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Ma H, Li H, Xu T, Gao Y, Liu S, Wang W, Wei L, Wang X, Jiang L, Chi Y, Shi J, Shuai J, Zou S, Cai Y, Zhu Y, Cheng G, Zhang H, Wang X, Zhu S, Wang J, Li G, Yang J, Zhang K, Lu N, Fang H, Wang S, Li Y, Zhou H, Tang Y, Jin J. Multidisciplinary team quality improves the survival outcomes of locally advanced rectal cancer patients: A post hoc analysis of the STELLAR trial. Radiother Oncol 2024; 200:110524. [PMID: 39243864 DOI: 10.1016/j.radonc.2024.110524] [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: 04/03/2024] [Revised: 08/25/2024] [Accepted: 09/02/2024] [Indexed: 09/09/2024]
Abstract
PURPOSE We sought to determine the association between multidisciplinary team (MDT) quality and survival of patients with locally advanced rectal cancer. METHODS In a post hoc analysis of the randomized phase III STELLAR trial, 464 patients with distal or middle-third, clinical tumor category cT3-4 and/or regional lymph node-positive rectal cancer who completed surgery were evaluated. Disease-free survival (DFS) and Overall survival (OS) were stratified by Multidisciplinary team (MDT) quality, which was also included in the univariable and multivariable analyses of DFS and OS. RESULTS According to the univariable analyses, a significantly worse DFS was associated with a fewer specialized medical disciplines participating in MDT (<5 vs ≥ 5; P=0.049),a lower frequency of MDT meetings ( 200; P=0.039). In addition, a lower number of specialized medical disciplines participating in MDT (<5 vs ≥ 5; P<0.001), a lower frequency of MDT meetings ( 200; P=0.001) were the variables associated with OS. These 3 factors were considered when assessing MDT quality, which was classified into 2 categories: high quality or general quality. Patients treated in hospitals with high MDT quality had longer 3-year OS (90.5 % vs 78.1 %; P=0.001) and similar 3-year DFS (70.3 % vs 61.3 %; P=0.109) compared to those treated in hospitals of the general MDT quality group. Furthermore, multivariable analyses revealed a significance for DFS (HR, 1.648; 95 % CI, 1.143-2.375; P=0.007) and OS (HR, 2.771; 95 % CI, 1.575-4.877; P<0.001) in MDT quality. CONCLUSIONS The use of hospitals with optimized multidisciplinary infrastructure had a significant influence on survival of patients with locally advanced rectal cancer.
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Affiliation(s)
- Huiying Ma
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Haoyue Li
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Tongzhen Xu
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Yuanhong Gao
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, China
| | - Shixin Liu
- Department of Radiation Oncology, Jilin Provincial Cancer Hospital, Changchun, China
| | - Wenling Wang
- Department of Oncology, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Lichun Wei
- Department of Radiation Oncology, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Xishan Wang
- State Key Laboratory of Molecular Oncology and Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, CAMS and PUMC, Beijing, China
| | - Liming Jiang
- State Key Laboratory of Molecular Oncology and Department of Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, CAMS and PUMC, Beijing, China
| | - Yihebali Chi
- State Key Laboratory of Molecular Oncology and Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, CAMS and PUMC, Beijing, China
| | - Jinming Shi
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Jiacheng Shuai
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Shuangmei Zou
- State Key Laboratory of Molecular Oncology and Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, CAMS and PUMC, Beijing, China
| | - Yong Cai
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, China
| | - Yuan Zhu
- Department of Radiation Oncology, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital),Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Guanghui Cheng
- Department of Radiation Oncology, China-Japan Union Hospital, Jilin University, Changchun, China
| | - Hongyan Zhang
- Department of Radiation Oncology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Anhui, China
| | - Xin Wang
- Department of Radiation Oncology, West China Hospital, Sichuan University, Chengdu, China
| | - Suyu Zhu
- Department of Radiation Oncology, Hunan Cancer Hospital and Affiliated Cancer Hospital of Xiangya School of Medicine, Changsha, China
| | - Jun Wang
- Department of Radiation Oncology, the Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Gaofeng Li
- Department of Radiation Oncology, Beijing Hospital, National Center of Gerontology, Beijing, China
| | - Jialin Yang
- Department of Radiation Oncology, Sichuan Provincial Cancer Hospital, Chengdu, China
| | - Kuan Zhang
- Department of Radiation Oncology, Qinghai Red Cross Hospital, Qinghai, China
| | - Ningning Lu
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Hui Fang
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Shulian Wang
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Yexiong Li
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China.
| | - Haitao Zhou
- State Key Laboratory of Molecular Oncology and Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, CAMS and PUMC, Beijing, China.
| | - Yuan Tang
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China.
| | - Jing Jin
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China; Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, CAMS and PUMC, Shenzhen, China.
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Rokan Z, Wale A, Day N, Kontovounisios C, Moran B, Brown G. Pelvic exenteration for locally advanced rectal cancer and associated outcomes in England between 1995 and 2016: Analysis of a national database. Colorectal Dis 2024. [PMID: 39148247 DOI: 10.1111/codi.17137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Revised: 06/29/2024] [Accepted: 07/24/2024] [Indexed: 08/17/2024]
Abstract
AIM The clinical burden of pelvic exenteration (PE) for locally advanced rectal cancer (LARC) is nationally under-reported. The widespread use of pelvic MRI since 2005 has increased the accuracy of local staging and awareness of the need for 'beyond TME (total mesorectal excision)' surgery. The aim of this study was to assess the volume of patients undergoing PE within England, which factors affected survival outcomes and whether the use of MRI has influenced these outcomes. METHOD The volume of patients undergoing PE and associated survival outcomes across England between 1995 and 2016 was evaluated from Public Health England Hospital Episode Statistics data. RESULTS A total of 2996 patients were recorded as undergoing PE. The 5-year overall survival rate improved after 2005 compared with prior to 2005 (61.7% vs. 37%, p < 0.001), with no significant difference between cancer registries throughout England. After 2005, the volume of patients undergoing PE and undergoing preoperative MRI increased, as did the number of non-T4 cancers operated on. After 2005, age, preoperative MRI and preoperative radiotherapy were the significant factors influencing 5-year overall survival on multivariate analysis. CONCLUSION This review of national data confirms that PE outcomes are under-reported. MRI staging aids with the identification of patients suitable for perioperative treatment, surgery or palliation and facilitates treatment planning. Since 2005, MRI, likely in combination with advances in surgery and perioperative treatment, has improved survival outcomes. It is imperative that detailed information from patients with LARC undergoing PE is captured and reported in order to optimize care and future service provision.
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Affiliation(s)
- Zena Rokan
- Department of Surgery and Cancer, Imperial College London, London, UK
- Pelican Cancer Foundation, Basingstoke, UK
| | - Anita Wale
- St George's University Hospital NHS Trust, London, UK
| | - Nigel Day
- Epsom and St Helier NHS Trust, Greater London, UK
| | - Christos Kontovounisios
- Department of Surgery and Cancer, Imperial College London, London, UK
- Athens General Hospital, Athens, Greece
- Royal Marsden Hospital, London, UK
- Chelsea and Westminster Hospital, London, UK
| | - Brendan Moran
- Pelican Cancer Foundation, Basingstoke, UK
- Basingstoke and North Hampshire Hospitals, Basingstoke, UK
- Royal Prince Alfred Hospital, Sydney, Australia
- Cancer Sciences Division, University of Southampton, Southampton, UK
| | - Gina Brown
- Department of Surgery and Cancer, Imperial College London, London, UK
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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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Panagiotopoulou IG, Przedlacka A, Piozzi GN, Mills GA, Harper M, Khan JS. Robotic beyond total mesorectal excision (TME) for locally advanced or recurrent rectal cancer: a systematic review protocol. BMJ Open 2024; 14:e080043. [PMID: 38272558 PMCID: PMC10824024 DOI: 10.1136/bmjopen-2023-080043] [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: 09/19/2023] [Accepted: 12/06/2023] [Indexed: 01/27/2024] Open
Abstract
INTRODUCTION The surgical treatment for locally advanced or recurrent rectal cancer requires oncological clearance with a pelvic exenteration or a beyond total mesorectal excision (TME). The aim of this systematic review is to explore the safety and feasibility of robotic surgery in locally advanced and recurrent rectal cancer by evaluating perioperative outcomes, oncological clearance rates, and survival and recurrence rates postrobotic beyond TME surgery. METHODS The systematic review will include studies published until the end of December 2023. The MEDLINE, EMBASE and Scopus databases will be searched. The screening process, study selection, data extraction, quality assessment and analysis will be performed by two independent reviewers. Discrepancies will be resolved by consensus with a third independent reviewer. The risk of bias will be assessed with validated scores. The primary outcomes will be oncological clearance, overall and disease-free survival, and local and systemic recurrence rates post robotic or robot-assisted beyond TME surgery for locally advanced or recurrent rectal cancer. Secondary outcomes will include perioperative outcomes. ETHICS AND DISSEMINATION No ethical approval is required for this systematic review as no individual patient cases are studied requiring access to individual medical records. The results of the systematic review will be disseminated with conference presentations and peer-reviewed paper publications. PROSPERO REGISTRATION OF THE STUDY CRD42023408098.
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Affiliation(s)
- Ioanna Georgiou Panagiotopoulou
- School of Health and Care Professions, Faculty of Science and Health, University of Portsmouth, Portsmouth, UK
- Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Anna Przedlacka
- Department of Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | | | - Graham A Mills
- School of Health and Care Professions, Faculty of Science and Health, University of Portsmouth, Portsmouth, UK
| | - Mick Harper
- School of Health and Care Professions, Faculty of Science and Health, University of Portsmouth, Portsmouth, UK
| | - Jim S Khan
- School of Health and Care Professions, Faculty of Science and Health, University of Portsmouth, Portsmouth, UK
- Department of Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
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Mukai T, Nagasaki T, Akiyoshi T, Hiyoshi Y, Yamaguchi T, Kawachi H, Fukunaga Y. The impact of staple transection of the dorsal venous complex and urethra on intraoperative blood loss in cooperative laparoscopic and transperineal endoscopic pelvic exenteration. Surg Today 2024; 54:23-30. [PMID: 37127776 DOI: 10.1007/s00595-023-02693-x] [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: 12/04/2022] [Accepted: 04/06/2023] [Indexed: 05/03/2023]
Abstract
PURPOSE While laparoscopic pelvic exenteration reduces intraoperative blood loss, dorsal venous complex bleeding during this procedure causes issues. We previously introduced a method to transect the dorsal venous complex and urethra using a linear stapler during cooperative laparoscopic and transperineal endoscopic (two-team) pelvic exenteration. The present study assessed its effectiveness in reducing intraoperative blood loss by comparing it with conventional laparoscopic pelvic exenteration. METHODS This retrospective cohort study was conducted at a Japanese tertiary referral center. Eleven cases of two-team laparoscopic pelvic exenteration with staple transection of the dorsal venous complex (T-PE group) were compared to 25 cases of conventional laparoscopic pelvic exenteration (C-PE group). The primary outcome measure was intraoperative blood loss. RESULTS There were no significant between-group differences in patient background. The mean intraoperative blood loss was significantly lower in the T-PE group than in the C-PE group (200 vs. 850 mL, p = 0.01). The respective mean operation time, postoperative complication rate, and R0 resection rate were similar between the T-PE and C-PE groups (636 min vs. 688 min, p = 0.36; 36% vs. 44%, p = 0.65; 100% vs. 100%, p = 1.00). CONCLUSIONS Two-team laparoscopic pelvic exenteration with staple transection of the dorsal venous complex reduced intraoperative blood loss from the dorsal venous complex in a technically safe and oncologically feasible manner.
