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Xu ZW, Zhu JT, Bai HY, Yu XJ, Hong QQ, You J. Clinical efficacy and pathological outcomes of transanal endoscopic intersphincteric resection for low rectal cancer. World J Gastrointest Oncol 2024; 16:933-944. [PMID: 38577453 PMCID: PMC10989362 DOI: 10.4251/wjgo.v16.i3.933] [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: 08/18/2023] [Revised: 11/05/2023] [Accepted: 12/29/2023] [Indexed: 03/12/2024] Open
Abstract
BACKGROUND Transanal endoscopic intersphincteric resection (ISR) surgery currently lacks sufficient clinical research and reporting. AIM To investigate the clinical effectiveness of transanal endoscopic ISR, in order to promote the clinical application and development of this technique. METHODS This study utilized a retrospective case series design. Clinical and pathological data of patients with lower rectal cancer who underwent transanal endoscopic ISR at the First Affiliated Hospital of Xiamen University between May 2018 and May 2023 were included. All patients underwent transanal endoscopic ISR as the surgical approach. We conducted this study to determine the perioperative recovery status, postoperative complications, and pathological specimen characteristics of this group of patients. RESULTS This study included 45 eligible patients, with no perioperative mortalities. The overall incidence of early complications was 22.22%, with a rate of 4.44% for Clavien-Dindo grade ≥ III events. Two patients (4.4%) developed anastomotic leakage after surgery, including one case of grade A and one case of grade B. Postoperative pathological examination confirmed negative circumferential resection margins and distal resection margins in all patients. The mean distance between the tumor lower margin and distal resection margin was found to be 2.30 ± 0.62 cm. The transanal endoscopic ISR procedure consistently yielded high quality pathological specimens. CONCLUSION Transanal endoscopic ISR is safe, feasible, and provides a clear anatomical view. It is associated with a low incidence of postoperative complications and favorable pathological outcomes, making it worth further research and application.
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Affiliation(s)
- Zhi-Wen Xu
- Department of Gastrointestinal Oncology Surgery, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen 361000, Fujian Province, China
| | - Jing-Tao Zhu
- Department of Gastrointestinal Oncology Surgery, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen 361000, Fujian Province, China
| | - Hao-Yu Bai
- Department of Gastrointestinal Oncology Surgery, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen 361000, Fujian Province, China
| | - Xue-Jun Yu
- Department of Gastrointestinal Oncology Surgery, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen 361000, Fujian Province, China
| | - Qing-Qi Hong
- Department of Gastrointestinal Oncology Surgery, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen 361000, Fujian Province, China
| | - Jun You
- Department of Gastrointestinal Oncology Surgery, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen 361000, Fujian Province, China
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Yellinek S, Krizzuk D, Gilshtein H, Freund MR, Wexner SD, Berho M. Distal Tumor Spread in Rectal Cancer-How Low Should We Go? Am Surg 2023; 89:5553-5558. [PMID: 36855994 DOI: 10.1177/00031348231157408] [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] [Indexed: 03/02/2023]
Abstract
BACKGROUND Distal tumor spread (DTS) is an adverse prognostic factor in rectal cancer correlating with advanced stage disease. We aimed to assess prevalence and location of distal tumor spread and impact of neoadjuvant chemoradiotherapy (NACRT) in patients who underwent proctectomy for rectal cancer. METHODS The pathology database at our institution was queried for all patients who underwent proctectomy with curative intent for rectal cancer from 1/2008 to 12/2016. Specimen slides were re-evaluated by a single expert rectal cancer pathologist to verify diagnosis and measure the distance to the distal resection margin. Main outcome measures were 3-year overall and disease-free survival. RESULTS 275 consecutive patients were identified. 109/111 patients with clinical stage 3 disease received preoperative neoadjuvant chemoradiotherapy. DTS was found in 13 (4.7%) specimens, 6 with intra-mural and 7 with extra-mural distal tumor spread. DTS was found only in patients with clinical stage 3 disease. Length of DTS from the distal end of the tumor ranged from 0 to 30 mm; in only 4 specimens DTS was >10 mm. A positive distal resection margin was found in 5/275 (1.8%) specimens. CONCLUSION A macroscopically tumor-free margin may suffice in patients with pre-treatment stage 1 or 2 disease. Furthermore, a 1 cm margin is adequate in most patients with stage 3 disease.
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Affiliation(s)
- Shlomo Yellinek
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Weston, FL, USA
- Department of General Surgery, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Dimitri Krizzuk
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Weston, FL, USA
- Department of General and Minimally-Invasive surgery, Aurelia Hospital, Rome, Italy
| | - Hayim Gilshtein
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Weston, FL, USA
| | - Michael R Freund
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Weston, FL, USA
- Department of General Surgery, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Weston, FL, USA
| | - Mariana Berho
- Department of Pathology, Cleveland Clinic Florida, Weston, FL, USA
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Kim HJ, Choi GS, Song SH, Park JS, Park SY, Lee SM, Na DH, Jeong MH. Single-Port Robotic Intersphincteric Resection for the Treatment of Rectal Cancer. Surg Laparosc Endosc Percutan Tech 2023; 33:249-255. [PMID: 37172021 DOI: 10.1097/sle.0000000000001179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 03/20/2023] [Indexed: 05/14/2023]
Abstract
BACKGROUND The da Vinci Single-port (SP) system is designed to facilitate single-incision robotic surgery in a narrow space. We developed a new procedure of intersphincteric resection (ISR) using the SP platform and evaluated the technical safety and feasibility of this procedure for the treatment of very low rectal cancer. MATERIALS AND METHODS Eleven rectal cancer patients who underwent SP robotic ISR between August 2020 and July 2021 were included. Patients' clinical characteristics, operative and pathologic findings of the patients were retrospectively analyzed. RESULTS The median tumor height was 3 cm (range, 2-4 cm). A single docking was performed, and the median docking time was 3 min 10 sec (range, 2 min 50 sec-3 min 30 sec). The median total operation time was 210 min (range, 150-280 min), and the median time of pelvic dissection was 57 min (range, 45-68 min). All patients presented with negative distal resection margins [median 1 cm (range, 0.5-2.0 cm)], and only one patient had less than 1mm of circumferential resection margin (0.9 mm). CONCLUSIONS Our initial experience suggests that SP robotic ISR is safe and feasible.
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Affiliation(s)
- Hye Jin Kim
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
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Required distal mesorectal resection margin in partial mesorectal excision: a systematic review on distal mesorectal spread. Tech Coloproctol 2023; 27:11-21. [PMID: 36036328 PMCID: PMC9807492 DOI: 10.1007/s10151-022-02690-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 08/15/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND The required distal margin in partial mesorectal excision (PME) is controversial. The aim of this systematic review was to determine incidence and distance of distal mesorectal spread (DMS). METHODS A systematic search was performed using PubMed, Embase and Google Scholar databases. Articles eligible for inclusion were studies reporting on the presence of distal mesorectal spread in patients with rectal cancer who underwent radical resection. RESULTS Out of 2493 articles, 22 studies with a total of 1921 patients were included, of whom 340 underwent long-course neoadjuvant chemoradiotherapy (CRT). DMS was reported in 207 of 1921 (10.8%) specimens (1.2% in CRT group and 12.8% in non-CRT group), with specified distance of DMS relative to the tumor in 84 (40.6%) of the cases. Mean and median DMS were 20.2 and 20.0 mm, respectively. Distal margins of 40 mm and 30 mm would result in 10% and 32% residual tumor, respectively, which translates into 1% and 4% overall residual cancer risk given 11% incidence of DMS. The maximum reported DMS was 50 mm in 1 of 84 cases. In subgroup analysis, for T3, the mean DMS was 18.8 mm (range 8-40 mm) and 27.2 mm (range 10-40 mm) for T4 rectal cancer. CONCLUSIONS DMS occurred in 11% of cases, with a maximum of 50 mm in less than 1% of the DMS cases. For PME, substantial overtreatment is present if a distal margin of 5 cm is routinely utilized. Prospective studies evaluating more limited margins based on high-quality preoperative magnetic resonance imaging and pathological assessment are required.
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Lim S, Nagai Y, Nozawa H, Kawai K, Sasaki K, Murono K, Emoto S, Yokoyama Y, Ozawa T, Abe S, Anzai H, Sonoda H, Ishihara S. Surgical outcomes of robotic, laparoscopic, and open low anterior resection after preoperative chemoradiotherapy for patients with advanced lower rectal cancer. Surg Today 2023; 53:109-115. [PMID: 35794286 DOI: 10.1007/s00595-022-02537-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 05/12/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE We investigated the surgical outcomes of robotic low anterior resection (LAR) for lower rectal cancer after preoperative chemoradiotherapy (pCRT). METHODS A total of 175 patients with lower rectal cancer who underwent LAR after pCRT between 2005 and 2020 were stratified into open (OS, n = 65), laparoscopic (LS, n = 64), and robotic surgery (RS, n = 46) groups. We compared the clinical, surgical, and pathological results among the three groups. RESULTS The RS and LS groups had less blood loss than the OS group (p < 0.0001). The operating time in the RS group was longer than in the LS and OS groups (p < 0.0001). The RS group had a significantly longer mean distal margin than the LS and OS groups (25.4 mm vs. 20.7 mm and 20.3 mm, respectively; p = 0.026). There was no significant difference in the postoperative complication rate among the groups. The local recurrence rate in the RS group was comparable to those in the LS and OS groups. CONCLUSION Robotic LAR after pCRT was performed safely for patients with advanced lower rectal cancer. It provided a longer distal margin and equivalent local control rates.
