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Regan SN, Hendren S, Krauss JC, Crysler OV, Cuneo KC. Treatment of Locally Recurrent Rectal Cancer: A Review. Cancer J 2024; 30:264-271. [PMID: 39042778 DOI: 10.1097/ppo.0000000000000728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Abstract
ABSTRACT Up to 10% of patients with locally advanced rectal cancer will experience locoregional recurrence. In the setting of prior surgery and often radiation and chemotherapy, these represent uniquely challenging cases. When feasible, surgical resection offers the best chance for oncologic control yet risks significant morbidity. Studies have consistently indicated that a negative surgical resection margin is the strongest predictor of oncologic outcomes. Chemoradiation is often recommended to increase the chance of an R0 resection, and in cases of close/positive margins, intraoperative radiation/brachytherapy can be utilized. In patients who are not surgical candidates, radiation can provide symptomatic relief. Ongoing phase III trials are aiming to address questions regarding the role of reirradiation and induction multiagent chemotherapy regimens in this population.
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Affiliation(s)
| | | | - John C Krauss
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Oxana V Crysler
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
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Takiyama H, Yamada S, Isozaki T, Ikawa H, Shinoto M, Imai R, Koto M. Carbon-Ion Radiation Therapy for Unresectable Locally Recurrent Colorectal Cancer: A Promising Curative Treatment for Both Radiation Therapy: Naïve Cases and Reirradiation Cases. Int J Radiat Oncol Biol Phys 2024; 118:734-742. [PMID: 37776980 DOI: 10.1016/j.ijrobp.2023.09.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 09/05/2023] [Accepted: 09/18/2023] [Indexed: 10/02/2023]
Abstract
PURPOSE It is difficult to effectively cure patients with unresectable locally recurrent colorectal cancers (LRCRCs) using conventional chemotherapy or chemoradiation therapy. Furthermore, treatment options vary depending on the patient's history of radiation therapy. Carbon-ion radiation therapy (CIRT) is a potentially curative treatment for these patients. Here, we compare the treatment outcomes of radiation therapy-naïve cases (nRT) and re-irradiation cases (reRT). METHODS AND MATERIALS Patients with LRCRC treated with CIRT at QST Hospital between 2003 and 2019 were eligible. CIRT was administered daily 4 d/wk for 16 fractions. The total irradiated dose was set at 73.6 Gy (relative biologic effectiveness-weighted dose [RBE]) for nRT and 70.4 Gy (RBE) for reRT patients. RESULTS We included 390 nRT cases and 83 reRT cases. The median follow-up period from the initiation of CIRT was 48 (5-208) months. The 3-year overall survival (OS) rates for nRT and reRT were 73% (95% CI, 68%-77%) and 76% (65%-84%), respectively. The 5-year OS rates were 50% (45%-55%) and 50% (38%-61%), respectively. These rates did not differ significantly (P = .55). The 3-year local control (LC) rates for nRT (73.6 Gy) and reRT (70.4 Gy) cases were 80% (75%-84%) and 80% (68%-88%), respectively. The 5-year LC rates were 72% (67%-78%) and 69% (55%-81%), respectively, without a significant difference (P = .56). CONCLUSIONS Our results suggest that CIRT for LRCRC is a very effective and promising treatment for both nRT and reRT cases.
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Affiliation(s)
- Hirotoshi Takiyama
- QST Hospital, National Institutes for Quantum Science and Technology, Chiba, Japan.
| | - Shigeru Yamada
- QST Hospital, National Institutes for Quantum Science and Technology, Chiba, Japan
| | - Tetsuro Isozaki
- QST Hospital, National Institutes for Quantum Science and Technology, Chiba, Japan
| | - Hiroaki Ikawa
- QST Hospital, National Institutes for Quantum Science and Technology, Chiba, Japan
| | - Makoto Shinoto
- QST Hospital, National Institutes for Quantum Science and Technology, Chiba, Japan
| | - Reiko Imai
- QST Hospital, National Institutes for Quantum Science and Technology, Chiba, Japan
| | - Masashi Koto
- QST Hospital, National Institutes for Quantum Science and Technology, Chiba, Japan
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Ralston C, Hainsworth A, de Naurois J, Schizas A, George M. Is an uncomplicated postoperative recovery following total pelvic exenteration a more important prognostic factor than achieving R0 in the first 2 years? Colorectal Dis 2024; 26:73-80. [PMID: 38071402 DOI: 10.1111/codi.16817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/30/2023] [Accepted: 10/18/2023] [Indexed: 01/28/2024]
Abstract
AIM Total pelvic exenteration (TPE) can achieve an R0 resection in locally advanced and recurrent rectal cancer (LARC and RRC) and remains the only curative option. The resultant high morbidity creates prolonged complex recoveries, rendering patients unfit for adjuvant chemotherapy. This study aims to evaluate the impact of this on overall survival (OS) and disease-free survival (DFS) as it has not been studied previously. METHOD This is a retrospective single-centre study from 2017 to 2021 evaluating patients with LARC or RRC who underwent a curative TPE. Demographics, oncological history, perioperative data [using Clavien-Dindo (CD) scoring], disease recurrence and mortality were analysed using multivariate Cox regression to assess the impact of variables on DFS and OS. RESULTS A total of 120 patients were included with a median follow-up of 3 years. 28% of patients received adjuvant chemotherapy, 27.5% had surgical follow-up and 44% missed systemic treatment. Missed treatment was predominantly due to prolonged recovery or poor performance status (59%). Patients who missed adjuvant chemotherapy experienced significantly higher CD scores (p = 0.0031), reintervention rates (p=0.0056) and further related surgeriesp (p = 0.0314). Missing adjuvant chemotherpy is a significant factor for poorer survival, with almost a three times higher mortality (p=0.0096, hazard ratio 2.7). R status was not a significant factor for OS following multivariate analysis (p = 0.336), indicating that another factor has an impact on survival within the first 2 years. CONCLUSIONS In the initial 2 years after exenteration, an uncomplicated postoperative recovery allows for the delivery of adjuvant chemotherapy, prolonging survival. R0/R1 status was not the main prognostic factor. Longer follow-up and further multivariate analysis may influence decisions about aggressive R0 resection balanced against the patient being fit for chemotherapy postoperatively.
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Affiliation(s)
| | | | | | | | - Mark George
- Guy's and St Thomas' NHS Foundation Trust, London, UK
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Shiba S, Okamoto M, Shibuya K, Kobayashi D, Miyasaka Y, Ohno T. Five-year outcomes in carbon-ion radiotherapy for postoperative pelvic recurrence of rectal cancer: A prospective clinical trial (GUNMA 0801). Clin Transl Radiat Oncol 2024; 44:100701. [PMID: 38033760 PMCID: PMC10685037 DOI: 10.1016/j.ctro.2023.100701] [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: 12/18/2022] [Revised: 10/12/2023] [Accepted: 11/05/2023] [Indexed: 12/02/2023] Open
Abstract
Introduction Carbon-ion radiotherapy (C-ion RT) is associated with favorable clinical outcomes for the pelvic recurrence of rectal cancer. However, few long-term follow-up studies after C-ion RT have been conducted. Hence, we performed an updated analysis of a prospective clinical trial of C-ion RT for the postoperative pelvic recurrence of rectal cancer. Materials and methods The study included 28 patients. Inclusion criteria were patients with confirmed pelvic recurrence of rectal cancer without distant metastasis; those who underwent curative resection of their primary disease and regional lymph nodes without gross or microscopic residual disease; and those who had radiographically measurable tumors. The total dose of C-ion RT for all the patients was 73.6 Gy (relative biological effectiveness) administered in 16 fractions. Results The median follow-up duration in all patients and those who survived were 51.2 and 69.2 months, respectively. The follow-up rate at the time of analysis was 96.4%. The 5-year overall survival and local control rates were 50% and 83%, respectively. Four patients had local recurrence, and 17 died of rectal cancer. Regarding late toxicities, two patients developed grade 3 pelvic infection, and nine developed grade 2 peripheral neuropathy. Conclusion Our updated analysis of a prospective clinical trial of C-ion RT for postoperative pelvic recurrence of rectal cancer confirmed its long-term efficacy and safety. These results suggest that C-ion RT may be a safe and effective treatment option for the postoperative pelvic recurrence of rectal cancer.
