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Cho SH, Park BS, Son GM, Kim HS, Kim SJ, Park SB, Choi CW, Kim HW, Shin DH, Yun MS. Differences in Factors Predicting Lymph Node Metastasis Between pT1 Rectal Cancer and pT1 Colon Cancer: A Retrospective Study. Am Surg 2023; 89:5829-5836. [PMID: 35766839 DOI: 10.1177/00031348221111517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Studies have demonstrated conflicting results regarding factors that predict lymph node metastasis (LNM) in pT1 colorectal cancers. We hypothesized that these discrepancies could be related to different factors predicting LNM between rectal and colon cancer. This study aimed to compare predicting factors for LNM between pT1 rectal and colon cancer. METHODS This retrospective study evaluated a prospectively maintained database that included 380 patients with pT1 colorectal cancer from January 2010 to December 2020. Patients were grouped according to whether they had rectal or colon cancer, with or without LNM, and factors predicting LNM were analyzed. RESULTS In pT1 rectal cancer, LNM was associated with deeper submucosal (SM) invasion (P = .024) and a higher proportion of poorly differentiated tumors (P = .006). In pT1 colon cancer, LNM was associated with a higher proportion of moderately/poorly differentiated tumors (P = .002) and lymphatic invasion (P = .004). In the multivariate analysis for rectal cancer, depth of SM invasion (≥3000 μm) was an independent predictive factor for LNM (95% confidence interval [CI], 1.48-27.94; P = .013), whereas for colon cancer, moderately/poorly differentiated tumors (95% CI, 1.38-8.13; P = .008) and lymphatic invasion (95% CI, 1.44-11.78; P = .008) were independent predictive factors for LNM. DISCUSSION There were distinct differences in the factors predicting LNM between pT1 rectal cancer and colon cancer. These results suggest the necessity in differentiating between rectal and colon cancer when performing studies on LNM in pT1 colorectal cancer.
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Affiliation(s)
- Sung Hwan Cho
- Department of Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Byung-Soo Park
- Department of Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Gyung Mo Son
- Department of Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Hyun Sung Kim
- Department of Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Su Jin Kim
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Su Bum Park
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Cheol Woong Choi
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Hyung Wook Kim
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Dong Hoon Shin
- Department of Pathology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Mi Sook Yun
- Division of Biostatistics, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
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Hu R, Li X, Zhou X, Ding S. Development and validation of a competitive risk model in patients with rectal cancer: based on SEER database. Eur J Med Res 2023; 28:362. [PMID: 37735712 PMCID: PMC10515244 DOI: 10.1186/s40001-023-01357-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 09/10/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Rectal cancer is one of the most common malignancies. To predict the specific mortality risk of rectal cancer patients, we constructed a predictive nomogram based on a competing risk model. METHODS The information on rectal cancer patients was extracted from the SEER database. Traditional survival analysis and specific death analysis were performed separately on the data. RESULTS The present study included 23,680 patients, with 16,580 in the training set and 7100 in the validation set. The specific mortality rate calculated by the competing risk model was lower than that of the traditional survival analysis. Age, Marriage, Race, Sex, ICD-O-3Hist/Behav, Grade, AJCC stage, T stage, N stage, Surgery, Examined LN, RX SUMM-SURG OTH, Chemotherapy, CEA, Deposits, Regional nodes positive, Brain, Bone, Liver, Lung, Tumor size, and Malignant were independent influencing factors of specific death. The overall C statistic of the model in the training set was 0.821 (Se = 0.001), and the areas under the ROC curve for cancer-specific survival (CSS) at 1, 3, and 5 years were 0.842, 0.830, and 0.812, respectively. The overall C statistic of the model in the validation set was 0.829 (Se = 0.002), and the areas under the ROC curve for CSS at 1, 3, and 5 years were 0.851, 0.836, and 0.813, respectively. CONCLUSIONS The predictive nomogram based on a competing risk model for time-specific mortality in patients with rectal cancer has very desirable accuracy. Thus, the application of the predictive nomogram in clinical practice can help physicians make clinical decisions and follow-up strategies.