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Affiliation(s)
- Sukchol Lim
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
| | - Yuzo Nagai
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Hiroaki Nozawa
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Kazushige Kawai
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Kazuhito Sasaki
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Koji Murono
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Shigenobu Emoto
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Yuichiro Yokoyama
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Tsuyoshi Ozawa
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Shinya Abe
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Hiroyuki Anzai
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Hirofumi Sonoda
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Soichiro Ishihara
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
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Measurement of distal intramural spread and the optimal distal resection by naked eyes after neoadjuvant radiation for rectal cancers. World J Surg Oncol 2022; 20:296. [PMID: 36104818 PMCID: PMC9472430 DOI: 10.1186/s12957-022-02756-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 08/19/2022] [Indexed: 11/30/2022] Open
Abstract
Background The safe distance between the intraoperative resection line and the visible margin of the distal rectal tumor after preoperative radiotherapy is unclear. We aimed to investigate the furthest tumor intramural spread distance in fresh tissue to determine a safe distal intraoperative resection margin length. Methods Twenty rectal cancer specimens were collected after preoperative radiotherapy. Tumor intramural spread distances were defined as the distance between the tumor’s visible and microscopic margins. Visible tumor margins in fresh specimens were identified during the operation and were labeled with 5 - 0 sutures under the naked eye at the distal 5, 6, and 7 o’clock directions of visible margins immediately after removal of the tumor. After fixation with formalin, the sutures were injected with nanocarbon particles. Longitudinal tissues were collected along three labels and stained with hematoxylin and eosin. The spread distance after formalin fixation was measured between the furthest intramural spread of tumor cells and the nanocarbon under a microscope. A positive intramural spread distance indicated that the furthest tumor cell was distal to the nanocarbon, and a negative value indicated that the tumor cell was proximal to the nanocarbon. The tumor intramural spread distance in fresh tissue during the operation was 1.75 times the tumor intramural spread distance after formalin fixation according to the literature. Results At the distal 5, 6, and 7 o’clock direction, seven (35%), five (25%), and six (30%) patients, respectively, had distal tumor cell intramural spread distance > 0 mm. The mean and 95% confidence interval of tumor cell intramural spread distance in fresh tissue during operation was − 0.3 (95%CI − 4.0 ~ 3.4) mm, − 0.9 (95%CI − 3.4 ~ 1.7) mm, and − 0.4 (95%CI − 3.5 ~ 2.8) mm, respectively. The maximal intraoperative intramural spread distances in fresh tissue were 8.8, 7, and 7 mm, respectively. Conclusions The intraoperative distance between the distal resection line and the visible margin of the rectal tumor after radiotherapy should not be less than 1 cm to ensure oncological safety.
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Ou W, Wu X, Zhuang J, Yang Y, Zhang Y, Liu X, Guan G. Clinical efficacy of different approaches for laparoscopic intersphincteric resection of low rectal cancer: a comparison study. World J Surg Oncol 2022; 20:43. [PMID: 35193605 PMCID: PMC8862381 DOI: 10.1186/s12957-022-02521-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 02/14/2022] [Indexed: 11/26/2022] Open
Abstract
Background The operative results of different approaches for the laparoscopic intersphincteric resection (LAISR) of low rectal cancer vary, and the patient characteristics associated with the best outcomes for each procedure have not been reported. We compared the efficacy of different approaches for LAISR of low rectal cancer and discussed the surgical indications for each approach. Methods We retrospectively reviewed data from 235 patients with low rectal cancer treated via LAISR from October 2010 to September 2016. Patients underwent either the transabdominal approach for ISR (TAISR, n = 142), the transabdominal perineal approach for ISR (TPAISR, n = 57), or the transanal pull-through approach for ISR (PAISR, n = 36). Results The PAISR and TAISR groups exhibited shorter operation times and less intraoperative blood loss than the TPAISR group. The anastomotic distance was shorter in the PAISR and TPAISR groups than in the TAISR group. No differences in the ability to perform radical resection, overall complications, postoperative recovery, Wexner score recorded 12 months after ostomy closure, 3-year disease-free survival, local recurrence-free survival, distant metastasis-free survival, or overall survival (OS) were observed among the three groups. Conclusions TAISR, TPAISR, and PAISR have unique advantages and do not differ in terms of operation safety, patient outcomes, or anal function. TPAISR requires a longer time to complete and is associated with more bleeding and a slower recovery of anal function. PAISR should be considered when TAISR cannot ensure a negative distal margin and the tumor and BMI are relatively small; otherwise, TPAISR is required.
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Affiliation(s)
- Wenquan Ou
- Department of General Surgery, Affiliated Nanping First Hospital, Fujian Medical University, 317 Zhongshan Road, Nanping, 353000, Fujian, China
| | - Xiaohua Wu
- Department of General Surgery, Affiliated Nanping First Hospital, Fujian Medical University, 317 Zhongshan Road, Nanping, 353000, Fujian, China
| | - Jinfu Zhuang
- Department of Colorectal Surgery, Affiliated First Hospital, Fujian Medical University, 20 Chazhong Road, Fuzhou, 350005, Fujian, China
| | - Yuanfeng Yang
- Department of Colorectal Surgery, Affiliated First Hospital, Fujian Medical University, 20 Chazhong Road, Fuzhou, 350005, Fujian, China
| | - Yiyi Zhang
- Department of Colorectal Surgery, Affiliated First Hospital, Fujian Medical University, 20 Chazhong Road, Fuzhou, 350005, Fujian, China
| | - Xing Liu
- Department of Colorectal Surgery, Affiliated First Hospital, Fujian Medical University, 20 Chazhong Road, Fuzhou, 350005, Fujian, China. .,Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fujian Medical University, 29 Xinquan Road, Fuzhou, 350001, Fujian, China.
| | - Guoxian Guan
- Department of Colorectal Surgery, Affiliated First Hospital, Fujian Medical University, 20 Chazhong Road, Fuzhou, 350005, Fujian, China. .,Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fujian Medical University, 29 Xinquan Road, Fuzhou, 350001, Fujian, China.
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Wlodarczyk JR, Lee SW. New Frontiers in Management of Early and Advanced Rectal Cancer. Cancers (Basel) 2022; 14:938. [PMID: 35205685 PMCID: PMC8870151 DOI: 10.3390/cancers14040938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 01/29/2022] [Accepted: 02/08/2022] [Indexed: 02/04/2023] Open
Abstract
It is important to understand advances in treatment options for rectal cancer. We attempt to highlight advances in rectal cancer treatment in the form of a systematic review. Early-stage rectal cancer focuses on minimally invasive endoluminal surgery, with importance placed on patient selection as the driving factor for improved outcomes. To achieve a complete pathologic response, various neoadjuvant chemoradiation regimens have been employed. Short-course radiation therapy, total neoadjuvant chemotherapy, and others provide unique advantages with select patient populations best suited for each. With a clinical complete response, a "watch and wait" non-operative surveillance has been introduced with preliminary equivalency to radical resection. Various modalities for total mesorectal excision, such as robotic or transanal, have advantages and can be utilized in select patient populations. Tumors demonstrating solid organ or peritoneal spread, traditionally defined as unresectable lesions conveying a terminal diagnosis, have recently undergone advances in hepatic and pulmonary metastasectomy. Hepatic and pulmonary metastasectomy has demonstrated clear advantages in 5-year survival over standard chemotherapy. With the peritoneal spread of colorectal cancer, HIPEC with cytoreductive therapy has emerged as the preferred treatment. Understanding the various therapeutic interventions will pave the way for improved patient outcomes.
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Affiliation(s)
| | - Sang W. Lee
- Division of Colorectal Surgery, Norris Cancer Center, Keck School of Medicine, University of Southern California, 1441 Eastlake Avenue, Suite NTT-7418, Los Angeles, CA 90033, USA;
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Zuhan A, Riwanto I, Listiana DE, Djannah F, Rosyidi RM. The extent of distal intramural spread of colorectal cancer cell study of it's relationship with histological grading, stage of disease and CEA level. Ann Med Surg (Lond) 2021; 64:102227. [PMID: 33850625 PMCID: PMC8039827 DOI: 10.1016/j.amsu.2021.102227] [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: 02/12/2021] [Revised: 03/10/2021] [Accepted: 03/10/2021] [Indexed: 12/07/2022] Open
Abstract
BACKGROUND The free margin of distal resection is an attempt to prevent local recurrence of the tumor and prolong survival. The recommended length of distal resection margin are varied among the researchers. This study was done to know the correlation between extents of distal intramural spread (DIS) and histology grading, stage and CEA levels of colorectal cancer. METHODS The design of the study was a cross sectional. Sample was patients diagnosed with colon or rectal adenocarcinoma in the period of September 2017-March 2018 and underwent resection at Dr.Kariadi Hospital. Resected fresh tissue tumors were directly measured for the distal resection margin and histopathologic examination done by anatomical pathologists. This study has been approved by the ethics committee of Dr.Kariadi Hospital/Faculty of Medicine Diponegoro University. The relationship between DIS length to histology grading, tumor stage and CEA level were analyzed using Spearman's correlation test. RESULTS The subjects of this study were 26 patients with colorectal cancer consisted of 15 men and 11 women. The average age of the patients was 53,04 years. The locations of the tumor were 17 in the rectum and 9 in the colon. The length DIS were between 1,07 and 11,49 mm. The longer DIS were occurred when the grading histology worsens, the tumor stage increases and the higher CEA levels with correlation coefficient were r = 0,77 (p < 0,001); r = 0,66 (p < 0,001) and r = 0,44 (p = 0,024) respectively. For the rectal location, the DIS length range were 0,28-10,36 mm. The longer DIS when grading histology worsens r = 0,59 (p = 0,012) and an increased tumor stage r = 0,73 (p = 0,001). The DIS length of the rectum was not proven to correlate with elevated CEA levels r = 0,14 (p = 0,588). CONCLUSION Histological grading, tumor stage and CEA levels can be predictors of distal intramural spread (DIS) colorectal cancer. The strongest correlation were between DIS and histologic grading. Thus, in mid and lower third of the rectal cancer, the histologic grade examination is strongly recommended. Based on this study, it is recommended that in rectal cancer undergoing sphincter preserving surgery distal resection sould be more than 2 cm from the tumor margin.
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Affiliation(s)
- Arif Zuhan
- Digestive Surgery Subdivision, Department of Surgery Medical Faculty of Mataram University, West Nusa Tenggara General Hospital, Mataram, Indonesia
| | - Ignatius Riwanto
- Department of Digestive Surgery, Faculty of Medicine, Diponegoro University/Dr.Kariadi General Hospital, Indonesia
| | - Devia Eka Listiana
- Department of Anatomical Pathology, Faculty of Medicine, Diponegoro University/Dr.Kariadi General Hospital, Indonesia
| | - Fathul Djannah
- Department of Anatomical Pathology, Medical Faculty of Mataram University, Mataram, Indonesia
| | - Rohadi Muhammad Rosyidi
- Department of Neurosurgery Medical Faculty of Mataram University, West Nusa Tenggara General Hospital, Mataram, Indonesia
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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Rectal Cancer. Dis Colon Rectum 2020; 63:1191-1222. [PMID: 33216491 DOI: 10.1097/dcr.0000000000001762] [Citation(s) in RCA: 152] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Ozawa H, Kotake K, Ike H, Sugihara K. Prognostic Impact of the Length of the Distal Resection Margin in Rectosigmoid Cancer: An Analysis of the JSCCR Database between 1995 and 2004. JOURNAL OF THE ANUS RECTUM AND COLON 2020; 4:59-66. [PMID: 32346644 PMCID: PMC7186012 DOI: 10.23922/jarc.2019-013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 01/16/2020] [Indexed: 11/30/2022]
Abstract
Objectives The necessary and sufficient length of the distal resection margin (l-DRM) for rectosigmoid cancer remains controversial. This study evaluated the validity of the 3-cm l-DRM rule for rectosigmoid cancer in the Japanese classification of colorectal cancer. Methods We retrospectively reviewed 1,443 patients with cT3 and cT4 rectosigmoid cancer who underwent R0 resection in Japanese institutions between 1995 and 2004. We identified the optimal cutoff point of the l-DRM affecting overall survival (OS) rate using a multivariate Cox regression analysis model. Using this cutoff point, the patients were divided into two groups after balancing the potential confounding factors of the l-DRM using propensity score matching, and the OS rates of the two groups were compared. Results A multivariate Cox regression analysis model revealed that the l-DRM of 4 cm was the best cutoff point with the greatest impact on OS rate (hazard ratio [HR], 1.37; 95% confidence interval [CI], 1.00-1.84; P = 0.0452) and with the lowest Akaike information criterion value. In the matched cohort study, the OS rate of patients who had l-DRM of 4 cm or more was significantly higher than that of patients who had l-DRM < 4 cm (n = 402; 5-year OS rates, 87.6% vs. 80.3%, respectively; HR, 1.60; 95% CI, 1.09-2.31; P = 0.0136). Conclusions For cT3 and cT4 rectosigmoid cancer, l-DRM of 4 cm may be an appropriate landmark for a curative intent surgery, and we were unable to definitively confirm the validity of the Japanese 3-cm l-DRM rule.
