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Chapellier P, Fasquelle F, Saglietti C, Kinj R, Mantziari S, Schäfer M, Haefliger L, Jreige M, Vietti Violi N, Sempoux C, Dromain C. Prospective evaluation of MR-TRG (Tumor Regression Grade) in esophageal cancer after neo-adjuvant therapy: Preliminary results. Eur J Radiol 2024; 171:111263. [PMID: 38159523 DOI: 10.1016/j.ejrad.2023.111263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 12/03/2023] [Accepted: 12/09/2023] [Indexed: 01/03/2024]
Abstract
PURPOSE To develop MRI-based criteria to assess tumor response to neoadjuvant therapies (NAT) of esophageal cancers (EC) and to evaluate its diagnostic performance in predicting the pathological Tumor Regression Grade (pTRG). METHOD From 2018 to 2022, patients with newly diagnosed locally advanced EC underwent MRI examinations for initial staging and restaging after NAT. Magnetic Resonance TRG (MR-TRG), equivalent to the Mandard and Becker classifications, were developed and independently assessed by two radiologists, blinded to pTRG, using T2W and DW-MR Images. All patients underwent surgery and benefited from a blinded pTRG evaluation by two pathologists. The agreement between readers and between MR-TRG and pTRG were assessed with Cohen's Kappa. The correlation of MR-TRG and pTRG was determined using Spearman's correlation. RESULTS 28 patients were included. Interrater agreement was substantial between radiologists, improved when grouping grade 1 and 2 (κ = 0.78 rose to 0,84 for Mandard and 0.68 to 0,78 for Becker score). Agreement between pTRG and MR-TRG was moderate with a percentaged agreement (p) = 87.5 %, kappa (κ) = 0.54 and p = 83.3 %, κ = 0.49 for Mandard and Becker, respectively. Agreement was improved to substantial when grouping grades 1-2 for Mandard and 1a-1b for Becker with p = 89.3 %, κ = 0.65 and p = 85.2 %, κ = 0.65 respectively. Sensitivity and specificity of MR-TRG in predicting pTRG were 88.2 % and 72.7 % for Mandard system (scores 1-2 versus 3-5), and 83.3 % and 80 % for Becker system (scores 1a-1b versus 2-3). CONCLUSION A substantial agreement between MR-TRG and pTRG was achieved when grouping grade 1-2. Hence, MR-TRG could be used as a surrogate of complete and near-complete pTRG.
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Affiliation(s)
- Pauline Chapellier
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - François Fasquelle
- Institute of Pathology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Chiara Saglietti
- Institute of Pathology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Rémy Kinj
- Service of radiation oncology, Department of Oncology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Styliani Mantziari
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Markus Schäfer
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Laura Haefliger
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Mario Jreige
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Naïk Vietti Violi
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Christine Sempoux
- Institute of Pathology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Clarisse Dromain
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
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Rouanet P, Castan F, Mazard T, Lemanski C, Nougaret S, Deshayes E, Chalbos P, Gourgou S, Taoum C. GRECCAR 14 - a multicentric, randomized, phase II-III study evaluating the tailored management of locally advanced rectal carcinoma after a favourable response to induction chemotherapy: Study protocol. Colorectal Dis 2023; 25:2078-2086. [PMID: 37697712 DOI: 10.1111/codi.16740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 07/27/2023] [Accepted: 08/03/2023] [Indexed: 09/13/2023]
Abstract
AIM Total neoadjuvant treatment (TNT) is becoming standard in patients with locally advanced rectal carcinoma (LARC). Preoperative chemoradiotherapy (CRT) has proven side effects on bowel and genitourinary function. An early tumoral response to induction chemotherapy demonstrates its high prognostic value. Tailored management could be used as an alternative to systematic CRT. The GRECCAR 14 trial will attempt to personalize treatment strategy according to the patient's early tumour response to intensive chemotherapy with the aim of achieving the best toxicity-efficiency ratio. METHOD GRECCAR 14 is a multicentric, randomized, two-arm, phase II-III noninferiority trial. Patients with mid or low LARC with a predictive circumferential resection margin ≤2 mm or T3c-d stage with extramural venous invasion will be included. Evaluation of the tumoral response will be performed after six courses of high-dose FOLFIRINOX chemotherapy. Good responders (GRs) will be defined by a 60% decrease in tumoral volume on magnetic resonance imaging. Patients will be randomized to CRT before surgery. The primary endpoints will be R0 resection for phase II and the 3-year disease-free survival (DFS) for phase III. RESULTS Tailored management of LARC is becoming an exciting challenge for the modality of neoadjuvant treatment and for the type of surgery or its omission. Neoadjuvant FOLFIRINOX has established efficacy, with a significant increase in the 3-year DFS. Better control of systemic disease must be accompanied by the same locoregional control, with the lowest morbidity. Our previous GRECCAR 4 trial demonstrated the high value of the early tumoral response after induction chemotherapy and the long-term safety of tailored management for GRs. CONCLUSION If GRECCAR 14 demonstrates the ability to tailor TNT for LARC, this could lead to changes in clinical practice.