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Affiliation(s)
- Shintaro Shiba
- Department of Radiation Oncology, Shonan Kamakura General Hospital, 1370-1, Okamoto, Kamakura, Kanagawa 247-8533, Japan
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22, Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Masahiko Okamoto
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22, Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Kei Shibuya
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22, Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Daijiro Kobayashi
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22, Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Yuhei Miyasaka
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22, Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Tatsuya Ohno
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22, Showa-machi, Maebashi, Gunma 371-8511, Japan
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Kim HJ, Choi GS, Joshi H, Cho SH, Park JS, Park SY, Song SH, Kang MK. Robotic and laparoscopic salvage lateral pelvic node dissection for the treatment of recurrent rectal cancer. Surg Endosc 2023:10.1007/s00464-023-10000-5. [PMID: 37016084 DOI: 10.1007/s00464-023-10000-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 02/27/2023] [Indexed: 04/06/2023]
Abstract
BACKGROUND The lateral pelvic sidewall is a major site of local recurrence after radical resection of rectal cancer. Salvage lateral pelvic node dissection (LPND) may be the only way to eliminate recurrent lateral pelvic nodes (LPNs). This study aimed to describe the technical details of robotic and laparoscopic salvage LPND and assess the short-term clinical and oncological outcomes in patients with recurrent LPNs who underwent salvage LPND by a minimally invasive approach for curative intent. METHODS Between September 2010 and 2019, 36 patients who underwent salvage surgery for LPN recurrence were retrospectively analyzed from a prospectively maintained database. Patients' characteristics, index operation, MRI findings, and perioperative and pathological outcomes were analyzed. RESULTS Eleven and 14 patients underwent robotic and laparoscopic salvage LPND, respectively. Eight patients (32.0%) underwent a combined salvage operation for resectable extra-pelvic sidewall metastases. There were four cases of open-conversion during the laparoscopic approach due to uncontrolled bleeding of iliac vessels. In these patients, metastatic LPNs were suspected of iliac vessel invasion and were found to be larger in size (median 15 mm; range 12-20) than that in patients who underwent successful LPND using the minimally invasive approach (median 10 mm; range 5-20). The median number of metastatic LPNs and harvested LPNs was 1 (range 0-3) and 6 (range 1-16), respectively. Six patients (24.0%) experienced postoperative complications including lymphoceles and voiding difficulties. During the follow-up (median 44.6 months; range 24.0-87.7), eight patients developed recurrences, mainly the lung and para-aortic lymph nodes, and one patient developed pelvic sidewall recurrence after laparoscopic salvage LPND. The 3-year disease-free survival and overall survival after salvage LPND were 66.4% and 79.2%, respectively. CONCLUSIONS Robotic and laparoscopic salvage LPND for recurrent LPNs are safe and feasible with favorable short-term surgical outcomes. However, the surgical approach should be carefully chosen in patients with large-sized and invasive recurrent LPNs.
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Affiliation(s)
- Hye Jin Kim
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, 807 Hogukro, Buk-Gu, Daegu, 41404, Korea
| | - Gyu-Seog Choi
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, 807 Hogukro, Buk-Gu, Daegu, 41404, Korea.
| | - Heman Joshi
- Department of Colorectal Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Seung Hyun Cho
- Department of Radiology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jun Seok Park
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, 807 Hogukro, Buk-Gu, Daegu, 41404, Korea
| | - Soo Yeun Park
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, 807 Hogukro, Buk-Gu, Daegu, 41404, Korea
| | - Seung Ho Song
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, 807 Hogukro, Buk-Gu, Daegu, 41404, Korea
| | - Min Kyu Kang
- Department of Radiation Oncology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
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Re-resection of Microscopically Positive Margins Found on Intraoperative Frozen Section Analysis Does Not Result in a Survival Benefit in Patients Undergoing Surgery and Intraoperative Radiation Therapy for Locally Recurrent Rectal Cancer. Dis Colon Rectum 2022; 65:1094-1102. [PMID: 35714345 DOI: 10.1097/dcr.0000000000002349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Intraoperative frozen-section analysis provides real-time margin resection status that can guide intraoperative decisions made by the surgeon and radiation oncologist. For patients with locally recurrent rectal cancer undergoing surgery and intraoperative radiation therapy, intraoperative re-resection of positive margins to achieve negative margins is common practice. OBJECTIVE This study aimed to assess whether re-resection of positive margins found on intraoperative frozen-section analysis improves oncologic outcomes. DESIGN This is a retrospective cohort study. SETTINGS This study was an analysis of a prospectively maintained multicenter database. PATIENTS All patients who underwent surgical resection of locally recurrent rectal cancer with intraoperative radiation therapy between 2000 and 2015 were included and followed for 5 years. Three groups were compared: initial R0 resection, initial R1 converted to R0 after re-resection, and initial R1 that remained R1 after re-resection. Grossly positive margin resections (R2) were excluded. MAIN OUTCOME MEASURES The primary outcome measures were 5-year overall survival, recurrence-free survival, and local re-recurrence. RESULTS A total of 267 patients were analyzed (initial R0 resection, n = 94; initial R1 converted to R0 after re-resection, n = 95; initial R1 that remained R1 after re-resection, n = 78). Overall survival was 4.4 years for initial R0 resection, 2.7 years for initial R1 converted to R0 after re-resection, and 2.9 years for initial R1 that remained R1 after re-resection ( p = 0.01). Recurrence-free survival was 3.0 years for initial R0 resection and 1.8 years for both initial R1 converted to R0 after re-resection and initial R1 that remained R1 after re-resection ( p ≤ 0.01). Overall survival did not differ for patients with R1 and re-resection R1 or R0 ( p = 0.62). Recurrence-free survival and freedom from local re-recurrence did not differ between groups. LIMITATIONS This study was limited by the heterogeneous patient population restricted to those receiving intraoperative radiation therapy. CONCLUSIONS Re-resection of microscopically positive margins to obtain R0 status does not appear to provide a significant survival advantage or prevent local re-recurrence in patients undergoing surgery and intraoperative radiation therapy for locally recurrent rectal cancer. See Video Abstract at http://links.lww.com/DCR/B886 . LA RERESECCIN DE LOS MRGENES MICROSCPICAMENTE POSITIVOS ENCONTRADOS DE MANERA INTRAOPERATORIA MEDIANTE LA TCNICA DE CRIOSECCIN, NO DA COMO RESULTADO UN BENEFICIO DE SUPERVIVENCIA EN PACIENTES SOMETIDOS A CIRUGA Y RADIOTERAPIA INTRAOPERATORIA PARA EL CNCER RECTAL LOCALMENTE RECIDIVANTE ANTECEDENTES:El análisis de la ténica de criosección para los margenes positivos encontrados de manera intraoperatoria proporciona el estado de la resección del margen en tiempo real que puede guiar las decisiones intraoperatorias tomadas por el cirujano y el oncólogo radioterapeuta. Para los pacientes con cáncer de recto localmente recurrente que se someten a cirugía y radioterapia intraoperatoria, la re-resección intraoperatoria de los márgenes positivos para lograr márgenes negativos es una práctica común.OBJETIVO:Evaluar si la re-resección de los márgenes positivos encontrados en el análisis de la ténica por criosecciónde manera intraoperatorios mejora los resultados oncológicos.DISEÑO:Estudio de cohorte retrospectivo.AJUSTES:Análisis de una base de datos multicéntrica mantenida de forma prospectiva.POBLACIÓN:Todos los pacientes que se sometieron a resección quirúrgica de cáncer de recto localmente recurrente con radioterapia intraoperatoria entre 2000 y 2015 fueron incluidos y seguidos durante 5 años. Se compararon tres grupos: resección inicial R0, R1 inicial convertido en R0 después de la re-resección y R1 inicial que permaneció como R1 después de la re-resección. Se excluyeron las resecciones de márgenes macroscópicamente positivos (R2).PRINCIPALES MEDIDAS DE RESULTADO:Supervivencia global a cinco años, supervivencia sin recidiva y recidiva local.RESULTADOS:Se analizaron un total de 267 pacientes (resección inicial R0 n = 94, R1 inicial convertido en R0 después de la re-resección n = 95, R1 inicial que permaneció como R1 después de la re-resección n = 78). La supervivencia global fue de 4,4 años para la resección inicial R0, 2,7 años para la R1 inicial convertida en R0 después de la re-resección y 2,9 años para la R1 inicial que permaneció como R1 después de la re-resección ( p = 0,01). La supervivencia libre de recurrencia fue de 3,0 años para la resección inicial R0 y de 1,8 años para el R1 inicial convertido en R0 después de la re-resección y el R1 inicial que permaneció como R1 después de la re-resección ( p ≤ 0,01). La supervivencia global no difirió para los pacientes con R1 y re-resección R1 o R0 ( p = 0,62). La supervivencia libre de recurrencia y la ausencia de recurrencia local no difirieron entre los grupos.LIMITACIONES:Población de pacientes heterogénea, restringida a aquellos que reciben radioterapia intraoperatoria.CONCLUSIONES:La re-resección de los márgenes microscópicamente positivos para obtener el estado R0 no parece proporcionar una ventaja de supervivencia significativa o prevenir la recurrencia local en pacientes sometidos a cirugía y radioterapia intraoperatoria para el cáncer de recto localmente recurrente. Consulte Video Resumen en http://links.lww.com/DCR/B886 . (Traducción-Dr. Daniel Guerra ).