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Affiliation(s)
- Toshiki Mukai
- Department of Gastroenterological Surgery, Cancer Institute Hospital, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan.
| | - Toshiya Nagasaki
- Department of Gastroenterological Surgery, Cancer Institute Hospital, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Takashi Akiyoshi
- Department of Gastroenterological Surgery, Cancer Institute Hospital, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Yukiharu Hiyoshi
- Department of Gastroenterological Surgery, Cancer Institute Hospital, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Tomohiro Yamaguchi
- Department of Gastroenterological Surgery, Cancer Institute Hospital, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Hiroshi Kawachi
- Department of Pathology, Cancer Institute Hospital, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Yosuke Fukunaga
- Department of Gastroenterological Surgery, Cancer Institute Hospital, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
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Harji DP, McKigney N, Koh C, Solomon MJ, Griffiths B, Evans M, Heriot A, Sagar PM, Velikova G, Brown JM. Short-term outcomes of health-related quality of life in patients with locally recurrent rectal cancer: multicentre, international, cross-sectional cohort study. BJS Open 2023; 7:zrac168. [PMID: 36787174 PMCID: PMC9927560 DOI: 10.1093/bjsopen/zrac168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 11/23/2022] [Accepted: 12/02/2022] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Overall survival rates for locally recurrent rectal cancer (LRRC) continue to improve but the evidence concerning health-related quality of life (HrQoL) remains limited. The aim of this study was to describe the short-term HrQoL differences between patients undergoing surgical and palliative treatments for LRRC. METHODS An international, cross-sectional, observational study was undertaken at five centres across the UK and Australia. HrQoL in LRRC patients was assessed using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-CR29 and functional assessment of cancer therapy - colorectal (FACT-C) questionnaires and subgroups (curative versus palliative) were compared. Secondary analyses included the comparison of HrQoL according to the margin status, location of disease and type of treatment. Scores were interpreted using minimal clinically important differences (MCID) and Cohen effect size (ES). RESULTS Out of 350 eligible patients, a total of 95 patients participated, 74.0 (78.0 per cent) treated with curative intent and 21.0 (22.0 per cent) with palliative intent. Median time between LRRC diagnosis and HrQoL assessments was 4 months. Higher overall FACT-C scores denoting better HrQoL were observed in patients undergoing curative treatment, demonstrating a MCID with a mean difference of 18.5 (P < 0.001) and an ES of 0.6. Patients undergoing surgery had higher scores denoting a higher burden of symptoms for the EORTC CR29 domains of urinary frequency (P < 0.001, ES 0.3) and frequency of defaecation (P < 0.001, ES 0.4). Higher overall FACT-C scores were observed in patients who underwent an R0 resection versus an R1 resection (P = 0.051, ES 0.6). EORTC CR29 scores identified worse body image in patients with posterior/central disease (P = 0.021). Patients undergoing palliative chemoradiation reported worse HrQoL scores with a higher symptom burden on the frequency of defaecation scale compared with palliative chemotherapy (P = 0.041). CONCLUSION Several differences in short-term HrQoL outcomes between patients undergoing curative and palliative treatment for LRRC were documented. Patients undergoing curative surgery reported better overall HrQoL and a higher burden of pelvic symptoms.
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Affiliation(s)
- Deena P Harji
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | - Niamh McKigney
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Cherry Koh
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
- Royal Prince Alfred Hospital, RPA Institute of Academic Surgery, Sydney, NSW, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Michael J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
- Royal Prince Alfred Hospital, RPA Institute of Academic Surgery, Sydney, NSW, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Ben Griffiths
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | - Martyn Evans
- Department of Colorectal Surgery, Heol Maes Eglwys, Morriston, Swansea, UK
| | - Alexander Heriot
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Peter M Sagar
- The John Goligher Department of Colorectal Surgery, St James’s University Hospital, Leeds, UK
| | - Galina Velikova
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
- St James’s Institute of Oncology, St James’s University Hospital, Leeds, UK
| | - Julia M Brown
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
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Fitzsimmons T, Thomas M, Tonkin D, Murphy E, Hollington P, Solomon M, Sammour T, Luck A. Establishing a state-wide pelvic exenteration multidisciplinary team meeting in South Australia. ANZ J Surg 2022; 93:1227-1231. [PMID: 36567641 DOI: 10.1111/ans.18220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/04/2022] [Accepted: 12/13/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Pelvic exenteration surgery is complex, necessitating co-ordinated multidisciplinary input and improved referral pathways. A state-wide pelvic exenteration multidisciplinary team (MDT) meeting was established in SA and the outcomes of this were audited and compared with historical data. METHODS All patients referred for discussion between August 2021 and July 2022 to the SA State-wide Pelvic Exenteration MDT were included in this study. MDT discussion centred around disease resectability, risk versus benefit of surgery, and need for local or interstate referral. Prospective data collection included patient demographics and MDT recommendations of surgery, palliation, or referral. Patients referred for surgery locally or interstate were compared with a retrospective patient cohort treated previously between January and December 2020. RESULTS Over 12 months, 91 patients were discussed (including nine multiple times), by a mean of 18 meeting participants each month. Forty-eight patients (58.5%) had primary malignancy, 25 (30.5%) recurrent malignancy, and 9 (11.0%) had non-malignant disease. Colorectal cancer was the most common presentation (56.1%), followed by gynaecological (30.5%) and urological (6.1%) malignancy. Pelvic exenteration surgery was recommended to be performed locally in 53.7% of patients and the remainder for non-surgical treatment, palliation, or re-discussion. During this time, 44 patients underwent surgery locally (versus 34 in 2020) and only 4 referred interstate (versus 8 in 2020). CONCLUSION The establishment of a dedicated state-wide pelvic exenteration MDT has resulted in better coordination of care for patients with locally advanced pelvic malignancy in SA, and significantly reduced the need for interstate referral.
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Affiliation(s)
- Tracy Fitzsimmons
- Surgical Specialties, Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia.,Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Michelle Thomas
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Darren Tonkin
- Colorectal Unit, Department of Surgery, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Elizabeth Murphy
- Colorectal Unit, Division of Surgery, Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Paul Hollington
- Flinders Medical Centre, Division of Surgery and Perioperative Medicine, Flinders University, Adelaide, South Australia, Australia
| | - Michael Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Tarik Sammour
- Surgical Specialties, Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia.,Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Andrew Luck
- Colorectal Unit, Division of Surgery, Lyell McEwin Hospital, Adelaide, South Australia, Australia
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Harji DP, Houston F, Cutforth I, Hawthornthwaite E, McKigney N, Sharpe A, Coyne P, Griffiths B. The impact of multidisciplinary team decision-making in locally advanced and recurrent rectal cancer. Ann R Coll Surg Engl 2022; 104:611-617. [PMID: 35639482 PMCID: PMC9680687 DOI: 10.1308/rcsann.2022.0045] [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] [Accepted: 03/08/2022] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Appropriate patient selection within the context of a multidisciplinary team (MDT) is key to good clinical outcomes. The current evidence base for factors that guide the decision-making process in locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LRRC) is limited to anatomical factors. METHODS A registry-based, prospective cohort study was undertaken of patients referred to our specialist MDT between 2015 and 2019. Data were collected on patients and disease characteristics including performance status, Charlson Comorbidity Index, the English Index of Multiple Deprivation quintiles and MDT treatment decision. Curative treatment was defined as neoadjuvant treatment and surgical resection that would achieve a R0 resection, and/or complete treatment of distant metastatic disease. Palliative treatment was defined as non-surgical treatment. RESULTS In total, 325 patients were identified; 72.7% of patients with LARC and 63.6% of patients with LRRC were offered treatment with curative intent (p = 0.08). Patients with poor performance status (PS > 2; p < 0.001), severe comorbidity (p < 0.001), socio-economic deprivation (p = 0.004), a positive predictive circumferential resection margin (p = 0.005) and metastatic disease (p < 0.001) were associated with palliative treatment. Overall survival in the curative cohort was 49 months (95% confidence interval [CI] 32.4-65.5) compared with 12 months (95% CI 9.1-14.9) in the palliative cohort (p < 0.001). The presence of metastatic disease was identified as a prognostic factor for patients undergoing curative treatment (p = 0.05). The only prognostic factor identified in patients treated palliatively was performance status (p < 0.001). CONCLUSIONS Our study identifies a number of preoperative, prognostic factors that affect MDT decision-making and overall survival.
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Affiliation(s)
| | | | | | | | | | - A Sharpe
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - P Coyne
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - B Griffiths
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
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9
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Javed MA, Kohler A, Tiernan J, Quyn A, Sagar P. Evaluating potential delays and outcomes of patients undergoing surgical resection for locally advanced and recurrent colorectal cancer during a pandemic. Ann R Coll Surg Engl 2022; 104:624-631. [PMID: 35132892 PMCID: PMC9433197 DOI: 10.1308/rcsann.2021.0274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2021] [Indexed: 09/03/2023] Open
Abstract
INTRODUCTION The COVID-19 pandemic resulted in a significant disruption of colorectal cancer (CRC) care pathways. This study evaluates the management and outcomes of patients with primary locally advanced or recurrent CRC during the pandemic in a single tertiary referral centre. METHODS Patients undergoing elective surgery for advanced or recurrent CRC with curative intent between March 2020 and March 2021 were identified. Following first multidisciplinary team discussion patients were broadly classified into two groups: straight to surgery (n=22, 45%) or neoadjuvant therapy followed by surgery (n=27, 55%). Primary outcome was COVID-19-related complication rate. RESULTS Forty-nine patients with a median age of 66 years (interquartile range: 54-73) were included. No patients developed a COVID-19 infection or related complication during hospital admission. Significant delays were identified in the treatment pathway of patients in the straight to surgery group, mostly due to delays in referral from external centres. Nine of 22 patients in the straight to surgery group had evidence of tumour progression compared with 3 of 27 in the neoadjuvant group (p=0.015839). Seven of 27 patients in the neoadjuvant group showed evidence of tumour regression. During the study, surgical waiting times were reduced, and more operations were performed during the second wave of COVID-19. CONCLUSION This study suggests that it is possible to mitigate the risks of COVID-19-related complications in patients undergoing complex surgery for locally advanced and recurrent CRC. Delay in surgical intervention is associated with tumour progression, particularly in patients who may not have neoadjuvant therapy. Efforts should be made to prioritise resources for patients requiring time-sensitive surgery for advanced and recurrent CRC.
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10
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Wang J, Prabhakaran S, Larach T, Warrier SK, Bednarski BK, Ngan SY, Leong T, Rodriguez-Bigas M, Peacock O, Chang G, Heriot AG, Kong JCH. Treatment strategies for locally recurrent rectal cancer. Eur J Surg Oncol 2022; 48:2292-2298. [DOI: 10.1016/j.ejso.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 05/03/2022] [Accepted: 05/13/2022] [Indexed: 10/18/2022] Open
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11
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Oerskov KM, Bondeven P, Laurberg S, Hagemann-Madsen RH, Christensen HK, Lauridsen H, Pedersen BG. Postoperative MRI Findings Following Conventional and Extralevator Abdominoperineal Excision in Low Rectal Cancer. Front Surg 2021; 8:771107. [PMID: 34869567 PMCID: PMC8635027 DOI: 10.3389/fsurg.2021.771107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 10/04/2021] [Indexed: 01/11/2023] Open
Abstract
Aim: The disparity in outcomes for low rectal cancer may reflect differences in operative approach and quality. The extralevator abdominoperineal excision (ELAPE) was developed to reduce margin involvement in low rectal cancers by widening the excision of the conventional abdominoperineal excision (c-APE) to include the posterior pelvic diaphragm. This study aimed to determine the prevalence and localization of inadvertent residual pelvic diaphragm on postoperative MRI after intended ELAPE and c-APE. Methods: A total of 147 patients treated with c-APE or ELAPE for rectal cancer were included. Postoperative MRI was performed on 51% of the cohort (n = 75) and evaluated with regard to the residual pelvic diaphragm by a radiologist trained in pelvic MRI. Patient records, histopathological reports, and standardized photographs were assessed. Pathology and MRI findings were evaluated independently in a blinded fashion. Additionally, preoperative MRIs were evaluated for possible risk factors for margin involvement. Results: Magnetic resonance imaging-detected residual pelvic diaphragm was identified in 45 (75.4%) of 61 patients who underwent ELAPE and in 14 (100%) of 14 patients who underwent c-APE. An increased risk of margin involvement was observed in anteriorly oriented tumors with 16 (22%) of 73 anteriorly oriented tumors presenting with margin involvement vs. 7 (9%) of 74 non-anteriorly oriented tumors (p = 0.038). Conclusion: Residual pelvic diaphragm following abdominoperineal excision can be depicted by postoperative MRI. Inadvertent residual pelvic diaphragm (RPD) was commonly found in the series of patients treated with the ELAPE technique. Anterior tumor orientation was a risk factor for circumferential resection margin (CRM) involvement regardless of surgical approach.