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Affiliation(s)
- Philippe Rouanet
- Institut régional du Cancer de Montpellier (ICM), Montpellier, France
| | - Florence Castan
- Institut régional du Cancer de Montpellier (ICM), Montpellier, France
| | - Thibault Mazard
- Institut régional du Cancer de Montpellier (ICM), Montpellier, France
| | - Claire Lemanski
- Institut régional du Cancer de Montpellier (ICM), Montpellier, France
| | | | - Emmanuel Deshayes
- Institut régional du Cancer de Montpellier (ICM), Montpellier, France
| | - Patrick Chalbos
- Institut régional du Cancer de Montpellier (ICM), Montpellier, France
| | - Sophie Gourgou
- Institut régional du Cancer de Montpellier (ICM), Montpellier, France
| | - Christophe Taoum
- Institut régional du Cancer de Montpellier (ICM), Montpellier, France
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Circumferential Resection Margin is Associated With Distant Metastasis After Rectal Cancer Surgery: A Nation-wide Population-based Study Cohort. Ann Surg 2023; 277:e346-e352. [PMID: 34793342 DOI: 10.1097/sla.0000000000005302] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate circumferential resection margin (CRM) as a risk factor for distant metastasis (DM) in rectal cancer. SUMMARY OF BACKGROUND DATA The treatment of rectal cancer has evolved over the last decades. Surgical radicality is considered the most important factor in preventing recurrences including local and distant. CRM ≤1.0 mm is considered to increase recurrence risk. This study explores the risk of DM in relation to exact CRM. METHODS All patients treated with abdominal resection surgery for rectal cancer between 2005 and 2013 in Sweden were eligible for inclusion in this retrospective study. Primary endpoint was DM. RESULTS Twelve thousand one hundred forty-six cases were identified. Eight thousand five hundred ninety-three cases were analyzed after exclusion. Seven hundred seventeen (8.6%) patients had CRM ≤1.0mm and 7577 (91.4%) patients had CRM >1.0 mm. DM recurrence rate at 5 years was 42.1% (95% CI 32.5-50.3), 31.5% (95% CI 27.3-35.5), 25.8% (95% Confidence Interval (CI) 16.2-34.4), and 19.5% (95% CI 18.5-19.5) when CRM was 0.0 mm, 0.1 to 1.0 mm, 1.1 to 1.9 mm, and CRM ≥2mm, respectively. Multivariable analysis revealed higher DM risk in CRM 0.0-1.0 mm versus >1.0 mm (hazard ratio 1.30, 95% CI 1.05-1.60; P = 0.015). No significant difference in DM risk in CRM 1.1-1.9 mm versus ≥2.0 mm (hazard ratio 0.66, 95% CI 0.34-1.28; P = 0.224) could be detected. CONCLUSIONS The risk of DM decreases with increasing CRM. Moreover, CRM ≤1.0 mm is a significant risk factor for DM. Thus, CRM is a dominant factor when discussing risk of DM after rectal cancer surgery.
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Tailored Strategy for Locally Advanced Rectal Carcinoma (GRECCAR 4): Long-term Results From a Multicenter, Randomized, Open-Label, Phase II Trial. Dis Colon Rectum 2022; 65:986-995. [PMID: 34759247 DOI: 10.1097/dcr.0000000000002153] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Systematic preoperative radiochemotherapy and total mesorectal excision are the standard of care for locally advanced rectal carcinoma. Some patients can be over- or undertreated. OBJECTIVE This study aimed to investigate the long-term oncological, functional, and late morbidity outcomes after tailored radiochemotherapy and induction high-dose chemotherapy. DESIGN This is a prospective, phase II, multicenter, open-label study at 16 tertiary centers in France. SETTINGS Patients were operated on by surgeons from the French GRECCAR group. PATIENTS Two hundred six patients were randomly assigned to treatment: good responders after chemotherapy (≥75% tumor volume reduction) to immediate surgery (arm A) or standard radiochemotherapy (capecitabine 50) plus surgery (arm B) and poor responders to capecitabine 50 (arm C) or intensive radiochemotherapy (capecitabine 60; 60 Gy irradiation; arm D) before surgery. INTERVENTIONS Treatment was tailored according to MRI response to induction chemotherapy. RESULTS