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Fadel MG, Ahmed M, Malietzis G, Pellino G, Rasheed S, Brown G, Tekkis P, Kontovounisios C. Oncological outcomes of multimodality treatment for patients undergoing surgery for locally recurrent rectal cancer: A systematic review. Cancer Treat Rev 2022; 109:102419. [PMID: 35714574 DOI: 10.1016/j.ctrv.2022.102419] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/01/2022] [Accepted: 06/05/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND There are several strategies in the management of locally recurrent rectal cancer (LRRC) with the optimum treatment yet to be established. This systematic review aims to compare oncological outcomes in patients undergoing surgery for LRRC who underwent neoadjuvant radiotherapy or chemoradiotherapy (CRT), adjuvant CRT, surgery only or surgery and intraoperative radiotherapy (IORT). METHODS A literature search of MEDLINE, EMBASE and CINAHL was performed for studies that reported data on oncological outcomes for the different treatment modalities in patients with LRRC from January 1990 to January 2022. Weighted means were calculated for the following outcomes: postoperative resection status, local control, and overall survival at 3 and 5 years. RESULTS Fifteen studies of 974 patients were included and they received the following treatment: 346 neoadjuvant radiotherapy, 279 neoadjuvant CRT, 136 adjuvant CRT, 189 surgery only, and 24 surgery and IORT. The highest proportion of R0 resection was found in the neoadjuvant CRT group followed by neoadjuvant radiotherapy and adjuvant CRT groups (64.07% vs 52.46% vs 47.0% respectively). The neoadjuvant CRT group had the highest mean 5-year local control rate (49.50%) followed by neoadjuvant radiotherapy (22.0%). Regarding the 5-year overall survival rate, the neoadjuvant CRT group had the highest mean of 34.92%, followed by surgery only (29.74%), neoadjuvant radiotherapy (28.94%) and adjuvant CRT (20.67%). CONCLUSIONS The findings of this systematic review suggest that neoadjuvant CRT followed by surgery can lead to improved resection status, long-term disease control and survival in the management of LRRC. However, treatment strategies in LRRC are complex and further comparisons, particularly taking into account previous treatments for the primary rectal cancer, are required.
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Affiliation(s)
- Michael G Fadel
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK; Department of Surgery and Cancer, Imperial College, London, UK.
| | - Mosab Ahmed
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK
| | - George Malietzis
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK; Department of Surgery and Cancer, Imperial College, London, UK; Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy; Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Shahnawaz Rasheed
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK; Department of Surgery and Cancer, Imperial College, London, UK; Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
| | - Gina Brown
- Department of Surgery and Cancer, Imperial College, London, UK
| | - Paris Tekkis
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK; Department of Surgery and Cancer, Imperial College, London, UK; Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
| | - Christos Kontovounisios
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK; Department of Surgery and Cancer, Imperial College, London, UK; Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
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Shine RJ, Glyn T, Frizelle F. Pelvic exenteration: a review of current issues/controversies. ANZ J Surg 2022; 92:2822-2828. [PMID: 35490337 DOI: 10.1111/ans.17734] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 03/09/2022] [Accepted: 04/01/2022] [Indexed: 11/28/2022]
Abstract
Management of advanced or recurrent pelvic cancer has evolved dramatically over the past few decades. Patients who were previously considered inoperable are now candidates for potentially curative surgery and avoid suffering with intractable symptoms. Up to 10% of primary rectal cancers present with isolated advanced local disease and between 10% and 15% of patients develop localized recurrence following proctectomy. Advances in surgical technique, reconstruction and multidisciplinary involvement have led to a reduction in mortality and morbidity and culminated in higher R0 resection rates with superior longer-term survival outcomes. Recent studies boast over 50% 5-year survival for rectal with an R0 resection. Exenteration has cemented itself as an important treatment option for advanced primary/recurrent pelvic tumours, however, there are still a few controversies. This review will discuss some of these issues, including: limitations of resection and the approach to high/wide tumours; the role of acute exenteration; re-exenteration; exenteration in the setting of metastatic disease and palliation; the role of radiotherapy (including intra-operative and re-irradiation); management of the empty pelvis; and the impact on quality of life and function.
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Affiliation(s)
- Rebecca J Shine
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Tamara Glyn
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand.,Department of Surgery, University of Otago, Christchurch, New Zealand
| | - Frank Frizelle
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand.,Department of Surgery, University of Otago, Christchurch, New Zealand
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Contemporary Management of Locally Advanced and Recurrent Rectal Cancer: Views from the PelvEx Collaborative. Cancers (Basel) 2022; 14:cancers14051161. [PMID: 35267469 PMCID: PMC8909015 DOI: 10.3390/cancers14051161] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 02/18/2022] [Accepted: 02/21/2022] [Indexed: 12/12/2022] Open
Abstract
Pelvic exenteration is a complex operation performed for locally advanced and recurrent pelvic cancers. The goal of surgery is to achieve clear margins, therefore identifying adjacent or involved organs, bone, muscle, nerves and/or vascular structures that may need resection. While these extensive resections are potentially curative, they can be associated with substantial morbidity. Recently, there has been a move to centralize care to specialized units, as this facilitates better multidisciplinary care input. Advancements in pelvic oncology and surgical innovation have redefined the boundaries of pelvic exenterative surgery. Combined with improved neoadjuvant therapies, advances in diagnostics, and better reconstructive techniques have provided quicker recovery and better quality of life outcomes, with improved survival This article provides highlights of the current management of advanced pelvic cancers in terms of surgical strategy and potential future developments.
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Popp J, Weinberg DS, Enns E, Nyman JA, Beck JR, Kuntz KM. Reevaluating the Evidence for Intensive Postoperative Extracolonic Surveillance for Nonmetastatic Colorectal Cancer. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:36-46. [PMID: 35031098 PMCID: PMC9186065 DOI: 10.1016/j.jval.2021.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 07/19/2021] [Accepted: 07/31/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES The FACS, GILDA, and COLOFOL trials have cast doubt on the value of intensive extracolonic surveillance for resected nonmetastatic colorectal cancer and by extension metastasectomy. We reexamined this pessimistic interpretation. We evaluate an alternative explanation: insufficient power to detect a realistically sized survival benefit that may be clinically meaningful. METHODS A microsimulation model of postdiagnosis colorectal cancer was constructed assuming an empirically plausible efficacy for metastasectomy and thus surveillance. The model was used to predict the large-sample mortality reduction expected for each trial and the implied statistical power. A potential recurrence imbalance in the FACS trial was investigated. Goodness of fit between model predictions and trial results were evaluated. Downstream life expectancy was estimated and power calculations performed for future trials evaluating surveillance and metastasectomy. RESULTS For all 3 trials, the model predicted a mortality reduction of ≤5% and power of <10%. The FACS recurrence imbalance likely led to a large relative bias (>2.5) in the hazard ratio for overall survival favoring control. After adjustment, both COLOFOL and FACS results were consistent with model predictions (P>.5). A 2.6 (95% credible interval 0.5-5.1) and 3.6 (95% credible interval 0.8-7.0) month increase in life expectancy is predicted comparing intensive extracolonic surveillance-routine computed tomography scans and carcinoembryonic antigen assays-with 1 computed tomography scan at 12 months or no surveillance, respectively. An adequately sized surveillance trial is not feasible. A metastasectomy trial should randomize at least 200 to 300 patients. CONCLUSIONS Recent trial results do not warrant de novo skepticism of metastasectomy nor targeted extracolonic surveillance. Given the potential for clinically meaningful life-expectancy gain and significant uncertainty, a trial of metastasectomy is needed.