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Affiliation(s)
| | - Peter Bondeven
- Department of Surgery, Randers Regional Hospital, Randers, Denmark
| | - Søren Laurberg
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | | | - Henrik Lauridsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Bodil Ginnerup Pedersen
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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12
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Assi H, Persson A, Palmquist I, Öberg M, Buchwald P, Lydrup ML. Short-term outcomes following beyond total mesorectal excision and reconstruction using myocutaneous flaps: A retrospective cohort study. Eur J Surg Oncol 2021; 48:1161-1166. [PMID: 34794841 DOI: 10.1016/j.ejso.2021.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 09/15/2021] [Accepted: 11/01/2021] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Beyond total mesorectal excision (bTME) offers long-term survival in patients with advanced pelvic malignancy. At Skåne University Hospital (SUS) Malmö in Sweden, the vertical rectus abdominis musculocutaneous (VRAM) and gluteal maximus (GM) flap have been used for perineal reconstruction to promote healing and functional outcomes after significant tissue loss. This study aims to examine 90-day overall and flap-specific complications in patients with advanced pelvic cancer treated with bTME and perineal flap reconstruction. METHOD This retrospective study conducted at SUS included patients undergoing surgery between January 01, 2010 and August 01, 2016. Patients' data were gathered through medical chart reviews. The Clavien-Dindo (CD) classification system was used to classify surgical and medical postoperative complications. Flap-specific complications were evaluated regardless of CD classification. RESULTS One hundred five patients (51 men, 54 women) underwent bTME surgery with perineal reconstruction, with VRAM flaps used in 27 (26%) patients, GM flaps in 51 (49%) patients and GM flaps with vaginal reconstruction in 27 (26%) patients. The 90-day mortality rate was one (1%), despite surgical CD ≥ III and/or medical CD ≥ II complications affecting 51 (48%) patients. Partial perineal dehiscence was noted in 45 (43%) patients, mostly treated conservatively. At the first outpatient postoperative visit (median, 42 days), flap healing was complete in 47 (45%) patients. CONCLUSION bTME surgery in pelvic cancer patients with perineal flap reconstruction using VRAM or GM flaps results in high overall and flap complication rates, but low mortality. Most complications can be conservatively treated.
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Affiliation(s)
- Hanin Assi
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Sweden.
| | - Anna Persson
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
| | - Ingrid Palmquist
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
| | - Martin Öberg
- Department of Plastic Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
| | - Pamela Buchwald
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
| | - Marie-Louise Lydrup
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
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13
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Pérez Lara FJ, Hebrero Jimenez ML, Moya Donoso FJ, Hernández Gonzalez JM, Pitarch Martinez M, Prieto-Puga Arjona T. Review of incomplete macroscopic resections (R2) in rectal cancer: Treatment, prognosis and future perspectives. World J Gastrointest Oncol 2021; 13:1062-1072. [PMID: 34616512 PMCID: PMC8465452 DOI: 10.4251/wjgo.v13.i9.1062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/28/2021] [Accepted: 07/23/2021] [Indexed: 02/06/2023] Open
Abstract
Colorectal cancer is one of the most prevalent tumours, but with improved treatment and early detection, its prognosis has greatly improved in recent years. However, when the tumour is locally advanced at diagnosis or if there is local recurrence, it is more difficult to perform a complete tumour resection, and there may be a residual macroscopic tumour. In this paper, we review the literature on residual macroscopic tumour resections, concerning both locally advanced primary tumours and recurrences, evaluating the main problems encountered, the treatments applied, the prognosis and future perspectives in this field.
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14
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Grove TN, Kontovounisios C, Montgomery A, Heniford BT, Windsor ACJ, Warren OJ. Perioperative optimization in complex abdominal wall hernias: Delphi consensus statement. BJS Open 2021; 5:6375607. [PMID: 34568888 PMCID: PMC8473840 DOI: 10.1093/bjsopen/zrab082] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 08/03/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The incidence of incisional hernia after major abdominal surgery via a midline laparotomy is 20-41 per cent with short-term follow-up, and over 50 per cent in those surviving an abdominal catastrophe. Abdominal wall reconstruction (AWR) requires complex operations, often involving mesh resection, management of scarred skin, fistula takedown, component separation or flap reconstruction. Patients tend to have more complex conditions, with multiple co-morbidities predisposing them to a vicious cycle of complications and, subsequently, hernia recurrence. Currently there appears to be variance in perioperative practice and minimal guidance globally. The aim of this Delphi consensus was to provide a clear benchmark of care for the preoperative assessment and perioperative optimization of patients undergoing AWR. METHODS The Delphi method was used to achieve consensus from invited experts in the field of AWR. Thirty-two hernia surgeons from recognized hernia societies globally took part. The process included two rounds of anonymous web-based voting with response analysis and formal feedback, concluding with a live round of voting followed by discussion at an international conference. Consensus for a strong recommendation was achieved with 80 per cent agreement, and a weak recommendation with 75 per cent agreement. RESULTS Consensus was obtained on 52 statements including surgical assessment, preoperative assessment, perioperative optimization, multidisciplinary team and decision-making, and quality-of-life assessment. Forty-six achieved over 80 per cent agreement; 14 statements achieved over 95 per cent agreement. CONCLUSION Clear consensus recommendations from a global group of experts in the AWR field are presented in this study. These should be used as a baseline for surgeons and centres managing abdominal wall hernias and performing complex AWR.
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Affiliation(s)
- T N Grove
- Department of Surgery, Chelsea and Westminster Hospital, London, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - C Kontovounisios
- Department of Surgery, Chelsea and Westminster Hospital, London, UK.,Department of Surgery and Cancer, Imperial College London, London, UK.,Department of General Surgery, Royal Marsden Hospital, London, UK
| | - A Montgomery
- Department of Surgery, Skåne University Hospital SUS, Malmö, Sweden
| | - B T Heniford
- Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | | | - O J Warren
- Department of Surgery, Chelsea and Westminster Hospital, London, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
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15
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Denost Q, Frison E, Salut C, Sitta R, Rullier A, Harji D, Maillou-Martinaud H, Rullier E, Smith D, Vendrely V. A phase III randomized trial evaluating chemotherapy followed by pelvic reirradiation versus chemotherapy alone as preoperative treatment for locally recurrent rectal cancer - GRECCAR 15 trial protocol. Colorectal Dis 2021; 23:1909-1918. [PMID: 33843133 DOI: 10.1111/codi.15670] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 03/14/2021] [Accepted: 03/23/2021] [Indexed: 12/16/2022]
Abstract
AIM Treatment strategies in locally recurrent rectal cancer (LRRC) are complex and need to be balanced against previous treatments received for the primary rectal cancer. Radiotherapy is an important component of treatment in LRRC. However, there is little high-quality evidence on the role of reirradiation in this cohort. Therefore, the aim of this trial is to assess the efficacy of neoadjuvant chemotherapy followed by pelvic reirradiation versus neoadjuvant chemotherapy alone on the rate of curative surgery (R0) in previously irradiated patients with LRRC. METHOD GRECCAR 15 is a prospective, multicentre, open-label, outcome assessor-blinded, superiority randomized controlled phase III clinical trial comparing neoadjuvant chemotherapy followed by pelvic reirradiation versus neoadjuvant chemotherapy alone in patients with LRRC previously irradiated for the primary cancer. Adult patients (>18 years old) with a histologically proven resectable LRRC, who have previously received pelvic radiotherapy for their primary rectal cancer at a dose of 25-50.4 Gy, and an Eastern Cooperative Oncology Group performance status of <2 will be eligible to participate. The pelvic reirradiation will consist of conformational intensity-modulated external irradiation, delivering a dose of 30.6 Gy with concomitant chemotherapy using capecitabine. The primary outcome of this trial is the R0 resection rate. Overall, GRECCAR 15 aims to recruit 186 patients to detect an absolute difference of 20% in the R0 resection rate with 80% power and 5% two-sided significance level. CONCLUSION The GRECCAR 15 trial is the first, definitive, phase III trial to investigate reirradiation in LRRC. The results of this trial will inform definitively the neoadjuvant treatment strategy in previously irradiated patients and assess whether there is any associated benefit of reirradiation in combination with induction chemotherapy in improving R0 resection rates.
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Affiliation(s)
- Quentin Denost
- Département de Chirurgie Colorectal, Hôpital Haut-Lévèque, CHU, Bordeaux, France
| | - Eric Frison
- Inserm, CIC1401-EC, Bordeaux, Service D'information Médicale, CHU, Bordeaux, France
| | - Cécile Salut
- Service de Radiologie, Hôpital Haut-Lévèque, CHU, Bordeaux, France
| | - Remy Sitta
- Inserm, CIC1401-EC, Bordeaux, Service D'information Médicale, CHU, Bordeaux, France
| | - Anne Rullier
- Service d'Anatomopathologie, Hôpital Pellegrin, CHU, Bordeaux, France
| | - Deena Harji
- Département de Chirurgie Colorectal, Hôpital Haut-Lévèque, CHU, Bordeaux, France
| | | | - Eric Rullier
- Département de Chirurgie Colorectal, Hôpital Haut-Lévèque, CHU, Bordeaux, France
| | - Denis Smith
- Service D'oncologie, Hôpital Haut-Lévèque, CHU, Bordeaux, France
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16
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Ozaki K, Kawai K, Nozawa H, Sasaki K, Murono K, Emoto S, Iida Y, Ishii H, Yokoyama Y, Anzai H, Sonoda H, Sugihara K, Ishihara S. Therapeutic effects and limitations of chemoradiotherapy in advanced lower rectal cancer focusing on T4b. Int J Colorectal Dis 2021; 36:1525-1534. [PMID: 33937942 DOI: 10.1007/s00384-021-03936-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/21/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE This study aimed to elucidate the benefits and limitations of preoperative chemoradiotherapy (CRT) in rectal cancer treatment, specifically in T4b rectal cancer. METHODS This retrospective cohort study reviewed 1014 consecutive patients with clinical T3/4a/T4b adenocarcinomas of the lower rectum, who underwent total mesorectal excision at the Department of Surgical Oncology of the University of Tokyo Hospital and 22 referral institutions affiliated with the Japanese Study Group for Postoperative Follow-up of Colorectal Cancer. Patients were divided into two cohorts: cohort 1 comprised 298 consecutive patients who underwent CRT followed by radical surgery and cohort 2 comprised 716 consecutive patients who underwent curative surgery without preoperative therapy. We assessed the prognostic differences between the two cohorts, focusing particularly on T stages. RESULTS In T3/4a patients, cohort 1 showed a significantly lower local recurrence rate than cohort 2 (4.8% vs. 9.4%, p=0.024), but not in T4b patients (23.5% vs. 16.0%, p=0.383). In contrast, no significant differences in survival were observed between T3/4a and T4b patients. T4b classification was found to be an independent predictive factor of local recurrence in cohort 1, but not in cohort 2. CONCLUSION In T4b rectal cancer, preoperative CRT demonstrated a limited benefit for local control and survival. In cases of suspected T4b rectal tumors, additional therapies such as induction chemotherapy to conventional CRT may contribute to better outcomes.
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Affiliation(s)
- Kosuke Ozaki
- Department of Surgical Oncology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
| | - Kazushige Kawai
- Department of Surgical Oncology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Hiroaki Nozawa
- Department of Surgical Oncology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Kazuhito Sasaki
- Department of Surgical Oncology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Koji Murono
- Department of Surgical Oncology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Shigenobu Emoto
- Department of Surgical Oncology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Yuuki Iida
- Department of Surgical Oncology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Hiroaki Ishii
- Department of Surgical Oncology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Yuichiro Yokoyama
- Department of Surgical Oncology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Hiroyuki Anzai
- Department of Surgical Oncology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Hirofumi Sonoda
- Department of Surgical Oncology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Kenichi Sugihara
- Department of Surgical Oncology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Soichiro Ishihara
- Department of Surgical Oncology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
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17
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Meyer J, Wheeler J, Simillis C, Davies J. Comment on: Prognostic importance of circumferential resection margin in the era of evolving surgical and multidisciplinary treatment of rectal cancer: a systematic review and meta-analysis. Surgery 2021; 170:1592-1593. [PMID: 34024473 DOI: 10.1016/j.surg.2021.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 04/19/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Jeremy Meyer
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, UK; Division of Digestive Surgery, University Hospitals of Geneva, Genève, Switzerland; Medical School, University of Geneva, Switzerland
| | - James Wheeler
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, UK
| | - Constantinos Simillis
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, UK
| | - Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, UK.