After induction treatment, 194 patients were classified as good (n = 30, 15%) or poor (n = 164, 85%) responders; they were included in arms A and B (16 and 14 patients) or C and D (113 and 51 patients). The primary objective was obtained: R0 resection rates (90% CI) in the 4 arms were 100% (74-100), 100% (85-100), 83% (72-91), and 88% (77-95). At 5 years, overall survival rates were 90% (47.3-98.5), 93.3% (61.3-99.0), 84.3% (71.0-91.8), and 86.1% (71.6-93.5); disease-free survival rates were 80% (40.9-94.6), 89.5% (64.1-97.3), 72.9% (58.5-82.9), and 72.8% (57.7-83.2); local recurrence rates were 0%, 0%, 2.1% (0.3-13.9), and 9.3% (3.6-23.0); and metastasis rates were 20% (5.4-59.1), 10.5% (2.7-35.9), 18% (31.8-94.6), and 18.8% (10.2-33.0). Late morbidity and quality-of-life evaluations showed no significant difference between arms. LIMITATIONS Limitations were due to the small number of patients randomly assigned in the good responder arms, especially arm A without radiotherapy. CONCLUSION Tailoring preoperative radiochemotherapy based on induction treatment response appears to be promising. Future prospective trials should confirm this strategy. See Video Abstract at http://links.lww.com/DCR/B761 . REGISTRATION URL: https://www.clinicaltrials.gov ; Identifier: NCT01333709. ESTRATEGIA HECHA A MEDIDA PARA EL TRATAMIENTO DEL CARCINOMA DE RECTO LOCALMENTE AVANZADO GRECCAR RESULTADOS A LARGO PLAZO DE UN ESTUDIO ALEATRIO MULTICNTRICO Y ABIERTO DE FASE II ANTECEDENTES:La radio-quimioterapia pré-operatoria sistemáticas y la excisión total del mesorrecto son el estándar en el tratamiento del carcinoma de recto localmente avanzado. En éste sentido, algunos pacientes podrían recibir un sobre o un infra-tratamiento.OBJETIVO:Evaluar los resultados oncológicos, funcionales y de morbilidad a largo plazo después de radio-quimioterapia personalizada y quimioterapia de inducción a dosis elevadas.DISEÑO:Estudio aleatório multicéntrico y abierto de Fase II° realizado en 16 centros terciarios en Francia.AJUSTE:Aquellos pacientes operados por cirujanos del grupo GRECCAR francés.PACIENTES:206 pacientes fueron asignados aleatoriamente al tratamiento: los buenos respondedores después de quimioterapia (reducción del volumen tumoral ≥75%) a la cirugía inmediata (brazo A) o a la radio-quimioterapia estándar (Cap 50) asociada a la cirugía (brazo B); los malos respondedores a Cap 50 (brazo C) o a la radio-quimioterapia intensiva (Cap 60 (irradiación de 60 Gy) (brazo D) previas a la cirugía.INTERVENCIONES:Tratamiento adaptado según la respuesta de la RM a la TC de inducción.RESULTADOS:Después del tratamiento de inducción, 194 pacientes fueron clasificados como buenos (n = 30, 15%) o malos (n = 164, 85%) respondedores, y se incluyeron en los brazos A y B (16 y 14 pacientes) o C y D (113 y 51 pacientes). Se alcanzó el objetivo principal: las tasas de resección R0 [intervalo de confianza del 90%] en los cuatro brazos respectivamente, fueron del 100% [74-100], 100% [85-100], 83% [72-91] y 88% [77-95]. A los 5 años, las tasas fueron: de sobrevida global 90% [47,3-98,5], 93,3% [61,3-99,0], 84,3% [71,0-91,8], 86,1% [71,6-93,5]; de sobrevida libre a la enfermedad 80% [40,9-94,6], 89,5% [64,1-97,3], 72,9% [58,5-82,9], 72,8% [57,7-83,2]; de recidiva local 0, 0, 2,1% [0,3-13,9], 9,3% [3,6-23,0]; de metástasis 20% [5,4-59,1], 10,5% [2,7-35,9], 18% [31,8-94,6], 18,8% [10,2-33,0]. La evaluación tardía de la morbilidad y la calidad de vida no mostraron diferencias significativas entre los brazos.LIMITACIONES:Debido al pequeño número de pacientes asignados al azar en los brazos de buenos respondedores, especialmente en el brazo A de aquellos sin radioterapia.CONCLUSIÓN:Parecería muy prometedor el adaptar la radio-quimioterapia pré-operatoria basada en la respuesta al tratamiento de inducción. Estudios prospectivos en el futuro podrán confirmar la presente estrategia. Consulte Video Resumen en http://links.lww.com/DCR/B761 . (Traducción-Dr. Xavier Delgadillo )IDENTIFICADOR DE CLINICALTRIALS.GOV:NCT01333709. Groupe de REcherche Chirurgicale sur le CAncer du Rectum.
