MEDLINE, and CENTRAL databases. The primary outcome was to assess the location and frequency of previously classified pelvic LRRC and translate this information into the BTME system. Secondary outcomes were assessing primary tumour characteristics. (3) Results: A total of 58 eligible studies classified 4558 sites of LRRC, most commonly found in the central compartment (18%), following anterior resection (44%), in patients with an 'advanced' primary tumour (63%) and following neoadjuvant radiotherapy (29%). Most patients also classified had a low rectal primary tumour. The lymph node status of the primary tumour leading to LRRC was comparable, with 52% node positive versus 48% node negative tumours. (4) Conclusions: This review evaluates the largest number of LRRCs to date using a single classification system. It has also highlighted the need for standardized reporting in order to optimise perioperative treatment planning.
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Affiliation(s)
- Zena Rokan
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK; (C.S.); (P.T.); (G.B.)
- Pelican Cancer Foundation, Basingstoke RG24 9NN, UK;
- Correspondence: (Z.R.); (C.K.)
| | - Constantinos Simillis
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK; (C.S.); (P.T.); (G.B.)
- Cambridge Colorectal Unit, Addenbrookes Hospital, Cambridge CB2 0QQ, UK
| | - Christos Kontovounisios
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK; (C.S.); (P.T.); (G.B.)
- Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
- Chelsea & Westminster Hospital, London SW10 9NH, UK
- Correspondence: (Z.R.); (C.K.)
| | - Brendan Moran
- Pelican Cancer Foundation, Basingstoke RG24 9NN, UK;
- Basingstoke & North Hampshire Hospital, Basingstoke RG24 9NA, UK
| | - Paris Tekkis
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK; (C.S.); (P.T.); (G.B.)
- Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Gina Brown
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK; (C.S.); (P.T.); (G.B.)
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9
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The oncological outcomes of postoperative radiotherapy in patients with stage II and III upper rectal cancer. MARMARA MEDICAL JOURNAL 2022. [DOI: 10.5472/marumj.1121383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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10
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Mathew DAP, Wagh DMS. Abdominoperineal Excision in current era. Cancer Treat Res Commun 2022; 32:100580. [PMID: 35668011 DOI: 10.1016/j.ctarc.2022.100580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 05/26/2022] [Indexed: 06/15/2023]
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11
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Type of recurrence is associated with disease-free survival after salvage surgery for locally recurrent rectal cancer. Int J Colorectal Dis 2021; 36:2603-2611. [PMID: 34296325 PMCID: PMC8923354 DOI: 10.1007/s00384-021-03998-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/14/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE To compare the characteristics and outcomes of rectal cancer patients with local recurrence at a perianastomotic site (PA), a surgical field (SF) site, or in lateral lymph nodes (LLN). METHODS A total of 114 consecutive patients who underwent surgery for recurrent, non-metastatic rectal cancer at a single comprehensive cancer center between 1997 and 2012 were grouped on the basis of radiographic assessment of type of recurrence: PA, 76 (67%) patients; SF, 25 (22%) patients; LLN, 13 (11%) patients. Demographic, clinical, and pathological features were compared between the three groups, as were disease-free survival (DFS) and overall survival (OS). RESULTS Recurrence type was associated with positive circumferential margin in the primary resection (PA, 4 [6%]; SF, 4 [19%]; LLN, 3 [25%]; P = 0.027), prior neoadjuvant therapy for the primary tumor (PA, 57 [75%]; SF, 18 [72%]; LLN, 4 [31%]; P = 0.007), and location of the primary tumor in the upper rectum (PA, 33 [45%]; SF, 5 [23%]; LLN, 1 [8%]; P < 0.001). Patients with PA had longer median DFS (PA, 5.1 years; SF, 1.5 years; LLN, 1.2 years; P = 0.036). There was a non-significant trend toward longer OS and higher rates of R0 resection for PA. CONCLUSION Type of recurrence after salvage surgery for locally recurrent rectal cancer is associated with longer DFS in patients with PA recurrence.
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12
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Drami I, Lord AC, Sarmah P, Baker RP, Daniels IR, Boyle K, Griffiths B, Mohan HM, Jenkins JT. Preoperative assessment and optimisation for pelvic exenteration in locally advanced and recurrent rectal cancer: A review. Eur J Surg Oncol 2021; 48:2250-2257. [PMID: 34922810 DOI: 10.1016/j.ejso.2021.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 11/03/2021] [Indexed: 01/06/2023] Open
Abstract
The pre-operative phase in planning a pelvic exenteration or extended resections is critical to optimising patient outcomes. This review summarises the key components of preoperative assessment and planning in patients with locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LLRC) being considered for potential curative resection. The preoperative period can be considered in 5 key phases: 1) Multidisciplinary meeting (MDT) review and recommendation for neoadjuvant therapy and surgery, 2) Anaesthetic preoperative assessment of fitness for surgery and quantification of risk, 3) Shared decision making with the patient and the process of informed consent, 4) Prehabilitation and physiological optimisation 5) Technical aspects of surgical planning. This review will focus on patients who have been recommended for surgery by the MDT and have completed neoadjuvant therapy. Other important considerations beyond the scope of this review are the various neoadjuvant strategies employed which in this patient group include Total Neo-adjuvant Therapy and reirradiation. Critical to improving perioperative outcomes is the dual aim of achieving a negative resection margin in a patient fit enough for extended surgery. Advanced, realistic communication is required pre-operatively and should be maintained throughout recovery. Optimising patient's physiological and psychological reserve with a preoperative prehabilitation programme is important, with physiotherapy, psychological and nutritional input. From a surgical perspective, image based technical preoperative planning is important to identify risk points and ensure correct surgical strategy. Careful attention to the entire patient journey through these 5 preoperative phases can optimise outcomes with the accumulation of marginal gains at multiple timepoints.
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Affiliation(s)
- I Drami
- Dukes' Club, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK.
| | - A C Lord
- Dukes' Club, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - P Sarmah
- Dukes' Club, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - R P Baker
- Advanced Malignancy Subcommittee, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - I R Daniels
- Advanced Malignancy Subcommittee, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - K Boyle
- Advanced Malignancy Subcommittee, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - B Griffiths
- Advanced Malignancy Subcommittee, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - H M Mohan
- Dukes' Club, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - J T Jenkins
- Advanced Malignancy Subcommittee, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
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13
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Rokan Z, Simillis C, Kontovounisios C, Moran BJ, Tekkis P, Brown G. Systematic review of classification systems for locally recurrent rectal cancer. BJS Open 2021; 5:6272170. [PMID: 33963369 PMCID: PMC8105621 DOI: 10.1093/bjsopen/zrab024] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 02/13/2021] [Indexed: 01/08/2023] Open
Abstract
Background Classification of pelvic local recurrence (LR) after surgery for primary rectal cancer is not currently standardized and optimal imaging is required to categorize anatomical site and plan treatment in patients with LR. The aim of this review was to evaluate the systems used to classify locally recurrent rectal cancer (LRRC) and the relevant published outcomes. Methods A systematic review of the literature prior to April 2020 was performed through electronic searches of the Science Citation Index Expanded, EMBASE, MEDLINE and CENTRAL databases. The primary outcome was to review the classifications currently in use; the secondary outcome was the extraction of relevant information provided by these classification systems including prognosis, anatomy and prediction of R0 after surgery. Results A total of 21 out of 58 eligible studies, classifying LR in 2086 patients, were reviewed. Studies used at least one of the following eight classification systems proposed by institutions or institutional groups (Mayo Clinic, Memorial Sloan-Kettering – original and modified, Royal Marsden and Leeds) or authors (Yamada, Hruby and Kusters). Negative survival outcomes were associated with increased pelvic fixity, associated symptoms of LR, lateral compared with central LR and involvement of three or more pelvic compartments. A total of seven studies used MRI with specifically defined anatomical compartments to classify LR. Conclusion This review highlights the various imaging systems in use to classify LRRC and some of the prognostic indicators for survival and oncological clearance based on these systems. Implementation of an agreed classification system to document pelvic LR consistently should provide more detailed information on anatomical site of recurrence, burden of disease and standards for comparative outcome assessment.
