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Liu Z, Lu T, Li J, Wang L, Xu K, Dang Q, Liu L, Guo C, Jiao D, Sun Z, Han X. Clinical Significance and Inflammatory Landscape of aNovel Recurrence-Associated Immune Signature in Stage II/III Colorectal Cancer. Front Immunol 2021; 12:702594. [PMID: 34394098 PMCID: PMC8358813 DOI: 10.3389/fimmu.2021.702594] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/19/2021] [Indexed: 01/31/2023] Open
Abstract
Background A considerable number of patients with stage II/III colorectal cancer (CRC) will relapse within 5 years after surgery, which is a leading cause of death in early-stage CRC. The current TNM stage system is limited due to the heterogeneous clinical outcomes displayed in patients of same stage. Therefore, searching for a novel tool to identify patients at high recurrence-risk for improving post-operative individual management is an urgent need. Methods Using four independent public cohorts and qRT-PCR data from 66 tissues, we developed and validated a recurrence-associated immune signature (RAIS) based on global immune genes. The clinical and molecular features, tumor immune microenvironment landscape, and immune checkpoints profiles of RAIS were also investigated. Results In five independent cohorts, this novel scoring system was proven to be an independent recurrent factor and displayed excellent discrimination and calibration in predicting the recurrence-risk at 1~5 years. Further analysis revealed that the high-risk group displayed high mutation rate of TP53, while the low-risk group had more abundance of activated CD4+/CD8+ T cells and high expression of PD-1/PD-L1. Conclusions The RAIS model is highly predictive of recurrence in patients with stage II/III CRC, which might serve as a powerful tool to further optimize decision-making in adjuvant chemotherapy and immunotherapy, as well as tailor surveillance protocol for individual patients.
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Affiliation(s)
- Zaoqu Liu
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Interventional Institute of Zhengzhou University, Zhengzhou, China.,Interventional Treatment and Clinical Research Center of Henan Province, Zhengzhou, China
| | - Taoyuan Lu
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Jing Li
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Interventional Institute of Zhengzhou University, Zhengzhou, China.,Interventional Treatment and Clinical Research Center of Henan Province, Zhengzhou, China
| | - Libo Wang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Kaihao Xu
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qin Dang
- Department of Colorectal Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Long Liu
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Chunguang Guo
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Dechao Jiao
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhenqiang Sun
- Department of Colorectal Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xinwei Han
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Interventional Institute of Zhengzhou University, Zhengzhou, China.,Interventional Treatment and Clinical Research Center of Henan Province, Zhengzhou, China
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2
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Liu Z, Lu T, Li J, Wang L, Xu K, Dang Q, Guo C, Liu L, Jiao D, Sun Z, Han X. Development and clinical validation of a novel six-gene signature for accurately predicting the recurrence risk of patients with stage II/III colorectal cancer. Cancer Cell Int 2021; 21:359. [PMID: 34233675 PMCID: PMC8265123 DOI: 10.1186/s12935-021-02070-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 06/29/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND A large number of patients with stage II/III colorectal cancer (CRC) have a high recurrence rate after radical resection. We aimed to develop a novel tool to stratify patients with different recurrence-risk for optimizing decision-making in post-operative surveillance and therapeutic regimens. METHODS We retrospectively enrolled four independent cohorts from the Gene Expression Omnibus and 66 CRC tissues from our hospital. The initial signature discovery was conducted in GSE143985 (n = 91). This was followed by independent validation of this signature in GSE17536 (n = 111), GSE29621 (n = 40), and GSE92921 (n = 59). Further experimental validation using qRT-PCR assays (n = 66) was performed to ensure the robustness and clinical feasible of this signature. RESULTS We developed a novel recurrence-related signature consisting of six genes. This signature was validated to be significantly associated with dismal recurrence-free survival in five cohorts GSE143985 (HR: 4.296 [2.612-7.065], P < 0.0001), GSE17536 (HR: 2.354 [1.662-3.334], P < 0.0001), GSE29621 (HR: 3.934 [1.622-9.539], P = 0.0024), GSE92921 (HR: 7.080 [2.011-24.924], P = 0.0023), and qPCR assays (HR: 3.654 [2.217-6.020], P < 0.0001). This signature was also proven to be an independent recurrent factor. More importantly, this signature displayed excellent discrimination and calibration in predicting the recurrence-risk at 1-5 years, with most AUCs were above 0.9, average C-index for the five cohorts was 0.8795, and near-perfect calibration. CONCLUSIONS We discovered and experimental validated a novel gene signature with stable and powerful performance for identifying patients at high recurrence-risk in stage II/III CRC.
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Affiliation(s)
- Zaoqu Liu
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, China.,Interventional Institute of Zhengzhou University, Zhengzhou, 450052, Henan, China.,Interventional Treatment and Clinical Research Center of Henan Province, Zhengzhou, 450052, Henan, China
| | - Taoyuan Lu
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Zhengzhou, 450003, Henan, China
| | - Jing Li
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, China.,Interventional Institute of Zhengzhou University, Zhengzhou, 450052, Henan, China.,Interventional Treatment and Clinical Research Center of Henan Province, Zhengzhou, 450052, Henan, China
| | - Libo Wang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, China
| | - Kaihao Xu
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, China
| | - Qin Dang
- Department of Colorectal Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, China
| | - Chunguang Guo
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, China
| | - Long Liu
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, China
| | - Dechao Jiao
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, China
| | - Zhenqiang Sun
- Department of Colorectal Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, China.
| | - Xinwei Han
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, China. .,Interventional Institute of Zhengzhou University, Zhengzhou, 450052, Henan, China. .,Interventional Treatment and Clinical Research Center of Henan Province, Zhengzhou, 450052, Henan, China.
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3
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Abstract
Circulating tumor cells (CTCs) in the blood have been used as diagnostic markers in patients with colorectal cancer (CRC). In this study, we evaluated a CTC detection system based on cell size to assess CTCs and their potential as early diagnostic and prognostic biomarkers for CRC.
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4
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A prognostic index based on an eleven gene signature to predict systemic recurrences in colorectal cancer. Exp Mol Med 2019; 51:1-12. [PMID: 31578316 PMCID: PMC6802642 DOI: 10.1038/s12276-019-0319-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 05/12/2019] [Accepted: 06/26/2019] [Indexed: 02/07/2023] Open
Abstract
Approximately half of colorectal cancer (CRC) patients experience disease recurrence and metastasis, and these individuals frequently fail to respond to treatment due to their clinical and biological diversity. Here, we aimed to identify a prognostic signature consisting of a small gene group for precisely predicting CRC heterogeneity. We performed transcriptomic profiling using RNA-seq data generated from the primary tissue samples of 130 CRC patients. A prognostic index (PI) based on recurrence-associated genes was developed and validated in two larger independent CRC patient cohorts (n = 795). The association between the PI and prognosis of CRC patients was evaluated using Kaplan–Meier plots, log-rank tests, a Cox regression analysis and a RT-PCR analysis. Transcriptomic profiling in 130 CRC patients identified two distinct subtypes associated with systemic recurrence. Pathway enrichment and RT-PCR analyses revealed an eleven gene signature incorporated into the PI system, which was a significant prognostic indicator of CRC. Multivariate and subset analyses showed that PI was an independent risk factor (HR = 1.812, 95% CI = 1.342–2.448, P < 0.001) with predictive value to identify low-risk stage II patients who responded the worst to adjuvant chemotherapy. Finally, a comparative analysis with previously reported Consensus Molecular Subgroup (CMS), high-risk patients classified by the PI revealed a distinct molecular property similar to CMS4, associated with a poor prognosis. This novel PI predictor based on an eleven gene signature likely represents a surrogate diagnostic tool for identifying high-risk CRC patients and for predicting the worst responding patients for adjuvant chemotherapy. A prognostic tool that searches for eleven genes associated with colorectal cancer recurrence shows promise in initial trials. The complexity of colorectal cancer (CRC) makes it challenging to treat. A significant number of patients relapse or experience metastasis even after surgical intervention, and fail to respond to post-surgical chemotherapy. Yong Sung Kim at the Korea Research Institute of Bioscience and Biotechnology, Daejeon, and Jin Cheon Kim from the University of Ulsan, Seoul, South Korea, and co-workers, conducted RNA-sequencing analysis on samples from 130 patients with CRC, 58 of whom had suffered relapse. They pinpointed eleven genes strongly associated with recurrence-free survival. They used these to develop a prognostic tool to identify high-risk patients and those more likely to respond poorly to chemotherapy. The tool was validated on a further 795 patients with CRC.