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18
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Mariathasan AB, Boye K, Dueland S, Flatmark K, Larsen SG. Metastases in locally advanced rectal cancer undergoing curatively intended treatment. Eur J Surg Oncol 2021; 47:2377-2383. [PMID: 34049768 DOI: 10.1016/j.ejso.2021.04.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 03/25/2021] [Accepted: 04/17/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The main cause of mortality in locally advanced rectal cancer (LARC) is metastatic progression. The aim of the present study was to describe frequency, pattern and outcome of metastatic disease in a cohort of LARC patients after curative resection. METHODS This was a single-centre cohort study of 628 LARC cases after neoadjuvant chemoradiotherapy/radiotherapy (CRT/RT) and surgery. Data, including the first site of metastasis, was registered in an institutional database linked to the National Cancer Registry. RESULTS Metastases were diagnosed in 270 patients (43.0%) with liver and lungs as the first site in 113 and 96 cases, respectively. Involved resection margins, high tumour stage and poor response to CRT/RT were associated with metastasis development and inferior overall survival (OS). Metastasectomy was performed in 76 (67.3%) patients with liver metastases and 28 (29.2%) patients with lung metastases. Five-year OS was 89% in patients without metastases and 32% in metastatic cases. In patients selected for metastasectomy, 5-year OS was 69% and 53% for lung and liver metastases, respectively. Corresponding numbers without metastasectomy were 12% and 0%. CONCLUSION In this large LARC cohort undergoing curatively intended treatment, liver and lung metastases occurred at similar frequencies. Liver as the first metastatic site was associated with inferior long-term outcome, while selection for metastasectomy was associated with better OS, with more than half of the resected patients being alive five years after LARC surgery. Our results show that the presence of resectable metastatic disease at diagnosis should not exclude a curative therapeutic approach in LARC.
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Affiliation(s)
- Anthony B Mariathasan
- Department of Gastroenterological Surgery, Section for Surgical Oncology, Norwegian Radium Hospital, Oslo University Hospital, Norway; Faculty of Medicine, University of Oslo, Norway
| | - Kjetil Boye
- Department of Oncology, Norwegian Radium Hospital, Oslo University Hospital, Norway; Department of Tumour Biology, Institute for Cancer Research, Norwegian Radium Hospital, Oslo University Hospital, Norway
| | - Svein Dueland
- Department of Oncology, Norwegian Radium Hospital, Oslo University Hospital, Norway
| | - Kjersti Flatmark
- Department of Gastroenterological Surgery, Section for Surgical Oncology, Norwegian Radium Hospital, Oslo University Hospital, Norway; Department of Tumour Biology, Institute for Cancer Research, Norwegian Radium Hospital, Oslo University Hospital, Norway; Faculty of Medicine, University of Oslo, Norway.
| | - Stein G Larsen
- Department of Gastroenterological Surgery, Section for Surgical Oncology, Norwegian Radium Hospital, Oslo University Hospital, Norway
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19
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Perioperative management and anaesthetic considerations in pelvic exenterations using Delphi methodology: results from the PelvEx Collaborative. BJS Open 2021; 5:6137382. [PMID: 33609393 PMCID: PMC7893479 DOI: 10.1093/bjsopen/zraa055] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 11/15/2020] [Indexed: 12/22/2022] Open
Abstract
Background The multidisciplinary perioperative and anaesthetic management of patients undergoing pelvic exenteration is essential for good surgical outcomes. No clear guidelines have been established, and there is wide variation in clinical practice internationally. This consensus statement consolidates clinical experience and best practice collectively, and systematically addresses key domains in the perioperative and anaesthetic management. Methods The modified Delphi methodology was used to achieve consensus from the PelvEx Collaborative. The process included one round of online questionnaire involving controlled feedback and structured participant response, two rounds of editing, and one round of web-based voting. It was held from December 2019 to February 2020. Consensus was defined as more than 80 per cent agreement, whereas less than 80 per cent agreement indicated low consensus. Results The final consensus document contained 47 voted statements, across six key domains of perioperative and anaesthetic management in pelvic exenteration, comprising preoperative assessment and preparation, anaesthetic considerations, perioperative management, anticipating possible massive haemorrhage, stress response and postoperative critical care, and pain management. Consensus recommendations were developed, based on consensus agreement achieved on 34 statements. Conclusion The perioperative and anaesthetic management of patients undergoing pelvic exenteration is best accomplished by a dedicated multidisciplinary team with relevant domain expertise in the setting of a specialized tertiary unit. This consensus statement has addressed key domains within the framework of current perioperative and anaesthetic management among patients undergoing pelvic exenteration, with an international perspective, to guide clinical practice, and has outlined areas for future clinical research.
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20
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Tuech JJ, Pinson J, Nouhaud FX, Wood G, Clavier T, Sabourin JC, Di Fiore F, Monge M, Papet E, Coget J. Total Pelvic Exenteration, Cytoreductive Surgery, and Hyperthermic Intraperitoneal Chemotherapy for Rectal Cancer with Associate Peritoneal Metastases: Surgical Strategies to Optimize Safety. Cancers (Basel) 2020; 12:cancers12113478. [PMID: 33238384 PMCID: PMC7700214 DOI: 10.3390/cancers12113478] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 11/19/2020] [Accepted: 11/20/2020] [Indexed: 12/15/2022] Open
Abstract
Simple Summary Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a curative treatment for patients with peritoneal carcinomatosis. Pelvic exenteration is an established treatment option for locally advanced pelvic malignancy. Based on the argument that high-risk complications arise from each procedure, the majority of researchers do not recommend performing a CRS/HIPEC with pelvis exenteration. Herein, we critically analyzed the data from 16 patients treated by these two procedures for 15 rectal and one appendiceal adenocarcinomas. Clear resection (R0) margins were achieved in 81.2% of cases. The median hospital stay was 46 days (26–129), and nine patients (56.2%) experienced severe complications that led to death in two cases (12.5%). Survival rates were not clarified, since the follow-up is ongoing. Pelvis exenteration associated with CRS/HIPEC may be a reasonable procedure in selected patients at expert centers. Pelvic involvement should not be considered a definitive contraindication for CRS/HIPEC if a R0 resection could be achieved. However, the morbidity and the mortality are high with this combination of treatment, and further research is needed to assess the oncologic benefit and quality of life before such a radical approach can be recommended. Abstract Background: Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a curative treatment option for patients with peritoneal carcinomatosis. Total pelvic exenteration (TPE) is an established treatment option for locally advanced pelvic malignancy. These two procedures have high mortality and morbidity, and therefore, their combination is not currently recommended. Herein, we reported our experience on TPE associated with CRS/HIPEC with a critical analysis for rectal cancer with associate peritoneal metastases. Methods: From March 2006 to August 2020, 319 patients underwent a CRS/HIPEC in our hospital. Among them, 16 (12 men and four women) underwent an associated TPE. The primary endpoints were perioperative morbidity and mortality. Results: There was locally recurrent rectal cancer in nine cases, six locally advanced primary rectal cancer, and a recurrent appendiceal adenocarcinoma. The median Peritoneal Cancer Index (PCI) was 8. (4–16). Mean duration of the surgical procedure was 596 min (420–840). Complete cytoreduction (CC0) was achieved in all patients, while clear resection (R0) margins on the resected pelvic organs were achieved in 81.2% of cases. The median hospital stay was 46 days (26–129), and nine patients (56.2%) experienced severe complications (grade III to V) that led to death in two cases (12.5%). The total reoperation rate for patients was 6/16 (37.5%) and 3/16 (18.75%) with percutaneous radiological-guided drainage. Conclusions: In summary, TPE/extended TPE (ETPE) associated with CRS/HIPEC may be a reasonable procedure in selected patients at expert centers. Pelvic involvement should not be considered a definitive contraindication for CRS/HIPEC in patients with resectable peritoneal surface diseases if a R0 resection could be achieved on all sites. However, the morbidity and the mortality are high with this combination of treatment, and further research is needed to assess the oncologic benefit and quality of life before such a radical approach can be recommended.
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Affiliation(s)
- Jean-Jacques Tuech
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, France; (J.P.); (M.M.); (E.P.); (J.C.)
- Correspondence: ; Tel.: +33-232-888-142; Fax: +33-232-8884
| | - Jean Pinson
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, France; (J.P.); (M.M.); (E.P.); (J.C.)
| | | | - Gregory Wood
- Department of Anesthesiology and Critical Care, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, France; (G.W.); (T.C.)
| | - Thomas Clavier
- Department of Anesthesiology and Critical Care, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, France; (G.W.); (T.C.)
| | - Jean-Christophe Sabourin
- Department of Pathology, Iron Group, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, France;
| | - Frederic Di Fiore
- Department of Digestive Oncology, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, France;
| | - Matthieu Monge
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, France; (J.P.); (M.M.); (E.P.); (J.C.)
| | - Eloïse Papet
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, France; (J.P.); (M.M.); (E.P.); (J.C.)
| | - Julien Coget
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, France; (J.P.); (M.M.); (E.P.); (J.C.)
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Mirnezami R, Mirnezami A. Multivisceral Resection of Advanced Pelvic Tumors: From Planning to Implementation. Clin Colon Rectal Surg 2020; 33:268-278. [PMID: 32968362 DOI: 10.1055/s-0040-1713744] [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] [Indexed: 10/23/2022]
Abstract
Pelvic exenteration involves radical multivisceral resection for locally advanced and recurrent pelvic tumors. Advances in tumor staging, oncological therapies, preoperative patient optimization, surgical techniques, and critical care medicine have permitted the safe expansion of pelvic exenterative surgery at specialist units. It is now understood that in carefully selected patients, 5-year survival can exceed 60% following pelvic exenteration, and that very low mortality figures and an optimum postexenteration quality of life are possible. In the present review, we provide a contemporary summary of the current state of the art in pelvic exenterative surgery following all key phases of the treatment pipeline from patient staging and tumor assessment, to treatment planning and surgery.
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Affiliation(s)
- R Mirnezami
- Department of Colorectal Surgery, Royal Free Hospital, Hampstead, London
| | - A Mirnezami
- Division of Cancer Sciences, Cancer Research UK Centre, University of Southampton, Southampton, United Kingdom.,Southampton Complex Cancer and Exenterative Unit, University Hospital Southampton, Southampton, United Kingdom
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22
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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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Baird DLH, Kontovounisios C, Simillis C, Pellino G, Rasheed S, Tekkis PP. Factors associated with metachronous metastases and survival in locally advanced and recurrent rectal cancer. BJS Open 2020; 4:1172-1179. [PMID: 32856767 PMCID: PMC7709378 DOI: 10.1002/bjs5.50341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 07/15/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Better understanding of the impact of metachronous metastases in locally advanced and recurrent rectal cancer may improve decision-making. The aim of this study was to investigate factors influencing metachronous metastasis and its impact on survival in patients who have a beyond total mesorectal excision (bTME) operation. METHODS This was a retrospective study of consecutive patients who had bTME surgery for locally advanced and recurrent rectal cancer at a tertiary referral centre between January 2006 and December 2016. The primary outcome was overall survival. Cox proportional hazards regression analyses were performed. The influence of metachronous metastases on survival was investigated. RESULTS Of 220 included patients, 171 were treated for locally advanced primary tumours and 49 for recurrent rectal cancer. Some 90·0 per cent had a complete resection with negative margins. Median follow-up was 26·0 (range 1·5-119·6) months. The 5-year overall survival rate was 71·1 per cent. Local recurrence and metachronous metastasis rates were 11·8 and 22·2 per cent respectively. Patients with metachronous metastases had a worse overall survival than patients without metastases (median 52·9 months versus estimated mean 109·4 months respectively; hazard ratio (HR) 6·73, 95 per cent c.i. 3·23 to 14·00). Advancing pT category (HR 2·01, 1·35 to 2·98), pN category (HR 2·43, 1·65 to 3·59), vascular invasion (HR 2·20, 1·22 to 3·97) and increasing numbers of positive lymph nodes (HR 1·19, 1·07 to 1·16) increased the risk of metachronous metastasis. Nine of 17 patients (53 per cent) with curatively treated synchronous metastases at presentation developed metachronous metastases, compared with 40 of 203 (19·7 per cent) without synchronous metastases (P = 0·002). Corresponding median length of disease-free survival was 17·5 versus 90·8 months (P < 0·001). CONCLUSION As metachronous metastases impact negatively on survival after bTME surgery, factors associated with metachronous metastases may serve as selection tools when determining suitability for treatment with curative intent.