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Affiliation(s)
- Z Rokan
- Department of Radiology, Royal Marsden Hospital, London, UK.,Pelican Cancer Foundation, Basingstoke, UK.,Cambridge Colorectal Unit, Addenbrookes Hospital, Cambridge, UK
| | - C Simillis
- Cambridge Colorectal Unit, Addenbrookes Hospital, Cambridge, UK.,Department of Surgery & Cancer, Imperial College, London, UK
| | - C Kontovounisios
- Department of Surgery & Cancer, Imperial College, London, UK.,Department of Colorectal Surgery, Royal Marsden Hospital, London, UK.,Department of Colorectal Surgery, Chelsea & Westminster Hospital, London, UK
| | - B J Moran
- Pelican Cancer Foundation, Basingstoke, UK.,Department of Peritoneal Malignancy, Basingstoke & North Hampshire Hospital, Basingstoke, UK
| | - P Tekkis
- Department of Surgery & Cancer, Imperial College, London, UK.,Department of Colorectal Surgery, Royal Marsden Hospital, London, UK.,Department of Colorectal Surgery, Chelsea & Westminster Hospital, London, UK
| | - G Brown
- Department of Radiology, Royal Marsden Hospital, London, UK.,Department of Surgery & Cancer, Imperial College, London, UK
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14
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Sorrentino L, Belli F, Guaglio M, Daveri E, Cosimelli M. Prediction of R0/R+ surgery by different classifications for locally recurrent rectal cancer. Updates Surg 2021; 73:539-545. [PMID: 33555570 DOI: 10.1007/s13304-020-00941-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 12/07/2020] [Indexed: 11/28/2022]
Abstract
A widely adopted classification system for locally recurrent rectal cancer (LRRC) is currently missing, and the indication for surgery is not standardized. To evaluate all the published classification systems in a large monocentric cohort of LRRC patients, assessing their capability to predict a radical (R0) resection. A total of 152 consecutive LRRC patients treated at the National Cancer Institute of Milan (NCIM) from 2009 to 2017 were classified according to Pilipshen, Mayo Clinic, Memorial Sloan-Kettering Cancer Center (MSKCC), Wanebo, Yamada, Boyle, Dutch TME Trial, Royal Marsden and National Cancer Institute of Milan (NCIM) classification systems. Central location of LRRC was significantly predictive of R0 resection across all classification systems. R + resection was predicted by the "anterior" category of MSKCC (OR 2.66, p = 0.007), the "S2b" (OR 3.50, p = 0.04) and the "S3" (OR 2.70, p = 0.01) categories of NCIM, "pelvic disease through anastomosis" of Pilipshen (OR 2.89, p = 0.002), "fixed at 2 sites" of Mayo Clinic (OR 2.68, p = 0.019), and "TR4" of Wanebo (OR 3.39, p = 0.002). The NCIM was the most predictive classification for R0 surgery. The NCIM classification seems to be superior among the others in predicting R0 surgery. Generally, lateral invasive and high sacral invasive relapses are associated with reduced probability of R0 surgery and unfavorable outcomes.
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Affiliation(s)
- Luca Sorrentino
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Filiberto Belli
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Marcello Guaglio
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy.
| | - Elena Daveri
- Unit of Immunotherapy of Human Tumors, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Maurizio Cosimelli
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
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15
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Nath J, Sarma G. Preoperative radiotherapy and total neoadjuvant therapy in locally advanced rectal cancer management: So far, so good. JOURNAL OF RADIATION AND CANCER RESEARCH 2021. [DOI: 10.4103/jrcr.jrcr_20_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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16
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Pechlivanides G, Gourtsoyianni S, Gouvas N, Sougklakos J, Xynos E. Management of the adenocarcinoma of the upper rectum: a reappraisal. Updates Surg 2020; 73:513-526. [PMID: 33108641 DOI: 10.1007/s13304-020-00903-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 10/15/2020] [Indexed: 12/25/2022]
Abstract
The present review attempts to assess whether upper rectal cancer (URC) should be treated either as colon cancer or as rectal one, namely to be managed with upfront surgery without neo-adjuvant treatment and partial mesorectal excision (PME), or with neo-adjuvant short course radiotherapy (SCRT) or chemoradiotherapy (CRT) as indicated, followed by surgery with total mesorectal excision. Reports from current evidence including studies, reviews and various guidelines are conflicting. Main reasons for inability to reach safe conclusions are (i) the various anatomical definitions of the rectum and its upper part, (ii) the inadequate preoperative local staging,(iii) the heterogeneity of selection criteria for the neo-adjuvant treatment,(iv) the different neo-adjuvant treatment regimens, and(v) the variety in the extent of surgical resection, among the studies. Although not adequately supported, locally advanced URC can be treated with neo-adjuvant CRT provided the lesion is within the radiation field of safety, and a PME if the lower border of the tumour is located above the anterior peritoneal reflection. There is evidence that adjuvant chemotherapy is of benefit in high-risk stage II and stage III lesions.
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Affiliation(s)
| | - Sophia Gourtsoyianni
- Department of Radiology, Medical School, Aretaieion Hospital, University of Athens, Athens, Greece
| | - Nikolaos Gouvas
- General Surgery, Medical School, University of Cyprus, Nicosia General Hospital, Nicosia, Cyprus.
| | - John Sougklakos
- Department of Medical Oncology, Laboratory of Translational Oncology, Medical School, University of Crete, Heraklion, Greece
| | - Evangelos Xynos
- Department of General Surgery, Creta Interclinic Hospital, Heraklion, Crete, Greece
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17
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Benson AB, Venook AP, Al-Hawary MM, Arain MA, Chen YJ, Ciombor KK, Cohen S, Cooper HS, Deming D, Garrido-Laguna I, Grem JL, Gunn A, Hoffe S, Hubbard J, Hunt S, Kirilcuk N, Krishnamurthi S, Messersmith WA, Meyerhardt J, Miller ED, Mulcahy MF, Nurkin S, Overman MJ, Parikh A, Patel H, Pedersen K, Saltz L, Schneider C, Shibata D, Skibber JM, Sofocleous CT, Stoffel EM, Stotsky-Himelfarb E, Willett CG, Johnson-Chilla A, Gurski LA. NCCN Guidelines Insights: Rectal Cancer, Version 6.2020. J Natl Compr Canc Netw 2020; 18:806-815. [PMID: 32634771 DOI: 10.6004/jnccn.2020.0032] [Citation(s) in RCA: 291] [Impact Index Per Article: 72.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The NCCN Guidelines for Rectal Cancer provide recommendations for the diagnosis, evaluation, treatment, and follow-up of patients with rectal cancer. These NCCN Guidelines Insights summarize the panel discussion behind recent important updates to the guidelines. These updates include clarifying the definition of rectum and differentiating the rectum from the sigmoid colon; the total neoadjuvant therapy approach for localized rectal cancer; and biomarker-targeted therapy for metastatic colorectal cancer, with a focus on new treatment options for patients with BRAF V600E- or HER2 amplification-positive disease.
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Affiliation(s)
- Al B Benson
- 1Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | - Alan P Venook
- 2UCSF Helen Diller Family Comprehensive Cancer Center
| | | | | | | | | | - Stacey Cohen
- 6Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | | | | | | | | | | | | | | | - Steven Hunt
- 14Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | - Smitha Krishnamurthi
- 16Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | | | - Eric D Miller
- 19The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | - Mary F Mulcahy
- 1Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | | | | | - Katrina Pedersen
- 14Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
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18
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Kamran SC, Zelefsky M, Nguyen PL, Lawton CAF. To Radiate or Not to Radiate-The Challenges of Pelvic Reirradiation. Semin Radiat Oncol 2020; 30:238-241. [PMID: 32503789 DOI: 10.1016/j.semradonc.2020.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Patients who receive pelvic radiation are at risk for both local recurrences of their primary malignancy or for the development of a new malignancy in the irradiated pelvic structures. The management of postirradiation pelvic tumor is complicated and can be associated with both poor prognosis and significant morbidity. Historically, reirradiation within the pelvis was never entertained as part of treatment management due to concern for severe toxicity and exceeding of normal-tissue tolerances. However, it may play a role with modern techniques and careful patient selection. The following case and accompanying expert opinions demonstrate some of the key considerations for pelvic reirradiation as a treatment option.
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Affiliation(s)
- Sophia C Kamran
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| | - Michael Zelefsky
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Colleen A F Lawton
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI
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19
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Belli F, Sorrentino L, Gallino G, Gronchi A, Scaramuzza D, Valvo F, Cattaneo L, Cosimelli M. A proposal of an updated classification for pelvic relapses of rectal cancer to guide surgical decision-making. J Surg Oncol 2020; 122:350-359. [PMID: 32424824 DOI: 10.1002/jso.25938] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 04/05/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND OBJECTIVES Selection of patients affected by pelvic recurrence of rectal cancer (PRRC) who are likely to achieve a R0 resection is mandatory. The aim of this study was to propose a classification for PRRC to predict both radical surgery and disease-free survival (DFS). METHODS PRRC patients treated at the National Cancer Institute of Milan (Italy) were included in the study. PRRC were classified as S1, if located centrally (S1a-S1b) or anteriorly (S1c) within the pelvis; S2, in case of sacral involvement below (S2a) or above (S2b) the second sacral vertebra; S3, in case of lateral pelvic involvement. RESULTS Of 280 reviewed PRRC patients, 152 (54.3%) were evaluated for curative surgery. The strongest predictor of R+ resection was the S3 category (OR, 6.37; P = .011). Abdominosacral resection (P = .012), anterior exenteration (P = .012) and extended rectal re-excision (P = .003) were predictive of R0 resection. S3 category was highly predictive of poor DFS (HR 2.53; P = .038). DFS was significantly improved after R0 surgery for S1 (P < .0001) and S2 (P = .015) patients but not for S3 cases (P = .525). CONCLUSIONS The proposed classification allows selection of subjects candidates to curative surgery, emphasizing that lateral pelvic involvement is the main predictor of R+ resection and independently affects the DFS.