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Affiliation(s)
- Heita Ozawa
- Department of Surgery, Tochigi Cancer Center, Utsunomiya, Japan
| | - Kenjiro Kotake
- Department of Gastroenterological Surgery, Sano City Hospital, Sano, Japan
| | - Hideyuki Ike
- Department of Surgery, Yokohama Hodogaya Central Hospital, Yokohama, Japan
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Manegold P, Taukert J, Neeff H, Fichtner-Feigl S, Thomusch O. The minimum distal resection margin in rectal cancer surgery and its impact on local recurrence - A retrospective cohort analysis. Int J Surg 2019; 69:77-83. [DOI: 10.1016/j.ijsu.2019.07.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 07/09/2019] [Accepted: 07/21/2019] [Indexed: 12/19/2022]
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Sato H, Shiota M, Okabe A, Tsukamoto T, Honda K, Morise Z, Uyama I. Rectal cancer with extensive distal intramural spread treated by abdominoperineal resection. Int Cancer Conf J 2019; 9:9-13. [PMID: 31950010 DOI: 10.1007/s13691-019-00385-3] [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] [Received: 06/07/2019] [Accepted: 07/30/2019] [Indexed: 10/26/2022] Open
Abstract
Distal intramural spread refers to microscopic tumor implantation in the intestinal wall, distal to the inferior edge of a macroscopic tumor but rarely beyond 2 cm. We report a case of rectal cancer with preoperatively diagnosed distant intramural spread to approximately 6.5 cm. A 75-year-old woman diagnosed with upper rectal cancer was scheduled to undergo low anterior resection 5 weeks after initial presentation. However, preoperative digital rectal examination and anoscopy under general anesthesia revealed a rectal tumor 4 cm proximal to the anal verge; adenocarcinoma was diagnosed based on frozen section analysis of the rectal tumor. Therefore, abdominoperineal resection was performed, and histopathological examination confirmed a moderately differentiated adenocarcinoma with distal intramural spread of 6.5 cm. The patient died 18 months postoperatively owing to lung metastasis. Although distal intramural spread is rare and can be difficult to detect prior to surgery, repeated rectal examination, with prompt histological examination of suspicious lesions, can ensure earlier diagnosis to achieve better local control by radical surgery including sufficient distal margin.
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Affiliation(s)
- Harunobu Sato
- 1Department of Surgery, School of Medicine, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, 470-1192 Aichi Japan
| | - Miho Shiota
- 1Department of Surgery, School of Medicine, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, 470-1192 Aichi Japan
| | - Asako Okabe
- 2Department of Pathology, School of Medicine, Fujita Health University, Toyoake, Japan
| | - Tetsuya Tsukamoto
- 2Department of Pathology, School of Medicine, Fujita Health University, Toyoake, Japan
| | | | - Zenichi Morise
- 1Department of Surgery, School of Medicine, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, 470-1192 Aichi Japan
| | - Ichiro Uyama
- 1Department of Surgery, School of Medicine, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, 470-1192 Aichi Japan
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15
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Bogner A, Kirchberg J, Weitz J, Fritzmann J. State of the Art - Rectal Cancer Surgery. Visc Med 2019; 35:252-258. [PMID: 31602388 DOI: 10.1159/000501133] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 05/22/2019] [Indexed: 12/24/2022] Open
Abstract
Background In an aging society, the incidence and relevance of rectal cancer as one of the most frequent gastrointestinal cancers gains in importance. Excellent surgery and up-to-date multimodal treatments are essential for adequate oncological results and good quality of life. Summary In this review, we describe modern developments in rectal cancer surgery and its embedment in modern multimodal therapy concepts. Key Message Distinguished interdisciplinary cooperation combined with an outstanding surgical expertise is the basic requirement for an optimal treatment of rectal cancer. Thus, high standards of oncological outcome and patient's quality of life can be achieved.
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Affiliation(s)
- Andreas Bogner
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Johanna Kirchberg
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Jürgen Weitz
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Johannes Fritzmann
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
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16
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Pradhan T, Padmanabhan K, Prasad M, Chandramohan K, Nair SA. Augmented CD133 expression in distal margin correlates with poor prognosis in colorectal cancer. J Cell Mol Med 2019; 23:3984-3994. [PMID: 30950180 PMCID: PMC6533563 DOI: 10.1111/jcmm.14284] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 02/08/2019] [Accepted: 02/24/2019] [Indexed: 12/13/2022] Open
Abstract
Pathological assessment of excised tumour and surgical margins in colorectal cancer (CRC) play crucial role in prognosis after surgery. Molecular assessment of margins could be more sensitive and informative than conventional histopathological analysis. Considering this view, we evaluated the distal surgical margins for expression of cancer stem cell (CSC) markers. Cellular and molecular assessment of normal, tumour and distal margin tissues were performed by flow cytometry, real-time q-PCR and immuno-histochemical analysis for CRC patients after tumour excision. CRC patients were evaluated for expression of CSC markers in their normal, tumour and distal tissues. Flow cytometry assay revealed CD133 and CD44 enriched cells in distal margin and tumour compared to normal colorectal tissues, which was further confirmed by immunohistochemistry. Most importantly, immunohistochemistry also revealed the enrichment of CSC markers expression in pathologically negative distal margins. Patients with distal margin enriched for CD133 expression showed an increased recurrence rate and decreased disease-free survival. This study proposes that although distal margin seems to be tumour free in conventional histopathological analysis, it could harbour cells enriched for CSC markers. Further CD133 could be a promising molecule to be used in molecular pathology for disease prognosis after surgery in CRC patients.
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Affiliation(s)
- Tapas Pradhan
- Cancer Research Program 4, Rajiv Gandhi Centre for Biotechnology, Trivandrum, Kerala, India
| | | | - Manu Prasad
- Cancer Research Program 4, Rajiv Gandhi Centre for Biotechnology, Trivandrum, Kerala, India
| | - K Chandramohan
- Department of surgical oncology, Regional Cancer Centre, Trivandrum, Kerala, India
| | - S Asha Nair
- Cancer Research Program 4, Rajiv Gandhi Centre for Biotechnology, Trivandrum, Kerala, India
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Socha J, Pietrzak L, Zawadzka A, Paciorkiewicz A, Krupa A, Bujko K. A systematic review and meta-analysis of pT2 rectal cancer spread and recurrence pattern: Implications for target design in radiation therapy for organ preservation. Radiother Oncol 2019; 133:20-27. [PMID: 30935577 DOI: 10.1016/j.radonc.2018.12.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 12/20/2018] [Accepted: 12/21/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND There are no guidelines on clinical target volume (CTV) delineation for cT2 rectal cancer treated with organ preservation. MATERIALS AND METHODS A systematic review and meta-analysis were performed to determine the extent of distal mesorectal (DMS) and distal intramural spread (DIS), the risk of lateral lymph node (LLN) metastases in pT2 tumours, and regional recurrence pattern after organ preservation. RESULTS The rate of DMS > 1 cm was 1.9% (95% CI: 0.4-5.4%), maximum extent: 1.3 cm. The rate of DIS > 0.5 cm was 4.7% (95% CI: 1.3-11.5%), maximum extent: 0.8 cm. The rate of LLN metastases was 8.2% (95% CI: 6.7-9.9%) for tumours below or at peritoneal reflexion and 0% for higher tumours. Regional nodal recurrences alone were recorded in 1.0% (95% CI: 0.5-1.7%) of patients after watch-and-wait and in 2.1% (95% CI: 1.2-3.4%) after preoperative radiotherapy and local excision. Thus, the following rules for CTV delineation are proposed: caudal border 1.5 cm from the tumour to account for DMS or 1 cm to account for DIS, whichever is more caudal; cranial border at S2/S3 interspace; inclusion of LLN for tumours at or below peritoneal reflexion. A planning study was performed in eight patients to compare dose-volume parameters obtained using these rules to that obtained using current guidelines for advanced cancers. The proposed rules led to a mean 18% relative reduction of planning target volume, which resulted in better sparing of organs-at-risk. CONCLUSION This meta-analysis suggests a smaller CTV for cT2 tumours than the current guidelines designed for advanced cancers.
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Affiliation(s)
- Joanna Socha
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland; Department of Radiotherapy, Regional Oncology Center, Czestochowa, Poland.
| | - Lucyna Pietrzak
- Department of Radiotherapy I, Maria Skłodowska-Curie Memorial Cancer Centre, Warsaw, Poland
| | - Anna Zawadzka
- Medical Physics Department, Maria Skłodowska-Curie Memorial Cancer Centre, Warsaw, Poland
| | - Anna Paciorkiewicz
- Medical Physics Department, Maria Skłodowska-Curie Memorial Cancer Centre, Warsaw, Poland
| | - Anna Krupa
- Department of Radiotherapy I, Maria Skłodowska-Curie Memorial Cancer Centre, Warsaw, Poland
| | - Krzysztof Bujko
- Department of Radiotherapy I, Maria Skłodowska-Curie Memorial Cancer Centre, Warsaw, Poland
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18
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Kondo A, Tsukada Y, Kojima M, Nishizawa Y, Sasaki T, Suzuki Y, Ito M. Effect of preoperative chemotherapy on distal spread of low rectal cancer located close to the anus. Int J Colorectal Dis 2018; 33:1685-1693. [PMID: 30215109 DOI: 10.1007/s00384-018-3159-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE This study aimed to clarify the frequency of distal spread and the optimal distal margin after preoperative chemotherapy for advanced low rectal cancer. METHODS The study included patients with advanced lower rectal cancer who received preoperative chemotherapy and underwent surgery during 2012-2015. We investigated the distal spread of tumor cells, defined as the distal distance from the intramucosal distal tumor edge to the farthest tumor cells located under the submucosal layer. Clinical characteristics were compared for distal spreads ≥ 10 and < 10 mm, and risk factors for distal spread ≥ 10 mm were investigated. RESULTS Of the 71 patients, 42 (59%) showed distal spread. Distal spreads of 1-9, 10-19, and ≥ 20 mm were observed in 27 (38%), 11 (15%), and 4 (6%) patients, respectively. Multivariate analysis revealed two independent risk factors for distal spread ≥ 10 mm after preoperative chemotherapy. The first risk factor is the presence of different therapeutic effects between the mucosal and deeper layers (meaning that superficial tumor shrinkage was evident on colonoscopy, but little tumor shrinkage was evident on magnetic resonance imaging) (odds ratio, 11.6; 95% CI, 2.22-61.3). The second risk factor is poorly differentiated or mucinous adenocarcinoma (odds ratio, 8.86; 95% CI, 1.58-49.9). CONCLUSION A distal margin of 20 mm is required (10 mm is insufficient) for advanced lower rectal cancer patients who receive preoperative chemotherapy followed by surgery. Independent risk factors for distal spread ≥ 10 mm include (1) the presence of different therapeutic effects between mucosal and deeper layers and (2) poorly differentiated or mucinous adenocarcinomas.