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Affiliation(s)
- D. L. H. Baird
- Department of Colorectal Surgery, The Royal Marsden HospitalLondonUK
- Department of Surgery and CancerImperial College LondonLondonUK
| | - C. Kontovounisios
- Department of Colorectal Surgery, The Royal Marsden HospitalLondonUK
- Department of Surgery and CancerImperial College LondonLondonUK
- Department of Colorectal SurgeryChelsea and Westminster HospitalLondonUK
| | - C. Simillis
- Department of Colorectal Surgery, The Royal Marsden HospitalLondonUK
| | - G. Pellino
- Department of Colorectal Surgery, The Royal Marsden HospitalLondonUK
| | - S. Rasheed
- Department of Colorectal Surgery, The Royal Marsden HospitalLondonUK
- Department of Surgery and CancerImperial College LondonLondonUK
- Department of Colorectal SurgeryChelsea and Westminster HospitalLondonUK
| | - P. P. Tekkis
- Department of Colorectal Surgery, The Royal Marsden HospitalLondonUK
- Department of Surgery and CancerImperial College LondonLondonUK
- Department of Colorectal SurgeryChelsea and Westminster HospitalLondonUK
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Kosakowska E, Pietrzak L, Michalski W, Kepka L, Polkowski W, Jankiewicz M, Cisel B, Krynski J, Zwolinski J, Wyrwicz L, Rutkowski A, Stylinski R, Nawrocki G, Sopylo R, Szczepkowski M, Tarnowski W, Bujko K. Neoadjuvant chemotherapy with or without oxaliplatin after short-course radiotherapy in high-risk rectal cancer: A subgroup analysis from a prospective study. Rep Pract Oncol Radiother 2020; 25:1017-1022. [PMID: 33390858 DOI: 10.1016/j.rpor.2020.08.002] [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: 06/26/2020] [Revised: 07/28/2020] [Accepted: 08/11/2020] [Indexed: 02/08/2023] Open
Abstract
Aim To evaluate the role of oxaliplatin in neoadjuvant chemotherapy delivered after short-course irradiation. Background Using oxaliplatin in the above setting is uncertain. Patients and methods A subgroup of 136 patients managed by short-course radiotherapy and 3 cycles of consolidation chemotherapy within the framework of a randomised study was included in this post-hoc analysis. Sixty-seven patients received FOLFOX4 (oxaliplatin group) while oxaliplatin was omitted in the second period of accrual in 69 patients because of protocol amendment (fluorouracil-only group). Results Grade 3+ acute toxicity from neoadjuvant treatment was observed in 30% of patients in the oxaliplatin group vs. 16% in the fluorouracil-only group (p = 0.053). The corresponding proportions of patients having radical surgery or achieving complete pathological response were 72% vs. 77% (odds ratio [OR] = 0.88; 95% confidence interval [CI]: 0.39-1.98; p = 0.75) and 15% vs. 7% (OR = 2.25; 95% CI: 0.83-6.94; p = 0.16), respectively. The long-term outcomes were similar in the two groups. Overall and disease-free survival rates at 5 years were 63% vs. 56% (p = 0.78) and 49% vs. 44% (p = 0.59), respectively. The corresponding numbers for cumulative incidence of local failure or distant metastases were 33% vs. 38% (hazard ratio [HR] = 0.89; 95% CI: 0.52-1.52; p = 0.68) and 33% vs. 33% (HR = 0.78; 95% CI: 0.43-1.40; p = 0.41), respectively. Conclusion Our findings do not support adding oxaliplatin to three cycles of chemotherapy delivered after short-course irradiation.
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Affiliation(s)
- Ewa Kosakowska
- Department of Gastroenterological Oncology, Maria Sklodowska-Curie National, Research Institute of Oncology, Warsaw, Poland
| | - Lucyna Pietrzak
- I Department of Radiotherapy, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Wojciech Michalski
- Department of Computational Oncology, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Lucyna Kepka
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland
| | | | | | - Bogumila Cisel
- Department of Surgical Oncology, Medical University of Lublin, Poland
| | - Jacek Krynski
- Department of Gastroenterological Oncology, Maria Sklodowska-Curie National, Research Institute of Oncology, Warsaw, Poland
| | - Jacek Zwolinski
- Department of Gastroenterological Oncology, Maria Sklodowska-Curie National, Research Institute of Oncology, Warsaw, Poland
| | - Lucjan Wyrwicz
- Department of Oncology and Radiotherapy, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Andrzej Rutkowski
- Department of Gastroenterological Oncology, Maria Sklodowska-Curie National, Research Institute of Oncology, Warsaw, Poland
| | - Roman Stylinski
- 1st Department of General Surgery, Transplantology and Nutritional Therapy, Medical University of Lublin, Poland
| | - Grzegorz Nawrocki
- Department of Surgery, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Rafal Sopylo
- Department of Surgery, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Marek Szczepkowski
- Clinical Department of Colorectal, General and Oncological Surgery, Centre of Postgraduate Medical Education, Bielanski Hospital, Warsaw, Poland
| | - Wieslaw Tarnowski
- Department of General, Oncologic and Digestive Tract Surgery, Medical Centre of Postgraduate Education, Orlowski Hospital, Warsaw, Poland
| | - Krzysztof Bujko
- I Department of Radiotherapy, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
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Smith T, O'Cathail SM, Silverman S, Robinson M, Tsang Y, Harrison M, Hawkins MA. Stereotactic Body Radiation Therapy Reirradiation for Locally Recurrent Rectal Cancer: Outcomes and Toxicity. Adv Radiat Oncol 2020; 5:1311-1319. [PMID: 33305093 PMCID: PMC7718547 DOI: 10.1016/j.adro.2020.07.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/16/2020] [Accepted: 07/27/2020] [Indexed: 12/29/2022] Open
Abstract
Purpose Stereotactic body radiation therapy (SBRT) has emerged as a potential therapeutic option for locally recurrent rectal cancer (LRRC) but contemporaneous clinical data are limited. We aimed to evaluate the local control, toxicity, and survival outcomes in a cohort of patients previously treated with neoadjuvant pelvic radiation therapy for nonmetastatic locally recurrent rectal cancer, now treated with SBRT. Methods and Materials Inoperable rectal cancer patients with ≤3 sites of pelvic recurrence and >6 months since prior pelvic radiation therapy were identified from a prospective registry over 4 years. SBRT dose was 30 Gy in 5 fractions, daily or alternate days, using cumulative organ at risk dose constraints. Primary outcome was local control (LC). Secondary outcomes were progression free survival, overall survival, toxicity, and patient reported quality of life scores using the EQ visual analog scale (EQ-VAS) tool. Results Thirty patients (35 targets) were included. Median gross tumor volume size was 14.3 cm3. In addition, 27 of 30 (90%) previously received 45 to 50.4 Gy in 25 of 28 fractions, with 10% receiving an alternative prescription. All patients received the planned reirradiation SBRT dose. The median follow-up was 24.5 months (interquartile range, 17.8-28.8). The 1-year LC was 84.9% (95% confidence interval [CI], 70.6-99) and a 2-year LC was 69% (95% CI, 51.8-91.9). The median progression free survival was 12.1 months (95% CI, 8.6-17.66), and median overall survival was 28.3 months (95% CI, 17.88-39.5 months). No patient experienced >G2 acute toxicity and only 1 patient experienced late G3 toxicity. Patient-reported QoL outcomes were improved at 3 months after SBRT (Δ EQ-VAS, +10 points, Wilcoxon signed-rank, P = .009). Conclusions Our study demonstrates that, for small volume pelvic disease relapses from rectal cancer, reirradiation with 30 Gy in 5 fractions is well tolerated and achieves an excellent balance between high local control rates with limited toxicity.
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Affiliation(s)
- Thomas Smith
- Mount Vernon Cancer Centre, East and North Herefordshire NHS Trust, Middlesex, UK
| | - Sean M O'Cathail
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Sabrina Silverman
- Mount Vernon Cancer Centre, East and North Herefordshire NHS Trust, Middlesex, UK
| | | | - Yatman Tsang
- Mount Vernon Cancer Centre, East and North Herefordshire NHS Trust, Middlesex, UK
| | - Mark Harrison
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Maria A Hawkins
- Medical Physics and Biomedical Engineering, University College London and University, London, England, UK.,College London Hospitals NHS Foundation Trust, London, England, UK
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Heah NH, Wong KY. Feasibility of robotic assisted bladder sparing pelvic exenteration for locally advanced rectal cancer: A single institution case series. World J Gastrointest Surg 2020; 12:190-196. [PMID: 32426098 PMCID: PMC7215973 DOI: 10.4240/wjgs.v12.i4.190] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 03/12/2020] [Accepted: 03/22/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pelvic exenteration for locally advanced rectal cancer involving prostate has been performed via open surgery. Robotic pelvic exenteration offers benefits of better pelvic visualisation and dissection for bladder preserving prostatectomy with vesicourethral anastomosis, while achieving clear margins.
AIM To determine the feasibility of robotic assisted bladder sparing pelvic exenteration.
METHODS We describe robotic assisted pelvic exenteration in three cases of locally advanced rectal cancer involving prostate and seminal vesicles (SV). The da Vinci S robotic system was used. Robotic console was docked at left oblique position for abdominal phase and redocked to between the patient’s legs for pelvic phase. All three cases were performed fully robotically at Tan Tock Seng Hospital by colorectal and urological teams.
RESULTS Case 1: 67-year-old with low rectal tumour 3cm from anal verge involving the prostate. He underwent neo-adjuvant chemoradiotherapy and robotic abdominoperineal resection with en-bloc prostatectomy. Case 2: 66-year-old with low rectal tumour 3cm from anal verge involving prostate and bilateral SV. He underwent neo-adjuvant chemoradiotherapy and robot assisted ultra-low anterior resection with coloanal anastomosis and en-bloc prostatectomy. Case 3: 57-year-old with metachronous rectal tumour in the rectovesical pouch inseparable from the anterior mid rectum, prostate and bilateral SV. He underwent robot assisted ultra-low anterior resection with en-bloc prostatectomy. Bladder neck margin revealed cauterized tumour cells, and he underwent total cystectomy and ileal conduit creation. Histology revealed no residual tumour. All patients are currently disease free
CONCLUSION Robot assisted bladder sparing pelvic exenteration can be safely performed in locally advanced rectal cancer with acceptable surgical outcome while preserving benefits of minimally invasive surgery.