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Affiliation(s)
- Filiberto Belli
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Luca Sorrentino
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Gianfrancesco Gallino
- Melanoma and Sarcoma Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Alessandro Gronchi
- Melanoma and Sarcoma Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Davide Scaramuzza
- Department of Radiology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Francesca Valvo
- Radiotherapy Unit, Clinical Department, CNAO National Center for Oncological Hadrontherapy, Pavia, Italy
| | - Laura Cattaneo
- Pathology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Maurizio Cosimelli
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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20
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Ma P, Yuan Y, Yan P, Chen G, Ma S, Niu X, Xu M, Yang K, Cai H. The efficacy and safety of lateral lymph node dissection for patients with rectal cancer: A systematic review and meta-analysis. Asian J Surg 2020; 43:891-901. [PMID: 31926817 DOI: 10.1016/j.asjsur.2019.11.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 11/08/2019] [Indexed: 12/17/2022] Open
Abstract
Lateral lymph node metastasis in rectal cancer was first reported in the 1950s, since then, there has been an on-going debate about the value of lateral lymph node dissection (LLND) in the management of rectal cancer. We carried out a systematic review and meta-analysis to evaluate the value of LLND for the patients with rectal cancer. To collect clinical studies for the comparison of LLND and non-LLND in patients with rectal cancer, PubMed, Embase, Cochrane Library, Web of Science, and Google Scholar databases were searched from inception to 2019.A total of 26 studies, including 6865 patients were enrolled. Data processing and statistical analyses were performed using Stata V.15.0 software and Review Manager 5.3 software. Outcome measures included the 5-year survival rate, recurrence rate, perioperative outcomes, urinary function, and male sexual function. Regarding efficacy, our meta-analysis results showed no difference in 5-year disease-free survival rate and local recurrences between the two groups, the Hazard Ratio (HR) and 95% confidence interval (CI) was1.07 and 0.89 to 1.28 (P = 0.496),and the Odds Ratio(OR) and 95% CI were 0.90 and 0.76 to 1.06 (P = 0.208), respectively. Concerning safety, the incidence of urinary dysfunction and male sexual dysfunction was significantly increased in the LLND group (OR = 2.14, 95%CI = 1.21-3.79, P = 0.009), and (OR = 4.19, 95%CI = 1.55-11.33, P = 0.005), respectively. In conclusion, LLND did not improve the long-term prognosis of patients with rectal cancer, and was associated with increased urinary dysfunction and male sexual dysfunction.
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Affiliation(s)
- Peilan Ma
- General Surgery Clinical Medical Center, Gansu Provincial Hospital, Lanzhou, Gansu, 730000, China
| | - Yuan Yuan
- Department of Critical Care Medicine, Gansu Provincial Hospital, Lanzhou, Gansu, 730000, China
| | - Peijing Yan
- Institute of Clinical Research and Evidence Based Medicine, Gansu Provincial Hospital, Lanzhou, Gansu, 730000, China
| | - Guohua Chen
- Clinical Medical College, China Medical University, Shenyang, Liaoning, 110000, China
| | - Shixun Ma
- General Surgery Clinical Medical Center, Gansu Provincial Hospital, Lanzhou, Gansu, 730000, China
| | - Xiangdong Niu
- General Surgery Clinical Medical Center, Gansu Provincial Hospital, Lanzhou, Gansu, 730000, China
| | - Meng Xu
- General Surgery Clinical Medical Center, Gansu Provincial Hospital, Lanzhou, Gansu, 730000, China
| | - Kehu Yang
- Institute of Clinical Research and Evidence Based Medicine, Gansu Provincial Hospital, Lanzhou, Gansu, 730000, China; Evidence Based Social Science Research Center, Lanzhou University, Lanzhou, Gansu, 730000, China; Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, Gansu, 730000, China; Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, 730000, China.
| | - Hui Cai
- General Surgery Clinical Medical Center, Gansu Provincial Hospital, Lanzhou, Gansu, 730000, China.
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21
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Hayes IP, Milanzi E, Gibbs P, Reece JC. Neoadjuvant Chemoradiotherapy and Tumor Recurrence in Patients with Early T-Stage Cancer of the Lower Rectum. Ann Surg Oncol 2019; 27:1570-1579. [PMID: 31773520 DOI: 10.1245/s10434-019-08105-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND The role neoadjuvant chemoradiotherapy (nCRT) plays in oncological outcomes in early T-stage rectal cancer is uncertain. The present work aims to clarify prognostic outcomes by estimating the effect of nCRT on tumor recurrence prior to major surgery compared with major surgery alone. PATIENTS AND METHODS Prospectively collected data were retrospectively analyzed for patients diagnosed with localized rectal adenocarcinoma ≤ 8 cm from the anal verge, with final histopathology ≤ T2 (≤ ypT2/≤ pT2), regardless of magnetic resonance imaging staging, between 1990 and 2017. As the effect of nCRT on recurrence varied over time, thereby violating the Cox proportional hazards assumption, the effect of nCRT on recurrence hazards was estimated using a time-varying multivariate Cox model over two separate time intervals (≤ 1 year and > 1 year postsurgery) by nCRT. RESULTS Long-course nCRT was associated with a 5.6-fold increase in the hazard of recurrence ≤ 1 year postsurgery [hazard ratio (HR) 5.6; 95% confidence interval (CI) 1.2-24.9; P = 0.02], but there was no increase in recurrence hazards > 1 year (HR 0.84; 95% CI 0.4-2.0; P = 0.70). In subgroup analysis restricted to ≤ mrT2/≤ ypT2 and ≤ pT2 tumors (omitting > mrT2 tumors), the effect of nCRT on recurrence no longer varied over time, indicating that tumor heterogeneity was responsible for the observed increased recurrence hazards ≤ 1 year postsurgery; That is, > mrT2 tumors that were downstaged to ≤ ypT2 after nCRT were responsible for the time-varying effects of nCRT and increased recurrence hazards ≤ 1 year postsurgery. Subsequently, no difference was found in prognostic outcomes either with or without nCRT before surgery in the homogeneous population of ≤ mrT2/≤ ypT2 and ≤ pT2 tumors. CONCLUSIONS No evidence was found to indicate that nCRT prior to surgery reduces tumor recurrence in early T-stage lower rectal cancer compared with surgery alone.
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Affiliation(s)
- Ian P Hayes
- Colorectal Surgery Unit, Suite 2, Private Medical Centre, Royal Melbourne Hospital, Parkville, VIC, Australia. .,Department of Surgery, The University of Melbourne, Parkville, VIC, Australia.
| | - Elasma Milanzi
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, VIC, Australia.,Victorian Centre for Biostatistics, Melbourne, VIC, Australia
| | - Peter Gibbs
- Personalised Oncology Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia.,Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia.,Department of Medical Oncology, Western Health, Melbourne, VIC, Australia
| | - Jeanette C Reece
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, VIC, Australia.,The University of Melbourne Centre for Cancer Research, The University of Melbourne, Parkville, VIC, Australia
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22
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Peltrini R, Luglio G, Cassese G, Amendola A, Caruso E, Sacco M, Pagano G, Sollazzo V, Tufano A, Giglio MC, Bucci L, Palma GDD. Oncological Outcomes and Quality of Life After Rectal Cancer Surgery. Open Med (Wars) 2019; 14:653-662. [PMID: 31565674 PMCID: PMC6744610 DOI: 10.1515/med-2019-0075] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/16/2019] [Indexed: 12/16/2022] Open
Abstract
Surgery for rectal cancer has been completely revolutionized thanks to the adoption of new technologies and up-to-date surgical procedures that have been applied to the traditional milestone represented by Total Mesorectal Excision (TME). The multimodal and multidisciplinary approach, with new technologies increased the patients’ life expectancies; nevertheless, they have placed the surgeon in front of newer issues, represented by both oncological outcomes and the patients’ need of a less destructive surgery and improved quality of life. In this review we will go through laparoscopic, robotic and transanal TME surgery, to show how the correct choice of the most appropriate technique, together with a deep knowledge of oncological principles and pelvic anatomy, is crucial to pursue an optimal cancer treatment. Novel technologies might also help to decrease the patients’ fear of surgery and address important issues such as cosmesis and improved preservation of postoperative functionality.
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Affiliation(s)
- Roberto Peltrini
- Department of Clinical Medicine and Surgery. University of Naples "Federico II", 80131 Naples, Via Pansini 5, Italy
| | - Gaetano Luglio
- Department of Public Health. University of Naples "Federico II", Naples, Italy
| | - Gianluca Cassese
- Department of Clinical Medicine and Surgery. University of Naples "Federico II", 80131 Naples, Via Pansini 5, Italy
| | - Alfonso Amendola
- Department of Clinical Medicine and Surgery. University of Naples "Federico II", 80131 Naples, Via Pansini 5, Italy
| | - Emanuele Caruso
- Department of Clinical Medicine and Surgery. University of Naples "Federico II", 80131 Naples, Via Pansini 5, Italy
| | - Michele Sacco
- Department of Clinical Medicine and Surgery. University of Naples "Federico II", 80131 Naples, Via Pansini 5, Italy
| | - Gianluca Pagano
- Department of Clinical Medicine and Surgery. University of Naples "Federico II", 80131 Naples, Via Pansini 5, Italy
| | - Viviana Sollazzo
- Department of Clinical Medicine and Surgery. University of Naples "Federico II", 80131 Naples, Via Pansini 5, Italy
| | - Antonio Tufano
- Department of Urology, University of Rome "La Sapienza", 00161 Roma RM Italy
| | - Mariano Cesare Giglio
- Department of Clinical Medicine and Surgery. University of Naples "Federico II", 80131 Naples, Via Pansini 5, Italy
| | - Luigi Bucci
- Department of Public Health. University of Naples "Federico II", Naples, Italy
| | - Giovanni Domenico De Palma
- Department of Clinical Medicine and Surgery. University of Naples "Federico II", 80131 Naples, Via Pansini 5, Italy.,Center of Excellence for Technical Innovation in Surgery (CEITC). University of Naples Federico II, 80131 Naples, Italy
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23
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Lupattelli M, Maranzano E, Bellavita R, Natalini G, Corgna E, Rossetti R, Trippa F, Mascioni F, Sidoni A, Anselmo P, Buzzi F, Brugia M, Latini P. Raltitrexed and Radiotherapy as Adjuvant Treatment for Stage II-III Rectal Cancer: A Feasibility Study. TUMORI JOURNAL 2019; 91:498-504. [PMID: 16457149 DOI: 10.1177/030089160509100610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims and Background Adjuvant 5-FU chemotherapy plus radiotherapy represents the standard treatment for radically resected rectal cancer at high risk of relapse according to the NIH Consensus Conference. The therapeutic gain was obtained with a high rate of severe treatment-related toxicity and a sub-optimal patient compliance with this regimen. Raltitrexed is a specific thymidylate synthase inhibitor with a convenient administration schedule, acceptable toxicity and radiosensitizing properties, as the published phase I trials in combination with radiotherapy have shown. The aim of this prospective multicenter phase II study was to evaluate the feasibility, gastrointestinal and hematological acute toxicity of raltitrexed in combination with radiotherapy in rectal cancer patients. Methods From September 2000 to June 2004, 50 patients with radically resected stage II-III rectal adenocarcinoma were treated. All patients were evaluable for compliance and acute toxicity. Within 45-60 days of surgery, each patient underwent concomitant adjuvant radiochemotherapy. Radiotherapy was administered to the pelvis (plus perineum after abdominoperineal resection) with photon beam energy exceeding 5 MV, 3-4 fields, 45 Gy/25 fractions/5 weeks plus a boost delivered to the site of resected disease with 3-4 fields, 9 Gy/5 fractions/1 week to a total dose of 54 Gy. The boost dose was administered after complete exclusion of the small bowel from the treatment volumes; if this was not possible a total dose of 50.4 Gy was given. Raltitrexed was administered intravenously at a dose of 3 mg/m2 as a bolus injection on days 1 and 22 of radiotherapy one hour before treatment, for a total of two cycles. Each patient underwent weekly clinical evaluation and laboratory tests. Toxicity was assessed by the WHO scale. Results Forty-five (90%) patients completed the established treatment. Acute severe toxicity included grade III proctitis in 4/50 (8%), grade III-IV diarrhea in 4/50 (8%), grade III perineal dermatitis in 4/50 (8%) and grade III leukopenia in 2/50 (4%) patients; five patients (10%) experienced a transient grade III increase in their liver biochemistry values. Conclusions Our data related to acute toxicity and patient compliance proved the feasibility of this adjuvant radiochemotherapy treatment. A longer follow-up is necessary to evaluate the effectiveness of this new regimen in terms of disease-free and overall survival.