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Surgical Resection for Recurrence After Two-Stage Hepatectomy for Colorectal Liver Metastases Is Feasible, Is Safe, and Improves Survival. J Gastrointest Surg 2019; 23:84-92. [PMID: 30084064 PMCID: PMC6329635 DOI: 10.1007/s11605-018-3890-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 07/16/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Recurrence rates are high for patients who have undergone two-stage hepatectomy (TSH) for bilateral colorectal liver metastases, and there is no established treatment approach for recurrent disease. This study aimed to determine the feasibility, safety, and prognostic impact of surgical resection for recurrence after TSH and the prognostic role of RAS mutation in this cohort. METHODS The study included 137 patients intended to undergo TSH for bilateral colorectal metastases during 2003-2016. Clinicopathologic factors were compared using univariate and multivariate analyses. RESULTS One hundred eleven patients (81%) completed TSH. The median recurrence-free survival in these patients was 12 months. Of the 83 patients with subsequent recurrence, 31 (37%) underwent resection for recurrence, and 11 underwent multiple resections for recurrence. Forty-eight operations were performed for recurrence: 23 repeat hepatectomies, 14 pulmonary resections, 5 locoregional resections, and 6 concurrent resections in multiple organ sites. The median overall survival (OS) among patients with recurrence was 143 months for patients who underwent resection and 49 months for those who did not (P < 0.001). On multivariate analysis, resection for recurrence (hazard ratio [HR] 0.25; 95% CI 0.10-0.54, P < 0.001) was associated with better OS, whereas RAS mutation (HR 2.25; 95% CI 1.16-4.50, P = 0.016) and first recurrence in multiple sites (HR 2.28; 95% CI 1.17-4.37, P = 0.016) were independent predictors of worse overall survival. CONCLUSIONS In patients who have undergone TSH for bilateral colorectal liver metastases, recurrence is frequent and should be treated with resection whenever possible. Patients with wild-type RAS fare particularly well with resection for recurrence.
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6
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Abstract
Advanced primary and recurrent colorectal cancer can be successfully treated by experienced, dedicated centers delivering good outcomes with low mortality and morbidity. Development and implementation of a comprehensive referral pathway is to be encouraged. Multidisciplinary team management is essential in the management of this complex group of patients and is associated with significantly more complete preoperative evaluation and more accurate provision of patient information, as well as improved access to the most appropriate individualized management plan. A structured selection process can improve outcomes through standardized approaches to service delivery to provide the highest quality of care.
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Affiliation(s)
- Christos Kontovounisios
- Department of Colorectal Surgery, The Royal Marsden Hospital, Chelsea, London, United Kingdom.,Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Paris Tekkis
- Department of Colorectal Surgery, The Royal Marsden Hospital, Chelsea, London, United Kingdom.,Department of Surgery and Cancer, Imperial College, London, United Kingdom
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Kontovounisios C, Tan E, Pawa N, Brown G, Tait D, Cunningham D, Rasheed S, Tekkis P. The selection process can improve the outcome in locally advanced and recurrent colorectal cancer: activity and results of a dedicated multidisciplinary colorectal cancer centre. Colorectal Dis 2017; 19:331-338. [PMID: 27629565 DOI: 10.1111/codi.13517] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Accepted: 06/23/2016] [Indexed: 12/31/2022]
Abstract
AIM There is wide disparity in the care of patients with multivisceral involvement of rectal cancer. The results are presented of treatment of advanced and recurrent colorectal cancer from a centre where a dedicated multidisciplinary team (MDT) is central to the management. METHOD All consecutive MDT referrals between 2010 and 2014 were examined. Analysis was undertaken of the referral pathway, site, selection process, management decision, R0 resection rate, mortality/morbidity/Clavien-Dindo (CD) classification of morbidity, length of stay (LOS) and improvement of quality of life. RESULTS There were 954 referrals. These included locally advanced primary rectal cancer (LAPRC b-TME) (39.0%), rectal recurrence (RR) (22.0%), locally advanced primary colon cancer (LAPCC T3c/d-T4) (21.1%), colon cancer recurrence (CR) (12.4%), locally advanced primary anal cancer (LAPAC-failure of CRT/T3c/d-T4) (3.0%) and anal cancer recurrence (AR) (2.2%). Among these patients 271 operations were performed, 212 primary and 59 for recurrence. These included 16 sacrectomies, 134 total pelvic exenterations and 121 other multi-visceral exenterative procedures. An R0 resection (no microscopic margin involvement) was achieved in 94.4% and R1 (microscopic margin involvement) in 5.1%. In LAPRC b-TME the R0 rate was 96.1% and for RR it was 79%. The LOS varied from 13.3 to 19.9 days. RR operations had the highest morbidity (CD 1-2, 33.3%) and LAPRC operations had the highest rate of CD 3-4 complications (18.4%). Most (39.6%) of the referred patients were from other UK hospitals. CONCLUSION Advanced colorectal cancer can be successfully treated in a dedicated referral centre, achieving R0 resection in over 90% with low morbidity and mortality. Implementation of a standardized referral pathway is encouraged.
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Affiliation(s)
- C Kontovounisios
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - E Tan
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - N Pawa
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK
| | - G Brown
- Department of Radiology, The Royal Marsden Hospital, London, UK
| | - D Tait
- Department of Clinical Oncology, The Royal Marsden Hospital, London, UK
| | - D Cunningham
- Gastrointestinal and Lymphoma Unit, The Royal Marsden Hospital, London, UK
| | - S Rasheed
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - P Tekkis
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
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8
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Quyn A, Austin K, Young J, Badgery-Parker T, Masya L, Roberts R, Solomon M. Outcomes of pelvic exenteration for locally advanced primary rectal cancer: Overall survival and quality of life. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2016; 42:823-8. [DOI: 10.1016/j.ejso.2016.02.016] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 01/22/2016] [Accepted: 02/11/2016] [Indexed: 10/22/2022]
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9
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Luo YJ, Liu ZL, Ye PC, Fu ZM, Lu F, Suleiman AA, Liao J, Xiao JW. Safety and efficacy of intraoperative iodine-125 seed implantation brachytherapy for rectal cancer patients: A retrospective clinical research. J Gastroenterol Hepatol 2016; 31:1076-84. [PMID: 26643583 DOI: 10.1111/jgh.13261] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 11/27/2015] [Accepted: 11/29/2015] [Indexed: 01/20/2023]
Abstract
BACKGROUND This pilot study was performed to evaluate the risk of anastomotic leakage (AL) and pelvic autonomic nerve dysfunction, and the effects of (125) I brachytherapy after intraoperative permanent implantation of iodine-125 seeds within the patients with rectal carcinoma. METHODS In a cohort consisting of 80 rectal cancer patients who received potentially curative resection of rectal carcinoma with implantation of (125) I brachytherapy or radical resection of rectal carcinoma underwent total mesorectal excision. The incidences of AL, fecal incontinence, urinary dysfunction, and sexual dysfunction were calculated for comparison, and risk factors for these complications were analyzed by logistic regression. Rates of tumor recurrence and overall survival were evaluated. RESULTS Six out of 17 (35.29%) patients in the (125) I implant group and 1 out of 34 (2.94%) patients in the non-implant group were complicated with AL (P = 0.006). The incidences of urinary dysfunction (P = 0.005) and fecal incontinence (P = 0.023) were significantly different between the two groups. Multivariate analyses revealed that (125) I brachytherapy was an independent risk factor for AL (odds ratio, 18.702; 95%CI, 1.802-194.062; P = 0.014) and urinary dysfunction (odds ratio, 4.340; 95%CI, 1.158-16.264; P = 0.029), respectively. At postoperative 2-year, the recurrence rates were 5.56% in the (125) I implant group and 9.09% in the non-implant group (P = 0.029). CONCLUSIONS Intraoperative implantation of (125) I brachytherapy significantly increases the risk of AL, fecal incontinence, urinary dysfunction, and improves local control and do not improve overall survival after total mesorectal excision.
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Affiliation(s)
- Ya-Jun Luo
- Department of Gastrointestinal Surgery, The Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China.,Institute of Hepatobiliary, Pancreatic and Intestinal Disease, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Zi-Lin Liu
- Department of Gastrointestinal Surgery, The Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China.,Institute of Hepatobiliary, Pancreatic and Intestinal Disease, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Peng-Cheng Ye
- Department of Gastrointestinal Surgery, The Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China.,Institute of Hepatobiliary, Pancreatic and Intestinal Disease, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Zhi-Ming Fu
- Department of Gastrointestinal Surgery, The Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China.,Institute of Hepatobiliary, Pancreatic and Intestinal Disease, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Fei Lu
- Department of Gastrointestinal Surgery, The Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China.,Institute of Hepatobiliary, Pancreatic and Intestinal Disease, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Abdihakin Ali Suleiman
- Department of Gastrointestinal Surgery, The Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China.,Institute of Hepatobiliary, Pancreatic and Intestinal Disease, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Juan Liao
- Department of Digestive Internal Medicine, The Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Jiang-Wei Xiao
- Department of Gastrointestinal Surgery, The Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China.,Institute of Hepatobiliary, Pancreatic and Intestinal Disease, North Sichuan Medical College, Nanchong, Sichuan, China
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Kim SK, Kim SY, Kim JH, Roh SA, Cho DH, Kim YS, Kim JC. A nineteen gene-based risk score classifier predicts prognosis of colorectal cancer patients. Mol Oncol 2014; 8:1653-66. [PMID: 25049118 DOI: 10.1016/j.molonc.2014.06.016] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 06/16/2014] [Indexed: 12/30/2022] Open
Abstract
Colorectal cancer (CRC) patients frequently experience disease recurrence and distant metastasis. This study aimed to identify prognostic indicators, including individual responses to chemotherapy, in CRC patients. RNA-seq data was generated using 54 samples (normal colon, primary CRC, and liver metastases) from 18 CRC patients and genes associated with CRC aggressiveness were identified. A risk score based on these genes was developed and validated in four independent CRC patient cohorts (n = 1063). Diverse statistical methods were applied to validate the risk scoring system, including a generalized linear model likelihood ratio test, Kaplan-Meier curves, a log-rank test, and the Cox model. TREM1 and CTGF were identified as two activated regulators associated with CRC aggressiveness. A risk score based on 19 genes regulated by TREM1 or CTGF activation (TCA19) was a significant prognostic indicator. In multivariate and subset analyses based on pathological staging, TCA19 was an independent risk factor (HR = 1.894, 95% CI = 1.227-2.809, P = 0.002). Subset stratification in stage III patients revealed that TCA19 had prognostic potential and identified patients who would benefit from adjuvant chemotherapy, regardless of age. The TCA19 predictor represents a novel diagnostic tool for identifying high-risk CRC patients and possibly predicting the response to adjuvant chemotherapy.