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Affiliation(s)
- Nathaniel H Heah
- Department of Urology, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Kar Yong Wong
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
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27
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A Comparison of the Short-term Outcomes of Three Flap Reconstruction Techniques Used After Beyond Total Mesorectal Excision Surgery for Anorectal Cancer. Dis Colon Rectum 2020; 63:461-468. [PMID: 31977583 DOI: 10.1097/dcr.0000000000001585] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Surgery for advanced or recurrent pelvic malignancy can result in perineal defects that cannot be closed by wound edge approximation. Myocutaneous flaps can fill the defect and accelerate healing. No reconstruction has been proven to be superior to the others. OBJECTIVE This study aimed to compare 3 flap procedures after beyond total mesorectal excision surgery. DESIGN This is a retrospective analysis of a prospective database, according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. SETTINGS This study was performed at a tertiary hospital. PATIENTS Consecutive series of patients who required flap reconstruction after beyond total mesorectal excision surgery between 2007 and 2016 were included. MAIN OUTCOME MEASURES Short-term outcomes after oblique rectus abdominis flap vs vertical rectus abdominis flap vs inferior gluteal artery perforator flap reconstruction were evaluated. RESULTS Included are 65 (59%) oblique rectus abdominis flap, 30 (27.3%) vertical rectus abdominis flap, and 15 (13.7%) inferior gluteal artery perforator flap outcomes. Sacrectomy was performed in 12 (18.5%), 10 (33.3%), and 8 (53.3%) patients (p = 0.016). Preoperative radiotherapy was used in 60 (92.3%), 26 (86.7%), and 11 (73.3%) patients (p = 0.11). Flap infection and dehiscence occurred in 7 (10.8%), 1 (3.3%), and 4 (26.7%) patients. There was an increased risk of flap complication with inferior gluteal artery perforator flap vs vertical rectus abdominis flap (p = 0.036). Inferior gluteal artery perforator flap (OR, 6.26; p = 0.02) and obesity (OR, 4.96; p = 0.02) were associated with flap complications. Only complications of the oblique rectus abdominis flap decreased significantly over time (p = 0.03). The length of stay and complete (R0) resection rate were not different between the groups. LIMITATIONS This study was limited because of its retrospective nature and because it was conducted at a single center. CONCLUSIONS The techniques appear comparable. The approaches should be considered complementary, and the choice should be individualized. See Video Abstract at http://links.lww.com/DCR/B141. COMPARACIÓN DE RESULTADOS A CORTO PLAZO DE TRES TÉCNICAS DE RECONSTRUCCIÓN CON COLGAJO UTILIZADAS DESPUÉS DE LA CIRUGÍA DE ESCISIÓN MESORRECTAL TOTAL EXTENDIDA PARA EL CÁNCER ANORRECTAL: La cirugía para malignidad pélvica avanzada o recurrente puede provocar defectos perineales, que no pueden cerrarse por aproximación de los bordes de la herida. Los colgajos miocutáneos pueden llenar el defecto y acelerar la curación. Ninguna reconstrucción ha demostrado ser superior a las demás.Comparar tres procedimientos de colgajo después de una cirugía de escisión mesorrectal total extendida.Análisis retrospectivo de una base de datos prospectiva, de acuerdo con la Declaración de Fortalecimiento de los informes de estudios observacionales en epidemiología.Hospital de tercer nivel.Series consecutivas de pacientes que requirieron reconstrucción con colgajo después de una cirugía de escisión mesorrectal total extendida entre 2007 y 2016.Resultados a corto plazo después del colgajo oblicuo recto abdominal versus colgajo vertical recto abdominal versus reconstrucción del colgajo perforador de la arteria glútea inferior.Se incluyen 65 (59%) colgajo oblicuo recto abdominal oblicuo, 30 (27.3%) colgajo vertical recto abdominal y 15 (13.7%) colgajo perforador de la arteria glútea inferior. Sacrectomía se realizó en 12 (18.5%), 10 (33.3%) y 8 (53.3%) pacientes respectivamente (p = 0.016). La radioterapia preoperatoria se utilizó en 60 (92.3%), 26 (86.7%) y 11 (73.3%) (p = 0,11). La infección del colgajo y la dehiscencia ocurrieron en 7 (10.8%), 1 (3.3%) y 4 (26.7%). Hubo un mayor riesgo de complicación con el colgajo perforador de la arteria glútea inferior en comparación al colgajo vertical del recto abdominal (p = 0.036). El colgajo perforador de la arteria glútea inferior (OR 6.26, p = 0.02) y la obesidad (OR 4.96, p = 0.02) se asociaron con complicaciones del colgajo. Solo las complicaciones del colgajo oblicuo recto abdominal disminuyeron significativamente con el tiempo (p = 0.03). La duración de la estancia hospitalaria y la tasa de resección completa (R0) no fue diferente entre los grupos.Estudio retrospectivo en centro único.Las técnicas parecen comparables. Los enfoques deben considerarse complementarios y la elección individualizada. Consulte Video Resumen en http://links.lww.com/DCR/B141.
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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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O'Shannassy SJ, Brown KGM, Steffens D, Solomon MJ. Referral patterns and outcomes of a highly specialised pelvic exenteration multidisciplinary team meeting: A retrospective cohort study. Eur J Surg Oncol 2020; 46:1138-1143. [PMID: 32122755 DOI: 10.1016/j.ejso.2020.02.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 01/31/2020] [Accepted: 02/20/2020] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION The purpose of this study was to review recommendations made from a specialist pelvic exenteration (PE) multidisciplinary team (MDT) and to provide insights as to the impact of the MDT on patient selection and clinical decision making. MATERIALS & METHODS A retrospective review was conducted at Royal Prince Alfred Hospital's PE MDT between June 2014 and December 2015. Data was collected from the recorded minutes of MDT meetings. Referral information and clinical data was extracted from individual patient files. Additional data including operative dates and surgical resection margins were collected from electronic medical records. RESULTS Of the 183 patients considered for PE during the MDT meeting, 104 (57%) were recommended for surgery. Factors that influenced the recommendation in favour of surgery were referral by a surgeon (P = 0.004), referral from a rural location (P = 0.05) and having locally advanced primary cancer (P < 0.001). Patients who were seen by the unit's surgeon prior to the MDT did not impact on the MDT recommendation nor the decision for or against surgery (P = 0.771). The most common reason for recommendation against PE was unresectable distant metastatic disease (43%). CONCLUSIONS The PE MDT meeting is a critical step in the patient care pathway and facilitates critical decision making. Anatomically-based contraindications to surgery (i.e. involvement of adjacent organs, bone and neurovascular structures) do not appear to influence MDT decision making regarding resectability.
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Affiliation(s)
- Sarah J O'Shannassy
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; RPA Institute of Academic Surgery (IAS), Sydney, Australia.
| | - Kilian G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; RPA Institute of Academic Surgery (IAS), Sydney, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; The University of Sydney, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; RPA Institute of Academic Surgery (IAS), Sydney, Australia; The University of Sydney, New South Wales, Australia
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30
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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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32
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Ganeshan D, Nougaret S, Korngold E, Rauch GM, Moreno CC. Locally recurrent rectal cancer: what the radiologist should know. Abdom Radiol (NY) 2019; 44:3709-3725. [PMID: 30953096 DOI: 10.1007/s00261-019-02003-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Despite advances in surgical techniques and chemoradiation therapy, recurrent rectal cancer remains a cause of morbidity and mortality. After successful treatment of rectal cancer, patients are typically enrolled in a surveillance strategy that includes imaging as studies have shown improved prognosis when recurrent rectal cancer is detected during imaging surveillance versus based on development of symptoms. Additionally, patients who experience a complete clinical response with chemoradiation therapy may elect to enroll in a "watch-and-wait" strategy that includes imaging surveillance rather than surgical resection. Factors that increase the likelihood of recurrence, patterns of recurrence, and the imaging appearances of recurrent rectal cancer are reviewed with a focus on CT, PET CT, and MR imaging.
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Affiliation(s)
- Dhakshinamoorthy Ganeshan
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX, 77030, USA
| | - Stephanie Nougaret
- Montpellier Cancer Research Institute, IRCM, Montpellier Cancer Research Institute, 208 Ave des Apothicaires, 34295, Montpellier, France
- Department of Radiology, Montpellier Cancer Institute, INSERM, U1194, University of Montpellier, 208 Ave des Apothicaires, 34295, Montpellier, France
| | - Elena Korngold
- Department of Radiology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Gaiane M Rauch
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX, 77030, USA
| | - Courtney C Moreno
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Road, NE, Atlanta, GA, 30322, USA.
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Liccardo F, Baird DLH, Pellino G, Rasheed S, Kontovounisios C, Tekkis PP. Predictors of short-term readmission after beyond total mesorectal excision for primary locally advanced and recurrent rectal cancer. Updates Surg 2019; 71:477-484. [PMID: 31250396 PMCID: PMC6686032 DOI: 10.1007/s13304-019-00669-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 06/22/2019] [Indexed: 11/24/2022]
Abstract
Unplanned readmissions heavily affect the cost of health care and are used as an indicator of performance. No clear data are available regarding beyond-total mesorectal excision (bTME) procedure. Aim of the study is to identify patient-related and surgery-related factors influencing the 30-day readmissions after bTME. Retrospective data were collected from 220 patients who underwent bTME procedures at single centre between 2006 and 2016. Patient-related and operative factors were assessed, including body mass index (BMI), age, gender, American Society of Anaesthesiologists' (ASA) score, preoperative stage, neo-adjuvant therapy, primary tumour vs recurrence, the extent of surgery. The readmission rate was 8.18%. No statistically significant association was found with BMI, ASA score, length of stay and stay in the intensive care unit, primary vs recurrent tumour or blood transfusions. Not quite statistically significant was the association with pelvic side wall dissection (OR 3.32, p = 0.054). Statistically significant factors included preoperative stage > IIIb (OR: 4.77, p = 0.002), neo-adjuvant therapy (OR: 0.13, p = 0.0006), age over 65 years (OR: 5.96, p = 0.0005), any re-intervention during the first admission (OR: 7.4, p = 0.0001), and any post-operative complication (OR: 9.01, p = 0.004). The readmission rate after beyond-TME procedure is influenced by patient-related factors as well as post-operative morbidity.
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Affiliation(s)
- Filomena Liccardo
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
| | - Daniel L. H. Baird
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
- Department of Surgery and Cancer, Imperial College, 369 Fulham Rd, London, SW10 9NH UK
| | - Gianluca Pellino
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
- Department of Advanced Medical and Surgical Sciences, Universitá della Campania “Luigi Vanvitelli, Naples, Italy
| | - Shahnawaz Rasheed
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
- Department of Surgery and Cancer, Imperial College, 369 Fulham Rd, London, SW10 9NH UK
| | - Christos Kontovounisios
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
- Department of Surgery and Cancer, Imperial College, 369 Fulham Rd, London, SW10 9NH UK
- Department of Colorectal Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK
| | - Paris P. Tekkis
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
- Department of Surgery and Cancer, Imperial College, 369 Fulham Rd, London, SW10 9NH UK
- Department of Colorectal Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK
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34
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Venchiarutti RL, Solomon MJ, Koh CE, Young JM, Steffens D. Pushing the boundaries of pelvic exenteration by maintaining survival at the cost of morbidity. Br J Surg 2019; 106:1393-1403. [PMID: 31282571 DOI: 10.1002/bjs.11203] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 02/26/2019] [Accepted: 03/12/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Pelvic exenteration (PE) provides a potentially curative option for advanced or recurrent malignancy confined to the pelvis. A clear (R0) resection margin is the strongest prognostic factor predicting long-term survival, driving most technical advances in PE surgery. The aim of this cohort study was to describe changing trends in extent of resection, postoperative complications, mortality and overall survival after PE surgery. METHODS Consecutive patients who underwent PE for advanced or recurrent pelvic malignancy at a single institution in Sydney, Australia, were identified. The cohort was divided into three groups based on time periods reflecting annual surgical volume: 1994-2006 (20 or fewer procedures per year), 2007-2013 (21-50 procedures per year) and 2014-2017 (over 50 procedures per year). Primary outcomes were extent of resection, postoperative complications, 60-day mortality and 3-year overall survival. Secondary outcomes were patient characteristics, receipt of neoadjuvant therapy and duration of hospital stay. RESULTS There were increases over time in rates of lateral and posterior compartment resections (P < 0·001), and bony pelvis (P = 0·002) and neurovascular (P < 0·001) excision. For patients undergoing reconstruction, the proportion receiving vertical rectus abdominus myocutaneous flaps increased significantly (P = 0·005). Rates of wound infection, dehiscence, and abdominal and pelvic collections increased over the study interval. Short-term mortality decreased, and 1- and 3-year survival rates improved. CONCLUSION Technical and surgical advancements have led to more complex PE resections, with R0 and mortality rates improving with higher annual volume. There were associated increases in intraoperative blood loss and postoperative morbidity.