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Affiliation(s)
- Jonah Popp
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, RI, USA.
| | - David S Weinberg
- Department of Medicine, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Eva Enns
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - John A Nyman
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - J Robert Beck
- Cancer Prevention and Control Program, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Karen M Kuntz
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
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11
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Lampe B, Luengas-Würzinger V, Weitz J, Roth S, Rawert F, Schuler E, Classen-von Spee S, Fix N, Baransi S, Dizdar A, Mallmann P, Schaser KD, Bogner A. Opportunities and Limitations of Pelvic Exenteration Surgery. Cancers (Basel) 2021; 13:6162. [PMID: 34944783 PMCID: PMC8699210 DOI: 10.3390/cancers13246162] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/26/2021] [Accepted: 12/03/2021] [Indexed: 11/17/2022] Open
Abstract
PURPOSE The practice of exenterative surgery is sometimes controversial and has garnered a certain scepticism. Surgical studies are difficult to conduct due to insufficient data. The aim of this review is to present the current standing of pelvic exenteration from a surgical, gynaecological and urological point of view. METHODS This review is based upon a literature review (MEDLINE (PubMed), CENTRAL (Cochrane) and EMBASE (Elsevier)) of retrospective studies on exenterative surgery from 1993-2020. Using MeSH (Medical Subject Headings) search terms, 1572 publications were found. These were evaluated and screened with respect to their eligibility using algorithms and well-defined inclusion and exclusion criteria. Therefore, the guidelines for systematic reviews (PRISMA) were used. RESULTS A complete tumour resection (R0) often represents the only curative option for advanced pelvic carcinomas and their recurrences. A recent systematic review showed significant symptom relief in 80% of palliative patients after pelvic exenteration. Surgical limitations (distant metastases, involvement of the pelvic wall, etc.) are diminished by adequate surgical expertise and close interdisciplinary cooperation. While the mortality rate is low (2-5%), the still relatively high morbidity rate (32-84%) can be minimized by optimizing the perioperative setting. Following exenterations, roughly 79-82% of patients report satisfying results according to PROs (patient-reported outcomes). CONCLUSION Due to multimodality treatment strategies combined with extended surgical expertise and patients' preferences, pelvic exenteration can be offered nowadays with low mortality and acceptable postoperative quality of life. The possibilities of surgical treatment are often underestimated. A multi-centre database (PelvEx Collaborative) was established to collect data and experiences to optimize the research in this field.
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Affiliation(s)
- Björn Lampe
- Department of Gynecology & Obstetrics, Florence Nightingale Hospital, Kreuzbergstr. 79, 40489 Düsseldorf, Germany; (B.L.); (F.R.); (E.S.); (S.C.-v.S.); (N.F.); (S.B.); (A.D.)
| | - Verónica Luengas-Würzinger
- Department of Gynecology & Obstetrics, Florence Nightingale Hospital, Kreuzbergstr. 79, 40489 Düsseldorf, Germany; (B.L.); (F.R.); (E.S.); (S.C.-v.S.); (N.F.); (S.B.); (A.D.)
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany; (J.W.); (A.B.)
| | - Stephan Roth
- Department of Urology and Pediatric Urology, Helios Faculty of Medicine Wuppertal, Universität Witten/Herdecke, Heusnerstraße 40, 42283 Wuppertal, Germany;
| | - Friederike Rawert
- Department of Gynecology & Obstetrics, Florence Nightingale Hospital, Kreuzbergstr. 79, 40489 Düsseldorf, Germany; (B.L.); (F.R.); (E.S.); (S.C.-v.S.); (N.F.); (S.B.); (A.D.)
| | - Esther Schuler
- Department of Gynecology & Obstetrics, Florence Nightingale Hospital, Kreuzbergstr. 79, 40489 Düsseldorf, Germany; (B.L.); (F.R.); (E.S.); (S.C.-v.S.); (N.F.); (S.B.); (A.D.)
| | - Sabrina Classen-von Spee
- Department of Gynecology & Obstetrics, Florence Nightingale Hospital, Kreuzbergstr. 79, 40489 Düsseldorf, Germany; (B.L.); (F.R.); (E.S.); (S.C.-v.S.); (N.F.); (S.B.); (A.D.)
| | - Nando Fix
- Department of Gynecology & Obstetrics, Florence Nightingale Hospital, Kreuzbergstr. 79, 40489 Düsseldorf, Germany; (B.L.); (F.R.); (E.S.); (S.C.-v.S.); (N.F.); (S.B.); (A.D.)
| | - Saher Baransi
- Department of Gynecology & Obstetrics, Florence Nightingale Hospital, Kreuzbergstr. 79, 40489 Düsseldorf, Germany; (B.L.); (F.R.); (E.S.); (S.C.-v.S.); (N.F.); (S.B.); (A.D.)
| | - Anca Dizdar
- Department of Gynecology & Obstetrics, Florence Nightingale Hospital, Kreuzbergstr. 79, 40489 Düsseldorf, Germany; (B.L.); (F.R.); (E.S.); (S.C.-v.S.); (N.F.); (S.B.); (A.D.)
| | - Peter Mallmann
- Department of Obstetrics and Gynecology, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany;
| | - Klaus-Dieter Schaser
- University Center for Orthopedics, Trauma and Plastic Surgery, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany;
| | - Andreas Bogner
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany; (J.W.); (A.B.)
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12
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Jankowski M, Las-Jankowska M, Rutkowski A, Bała D, Wiśniewski D, Tkaczyński K, Kowalski W, Głowacka-Mrotek I, Zegarski W. Clinical Reality and Treatment for Local Recurrence of Rectal Cancer: A Single-Center Retrospective Study. ACTA ACUST UNITED AC 2021; 57:medicina57030286. [PMID: 33808603 PMCID: PMC8003449 DOI: 10.3390/medicina57030286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/11/2021] [Accepted: 03/15/2021] [Indexed: 01/31/2023]
Abstract
Background and Objectives: Despite advances in treatment, local recurrence remains a great concern in patients with rectal cancer. The aim of this study was to investigate the incidence and risk factors of local recurrence of rectal cancer in our single center over a 7-year-period. Materials and Methods: Patients with stage I-III rectal cancer were treated with curative intent. The necessity for radiotherapy and chemotherapy was determined before surgery and/or postoperative histopathological results. Results: Of 365 rectal cancer patients, 76 (20.8%) developed recurrent disease. In total, 27 (7.4%) patients presented with a local tumor recurrence (isolated in 40.7% of cases). Radiotherapy was performed in 296 (81.1%) patients. The most often used schema was 5 × 5 Gy followed by immediate surgery (n = 214, 58.6%). Local recurrence occurred less frequently in patients treated with 5 × 5 Gy radiotherapy followed by surgery (n = 9, 4%). Surgical procedures of relapses were performed in 12 patients, six of whom were operated with radical intent. Only two (7.4%) patients lived more than 5 years after local recurrence treatment. The incidence of local recurrence was associated with primary tumor distal location and worse prognosis. The median overall survival of patients after local recurrence treatment was 19 months. Conclusions: Individualized rectal cancer patient selection and systematic treatment algorithms should be used clinical practice to minimize likelihood of relapse. 5 × 5 Gy radiotherapy followed by immediate surgery allows good local control in resectable cT2N+/cT3N0 patients. Radical resection of isolated local recurrence offers the best chances of cure.
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Affiliation(s)
- Michał Jankowski
- Department of Surgical Oncology, Ludwik Rydygier’s Collegium Medicum, Bydgoszcz, Nicolaus Copernicus University, 85-067 Torun, Poland; (M.L.-J.); (D.B.); (W.K.); (W.Z.)
- Department of Surgical Oncology, Oncology Center—Prof Franciszek Łukaszczyk Memorial Hospital, 85-796 Bydgoszcz, Poland; (D.W.); (K.T.)
- Correspondence: or
| | - Manuela Las-Jankowska
- Department of Surgical Oncology, Ludwik Rydygier’s Collegium Medicum, Bydgoszcz, Nicolaus Copernicus University, 85-067 Torun, Poland; (M.L.-J.); (D.B.); (W.K.); (W.Z.)
- Department of Clinical Oncology, Oncology Center—Prof Franciszek Łukaszczyk Memorial Hospital, 85-796 Bydgoszcz, Poland
| | - Andrzej Rutkowski
- Department of Gastroenterological Oncology, M. Skłodowska-Curie Memorial Cancer Centre, 02-781 Warsaw, Poland;
| | - Dariusz Bała
- Department of Surgical Oncology, Ludwik Rydygier’s Collegium Medicum, Bydgoszcz, Nicolaus Copernicus University, 85-067 Torun, Poland; (M.L.-J.); (D.B.); (W.K.); (W.Z.)