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Affiliation(s)
- Seon-Kyu Kim
- Medical Genomics Research Centre, Korea Research Institute of Bioscience and Biotechnology, Daejeon, Korea
| | - Seon-Young Kim
- Medical Genomics Research Centre, Korea Research Institute of Bioscience and Biotechnology, Daejeon, Korea
| | - Jeong-Hwan Kim
- Medical Genomics Research Centre, Korea Research Institute of Bioscience and Biotechnology, Daejeon, Korea
| | - Seon Ae Roh
- Department of Surgery, University of Ulsan College of Medicine, Seoul, Korea; Department of Cancer Research, Institute of Innovative Cancer Research and Asan Institute for Life Sciences, Asan Medical Centre, Seoul, Korea
| | - Dong-Hyung Cho
- Department of Cancer Research, Institute of Innovative Cancer Research and Asan Institute for Life Sciences, Asan Medical Centre, Seoul, Korea; Graduate School of East-West Medical Science, Kyung Hee University, Gyeonggi-do, Korea
| | - Yong Sung Kim
- Medical Genomics Research Centre, Korea Research Institute of Bioscience and Biotechnology, Daejeon, Korea; Department of Cancer Research, Institute of Innovative Cancer Research and Asan Institute for Life Sciences, Asan Medical Centre, Seoul, Korea.
| | - Jin Cheon Kim
- Department of Surgery, University of Ulsan College of Medicine, Seoul, Korea; Department of Cancer Research, Institute of Innovative Cancer Research and Asan Institute for Life Sciences, Asan Medical Centre, Seoul, Korea.
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11
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Akagi Y, Hisaka T, Mizobe T, Kinugasa T, Ogata Y, Shirouzu K. Histopathological predictors for local recurrence in patients with T3 and T4 rectal cancers without preoperative chemoradiotherapy. J Surg Oncol 2014; 110:739-44. [DOI: 10.1002/jso.23678] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 05/15/2014] [Indexed: 12/24/2022]
Affiliation(s)
- Yoshito Akagi
- Department of Surgery; Kurume University School of Medicine; Kurume Japan
| | - Toru Hisaka
- Department of Surgery; Kurume University School of Medicine; Kurume Japan
| | - Tomoaki Mizobe
- Department of Surgery; Kurume University School of Medicine; Kurume Japan
| | - Tetsushi Kinugasa
- Department of Surgery; Kurume University School of Medicine; Kurume Japan
| | - Yutaka Ogata
- Department of Surgery; Kurume University School of Medicine; Kurume Japan
| | - Kazuo Shirouzu
- Department of Surgery; Kurume University School of Medicine; Kurume Japan
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12
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van Leersum N, Snijders H, Wouters M, Henneman D, Marijnen C, Rutten H, Tollenaar R, Tanis P. Evaluating national practice of preoperative radiotherapy for rectal cancer based on clinical auditing. Eur J Surg Oncol 2013; 39:1000-6. [DOI: 10.1016/j.ejso.2013.06.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 04/02/2013] [Accepted: 06/06/2013] [Indexed: 01/30/2023] Open
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13
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Abstract
BACKGROUND Pelvic exenteration is a potentially curative treatment for locally advanced primary or recurrent rectal cancer. OBJECTIVE This systematic review examines the current evidence regarding clinical and oncological outcomes in patients with locally advanced primary and recurrent rectal cancer who undergo pelvic exenteration. DATA SOURCES A literature search of PubMed, Medline, and the Cochrane library was undertaken, and studies published in the English language from January 2000 to August 2012 were identified. STUDY SELECTION Prospective and retrospective studies that report outcomes of pelvic exenteration for primary advanced and locally recurrent rectal cancer with or without subgroup evaluation were included for examination. MAIN OUTCOME MEASURES Oncological outcomes included 5-year survival, median survival, and local recurrence rates. Clinical outcomes included complication rates and perioperative mortality rates. RESULTS A total of 23 studies with 1049 patients were reviewed. The complication rates ranged from 37% to 100% (median, 57%) and the perioperative mortality rate ranged from 0% to 25% (median, 2.2%). The rate of local recurrence ranged from 4.8% to 61% (median, 22%). The median survival for primary advanced rectal cancers was 14 to 93 months (median, 35.5 months) and 8 to 38 months (median, 24 months) for locally recurrent rectal cancer. LIMITATIONS Our review was limited by the small sample sizes from single-institutional studies reporting outcomes over long periods of time with heterogeneity in both the disease and treatments reported. CONCLUSIONS Although the human costs and risks are significant, the potentially favorable survival outcomes make this acceptable in the absence of other effective treatment modalities that would otherwise result in debilitating symptoms that afflict patients who have advanced pelvic malignancy.
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14
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Dozois E, Privitera A, Holubar S, Aldrete J, Sim F, Rose P, Walsh M, Bower T, Leibovich B, Nelson H, Larson D. High sacrectomy for locally recurrent rectal cancer: Can long-term survival be achieved? J Surg Oncol 2010; 103:105-9. [DOI: 10.1002/jso.21774] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2010] [Accepted: 09/14/2010] [Indexed: 12/12/2022]
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15
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Real-time magnetic resonance-guided microwave coagulation therapy for pelvic recurrence of rectal cancer: initial clinical experience using a 0.5 T open magnetic resonance system. Dis Colon Rectum 2010; 53:1555-62. [PMID: 20940606 DOI: 10.1007/dcr.0b013e3181e8f4b6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This study aims to evaluate consecutive cases of recurrent rectal cancer in the pelvic cavity treated with microwave coagulation therapy using real-time navigation by an open magnetic resonance system. METHODS Nine recurrent pelvic lesions in 8 patients after curative resection of rectal cancer were treated with real-time magnetic resonance-guided microwave coagulation therapy as a palliative local therapy to reduce tumor volume and/or local pain. Clinical and pathological data were collected retrospectively by reviewing medical records and clinical imaging results. RESULTS Seven patients received other treatments before real-time magnetic resonance-guided microwave coagulation. Six patients had distant synchronous metastases. Three patients underwent surgery under lumbar anesthesia. Microwave coagulation was performed percutaneously in 5 lesions and under laparotomy in 4 lesions. Although adverse events related to microwave coagulation (skin necrosis and nerve injury) were observed, no fatal complications occurred. Local re-recurrence was observed in 2 of 9 ablated lesions. Except for 1 patient who died of chronic renal failure, the remaining 7 patients died of cancer. Median overall survival after microwave coagulation for all patients was 10 months (range, 4-37 mo). Median overall survival after discovery of pelvic recurrence in all patients was 22 months (range, 9-42 mo). CONCLUSIONS The benefits of using an open magnetic resonance system in the pelvic cavity include the abilities to treat tumors that cannot be visualized by other modalities, to demonstrate internal architectural changes during treatment, to differentiate treated vs untreated areas, and to allow adjustments to the treatment plan during the procedure. Additional studies are required to clarify the efficacy of tumor coagulation for local control.
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Sagar PM, Gonsalves S, Heath RM, Phillips N, Chalmers AG. Composite abdominosacral resection for recurrent rectal cancer. Br J Surg 2009; 96:191-6. [PMID: 19160364 DOI: 10.1002/bjs.6464] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND En bloc resection of the tumour and adjacent involved organs offers the only realistic curative option for patients with locally recurrent rectal cancer. This study assessed outcomes of composite resection for recurrent tumours involving the sacrum. METHODS A consecutive series of patients underwent composite abdominosacral resection (abdominal mobilization and stoma construction followed by sacral division and tumour retrieval) for recurrent rectal cancer between 2001 and 2007. Patients were staged with preoperative computed tomography, magnetic resonance imaging and positron emission tomography. Data were collected prospectively. RESULTS Forty patients (28 men; median age 59 (range 31-77) years) underwent surgery with sacral division at the S2/3 interface in 13, S3/4 level in 20 and S4/5 level in seven patients. One patient died and 24 had complications. An R0 resection was achieved in 20 patients and conferred benefit in disease-free interval over an R1 resection. The mean disease-free interval was 55.6 (95 per cent confidence interval (c.i.) 40.0 to 71.3) months for R0 and 32.2 (95 per cent c.i. 19.7 to 44.7) months for R1 resection (P = 0.048). CONCLUSION Composite abdominosacral resection of locally recurrent rectal cancer is an effective treatment for a difficult clinical scenario.
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Affiliation(s)
- P M Sagar
- Department of Colon and Rectal Surgery, General Infirmary at Leeds, Leeds, UK.