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Affiliation(s)
- R L Venchiarutti
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital and University of Sydney, Camperdown, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
| | - M J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital and University of Sydney, Camperdown, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia.,Royal Prince Alfred Institute of Academic Surgery, Sydney Local Health District, Camperdown, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - C E Koh
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital and University of Sydney, Camperdown, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia.,Royal Prince Alfred Institute of Academic Surgery, Sydney Local Health District, Camperdown, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - J M Young
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital and University of Sydney, Camperdown, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia.,Royal Prince Alfred Institute of Academic Surgery, Sydney Local Health District, Camperdown, New South Wales, Australia
| | - D Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital and University of Sydney, Camperdown, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
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35
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Davis BR, Schlosser KA. Management of locally recurrent rectal cancer. SEMINARS IN COLON AND RECTAL SURGERY 2019. [DOI: 10.1053/j.scrs.2019.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Baird DLH, Simillis C, Pellino G, Kontovounisios C, Rasheed S, Tekkis PP. The obesity paradox in beyond total mesorectal excision surgery for locally advanced and recurrent rectal cancer. Updates Surg 2019; 71:313-321. [PMID: 30790208 PMCID: PMC6647851 DOI: 10.1007/s13304-019-00631-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 02/11/2019] [Indexed: 12/18/2022]
Abstract
The objective is to investigate preoperative body mass index (BMI) in patients receiving beyond total mesorectal excision (bTME) surgery. The primary end point is length of postoperative stay. Secondary end points are length of intensive care stay, postoperative morbidity and overall survival. BMI is the most commonly used anthropometric measurement of nutrition and studies have shown that overweight and obese patients can have improved surgical outcomes. Patients who underwent a bTME operation for locally advanced or recurrent rectal cancer were put into three BMI (kg/m2) groups of normal weight (18.5-24.9), overweight (25-29.9) and obese (≥ 30) for analysis. Included are 220 consecutive patients from a single centre. The overall length of stay, in days ± standard deviation (range), for normal weight, overweight and obese patients was 21.14 ± 16.4 (6-99), 15.24 ± 4.3 (7-32) and 19.10 ± 9.8 (8-62) respectively (p = 0.002). The mean ICU length of stay was 5.40 ± 9.1 (1-69), 3.37 ± 2.4 (0-19) and 3.60 ± 2.4 (1-14), respectively (p = 0.030). There was no significant difference between the three groups in terms of postoperative morbidity or overall survival. Patients with a normal weight BMI in this cohort have a significantly longer length of stay in ICU and in hospital than overweight or obese patients. This is seen with no significant difference in morbidity or overall survival.
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Affiliation(s)
- Daniel L H Baird
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK
- Department of Surgery and Cancer, Imperial College London, Chelsea and Westminster and the Royal Marsden Campus, London, UK
| | | | - Gianluca Pellino
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK
| | - Christos Kontovounisios
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK.
- Department of Surgery and Cancer, Imperial College London, Chelsea and Westminster and the Royal Marsden Campus, London, UK.
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK.
| | - Shahnawaz Rasheed
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK
- Department of Surgery and Cancer, Imperial College London, Chelsea and Westminster and the Royal Marsden Campus, London, UK
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK
| | - Paris P Tekkis
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK
- Department of Surgery and Cancer, Imperial College London, Chelsea and Westminster and the Royal Marsden Campus, London, UK
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK
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37
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Teoh B, Waters PS, Peacock O, Smart P, Reid K, Rajkumar A, Heriot AG, Warrier SK. Utilising taTME and robotics to reduce R1 risk in locally advanced rectal cancer with rectovaginal and cervical involvement. Tech Coloproctol 2019; 23:387-390. [PMID: 30778783 DOI: 10.1007/s10151-019-01941-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 01/31/2019] [Indexed: 02/08/2023]
Affiliation(s)
- B Teoh
- Division of Cancer Surgery, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - P S Waters
- Division of Cancer Surgery, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - O Peacock
- Division of Cancer Surgery, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - P Smart
- Epworth Freemasons Hospital, Melbourne, Australia
| | - K Reid
- Epworth Freemasons Hospital, Melbourne, Australia
| | - A Rajkumar
- Epworth Freemasons Hospital, Melbourne, Australia
| | - A G Heriot
- Division of Cancer Surgery, Victorian Comprehensive Cancer Centre, Melbourne, Australia
- Epworth Freemasons Hospital, Melbourne, Australia
| | - S K Warrier
- Division of Cancer Surgery, Victorian Comprehensive Cancer Centre, Melbourne, Australia.
- Epworth Freemasons Hospital, Melbourne, Australia.
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC, 3000, Australia.
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38
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Brown KGM, Solomon MJ. Progress and future direction in the management of advanced colorectal cancer. Br J Surg 2019; 105:615-617. [PMID: 29652083 DOI: 10.1002/bjs.10759] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 10/17/2017] [Indexed: 11/11/2022]
Abstract
Improving advanced colorectal cancer care
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Affiliation(s)
- K G M Brown
- Surgical Outcomes Research Centre (SOuRCe), Institute of Academic Surgery at Royal Prince Alfred Hospital, and Department of Colorectal Surgery, Royal Prince Alfred Hospital, PO, Box M157, Missenden Road, Sydney, New South Wales, 2050, Australia
| | - M J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Institute of Academic Surgery at Royal Prince Alfred Hospital, and Department of Colorectal Surgery, Royal Prince Alfred Hospital, PO, Box M157, Missenden Road, Sydney, New South Wales, 2050, Australia.,University of Sydney, Sydney, New South Wales, Australia
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39
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Hureibi K. Management of locally recurrent rectal cancer. Eur J Surg Oncol 2018; 44:1281. [DOI: 10.1016/j.ejso.2018.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 05/07/2018] [Indexed: 11/27/2022] Open
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40
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Beyond total mesorectal excision in locally advanced rectal cancer with organ or pelvic side-wall involvement. Eur J Surg Oncol 2018; 44:1226-1232. [DOI: 10.1016/j.ejso.2018.03.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 02/28/2018] [Accepted: 03/31/2018] [Indexed: 01/07/2023] Open
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41
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Bolmstrand B, Nilsson PJ, Holm T, Buchli C, Palmer G. Patterns of complications following urinary tract reconstruction after multivisceral surgery in colorectal and anal cancer. Eur J Surg Oncol 2018; 44:1513-1517. [PMID: 30017328 DOI: 10.1016/j.ejso.2018.06.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 06/14/2018] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Multi-visceral resection, including parts of the urinary tract, is sometimes warranted to achieve cancer clear resection margins and optimize survival in patients with locally advanced colorectal and anal cancer. The aim of this study was to assess morbidity after urinary tract reconstruction dictated by colorectal and anal malignancy and to identify potential predictors of urological complications. METHODS All patients undergoing surgery for colorectal or anal malignancy, including urinary tract resection and synchronous reconstruction, performed at the Karolinska University Hospital during 2004-2015 were included in this retrospective cohort study. Data was collected from medical records with follow-up until at least one year after the index surgery. Complications were graded according to the Clavien-Dindo classification system of surgical complications. RESULTS The study included 189 patients; 121 underwent cystectomy and 68 partial ureter resection. The rate of high grade urological complications was 22%. The risk of major urological complications was significantly higher in patients subjected to ureter resection compared to after cystectomy (OR 2.60, 95% CI 1.23-5.49). Also, preoperative radiotherapy and intestinal anastomotic dehiscence significantly increased the risk of high grade urological complications. CONCLUSION To achieve potentially curative resections with uninvolved margins in patients with locally advanced colorectal and anal cancer, multi-visceral resection including urinary tract reconstruction can be performed with reasonable morbidity.
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Affiliation(s)
- Björn Bolmstrand
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Center of Digestive Diseases, P9:03, Karolinska University Hospital, S-171 76, Stockholm, Sweden.
| | - Per J Nilsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Center of Digestive Diseases, P9:03, Karolinska University Hospital, S-171 76, Stockholm, Sweden
| | - Torbjörn Holm
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Center of Digestive Diseases, P9:03, Karolinska University Hospital, S-171 76, Stockholm, Sweden
| | - Christian Buchli
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Center of Digestive Diseases, P9:03, Karolinska University Hospital, S-171 76, Stockholm, Sweden
| | - Gabriella Palmer
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Center of Digestive Diseases, P9:03, Karolinska University Hospital, S-171 76, Stockholm, Sweden
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Abstract
BACKGROUND Pelvic exenteration for locally recurrent rectal cancer (LRRC) is associated with variable outcomes, with the majority of data from single-centre series. This study analysed data from an international collaboration to determine robust parameters that could inform clinical decision-making. METHODS Anonymized data on patients who had pelvic exenteration for LRRC between 2004 and 2014 were accrued from 27 specialist centres. The primary endpoint was survival. The impact of resection margin, bone resection, node status and use of neoadjuvant therapy (before exenteration) was assessed. RESULTS Of 1184 patients, 614 (51·9 per cent) had neoadjuvant therapy. A clear resection margin (R0 resection) was achieved in 55·4 per cent of operations. Twenty-one patients (1·8 per cent) died within 30 days and 380 (32·1 per cent) experienced a major complication. Median overall survival was 36 months following R0 resection, 27 months after R1 resection and 16 months following R2 resection (P < 0·001). Patients who received neoadjuvant therapy had more postoperative complications (unadjusted odds ratio (OR) 1·53), readmissions (unadjusted OR 2·33) and radiological reinterventions (unadjusted OR 2·12). Three-year survival rates were 48·1 per cent, 33·9 per cent and 15 per cent respectively. Bone resection (when required) was associated with a longer median survival (36 versus 29 months; P < 0·001). Node-positive patients had a shorter median overall survival than those with node-negative disease (22 versus 29 months respectively). Multivariable analysis identified margin status and bone resection as significant determinants of long-term survival. CONCLUSION Negative margins and bone resection (where needed) were identified as the most important factors influencing overall survival. Neoadjuvant therapy before pelvic exenteration did not affect survival, but was associated with higher rates of readmission, complications and radiological reintervention.
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43
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Rondelli F, Santinelli R, Stella P, Bugiantella W, Ceccarelli G, Balzarotti RC, De Rosa M, Avenia N. A New Surgical Device for Anterograde Intraoperative Rectal Washout. Surg Innov 2018; 25:203-207. [PMID: 29473452 DOI: 10.1177/1553350618759767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Colorectal cancer is the fourth most diffuse cause of death in the world and local recurrence is associated with a reduced long-term life expectancy, with a reduced quality of life. Rectal washout at the anastomosis site leads to a statistically significant reduction of local recurrences. METHODS We developed the idea of a new laparoscopic stapler with an integrated washout system that could decontaminate the rectal stump before resection, without the need to enlarge the standard surgical incision or even to distort the incision site, closing the rectal stump just below the inferior part of the cancer, and then proceeding with the resection and stapling of the distal part of the tumor. Combined with these canonical functionalities, the new device, equipped with a patented washout system (patent number EP 3103401A1) will also allow to inject in the closed bowel a physiologic saline liquid. RESULTS In force of the mechanical action of the liquid injected, carcinogenic exfoliated cells eventually floating in the affected region of the colonic lumen will be expelled through the anal orifice. The intraoperative rectal washout, both in minimally invasive and in traditional open surgery, thus becomes a simple, effective, and reproducible procedure. CONCLUSIONS We describe the technical features and the possible clinical applications of a potentially new surgical laparoscopic stapler coupled with an integrated irrigation system. We have patented the system and we are developing a prototype with the aim to start an experimental pilot study.
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Affiliation(s)
- Fabio Rondelli
- 1 "San Giovanni Battista" Hospital, Perugia, Italy.,2 University of Perugia, Perugia, Italy
| | | | - Paolo Stella
- 1 "San Giovanni Battista" Hospital, Perugia, Italy
| | | | | | | | | | - Nicola Avenia
- 2 University of Perugia, Perugia, Italy.,6 S. Maria University Hospital, Terni, Italy
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44
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Rombouts AJM, Hugen N, Elferink MAG, Feuth T, Poortmans PMP, Nagtegaal ID, de Wilt JHW. Incidence of second tumors after treatment with or without radiation for rectal cancer. Ann Oncol 2017; 28:535-540. [PMID: 27993790 DOI: 10.1093/annonc/mdw661] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background The aim of this study was to analyze the association between radiation therapy (RT) for rectal cancer and the development of second tumors. Patients and methods Data on all surgically treated non-metastatic primary rectal cancer patients diagnosed between 1989 and 2007 were retrieved from the Netherlands population-based cancer registry. Fine and Gray's competing risk model was used for estimation of the cumulative incidence of second tumors. Multivariable analysis was conducted using Cox regression. Results The cohort consisted of 29 027 patients of which 15 467 patients had undergone RT. Median follow-up was 7.7 years (range 0-27). Among all 4398 patients who were diagnosed with a second primary tumor, 1030 had one or more pelvic tumors. The standardized incidence risk for any second tumor was 1.16 (95% confidence interval [CI] 1.12-1.19), resulting in 27.7/10 000 excess cancer cases per year in patients treated for rectal cancer compared with the general population. RT reduced the cumulative incidence of second pelvic tumors compared with patients who did not receive RT (subhazard ratio [SHR] 0.77, CI 0.68-0.88). Second prostate tumors were less common in patients who received RT (SHR 0.54, CI 0.46-0.64), gynecological tumors were more frequently observed in patients who received RT (SHR 1.49, CI 1.11-2.00). Conclusions Patients with previous rectal cancer had a marginally increased risk of a second tumor compared with the general population. Gynecological tumors occurred more often in females who received RT, but this did not result in an overall increased risk for a second cancer. RT even seemed to have a protective effect on the development of other second pelvic tumors, pre-dominantly for prostate cancer. These findings are highly important and can contribute to improved patient counseling.