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Affiliation(s)
- Ruobing Hu
- Department of Gastroenterology and Hepatology, People's Hospital of Zhengzhou University, No.7 Weiwu Road, Zhengzhou, 450003, Henan, China
| | - Xiuling Li
- Department of Gastroenterology and Hepatology, People's Hospital of Zhengzhou University, No.7 Weiwu Road, Zhengzhou, 450003, Henan, China
| | - Xiaomin Zhou
- Department of Infection Disease, Shanghai Jinshan District Tinglin Hospital, Shanghai, 201505, China
| | - Songze Ding
- Department of Gastroenterology and Hepatology, People's Hospital of Zhengzhou University, No.7 Weiwu Road, Zhengzhou, 450003, Henan, China.
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3
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Wan L, Hu J, Chen S, Zhao R, Peng W, Liu Y, Hu S, Zou S, Wang S, Zhao X, Zhang H. Prediction of lymph node metastasis in stage T1-2 rectal cancers with MRI-based deep learning. Eur Radiol 2023; 33:3638-3646. [PMID: 36905470 DOI: 10.1007/s00330-023-09450-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 12/01/2022] [Accepted: 02/03/2023] [Indexed: 03/12/2023]
Abstract
OBJECTIVES This study aimed to investigate whether a deep learning (DL) model based on preoperative MR images of primary tumors can predict lymph node metastasis (LNM) in patients with stage T1-2 rectal cancer. METHODS In this retrospective study, patients with stage T1-2 rectal cancer who underwent preoperative MRI between October 2013 and March 2021 were included and assigned to the training, validation, and test sets. Four two-dimensional and three-dimensional (3D) residual networks (ResNet18, ResNet50, ResNet101, and ResNet152) were trained and tested on T2-weighted images to identify patients with LNM. Three radiologists independently assessed LN status on MRI, and diagnostic outcomes were compared with the DL model. Predictive performance was assessed with AUC and compared using the Delong method. RESULTS In total, 611 patients were evaluated (444 training, 81 validation, and 86 test). The AUCs of the eight DL models ranged from 0.80 (95% confidence interval [CI]: 0.75, 0.85) to 0.89 (95% CI: 0.85, 0.92) in the training set and from 0.77 (95% CI: 0.62, 0.92) to 0.89 (95% CI: 0.76, 1.00) in the validation set. The ResNet101 model based on 3D network architecture achieved the best performance in predicting LNM in the test set, with an AUC of 0.79 (95% CI: 0.70, 0.89) that was significantly greater than that of the pooled readers (AUC, 0.54 [95% CI: 0.48, 0.60]; p < 0.001). CONCLUSION The DL model based on preoperative MR images of primary tumors outperformed radiologists in predicting LNM in patients with stage T1-2 rectal cancer. KEY POINTS • Deep learning (DL) models with different network frameworks showed different diagnostic performance for predicting lymph node metastasis (LNM) in patients with stage T1-2 rectal cancer. • The ResNet101 model based on 3D network architecture achieved the best performance in predicting LNM in the test set. • The DL model based on preoperative MR images outperformed radiologists in predicting LNM in patients with stage T1-2 rectal cancer.
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Affiliation(s)
- Lijuan Wan
- Department of Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, #17 Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China
| | - Jiesi Hu
- Department of Pharmaceutical Diagnosis, GE Healthcare, Life Sciences, #1 Tongji South Road, Beijing, 100176, China
- Harbin Institute of Technology, 518000, Shenzhen, China
| | - Shuang Chen
- Department of Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, #17 Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China
| | - Rui Zhao
- Department of Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, #17 Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China
| | - Wenjing Peng
- Department of Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, #17 Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China
| | - Yuan Liu
- Department of Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, #17 Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China
| | - Shangying Hu
- Department of Cancer Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, #17 Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China
| | - Shuangmei Zou
- Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, #17 Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China
| | - Sicong Wang
- Department of Pharmaceutical Diagnosis, GE Healthcare, Life Sciences, #1 Tongji South Road, Beijing, 100176, China
| | - Xinming Zhao
- Department of Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, #17 Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China
| | - Hongmei Zhang
- Department of Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, #17 Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China.