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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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18
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Soyka JD, Veit-Haibach P, Strobel K, Breitenstein S, Tschopp A, Mende KA, Lago MP, Hany TF. Staging Pathways in Recurrent Colorectal Carcinoma: Is Contrast-Enhanced 18F-FDG PET/CT the Diagnostic Tool of Choice? J Nucl Med 2008; 49:354-61. [DOI: 10.2967/jnumed.107.048249] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
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Patterns of recurrence following therapy for rectal cancer. COLORECTAL CANCER 2007. [DOI: 10.1017/cbo9780511902468.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Henry LR, Sigurdson E, Ross EA, Lee JS, Watson JC, Cheng JD, Freedman GM, Konski A, Hoffman JP. Resection of isolated pelvic recurrences after colorectal surgery: long-term results and predictors of improved clinical outcome. Ann Surg Oncol 2007; 14:2000-9. [PMID: 17431726 DOI: 10.1245/s10434-006-9343-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Recurrence in the pelvis after resection of a rectal or rectosigmoid cancer presents a dilemma. Resection offers the only reasonable probability for cure, but at the cost of perioperative morbidity and potential mortality. Clinical decision making remains difficult. METHODS Patients resected with curative intent for isolated pelvic recurrences after curative colorectal surgery from 1988 through 2003 were reviewed retrospectively. Clinical and pathologic factors, salvage operations, and complications were recorded. The primary measured outcome was overall survival. Univariate and multivariate analyses were conducted to identify prognostic factors of improved outcome. RESULTS Ninety patients underwent an attempt at curative resection of a pelvic recurrence with median follow-up of 31 months. Complications occurred in 53% of patients. Operative mortality was 4.4% (4 of 90). Median overall survival was 38 months, and estimated 5-year survival was 40%. A total of 51 of 86 patients had known recurrences (15 local, 16 distant, 20 both). Multivariate analysis revealed that preoperative carcinoembryonic antigen level and final margin status were statistically significant predictors of outcome. CONCLUSIONS The resection of pelvic recurrences after colorectal surgery for cancer can be performed with low mortality and good long-term outcome; however, morbidity from such procedures is high. Low preoperative carcinoembryonic antigen and negative margin of resection predict improved survival.
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Affiliation(s)
- Leonard R Henry
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania 19111, USA
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21
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Badger SA, Devlin PB, Neilly PJD, Gilliland R. Preoperative staging of rectal carcinoma by endorectal ultrasound: is there a learning curve? Int J Colorectal Dis 2007; 22:1261-8. [PMID: 17294198 DOI: 10.1007/s00384-007-0273-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2007] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Endorectal ultrasound (ERUS) is becoming an essential tool in the management of rectal cancer. However, accuracy in the assessment of disease staging may be dependent on operator experience. The aim of this study was to determine if a learning curve exists. MATERIALS AND METHODS From October 1999 to December 2004, all patients with rectal cancer had a pre-operative ERUS performed by a single radiologist. ERUS staging was compared with post-operative pathology findings using the tumour, node, metastases (TNM) classification. The accuracy of ERUS in tumour (T) and node (N) staging after each additional consecutive ten patients was calculated. RESULTS One hundred and thirty one patients were investigated by ERUS, of which 36 were excluded, leaving 95 patients in the study (60 men). Overall accuracy for T staging was 71.6%. No improvement with experience was noted (p > 0.05). With regard to T staging, ERUS tended to overstage more frequently than understage (24.2 versus 4.2%). The sensitivity, specificity, positive predictive value and negative predictive value of uT3 staging were 96.6, 33.3, 70.4 and 85.7%, respectively. Overall accuracy of uN staging was 68.8%. ERUS tended to overstage nodal disease more frequently than understage (16.1 versus 15.1%). Sensitivity, specificity, positive predictive value and negative predictive value were calculated for ultrasound-detected nodal disease (73.2, 62.2, 74.5 and 60.5%, respectively). Nodal staging accuracy improved from 50% after assessment of 10 cases to 77% after 30 cases were examined. CONCLUSIONS ERUS is an accurate method for staging rectal cancer pre-operatively. Accurate assessment of tumour stage can be achieved immediately by an experienced radiologist without specific training in ERUS. Nodal staging accuracy tends to improve with experience but reaches a plateau after 30 cases.
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Affiliation(s)
- S A Badger
- Department of Surgery, Altnagelvin Area Hospital, Glenshane Road, Northern Ireland, UK.
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Cho YB, Chun HK, Yun HR, Lee WS, Yun SH, Lee WY. Clinical and pathologic evaluation of patients with recurrence of colorectal cancer five or more years after curative resection. Dis Colon Rectum 2007; 50:1204-10. [PMID: 17566830 DOI: 10.1007/s10350-007-0247-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was designed to evaluate the characteristics of recurrences that occur five or more years after curative resection for colorectal cancer. METHODS This study included a total of 352 patients who were confirmed as having recurrence after curative resection for colorectal cancer during the period from January 1995 to December 2000. Of the 352 patients, 231 had early recurrence (less than 2 years after operation), 103 had intermediate recurrence (2-5 years after operation), and 18 had late recurrence (more than 5 years after operation). The clinicopathologic findings of the patients with late recurrence were compared with those of the other two recurrence groups, with special reference to the pattern of recurrence. RESULTS The rate of late recurrence was 1.2 percent. In the late recurrence group, males outnumbered females by a ratio of 3.5:1 and the mean level of preoperative carcinoembryonic antigen was 4.5 ng/ml, whereas that of the early recurrence group was 30.5 ng/ml. All the lesions in the cases with late recurrence except one lesion were located in the left colon or rectum, the tumors were small-sized and polypoid, and well-differentiated adenocarcinomas were more frequently observed. Distant metastasis, especially lung metastasis, was most frequently observed. CONCLUSIONS Late recurrent colorectal cancer has some characteristics compared with early or intermediate recurrence. Although recurrence at more than five years postoperatively is not common, its possibility should be considered whenever performing follow-up, and surveillance for lung metastasis is recommended after more than five years of surgery.
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Affiliation(s)
- Yong Beom Cho
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Ilwon-dong 50, Gangnam-Gu, Seoul, South Korea
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Henry LR, Sigurdson E, Ross EA, Lee JS, Watson JC, Cheng JD, Freedman GM, Konski A, Hoffman JP. Resection of Isolated Pelvic Recurrences After Colorectal Surgery: Long-Term Results and Predictors of Improved Clinical Outcome. Ann Surg Oncol 2006; 14:1081-91. [PMID: 17176982 DOI: 10.1245/s10434-006-9266-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2005] [Accepted: 10/05/2006] [Indexed: 11/18/2022]
Abstract
BACKGROUND Recurrence in the pelvis after resection of a rectal or rectosigmoid cancer presents a dilemma. Resection offers the only reasonable probability for cure, but at the cost of marked perioperative morbidity and potential mortality. Clinical decision making remains difficult. METHODS Patients who underwent resection with curative intent for isolated pelvic recurrences after curative colorectal surgery from 1988 through 2003 were reviewed retrospectively. Clinical and pathological factors, salvage operations, and complications were recorded. The primary measured outcome was overall survival. Univariate and multivariate analyses were conducted to identify prognostic factors of improved outcome. RESULTS Ninety patients underwent an attempt at curative resection of a pelvic recurrence; median follow-up was 31 months. Complications occurred in 53% of patients. Operative mortality occurred in 4 (4.4%) of 90 patients. Median overall survival was 38 months, and estimated 5-year survival was 40%. A total of 51 of 86 patients had known recurrences (15 local, 16 distant, 20 both). Multivariate analysis revealed that preoperative carcinoembryonic antigen level and final margin status were statistically significant predictors of outcome. CONCLUSIONS The resection of pelvic recurrences after colorectal surgery for cancer can be performed with low mortality and good long-term outcome; however, morbidity from such procedures is high. Low preoperative carcinoembryonic antigen and negative margin of resection predict improved survival.
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Affiliation(s)
- Leonard R Henry
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania 19111, USA
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Okaro AC, Worthington T, Stebbing JF, Broughton M, Caffarey S, Marks CG. Curative resection for low rectal adenocarcinoma: abdomino-perineal vs anterior resection. Colorectal Dis 2006; 8:645-9. [PMID: 16970573 DOI: 10.1111/j.1463-1318.2006.01045.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Local recurrence after abdomino-perineal excision of the rectum for tumours has been reported to occur in up to a third of patients in contrast to 4% after restorative anterior resection. METHOD Low rectal tumours were defined as tumours within 8 cm of the anal verge and were treated by either stapled low anterior resection (SLAR) or abdomino-perineal excision of the rectum (APER). One hundred and seventy-eight patients with tumours in the lower third of the rectum (30% of 591 rectal cancers) underwent surgical resection between 1980 and 2001. Data were collected prospectively; 68 (38%) had SLAR and 110 (62%) had APER with median follow up of approximately 12 years; 54 SLAR (79%) and 76 APER (69%) had curative procedures on clinical and pathological criteria. RESULTS Local and distant recurrence occurred in seven (13%) and eight (15%) patients in the SLAR group and six (8%) and 14 (18%) patients in the APER group, respectively. Overall 5-year survival was 63% and 60% in the SLAR and APER groups, respectively CONCLUSION For rectal cancers within 8 cm of the anal verge, both procedures achieved equivalent results measured by low local recurrence rates and overall survival.