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Affiliation(s)
- Marco Lupattelli
- Radiation Oncology Center, Policlinico Monteluce, Via B. Brunamonti, 06125 Perugia, Italy.
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24
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Chung SY, Koom WS, Keum KC, Chang JS, Shin SJ, Ahn JB, Min BS, Lee KY, Kim NK, Yoon HI. Treatment Outcomes of Re-irradiation in Locoregionally Recurrent Rectal Cancer and Clinical Significance of Proper Patient Selection. Front Oncol 2019; 9:529. [PMID: 31275858 PMCID: PMC6593136 DOI: 10.3389/fonc.2019.00529] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 05/31/2019] [Indexed: 12/22/2022] Open
Abstract
Background and Purpose: Majority of patients with locoregionally recurrent rectal cancer will require re-irradation (reRT). This study aimed to analyze the treatment outcomes, particularly infield progression, and severe late toxicity rates after reRT for recurrent rectal cancer and further identify a subgroup of patients who may optimally benefit from reRT. Materials and Methods: Patients with rectal cancer who underwent reRT to the pelvis between January 2000 and December 2017 were included for analysis. Results: The records of 41 patients were retrospectively reviewed. The median follow-up period after reRT was 53.7 months (range 3.5–130.3 months). The 2-year infield progression-free rate (IPFR) was 49.4%. The 2-year overall survival (OS) and progression-free survival (PFS) rates were 55.3 and 28.5%, respectively. Severe late toxicity events occurred in 17 patients, and the median time from reRT to severe late toxicity event was 10.5 months (range 2.3–33.3 months). The 2-year severe late toxicity free-rate (SLTFR) was 55.5%, and the median SLTFR was 33.3 months. Patients who did not experience severe late toxicity events showed a significantly higher number of recurred tumors at the posterior or lateral location compared to axial or anterior location. The selected subgroup with recurrent tumor size <3.3 cm and treated with total reRT dose of >50 Gyab10 (n = 13) showed superior IPFR, OS, and PFS to the other patients. Conclusion: ReRT was a reasonable treatment option for patients with locoregionally recurrent rectal cancer. However, severe late toxicity rates were substantially high. Thus, patients indicated for ReRT with curative dose should be selected properly according to tumor size and location.
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Affiliation(s)
- Seung Yeun Chung
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Woong Sub Koom
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Ki Chang Keum
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Jee Suk Chang
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Sang Joon Shin
- Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Joong Bae Ahn
- Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Byung Soh Min
- Department of Surgery, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Kang Young Lee
- Department of Surgery, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Nam Kyu Kim
- Department of Surgery, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Hong In Yoon
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
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Wilson K, Waters PS, Peacock O, Heriot AG, Wagner T, Warrier SK. Multivisceral, vascular and nodal resection for recurrent rectal cancer involving the left renal tract, left pelvic side wall and abdominal aorta. ANZ J Surg 2019; 90:632-634. [DOI: 10.1111/ans.15281] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 04/10/2019] [Accepted: 04/14/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Kasmira Wilson
- Colorectal Surgery UnitPeter MacCallum Cancer Centre Melbourne Victoria Australia
| | - Peadar S. Waters
- Colorectal Surgery UnitPeter MacCallum Cancer Centre Melbourne Victoria Australia
| | - Oliver Peacock
- Colorectal Surgery UnitPeter MacCallum Cancer Centre Melbourne Victoria Australia
| | - Alexander G. Heriot
- Colorectal Surgery UnitPeter MacCallum Cancer Centre Melbourne Victoria Australia
| | - Timothy Wagner
- Department of Vascular SurgeryThe Royal Melbourne Hospital Melbourne Victoria Australia
| | - Satish K. Warrier
- Colorectal Surgery UnitPeter MacCallum Cancer Centre Melbourne Victoria Australia
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Rectal Cancer Surveillance-Recurrence Patterns and Survival Outcomes from a Cohort Followed up Beyond 10 Years. J Gastrointest Cancer 2019; 49:422-428. [PMID: 28660522 DOI: 10.1007/s12029-017-9984-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AIM The intensity and duration of surveillance for rectal cancer after surgical resection remain contentious. We evaluated the pattern of recurrences in a rectal cancer cohort followed up beyond 10 years. METHODS An analysis was performed on a retrospective database of 326 patients with rectal cancer who underwent curative surgical resection from 1999 to 2007. The above study duration was chosen to ensure at least 10 years of follow-up. Data on patient demographics, peri-operative details, and follow-up outcomes were extracted from the database. The pattern of recurrences and investigative modality that detected recurrences was identified. Patients were followed up until either year 2016 or the day of their demise. RESULTS Two hundred seventeen patients (66.6%) were male and 109 patients (33.3%) female. Median age was 64 years old. Close to a third of the patients received adjuvant therapy (34%). Among the 326 patients studied, 29.8% of (97/326) patients developed recurrence. 7.7% (25/326) had loco-regional recurrence while 22.1% (72/326) had distant metastasis. Median time to recurrence was 16 months (4-83) and 18 months (3-81), respectively. Computed tomography scan was the best modality to detect both loco-regional and distant recurrences (48% in loco-regional and 41.7% in distant metastasis). The most common site of distant metastasis is the lung (34.7%). The salvage rate for loco-regional and distant recurrences was 52 and 12.5%, respectively. CONCLUSION The predominant pattern of recurrence in rectal cancer is distant disease. Surveillance regimes may need to be altered to increase early detection of distant metastases.
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Goldenberg BA, Holliday EB, Helewa RM, Singh H. Rectal Cancer in 2018: A Primer for the Gastroenterologist. Am J Gastroenterol 2018; 113:1763-1771. [PMID: 30008472 PMCID: PMC6768608 DOI: 10.1038/s41395-018-0180-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The rectum has distinctive anatomic and physiologic features, which increase the risk of local spread and recurrence among rectal cancers as compared to colon cancers. Essential to the management of rectal cancers is accurate endoscopic localization as well as preoperative imaging assessment of local and distant disease. Successful oncologic care is multidisciplinary including input from Gastroenterologists, Surgeons, Medical and Radiation Oncologists, Radiologists, and Pathologists. Extensive planning of curative intent is mandatory as failures of upfront treatment present great long‐term difficulty for patients and caregivers. Local recurrences are frequently associated with major morbidity including bowel and urinary obstruction, severe pain, and significantly diminished quality of life. Distant recurrence is associated with lower survival. Over the last two decades, there have been many advances in diagnostic imaging techniques as well as surgical techniques including transanal endoscopic microsurgery for very early stage cancers. Progress in curative management paradigms includes shorter courses of preoperative radiotherapy and chemotherapy doublet paradigms for perioperative treatment. This review describes the diagnosis, workup, and multimodality curative intent treatment of rectal cancers. It is emphasized that success begins in the hands and eyes of the gastroenterologist.