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Affiliation(s)
- A J M Rombouts
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - N Hugen
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - M A G Elferink
- Netherlands Comprehensive Cancer Care Organisation, Utrecht, The Netherlands
| | - T Feuth
- Departments of Health Science, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - P M P Poortmans
- Radiation Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - I D Nagtegaal
- Pathology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - J H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
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45
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Abstract
Advanced primary and recurrent colorectal cancer can be successfully treated by experienced, dedicated centers delivering good outcomes with low mortality and morbidity. Development and implementation of a comprehensive referral pathway is to be encouraged. Multidisciplinary team management is essential in the management of this complex group of patients and is associated with significantly more complete preoperative evaluation and more accurate provision of patient information, as well as improved access to the most appropriate individualized management plan. A structured selection process can improve outcomes through standardized approaches to service delivery to provide the highest quality of care.
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Affiliation(s)
- Christos Kontovounisios
- Department of Colorectal Surgery, The Royal Marsden Hospital, Chelsea, London, United Kingdom.,Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Paris Tekkis
- Department of Colorectal Surgery, The Royal Marsden Hospital, Chelsea, London, United Kingdom.,Department of Surgery and Cancer, Imperial College, London, United Kingdom
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46
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Management and prognosis of locally recurrent rectal cancer - A national population-based study. Eur J Surg Oncol 2017; 44:100-107. [PMID: 29224985 DOI: 10.1016/j.ejso.2017.11.013] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 10/27/2017] [Accepted: 11/16/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The rate of local recurrence of rectal cancer (LRRC) has decreased but the condition remains a therapeutic challenge. This study aimed to examine treatment and prognosis in patients with LRRC in Sweden. Special focus was directed towards potential differences between geographical regions and time periods. METHOD All patients with LRRC as first event, following primary surgery for rectal cancer performed during the period 1995-2002, were included in this national population-based cohort-study. Data were collected from the Swedish Colorectal Cancer Registry and from medical records. The cohort was divided into three time periods, based on the date of diagnosis of the LRRC. RESULTS In total, 426 patients fulfilled the inclusion criteria. Treatment with curative intent was performed in 149 patients (35%), including 121 patients who had a surgical resection of the LRRC. R0-resection was achieved in 64 patients (53%). Patients with a non-centrally located tumour were more likely to have positive resection margins (R1/R2) (OR 5.02, 95% CI:2.25-11.21). Five-year survival for patients resected with curative intent was 43% after R0-resection and 14% after R1-resection. There were no significant differences in treatment intention or R0-resection rate between time periods or regions. The risk of any failure was significantly higher in R1-resected patients compared with R0-resected patients (HR 2.04, 95% CI:1.22-3.40). CONCLUSION A complete resection of the LRRC is essential for potentially curative treatment. Time period and region had no influence on either margin status or prognosis.
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47
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van Zoggel DMGI, Bosman SJ, Kusters M, Nieuwenhuijzen GAP, Cnossen JS, Creemers GJ, van Lijnschoten G, Rutten HJT. Preliminary results of a cohort study of induction chemotherapy-based treatment for locally recurrent rectal cancer. Br J Surg 2017; 105:447-452. [PMID: 29168556 DOI: 10.1002/bjs.10694] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 08/08/2017] [Accepted: 08/14/2017] [Indexed: 01/27/2023]
Abstract
BACKGROUND A significant number of patients treated for locally recurrent rectal cancer have local or systemic failure, especially after incomplete surgical resection. Neoadjuvant treatment regimens in patients who have already undergone preoperative (chemo)radiotherapy for the primary tumour are limited. The objective of the present study was to evaluate the influence of a neoadjuvant regimen incorporating induction chemotherapy (ICT) in patients with locally recurrent rectal cancer who had preoperative (chemo)radiotherapy for the primary cancer or an earlier local recurrence. METHODS Patients were treated with a sequential neoadjuvant regimen including three or four cycles of 5-fluorouracil and oxaliplatin-containing chemotherapy. When no progressive disease was found at evaluation, neoadjuvant treatment was continued with chemoradiation therapy (CRRT) using 30 Gy with concomitant capecitabine. If there was a response to ICT, the patient was advised to continue with systemic chemotherapy after CRRT as consolidation chemotherapy while waiting for resection. These patients were compared with patients who received CRRT alone in the same time interval. RESULTS Of 58 patients who had ICT, 32 (55 per cent) had surgery with clear resection margins, of whom ten (17 per cent) exhibited a pathological complete response (pCR). The remaining 26 patients had 23 R1 and three R2 resections. In 71 patients who received CRRT, a similar rate of R0 (35 patients) and R1 (36) resection was found (P = 0·506), but only three patients (4 per cent) had a pCR (P = 0·015). CONCLUSION The incorporation of ICT in neoadjuvant regimens for locally recurrent rectal cancer is a promising strategy.
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Affiliation(s)
| | - S J Bosman
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - M Kusters
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands.,Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - J S Cnossen
- Department of Radiotherapy, Catharina Hospital, Eindhoven, The Netherlands
| | - G J Creemers
- Department of Medical Oncology, Catharina Hospital, Eindhoven, The Netherlands
| | | | - H J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands.,GROW School of Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
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48
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An audit comparing the reporting of staging MRI scans for rectal cancer with the London Cancer Alliance (LCA) guidelines. Eur J Surg Oncol 2017; 43:2093-2104. [DOI: 10.1016/j.ejso.2017.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 06/30/2017] [Accepted: 09/01/2017] [Indexed: 02/06/2023] Open
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49
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Jonker F, Hagemans J, Verhoef C, Burger J. The impact of hospital volume on perioperative outcomes of rectal cancer. Eur J Surg Oncol 2017; 43:1894-1900. [DOI: 10.1016/j.ejso.2017.07.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 06/03/2017] [Accepted: 07/14/2017] [Indexed: 10/19/2022] Open
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50
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Battersby NJ, Dattani M, Rao S, Cunningham D, Tait D, Adams R, Moran BJ, Khakoo S, Tekkis P, Rasheed S, Mirnezami A, Quirke P, West NP, Nagtegaal I, Chong I, Sadanandam A, Valeri N, Thomas K, Frost M, Brown G. A rectal cancer feasibility study with an embedded phase III trial design assessing magnetic resonance tumour regression grade (mrTRG) as a novel biomarker to stratify management by good and poor response to chemoradiotherapy (TRIGGER): study protocol for a randomised controlled trial. Trials 2017; 18:394. [PMID: 28851403 PMCID: PMC5576102 DOI: 10.1186/s13063-017-2085-2] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 07/03/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Pre-operative chemoradiotherapy (CRT) for MRI-defined, locally advanced rectal cancer is primarily intended to reduce local recurrence rates by downstaging tumours, enabling an improved likelihood of curative resection. However, in a subset of patients complete tumour regression occurs implying that no viable tumour is present within the surgical specimen. This raises the possibility that surgery may have been avoided. It is also recognised that response to CRT is a key determinant of prognosis. Recent radiological advances enable this response to be assessed pre-operatively using the MRI tumour regression grade (mrTRG). Potentially, this allows modification of the baseline MRI-derived treatment strategy. Hence, in a 'good' mrTRG responder, with little or no evidence of tumour, surgery may be deferred. Conversely, a 'poor response' identifies an adverse prognostic group which may benefit from additional pre-operative therapy. METHODS/DESIGN TRIGGER is a multicentre, open, interventional, randomised control feasibility study with an embedded phase III design. Patients with MRI-defined, locally advanced rectal adenocarcinoma deemed to require CRT will be eligible for recruitment. During CRT, patients will be randomised (1:2) between conventional management, according to baseline MRI, versus mrTRG-directed management. The primary endpoint of the feasibility phase is to assess the rate of patient recruitment and randomisation. Secondary endpoints include the rate of unit recruitment, acute drug toxicity, reproducibility of mrTRG reporting, surgical morbidity, pathological circumferential resection margin involvement, pathology regression grade, residual tumour cell density and surgical/specimen quality rates. The phase III trial will focus on long-term safety, regrowth rates, oncological survival analysis, quality of life and health economics analysis. DISCUSSION The TRIGGER trial aims to determine whether patients with locally advanced rectal cancer can be recruited and subsequently randomised into a control trial that offers MRI-directed patient management according to radiological response to CRT (mrTRG). The feasibility study will inform a phase III trial design investigating stratified treatment of good and poor responders according to 3-year disease-free survival, colostomy-free survival as well as an increase in cases managed without a major resection. TRIAL REGISTRATION ClinicalTrials.gov, ID: NCT02704520 . Registered on 5 February 2016.
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Affiliation(s)
- Nick J. Battersby
- Pelican Cancer Foundation, The Ark, Basingstoke, RG24 9NN UK
- North Hampshire Hospital Foundation Trust, Basingstoke, RG24 9NA UK
| | - Mit Dattani
- Pelican Cancer Foundation, The Ark, Basingstoke, RG24 9NN UK
| | - Sheela Rao
- Department of Medicine Royal Marsden Hospital Sutton, Sutton, SM2 5PT UK
| | - David Cunningham
- Department of Medicine Royal Marsden Hospital Sutton, Sutton, SM2 5PT UK
| | - Diana Tait
- Department of Medicine Royal Marsden Hospital Sutton, Sutton, SM2 5PT UK
| | - Richard Adams
- Velindre Cancer Centre Velindre Hospital Cardiff, Cardiff, CF4 7XL UK
| | - Brendan J. Moran
- Pelican Cancer Foundation, The Ark, Basingstoke, RG24 9NN UK
- North Hampshire Hospital Foundation Trust, Basingstoke, RG24 9NA UK
| | - Shelize Khakoo
- Gastrointestinal Unit Royal Marsden Hospital Sutton, Sutton, SM2 5PT UK
| | - Paris Tekkis
- Department of Colorectal Surgery, Royal Marsden Hospital London, London, SW3 6JJ UK
| | - Shahnawaz Rasheed
- Department of Colorectal Surgery, Royal Marsden Hospital London, London, SW3 6JJ UK
| | - Alex Mirnezami
- Department of Surgery and Department for Tissue Microarray analysis, University of Southampton, Southampton, SO16 6YD UK
| | - Philip Quirke
- Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, Wellcome Trust Brenner Building, St. James’s University Hospital, Leeds, LS9 7TF UK
| | - Nicholas P. West
- Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, Wellcome Trust Brenner Building, St. James’s University Hospital, Leeds, LS9 7TF UK
| | - Iris Nagtegaal
- Department of Pathology Radboud University, Nijmegen, 6500HB Netherlands
| | - Irene Chong
- Division of Molecular Pathology Institute of Cancer Research, London, SW3 6JB UK
| | - Anguraj Sadanandam
- Division of Molecular Pathology Institute of Cancer Research, London, SW3 6JB UK
| | - Nicola Valeri
- Division of Molecular Pathology Institute of Cancer Research, London, SW3 6JB UK
| | - Karen Thomas
- Statistics Unit, R&D Royal Marsden Hospital Sutton, Sutton, SM2 5PT UK
| | - Michelle Frost
- Department of Radiology, Royal Marsden Hospital Sutton, Sutton, SM2 5PT UK
| | - Gina Brown
- Department of Radiology, Royal Marsden Hospital Sutton, Sutton, SM2 5PT UK
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