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Affiliation(s)
- A C Okaro
- Colorectal Unit, Royal Surrey County Hospital, Guildford, Surrey, UK
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Caricato M, Borzomati D, Ausania F, Valeri S, Rosignoli A, Coppola R. Prognostic factors after surgery for locally recurrent rectal cancer: an overview. Eur J Surg Oncol 2005; 32:126-32. [PMID: 16377120 DOI: 10.1016/j.ejso.2005.11.001] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2005] [Accepted: 11/08/2005] [Indexed: 01/05/2023] Open
Abstract
PURPOSE Local recurrence of rectal cancer occurs in a considerable group of patients who have undergone radical treatment for primary tumour. The treatment of choice is surgical resection but the prognosis remains poor, as a negative margin excision is possible in only a small subset of patients. A review of prognostic factors for locally recurrent rectal cancer (LRRC) after surgery is presented. METHODS We systematically reviewed the literature for reports on prognostic factors after surgical excision of LRRC. These reports were identified through a review of the Medline database from 1982 to 2004. RESULTS This review highlights the most important prognostic factors for LRRC patients treated with surgery. Data are grouped on the basis of the prognostic factors investigated. CONCLUSIONS R0 resection seems to be the only reliable prognostic factor; however, symptoms, pre-operative CEA doubling time, performance status and pre-operative radiotherapy can help patient selection before surgery. The results of this review provide the basis for improved outcome, aiming to assess patients who would benefit from reoperation.
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Affiliation(s)
- M Caricato
- Department of Surgery, Campus Bio-Medico University, Rome, Italy
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26
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Farouk R, Nelson H, Gunderson LL. Aggressive multimodality treatment for locally advanced irresectable rectal cancer. Br J Surg 2005. [DOI: 10.1046/j.1365-2168.1997.02789.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Folkesson J, Birgisson H, Pahlman L, Cedermark B, Glimelius B, Gunnarsson U. Swedish Rectal Cancer Trial: long lasting benefits from radiotherapy on survival and local recurrence rate. J Clin Oncol 2005; 23:5644-50. [PMID: 16110023 DOI: 10.1200/jco.2005.08.144] [Citation(s) in RCA: 556] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To evaluate the long-term effects on survival and recurrence rates of preoperative radiotherapy in the treatment of curatively operated rectal cancer patients. PATIENTS AND METHODS Of 1,168 randomly assigned patients in the Swedish Rectal Cancer Trial between 1987 and 1990, 908 had curative surgery; 454 of these patients had surgery alone, and 454 were administered preoperative radiotherapy (25 Gy in 5 days) followed by surgery within 1 week. Follow-up was performed by matching against three Swedish nationwide registries (the Swedish Cancer Register, the Hospital Discharge Register, and the Cause of Death Register). RESULTS Median follow-up time was 13 years (range, 3 to 15 years). The overall survival rate in the irradiated group was 38% v 30% in the nonirradiated group (P = .008). The cancer-specific survival rate in the irradiated group was 72% v 62% in the nonirradiated group (P = .03), and the local recurrence rate was 9% v 26% (P < .001), respectively. The reduction of local recurrence rates was observed at all tumor heights, although it was not statistically significant for tumors greater than 10 cm from the anal verge. CONCLUSION Preoperative radiotherapy with 25 Gy in 1 week before curative surgery for rectal cancer is beneficial for overall and cancer-specific survival and local recurrence rates after long-term follow-up.
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Affiliation(s)
- Joakim Folkesson
- Department of Surgical Sciences and Oncology, Uppsala University Hospital, 751 85 Uppsala, Sweden.
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Henry LR, Sigurdson E, Ross E, Hoffman JP. Hydronephrosis Does Not Preclude Curative Resection of Pelvic Recurrences After Colorectal Surgery. Ann Surg Oncol 2005; 12:786-92. [PMID: 16075180 DOI: 10.1245/aso.2005.10.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2004] [Accepted: 04/21/2005] [Indexed: 02/02/2023]
Abstract
BACKGROUND In one third of patients who die of rectal cancer, a pelvic recurrence after resection represents isolated disease for which re-resection may provide cure. These extensive resections can carry high morbidity. Proper patient selection is desirable but difficult. Hydronephrosis has been documented previously to portend a poor prognosis, and some consider it a contraindication to attempted resection. It was our goal to review our experience and either confirm or refute these conclusions. METHODS We performed a retrospective analysis of 90 patients resected with curative intent for pelvic recurrence at our center from 1988 through 2003. Seventy-one records documented the preoperative presence or absence of hydronephrosis. Clinical and pathologic data were recorded. The groups with and without hydronephrosis were compared. RESULTS There were 15 patients with hydronephrosis in this study and 56 without. Although patients with hydronephrosis had shorter overall survival, disease-free survival, and rate of local control, none of these differences was statistically significant. Patients in the hydronephrosis group were younger and had higher-stage primary tumors and larger recurrent tumors. Subsequently, they underwent more extensive resections and were more likely to be treated with adjuvant therapies. There was no difference in the rate of margin-negative resections between the groups. CONCLUSIONS Hydronephrosis correlates with younger patients with larger recurrent tumors undergoing more extensive operations and multimodality therapy but does not preclude curative (R0) resection or independently affect overall survival, disease-free survival, or local control. We believe that it should not be considered a contraindication to attempting curative resection.
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Affiliation(s)
- Leonard R Henry
- Department of Surgical Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, Pennsylvania 19111, USA
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Faria SC, Tamm EP, Varavithya V, Phongkitkarun S, Kaur H, Szklaruk J, Dubrow R, Charnsangavej C. Systematic approach to the analysis of cross-sectional imaging for surveillance of recurrent colorectal cancer. Eur J Radiol 2005; 53:387-96. [PMID: 15741012 DOI: 10.1016/j.ejrad.2004.12.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2004] [Revised: 12/14/2004] [Accepted: 12/17/2004] [Indexed: 11/20/2022]
Abstract
Recurrent disease in colorectal cancer occurs in approximately 50% of patients who undergo a "curative" operation. Tumor recurrence may occur locally (at the anastomotic site), in the mesentery or mesocolon adjacent to the post-operative site, in the nodal echelon downstream to the post-operative site, and as distant metastases to the peritoneal cavity, liver or lung. Local recurrence at the anastomosis is frequently diagnosed at follow-up endoscopic examinations as part of screening for metachronous lesions. Other types of recurrences require imaging studies, most frequently CT or MR imaging to diagnose. We developed an approach to analyze imaging obtained after curative resection of colorectal cancer. Our approach is based on the knowledge of patterns of disease spread, of types of surgical procedures and of pathologic staging. Using this approach has the potential to detect recurrent disease at an early stage because the locoregional and nodal spread of this disease is predictable. Early diagnosis of recurrent disease, even in asymptomatic cases, allows for more effective treatment that can improve the long-term survival of these patients.
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Affiliation(s)
- Silvana C Faria
- Department of Diagnostic Radiology, Division of Diagnostic Imaging, University of Texas M.D. Anderson Cancer Center, Department of Diagnostic Radiology, 1515 Holcombe Blvd., Box 57, Houston, TX 77030, USA
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Hahnloser D, Haddock MG, Nelson H. Intraoperative radiotherapy in the multimodality approach to colorectal cancer. Surg Oncol Clin N Am 2004; 12:993-1013, ix. [PMID: 14989129 DOI: 10.1016/s1055-3207(03)00091-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The addition of intraoperative radiotherapy (IORT) to the multimodality approach for the treatment of locally advanced and locally recurrent colorectal cancer seems to result in improvements in local control and long-term survival. Local control and survival are most likely in patients in whom a gross total resection is accomplished. Peripheral nerve is the dose-limiting structure for patients treated with IORT. Further improvements in local control require the addition of dose modifiers during external beam radiotherapy or IORT. Distant relapse remains problematic, and effective systemic therapy is necessary to significantly improve long-term survival.
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Affiliation(s)
- Dieter Hahnloser
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Kakuda JT, Lamont JP, Chu DZJ, Paz IB. The role of pelvic exenteration in the management of recurrent rectal cancer. Am J Surg 2004; 186:660-4. [PMID: 14672775 DOI: 10.1016/j.amjsurg.2003.08.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Use of extirpative surgery in the setting of recurrent rectal cancer is controversial given the poor overall outcome of such patients and the morbidity associated with exenteration. METHODS A retrospective review of patients treated for recurrent rectal cancer from 1990 to 2002 was performed. RESULTS Twenty-two patients underwent pelvic exenteration. Seventeen underwent potentially curative resection, 5 were for palliation only. There was 1 operative death. Fifteen suffered at least 1 complication; 9 suffered multiple complications. Ten patients required readmission to the hospital. The overall disease-free interval was 11 months. Potentially curative and palliative resections resulted in median survivals of 20.4 and 8.4 months, respectively (P = 0.049). CONCLUSIONS While patients may derive oncologic and palliative benefits from exenteration, the price in terms of operative morbidity remains high. Newer measures of operative morbidity are necessary to better appraise the value of this radical approach to recurrent rectal cancer.