- Department of Surgical Oncology, Oncology Center—Prof Franciszek Łukaszczyk Memorial Hospital, 85-796 Bydgoszcz, Poland; (D.W.); (K.T.)
| | - Dorian Wiśniewski
- Department of Surgical Oncology, Oncology Center—Prof Franciszek Łukaszczyk Memorial Hospital, 85-796 Bydgoszcz, Poland; (D.W.); (K.T.)
| | - Karol Tkaczyński
- Department of Surgical Oncology, Oncology Center—Prof Franciszek Łukaszczyk Memorial Hospital, 85-796 Bydgoszcz, Poland; (D.W.); (K.T.)
| | - Witold Kowalski
- Department of Surgical Oncology, Ludwik Rydygier’s Collegium Medicum, Bydgoszcz, Nicolaus Copernicus University, 85-067 Torun, Poland; (M.L.-J.); (D.B.); (W.K.); (W.Z.)
| | - Iwona Głowacka-Mrotek
- Department of Rehabilitation, Ludwik Rydygier’s Collegium Medicum, Bydgoszcz, Nicolaus Copernicus University, 85-067 Torun, Poland;
| | - Wojciech Zegarski
- Department of Surgical Oncology, Ludwik Rydygier’s Collegium Medicum, Bydgoszcz, Nicolaus Copernicus University, 85-067 Torun, Poland; (M.L.-J.); (D.B.); (W.K.); (W.Z.)
- Department of Surgical Oncology, Oncology Center—Prof Franciszek Łukaszczyk Memorial Hospital, 85-796 Bydgoszcz, Poland; (D.W.); (K.T.)
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13
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Tanaka A, Uehara K, Aiba T, Ogura A, Mukai T, Yokoyama Y, Ebata T, Kodera Y, Nagino M. The role of surgery for locally recurrent and second recurrent rectal cancer with metastatic disease. Surg Oncol 2020; 35:328-335. [PMID: 32979698 DOI: 10.1016/j.suronc.2020.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/17/2020] [Accepted: 09/06/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND The role of surgery for locally recurrent rectal cancer (LRRC) with resectable distant metastases or second LRRC remains unclear. This study aimed to clarify the influence of synchronous distant metastases (SDMs), a history of distant metastasis resection (HDMR), and a second LRRC on the outcome. METHODS The long-term outcomes of 70 surgically treated patients with LRRC between 2006 and 2018 were compared by SDM (n = 10), HDMR (n = 17), and second LRRC (n = 7). RESULTS Among the 10 patients with SDM, 4 patients underwent simultaneous resection, whereas the other 6 underwent staged resection with distant first approach. Recurrence developed in 9 patients, of which 2 patients with liver re-resection achieved long-term survival without cancer. The patients with and without SDM had equivalent 5-year overall survival rate (40.5% vs. 53.3%, p = 0.519); however, patients with SDM had a worse 3-year recurrence-free survival rate than those without SDM (10.0% vs. 37.5%, p = 0.031). Multivariate analysis showed that primary non-sphincter-preserving surgery, second LRRC, and R1 resection were independent risk factors for overall survival. Similarly, primary non-sphincter-preserving surgery, second LRRC, SDM, and R1 resection were risk factors for recurrence-free survival. CONCLUSIONS Patients with SDM might still be suitable to undergo salvage surgery and achieve favourable overall survival. Distant metastasectomy should be performed first, followed by a sufficient interval to avoid unnecessary LRRC resection in uncurable patients. An HDMR should not be taken into consideration when making surgical plans. Surgical indication of second LRRC should be strict, especially in referred patients.
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Affiliation(s)
- Aya Tanaka
- Division of Surgical Oncology, Department of Surgery, Nagoya Graduate School of Medicine, Nagoya, Japan
| | - Kay Uehara
- Division of Surgical Oncology, Department of Surgery, Nagoya Graduate School of Medicine, Nagoya, Japan.
| | - Toshisada Aiba
- Division of Surgical Oncology, Department of Surgery, Nagoya Graduate School of Medicine, Nagoya, Japan
| | - Atsushi Ogura
- Division of Surgical Oncology, Department of Surgery, Nagoya Graduate School of Medicine, Nagoya, Japan
| | - Toshiki Mukai
- Division of Surgical Oncology, Department of Surgery, Nagoya Graduate School of Medicine, Nagoya, Japan
| | - Yukihiro Yokoyama
- Division of Surgical Oncology, Department of Surgery, Nagoya Graduate School of Medicine, Nagoya, Japan
| | - Tomoki Ebata
- Division of Surgical Oncology, Department of Surgery, Nagoya Graduate School of Medicine, Nagoya, Japan
| | - Yasuhiro Kodera
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masato Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya Graduate School of Medicine, Nagoya, Japan
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14
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The use of intraoperative radiation therapy in the management of locally recurrent rectal cancer. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100763] [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]
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15
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Brown KG, Solomon MJ. Decision making, treatment planning and technical considerations in patients undergoing surgery for locally recurrent rectal cancer. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100764] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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16
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Balancing Fractionation and Advanced Technology in Consideration of Reirradiation. Semin Radiat Oncol 2020; 30:201-203. [DOI: 10.1016/j.semradonc.2020.02.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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17
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Predictors of overall survival following extended radical resections for locally advanced and recurrent pelvic malignancies. Langenbecks Arch Surg 2020; 405:491-502. [PMID: 32533361 DOI: 10.1007/s00423-020-01895-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 05/15/2020] [Indexed: 01/11/2023]
Abstract
PURPOSE In an era of personalised medicine, there is an overwhelming effort for predicting patients who will benefit from extended radical resections for locally advanced pelvic malignancy. However, there is paucity of data on the effect of comorbidities and postoperative complications on long-term overall survival (OS). The aim of this study was to define predictors of 1-year and 5-year OS. METHODS Data were collected from prospective databases at two high-volume institutions specialising in beyond TME surgery for locally advanced and recurrent pelvic malignancies between 1990 and 2015. The primary outcome measures were 1-year and 5-year OS. RESULTS A total of 646 consecutive extended radical resections were performed between 1990 and 2015. The majority were female patients (371, 57.4%) and the median age was 63 years (range 19-89 years). One-year OS, primary rectal adenocarcinoma had the best survival while recurrent colon cancer had the worse survival (p = 0.047). The 5-year OS between primary and recurrent cancers were 64.7% and 53%, respectively (p = 0.004). Poor independent prognostic markers for 5-year OS were increasing ASA score, cardiovascular disease, recurrent cancers, ovarian cancers, pulmonary embolus and acute respiratory distress syndrome. A positive survival benefit was demonstrated with preoperative radiotherapy (HR 0.55; 95% CI 0.4-0.75, p < 0.001). CONCLUSION Patient comorbidities and specific complications can influence long-term survival following extended radical resections. This study highlights important predictors, enabling clinicians to better inform patients of the potential short- and long-term outcomes in the management of locally advanced and recurrent pelvic malignancy.
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18
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Abstract
There have been significant developments in the management of advanced and recurrent colorectal cancer in recent decades. 70% of primary colorectal tumours arise in the colon and for patients with stage I-III disease, the standard of care is surgical resection followed by adjuvant therapy where appropriate. Locoregional recurrence (LR) occurs in 4-11.5% of patients following treatment of primary colon cancer with curative intent, and can be categorised as peri-anastomotic, mesenteric/paracolic (nodal), retroperitoneal and peritoneal. Of these, peritoneal recurrence is usually recognised as the most challenging type of recurrence to manage. Patients with isolated peri-anastomotic or limited nodal recurrence in the mesentery or retroperitoneum may be curable by radical salvage surgery, which often requires en bloc multi-visceral resection, while patients with low volume peritoneal metastases may be candidates for cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. Ensuring complete resection along embryonic mesocolic planes or en bloc resection of contiguously involved structures are best strategies to reduce the likelihood of local recurrence through a R1 resection margin. The role of complete mesocolic excision (CME) with high vascular ligation has been demonstrated to increase nodal yield and improve overall survival although this is more contentious. In patients with T4a disease and serosal surface involvement, peritoneal recurrence represents the greatest threat. Efforts for early diagnosis of peritoneal recurrence in these patients or prophylactic treatment, while intuitive have not demonstrated the survival benefit that would be expected. Other than locoregional recurrence (LR), systemic recurrence may occur in up to 50% of patients who have undergone curative resection for colorectal cancer. In keeping with portal venous outflow, the most common site of systemic recurrence is the liver. Although previously thought to be a fatal condition, liver resection is now the standard of care where liver metastases can be completely resected with clear margins plus leaving an adequate liver remnant with intact vascular inflow, outflow and biliary drainage. This can usually be achieved in 26-45% of patients presenting with liver metastases. Liver surgeons at the forefront of liver resection have also developed techniques to induce liver hypertrophy so as to improve likelihood of resectability. Even where patients have non-resectable disease, ablative techniques have become increasingly common. Naturally, none of these would be possible without the advent of improved chemotherapeutic and biological options in the field of medical oncology. Pulmonary metastasectomy with curative intent may be possible in a small number (10%) of patients with lung metastases, which is associated with an overall survival of up to 40%. Unlike liver metastases, proportionally less patients with pulmonary metastases will be resectable. For these patients, several ablative options are available. For all patients with recurrent colon cancer, patient selection for radical salvage surgery and decisions surrounding treatment strategy (including use of systemic therapy or ablative procedures) should take place in a multidisciplinary team setting.