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Kim CH. The risk-benefit trade-off in local excision of early rectal cancer. Ann Coloproctol 2022; 38:95-96. [PMID: 35436839 PMCID: PMC9021848 DOI: 10.3393/ac.2022.00171.0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 03/10/2022] [Indexed: 11/12/2022] Open
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Whelan S, Burneikis D, Kalady MF. Rectal cancer: Maximizing local control and minimizing toxicity. J Surg Oncol 2021; 125:46-54. [PMID: 34897711 DOI: 10.1002/jso.26743] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 10/11/2021] [Indexed: 12/31/2022]
Abstract
Adoption of multimodality treatment approach for rectal cancer has resulted in significant improvements in oncologic outcomes. The roles of chemotherapy, radiation, and surgery in rectal cancer treatment are continuously evolving with the goal of achieving the best possible oncologic and functional outcome while minimizing treatment toxicity. The aim of this review is to summarize the most recent trials focusing on organ-sparing treatment strategies and the optimal selection of patients for neoadjuvant radiation therapy.
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Affiliation(s)
- Sean Whelan
- Department of Surgery, Division of Colon and Rectal Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Dominykas Burneikis
- Department of Surgery, Division of Colon and Rectal Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Matthew F Kalady
- Department of Surgery, Division of Colon and Rectal Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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6
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Wang AY, Hwang JH, Bhatt A, Draganov PV. AGA Clinical Practice Update on Surveillance After Pathologically Curative Endoscopic Submucosal Dissection of Early Gastrointestinal Neoplasia in the United States: Commentary. Gastroenterology 2021; 161:2030-2040.e1. [PMID: 34689964 DOI: 10.1053/j.gastro.2021.08.058] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 08/05/2021] [Accepted: 08/12/2021] [Indexed: 12/11/2022]
Abstract
The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update was to review the available evidence and provide expert advice regarding surveillance using endoscopy and other relevant modalities after removal of dysplastic lesions and early gastrointestinal cancers with endoscopic submucosal dissection deemed to be pathologically curative. This Clinical Practice Update was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. This expert commentary incorporates important as well as recently published studies in this field, and it reflects the experiences of the authors, who are advanced endoscopists with high-level expertise in performing endoscopic submucosal dissection to treat dysplasia and early cancers in the luminal gastrointestinal tract.
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Affiliation(s)
- Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia.
| | - Joo Ha Hwang
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, California
| | - Amit Bhatt
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio
| | - Peter V Draganov
- Division of Gastroenterology, Hepatology & Nutrition, University of Florida, Gainesville, Florida
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7
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Takashina Y, Kudo SE, Ichimasa K, Kouyama Y, Mochizuki K, Akimoto Y, Maeda Y, Mori Y, Misawa M, Ogata N, Kudo T, Hisayuki T, Hayashi T, Wakamura K, Sawada N, Baba T, Ishida F, Yokoyama K, Daita M, Nemoto T, Miyachi H. Clinicopathological features of small T1 colorectal cancers. World J Clin Cases 2021; 9:10088-10097. [PMID: 34904078 PMCID: PMC8638043 DOI: 10.12998/wjcc.v9.i33.10088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/26/2021] [Accepted: 10/11/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Although small colorectal neoplasms (< 10 mm) are often easily resected endoscopically and are considered to have less malignant potential compared with large neoplasms (≥ 10 mm), some are invasive to the submucosa.
AIM To clarify the clinicopathological features of small T1 colorectal cancers.
METHODS Of 32025 colorectal lesions between April 2001 and March 2018, a total of 1152 T1 colorectal cancers resected endoscopically or surgically were included in this study and were divided into two groups by tumor size: a small group (< 10 mm) and a large group (≥ 10 mm). We compared clinicopathological factors including lymph node metastasis (LNM) between the two groups.
RESULTS The incidence of small T1 cancers was 10.1% (116/1152). The percentage of initial endoscopic treatment in small group was significantly higher than in large group (< 10 mm 74.1% vs ≥ 10 mm 60.2%, P < 0.01). In the surgical resection cohort (n = 798), the rate of LNM did not significantly differ between the two groups (small 12.3% vs large 10.9%, P = 0.70). In addition, there were also no significant differences between the two groups in pathological factors such as histological grade, vascular invasion, or lymphatic invasion.