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Affiliation(s)
- Akihiro Kondo
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa-shi, Chiba, 277-8577, Japan
| | - Yuichiro Tsukada
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa-shi, Chiba, 277-8577, Japan
| | - Motohiro Kojima
- Division of Pathology, Exploratory Oncology Research and Clinical Trial Center, National Cancer Center, 6-5-1, Kashiwanoha, Kashiwa-shi, Chiba, 277-8577, Japan
| | - Yuji Nishizawa
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa-shi, Chiba, 277-8577, Japan
| | - Takeshi Sasaki
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa-shi, Chiba, 277-8577, Japan
| | - Yasuyuki Suzuki
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Masaaki Ito
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa-shi, Chiba, 277-8577, Japan.
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19
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Park IJ, Kim JC. Intersphincteric Resection for Patients With Low-Lying Rectal Cancer: Oncological and Functional Outcomes. Ann Coloproctol 2018; 34:167-174. [PMID: 30208679 PMCID: PMC6140365 DOI: 10.3393/ac.2018.08.02] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 08/02/2018] [Indexed: 12/12/2022] Open
Abstract
The aim of this review is to evaluate the outcomes after an intersphincteric resection (ISR) for patients with low-lying rectal cancer. Reports published in the literature regarding surgical, oncological, and functional outcomes of an ISR were reviewed. The morbidity after an ISR was 7.7%–32%, and anastomotic leakage was the most common adverse event. Local recurrence rates ranged from 0% to 12%, 5-year overall survival rates ranged from 62% to 92%, and rates of major incontinence ranged from 0% to 25.8% after an ISR. An ISR is a safe procedure for sphincter-saving rectal surgery in patients with very low rectal cancer; it does not compromise the oncological outcomes of the resection and is a valuable alternative to an abdominoperineal resection. While the functional outcomes after an ISR were found to be acceptable, the long-term functional outcome and quality of life still require careful investigation. ISRs have been performed with surgical and oncologic safety on patients with low-lying rectal cancer. However, patients must be selected very carefully for an ISR, considering the associated functional derangement and the limited extent of the resection.
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Affiliation(s)
- In Ja Park
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Cheon Kim
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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20
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The Future of Rectal Cancer Surgery: A Narrative Review of an International Symposium. Surg Innov 2018; 25:525-535. [DOI: 10.1177/1553350618781227] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Surgery remains the mainstay of curative treatment for primary rectal cancer. For mid and low rectal tumors, optimal oncologic surgery requires total mesorectal excision (TME) to ensure the tumor and locoregional lymph nodes are removed. Adequacy of surgery is directly linked to survival outcomes and, in particular, local recurrence. From a technical perspective, the more distal the tumor, the more challenging the surgery and consequently, the risk for oncologically incomplete surgery is higher. TME can be performed by an open, laparoscopic, robotic or transanal approach. There is a lack of consensus on the “gold standard” approach with each of these options offering specific advantages. The International Symposium on the Future of Rectal Cancer Surgery was convened to discuss the current challenges and future pathways of the 4 approaches for TME. This article reviews the findings and discussion from an expert, international panel.
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21
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A Distal Resection Margin of ≤1 mm and Rectal Cancer Recurrence After Sphincter-Preserving Surgery: The Role of a Positive Distal Margin in Rectal Cancer Surgery. Dis Colon Rectum 2017; 60:1175-1183. [PMID: 28991082 DOI: 10.1097/dcr.0000000000000900] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND There is little information about the prognostic value of a microscopically positive distal margin in patients who have rectal cancer. OBJECTIVE We aimed to investigate the influence of a distal margin of ≤1 mm on oncologic outcomes after sphincter-preserving resection for rectal cancer. DESIGN This is a retrospective cohort study. SETTINGS The study was conducted at 2 hospitals. PATIENTS A total of 6574 patients underwent anterior resection for rectal cancer from January 1999 to December 2014; 97 (1.5%) patients with a distal margin of ≤1 mm were included in this study. For comparative analyses, patients were matched with 194 patients with a negative distal margin (>1 mm) according to sex, age, BMI, ASA score, neoadjuvant treatment, tumor location, and stage. MAIN OUTCOME MEASURES The oncologic outcomes of the 2 groups were compared. RESULTS Perineural and lymphovascular invasion rates were significantly higher in patients with a positive distal margin (54.6% vs 28.9%; 67.0% vs 42.8%; both p < 0.001) compared with to patients with negative distal margin. Comparison between microscopically positive and negative distal margin showed worse oncologic outcomes in patients with a microscopically positive distal margin, including 5-year local recurrence rate (24.1% vs 12.0%, p = 0.005); 5-year distant recurrence rate (35.5% vs 20.2%, p = 0.011); 5-year disease-free survival (45.5% vs 69.5%, p < 0.001); and 5-year OS (69.2% vs 79.7%, p = 0.004). Among the 97 patients with a microscopically positive distal margin, the 5-year disease-free survival rate was higher in patients who received adjuvant therapy (52.0% vs 30.7%, p = 0.089). LIMITATIONS This is a retrospective study; bias may exist. CONCLUSIONS A distal margin of 1 mm is associated with worse oncologic results. Our data indicate the importance of achieving a clear distal margin in the surgical treatment of rectal cancer. Adjuvant therapy should be used in these patients to reduce recurrence. See Video Abstract at http://links.lww.com/DCR/A408.
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22
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Zhu HB, Wang L, Li ZY, Li XT, Zhang XY, Sun YS. Sphincter-preserving surgery for low-middle rectal cancer: Can we predict feasibility with high-resolution magnetic resonance imaging? Medicine (Baltimore) 2017; 96:e7418. [PMID: 28723750 PMCID: PMC5521890 DOI: 10.1097/md.0000000000007418] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The study proposed to evaluate the feasibility of predicting sphincter-sparing surgery (SSS) preoperatively in low-middle rectal cancer by using magnetic resonance (MR).The study included both retrospective and prospective design. In the retrospective design, the distance from lower edge of tumor to upper margin of the internal sphincter (Dis1) and distance to anal verge (Dis2) were measured on MR, the distance to anal verge recorded by colonoscopy (Dis3) and digital rectal examination (Dis4) were also obtained. ROC analysis was conducted and cut-off value was determined with overall and stratified analysis. The prospective part was designed to validate the predictive capability of the optimal distance.The retrospective design included 278 patients with middle or lower rectal adenocarcinoma, the prospective design included 106 patients with neoadjuvant therapies. The primary outcome was the actual surgical method and pathological distal resection margin. Dis1 obtained from MRI presented better performance than other distances in determining the surgical approach, with AUC of 0.997 (95% CI, 0.934-1.000). Dis1 was selected as the optimal distance and a cut-off value of 2 cm was determined. Dis1 and the cut-off value were also validated in the prospective sample, with AUC of 0.996 (95% CI, 0.989-1.000) and an overall accuracy of 99.1%.MR-based distance from lower edge of tumor to upper margin of the internal sphincter could be used to help the surgeons to predict the feasibility of SSS preoperatively.
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Affiliation(s)
- Hai-Bin Zhu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Radiology
| | - Lin Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Colorectal Surgery
| | - Zi-Yu Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery, Peking University Cancer Hospital & Institute, Hai Dian District, Beijing, China
| | - Xiao-Ting Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Radiology
| | - Xiao-Yan Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Radiology
| | - Ying-Shi Sun
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Radiology
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23
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Ono K, Murakami M, Watanabe M, Fujimori A, Otsuka K, Aoki T, Yamochi-Onizuka T, Takimoto M. Rare Case of Cecal Signet Ring Cell Carcinoma with Distal Intramural Spread. ACTA ACUST UNITED AC 2017; 31:705-708. [PMID: 28652443 DOI: 10.21873/invivo.11117] [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: 04/13/2017] [Revised: 04/27/2017] [Accepted: 04/28/2017] [Indexed: 11/10/2022]
Abstract
In this paper, we report a rare case of cecal Signet ring cell carcinoma (SRCC) with Distal intramural spread (DIS) along with a review of the literature. A 71-year-old woman suffering from vomiting, abdominal pain, and abdominal distension was admitted to a hospital and was suspected to have ileus. She was transferred to our hospital and diagnosed with cecal cancer with intestinal obstruction. Laparotomy was performed, after which she was diagnosed with cecal SRCC by histopathological examination. A submucosal lesion was located 55 mm from the distal side of the main tumor. This lesion was also diagnosed as SRCC. It was not exposed to the epithelium or the serous membrane. The submucosal tumor was diagnosed as DIS of cecal SRCC. After the operation, she underwent chemotherapy with FOLFIRI+Cet (5-fluorouracil, leucovorin, and irinotecan plus cetuximab). At a follow-up examination nine months after surgery, she was found to be doing well.