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Affiliation(s)
- James T Kakuda
- City of Hope National Medical Center, Department of General Oncologic Surgery, Duarte, CA 91010, USA
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Hahnloser D, Nelson H, Gunderson LL, Hassan I, Haddock MG, O'Connell MJ, Cha S, Sargent DJ, Horgan A. Curative potential of multimodality therapy for locally recurrent rectal cancer. Ann Surg 2003; 237:502-8. [PMID: 12677146 PMCID: PMC1514480 DOI: 10.1097/01.sla.0000059972.90598.5f] [Citation(s) in RCA: 141] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To assess the results of multimodality therapy for patients with recurrent rectal cancer and to analyze factors predictive of curative resection and prognostic for overall survival. SUMMARY BACKGROUND DATA Locally recurrent rectal cancer is a difficult clinical problem, and radical treatment options with curative intent are not generally accepted. METHODS A total of 394 patients underwent surgical exploration for recurrent rectal cancer. Ninety were found to have unresectable local or extrapelvic disease and 304 underwent resection of the recurrence. The latter patients were prospectively followed to determine long-term survival and factors influencing survival. RESULTS Overall 5-year survival was 25%. Curative, negative resection margins were obtained in 45% of patients; in these patients a 5-year survival of 37% was achieved, compared to 16% (P <.001) in patients with either microscopic or gross residual disease. In a logistic regression analysis, initial surgery with end-colostomy and symptomatic pain (both univariate) and increasing number of sites of the recurrent tumor fixation in the pelvis (multivariate) were associated with palliative surgery. Overall survival was significantly decreased for symptomatic pain (P <.001) and more than one fixation (P =.029). Survival following extended resection of adjacent organs was not different from limited resection (28% vs. 21%, P =.11). Patient demographics and factors related to the initial rectal cancer did not affect outcome. Perioperative mortality was only 0.3%, but significant morbidity occurred in 26% of patients, with pelvic abscess being the most common complication. CONCLUSIONS This study demonstrates that many patients with locally recurrent rectal cancer can be resected with negative margins. Long-term survival can be achieved, especially for patients with no symptoms and minimal fixation of the recurrence in the pelvis, provided no gross residual disease remains.
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Affiliation(s)
- Dieter Hahnloser
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Tumores sacropélvicos primarios y secundarios. Tratamiento con cirugía radical y radioterapia intraoperatoria. Cir Esp 2003. [DOI: 10.1016/s0009-739x(03)72096-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Hruby G, Barton M, Miles S, Carroll S, Nasser E, Stevens G. Sites of local recurrence after surgery, with or without chemotherapy, for rectal cancer: implications for radiotherapy field design. Int J Radiat Oncol Biol Phys 2003; 55:138-43. [PMID: 12504046 DOI: 10.1016/s0360-3016(02)03812-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
PURPOSE To examine the sites of pelvic recurrence in patients with rectal cancer previously untreated with radiotherapy to determine the relative frequency and location of recurrence within the pelvis. METHODS AND MATERIALS The records of patients with locally recurrent rectal cancer referred to three radiation oncology departments between 1984 and 1997 were reviewed. The data collected included the date and type of the initial resection and the pathologic findings. The site of recurrence within the pelvis, presence of metastasis, and date of recurrence were documented. RESULTS A total of 269 patients were included. Tumor had invaded through the muscularis in 74% and involved other organs in 9%. Fifty-two percent of patients were node positive at initial surgery. The median time to local recurrence from surgery was 18 months (range 15-20) and from local recurrence to death was 14 months (range 12-17). Both the initial tumor stage and the resection type influenced the recurrence location within the pelvis (p <0.01). T4 tumors comprised only 9% of initial T stage tumors but accounted for 38% of anterior central pelvic recurrences (p <0.01). All perineal recurrences occurred after abdominoperineal resection. The sites of recurrence within the pelvis were the posterior central pelvis (47%) and anastomotic (21%). CONCLUSION If those patients with T4 tumors at presentation were excluded, 89% had local recurrence at, or posterior to, the anastomosis. Furthermore, if we exclude both patients who underwent abdominoperineal resection and those with T4 tumors at presentation, the rate increases to 93%. The rate of recurrence anteriorly (7%) does not justify routine radiation of the anterior pelvis beyond that required to adequately cover the anastomotic site.
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Affiliation(s)
- George Hruby
- Department of Radiation Oncology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
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Kapiteijn E, Putter H, van de Velde CJH. Impact of the introduction and training of total mesorectal excision on recurrence and survival in rectal cancer in The Netherlands. Br J Surg 2002; 89:1142-9. [PMID: 12190680 DOI: 10.1046/j.1365-2168.2002.02196.x] [Citation(s) in RCA: 367] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Local control and survival following surgical treatment of rectal cancer have been improved by the introduction of total mesorectal excision (TME). The aim of this study was to determine the nationwide impact of the introduction and training of TME on recurrence and survival in rectal cancer. METHODS Short- and long-term outcomes of a recently published trial of rectal cancer surgery (TME trial) were compared with results from an older trial (cancer recurrence and blood transfusion (CRAB) trial), in which conventional surgery was performed without quality control. Only patients who were operated on with curative intent and who did not receive neoadjuvant radiotherapy were studied. Differences in clinicopathological characteristics were corrected for by multivariate analysis. To ensure valid comparisons, only events that occurred within 2 years of operation were analysed with regard to long-term outcome. RESULTS In the univariate analysis, a higher clinical anastomotic leak rate was found in patients following low anterior resection in the TME trial (P = 0.046), but this association was not significant in the multivariate analysis. The local recurrence rate decreased from 16 per cent in the CRAB trial to 9 per cent in the TME trial, and type of operation (conventional (CRAB trial) versus TME (TME trial)) was an independent predictor of local recurrence (P = 0.002). Type of operation was also an independent predictor of overall survival (P = 0.019); there was a higher survival rate in the TME trial. CONCLUSION The introduction and training of TME has led to improved long-term outcome of patients with rectal cancer in the Netherlands.
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Affiliation(s)
- E Kapiteijn
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
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Abstract
Follow-up after curative treatment of patients with colorectal cancer has as its main aims the quality assessment of the treatment given, patient support, and improved outcome by the early detection and treatment of cancer recurrence. How often, and to what extent, the final aim, improved survival, is indeed realised is so far unclear. A literature search was performed to provide quantitative estimates for the main determinants of the effectiveness of the follow-up. Data were extracted from a total of 267 articles and databases, and were aggregated using modern meta-analytic methods. In order to provide one more colorectal cancer patient with long-term survival through follow-up, 360 positive follow-up tests and 11 operations for colorectal cancer recurrence are needed. In the remaining 359 tests and 10 operations, either no gains are achieved or harm is done. As the third aim of colorectal cancer follow-up, improved survival, is realised in only few patients, follow-up should focus less on diagnosis and treatment of recurrences. It should be of limited intensity and duration (3 years), and the search for preclinical cancer recurrence should primarily be performed by carcino-embryonic antigen (CEA) testing and ultrasound (US). The focus of colorectal cancer follow-up should shift from the early detection of recurrence towards quality assessment and patient support. As support that is as good or even better can be provided by a patient's general practitioner (GP) or by specialised nursing personnel, there is no need for routine follow-up to be performed by the surgeon.
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Affiliation(s)
- J Kievit
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands.
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Abstract
One of the main problems in the treatment of rectal cancer is the development of local recurrences. In the last decades, major improvements have been realized in the surgical treatment of rectal cancer. The introduction of TME-surgery has led to a large reduction in local recurrence rates and improved survival. TME-based operations are now established as the standard of care for rectal cancer, and should form the basis for trials concerning the role of (neo)adjuvant therapy. However, training and quality control are prerequisites to obtain good results in all surgeons' hands. Furthermore, standardization in the description of operations and reporting of pathology specimens should be implemented as important features of quality control. In general, it is thought that high volume and specialist care produces superior results to low volume and non-specialist care, especially for those less frequent forms of cancer and in technically difficult operations, like those for rectal cancer. However, limiting the performance of rectal cancer surgery to highly specialized surgeons or to only those general surgeons who perform more than a certain volume is impractical in view of the prevalence of rectal cancer. This article reviews developments in the treatment of especially mobile rectal cancer and pays attention to variability in outcomes and quality assurance of surgery.
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Affiliation(s)
- E Kapiteijn
- Department of Surgery K6-R, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
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Nissan A, Dangelica MI, Shoup MC, Hartley JE. Randomized clinical trials in rectal and anal cancer. Surg Oncol Clin N Am 2002; 11:149-72, ix. [PMID: 11928798 DOI: 10.1016/s1055-3207(03)00079-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Treatment of rectal cancer has changed dramatically over the past two decades. Radical surgery alone for resectable rectal cancer has been replaced by combined modality therapy. Interest in optimizing sphincter preservation and quality of life motivated surgeons to seek less radical surgery without compromising oncologic principles.
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Affiliation(s)
- Aviram Nissan
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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Sadahiro S, Suzuki T, Ishikawa K, Yasuda S, Tajima T, Makuuchi H, Murayama C, Ohizumi Y. Intraoperative radiation therapy for curatively resected rectal cancer. Dis Colon Rectum 2001; 44:1689-95. [PMID: 11711743 DOI: 10.1007/bf02234391] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Intraoperative radiotherapy has been used for local control of locally advanced rectal cancer. The aim of this study was to investigate the efficacy of intraoperative radiotherapy for curatively resected rectal cancer. METHODS Between 1982 and 1998, intraoperative radiotherapy was administered in combination with curative resection in 78 patients with adenocarcinoma of the middle or lower third of the rectum (intraoperative radiotherapy group). Sixty-two of the patients had received preoperative radiotherapy with 20 Gy. Intraoperative radiotherapy was performed by a new strategy in which an electron beam was administered as uniformly as possible to the entire dissected surface of the pelvis. Retrospective comparisons were made with 248 patients treated by surgery alone during the same period (non-intraoperative radiotherapy group). RESULTS The differences in tumor stage or surgical procedures between the two groups were not statistically significant. Survival, disease-free survival, and local recurrence-free survival in the intraoperative radiotherapy group were significantly more favorable than in the non-intraoperative radiotherapy group (P = 0.01, P = 0.04, and P = 0.02). Differences in survival were observed in Stage II patients but not in Stage I or Stage III patients. The local failure rate was 2.6 percent in the intraoperative radiotherapy group and 11.3 percent in the non-intraoperative radiotherapy group, and the difference was significant (P = 0.02). The distant metastasis rate was 18.0 percent in the intraoperative radiotherapy group and 19.5 percent in the non-intraoperative radiotherapy group, and the difference was not significant. There was a significantly higher rate of wound infection in the intraoperative radiotherapy group, but no infections were serious. CONCLUSIONS In patients with adenocarcinoma of the middle or lower third of the rectum, intraoperative radiotherapy to the entire dissected surface of the pelvis reduced local recurrence in Stage II and Stage III patients and improved survival in Stage II patients.