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Affiliation(s)
- Benjamin A. Goldenberg
- 1Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada.,2Department of Hematology and Oncology, CancerCare Manitoba, Winnipeg, MB, Canada
| | - Emma B. Holliday
- 3Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ramzi M. Helewa
- 4Department of Surgery, University of Manitoba, Winnipeg, MB, Canada
| | - Harminder Singh
- 1Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada.,2Department of Hematology and Oncology, CancerCare Manitoba, Winnipeg, MB, Canada.,5Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
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28
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Enker WE. Reprint of: The natural history of rectal cancer 1908-2008: the evolving treatment of rectal cancer into the twenty-first century. SEMINARS IN COLON AND RECTAL SURGERY 2018. [DOI: 10.1053/j.scrs.2018.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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29
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Hsu TC, Chen MJ. Presence of colon carcinoma cells at the resection line may cause recurrence following stapling anastomosis. Asian J Surg 2018; 41:569-572. [DOI: 10.1016/j.asjsur.2018.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 12/22/2017] [Accepted: 01/29/2018] [Indexed: 12/24/2022] Open
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30
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Musselman RP, Rothwell D, Auer RC, Moloo H, Boushey RP, van Walraven C. Can Text-Search Methods of Pathology Reports Accurately Identify Patients with Rectal Cancer in Large Administrative Databases? J Pathol Inform 2018; 9:18. [PMID: 29862128 PMCID: PMC5952547 DOI: 10.4103/jpi.jpi_71_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 02/26/2018] [Indexed: 01/05/2023] Open
Abstract
Background: The aim of this study is to derive and to validate a cohort of rectal cancer surgical patients within administrative datasets using text-search analysis of pathology reports. Materials and Methods: A text-search algorithm was developed and validated on pathology reports from 694 known rectal cancers, 1000 known colon cancers, and 1000 noncolorectal specimens. The algorithm was applied to all pathology reports available within the Ottawa Hospital Data Warehouse from 1996 to 2010. Identified pathology reports were validated as rectal cancer specimens through manual chart review. Sensitivity, specificity, and positive predictive value (PPV) of the text-search methodology were calculated. Results: In the derivation cohort of pathology reports (n = 2694), the text-search algorithm had a sensitivity and specificity of 100% and 98.6%, respectively. When this algorithm was applied to all pathology reports from 1996 to 2010 (n = 284,032), 5588 pathology reports were identified as consistent with rectal cancer. Medical record review determined that 4550 patients did not have rectal cancer, leaving a final cohort of 1038 rectal cancer patients. Sensitivity and specificity of the text-search algorithm were 100% and 98.4%, respectively. PPV of the algorithm was 18.6%. Conclusions: Text-search methodology is a feasible way to identify all rectal cancer surgery patients through administrative datasets with high sensitivity and specificity. However, in the presence of a low pretest probability, text-search methods must be combined with a validation method, such as manual chart review, to be a viable approach.
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Affiliation(s)
| | - Deanna Rothwell
- Department Epidemiology and Community Medicine, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Rebecca C Auer
- Division of General Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Husein Moloo
- Division of General Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Robin P Boushey
- Division of General Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Carl van Walraven
- Department Epidemiology and Community Medicine, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Comparative Effectiveness of Neoadjuvant Chemoradiation Versus Upfront Surgery in the Management of Recto-Sigmoid Junction Cancer. Clin Colorectal Cancer 2018; 17:e557-e568. [PMID: 29910004 DOI: 10.1016/j.clcc.2018.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 05/07/2018] [Accepted: 05/09/2018] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The optimal management of locally advanced recto-sigmoid cancer is unclear. Although some experts advocate for upfront surgery, others recommend neoadjuvant chemoradiation followed by surgery. We used the National Cancer Database to characterize patterns-of-care and overall survival (OS) associated with these treatment strategies. PATIENTS AND METHODS Patients with clinical stage II or III recto-sigmoid cancer who underwent surgery with or without adjunctive chemotherapy and/or radiotherapy from 2006 to 2014 were identified, and dichotomized into: (1) upfront surgery, and (2) neoadjuvant chemoradiation cohorts. Patterns-of-care were assessed using multivariable logistic regression. The association between neoadjuvant chemoradiation use and OS was assessed using Cox proportional hazards analysis with propensity score-matching. RESULTS Of 9313 identified patients, 6756 (73%) underwent upfront surgery and 2557 (27%) received neoadjuvant chemoradiation. Treatment at academic facilities and higher clinical T stage were predictors of neoadjuvant chemoradiation use. Compared with upfront surgery, neoadjuvant chemoradiation resulted in fewer positive circumferential resection margins (384 [11%] patients vs. 108 [8%] patients; P = .001), and 478 [18.7%] patients achieved a pathologic complete response at surgery. In propensity score-matched analysis, neoadjuvant chemoradiation use was associated with improved OS (hazard ratio, 0.79; 95% confidence interval, 0.69-0.90) compared with upfront surgery; 5-year estimated OS was 77.0% versus 72.0%, respectively. The improvement in OS persisted in landmark analysis of patients who survived at least 12 months. CONCLUSION Only a small percentage of patients with locally advanced recto-sigmoid cancer receive neoadjuvant chemoradiation even though its use might result in improved OS relative to upfront surgery. Prospective research is warranted to validate and standardize therapeutic strategies in patients with recto-sigmoid cancer.
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Lupattelli M, Maranzano E, Bellavita R, Tarducci R, Latini R, Castagnoli P, Bufalari A, Corgna E, Pinaglia D, Rossetti R, Ribacchi R, Latini P. Adjuvant Radiochemotherapy in High-Risk Rectal Cancer Results of a Prospective Non-Randomized Study. TUMORI JOURNAL 2018; 87:239-47. [PMID: 11693802 DOI: 10.1177/030089160108700406] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims and Background In 1990 the National Institutes of Health Consensus Conference recommended adjuvant combined therapy for patients with radically resected rectal cancer at high risk for relapse (ie, stage II-III). The purpose of our prospective non-randomized study was to verify the feasibility and effectiveness of postoperative radiochemotherapy in terms of improvement in disease-free and overall survival in this patient subgroup. Study design From January 1990 to October 1998, 191 consecutive patients with radically resected stage II-III rectal cancer were treated. A total of 159 patients with a 24-month follow-up were assessable for toxicity and survival. Anterior resection was performed in 129 (81%) and abdomino-perineal resection in 30 (19%) patients. Fifty-four (34%) stage II and 105 (66%) stage III patients entered the study. Within 45-60 days of surgery, all patients received 5-fluorouracil chemotherapy at the dose of 500 mg/m2 as an iv bolus on days 1-5, every 4 weeks, for 6 cycles. Chemotherapy cycles III and IV were administered at the same daily dose on radiotherapy days 1-3 and 29-31. Radiotherapy consisted of 45 Gy/25 fractions plus a boost dose of 5.4 Gy. Results After a median follow-up of 57 months (range, 25-123), overall recurrent disease was reported in 58 (36%) patients: local, systemic, and both local and systemic relapses in 12 (8%), 37 (23%) and 9 (6%) cases, respectively. According to local extension, recurrence rates were 15% and 48% in stage II and III, respectively. Five-year overall and disease-free survival were 71% and 66%, respectively. Overall survival was 87% in stage II and 62% in stage III patients, and disease-free survival was 84% and 56% in stage II and III disease, respectively. According to univariate and multivariate analyses, significant prognostic factors for better tumor control were: stage (II vs III, P <0.001), the number of involved nodes (≤3 vs >3, P <0.0001), and no extracapsular node invasion (P <0.0001). The recommended dose of the combined radiochemotherapy regimen was generally well tolerated. The incidence of any ≥ grade 3 acute toxicity (according to the WHO scale) was 13% diarrhea, 11% proctitis, 5% perineal dermatitis and 4% myelosuppression. Four (3%) patients had radiotherapy-related severe late toxicity which required surgery. Conclusions The study provided recurrence rates and survival similar to other adjuvant radiochemotherapy regimens published in the literature. However, in view of the low 5-year survival rate recorded in stage III patients, a different approach should be investigated.
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Affiliation(s)
- M Lupattelli
- Radiation Oncology Center, Policlinico Hospital of Perugia, Italy
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Wang SJ, Hathout L, Malhotra U, Maloney-Patel N, Kilic S, Poplin E, Jabbour SK. Decision-Making Strategy for Rectal Cancer Management Using Radiation Therapy for Elderly or Comorbid Patients. Int J Radiat Oncol Biol Phys 2018; 100:926-944. [PMID: 29485072 PMCID: PMC11131033 DOI: 10.1016/j.ijrobp.2017.12.261] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 11/14/2017] [Accepted: 12/11/2017] [Indexed: 02/07/2023]
Abstract
Rectal cancer predominantly affects patients older than 70 years, with peak incidence at age 80 to 85 years. However, the standard treatment paradigm for rectal cancer oftentimes cannot be feasibly applied to these patients owing to frailty or comorbid conditions. There are currently little information and no treatment guidelines to help direct therapy for patients who are elderly and/or have significant comorbidities, because most are not included or specifically studied in clinical trials. More recently various alternative treatment options have been brought to light that may potentially be utilized in this group of patients. This critical review examines the available literature on alternative therapies for rectal cancer and proposes a treatment algorithm to help guide clinicians in treatment decision making for elderly and comorbid patients.
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Affiliation(s)
- Shang-Jui Wang
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Lara Hathout
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Usha Malhotra
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Nell Maloney-Patel
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Sarah Kilic
- Rutgers New Jersey Medical School, Rutgers, the State University of New Jersey, Newark, New Jersey
| | - Elizabeth Poplin
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey.
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Abstract
Advanced primary and recurrent colorectal cancer can be successfully treated by experienced, dedicated centers delivering good outcomes with low mortality and morbidity. Development and implementation of a comprehensive referral pathway is to be encouraged. Multidisciplinary team management is essential in the management of this complex group of patients and is associated with significantly more complete preoperative evaluation and more accurate provision of patient information, as well as improved access to the most appropriate individualized management plan. A structured selection process can improve outcomes through standardized approaches to service delivery to provide the highest quality of care.