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Affiliation(s)
- Kohei Ono
- Department of Gastroenterological & General Surgery, School of Medicine, Showa University, Tokyo, Japan
| | - Masahiko Murakami
- Department of Gastroenterological & General Surgery, School of Medicine, Showa University, Tokyo, Japan
| | - Makoto Watanabe
- Department of Gastroenterological & General Surgery, School of Medicine, Showa University, Tokyo, Japan
| | - Akira Fujimori
- Department of Gastroenterological & General Surgery, School of Medicine, Showa University, Tokyo, Japan
| | - Koji Otsuka
- Department of Gastroenterological & General Surgery, School of Medicine, Showa University, Tokyo, Japan
| | - Takeshi Aoki
- Department of Gastroenterological & General Surgery, School of Medicine, Showa University, Tokyo, Japan
| | | | - Masafumi Takimoto
- Department of Pathology, School of Medicine, Showa University, Tokyo, Japan
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24
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Shirouzu K, Murakami N, Akagi Y. Intersphincteric resection for very low rectal cancer: A review of the updated literature. Ann Gastroenterol Surg 2017; 1:24-32. [PMID: 29863144 PMCID: PMC5881339 DOI: 10.1002/ags3.12003] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 02/16/2017] [Indexed: 12/15/2022] Open
Abstract
Intersphincteric resection (ISR) has rapidly increased worldwide including laparoscopic surgery. However, there are some concerns for the definition of ISR, surgical technique, oncological outcome, anal function, and quality of life (QoL). The aim of the present study is to evaluate those issues. A review of this surgical technique was carried out by searching English language literature of the PubMed online database and appropriate articles were identified. With regard to open‐ISR, the morbidity rate ranged from 7.5% to 38.3%, with lower mortality rates. Local recurrence rates varied widely from 0% to 22.7%, with a mean follow‐up duration of 40–94 months. Disease‐free and overall 5‐year survival rates were 68–86% and 76–97%, respectively. Those outcomes were equivalent to laparoscopic‐ISR. Surgical and oncological outcomes of ISR were generally acceptable. However, accurate evaluation of anal function and QoL was difficult because of a lack of standard assessment of various patient‐related factors. The surgical and oncological outcomes after ISR seem to be acceptable. The ISR technique seems to be valid as an alternative to abdominoperineal resection in selected patients with a very low rectal cancer. However, both necessity for ISR and expectations of QoL impairment as a result of functional disorder should be fully discussed with patients before surgery.
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Affiliation(s)
- Kazuo Shirouzu
- Department of Gastrointestinal Surgery Japan Community Health care Organization Kurume General Hospital Kurume Japan
| | - Naotaka Murakami
- Department of Gastrointestinal Surgery Japan Community Health care Organization Kurume General Hospital Kurume Japan
| | - Yoshito Akagi
- Department of Surgery Kurume University Faculty of Medicine Kurume Japan
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25
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Mukkai Krishnamurty D, Wise PE. Importance of surgical margins in rectal cancer. J Surg Oncol 2016; 113:323-32. [DOI: 10.1002/jso.24136] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 11/18/2015] [Indexed: 12/14/2022]
Affiliation(s)
- Devi Mukkai Krishnamurty
- Section of Colon and Rectal Surgery; Washington University School of Medicine in St. Louis; St. Louis Missouri
| | - Paul E. Wise
- Section of Colon and Rectal Surgery; Washington University School of Medicine in St. Louis; St. Louis Missouri
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26
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Toda K, Kawada K, Hasegawa S, Yamada M, Kawamura J, Sakai Y. Intramural metastasis of T1 rectal cancer: report of a case report. World J Surg Oncol 2015; 13:337. [PMID: 26671688 PMCID: PMC4681015 DOI: 10.1186/s12957-015-0749-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 12/09/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intramural metastasis (IM) is extremely rare in colorectal cancer, although it often occurred in esophageal cancer. CASE PRESENTATION We report a rare case of T1 rectal cancer with IM which was successfully resected by laparoscopic surgery. A 62-year-old man was admitted to our institution for the treatment of rectal cancer detected by medical examination. Colonoscopy revealed two tumors in the rectum: a type II rectal cancer of 2 cm in diameter located 5 cm proximal to the anal verge and a submucosal tumor of 1 cm in diameter located approximately 1.5 cm proximal to the rectal cancer. Abdominal computed tomography (CT), magnetic resonance imaging (MRI), and transrectal ultrasonography indicated the rectal cancer invaded into the submucosal layer with no metastasis to regional lymph nodes or distant organs. The patient underwent laparoscopic intersphincteric resection.Histopathological analysis revealed that the rectal cancer was moderately differentiated adenocarcinoma (stage I; pT1N0M0 according to the 7th edition of UICC) with severe lymphovascular invasion (ly1, v3) and that the submucosal tumor was composed of moderately differentiated adenocarcinoma proliferating within the muscularis propria. A number of features of the submucosal tumor indicated that this was an IM of the rectal cancer: clearly distinct location from the rectal cancer, growth predominantly within the muscularis propria, similar structural and cellular heterogeneity, and the presence of tumor emboli within vascular vessels. The patient was postoperatively followed for more than 4 years without any sign of recurrence. CONCLUSIONS To the best of our knowledge, this is the first report of the T1 rectal cancer with IM.
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Affiliation(s)
- Kosuke Toda
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin- Kawara-cho, Sakyo-ku, 606-8507, Kyoto, Japan
| | - Kenji Kawada
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin- Kawara-cho, Sakyo-ku, 606-8507, Kyoto, Japan.
| | - Suguru Hasegawa
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin- Kawara-cho, Sakyo-ku, 606-8507, Kyoto, Japan
| | - Masahiro Yamada
- Department of Surgery, Shiga Medical Center for Adults, Moriyama, Japan
| | - Junichiro Kawamura
- Department of Surgery, Faculty of Medicine, Kinki University, Osaka Sayama, Japan
| | - Yoshiharu Sakai
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin- Kawara-cho, Sakyo-ku, 606-8507, Kyoto, Japan
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27
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Role of intraoperative frozen section for assessing distal resection margin after anterior resection. Int J Colorectal Dis 2015; 30:1081-9. [PMID: 25982468 DOI: 10.1007/s00384-015-2244-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/08/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS The use of neoadjuvant long-course chemoradiotherapy (LCRT), shorter distal safety margins (DSMs) and stapled or intersphincteric resections has increased sphincter preservation rates. While intraoperative frozen section (IOFS) is not mandatory, it helps achieve negative distal resection margins (DRMs). Our aim was to audit the role of IOFS for DRM assessment while performing sphincter-saving rectal surgery and to identify those subgroups that would benefit the most from IOFS analysis. METHODS Patients who underwent rectal cancer surgery between 2009 and 2013 were identified from a prospectively maintained database. Patients who intraoperatively underwent an IOFS for DRM assessment were included in the study. Factors associated with a positive margin on IOFS were analysed. The sensitivity and specificity of IOFS were also assessed. RESULTS Of 250 patients, who had an anterior resection with an IOFS, 12 had an involved DRM. Of these patients, eight were involved by adenocarcinoma, two by acellular mucin, one by moderate dysplasia and one by adenoma confirmed on paraffin section. Positive margins had a 100 % intervention rate. There were two false negative on IOFS. IOFS had a sensitivity of 85.17 % with a specificity of 100 % and a negative predictive value of 99.16 %. Specimens with a positive IOFS were lower rectal (P < 0.05), poorly differentiated and post LCRT locally advanced tumours. CONCLUSIONS IOFS to confirm negative DRM is recommended in lower rectal tumours irrespective of DSM. It can be considered for locally advanced post LCRT poorly differentiated mid rectal tumours and avoided for upper rectal tumours.
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Abstract
The two goals of surgery for lower rectal cancer surgery are to obtain clear "curative" margins and to limit post-surgical functional disorders. The question of whether or not to preserve the anal sphincter lies at the center of the therapeutic choice. Histologically, tumor-free distal and circumferential margins of>1mm allow a favorable oncologic outcome. Whether such margins can be obtained depends of TNM staging, tumor location, response to chemoradiotherapy and type of surgical procedure. The technique of intersphincteric resection relies on these narrow margins to spare the sphincter. This procedure provides satisfactory oncologic outcome with a rate of circumferential margin involvement ranging from 5% to 11%, while good continence is maintained in half of the patients. The extralevator abdominoperineal resection provides good oncologic results, however this procedure requires a permanent colostomy. A permanent colostomy alters several domains of quality of life when located at the classical abdominal site but not when brought out at the perineal site as a perineal colostomy.
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Affiliation(s)
- F Dumont
- Départment de chirurgie oncologique, institut Gustave-Roussy, 114, rue Edouard-Vaillant, 94805 Villejuif cedex, France.
| | - A Mariani
- Départment de chirurgie oncologique, institut Gustave-Roussy, 114, rue Edouard-Vaillant, 94805 Villejuif cedex, France
| | - D Elias
- Départment de chirurgie oncologique, institut Gustave-Roussy, 114, rue Edouard-Vaillant, 94805 Villejuif cedex, France
| | - D Goéré
- Départment de chirurgie oncologique, institut Gustave-Roussy, 114, rue Edouard-Vaillant, 94805 Villejuif cedex, France
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Hida JI, Okuno K, Tokoro T. Distal dissection in total mesorectal excision, and preoperative chemoradiotherapy and lateral lymph node dissection for rectal cancer. Surg Today 2013; 44:2227-42. [PMID: 24363114 DOI: 10.1007/s00595-013-0811-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Accepted: 11/05/2013] [Indexed: 01/26/2023]
Abstract
The local recurrence rate after total mesorectal excision (TME) appears to be markedly lower than that after conventional operations. We reviewed all relevant articles identified from the MEDLINE databases and clarified the rationale for TME. It is clear that distal intramural spread is rare. Even when present, such spread is not likely to extend beyond 2 cm. Data with attention to mesorectal cancer deposits suggest that mesorectal clearance of at least 4-5 cm distal to the tumor should be sufficient. TME should be performed for most tumors of the mid- and lower rectum. This does not mean that the gut tube needs to be divided at the same level in every case. Dissection of the distal mesorectum off the gut tube can be performed, so the distal line of division of the bowel wall can be made at a minimum of 2 cm below the tumor if such a maneuver would ensure that the sphincters are preserved. In cases with cancer in the upper third of the rectum, the mesorectum and gut tube can safely be divided 5 cm below the tumor without jeopardizing the recurrence rates. Our findings indicate that TME is an essential treatment approach for rectal cancer, and lateral lymph node dissection and preoperative chemoradiotherapy are additional therapies that should be considered for advanced rectal cancer.