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Affiliation(s)
- S Sadahiro
- Department of Surgery and Department of Radiology, Tokai University School of Medicine, Kanagawa, Japan
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40
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Kapiteijn E, Marijnen CA, Nagtegaal ID, Putter H, Steup WH, Wiggers T, Rutten HJ, Pahlman L, Glimelius B, van Krieken JH, Leer JW, van de Velde CJ. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 2001; 345:638-46. [PMID: 11547717 DOI: 10.1056/nejmoa010580] [Citation(s) in RCA: 3009] [Impact Index Per Article: 130.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Short-term preoperative radiotherapy and total mesorectal excision have each been shown to improve local control of disease in patients with resectable rectal cancer. We conducted a multicenter, randomized trial to determine whether the addition of preoperative radiotherapy increases the benefit of total mesorectal excision. METHODS We randomly assigned 1861 patients with resectable rectal cancer either to preoperative radiotherapy (5 Gy on each of five days) followed by total mesorectal excision (924 patients) or to total mesorectal excision alone (937 patients). The trial was conducted with the use of standardization and quality-control measures to ensure the consistency of the radiotherapy, surgery, and pathological techniques. RESULTS Of the 1861 patients randomly assigned to one of the two treatment groups, 1805 were eligible to participate. The overall rate of survival at two years among the eligible patients was 82.0 percent in the group assigned to both radiotherapy and surgery and 81.8 percent in the group assigned to surgery alone (P=0.84). Among the 1748 patients who underwent a macroscopically complete local resection, the rate of local recurrence at two years was 5.3 percent. The rate of local recurrence at two years was 2.4 percent in the radiotherapy-plus-surgery group and 8.2 percent in the surgery-only group (P<0.001). CONCLUSIONS Short-term preoperative radiotherapy reduces the risk of local recurrence in patients with rectal cancer who undergo a standardized total mesorectal excision.
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Affiliation(s)
- E Kapiteijn
- Department of Surgery, Leiden University Medical Center, The Netherlands
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Kraemer M, Wiratkapun S, Seow-Choen F, Ho YH, Eu KW, Nyam D. Stratifying risk factors for follow-up: a comparison of recurrent and nonrecurrent colorectal cancer. Dis Colon Rectum 2001; 44:815-21. [PMID: 11391141 DOI: 10.1007/bf02234700] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The selection of patients for individualized follow-up and adjuvant therapy after curative resection of colorectal carcinoma depends on finding reliable prognostic criteria for recurrence. However, such criteria are not universally accepted, and follow-up is often standardized for all patients without regard for each individual's level of risk of recurrence. Such a system of follow-up is not cost-effective. METHODS A comparison of operative findings, pathologic features, and follow-up data of 1,731 cases of nonrecurrent colorectal cancer (821 colon, 910 rectum) with 357 cases of recurrent colorectal cancer (164 colon, 193 rectum) following potentially curative surgery was made, and results were analyzed to ascertain criteria for stratifying follow-up according to risk factors. RESULTS Single-factor analysis showed that Dukes staging and tumor invasion were significantly associated with recurrence in both rectal and colon carcinoma. Tumor fixation and grading were additional significant factors in rectal cancer. Recurrence rates, time to recurrence, site of recurrence (locoregional vs. distant), and pattern of metastatic spread were not significantly affected by original tumor site. Recurrence was not significantly affected by patient age and gender. Individual surgeon performance in this series had also no significant effects on tumor recurrence. With multivariate analysis only, Dukes staging and tumor invasion into adjacent tissues were found to be independent adverse prognostic factors for recurrence. CONCLUSIONS Dukes staging and tumor penetration into adjacent tissues are the only significant adverse prognostic factors for tumor recurrence of colonic and rectal carcinoma. Tumor grade and tumor fixation are additional adverse prognostic factors in rectal cancer. Guidelines for follow-up may be based on these factors and follow-up thus stratified according to risk of developing recurrence.
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Affiliation(s)
- M Kraemer
- Department of Colorectal Surgery, Singapore General Hospital, Singapore
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Anthony T, Fleming JB, Bieligk SC, Sarosi GA, Kim LT, Gregorcyk SG, Simmang CL, Turnage RH. Postoperative colorectal cancer surveillance. J Am Coll Surg 2000; 190:737-49. [PMID: 10873011 DOI: 10.1016/s1072-7515(99)00298-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- T Anthony
- Division of Surgical Oncology, University of Texas, Southwestern Medical Center, Dallas 75235-9031, USA
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43
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Abstract
OBJECTIVE There have been significant developments in treatment for rectal carcinoma, both in surgical and adjuvant therapy. They may however have associated morbidity and hence individualized therapy for rectal cancer is desirable, to optimize treatment but avoid over-treatment for cases where the risk of recurrence is low. MATERIALS AND METHODS A literature review was undertaken of the reported incidence of recurrence of rectal carcinoma following curative surgery, factors which predispose to recurrence and proposed mechanisms for recurrence, and the evidence for each critically evaluated. RESULTS The incidence of local recurrence of rectal carcinoma following curative resection ranges from 2.6% to 32%, with an average of 15%. Tumour stage is the strongest predictor of tumour recurrence. Upstaging using molecular biology may predict increased risk of recurrence but is not yet proven. Histological factors including differentiation and vascular invasion increase recurrence but are imprecise. Tumour microvascular density and vascular endothelial growth factor (VEGF) levels may be predictive but need refinement. Adequate resection margins are important but recurrence may occur despite this. Tumour cell spillage and distant dissemination may be a mechanism for tumour recurrence following curative resection, but further research is required before this could be applied clinically. CONCLUSION Recurrence of rectal cancer remains a significant problem following 'curative' surgery. Multiple factors may influence recurrence risk, though currently however only tumour stage and histological resection margins have demonstrated sufficient importance for management decisions to be made upon them.
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Affiliation(s)
- Heriot
- Department of Colorectal Surgery, St George's Hospital, London, UK
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44
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Horgan AF, Finlay IG. Preoperative staging of rectal cancer allows selection of patients for preoperative radiotherapy. Br J Surg 2000; 87:575-9. [PMID: 10792312 DOI: 10.1046/j.1365-2168.2000.01396.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Variability in rates of local recurrence following resection of rectal cancer has led to the suggestion that all patients should undergo preoperative radiotherapy. This centre employs a selective policy of radiotherapy only in patients with evidence of advanced local disease determined by preoperative staging. METHODS A retrospective review was carried out of 114 consecutive patients with rectal cancer. Patients were divided before operation into palliative and curative groups based on preoperative staging. Only patients in the palliative group were offered preoperative radiotherapy. Total mesorectal excision (TME) was performed for all tumours of the middle or lower rectum. RESULTS The perioperative mortality rate was 0.9 per cent and anastomotic dehiscence occurred in 2.8 per cent. Local recurrence developed in 4 per cent of patients in the 'curative' group and in seven of 15 of those assigned to the palliative group before operation (P < 0.01). Positive lateral resection margins were significantly associated with a risk of subsequent recurrence (ten of 13 versus three (3 per cent) of 93; P < 0.001). CONCLUSION Preoperative adjuvant radiotherapy can be omitted reasonably in patients in whom there is no evidence of locally advanced disease, provided that adequate surgery, incorporating TME for low tumours, is performed.
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Affiliation(s)
- A F Horgan
- Department of Coloproctology, Glasgow Royal Infirmary, Glasgow G31 2ER, UK
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45
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Abstract
BACKGROUND Since its first description in 1948, total pelvic exenteration has been a surgical option for the treatment of locally advanced rectal cancer in selected patients. During these 50 years, it has remained a formidable procedure with high mortality and substantial morbidity. This report describes the results of total pelvic exenteration for rectal cancer in terms of post-operative mortality, morbidity, and longterm survival in patients with locally advanced primary and recurrent rectal cancer. STUDY DESIGN A study of the patient records revealed that 24 patients underwent total pelvic exenteration as the treatment for locally advanced primary or recurrent cancer of the rectum from 1983 to 1998. The charts of the patients were reviewed, and morbidity and mortality were documented. The survival of the patients was also analyzed. RESULTS Fifteen patients had primary tumor and 9 had locally recurrent cancer. The mean age was 62 years old. There were no postoperative deaths, and the complication rate was 54%. In the treatment of primary tumor, bowel continuity was possible in 60% of the patients. Previous radiation or operation for recurrent disease was not associated with increased morbidity. The overall 5-year survival was 44%. The 5-year survival of patients with primary cancer was 64% and was significantly better than the rate for those with recurrent disease. Only one patient with recurrent disease survived more than 24 months. CONCLUSIONS Total pelvic exenteration now can be performed with low mortality rates, but the morbidity remains high. In the treatment of primary rectal cancer, good survival (64%) can be achieved, but results are dismal for the treatment of recurrent disease. We suggest better selection of patients for this procedure, especially as a treatment for recurrent rectal cancer.