CONCLUSION Because there was no significant difference in the rate of LNM between small and large T1 colorectal cancers, the requirement for additional surgical resection should be determined according to pathological findings, regardless of tumor size.
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Affiliation(s)
- Yuki Takashina
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
- Department of Gastroenterology, Nikko Kinen Hospital, Muroran 051-8501, Japan
| | - Shin-Ei Kudo
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Katsuro Ichimasa
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Yuta Kouyama
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Kenichi Mochizuki
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Yoshika Akimoto
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Yasuharu Maeda
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Yuichi Mori
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo 0001, Norway
| | - Masashi Misawa
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Noriyuki Ogata
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Toyoki Kudo
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Tomokazu Hisayuki
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Takemasa Hayashi
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Kunihiko Wakamura
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Naruhiko Sawada
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Toshiyuki Baba
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Fumio Ishida
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Kazunori Yokoyama
- Department of Gastroenterology, Nikko Kinen Hospital, Muroran 051-8501, Japan
| | - Mitsuru Daita
- Department of Gastroenterology, Nikko Kinen Hospital, Muroran 051-8501, Japan
| | - Tetsuo Nemoto
- Department of Pathology, Showa University Nothern Yokohama Hospital, Yokohama 224-8503, Japan
| | - Hideyuki Miyachi
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama 224-8503, Japan
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8
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Ye H, Zheng B, Zheng Q, Chen P. Influence of Old Age on Risk of Lymph Node Metastasis and Survival in Patients With T1 Colorectal Cancer: A Population-Based Analysis. Front Oncol 2021; 11:706488. [PMID: 34722251 PMCID: PMC8548379 DOI: 10.3389/fonc.2021.706488] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 09/21/2021] [Indexed: 01/05/2023] Open
Abstract
Background We aimed at determining the influence of old age on lymph node metastasis (LNM) and prognosis in T1 colorectal cancer (CRC). Methods We collected data from eligible patients in Surveillance, Epidemiology, and End Results database between 2004 and 2015. Independent predictors of LNM were identified by logistic regression analysis. Cox regression analysis, propensity score-matched analysis, and competing risks analysis were used to analyze the associations between old age and lymph node (LN) status and to validate the prognostic value of old age on cancer-specific survival (CSS). Results In total, 10,092 patients were identified. Among them, 6,423 patients (63.6%) had greater than or equal to 12 examined lymph nodes (LNE ≥12), and 5,777 patients (57.7%) were 65 years or older. The observed rate of LNM was 4.6% (15 out of 325) in T1 CRC elderly patients, with tumor size <3 cm, well differentiated, with negative carcinoembryonic antigen (CEA) level, and adenocarcinoma. Logistic regression models demonstrated that tumor size ≥3 cm (odds ratio, OR = 1.316, P = 0.038), poorly differentiated (OR = 3.716, P < 0.001), older age (OR = 0.633 for ages 65–79 years, OR = 0.477 for age over 80 years, both P <0.001), and negative CEA level (OR = 0.71, P = 0.007) were independent prognostic factors. Cox regression analysis demonstrated that CSS was not significantly different between elderly patients undergoing radical resection with LNE ≥12 and those with LNE <12 (hazard ratio = 0.865, P = 0.153), which was firmly validated after a propensity score-matched analysis by a competing risks model. Conclusions The predictive value of tumor size, grading, primary site, histology, CEA level, and age for LNM should be considered in medical decision making about local resection. We found that tumor size was <3 cm, well differentiated, negative CEA level, and adenocarcinoma in elderly patients with T1 colorectal cancer which was suitable for local excision.