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Affiliation(s)
- Jin-ichi Hida
- Department of Surgery, Kinki University School of Medicine, 377-2 Ohno-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan,
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Marks J, Nassif G, Schoonyoung H, DeNittis A, Zeger E, Mohiuddin M, Marks G. Sphincter-sparing surgery for adenocarcinoma of the distal 3 cm of the true rectum: results after neoadjuvant therapy and minimally invasive radical surgery or local excision. Surg Endosc 2013; 27:4469-77. [PMID: 24057070 DOI: 10.1007/s00464-013-3092-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Accepted: 07/01/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Ideal treatment of rectal cancer includes controlling the cancer; minimizing trauma, morbidity, and mortality; and avoiding a colostomy with preservation of adequate function. These goals become more challenging the further distal in the rectum the cancer is located. We sought to determine whether minimally invasive sphincter-preservation surgery (SPS) can accomplish good cancer control, maintaining sphincter function with minimal morbidity and mortality in rectal cancers of the distal 3 cm after receiving neoadjuvant chemoradiotherapy. METHODS We retrospectively reviewed a prospectively maintained rectal cancer database of a single colorectal surgeon to identify all patients with cancers of the distal 3 cm undergoing SPS via a laparoscopic total mesorectal excision or transanal endoscopic microsurgery (TEM). All patients received neoadjuvant chemoradiotherapy. Patient data, including demographics, initial tumor characteristics, staging, radiation dose, perioperative morbidity and mortality, and local recurrence (LR) and survival, were analyzed. RESULTS A total of 161 patients (108 men) underwent SPS via 3 techniques: transanal abdominal transanal proctosigmoidectomy (TATA, n = 106), TEM (n = 49), or ultralow anterior resection (LAR, n = 6). Average age was 62 years (range 22-90 years). The mean levels in rectum from the anorectal ring were as follows: TATA, 1.3 cm (range -1.0 to 3.0 cm), TEM, 1.5 cm (range -0.5 to -3.0 cm), and LAR, 2.9 cm (range 2.5-3.0 cm) (p > 0.05). Preoperative T stage was as follows: T3, n = 108 (TATA 83, TEM 20, LAR 5), T2, n = 48 (TATA 22, TEM 25, LAR 1), T1, n = 3 (TATA 1, TEM 2), and T4, n = 2 (both TEM). All patients received concomitant 5-fluorouracil-based chemotherapy and radiotherapy (mean, 5300 cGy; range 3,000-7,295 cGy). The mean estimated blood loss was 376 ml (range 10-3,600 ml). There were no mortalities. Morbidity rates were as follows: LAR, 0; TATA, 13.2%; and TEM, 32 % (wound disruption: major, 10%; minor, 16%). Pathologic staging was as follows: ypCR: uT2, 34%, and uT3, 19%. Overall LR was 3.7%. By procedure, the follow-up, LR, and KM5YAS, respectively, were: TATA, 37.9 months, 3 and 95%; TEM, 36.3 months, 6 and 88%; and LAR, 63.1 months, 0 and 75% (p > 0.05). CONCLUSIONS This study demonstrates positive oncologic outcomes, low LR rates, and high KM5YS after minimally invasive SPS. A colostomy-free lifestyle and cancer control make the minimally invasive surgical approach an excellent treatment option for complex distal rectal cancers.
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Affiliation(s)
- John Marks
- Section of Colorectal Surgery, Lankenau Medical Center, Wynnewood, PA, USA,
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Bednarski BK, Chang GJ. Ultra-low anterior resection following neoadjuvant chemoradiation for rectal cancer: The end of the 1-cm rule? SEMINARS IN COLON AND RECTAL SURGERY 2013. [DOI: 10.1053/j.scrs.2013.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Yeh YS, Chen MJ, Tsai HL, Huang MY, Chen CW, Huang YH, Sheen MC, Wang JY. Transanal inside-out rectal resection for ultra-low rectal cancer. J INVEST SURG 2013; 25:375-80. [PMID: 23215794 DOI: 10.3109/08941939.2012.655369] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Two major issues encountered in the surgical resection of low rectal cancers (tumor located <6 cm from anal verge) are tumor-free surgical resection margin and adequate fields of colo-anal pull-through anastomosis. The clinical consequences of ensuring gross tumor-free surgical resection margin by transanal inside-out rectal resection technique were assessed for ultra-low rectal cancer patients. From February 2009 to September 2011, ultra-low anterior resection with a new method of eversion of the rectum through the anal canal after resecting the distal rectum and colo-anal anastomosis extracorporally performed in 30 patients (age range, 41-80 years) was reviewed. All patients received preoperative neoadjuvant concurrent chemoradiotherapy (CCRT) before the surgical resection. The median operating time was 265 min (range, 220-400 min), and the median intraoperative blood loss was 325 ml (range, 80-855 ml). No in-hospital mortality was noted among these patients. R0 resection (tumor-free margin range, 0.9-2.5 cm) was confirmed in all patients by pathologic reports, except one patient with 0.5 cm tumor-free margin. The new surgical technique of transanal inside-out rectal resection and colo-anal pull-through anastomosis for selected patients with ultra-low rectal cancers seems to be a safe and alternative procedure.
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Affiliation(s)
- Yung-Sung Yeh
- Division of Trauma, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
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Abstract
BACKGROUND After the impressive response of rectal cancers to neoadjuvant therapy, it seems reasonable to ask: can we can excise the small ulcer locally or avoid a radical resection if there is no gross residual tumor? Does gross response reflect what happens to tumor cells microscopically after radiation? OBJECTIVE The aim of this study was to identify microscopic tumor cell response to radiation. DESIGN This study is a retrospective review of a prospectively collected database. SETTING This investigation was conducted at a single tertiary medical center. PATIENTS Patients were selected who had elective radical resection for rectal cancer after preoperative chemotherapy and radiation performed by 2 colorectal surgeons between 2006 and 2011. MAIN OUTCOME MEASURES The primary outcome measured was tumor presence after radiation therapy RESULTS Of the 75 patients, 20 patients were complete responders and 55 had residual cancer. Of these patients, 28 had no tumor cells seen outside the gross ulcer, and 27 (49.1%) had tumor outside the visible ulcer or microscopic tumor present with no overlying ulcer. Of these tumors, 81.5% were skewed away from the ulcer center. The mean distance of distal scatter was 1.0 cm from the visible ulcer edge to a maximum of 3 cm; 3 patients had tumor cells more than 2 cm distal to the visible ulcer edge. Tumor scatter outside the ulcer was not associated with poor prognostic factors, such as nodal and distant disease, perineural invasion, or mucin; however, it was associated with lymphovascular invasion (χ2 = 4.12, p = 0.038) LIMITATIONS There was limited access to clinical information gathered outside our institution. CONCLUSIONS Our study suggests that 1) after radiation, the gross ulcer cannot be used to determine the sole area of potential residual tumor, 2) cancer cells may be found up to 3 cm distally from the gross ulcer, so the traditional 2-cm margin may not be adequate, and 3) local excision of the ulcer or no excision after apparent complete response appears to be insufficient treatment for rectal cancer.
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Intersphincteric resection for very low rectal cancer: a systematic review. Surg Today 2012; 43:838-47. [PMID: 23139048 DOI: 10.1007/s00595-012-0394-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Accepted: 07/30/2012] [Indexed: 12/11/2022]
Abstract
Radical surgical treatment for very low rectal cancer near the anus has generally involved abdominoperineal resection. Various sphincter-saving operations have been developed for such tumors to optimize the patients' postoperative quality of life. Current protocols focus on intersphincteric resection (ISR), which differs from conventional hand-sewn coloanal anastomosis (CAA) after low anterior resection. However, the efficacy of ISR remains unclear. The surgical, oncologic, and functional outcomes after intersphincteric resection (ISR) were reviewed. This review of the current literature was conducted by searching the PubMed online database. Articles focusing specifically on conventional hand-sewn CAA were excluded from this study. The mean mortality rate is <2 %, and the mean morbidity rate ranges from 7.7 to 38.3 %. The mean local recurrence rate varies widely from 0 to 22.7 %, with a mean follow-up duration of 40-94 months. The mean disease-free and overall 5-year survival rates are 69-86 and 79-97 months, respectively. Functional outcomes are generally acceptable, but accurate evaluation is extremely difficult due to the absence of unified appraisal methods. ISR appears surgically, oncologically and functionally acceptable. However, more experience and better understanding of the oncology, anal physiology, and pelvic anatomy are necessary to achieve successful outcomes without complications, and to improve patient survival.
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Tsumura A, Yokoyama S, Takifuji K, Hotta T, Matsuda K, Watanabe T, Mitani Y, Yamaue H. Endoscopically observable white nodule caused by distal intramural lymphatic spread of rectal cancer: a case report. World J Surg Oncol 2012; 10:216. [PMID: 23050553 PMCID: PMC3506560 DOI: 10.1186/1477-7819-10-216] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Accepted: 09/26/2012] [Indexed: 02/06/2023] Open
Abstract
This report describes a case of rectal cancer with endoscopically observable white nodules caused by distal intramural lymphatic spread. A 57-year-old female presented to our hospital with frequent diarrhea and hemorrhoids. Computed tomography showed bilateral ovarian masses and three hepatic tumors diagnosed as rectal cancer metastases, and also showed multiple lymph node involvement. The patient was preoperatively diagnosed with stage IV rectal cancer. Colonoscopy demonstrated that primary rectal cancer existed 15 cm from the anal verge and that there were multiple white small nodules on the anal side of the primary tumor extending to the dentate line. Biopsies of the white spots were performed, and they were identified as adenocarcinoma. The patient underwent Hartmann’s procedure because of the locally advanced primary tumor. The white nodules were ultimately diagnosed as being caused by intramural lymphatic spreading because lymphatic permeation was strongly positive at the surrounding area. Small white nodules near a primary rectal cancer should be suspected of being intramural spreading. Endoscopic detection of white nodules may be useful for the diagnosis of distal intramural spread.
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Affiliation(s)
- Ayako Tsumura
- Second Department of Surgery, Wakayama Medical University, School of Medicine, 811-1 Kimiidera, Wakayama 641-8510, Japan
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Lim JWM, Chew MH, Lim KH, Tang CL. Close distal margins do not increase rectal cancer recurrence after sphincter-saving surgery without neoadjuvant therapy. Int J Colorectal Dis 2012; 27:1285-94. [PMID: 22918660 DOI: 10.1007/s00384-012-1467-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2012] [Indexed: 02/04/2023]
Abstract
PURPOSE The oncological results of close distal resection margins (DM) have been mixed due to variations in perioperative treatment protocols and surgical expertise. With the increased application of sphincter-saving surgery in the management of rectal cancer, "close shave" DM is an increasingly encountered phenomenon. Our center aims to examine the oncological outcomes of "close shave" DM in the absence of neoadjuvant therapy in the surgical treatment of rectal cancer. METHODS A prospective database of 320 patients who underwent curative surgical resection for primary rectal cancer between 1999 and 2007 was reviewed. One hundred forty-eight patients had "close shave" DM (DM <1 cm) and 70 (22 %) patients had stage 1, 102 (32 %) patients had stage 2, and 148 (46 %) patients presented with stage 3 disease. Median follow-up was 45 months. RESULTS The overall recurrence rate for the entire study cohort was 29 % (n = 94), with 6.6 % of patients developing locoregional recurrence. Recurrence was noted to be significantly associated with decreasing circumferential resection margin (p = 0.008) and increasing American Joint Committee on Cancer stage (p < 0.001). Five-year cancer-specific survival (CSS) for patients with DM <1 cm was 75.6 % and is higher compared to patients with longer DM (p = 0.041). Multivariate analysis showed that CSS was worsened with T stage, N stage, and perineural invasion status. Decreasing DM, however, was not significantly associated with poorer CSS or recurrence rates. CONCLUSION Close distal resection margins do not negatively impact long-term disease control, even without the use of neoadjuvant therapy, provided that safe, optimal surgical resection is performed. Circumferential radial margin may be a more important indicator for outcomes.