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Affiliation(s)
- W L Law
- Department of Surgery, Queen Mary Hospital, University of Hong Kong Medical Centre, Hong Kong
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Wanebo HJ, Antoniuk P, Koness RJ, Levy A, Vezeridis M, Cohen SI, Wrobleski DE. Pelvic resection of recurrent rectal cancer: technical considerations and outcomes. Dis Colon Rectum 1999; 42:1438-48. [PMID: 10566532 DOI: 10.1007/bf02235044] [Citation(s) in RCA: 175] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE Pelvic recurrence of rectal cancer is an ominous event for the patient and a formidable challenge to the managing surgeon. We reviewed the results of abdominosacral resection to manage these patients and correlated outcome (survival and recurrence) with known prognostic factors. METHODS An abdominosacral resection was performed on 61 patients with pelvic recurrence (53 with curative intent and 6 for palliation; 2 had extended pelvic resection). Of the 53 patients (32 males; average age, 59 years) previous resection included abdominoperineal resection in 27 patients, abdominoperineal resection plus hepatic lobectomy in 2 patients, low anterior resection in 19 patients, plus trisegmentectomy in 1 patient, and advanced primary cancers in 4 patients. Initial primary stage was Dukes B (64 percent) and Dukes C (36 percent). All had been irradiated (3,000-6,500 in 50 patients, 8,300 and 11,000 in 2 patients, and unknown dose in 3 patients). Preoperative carcinoembryonic antigen was elevated (>5 ng/ml) in 54 percent. Extent of resection: high sacral resection S-1-S2 was done in 32 patients, midsacrum in 14 patients, and low S-4-S-5 in 6 patients. Twenty-eight patients (60 percent) required partial or complete bladder resection with or without adjacent viscera, and all had internal iliac and obturator node dissection. RESULTS There were four postoperative (within 60 days) deaths, 8 percent in curative groups (5.4 percent overall). Major complications included prolonged intubation (20 percent), sepsis (34 percent), posterior wound infection or flap separation (38 percent). The survival rate in the curative group (49 postoperative survivors) was 31 percent at five years, with 13 patients surviving beyond five years. Seven of these patients survived from 5 to 21 years, whereas six patients recurred again and died within 5.5 to 7.5 years after abdominosacral resection. Disease-free survival rate at five years was 23 percent. Recent reconstruction with large composite myocutaneous gluteal flaps in 5 patients permitted complete sacral wound coverage, resulting in earlier ambulation and reduced hospital stay. CONCLUSIONS Abdominosacral resection permits removal of pelvic recurrence of rectal cancer that is fixed to the sacrum and is associated with long-term survival in 31 percent of patients. Recent technical advances have improved the short-term outcome and have made the procedure more feasible for surgical teams familiar with these techniques.
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Affiliation(s)
- H J Wanebo
- Department of Surgery, Roger Williams Medical Center, Providence, Rhode Island 02908, USA
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47
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Abstract
Carcinoma of the colon and rectum is one of the most common causes of cancer deaths in the United States. The mortality of patients treated by surgery alone is 55% within 5 years of surgery. Despite efforts to decrease local recurrence and their concomitant problems of pain and disability, a significant number of patients will still have pelvic recurrences that carry a significant morbidity. In selected cases, pelvic exenteration may cure or provide palliation of the symptoms of colorectal carcinoma. Pre-operative evaluation is performed to detect signs of unresectability. During surgery, exploration is performed for evidence of metastases to the liver, omentum, and peritoneum, followed by an assessment of the local extent of the tumor. The margins of resection must be clear even if resection of contiguous organs or bony structures is necessary. The urinary tract is resected with an ileal loop, sigmoid or transverse colon conduits, or continent urinary diversion. Depending upon the involvement of neighboring structures, exenterative pelvic surgery can be modified for organ preservation.
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Affiliation(s)
- J G Petros
- Department of Surgery, St. Elizabeth's Medical Center of Boston and Tufts University School of Medicine, Boston, Massachusetts 02135, USA.
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Berger A, Tiret E, Cunningham C, Dehni N, Parc R. Rectal excision and colonic pouch-anal anastomosis for rectal cancer: oncologic results at five years. Dis Colon Rectum 1999; 42:1265-71. [PMID: 10528762 DOI: 10.1007/bf02234211] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Preservation of the anal sphincter is now accepted as a primary aim in surgical treatment of rectal cancer. The use of colonic J-pouch-anal anastomosis after complete rectal excision is one method that permits retention of continence without compromising oncologic principles. This study aimed to assess carcinologic results of rectal excision followed by colonic J-pouch anal anastomosis, with particular reference to rate of locoregional recurrence. METHOD From 1984 to 1990 complete rectal excision and colonic pouch-anal anastomosis were performed in 167 patients for cancer of the middle or low rectum. A total of 154 patients were followed for this study for a minimum of five years, with evaluation of the frequency of locoregional recurrence. RESULTS Sixty-five patients died during the period of surveillance, giving a five-year survival rate of 68.8 percent. Twenty patients (13 percent) presented with locoregional recurrence at an average of 31 months after surgery. In 11 cases (7 percent) the local recurrence was not associated with metastatic disease, and six of these patients underwent further curative surgery. CONCLUSIONS These results confirm that coloanal anastomosis after complete rectal excision is a valuable option in the surgical treatment of rectal cancer and is accompanied by a frequency of isolated locoregional recurrence of less than 7 percent, of which half underwent surgical resection with curative intent.
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Affiliation(s)
- A Berger
- Department of Surgery, Saint Antoine Hospital AP-HP and Faculty of Medicine, University of Pierre and Marie Curie, Paris, France
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Bokey EL, Ojerskog B, Chapuis PH, Dent OF, Newland RC, Sinclair G. Local recurrence after curative excision of the rectum for cancer without adjuvant therapy: role of total anatomical dissection. Br J Surg 1999; 86:1164-70. [PMID: 10504371 DOI: 10.1046/j.1365-2168.1999.01216.x] [Citation(s) in RCA: 154] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The wide variability of reported local recurrence rates after curative resection of rectal cancer without adjuvant therapy may be a consequence of many different factors. However, few studies have investigated the potential effects of such factors on local recurrence by multivariate analysis. The present study examined clinical and tumour characteristics, operation type and operative technique as potential predictors of local recurrence in patients treated by surgery alone. METHODS Prospective data were analysed by bivariate and multivariate methods including actuarial survival and proportional hazards regression. RESULTS Local recurrence (pelvic or pelvic and systemic) was diagnosed in 59 of 596 patients. The 5-year actuarial local recurrence rate was 11.1 (95 per cent confidence interval 8.7-14.3) per cent. Independent predictive factors for local recurrence were: positive nodes (hazard ratio (HR) 5.5, P < 0.01); distal margin of 1 cm or less (HR 3.8, P < 0.01); venous invasion (HR 2.0, P = 0.02) and total anatomical dissection of the rectum (HR 2.0, P = 0.01). There was no difference in local recurrence between patients who had the mesorectum divided and those in whom it was totally excised. CONCLUSION Nodal involvement is the most potent predictor of local recurrence. In patients in whom total anatomical dissection is performed, total mesorectal excision confers no additional protection against local recurrence.
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Affiliation(s)
- E L Bokey
- Department of Colon and Rectal Surgery, The University of Sydney at Concord Hospital, New South Wales, Australia
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50
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Francois Y, Nemoz CJ, Baulieux J, Vignal J, Grandjean JP, Partensky C, Souquet JC, Adeleine P, Gerard JP. Influence of the interval between preoperative radiation therapy and surgery on downstaging and on the rate of sphincter-sparing surgery for rectal cancer: the Lyon R90-01 randomized trial. J Clin Oncol 1999; 17:2396. [PMID: 10561302 DOI: 10.1200/jco.1999.17.8.2396] [Citation(s) in RCA: 540] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
PURPOSE The optimal timing of surgery after preoperative radiotherapy in rectal cancer is unknown. The aim of this trial was to evaluate the role of the interval between preoperative radiotherapy and surgery. PATIENTS AND METHODS Patients with rectal carcinoma accessible to rectal digital examination, staged T2 to T3, NX, M0, were randomized before radiotherapy (39 Gy in 13 fractions) into two groups: in the short interval (SI) group, surgery had to be performed within 2 weeks after completion of radiation therapy, compared with 6 to 8 weeks in the long interval (LI) group. Between 1991 and 1995, 201 patients were enrolled onto the study. RESULTS A long interval between preoperative radiotherapy and surgery was associated with a significantly better clinical tumor response (53. 1% in the SI group v 71.7% in the LI group, P =.007) and pathologic downstaging (10.3% in the SI group v 26% in the LI group, P =.005). At a median follow-up of 33 months, there were no differences in morbidity, local relapse, and short-term survival between the two groups. Sphincter-preserving surgery was performed in 76% of cases in the LI group versus 68% in the SI group (P = 0.27). CONCLUSION A long interval between preoperative irradiation and surgery provides increased tumor downstaging with no detrimental effect on toxicity and early clinical results. When sphincter preservation is questionable, a long interval may increase the chance of a successful sphincter-saving surgery.
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Affiliation(s)
- Y Francois
- Departments of Surgery and Radiation Oncology, Centre Hospitalier Lyon-Sud, Pierre-Bénite
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