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Affiliation(s)
- Hua Ye
- Department of Gastrointestinal and Hernia Ward, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, China.,Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, China.,Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Ningbo, China
| | - Bin Zheng
- Department of Endoscopy Center, YinZhou JiangShan MaoShan Hospital, Ningbo, China
| | - Qi Zheng
- Department of Gastrointestinal and Hernia Ward, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, China.,Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, China.,Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Ningbo, China
| | - Ping Chen
- Department of Gastrointestinal and Hernia Ward, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, China.,Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, China.,Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Ningbo, China
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Dykstra MA, Gimon TI, Ronksley PE, Buie WD, MacLean AR. Classic and Novel Histopathologic Risk Factors for Lymph Node Metastasis in T1 Colorectal Cancer: A Systematic Review and Meta-analysis. Dis Colon Rectum 2021; 64:1139-1150. [PMID: 34397562 DOI: 10.1097/dcr.0000000000002164] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Treatment of endoscopically resected T1 colorectal cancers is based on the risk of lymph node metastasis. Risk is based on histopathologic features, although there is lack of consensus as to what constitutes high-risk features. OBJECTIVE The purpose of this study was to conduct a systematic review and meta-analysis of histopathologic risk factors for lymph node metastasis. DATA SOURCES A search of MEDLINE, Embase, Scopus, and Cochrane controlled register of trials for risk factors for lymph node metastasis was performed from inception until August 2018. STUDY SELECTION Included patients must have had an oncologic resection to confirm lymph node status and reported at least 1 histopathologic risk factor. INTERVENTION Rates of lymph node positivity were compared between patients with and without risk factors. MAIN OUTCOME MEASURES We report the results of the meta-analysis as ORs. RESULTS Of 8592 citations, 60 met inclusion criteria. Pooled analyses found that lymphovascular invasion, vascular invasion, neural invasion, and poorly differentiated histology were significantly associated with lymph node metastasis, as were depths of 1000 µm (OR = 2.76), 1500 µm (OR = 4.37), 2000 µm (OR = 2.37), submucosal level 3 depth (OR = 3.08), and submucosal level 2/3 (OR = 3.08) depth. Depth of 3000 µm, Haggitt level 4, and widths of 3000 µm and 4000 µm were not significantly associated with lymph node metastasis. Tumor budding (OR = 4.99) and poorly differentiated clusters (OR = 14.61) were also significantly associated with lymph node metastasis. LIMITATIONS Included studies reported risk factors independently, making it impossible to examine the additive metastasis risk in patients with numerous risk factors. CONCLUSIONS We identified 1500 μm as the depth most significantly associated with lymph node metastasis. Novel factors tumor budding and poorly differentiated clusters were also significantly associated with lymph node metastasis. These findings should help inform guidelines regarding risk stratification of T1 tumors and prompt additional investigation into the exact contribution of poorly differentiated clusters to lymph node metastasis.
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Affiliation(s)
- Mark A Dykstra
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Tamara I Gimon
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Paul E Ronksley
- Department of Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - W Donald Buie
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Anthony R MacLean
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
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Yan W, Zhou H, Shi S, Lin J, Lin Q. Association Between Chemotherapy and Survival in T1 Colon Cancer With Lymph Node Metastasis: A Propensity-Score Matched Analysis. Front Oncol 2021; 11:699400. [PMID: 34395267 PMCID: PMC8361445 DOI: 10.3389/fonc.2021.699400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 06/28/2021] [Indexed: 12/09/2022] Open
Abstract
This study aimed to comprehensively examine the efficacy of chemotherapy in T1 colon cancer patients with lymph node metastasis.