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Affiliation(s)
- Kilian G M Brown
- SOuRCe (Surgical Outcomes Research Centre), Royal Prince Alfred Hospital, Sydney, Australia.,RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Cherry E Koh
- SOuRCe (Surgical Outcomes Research Centre), Royal Prince Alfred Hospital, Sydney, Australia.,RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Sydney Medical School, Discipline of Surgery, University of Sydney, Australia
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19
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Cyr DP, Zih FS, Wells BJ, Swett-Cosentino J, Burkes RL, Brierley JD, Cummings B, Smith AJ, Swallow CJ. Long-term outcomes following salvage surgery for locally recurrent rectal cancer: A 15-year follow-up study. Eur J Surg Oncol 2020; 46:1131-1137. [PMID: 32224071 DOI: 10.1016/j.ejso.2020.02.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 02/20/2020] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Locally recurrent rectal cancer (LRRC) is a complex problem requiring multidisciplinary consultation and specialized surgical care. Given the paucity of published longer-term survival data, skepticism persists regarding the benefit of major extirpative surgery. We investigated ultra-long-term (~15 years) outcomes following radical resection of LRRC and sought relevant clinicopathologic prognostic variables. METHODS A cohort of 52 consecutive patients who underwent resection of LRRC at our institution between 1997 and 2005 were followed with serial exams and imaging up to the point of death, or 30/06/2019. RESULTS Median follow-up time was 16.5 years (9.9-18.3) for patients who were alive at last follow-up; only one patient was lost to follow-up, at 9.9 years. For the entire cohort of 52 patients, disease-specific survival (DSS) at 5, 10, and 15 years following salvage surgery was 41%, 33%, and 31%, respectively. All patients who had distant metastatic disease at the time of LRRC resection (n = 6) subsequently died of cancer, at a median of 21 months (4-46). In those without distant metastases at time of salvage surgery (n = 46), DSS at 5, 10, and 15 years was 47%, 38%, and 35%, respectively, median 60 months. Negative resection margin (R0) was independently predictive of superior outcomes. In patients with M0 disease who had R0 resection (n = 37), DSS at 5, 10 and 15 years was 58%, 47%, and 44%, respectively, median 73 months. No patient developed re-recurrence after 5.5 years. CONCLUSIONS This study demonstrates exceptionally durable long-term cancer-free survival following salvage surgery for LRRC, indicating that cure is possible.
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Affiliation(s)
- David P Cyr
- Department of Surgical Oncology, Princess Margaret Cancer Centre and Mount Sinai Hospital, Toronto, Canada; Division of General Surgery, Department of Surgery, University of Toronto, Canada; Institute of Medical Science, University of Toronto, Toronto, Canada; Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Canada
| | - Francis Sw Zih
- Department of Surgery, Surrey Memorial Hospital, Surrey, Canada; Division of General Surgery, Department of Surgery, University of British Columbia, Canada
| | - Bryan J Wells
- Division of General Surgery, Nanaimo Regional General Hospital, Nanaimo, Canada
| | | | - Ronald L Burkes
- Department of Medical Oncology, Mount Sinai Hospital and Princess Margaret Cancer Centre, Department of Medicine, University of Toronto, Canada
| | - James D Brierley
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Canada
| | - Bernard Cummings
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Canada
| | - Andrew J Smith
- Sunnybrook Health Sciences Centre and Odette Cancer Centre, Toronto, Canada
| | - Carol J Swallow
- Department of Surgical Oncology, Princess Margaret Cancer Centre and Mount Sinai Hospital, Toronto, Canada; Division of General Surgery, Department of Surgery, University of Toronto, Canada; Institute of Medical Science, University of Toronto, Toronto, Canada; Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Canada.
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20
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What Constitutes a Clear Margin in Patients With Locally Recurrent Rectal Cancer Undergoing Pelvic Exenteration? Ann Surg 2020; 275:157-165. [DOI: 10.1097/sla.0000000000003834] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Isozaki Y, Takiyama H, Bhattacharyya T, Ebner D, Kasuya G, Makishima H, Tsuji H, Kamada T, Yamada S. Heavy charged particles for gastrointestinal cancers. J Gastrointest Oncol 2020; 11:203-211. [PMID: 32175123 DOI: 10.21037/jgo.2019.03.14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Carbon ion beams constitute the primary delivery method of heavy ion radiotherapy. It offers improved dose distribution, and enables concentration of dose within target volumes with minimal extraneous exposure of normal tissue, while delivering superior biological effect in comparison with photon and proton technologies. Here, we review the application of this technology to various gastrointestinal cancers.
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Affiliation(s)
- Yuka Isozaki
- Department of Radiation Oncology, Hospital of the National Institute of Radiological Science, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan
| | - Hirotoshi Takiyama
- Department of Radiation Oncology, Hospital of the National Institute of Radiological Science, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan
| | - Tapesh Bhattacharyya
- Department of Radiation Oncology, Hospital of the National Institute of Radiological Science, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan
| | - Daniel Ebner
- Department of Radiation Oncology, Hospital of the National Institute of Radiological Science, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan
| | - Goro Kasuya
- Department of Radiation Oncology, Hospital of the National Institute of Radiological Science, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan
| | - Hirokazu Makishima
- Department of Radiation Oncology, Hospital of the National Institute of Radiological Science, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan
| | - Hiroshi Tsuji
- Department of Radiation Oncology, Hospital of the National Institute of Radiological Science, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan
| | - Tadashi Kamada
- Department of Radiation Oncology, Hospital of the National Institute of Radiological Science, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan
| | - Shigeru Yamada
- Department of Radiation Oncology, Hospital of the National Institute of Radiological Science, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan
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22
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Lau YC, Brown KGM, Lee P. Pelvic exenteration for locally advanced and recurrent rectal cancer-how much more? J Gastrointest Oncol 2019; 10:1207-1214. [PMID: 31949941 DOI: 10.21037/jgo.2019.01.21] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
There have been significant advances in the surgical management of locally advanced and recurrent rectal cancer in recent decades. Patient with advanced pelvic tumours involving adjacent organs and neurovascular structures, beyond the traditional mesorectal planes, who would have traditionally been considered irresectable at many centres, now undergo surgery routinely at specialised units. While high rates of morbidity and mortality were reported by the pioneers of pelvic exenteration (PE) in early literature, this is now considered historical data. In 2019, patients who undergo PE for advanced or recurrent rectal cancer can expect reasonable rates of long-term survival (up to 60% at 5 years) and acceptable morbidity and quality of life. This article describes the surgical techniques that have been developed for radical multivisceral pelvic resections and reviews contemporary outcomes.
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Affiliation(s)
- Yee Chen Lau
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia
| | - Kilian G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia.,The Institute of Academic Surgery at RPA, Sydney, Australia
| | - Peter Lee
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia.,The Institute of Academic Surgery at RPA, Sydney, Australia
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23
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Image-guided high-dose-rate interstitial brachytherapy for recurrent rectal cancer after salvage surgery: a case report. J Contemp Brachytherapy 2019; 11:343-348. [PMID: 31523235 PMCID: PMC6737566 DOI: 10.5114/jcb.2019.87000] [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: 01/23/2019] [Accepted: 06/11/2019] [Indexed: 11/26/2022] Open
Abstract
Treatment options for patients with recurrent rectal cancer in pelvis represent a significant challenge because the balance of efficiency and toxicity needs to be pursued. This case report illustrates a treatment effect of image-guided high-dose-rate interstitial brachytherapy (HDR-ISBT) for locally relapsed rectal cancer after salvage surgery. A 61-year-old male who underwent laparoscopic high anterior resection (LAP-HAR) with D3 lymph node dissection as a primary treatment for rectal cancer (pT3N0M0, well-differentiated adenocarcinoma) had relapsed locally 8 months after initial surgery, for which he underwent salvage abdominal perineal resection (APR), followed by adjuvant 8 cycles of XELOX (capecitabine and oxaliplatin) chemotherapy. He developed pelvic recurrence 1 year after the second surgery. Image-guided HDR-ISBT was performed (30 Gy/5 fractions/3 days) followed by external beam radiation therapy with 39.6 Gy in 22 fractions. There were no severe complications related to salvage radiotherapy. CEA was decreased from 24.5 ng/ml to 0.7 ng/ml, 4 months after the salvage radiotherapy. Complete response was noted on follow-up MRIs done on 2, 5, 8, and 14 months after the treatment. Hence, HDR-ISBT appears to be effective for locally recurrent rectal cancer even after salvage surgery.