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Rouleau Fournier F, Motamedi MAK, Brown CJ, Phang T, Raval MJ, Hague CJ, Karimuddin AA. Oncologic Outcomes Associated With MRI-detected Extramural Venous Invasion (mrEMVI) in Rectal Cancer: A Systematic Review and Meta-analysis. Ann Surg 2022; 275:303-314. [PMID: 33491979 DOI: 10.1097/sla.0000000000004636] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The role of MRI-detected EMVI (mrEMVI) as a reliable prognostic factor in rectal cancer has been emphasized in recent years but this finding remains underreported by many institutions. OBJECTIVE This review aimed to demonstrate the importance of pre- and post-treatment MRI-detected EMVI as independent prognostic factors of adverse oncologic outcomes in patients undergoing neoadjuvant therapy followed by total mesorectal excision. METHODS This review was designed using the PRISMA guidelines. The following electronic databases were searched from January 2002 to January 2020: CENTRAL, Ovid MEDLINE, PubMed, and Ovid Embase. Main outcomes included DFS and overall survival (OS). Other outcomes of interest comprised positive resection margin and synchronous metastases. RESULTS Seventeen studies involving a total of 3821 patients were included for data synthesis. For preneoadjuvant treatment mrEMVI, pooled hazard ratio (HR) estimate for DFS was 2.30 (95% confidence intervals (CI) 1.54-3.44) for higher recurrence in mrEMVI-positive patients. mrEMVI-positive patients were found to have a lower OS with a pooled HR of 1.68 (95%CI 1.27-2.22). Pooled risk ratio for synchronous metastasis was 4.11 (95%CI 2.80-6.02) for mrEMVI-positivity. For postneoadjuvant treatment EMVI (ymrEMVI), positive status showed a lower DFS with a pooled HR of 2.04 (95%CI 1.55-2.69). Risk ratio of having a positive resection margin status was 2.95 (95%CI 1.75-4.98) for ymrEMVI-positive patients. CONCLUSIONS This review showed that oncologic outcomes are significantly worse for both pre- and post-neoadjuvant treatment mrEMVI-positive patients. MRI-detected EMVI should be consistently reported in rectal cancer staging and may provide guidance for the targeted use of additional systemic therapy.
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Affiliation(s)
- François Rouleau Fournier
- Department of Surgery, St-Paul's Hospital, University of British Columbia, 1081 Burrard Street, Third Floor, Burrard Building, Vancouver, BC V6Z 1Y6, Canada
| | - Mohammad Ali K Motamedi
- Department of Surgery, St-Paul's Hospital, University of British Columbia, 1081 Burrard Street, Third Floor, Burrard Building, Vancouver, BC V6Z 1Y6, Canada
| | - Carl J Brown
- Department of Surgery, St-Paul's Hospital, University of British Columbia, 1081 Burrard Street, Third Floor, Burrard Building, Vancouver, BC V6Z 1Y6, Canada
| | - Terry Phang
- Department of Surgery, St-Paul's Hospital, University of British Columbia, 1081 Burrard Street, Third Floor, Burrard Building, Vancouver, BC V6Z 1Y6, Canada
| | - Manoj J Raval
- Department of Surgery, St-Paul's Hospital, University of British Columbia, 1081 Burrard Street, Third Floor, Burrard Building, Vancouver, BC V6Z 1Y6, Canada
| | - Cameron J Hague
- Department of Radiology, St-Paul's Hospital, University of British Columbia, 1081 Burrard Street, Third Floor, Burrard Building, Vancouver, BC V6Z 1Y6, Canada
| | - Ahmer A Karimuddin
- Department of Surgery, St-Paul's Hospital, University of British Columbia, 1081 Burrard Street, Third Floor, Burrard Building, Vancouver, BC V6Z 1Y6, Canada
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Tibermacine H, Rouanet P, Sbarra M, Forghani R, Reinhold C, Nougaret S. Radiomics modelling in rectal cancer to predict disease-free survival: evaluation of different approaches. Br J Surg 2021; 108:1243-1250. [PMID: 34423347 DOI: 10.1093/bjs/znab191] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 04/11/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Radiomics may be useful in rectal cancer management. The aim of this study was to assess and compare different radiomics approaches over qualitative evaluation to predict disease-free survival (DFS) in patients with locally advanced rectal cancer treated with neoadjuvant therapy. METHODS Patients from a phase II, multicentre, randomized study (GRECCAR4; NCT01333709) were included retrospectively as a training set. An independent cohort of patients comprised the independent test set. For both time points and both sets, radiomic features were extracted from two-dimensional manual segmentation (MS), three-dimensional (3D) MS, and from bounding boxes. Radiomics predictive models of DFS were built using a hyperparameters-tuned random forests classifier. Additionally, radiomics models were compared with qualitative parameters, including sphincter invasion, extramural vascular invasion as determined by MRI (mrEMVI) at baseline, and tumour regression grade evaluated by MRI (mrTRG) after chemoradiotherapy (CRT). RESULTS In the training cohort of 98 patients, all three models showed good performance with mean(s.d.) area under the curve (AUC) values ranging from 0.77(0.09) to 0.89(0.09) for prediction of DFS. The 3D radiomics model outperformed qualitative analysis based on mrEMVI and sphincter invasion at baseline (P = 0.038 and P = 0.027 respectively), and mrTRG after CRT (P = 0.017). In the independent test cohort of 48 patients, at baseline and after CRT the AUC ranged from 0.67(0.09) to 0.76(0.06). All three models showed no difference compared with qualitative analysis in the independent set. CONCLUSION Radiomics models can predict DFS in patients with locally advanced rectal cancer.