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Affiliation(s)
- Wangxin Yan
- Department of Colorectal and Anal Surgery, The Third Affiliated Hospital of Shanghai University, Wenzhou People's Hospital, Wenzhou No. 3 Clinical Institute Affiliated to Wenzhou Medical University, Wenzhou, China
| | - Huizhen Zhou
- Department of Colorectal and Anal Surgery, The Third Affiliated Hospital of Shanghai University, Wenzhou People's Hospital, Wenzhou No. 3 Clinical Institute Affiliated to Wenzhou Medical University, Wenzhou, China
| | - Si Shi
- Department of Colorectal and Anal Surgery, The Third Affiliated Hospital of Shanghai University, Wenzhou People's Hospital, Wenzhou No. 3 Clinical Institute Affiliated to Wenzhou Medical University, Wenzhou, China
| | - Jixu Lin
- Department of Colorectal and Anal Surgery, The Third Affiliated Hospital of Shanghai University, Wenzhou People's Hospital, Wenzhou No. 3 Clinical Institute Affiliated to Wenzhou Medical University, Wenzhou, China
| | - Qiangkang Lin
- Department of Colorectal and Anal Surgery, The Third Affiliated Hospital of Shanghai University, Wenzhou People's Hospital, Wenzhou No. 3 Clinical Institute Affiliated to Wenzhou Medical University, Wenzhou, China
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11
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Ebbehøj AL, Jørgensen LN, Krarup PM, Smith HG. Histopathological risk factors for lymph node metastases in T1 colorectal cancer: meta-analysis. Br J Surg 2021; 108:769-776. [PMID: 34244752 DOI: 10.1093/bjs/znab168] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/16/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND National screening programmes increase the proportion of T1 colorectal cancers. Local excision may be possible, but the risk of lymph node metastases (LNMs) could jeopardize long-term outcomes. The aim of the present study was to review the association between histopathological findings and LNMs in T1 colorectal cancer. METHODS A systematic literature search was conducted using PubMed,Embase, and Cochrane online databases. Studies investigating the association between one or more histopathological factors and LNMs in patients who underwent resection for T1 colorectal cancer were included. RESULTS Sixteen observational studies were included in the meta-analysis, including a total of 10 181 patients, of whom 1 307 had LNMs. Lymphovascular invasion (odds ratio (OR) 7.42; P < 0.001), tumour budding (OR 4.00; P < 0.001), depth of submucosal invasion, whether measured as at least 1000 µm (OR 3.53; P < 0.001) or Sm2-3 (OR 2.12; P = 0.020), high tumour grade (OR 3.75; P < 0.001), polypoid growth pattern (OR 1.59; P = 0.040), and rectal location of tumour (OR 1.36; P = 0.003) were associated with LNMs. CONCLUSION Distinct histopathological factors associated with nodal metastases in T1 colorectal cancer can aid selection of patients for local excision or major excisional surgery.
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Affiliation(s)
- A L Ebbehøj
- Digestive Disease Centre, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - L N Jørgensen
- Digestive Disease Centre, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - P-M Krarup
- Digestive Disease Centre, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - H G Smith
- Digestive Disease Centre, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
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12
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Wada Y, Shimada M, Murano T, Takamaru H, Morine Y, Ikemoto T, Saito Y, Balaguer F, Bujanda L, Pellise M, Kato K, Saito Y, Ikematsu H, Goel A. A Liquid Biopsy Assay for Noninvasive Identification of Lymph Node Metastases in T1 Colorectal Cancer. Gastroenterology 2021; 161:151-162.e1. [PMID: 33819484 DOI: 10.1053/j.gastro.2021.03.062] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 03/02/2021] [Accepted: 03/22/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS We recently reported use of tissue-based transcriptomic biomarkers (microRNA [miRNA] or messenger RNA [mRNA]) for identification of lymph node metastasis (LNM) in patients with invasive submucosal colorectal cancers (T1 CRC). In this study, we translated our tissue-based biomarkers into a blood-based liquid biopsy assay for noninvasive detection of LNM in patients with high-risk T1 CRC. METHODS We analyzed 330 specimens from patients with high-risk T1 CRC, which included 188 serum samples from 2 clinical cohorts-a training cohort (N = 46) and a validation cohort (N = 142)-and matched formalin-fixed paraffin-embedded samples (N = 142). We performed quantitative reverse-transcription polymerase chain reaction, followed by logistic regression analysis, to develop an integrated transcriptomic panel and establish a risk-stratification model combined with clinical risk factors. RESULTS We used comprehensive expression profiling of a training cohort of LNM-positive and LMN-negative serum specimens to identify an optimized transcriptomic panel of 4 miRNAs (miR-181b, miR-193b, miR-195, and miR-411) and 5 mRNAs (AMT, forkhead box A1 [FOXA1], polymeric immunoglobulin receptor [PIGR], matrix metalloproteinase 1 [MMP1], and matrix metalloproteinase 9 [MMP9]), which robustly identified patients with LNM (area under the curve [AUC], 0.86; 95% confidence interval [CI], 0.72-0.94). We validated panel performance in an independent validation cohort (AUC, 0.82; 95% CI, 0.74-0.88). Our risk-stratification model was more accurate than the panel and an independent predictor for identification of LNM (AUC, 0.90; univariate: odds ratio [OR], 37.17; 95% CI, 4.48-308.35; P < .001; multivariate: OR, 17.28; 95% CI, 1.82-164.07; P = .013). The model limited potential overtreatment to only 18% of all patients, which is dramatically superior to pathologic features that are currently used (92%). CONCLUSIONS A novel risk-stratification model for noninvasive identification of T1 CRC has the potential to avoid unnecessary operations for patients classified as high-risk by conventional risk-classification criteria.