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Affiliation(s)
- Christos Kontovounisios
- Department of Colorectal Surgery, The Royal Marsden Hospital, Chelsea, London, United Kingdom.,Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Paris Tekkis
- Department of Colorectal Surgery, The Royal Marsden Hospital, Chelsea, London, United Kingdom.,Department of Surgery and Cancer, Imperial College, London, United Kingdom
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Nayor J, Rotman SR, Chan WW, Goldberg JE, Saltzman JR. Endoscopic Localization of Colon Cancer Is Frequently Inaccurate. Dig Dis Sci 2017; 62:2120-2125. [PMID: 28466261 DOI: 10.1007/s10620-017-4591-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 04/25/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Colonoscopic location of a tumor can influence both the surgical procedure choice and overall treatment strategy. AIMS To determine the accuracy of colonoscopy in determining the location of colon cancer compared to surgical localization and to elucidate factors that predict discordant colon cancer localization. METHODS We conducted a retrospective cross-sectional study of colon cancers diagnosed on colonoscopy at two academic tertiary-care hospitals and two affiliated community hospitals from 2012 to 2014. Colon cancer location was obtained from the endoscopic and surgical pathology reports and characterized by colon segment. We collected data on patient demographics, tumor characteristics, endoscopic procedure characteristics, surgery planned, and surgery performed. Univariate analyses using Chi-squared test and multivariate analysis using forward stepwise logistic regression were performed to determine factors that predict discordant colon cancer localization. RESULTS There were 110 colon cancer cases identified during the study period. Inaccurate endoscopic colon cancer localization was found in 29% (32/110) of cases. These included 14 cases (12.7%) that were discordant by more than one colonic segment and three cases where the presurgical planned procedure was significantly changed at the time of surgery. On univariate analyses, right-sided colon lesions were associated with increased inaccuracy (43.8 vs 24.4%, p = 0.04). On multivariate analysis, right-sided colon lesions remained independently associated with inaccuracy (OR 1.74, 95% CI 1.03-2.93, p = 0.04). CONCLUSIONS Colon cancer location as determined by colonoscopy is often inaccurate, which can result in intraoperative changes to surgical management, particularly in the right colon.
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Affiliation(s)
- Jennifer Nayor
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02446, USA. .,Harvard Medical School, Boston, MA, USA.
| | - Stephen R Rotman
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02446, USA.,Harvard Medical School, Boston, MA, USA
| | - Walter W Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02446, USA.,Harvard Medical School, Boston, MA, USA
| | - Joel E Goldberg
- Harvard Medical School, Boston, MA, USA.,Division of General and Gastrointestinal Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - John R Saltzman
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02446, USA.,Harvard Medical School, Boston, MA, USA
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Gash KJ, Chambers AC, Cotton DE, Williams AC, Thomas MG. Potentiating the effects of radiotherapy in rectal cancer: the role of aspirin, statins and metformin as adjuncts to therapy. Br J Cancer 2017; 117:210-219. [PMID: 28641310 PMCID: PMC5520519 DOI: 10.1038/bjc.2017.175] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 05/03/2017] [Accepted: 05/22/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Complete tumour response (pCR) to neo-adjuvant chemo-radiotherapy for rectal cancer is associated with a reduction in local recurrence and improved disease-free and overall survival, but is achieved in only 20-30% of patients. Drug repurposing for anti-cancer treatments is gaining momentum, but the potential of such drugs as adjuncts, to increase tumour response to chemo-radiotherapy in rectal cancer, is only just beginning to be recognised. METHODS A systematic literature search was conducted and all studies investigating the use of drugs to enhance response to neo-adjuvant radiation in rectal cancer were included. 2137 studies were identified and following review 12 studies were extracted for full text review, 9 studies were included in the final analysis. RESULTS The use of statins or aspirin during neo-adjuvant therapy was associated with a significantly higher rate of tumour downstaging. Statins were identified as a significant predictor of pCR and aspirin users had a greater 5-year progression-free survival and overall survival. Metformin use was associated with a significantly higher overall and disease-free survival, in a subset of diabetic patients. CONCLUSIONS Aspirin, metformin and statins are associated with increased downstaging of rectal tumours and thus may have a role as adjuncts to neoadjuvant treatment, highlighting a clear need for prospective randomised controlled trials to determine their true impact on tumour response and overall survival.
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Affiliation(s)
- K J Gash
- School of Cellular and Molecular Medicine, University of Bristol, Bristol BS1 8TD, UK
- Department of Coloproctology, University Hospitals Bristol NHS Foundation Trust, Bristol BS2 8HW, UK
| | - A C Chambers
- School of Cellular and Molecular Medicine, University of Bristol, Bristol BS1 8TD, UK
- Department of Coloproctology, University Hospitals Bristol NHS Foundation Trust, Bristol BS2 8HW, UK
| | - D E Cotton
- Department of Coloproctology, University Hospitals Bristol NHS Foundation Trust, Bristol BS2 8HW, UK
| | - A C Williams
- School of Cellular and Molecular Medicine, University of Bristol, Bristol BS1 8TD, UK
| | - M G Thomas
- School of Cellular and Molecular Medicine, University of Bristol, Bristol BS1 8TD, UK
- Department of Coloproctology, University Hospitals Bristol NHS Foundation Trust, Bristol BS2 8HW, UK
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A comparison of the localization of rectal carcinomas according to the general rules of the Japanese classification of colorectal carcinoma (JCCRC) and Western guidelines. Surg Today 2017; 47:1086-1093. [PMID: 28271342 DOI: 10.1007/s00595-017-1487-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 01/04/2017] [Indexed: 02/06/2023]
Abstract
PURPOSE The aim of this study was to compare the localization of rectal cancers as classified according to the general rules of the Japanese classification of colorectal carcinoma (JCCRC) and also according to the European Society for Medical Oncology (ESMO) and the National Comprehensive Cancer Network (NCCN) guidelines, which are based on rigid endoscopic measurements. METHODS The medical records of patients scheduled to receive curative surgery for histologically proven rectal adenocarcinoma during 2009-2015 were investigated (n = 230). Rigid proctoscopy was performed in patients with rectal cancer located in the upper (Ra) or lower (Rb) division using double-contrast barium enema. RESULTS The median values of height from the anal verge were 7.5 cm (range 2-12) and 3 cm (0-9.5) on rigid proctoscopy for cancers assigned as Ra and Rb, respectively. All 159 cancers at Ra or Rb were located within 12 cm from the anal verge by rigid proctoscopy, while only 79.7% of Ra or 82.1% of Rb cancers were located in the mid (5.1-10 cm) or low (≤5 cm) rectum, respectively. CONCLUSION Ra and Rb cancers are deemed to be rectal cancers according to NCCN guidelines, but these classifications are not interchangeable with mid- and low-rectal cancers, respectively, according to the ESMO guidelines.
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38
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Abdelfatah E, Page A, Sacks J, Pierorazio P, Bivalacqua T, Efron J, Terezakis S, Gearhart S, Fang S, Safar B, Pawlik TM, Armour E, Hacker-Prietz A, Herman J, Ahuja N. Postoperative complications following intraoperative radiotherapy in abdominopelvic malignancy: A single institution analysis of 113 consecutive patients. J Surg Oncol 2017; 115:883-890. [PMID: 28252805 DOI: 10.1002/jso.24597] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 12/28/2016] [Accepted: 02/09/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Intraoperative radiotherapy (IORT) has advantages over external beam radiation therapy (EBRT). Few studies have described side effects associated with its addition. We evaluated our institution's experience with abdominopelvic IORT to assess safety by postoperative complication rates. METHODS Prospectively collected IRB-approved database of all patients receiving abdominopelvic IORT (via high dose rate brachytherapy) at Johns Hopkins Hospital between November 2006 and May 2014 was reviewed. Patients were discussed in multidisciplinary conferences. Those selected for IORT were patients for whom curative intent resection was planned for which IORT could improve margin-negative resection and optimize locoregional control. Perioperative complications were classified via Clavien-Dindo scale for postoperative surgical complications. RESULTS A total of 113 patients were evaluated. Most common diagnosis was sarcoma (50/113, 44%) followed by colorectal cancer (45/113, 40%), most of which were recurrent (84%). There were no perioperative deaths. A total of 57% of patients experienced a complication Grade II or higher: 24% (27/113) Grade II; 27% (30/113) Grade III; 7% (8/113) Grade IV. Wound complications were most common (38%), then gastrointestinal (25%). No radiotherapy variables were significantly associated with complications on uni/multi-variate analysis. CONCLUSIONS Our institution's experience with IORT demonstrated historically expected postoperative complication rates. IORT is safe, with acceptable perioperative morbidity.