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Affiliation(s)
- H Tibermacine
- Radiology Department, Institut du Cancer de Montpellier, University of Montpellier, Montpellier, France.,Institut de Recherche en Cancérologie de Montpellier, INSERM, U1194, Montpellier, France
| | - P Rouanet
- Surgical Oncology Department, Institut du Cancer de Montpellier, University of Montpellier, Montpellier, France
| | - M Sbarra
- Departmental Faculty of Medicine and Surgery, Unit of Diagnostic Imaging and Interventional Radiology, Università Campus Bio-Medico di Roma, 00128 Rome, Italy
| | - R Forghani
- Augmented Intelligence and Precision Health Laboratory (AIPHL), Department of Radiology and the Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - C Reinhold
- Augmented Intelligence and Precision Health Laboratory (AIPHL), Department of Radiology and the Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - S Nougaret
- Radiology Department, Institut du Cancer de Montpellier, University of Montpellier, Montpellier, France.,Institut de Recherche en Cancérologie de Montpellier, INSERM, U1194, Montpellier, France
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7
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Teneva T, Zlatarov A, Grigorov R. Role of Magnetic Resonance Imaging in Patients with Rectal Cancer. COLORECTAL CANCER 2021. [DOI: 10.5772/intechopen.94868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In a chapter about rectal cancer there is content about rectal anatomy in relation to magnet-resonanse imaging and TME- surgery (total mesorectal excision). Secondly there is content about imaging methods used in diagnosis and follow-up of rectal cancer. Very important topic is concerning the novel imaging strategies in surgical and radiotherapy planning in the era of individual oncologic approach to the patient. At last there is detailed desctiption and metaanalysis of imaging strategies concerning neoadjuvant and adjuvant radiotherapy and chemotherapy for rectal cancer patients. All imaging markers correspond to substantial oncologic parameters such as survival rates. The connecting bridge is magnet-resonance imaging.
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Haak HE, Beets GL, Peeters K, Nelemans PJ, Valentini V, Rödel C, Kuo L, Calvo FA, Garcia-Aguilar J, Glynne-Jones R, Pucciarelli S, Suarez J, Theodoropoulos G, Biondo S, Lambregts DMJ, Beets-Tan RGH, Maas M. Prevalence of nodal involvement in rectal cancer after chemoradiotherapy. Br J Surg 2021; 108:1251-1258. [PMID: 34240110 DOI: 10.1093/bjs/znab194] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 04/28/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND The purpose of this study was to investigate the prevalence of ypN+ status according to ypT category in patients with locally advanced rectal cancer treated with chemoradiotherapy and total mesorectal excision, and to assess the impact of ypN+ on disease recurrence and survival by pooled analysis of individual-patient data. METHODS Individual-patient data from 10 studies of chemoradiotherapy for rectal cancer were included. Pooled rates of ypN+ disease were calculated with 95 per cent confidence interval for each ypT category. Kaplan-Meier and Cox regression analyses were undertaken to assess influence of ypN status on 5-year disease-free survival (DFS) and overall survival (OS). RESULTS Data on 1898 patients were included in the study. Median follow-up was 50 (range 0-219) months. The pooled rate of ypN+ disease was 7 per cent for ypT0, 12 per cent for ypT1, 17 per cent for ypT2, 40 per cent for ypT3, and 46 per cent for ypT4 tumours. Patients with ypN+ disease had lower 5-year DFS and OS (46.2 and 63.4 per cent respectively) than patients with ypN0 tumours (74.5 and 83.2 per cent) (P < 0.001). Cox regression analyses showed ypN+ status to be an independent predictor of recurrence and death. CONCLUSION Risk of nodal metastases (ypN+) after chemoradiotherapy increases with advancing ypT category and needs to be considered if an organ-preserving strategy is contemplated.
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Affiliation(s)
- H E Haak
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands.,GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
| | - G L Beets
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands.,GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
| | - K Peeters
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - P J Nelemans
- Department of Epidemiology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - V Valentini
- Department of Radiation Oncology, Universita Cattolica del Sacro Cuore, Rome, Italy
| | - C Rödel
- Department of Radiation Oncology, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - L Kuo
- Department of Colorectal Surgery, Taipei Medical University Hospital, Taipei, Taiwan
| | - F A Calvo
- Department of Oncology, General University Hospital Gregorio Marañón, Madrid, Spain
| | - J Garcia-Aguilar
- Department of Surgery, Memorial Sloan Kettering Cancer Centre, New York, USA
| | - R Glynne-Jones
- Department of Clinical Oncology, Mount Vernon Hospital, London, UK
| | - S Pucciarelli
- Department of Surgical, Oncological and Gastroenterological Sciences, First Surgical Clinic, University of Padua, Padua, Italy