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Affiliation(s)
- Yuma Wada
- Center for Gastrointestinal Research, Baylor Scott & White Research Institute and Charles A. Sammons Cancer Center, Baylor University Medical Center, Dallas, Texas; Department of Surgery, Tokushima University, Tokushima, Japan; Department of Molecular Diagnostics and Experimental Therapeutics, Beckman Research Institute of City of Hope Comprehensive Cancer Center, Duarte, California
| | - Mitsuo Shimada
- Department of Surgery, Tokushima University, Tokushima, Japan
| | - Tatsuro Murano
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Chiba, Japan
| | | | - Yuji Morine
- Department of Surgery, Tokushima University, Tokushima, Japan
| | - Tetsuya Ikemoto
- Department of Surgery, Tokushima University, Tokushima, Japan
| | - Yu Saito
- Department of Surgery, Tokushima University, Tokushima, Japan
| | - Francesc Balaguer
- Gastroenterology Department, Hospital Clinic de Barcelona, Barcelona, Spain; Department of Gastroenterology, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Luis Bujanda
- Gastroenterology Department, Instituto Biodonostia, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Universidad del País Vasco (UPV)/Euskal Herriko Unibertsitatea (EHU), San Sebastián, Spain
| | - Maria Pellise
- Gastroenterology Department, Hospital Clinic de Barcelona, Barcelona, Spain; Department of Gastroenterology, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Ken Kato
- Department of Gastrointestinal Medical Oncology, National Cancer Center Hospital, Tokyo, Japan; Clinical Research Support Office, Clinical Research Coordinating Section, Biobank Translational Research Support Section, National Cancer Center Hospital, Tokyo, Japan
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroaki Ikematsu
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Chiba, Japan
| | - Ajay Goel
- Center for Gastrointestinal Research, Baylor Scott & White Research Institute and Charles A. Sammons Cancer Center, Baylor University Medical Center, Dallas, Texas; Department of Molecular Diagnostics and Experimental Therapeutics, Beckman Research Institute of City of Hope Comprehensive Cancer Center, Duarte, California.
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13
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Xu Y, Chen Y, Long C, Zhong H, Liang F, Huang LX, Wei C, Lu S, Tang W. Preoperative Predictors of Lymph Node Metastasis in Colon Cancer. Front Oncol 2021; 11:667477. [PMID: 34136399 PMCID: PMC8202411 DOI: 10.3389/fonc.2021.667477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 05/07/2021] [Indexed: 12/24/2022] Open
Abstract
Background Lymph node metastasis (LNM) is a well-established prognostic factor for colon cancer. Preoperative LNM evaluation is relevant for planning colon cancer treatment. The aim of this study was to construct and evaluate a nomogram for predicting LNM in primary colon cancer according to pathological features. Patients and Methods Six-hundred patients with clinicopathologically confirmed colon cancer (481 cases in the training set and 119 cases in the validation set) were enrolled in the Affiliated Cancer Hospital of Guangxi Medical University from January 2010 to December 2019. The expression of molecular markers (p53 and β-catenin) was determined by immunohistochemistry. Multivariate logistic regression was used to screen out independent risk factors, and a nomogram was established. The accuracy and discriminability of the nomogram were evaluated by consistency index and calibration curve. Results Univariate logistic analysis revealed that LNM in colon cancer is significantly correlated (P <0.05) with tumor size, grading, stage, preoperative carcinoembryonic antigen (CEA) level, and peripheral nerve infiltration (PNI). Multivariate logistic regression analysis confirmed that CEA, grading, and PNI were independent prognostic factors of LNM (P <0.05). The nomogram for predicting LNM risk showed acceptable consistency and calibration capability in the training and validation sets. Conclusions Preoperative CEA level, grading, and PNI were independent risk factor for LNM. Based on the present parameters, the constructed prediction model of LNM has potential application value.