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Affiliation(s)
- Jason Wei-Min Lim
- Department of Colorectal Surgery, Singapore General Hospital, Outram Road, Singapore
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Melanoma-associated antigen (MAGE) expression in the normal mucosa around colorectal cancer after curative resection: presence of undetectable free cancer cells. Int J Biol Markers 2011; 26:88-93. [PMID: 21574154 DOI: 10.5301/jbm.2011.8320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2011] [Indexed: 01/01/2023]
Abstract
PURPOSE Curative surgical resection is of great importance and some trials have been performed to identify free undetectable cancer cells using molecular markers. The aim of this study is to investigate melanoma-associated antigen (MAGE) expression in normal mucosa around colorectal cancer and its clinical significance.? MATERIAL AND METHOD From October 2003 to June 2004, we collected 46 colorectal cancer and matched normal mucosal tissues within 20 mm, 20 to 50 mm and more than 50 mm from tumors after the curative operation. Twenty-two mucosal tissues were harvested from patients with benign colorectal diseases as controls. MAGE expression was assayed using nested RT-PCR of MAGE A1-6 mRNA.? RESULTS The MAGE expression rates in cancer tissue and adjacent normal mucosa were 65.2%, 6.5% (<20 mm), 2.2% (20-50 mm) and 0.0% (>50 mm), respectively, while MAGE was not expressed in the mucosa of benign diseases. The MAGE-positive cases in the normal mucosa around tumors were located in the left colon or rectum, and one patient showed anastomotic mucosal site recurrence.? CONCLUSIONS MAGE expression in normal-appearing mucosa around colorectal cancer showed some clinical findings suggesting the presence of undetectable free cancer cells after curative resection.
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Does a subcentimeter distal resection margin adversely influence oncologic outcomes in patients with rectal cancer undergoing restorative proctectomy? Dis Colon Rectum 2011; 54:157-63. [PMID: 21228662 DOI: 10.1007/dcr.0b013e3181fc9378] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND A 1-cm distal clearance margin is recommended for mid/low rectal cancers. OBJECTIVE We evaluate whether shorter distal margins after restorative rectal resection affect oncologic outcomes for patients with a clear circumferential margin. DESIGN From a prospective cancer database, patients undergoing restorative proctectomy for mid/lower third rectal cancer from 1991 to 2006 with a distal margin of ≤ 1 cm (group A) were compared with those with >1-cm distal margin (group B) for demographics, tumor, treatment, and outcomes. The impact of a distal margin ≤ 0.5 cm was also similarly assessed. RESULTS Of 784 patients, distal resection margin was ≤ 1 cm in 198 and >1 cm in 586. Local recurrence occurred in 26 patients (3.3%). Mean distal resection margin was 2.3 ± 1.6 cm. Group A was associated with a lower level of tumor (1.3, 0.1-9 cm vs 2, 0.1-9 cm; P < .001), a higher rate of handsewn anastomosis (29.5% vs 12.9%, P < .001), and fewer T3/T4 tumors (28.2% vs 39.1%, P = .06). The 5-year local recurrence rate was 4.4% in group A and 4.3% in group B, and was 6.4% in patients with a distal margin <5 mm and 4.1% in those with a distal margin >5 mm. On multivariable analysis, local recurrence or disease-free survival was not associated with distal margin irrespective of whether this was <1 or <0.5 cm, adjusting for age, sex, use of adjuvant therapy, T stage, and differentiation. CONCLUSIONS A distal resection margin of <1 cm for patients undergoing restorative radical resection for low-lying rectal cancer does not adversely influence oncologic outcomes when other factors are carefully considered and a multimodality approach is used. This factor, when carefully considered, will help avoid a permanent stoma in some circumstances.
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Silberfein EJ, Kattepogu KM, Hu CY, Skibber JM, Rodriguez-Bigas MA, Feig B, Das P, Krishnan S, Crane C, Kopetz S, Eng C, Chang GJ. Long-term survival and recurrence outcomes following surgery for distal rectal cancer. Ann Surg Oncol 2010; 17:2863-9. [PMID: 20552409 PMCID: PMC3071558 DOI: 10.1245/s10434-010-1119-8] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Indexed: 12/13/2022]
Abstract
BACKGROUND Treatment of distal rectal cancer remains clinically challenging and includes proctectomy and coloanal anastomosis (CAA) or abdominoperineal resection (APR). The purpose of this study is to evaluate operative and pathologic factors associated with long-term survival and local recurrence outcomes in patients treated for distal rectal cancer. METHODS A retrospective consecutive cohort study of 304 patients treated for distal rectal cancer with radical resection from 1993 to 2003 was performed. Patients were grouped by procedure (CAA or APR). Demographic, pathologic, recurrence, and survival data were analyzed utilizing chi-square analysis for comparison of proportions. Survival analysis was performed using Kaplan-Meier method and log-rank test for univariate and Cox regression for multivariate comparison. RESULTS The median tumor distance from the anal verge was 2 cm [interquartile range (IQR) 0.5-4 cm]. Margins were negative in all but four patients (one distal, 0.3%; three radial, 1%). The 5-year overall survival rate was 82% (88.6% stage pI, 80.5% stage pII, 67.9% stage pIII). Older age, advanced pathologic stage, presence of lymphovascular or perineural invasion, earlier treatment period, and APR surgery type were associated with worse survival on multivariate analysis. The 5-year local recurrence rate was 5.3% after CAA and 7.9% after APR (p = 0.33). CONCLUSIONS Low rates of local recurrence and good overall survival can be achieved after treatment of distal rectal cancer with stage-appropriate chemoradiation and proctectomy with CAA or APR. Sphincter preservation can be achieved even with distal margins less than 2 cm.
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Affiliation(s)
- Eric J Silberfein
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
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Abstract
The improvements in outcomes associate with the use of preoperative therapy rather than postoperative treatment means that clinical teams are increasingly reliant on imaging to identify high-risk features of disease to determine treatment plans. For many solid tumours, including rectal cancer, validated techniques have emerged in identifying prognostic factors pre-operatively. In the MERCURY study, a standardised scanning technique and the use of reporting proformas enabled consistently accurate assessment and documentation of the prognostic factors. This is now an essential tool to enable our clinical colleagues to make treatment decisions. In this review, we describe the proforma-based reporting tool that enables a systematic approach to the interpretation of the magnetic resonance images, thereby enabling all the clinically relevant features to be adequately assessed.
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Affiliation(s)
- F Taylor
- Mayday University Hospital, Croydon, Surrey, UK
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Park IJ, Kim JC. Adequate length of the distal resection margin in rectal cancer: from the oncological point of view. J Gastrointest Surg 2010; 14:1331-7. [PMID: 20143273 DOI: 10.1007/s11605-010-1165-3] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Accepted: 01/11/2010] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The distal resection margin (DRM) has been considered an important factor for the oncological outcome of rectal cancer surgery. However, the optimal distal margins required to achieve safe oncological outcome remains to be controversial. MATERIAL AND METHODS More recently, as circumferential resection margin or mesorectal margin has been additionally reported to be more important factors predicting patient outcome than the distal mucosal margin, a re-evaluation of the impact of DRM on patient outcome is needed. RESULTS The extent of distal tumor spread is known to be influenced by a variety of factors such as tumor location, lymph node metastasis, and tumor size. DRM might affect survival more than a local recurrence. Because distal intramural tumor spread rarely exceeds 1 to 2 cm in most rectal cancers, and local control and survival do not seem to be compromised by shorter distal resection margins, the generally accepted practice is to aim for a 2-cm DRM. However, in the recent trend of curative resection after preoperative chemoradiotherapy, with an otherwise favorable tumor such as well-differentiated tumor and no lymph node metastasis, a DRM at < or =1 cm does not necessarily portend a poor prognosis. In cases with preoperative chemoradiotherapy, distal resection margins need to be evaluated individually. DISCUSSION It has been suggested that down-staging of low-lying rectal cancers after preoperative radiation might well include the pathological clearance of distal intramural microscopic spread. Moreover, the measurement of DRM varies with respective study, making it difficult to compare. CONCLUSION We need an applicable intraoperative method to accurately measure distal resection margin, enabling comparative outcome.
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Affiliation(s)
- In Ja Park
- Department of Surgery, Vievis Namuh Hospital, Seoul, South Korea
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Marks J, Mizrahi B, Dalane S, Nweze I, Marks G. Laparoscopic transanal abdominal transanal resection with sphincter preservation for rectal cancer in the distal 3 cm of the rectum after neoadjuvant therapy. Surg Endosc 2010; 24:2700-7. [PMID: 20414681 DOI: 10.1007/s00464-010-1028-8] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2009] [Accepted: 02/18/2010] [Indexed: 01/03/2023]
Abstract
BACKGROUND This study reports the short- and long-term results for a prospective rectal cancer management program using laparoscopic radical transanal abdominal transanal proctosigmoidectomy with coloanal anastomosis (TATA) after neoadjuvant therapy. METHODS A prospective database included 102 rectal cancer patients treated with laparoscopic TATA from 1998 to 2008. Patients with distant metastasis at presentation, patients with a tumor more than 3 cm from the anorectal ring, and patients not undergoing neoadjuvant therapy were excluded, leaving 79 patients (54 men and 25 women) with a mean age of 59.2 years (range, 22-85 years) for this study. 13 patients completed neoadjuvant therapy before the original evaluation, and they are excluded from the report of initial clinical assessment. Before treatment, 50 patients were staged as T3 and 16 patients as T2. The mean level in the rectum superior to the anorectal ring was 1.2 cm (range, -0.5 to 3 cm). In terms of fixity, 31 of the tumors were mobile, 27 were tethered, and 8 showed early fixation. Ulceration was absent in 8 cases, minimal in 12 cases, superficial in 7 cases, moderate in 22 cases, and deep in 17 cases. The mean pretreatment tumor size tumor was 4.8 cm (range, 1.5-12 cm). The median external beam radiation was 5,400 cGy (range, 3,000-8,040 cGy), and 77 patients underwent chemotherapy. RESULTS The mean follow-up period was 34.2 months (range, 1.9-113.9 months). There were no perioperative mortalities. The conversion rate was 2.5%, and the mean largest incision length was 4.3 cm (range, 1.2-21 cm). For 84% of the patients, the incision was less than 6.0 cm, and 46% of the patients had no abdominal incision for delivery of the specimen. The mean estimated blood loss was 367 ml (range, 75-2,200 ml). All the patients had a temporary diverting stoma. The major morbidity rate was 11%, and the minor morbidity rate was 19%. The major complications included four full-thickness rectal prolapses with repair, one ischemic neorectum with successful reanastomosis, two bowel obstructions, and two failed anastomoses requiring stoma. The ypT stages included 22 complete responses, 12 cases of ypT1, 22 cases of ypT2, 23 cases of ypT3; 65 cases of ypN0, and 14 cases of ypN + (T3 = 7, T2 = 4, T1 = 3). The local recurrence rate was 2.5% (2/79), and the distant metastases rate was 10.1% (8/79). The KM5YAS rate was 97%. Overall, 90% of the patients lived without a stoma. Neorectal loss was due to positive margins or recurrence and was followed by abdominoperineal resection in three cases and ischemia in two cases. The condition of two patients was not reversed due to comorbidities, and one patient had a stoma secondary to bowel obstruction. CONCLUSION The study results indicate excellent local recurrence (2.7%) and 5-year survival rates without the need for permanent colostomy in patients with cancers in the distal one-third of the rectum. Laparoscopic total mesorectal excision (TME) with the TATA approach is safe and can be performed laparoscopically. Multi-institutional studies are required to establish the reproducibility of this promising approach.