| | - J Suarez
- Department of Surgery, Hospital de Navarra, Pamplona, Spain
| | - G Theodoropoulos
- First Department of Propaedeutic Surgery, Athens Medical School, Hippocration General Hospital, Athens, Greece
| | - S Biondo
- Department of Surgery, Bellvitge University Hospital, Barcelona, Spain.,IDIBELL, University of Barcelona, Barcelona, Spain
| | - D M J Lambregts
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - R G H Beets-Tan
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands.,Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - M Maas
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
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The prognostic value of MRI-detected extramural vascular invasion (mrEMVI) for rectal cancer patients treated with neoadjuvant therapy: a meta-analysis. Eur Radiol 2021; 31:8827-8837. [PMID: 33993333 DOI: 10.1007/s00330-021-07981-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/10/2021] [Accepted: 04/01/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The purpose of this meta-analysis was to evaluate the prognostic value of MRI-detected extramural vascular invasion (mrEMVI) and mrEMVI after neoadjuvant therapy (ymrEMVI) in rectal cancer patients receiving neoadjuvant therapy. METHODS A systematic search of the PubMed, Web of Science, Embase, and Cochrane Library databases was carried out up to June 2020. Studies that evaluated mrEMVI, used treatment with neoadjuvant therapy, and reported survival were included. The time-to-event outcomes (OS and DFS rates) are expressed as hazard ratios (HRs) with 95% confidence intervals (CIs). If the HR was not reported in the study, it was calculated from the survival curve using methods according to Parmar's recommendation. The Newcastle-Ottawa scale was used to assess the methodological quality of the studies included in the meta-analysis. RESULTS A total of 2237 patients from 11 studies were included, and the pooled analysis of the overall results from eight studies showed that patients who were mrEMVI positive at baseline had significantly worse disease-free survival (DFS) (random-effects model: HR = 2.50 [1.84, 3.14]; Z = 5.83, p < 0.00001). The pooled analysis of the overall results from six studies showed that patients who were ymrEMVI positive following neoadjuvant therapy had significantly worse DFS (random-effects model: HR = 2.24 [1.73, 2.90], Z = 6.12, p < 0.00001). Patients with mrEMVI positivity at baseline were also associated with worse overall survival (OS) (random-effects model: HR = 1.93 [1.36, 2.73]; Z = 3.71, p < 0.00001). CONCLUSION mrEMVI and ymrEMVI positivity are poor prognostic factors for rectal cancer patients treated with neoadjuvant therapy. The precise evaluation of EMVI may contribute to designing individualised treatments and improving patient outcomes. KEY POINTS • Extramural vascular invasion (EMVI) is a prognostic factor for rectal cancer. • MRI can be used to evaluate EMVI status before (mrEMVI) and after neoadjuvant therapy (ymrEMVI). • The evaluation of mrEMVI and ymrEMVI in neoadjuvant therapy would provide an early assessment of patient prognosis.
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Lau S, Kong J, Bell S, Heriot A, Stevenson A, Moloney J, Hayes J, Merrie A, Eglinton T, Guest G, Clark D, Warrier S. Transanal mesorectal excision: early outcomes in Australia and New Zealand. Br J Surg 2021; 108:214-219. [PMID: 33711138 DOI: 10.1093/bjs/znaa098] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 10/22/2020] [Accepted: 10/24/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Transanal total mesorectal excision (taTME) aims to overcome some of the technical challenges faced when operating on mid and low rectal cancers. Specimen quality has been confirmed previously, but recent concerns have been raised about oncological safety. This multicentre prospective study aimed to evaluate the safety of taTME among early adopters in Australia and New Zealand. METHODS Data from all consecutive patients who had taTME for rectal cancer from July 2014 to February 2020 at six tertiary referral centres in Australasia were recorded and analysed. RESULTS A total of 308 patients of median age of 64 years underwent taTME. Some 75.6 per cent of patients were men, and the median BMI was 26.8 kg/m2. The median distance of tumour from anal verge was 7 cm. Neoadjuvant chemoradiotherapy was administered to 57.8 per cent of patients. The anastomotic leak rate was 8.1 per cent and there was no mortality within 30 days of surgery. Pathological examination found a complete mesorectum in 295 patients (95.8 per cent), a near-complete mesorectum in seven patients (2.3 per cent), and an incomplete mesorectum in six patients (1.9 per cent). The circumferential resection margin and distal resection margin was involved in nine patients (2.9 per cent), and two patients (0.6 per cent) respectively. Over a median follow-up of 22 months, the local recurrence rate was 1.9 per cent and median time to local recurrence was 30.5 months. CONCLUSION This study showed that, with appropriate training and supervision, skilled minimally invasive rectal cancer surgeons can perform taTME with similar pathological and oncological results to open and laparoscopic surgery.