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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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Detering R, Karthaus EG, Borstlap WAA, Marijnen CAM, van de Velde CJH, Bemelman WA, Beets GL, Tanis PJ, Aalbers AGJ. Treatment and survival of locally recurrent rectal cancer: A cross-sectional population study 15 years after the Dutch TME trial. Eur J Surg Oncol 2019; 45:2059-2069. [PMID: 31230980 DOI: 10.1016/j.ejso.2019.06.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 06/12/2019] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION Optimized treatment of primary rectal cancer might have influenced treatment characteristics and outcome of locally recurrent rectal cancer (LRRC). Subgroup analysis of the Dutch TME trial showed that preoperative radiotherapy (PRT) for the primary tumour was an independent poor prognostic factor after diagnosis of LRRC. This cross-sectional population study aimed to evaluate treatment and overall survival (OS) of LRRC patients, stratified for prior preoperative radiotherapy (PRT) and intention of treatment of LRRC. METHODS All patients developing LRRC were selected from a collaborative Snapshot study on 2095 surgically treated rectal cancer patients from 71 Dutch hospitals in the year 2011. Cox proportional hazard analysis was performed to determine predictors for OS. RESULTS A total of 107 LRRC patients (5.1%) were included, of whom 88 (82%) underwent PRT for their primary tumour. LRRC was treated with initial curative intent in 31 patients (29%), with eventual resection in 20 patients (19%). Median OS was 22 and 8 months after curative and palliative intent treatment, respectively (p < 0.001). Initial CRM positivity and palliative intent treatment were associated with worse OS after LRRC, while prior PRT was not. CONCLUSIONS This cross-sectional study revealed that rectal cancer patients, who underwent curative resection in the Netherlands in 2011 and subsequently developed local recurrence, were amenable for again curative intent treatment in 29%, with a corresponding median survival of 22 months. Prior PRT was not significantly associated with survival after diagnosis of LRRC.
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Affiliation(s)
- Robin Detering
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands.
| | - Eleonora G Karthaus
- Leiden University Medical Center, Department of Surgery, Leiden, the Netherlands
| | - Wernard A A Borstlap
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
| | - Corrie A M Marijnen
- Netherlands Cancer Institute-Antoni van Leeuwenhoek, Department of Radiotherapy, Amsterdam, the Netherlands
| | | | - Willem A Bemelman
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
| | - Geerard L Beets
- Netherlands Cancer Institute-Antoni van Leeuwenhoek, Department of Surgery, Amsterdam, the Netherlands
| | - Pieter J Tanis
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
| | - Arend G J Aalbers
- Netherlands Cancer Institute-Antoni van Leeuwenhoek, Department of Surgery, Amsterdam, the Netherlands
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Yang Y, Malakorn S, Maldonado K, Bednarski BK, Kiernan CM, Thirumurthi S, Chang GJ, You YN. The Pelvis-First Approach for Robotic Proctectomy in Patients with Redundant Abdominal Colon. Ann Surg Oncol 2019; 26:2514-2515. [PMID: 31102088 DOI: 10.1245/s10434-019-07416-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Robotic surgery is increasingly performed for low rectal cancer.1 A redundant sigmoid colon makes retraction and pelvic dissection challenging. We present a 'pelvis-first' approach to robotic proctectomy where pelvic dissection occurs prior to colonic mobilization. METHODS A 26-year-old woman was diagnosed with a clinical T3N1 rectal adenocarcinoma at 3 cm from the anal verge. The patient had Lynch syndrome, with a germline mutation in the PMS2 gene. A near-complete clinical response was observed after neoadjuvant chemoradiation (NCRT), and the patient wished to delay surgery and permanent colostomy. Additional FOLFOX was administered and led to a complete clinical response. After 2.5 months of watchful delay of surgery, the tumor regrew, and the patient then underwent robotic abdominoperineal resection (APR). RESULTS Initial exploration revealed a highly redundant sigmoid colon. A pelvis-first approach was undertaken. The colon was left tethered and outside of the pelvis during the pelvic dissection. The levator ani was divided transabdominally. Vascular dissection and left colon mobilization were completed after pelvic dissection.2 The specimen was removed transanally, obviating the need for abdominal incision. An end colostomy was created laparoscopically, and the perineum was closed primarily after omental flap. The patient recovered without complications. CONCLUSIONS The 'pelvis-first' approach to proctectomy is advantageous for patients with a highly redundant sigmoid colon. Transabdominal division of the levator ani during APR ensures excellent circumferential margin. Although Lynch syndrome-associated rectal cancer can show excellent response to NCRT,3 patients undergoing watchful delay of surgery require close monitoring and prompt triggering of salvage proctectomy when tumor regrowth is observed.4,5.
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Affiliation(s)
- Yun Yang
- Department of General Surgery, Chinese PLA General Hospital, Beijing, China.,Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, PO Box 301402, Houston, TX, 77230, USA
| | - Songphol Malakorn
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, PO Box 301402, Houston, TX, 77230, USA
| | - Kelly Maldonado
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, PO Box 301402, Houston, TX, 77230, USA
| | - Brian K Bednarski
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, PO Box 301402, Houston, TX, 77230, USA
| | - Colleen M Kiernan
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, PO Box 301402, Houston, TX, 77230, USA
| | - Selvi Thirumurthi
- Department of Gastroenterology Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - George J Chang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, PO Box 301402, Houston, TX, 77230, USA
| | - Y Nancy You
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, PO Box 301402, Houston, TX, 77230, USA.
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Humphries EL, Kroon HM, Dudi-Venkata NN, Thomas ML, Moore JW, Sammour T. Short- and long-term outcomes of selective pelvic exenteration surgery in a low-volume specialized tertiary setting. ANZ J Surg 2019; 89:E226-E230. [PMID: 31067602 DOI: 10.1111/ans.15212] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 03/03/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Most published data on pelvic exenteration comes from high-volume quaternary units, with limited data available from outside of this setting. This study reports outcomes of selective pelvic exenteration performed in a low-volume tertiary unit with multidisciplinary support. METHODS A retrospective review of consecutive patients who underwent pelvic exenteration surgery for rectal/anal carcinoma, or gynaecological malignancy at Royal Adelaide Hospital between June 2008 and September 2018. Descriptive statistics and Kaplan-Meier analysis of 5-year disease-free and overall survival for patients treated with curative intent were performed. RESULTS A total of 54 patients who underwent pelvic exenteration were included. Most patients presented with primary rectal adenocarcinoma, and posterior and total pelvic exenterations were the most common operations performed (>90%). Median total operating time was 323 min, median hospital stay was 15 days, and the readmission rate was 14.8%. The overall complication rate (per patient) was 70.4%, and the re-intervention rate was 20.4%. Thirteen percent of patients required intensive care unit-admission, and there was one postoperative death (1.9%). R0 resection margins were achieved in 81.5% of patients, with R1 and R2 margins in 13.0 and 5.6% of patients, respectively. Estimated 5-year disease-free survival was 38.8%, and 5-year overall survival was 65.7%. CONCLUSION Short- and long-term outcomes of selective pelvic exenteration surgery are acceptable in a low-volume specialized tertiary setting with suitable multidisciplinary expertise. If the required expertise is not readily available, then outside referral is recommended.
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Affiliation(s)
- Emily L Humphries
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Hidde M Kroon
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Nagendra N Dudi-Venkata
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Michelle L Thomas
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - James W Moore
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Tarik Sammour
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Surgical Resection for Recurrence After Two-Stage Hepatectomy for Colorectal Liver Metastases Is Feasible, Is Safe, and Improves Survival. J Gastrointest Surg 2019; 23:84-92. [PMID: 30084064 PMCID: PMC6329635 DOI: 10.1007/s11605-018-3890-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 07/16/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Recurrence rates are high for patients who have undergone two-stage hepatectomy (TSH) for bilateral colorectal liver metastases, and there is no established treatment approach for recurrent disease. This study aimed to determine the feasibility, safety, and prognostic impact of surgical resection for recurrence after TSH and the prognostic role of RAS mutation in this cohort. METHODS The study included 137 patients intended to undergo TSH for bilateral colorectal metastases during 2003-2016. Clinicopathologic factors were compared using univariate and multivariate analyses. RESULTS One hundred eleven patients (81%) completed TSH. The median recurrence-free survival in these patients was 12 months. Of the 83 patients with subsequent recurrence, 31 (37%) underwent resection for recurrence, and 11 underwent multiple resections for recurrence. Forty-eight operations were performed for recurrence: 23 repeat hepatectomies, 14 pulmonary resections, 5 locoregional resections, and 6 concurrent resections in multiple organ sites. The median overall survival (OS) among patients with recurrence was 143 months for patients who underwent resection and 49 months for those who did not (P < 0.001). On multivariate analysis, resection for recurrence (hazard ratio [HR] 0.25; 95% CI 0.10-0.54, P < 0.001) was associated with better OS, whereas RAS mutation (HR 2.25; 95% CI 1.16-4.50, P = 0.016) and first recurrence in multiple sites (HR 2.28; 95% CI 1.17-4.37, P = 0.016) were independent predictors of worse overall survival. CONCLUSIONS In patients who have undergone TSH for bilateral colorectal liver metastases, recurrence is frequent and should be treated with resection whenever possible. Patients with wild-type RAS fare particularly well with resection for recurrence.