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Affiliation(s)
- Eihab Abdelfatah
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Andrew Page
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Justin Sacks
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Phillip Pierorazio
- Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Trinity Bivalacqua
- Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jonathan Efron
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stephanie Terezakis
- Department of Radiation Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Susan Gearhart
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sandy Fang
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bashar Safar
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elwood Armour
- Department of Radiation Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Amy Hacker-Prietz
- Department of Radiation Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joseph Herman
- Department of Radiation Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nita Ahuja
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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39
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Lymphadenectomy in Colorectal Cancer: Therapeutic Role and How Many Nodes Are Needed for Appropriate Staging? CURRENT COLORECTAL CANCER REPORTS 2017. [DOI: 10.1007/s11888-017-0349-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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40
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Haksal M, Okkabaz N, Atici AE, Civil O, Ozdenkaya Y, Erdemir A, Aksakal N, Oncel M. Fortune of temporary ileostomies in patients treated with laparoscopic low anterior resection for rectal cancer. Ann Surg Treat Res 2016; 92:35-41. [PMID: 28090504 PMCID: PMC5234425 DOI: 10.4174/astr.2017.92.1.35] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 08/23/2016] [Accepted: 09/12/2016] [Indexed: 12/22/2022] Open
Abstract
PURPOSE The current study aims to analyze the risk factors for the failure of ileostomy reversal after laparoscopic low anterior resection for rectal cancer. METHODS All patients who underwent a laparoscopic low anterior resection for rectal cancer with a diverting ileostomy between 2007 and 2014 were abstracted. The patients who underwent and did not undergo a diverting ileostomy procedure were compared regarding patient, tumor, treatment related parameters, and survival. RESULTS Among 160 (103 males [64.4%], mean [± standard deviation] age was 58.1 ± 11.9 years) patients, stoma reversal was achieved in 136 cases (85%). Anastomotic stricture (n = 13, 52.4%) was the most common reason for stoma reversal. These were the risk factors for the failure of stoma reversal: Male sex (P = 0.035), having complications (P = 0.01), particularly an anastomotic leak (P < 0.001), or surgical site infection (P = 0.019) especially evisceration (P = 0.011), requirement for reoperation (P = 0.003) and longer hospital stay (P = 0.004). Multivariate analysis revealed that male sex (odds ratio [OR], 7.82; P = 0.022) and additional organ resection (OR, 6.71; P = 0.027) were the risk factors. Five-year survival rates were similar (P = 0.143). CONCLUSION Fifteen percent of patients cannot receive a stoma reversal after laparoscopic low anterior resection for rectal cancer. Anastomotic stricture is the most common reason for the failure of stoma takedown. Having complications, particularly an anastomotic leak and the necessity of reoperation, limits the stoma closure rate. Male sex and additional organ resection are the risk factors for the failure in multivariate analyses. These patients require a longer hospitalization period, but have similar survival rates as those who receive stoma closure procedure.
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Affiliation(s)
- Mustafa Haksal
- Department of General Surgery, Kartal Education and Research Hospital, Istanbul, Turkey.; Department of General Surgery, Medipol University Medical School, Istanbul, Turkey
| | - Nuri Okkabaz
- Department of General Surgery, Kartal Education and Research Hospital, Istanbul, Turkey
| | - Ali Emre Atici
- Department of General Surgery, Kartal Education and Research Hospital, Istanbul, Turkey
| | - Osman Civil
- Department of General Surgery, Kartal Education and Research Hospital, Istanbul, Turkey
| | - Yasar Ozdenkaya
- Department of General Surgery, Medipol University Medical School, Istanbul, Turkey
| | - Ayhan Erdemir
- Department of General Surgery, Kartal Education and Research Hospital, Istanbul, Turkey
| | - Nihat Aksakal
- Department of General Surgery, Kartal Education and Research Hospital, Istanbul, Turkey
| | - Mustafa Oncel
- Department of General Surgery, Medipol University Medical School, Istanbul, Turkey
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Chia D, Lu J, Zheng H, Loy E, Lim K, Leong C, Wong L, Tan G, Chen D, Ho F, Tey J. Efficacy of palliative radiation therapy for symptomatic rectal cancer. Radiother Oncol 2016; 121:258-261. [DOI: 10.1016/j.radonc.2016.06.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Revised: 06/04/2016] [Accepted: 06/05/2016] [Indexed: 11/28/2022]
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Saeed N, Hoffe SE, Frakes JM. Treatment of High Rectal Cancers: Do We Need Radiation? CURRENT COLORECTAL CANCER REPORTS 2016. [DOI: 10.1007/s11888-016-0333-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Susko M, Lee J, Salama J, Thomas S, Uronis H, Hsu D, Migaly J, Willett C, Czito B, Palta M. The Use of Re-irradiation in Locally Recurrent, Non-metastatic Rectal Cancer. Ann Surg Oncol 2016; 23:3609-3615. [DOI: 10.1245/s10434-016-5250-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Indexed: 11/18/2022]
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Park JS, Sakai Y, Simon NSM, Law WL, Kim HR, Oh JH, Shan HCY, Kwak SG, Choi GS. Long-Term Survival and Local Relapse Following Surgery Without Radiotherapy for Locally Advanced Upper Rectal Cancer: An International Multi-Institutional Study. Medicine (Baltimore) 2016; 95:e2990. [PMID: 27258487 PMCID: PMC4900695 DOI: 10.1097/md.0000000000002990] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Controversy remains regarding whether preoperative chemoradiation protocol should be applied uniformly to all rectal cancer patients regardless of tumor height. This pooled analysis was designed to evaluate whether preoperative chemoradiation can be safely omitted in higher rectal cancer.An international consortium of 7 institutions was established. A review of the database that was collected from January 2004 to May 2008 identified a series of 2102 patients with stage II/III rectal or sigmoid cancer (control arm) without concurrent chemoradiation. Data regarding patient demographics, recurrence pattern, and oncological outcomes were analyzed. The primary end point was the 5-year local recurrence rate.The local relapse rate of the sigmoid colon cancer (SC) and upper rectal cancer (UR) cohorts was significantly lower than that of the mid/low rectal cancer group (M-LR), with 5-year estimates of 2.5% for the SC group, 3.5% for the UR group, and 11.1% for the M-LR group, respectively. A multivariate analysis showed that tumor depth, nodal metastasis, venous invasion, and lower tumor level were strongly associated with local recurrence. The cumulative incidence rate of local failure was 90.6%, 92.5%, and 94.4% for tumors located within 5, 7, and 9 cm from the anal verge, respectively.Routine use of preoperative chemoradiation for stage II/III rectal tumors located more than 8 to 9 cm above the anal verge would be excessive. The integration of a more individualized approach focused on systemic control is warranted to improve survival in patients with upper rectal cancer.
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Affiliation(s)
- Jun Seok Park
- From the Colorectal Cancer Center (JSP, G-SC), Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea; Department of Surgery (YS), Kyoto University Hospital, Kyoto, Japan; Department of Surgery (NGSMS), The Chinese University of Hong Kong, Sha Tin, Hong Kong; Division of Colorectal Surgery (WLL), The University of Hong Kong, Pok Fu Lam, Hong Kong; Department of Surgery (HRK), Chonnam National University Hwasun Hospital and Medical School, Gwangju, Korea; Center for Colorectal Cancer (JHO), National Cancer Center Hospital, Goyang city, Korea; Department of surgery (HCYS), Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong; and Department of Medical Statistics (SGK), School of Medicine, Catholic University of Daegu, Korea
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Jo S, Choi Y, Park SK, Kim JY, Kim HJ, Lee YH, Oh WY, Cho H, Ahn KJ. Efficacy of Dose-Escalated Radiotherapy for Recurrent Colorectal Cancer. Ann Coloproctol 2016; 32:66-72. [PMID: 27218097 PMCID: PMC4865467 DOI: 10.3393/ac.2016.32.2.66] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 12/23/2015] [Indexed: 11/14/2022] Open
Abstract
Purpose This study aimed to evaluate the effects of radiotherapy (RT) on progression-free survival (PFS) for patients with recurrent colorectal cancer. Methods We reviewed the records of 22 patients with recurrent colorectal cancer treated with RT between 2008 and 2014. The median radiation dose for recurrent disease was 57.6 Gy (range, 45–75.6 Gy). Patients were divided into 2 groups according to the type of RT: patients underwent RT without previous history of irradiation (n = 14) and those treated with secondary RT (reirradiation: n = 8) at the time of recurrence. Results The median follow-up period was 24.9 months (range, 4.5–66.6 months). Progression was observed in 14 patients (including 8 with loco-regional failure and 9 with distant metastases). Distant metastases were related to the RT dose (<70 Gy, P = 0.031). The 2-year loco-regional control (LRC), PFS, and overall survival (OS) rates were 74.6%, 45.1%, and 82.0%, respectively. The LRC rate was not different between the patients treated with RT for the first time and those treated with reirradiation (P = 0.101, 2-year LRC 79.5% vs. 41.7%). However, reirradiation was related to poor PFS (P = 0.022) and OS (P = 0.002). An escalated RT dose (≥70 Gy) was associated with a higher PFS (P = 0.014, 2-year PFS 63.5% vs. 20.8%). Conclusion Salvage RT for locally recurrent colorectal cancer can be offered when surgery is impossible. Dose-escalated RT shows a possible benefit in reducing the risk of progression.