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Affiliation(s)
- S Lau
- Department of Surgery, University Hospital Geelong, Geelong, Victoria, Australia
| | - J Kong
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - S Bell
- Department of Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - A Heriot
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - A Stevenson
- Department of Surgery, Royal Brisbane Hospital, Herston, Queensland, Australia
| | - J Moloney
- Department of Surgery, Royal Brisbane Hospital, Herston, Queensland, Australia
| | - J Hayes
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | - A Merrie
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | - T Eglinton
- Department of Surgery, University of Otago, Christchurch, New Zealand
| | - G Guest
- Department of Surgery, University Hospital Geelong, Geelong, Victoria, Australia
| | - D Clark
- Department of Surgery, Royal Brisbane Hospital, Herston, Queensland, Australia
| | - S Warrier
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Surgery, Alfred Hospital, Melbourne, Victoria, Australia
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Rouanet P, Rivoire M, Gourgou S, Lelong B, Rullier E, Jafari M, Mineur L, Pocard M, Faucheron JL, Dravet F, Pezet D, Fabre JM, Bresler L, Balosso J, Lemanski C. Sphincter-saving surgery after neoadjuvant therapy for ultra-low rectal cancer where abdominoperineal resection was indicated: 10-year results of the GRECCAR 1 trial. Br J Surg 2021; 108:10-13. [PMID: 33640922 DOI: 10.1093/bjs/znaa010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 08/17/2020] [Accepted: 08/28/2020] [Indexed: 12/22/2022]
Abstract
This phase III trial included patients with ultra-low rectal adenocarcinoma that initially required abdominoperineal resection. The surgical decision was based on clinical tumour status after preoperative treatment. The overall sphincter-saving resection rate was 85 per cent, with 72 per cent rate of intersphincteric resection. Long-term results showed that changing the initial abdominoperineal resection indication into a sphincter-saving resection according to tumoral response is oncologically safe.
Saving the sphincter
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Affiliation(s)
- P Rouanet
- Department of Surgical Oncology, Institut Régional du Cancer de Montpellier-Val d'Aurelle, Montpellier, France
| | - M Rivoire
- Department of Surgical Oncology, Centre Léon Berard, Lyon, France
| | - S Gourgou
- Biometrics Unit, Montpellier Cancer Institute, Montpellier, France
| | - B Lelong
- Department of Surgical Oncology, Institut Paoli Calmettes, Marseille, France
| | - E Rullier
- Colorectal Department, Centre Hospitalier Universitaire Bordeaux, Bordeaux, France
| | - M Jafari
- Department of Surgical Oncology, Centre Oscar Lambret, Lille, France
| | - L Mineur
- Department of Radiation Oncology, Institut Sainte Catherine, Avignon, France
| | - M Pocard
- Department of Surgical Oncology, Gustave Roussy (Hôpital Lariboisière Assistance Publique-Hôpitaux de Paris), Paris, France
| | - J L Faucheron
- Colorectal Department, Centre Hospitalier Universitaire Grenoble, Grenoble, France
| | - F Dravet
- Department of Surgical Oncology, Centre René Gauducheau, Nantes, France
| | - D Pezet
- Colorectal Department, Centre Hospitalier Universitaire Clermont-Ferrand, Clermont-Ferrand, France
| | - J M Fabre
- Colorectal Department, Centre Hospitalier Universitaire Montpellier, Montpellier, France
| | - L Bresler
- Colorectal Department, Centre Hospitalier Universitaire Nancy, Nancy, France
| | - J Balosso
- Department of Radiotherapy, Centre Hospitalier Universitaire Grenoble, Grenoble, France
| | - C Lemanski
- Department of Radiotherapy, Institut Régional du Cancer de Montpellier-Val d'Aurelle, Montpellier, France
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12
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Jia X, Xie P, Bi L, Meng X, Wang Z, Hong N, Wang Y. MRI-defined high-risk rectal cancer patients: outcome comparison between neoadjuvant chemoradiotherapy plus TME and TME plus adjuvant chemotherapy or TME alone. Br J Radiol 2021; 94:20201221. [PMID: 33591799 DOI: 10.1259/bjr.20201221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE The goal of this study was to investigate whether neoadjuvant chemoradiotherapy (NCRT) plus total mesorectal excision (TME) would improve the outcome of patients with MRI-defined high-risk rectal cancer compared with TME plus adjuvant chemotherapy (ACT) or TME alone. METHODS We retrospectively enrolled 362 patients with MRI-defined high-risk rectal cancer who were treated with NCRT plus TME, TME plus ACT, or TME alone between January 2008 and August 2018. Cases with a high-risk tumor stage, positive extramural venous invasion, or mesorectal fascia involvement on baseline MRI were considered cases of high-risk rectal cancer. We matched patients treated with NCRT plus TME to patients treated with TME plus ACT and to those treated with TME alone. Kaplan-Meier curves were used to compare local recurrence (LR), disease-free survival (DFS), and overall survival (OS) rates. RESULTS The cumulative 3 year LR rate in the matched NCRT plus TME group was more favorable than in the TME plus ACT group (0% vs 5.1%; p = 0.037; n = 98) and in the TME alone group (0% vs 11.5%; p = 0.016; n = 61). Patients who received NCRT plus TME demonstrated better cumulative 3 year DFS rates than patients treated with TME plus ACT (85.7% vs 65.3%; p = 0.009) or with TME alone (86.9% vs 68.9%; p = 0.046). No difference in OS was observed among the groups. CONCLUSION NCRT may improve DFS and LR rates in patients with MRI-defined high-risk rectal cancer when compared with TME plus ACT or TME alone. ADVANCES IN KNOWLEDGE This study illustrated the specific benefit of NCRT on the outcome measures of MRI-defined high-risk rectal cancer compared with TME plus ACT or TME alone, which was not clearly clarified in previous studies enrolling all patients with Stage II/III rectal cancer.