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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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30
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Outcomes and prognostic factors of multimodality treatment for locally recurrent rectal cancer with curative intent. Int J Colorectal Dis 2018; 33:393-401. [PMID: 29468354 DOI: 10.1007/s00384-018-2985-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/13/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE Radical management of locally recurrent rectal cancer (LRRC) can lead to prolonged survival. This study aims to assess outcomes and identify prognostic factors for patients with LRRC treated using a multimodality treatment protocol. METHODS An analysis of a prospectively maintained institutional database of consecutive patients who underwent radical surgical resection for LRRC was performed. Potential prognostic factors were investigated using a Cox proportional hazards model. RESULTS Ninety-eight patients were included in this study. A multimodality approach was taken in the majority, including preoperative chemoradiation (78%), intraoperative radiation therapy (47%) and adjuvant chemotherapy (41%). Extended resection was performed where required: bone resection (34%) and lateral pelvic sidewall dissection (31%). The rate of R0 resection was 66%. Estimated rates of 5-year overall survival (OS) and progression-free survival (PFS) were 41.8% (95% CI 32.5-53.7) and 22.5% (95% CI 15.3-33.1). On multivariate analysis, stage III disease at initial primary surgery, a positive margin at initial primary surgery, synchronous or previously resected oligometastases, a lateral or sacral invasive-type pelvic recurrence and the requirement for IORT all predicted for inferior PFS (p < 0.05). Eleven percent of patients subsequently underwent further pelvic surgery for pelvic re-recurrence and had an estimated 5-year OS rate of 54.5% (95% CI 29.0-100.0) from repeat surgery. CONCLUSIONS Radical multimodality management of LRRC leads to prolonged survival in approximately 40% of patients. Those with sacral or lateral invasive-type recurrence or oligometastatic disease have inferior outcomes and further research is needed to optimise treatment for these groups.
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Ikoma N, You YN, Bednarski BK, Rodriguez-Bigas MA, Eng C, Das P, Kopetz S, Messick C, Skibber JM, Chang GJ. Impact of Recurrence and Salvage Surgery on Survival After Multidisciplinary Treatment of Rectal Cancer. J Clin Oncol 2017; 35:2631-2638. [PMID: 28657814 DOI: 10.1200/jco.2016.72.1464] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Purpose After preoperative chemoradiotherapy followed by total mesorectal excision for locally advanced rectal cancer, patients who experience local or systemic relapse of disease may be eligible for curative salvage surgery, but the benefit of this surgery has not been fully investigated. The purpose of this study was to characterize recurrence patterns and investigate the impact of salvage surgery on survival in patients with rectal cancer after receiving multidisciplinary treatment. Patients and Methods Patients with locally advanced (cT3-4 or cN+) rectal cancer who were treated with preoperative chemoradiotherapy followed by total mesorectal excision at our institution during 1993 to 2008 were identified. We examined patterns of recurrence location, time to recurrence, treatment factors, and survival. Results A total of 735 patients were included. Tumors were mostly midrectal to lower rectal cancer, with a median distance from the anal verge of 5.0 cm. The most common recurrence site was the lung followed by the liver. Median time to recurrence was shorter in liver-only recurrence (11.2 months) than in lung-only recurrence (18.2 months) or locoregional-only recurrence (24.7 months; P = .001). Salvage surgery was performed in 57% of patients with single-site recurrence and was associated with longer survival after recurrence in patients with lung-only and liver-only recurrence ( P < .001) but not in those with locoregional-only recurrence ( P = .353). Conclusion We found a predilection for lung recurrence in patients with rectal cancer after multidisciplinary treatment. Salvage surgery was associated with prolonged survival in patients with lung-only and liver-only recurrence, but not in those with locoregional recurrence, which demonstrates a need for careful consideration of the indications for resection.
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Affiliation(s)
- Naruhiko Ikoma
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Y Nancy You
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Brian K Bednarski
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Cathy Eng
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Prajnan Das
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Scott Kopetz
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Craig Messick
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - John M Skibber
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - George J Chang
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
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Pelvic Reirradiation for the Treatment of Locally Recurrent Rectal Cancer. CURRENT COLORECTAL CANCER REPORTS 2017. [DOI: 10.1007/s11888-017-0360-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Tao R, Tsai CJ, Jensen G, Eng C, Kopetz S, Overman MJ, Skibber JM, Rodriguez-Bigas M, Chang GJ, You YQN, Bednarski BK, Minsky BD, Delclos ME, Koay E, Krishnan S, Crane CH, Das P. Hyperfractionated accelerated reirradiation for rectal cancer: An analysis of outcomes and toxicity. Radiother Oncol 2017; 122:146-151. [PMID: 28057329 DOI: 10.1016/j.radonc.2016.12.015] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 11/28/2016] [Accepted: 12/04/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE To evaluate outcomes and toxicity in patients treated with hyperfractionated pelvic reirradiation for recurrent rectal cancer. MATERIALS AND METHODS 102 patients with recurrent rectal adenocarcinoma were treated with pelvic reirradiation with a hyperfractionated accelerated approach, consisting of 1.5Gy twice daily fractions to a total dose of 30-45Gy (median 39Gy), with the most common total dose 39Gy (n=90, 88%). The median dose of prior pelvic radiation therapy (RT) was 50.4Gy (range: 25-63Gy). RESULTS The median follow-up was 40months for living patients (range, 3-150months). The 3-year freedom from local progression (FFLP) rate was 40% and the 3-year overall survival (OS) rate was 39%. Treatment with surgery was significantly associated with improved FFLP and OS, with 3-year FFLP rate of 49% vs. 30% (P=0.013), and 3-year OS rate of 62% vs. 20% (P<0.0001), compared to those without surgery. The actuarial 3-year rate of grade 3-4 late toxicity was 34%; patients who underwent surgery had a significantly higher rate of grade 3-4 late toxicity compared to those without surgery (54% vs. 16%, P=0.001). CONCLUSIONS This large, retrospective, single-institution study shows that hyperfractionated accelerated reirradiation was well tolerated. The rate of FFLP was promising, given that the study comprised heavily pre-treated patients with recurrences. Rates of FFLP and OS were particularly impressive in patients who underwent both reirradiation and surgery.
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Affiliation(s)
- Randa Tao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA; Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, USA.
| | - Chiaojung Jillian Tsai
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA; Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Garrett Jensen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Cathy Eng
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Scott Kopetz
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Michael J Overman
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - John M Skibber
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Miguel Rodriguez-Bigas
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - George J Chang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Yi-Qian Nancy You
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Brian K Bednarski
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Marc E Delclos
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Eugene Koay
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Sunil Krishnan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Christopher H Crane
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA; Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
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Sammour T, Rodriguez-Bigas MA, Skibber JM. Locally Recurrent Disease Related to Anal Canal Cancers. Surg Oncol Clin N Am 2016; 26:115-125. [PMID: 27889030 DOI: 10.1016/j.soc.2016.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Surgery for anal cancer is usually reserved for patients with persistent disease or local recurrence after definitive chemoradiation therapy. Patients with local recurrence should be re-evaluated for evidence of metastatic disease using positron emission tomography-computed tomography, and the local anatomy should be delineated with MRI. Eligible patients should undergo tailored surgery with the aim of achieving an R0 resection. Management is best undertaken within a specialized multidisciplinary setting. Careful patient selection and shared decision making are paramount for achieving acceptable patient-centered outcomes.
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Affiliation(s)
- Tarik Sammour
- Division of Surgery, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, P.O. Box 301402, Houston, TX 77230-1402, USA
| | - Miguel A Rodriguez-Bigas
- Division of Surgery, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, P.O. Box 301402, Houston, TX 77230-1402, USA
| | - John M Skibber
- Division of Surgery, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, P.O. Box 301402, Houston, TX 77230-1402, USA.
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