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Affiliation(s)
- Sunmi Jo
- Department of Radiation Oncology, Inje University Haeundae Paik Hospital, Inje University School of Medicine, Busan, Korea
| | - Yunseon Choi
- Department of Radiation Oncology, Inje University Busan Paik Hospital, Inje University School of Medicine, Busan, Korea
| | - Sung-Kwang Park
- Department of Radiation Oncology, Inje University Busan Paik Hospital, Inje University School of Medicine, Busan, Korea
| | - Jin-Young Kim
- Department of Radiation Oncology, Inje University Haeundae Paik Hospital, Inje University School of Medicine, Busan, Korea
| | - Hyun Jung Kim
- Department of Radiation Oncology, Inje University Haeundae Paik Hospital, Inje University School of Medicine, Busan, Korea
| | - Yun-Han Lee
- Department of Radiation Oncology, Yonsei University Health System, Yonsei University College of Medicine, Seoul, Korea
| | - Won Yong Oh
- Department of Radiation Oncology, Inje University Haeundae Paik Hospital, Inje University School of Medicine, Busan, Korea
| | - Heunglae Cho
- Department of Radiation Oncology, Inje University Busan Paik Hospital, Inje University School of Medicine, Busan, Korea
| | - Ki Jung Ahn
- Department of Radiation Oncology, Inje University Busan Paik Hospital, Inje University School of Medicine, Busan, Korea
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La Torre F, Giuliani G. Clinical Presentation and Classifications. Updates Surg 2016. [DOI: 10.1007/978-88-470-5767-8_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Shi L, Li X, Pei H, Zhao J, Qiang W, Wang J, Xu B, Chen L, Wu J, Ji M, Lu Q, Li Z, Wang H, Jiang J, Wu C. Phase II study of computed tomography-guided (125)I-seed implantation plus chemotherapy for locally recurrent rectal cancer. Radiother Oncol 2015; 118:375-81. [PMID: 26522058 DOI: 10.1016/j.radonc.2015.10.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 10/23/2015] [Accepted: 10/25/2015] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND PURPOSE This trial evaluated the efficacy and safety of CT guided (125)I-seed implantation (CTII) plus chemotherapy with fluorouracil, leucovorin, and irinotecan (FOLFIRI) compared with FOLFIRI alone as second-line treatment for locally recurrent rectal cancer (LRRC). MATERIAL AND METHODS Patients with LRRC who received one prior chemotherapy regimen were enrolled and divided randomly assigned to FOLFORI alone (Arm A) and FOLFORI plus CTII (Arm B). The primary endpoint was local control time (LCT). Overall survival (OS) and treatment related adverse events (TRAEs) were also observed. RESULTS Fifty-seven patients were enrolled from October 2008 and December 2014. Twenty-seven were assigned into Arm A and 30 into Arm B. The overall response rate of locally recurrent tumor was improved to 100% in Arm B versus 29.6% in Arm A (P<0.001). A significant longer LCT was observed in Arm A (P<0.001); median LCT was 12 months in Arm B versus 4 months in Arm A. A borderline significant improvement in OS was also observed in Arm B (P=0.0464); median OS was 25 months in Arm B versus 19 months in Arm A. For patients without distant metastases, median OS was 37 months in Arm B versus 21 months in Arm A (P=0.0101). For patients with (neo)adjuvant radiotherapy (ART), a longer LCT and OS were also found in Arm B (P<0.001 and P=0.0217, respectively). TRAEs were not serious generally. There was no statistically significant difference in treatment related toxicity between Arm A and B both for all patients and patients receiving ART. CONCLUSIONS CTII plus FOLFIRI improves the LCT with tolerable toxicities as a second-line treatment in patients with local recurrent rectal cancer, and is helpful to prolong the OS, particularly in patients without distant metastases or with a history of radiotherapy.
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Affiliation(s)
- Liangrong Shi
- Department of Oncology, The Third Affiliated Hospital of Soochow University, China; Department of Biological Treatment, The Third Affiliated Hospital of Soochow University, China; Jiangsu Engineering Research Center for Tumor Immunotherapy, China
| | - Xiaodong Li
- Department of Oncology, The Third Affiliated Hospital of Soochow University, China; Department of Biological Treatment, The Third Affiliated Hospital of Soochow University, China; Jiangsu Engineering Research Center for Tumor Immunotherapy, China
| | - Honglei Pei
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, China.
| | - Jiemin Zhao
- Department of Oncology, The Third Affiliated Hospital of Soochow University, China
| | - Weiguang Qiang
- Department of Oncology, The Third Affiliated Hospital of Soochow University, China
| | - Jin Wang
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, China
| | - Bin Xu
- Department of Biological Treatment, The Third Affiliated Hospital of Soochow University, China; Jiangsu Engineering Research Center for Tumor Immunotherapy, China
| | - Lujun Chen
- Department of Biological Treatment, The Third Affiliated Hospital of Soochow University, China; Jiangsu Engineering Research Center for Tumor Immunotherapy, China
| | - Jun Wu
- Department of Oncology, The Third Affiliated Hospital of Soochow University, China
| | - Mei Ji
- Department of Oncology, The Third Affiliated Hospital of Soochow University, China
| | - Qicheng Lu
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Soochow University, China
| | - Zhong Li
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Soochow University, China
| | - Haitao Wang
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Soochow University, China
| | - Jingting Jiang
- Department of Biological Treatment, The Third Affiliated Hospital of Soochow University, China; Jiangsu Engineering Research Center for Tumor Immunotherapy, China.
| | - Changping Wu
- Department of Oncology, The Third Affiliated Hospital of Soochow University, China; Department of Biological Treatment, The Third Affiliated Hospital of Soochow University, China; Jiangsu Engineering Research Center for Tumor Immunotherapy, China.
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Impact of Postoperative Chemoradiotherapy versus Chemotherapy Alone on Recurrence and Survival in Patients with Stage II and III Upper Rectal Cancer: A Propensity Score-Matched Analysis. PLoS One 2015; 10:e0123657. [PMID: 25902069 PMCID: PMC4406553 DOI: 10.1371/journal.pone.0123657] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Accepted: 02/20/2015] [Indexed: 02/01/2023] Open
Abstract
Purpose To compare the impact of postoperative chemoradiotherapy (CRT) versus adjuvant chemotherapy alone on recurrence and survival in patients with stage II and III upper rectal cancer undergoing curative resection. Materials and Methods From our institutional database, 190 patients who underwent primary curative resection between 2003 and 2010 for stage II or III upper rectal cancer were identified. None of the patients received preoperative CRT. Of these, 136 patients received postoperative chemotherapy alone (the CTx group) and 54 patients received postoperative CRT (the CRT group). The CRT group had poorer prognostic features (pT4, pN2, poor differentiation, or involved resection margin) compared with the CTx group. To reduce the impact of treatment selection bias on treatment outcomes, propensity score-matching analysis was used. Results The matched cohort consisted of 50 CRT and 50 CTx patients with a median follow-up period of 76 and 63 months, respectively. In the matched cohort, CRT resulted in an improved 5-year local control (98.0% vs. 85.2%, p = 0.024) and overall survival rate (89.9% vs. 69.8%, p = 0.021) compared with CTx. In the subgroup analysis to identify subpopulations of patients that benefit most from receiving CRT, local recurrence did not occur in patients who did not have poor prognostic features regardless of the receipt of CRT. For patients with any poor prognostic features, CRT resulted in an improved 5-year local control compared with CTx (96.4% vs. 70.7%, p = 0.013). Conclusions After adjusting for clinicopathologic factors by propensity score-matching, postoperative CRT was associated with improved local control and overall survival in stage II and III upper rectal cancer. Our results suggest that surgery followed by chemotherapy alone is acceptable for patients who did not have poor prognostic features, while additional radiotherapy should be given for patients who have any poor prognostic features.
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Bujko K, Glimelius B, Valentini V, Michalski W, Spalek M. Postoperative chemotherapy in patients with rectal cancer receiving preoperative radio(chemo)therapy: A meta-analysis of randomized trials comparing surgery ± a fluoropyrimidine and surgery + a fluoropyrimidine ± oxaliplatin. Eur J Surg Oncol 2015; 41:713-23. [PMID: 25911110 DOI: 10.1016/j.ejso.2015.03.233] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 03/23/2015] [Accepted: 03/26/2015] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND There is no consensus on the role of postoperative chemotherapy in patients with rectal cancer who have received preoperative radio(chemo)therapy. MATERIALS AND METHODS A systematic review and meta-analysis were performed of trials that used preoperative radio(chemo)therapy and randomized patients either between postoperative chemotherapy and observation or between a fluoropyrimidine only (FU-only) and a fluoropyrimidine with oxaliplatin (FU-OXA) as postoperative chemotherapy. RESULTS Five randomized studies compared postoperative chemotherapy with observation in a total of 2398 patients. None of these trials demonstrated a statistically significant benefit of chemotherapy for OS and DFS. The pooled differences in OS and DFS did not differ statistically significantly between the chemotherapy group and the observation group. The hazard ratios (HRs) and 95% confidence intervals (CIs) were 0.95 (CI: 0.82-1.10), P = 0.49 and 0.92 (CI: 0.80-1.04), P = 0.19, respectively. In the subgroup of trials in which randomization was performed after surgery (n = 753), a statistically significant positive pooled chemotherapy effect was observed for DFS (HR = 0.79, 95% CI: 0.62-1.00, P = 0.047), but not for OS (P = 0.39). Four randomized trials compared adjuvant FU-OXA with adjuvant FU-only in 2710 patients. In two trials, the difference in DFS between groups was statistically significant in favour of FU-OXA, and in the other two trials, the difference was not significant. The pooled difference in DFS between the FU-OXA group and the FU-only group was not statistically significant: HR = 0.84 (CI: 0.66-1.06), P = 0.15. CONCLUSION The use of postoperative chemotherapy in patients with rectal cancer receiving preoperative radio(chemo)therapy is not based on strong scientific evidence.
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Affiliation(s)
- K Bujko
- Department of Radiotherapy II, M. Sklodowska-Curie Memorial Cancer Centre, Warsaw, Poland.
| | - B Glimelius
- Department of Radiology, Oncology, and Radiation Science, Uppsala University, Uppsala, Sweden
| | - V Valentini
- Department of Radiation Oncology, Università Cattolica S Cuore, Rome, Italy
| | - W Michalski
- Bioinformatics and Biostatistics Unit, M. Sklodowska-Curie Memorial Cancer Centre, Warsaw, Poland
| | - M Spalek
- Department of Radiotherapy II, M. Sklodowska-Curie Memorial Cancer Centre, Warsaw, Poland
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