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Affiliation(s)
- J Marks
- Section of Colorectal Surgery, Lankenau Hospital and Institute for Medical Research, Wynnewood, PA, USA.
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Affiliation(s)
- Seung-Yong Jeong
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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Sphincter preservation in low rectal cancer is facilitated by preoperative chemoradiation and intersphincteric dissection. Ann Surg 2009; 249:236-42. [PMID: 19212176 DOI: 10.1097/sla.0b013e318195e17c] [Citation(s) in RCA: 186] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate oncologic outcome in patients with locally advanced distal rectal cancer treated with preoperative chemoradiation followed by low anterior resection (LAR)/stapled coloanal anastomosis, LAR/intersphincteric dissection/hand-sewn coloanal anastomosis, or abdominoperineal resection (APR). SUMMARY BACKGROUND DATA Distal rectal cancer presents a surgical challenge, and the goals of treatment often include tumor eradication without sacrifice of the anal sphincters. The technique of intersphincteric resection removes the internal anal sphincter to gain additional distal rectal margin in hopes of avoiding a permanent stoma. METHODS We analyzed 148 patients with stage II and III rectal cancers (endorectal ultrasound staged uT3-4 and/or uN1) located < or =6 cm from the anal verge, treated by preoperative chemoradiation and total mesorectal excision from 1998 to 2004. Eighty-five patients (57%) had sphincter-preserving resection (41, LAR/stapled coloanal anastomosis; 44, LAR/intersphincteric resection/hand-sewn coloanal anastomosis); 63 patients had APR. RESULTS Patients undergoing APR were older, with more poorly differentiated tumors evidencing less response to chemoradiation and more likely to require extended resection. Complete resection with negative histologic margins was achieved in 92%; circumferential margins were positive in 2 (5%) of 44 in the intersphincteric resection group and 8 (13%) of 63 in the APR group. Distal margins were positive in 2 (5%) of 44 in the intersphincteric resection group. With median follow-up of 47 months, there were a total of 7 local recurrences (5%): 1, 0, and 6 in the stapled anastomosis, intersphincteric resection, and APR groups, respectively. Estimated 5-year recurrence-free survival for the stapled anastomosis, intersphincteric resection, and APR groups were 85%, 83%, and 47% respectively (P = 0.001). CONCLUSIONS In low rectal cancer, sphincter preservation is facilitated by a significant response to preoperative chemoradiation and intersphincteric resection, without compromise of margins or outcome. In those who have a less favorable response, abdominoperineal resection is more likely to be required and is associated with poorer outcome.
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Leo E, Belli F, Miceli R, Mariani L, Gallino G, Battaglia L, Vannelli A, Andreola S. Distal clearance margin of 1 cm or less: a safe distance in lower rectum cancer surgery. Int J Colorectal Dis 2009; 24:317-22. [PMID: 18931846 DOI: 10.1007/s00384-008-0604-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/02/2008] [Indexed: 02/04/2023]
Abstract
PURPOSE The purpose of this study was to investigate the prognostic role of distal clearance margin (DCM) in lower rectum cancer surgery. MATERIALS AND METHODS Two-hundred-three cancer patients underwent total rectal resection, possibly followed by adjuvant chemoradiotherapy. DCM was classified as positive or negative (<1, > or =1 cm) and investigated with multivariable proportional hazard models. RESULTS A total of 52 deaths, 19 local relapses, 40 distant metastases, and three second primaries were observed as first events. Five-year survival with positive, negative <1, or negative > or =1 cm DCM was 51%, 81%, and 69%, respectively (p = 0.018). The difference was significant between positive and negative DCM (p = 0.031), not between negative <1 and > or =1 cm (p = 0.106). Local and distant 5-year incidences according to DCM were 30%, 8%, and 8% (p = 0.006) and 38%, 26%, and 19% (p = 0.857), respectively. CONCLUSIONS DCM, but not tumor size, is a prognostic factor after sphincter-saving surgery, which is safe whenever a negative margin is achieved.
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Affiliation(s)
- Ermanno Leo
- Division of Colorectal Surgery, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
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Kim NK, Kim YW, Min BS, Lee KY, Sohn SK, Cho CH. Operative safety and oncologic outcomes of anal sphincter-preserving surgery with mesorectal excision for rectal cancer: 931 consecutive patients treated at a single institution. Ann Surg Oncol 2009; 16:900-9. [PMID: 19198951 DOI: 10.1245/s10434-009-0340-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2008] [Revised: 12/31/2008] [Accepted: 12/31/2008] [Indexed: 12/28/2022]
Abstract
BACKGROUND This study was designed to evaluate the operative safety and long-term oncologic outcomes of sphincter-preserving surgery based on sharp mesorectal excision for rectal cancer. METHODS Between January 1989 and June 2004, 931 patients underwent sphincter-preserving surgery based on sharp mesorectal excision. The operative safety and oncologic outcomes were assessed for the periods of 1989-1996 (n = 208) and 1997-2004 (n = 723). Total mesorectal excision (TME)-based sphincter-preserving surgery was performed during the period of 1989-1996. A multidisciplinary team approach and tailored mesorectal excision, which is the differential removal of the mesorectum, were our standard treatment for patients with rectal cancer during the period of 1997-2004. RESULTS The use of preoperative chemoradiation (P < 0.001), ultralow anterior resection with coloanal anastomosis (P = 0.01), diverting stoma (P = 0.001), and <2 cm of a distal resection margin (P = 0.01) were more common during the period of 1997-2004. There were no differences between the two periods with regard to perioperative complications (P = 0.2), such as anastomosis leakage (2.4% vs. 3.6%). Cancer-specific survival rates (79.1% vs. 79.6%, P = 0.7) and local recurrence (8.4% vs. 8.6%, P = 0.99) did not differ significantly for the two periods. CONCLUSIONS Based on sharp mesorectal excision, operative safety and oncologic outcomes were not compromised by technical advances in sphincter-preserving surgery using tailored mesorectal excision and a shortened distal margin.
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Affiliation(s)
- Nam-Kyu Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea.
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Intersphincteric resection with partial removal of external anal sphincter for low rectal cancer. ACTA ACUST UNITED AC 2009; 55:45-53. [PMID: 19069692 DOI: 10.2298/aci0803045s] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Abdominoperineal resection (APR) remains the standard procedure for rectal cancer located within 0.5 cm from dentate line (DL). In this study, we present a new type of restorative surgery: intersphincteric resection with partial removal of external anal sphincter (EAS) and anorectal reconstruction for-ultra low rectal cancer. Between March 2003 and May 2008 fifty patients (28 males, aged between 39 and 71) were operated on for ultra low rectal cancer uT2-3N0M0 with partial preservation of EAS and total anorectal reconstruction (smooth-muscle neosphincter and colonic pouch). A protective stoma was performed in all cases. Functional outcome and quality of life were recorded at 3, 6, 12, 18, 24 months after stoma closure using Wexner score and FIQL respectively. Anal manometry, vectrum volumetry and myography data were taken as well. Results. Postoperative complications developed in 2 patients, but no secondary surgery was required. Carcinomas were staged as pT2 (n = 14) and pT3 (n = 36). The distal clearance was 2.00.4 (range 1.5-2.8) cm, lateral clearance was 0.80.3 (range 0.2-1.4) cm. After a median follow-up of 24 (range 2-61) months, 2 local recurrences were occurred and salvaged by APR. Contractive activity of saved elements of EAS improved with a course of time and squeezing anal pressure increased as well. Perfect functional outcome was achieved in 25 of 34 patients at 12 months after stoma closure, and all the patients were satisfied with procedure. Good functional results of suggested surgery seems to be an acceptable alternative to APR with permanent stoma in selected patients.
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Wasserberg N, Gutman H. Resection margins in modern rectal cancer surgery. J Surg Oncol 2009; 98:611-5. [PMID: 19072854 DOI: 10.1002/jso.21036] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
At present, the preferred treatment for rectal cancer is low anterior resection with total mesorectal excision and sphincter preservation. Complete removal of the tumor's lymphatic and vascular pad with free resection margins has led to a reduction in rates of local recurrence and improved disease-specific survival. In addition to the distal and proximal margins from the tumor edge, for an optimal outcome, it is essential to consider distal mesorectal spread and the circumferential mesorectal margin.
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Affiliation(s)
- Nir Wasserberg
- Department of Surgery B, Rabin Medical Center, Petah Tiqwa, Israel
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Kim YW, Kim NK, Min BS, Huh H, Kim JS, Kim JY, Sohn SK, Cho CH. Factors associated with anastomotic recurrence after total mesorectal excision in rectal cancer patients. J Surg Oncol 2009; 99:58-64. [PMID: 18937260 DOI: 10.1002/jso.21166] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND In patients undergoing total mesorectal excision (TME), the clinical variables most relevant to anastomotic recurrence have not been identified. We evaluated factors associated with anastomotic recurrence in patients undergoing TME and the impact of a reduced distal margin on anastomotic recurrence. METHODS Thirty-eight patients with anastomotic recurrence were compared with 876 patients who received curative rectal cancer surgery. Patients were compared according to: (1) the presence of anastomotic recurrence (recurrence vs. recurrence-free), (2) distal margin length (< or =10 mm vs. >10 mm) and (3) additional treatment (none, adjuvant, or neoadjuvant). The risk factors for anastomotic recurrence were analyzed. RESULTS In the recurrence group, an advanced T stage (T3 and T4) (P = 0.01) microscopic distal margin involvement (P = 0.002) and an elevated CEA level (>5 ng/ml) (P = 0.04) were more commonly found. The incidence of anastomotic recurrence was not higher in the distal margin < or =10 mm group and did not differ according to additional treatment. The multivariate analysis showed that an advanced T stage (T3 and T4) and microscopic distal margin involvement were risk factors for anastomotic recurrence. CONCLUSION A distal margin < or =10 mm appears to be acceptable in terms of anastomotic recurrence. Patients with a positive distal margin, on the postoperative pathology, should be considered at high risk for anastomotic recurrence.
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Affiliation(s)
- Young-Wan Kim
- Department of Surgery, Yonsei University College of Medicine, Seodaemun-Gu, Seoul, Korea
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