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Affiliation(s)
- Xiaoxuan Jia
- Department of Radiology, Peking University People's Hospital, Beijing, China
| | - Peiyi Xie
- Department of Radiology, Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Liang Bi
- Department of Colorectal Surgery, Gansu Provincial Hospital, Lanzhou, Gansu, China
| | - Xiaochun Meng
- Department of Radiology, Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Ziqiang Wang
- Department of Gastrointestinal Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Nan Hong
- Department of Radiology, Peking University People's Hospital, Beijing, China
| | - Yi Wang
- Department of Radiology, Peking University People's Hospital, Beijing, China
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13
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Lee HJ, Chung WS, An JH, Kim JH. Preoperative concurrent chemoradiotherapy MRI characteristics favouring pathologic complete response in patients with rectal cancer: Usefulness of MR T2-stage as an ancillary finding for predicting pathologic complete response. J Med Imaging Radiat Oncol 2020; 65:166-174. [PMID: 33319450 DOI: 10.1111/1754-9485.13132] [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: 05/22/2020] [Revised: 10/20/2020] [Accepted: 11/09/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION This study sought to assess preoperative concurrent chemoradiotherapy (CRT) magnetic resonance imaging (MRI)-based findings according to a structured MRI report template for primary staging of rectal cancer, and to evaluate the prognostic relevance of the pre-CRT MRI-based findings in patients with rectal cancer after CRT. METHODS We retrospectively evaluated pre- and post-CRT MRI data of patients with pathologically proven rectal adenocarcinoma, between January 2008 and October 2019. Image interpretation was performed independently by two radiologists and each reviewer assessed the cancer characteristics on MRI, based on the structured MRI report for primary staging. MRI-based findings associated with pathologic complete tumour regression grade (TRG) after CRT were analysed by univariate and multivariate analysis. Significant factors from pre-CRT MRI were weighted to score mrTRG in post-CRT MRI. RESULTS On univariate analysis, MR T-stage, tumour infiltration, mesorectal fascia involvement, extramural vascular invasion and serum carcinoembryonic antigen level correlated significantly with pathologic complete response (pCR). Multivariate analysis identified that only MR T-stage was independently associated with pCR (odds ratio, 3.89, 95% confidence interval, 1.18-12.84; P = 0.0278). Adding MRI-based T2-stage as an ancillary finding to mrTRG statistically significantly improved the sensitivity as compared to using only mrTRG for considering a CR. T2_mrTRG was significantly different in terms of the time to tumour progression between the CR and non-CR group. CONCLUSIONS The MR T2-stage was independently associated with pCR after CRT in patients with rectal cancer and was helpful as ancillary predictive factor, adding to mrTRG for prediction of pCR.
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Affiliation(s)
- Hyeon Jin Lee
- Department of Radiology, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
| | - Woo-Suk Chung
- Department of Radiology, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea.,Department of Radiology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Ji Hae An
- Department of Radiology, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
| | - Jung Hoon Kim
- Department of Radiation Oncology, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
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Healey Bird BRJ. Total neoadjuvant therapy for locally advanced rectal cancer: the fuse is lit. Br J Surg 2020; 107:1705-1707. [PMID: 33104240 DOI: 10.1002/bjs.12014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 07/29/2020] [Indexed: 12/20/2022]
Abstract
Explosively disrupting
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Affiliation(s)
- B R J Healey Bird
- Department of Medical Oncology, Bon Secours Hospital Cork, Cork, T12 DV56, Ireland
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Factors impacting oncologic outcomes in patients undergoing surgery for locally recurrent rectal cancer. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Are oncological long-term outcomes equal after laproscopic completed and converted laparoscopic converted rectal resection for cancer? Tech Coloproctol 2020; 25:91-99. [PMID: 32857297 DOI: 10.1007/s10151-020-02334-2] [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] [Received: 03/23/2020] [Accepted: 08/18/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aim of this study was to compare long-term survival after laproscopic completed and laparoscopic converted rectal resection for cancer. METHODS All consecutive patients who underwent curative laparoscopic rectal surgery for cancer at our institution between January 2001 and December 2016 were included in a single-center retrospective study. Patients were divided into two groups: the converted (CONV) group and the totally laparoscopic (LAP) group. The primary outcomes were long-term oncologic outcomes including overall survival (OS) and disease-free survival (DFS), as well as local and distant recurrence (LR, DR). The secondary outcomes included postoperative mortality and morbidity as defined as death or any complication occurring within 90 days postoperatively. RESULTS Of 214 consecutive patients included, 57 were converted to open surgery (CONV group), leading to a 26.6% conversion rate. Mean length of follow-up was 68 ± 42 months in the LAP group and 70 ± 41 months in the CONV group. Five-year OS was significantly shorter in the CONV group compared to the LAP group (p = 0.0016). On multivariate analysis, rectal tumor location (middle and low) and conversion to open surgery were predictors of both OS and DFS. CONCLUSIONS This study suggests that conversion to open surgery after laparoscopic rectal resection appears to significantly reduce OS without having a significant impact on DFS and recurrence rates.
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