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Affiliation(s)
- Yansong Xu
- Department of Emergency, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yi Chen
- Guangxi Clinical Research Center for CRC, Department of Gastrointestinal Surgery, Guangxi Medical University Cancer Hospital, Nanning, China
| | - Chenyan Long
- Department of Anorectal Surgery, Zhuzhou Center Hospital, Zhuzhou, China
| | - Huage Zhong
- Guangxi Clinical Research Center for CRC, Department of Gastrointestinal Surgery, Guangxi Medical University Cancer Hospital, Nanning, China
| | - Fangfang Liang
- Department of Medical Oncology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Ling-Xu Huang
- Guangxi Clinical Research Center for CRC, Department of Gastrointestinal Surgery, Guangxi Medical University Cancer Hospital, Nanning, China
| | - Chuanyi Wei
- Guangxi Clinical Research Center for CRC, Department of Gastrointestinal Surgery, Guangxi Medical University Cancer Hospital, Nanning, China
| | - Shaolong Lu
- Department of Hepatological Surgery, Guangxi Medical University Cancer Hospital, Nanning, China
| | - Weizhong Tang
- Guangxi Clinical Research Center for CRC, Department of Gastrointestinal Surgery, Guangxi Medical University Cancer Hospital, Nanning, China
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14
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Luo D, Shan Z, Liu Q, Cai S, Ma Y, Li Q, Li X. The correlation between tumor size, lymph node status, distant metastases and mortality in rectal cancer patients without neoadjuvant therapy. J Cancer 2021; 12:1616-1622. [PMID: 33613748 PMCID: PMC7890314 DOI: 10.7150/jca.52165] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 12/15/2020] [Indexed: 12/24/2022] Open
Abstract
Tumor size has an effect on decision making for the treatment rectal cancer. Transanal local excision can be selected to remove rectal cancer with favorable histopathological features. It is generally recognized that the risk of lymph node involvement and distant metastases increases as the tumor enlarges. However, the majority of the studies classified patients into two groups using concrete value as a cutoff point. The coarse classification was not sufficient to reveal a correlation between the tumor size and lymph node status or distant metastases across the full range of sizes examined. Between 1988 and 2015, a total of 77,746 patients were diagnosed with first primary rectal cancer who had not received neoadjuvant therapy. These subjects were identified using the Surveillance, Epidemiology and End Results (SEER) database. The association between tumor size, lymph node status, distant metastases and cancer-specific mortality was investigated. Tumor size was examined as a continuous (1-30 mm) and categorical variable (11 size groups; 10-mm intervals). A non-linear correlation between increasing tumor size and the prevalence of lymph node involvement was observed, while a near-positive correlation between tumor size and distant metastases was presented. In addition, the 5-year and 10-year rates of rectal cancer-specific mortality were increased as the tumor enlarged. For small tumors (under 30 mm), a positive correlation was noted between tumor size and lymph node involvement. The clinical value of the tumor size should be reevaluated by exact classification.
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Affiliation(s)
- Dakui Luo
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Zezhi Shan
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Qi Liu
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Sanjun Cai
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Yanlei Ma
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Qingguo Li
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Xinxiang Li
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
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15
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Recursive Partitioning Analysis for Local Control Achieved With Stereotactic Body Radiation Therapy for the Liver, Spine, or Lymph Nodes. Adv Radiat Oncol 2020; 6:100612. [PMID: 34195484 PMCID: PMC8233465 DOI: 10.1016/j.adro.2020.10.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/04/2020] [Accepted: 10/29/2020] [Indexed: 01/05/2023] Open
Abstract
Purpose This study aims to develop a local control risk stratification using recursive partitioning analysis (RPA) for patients receiving stereotactic body radiation therapy (SBRT) for metastatic cancer. Methods and Materials A single institutional database of 397 SBRT treatments to the liver, spine, and lymph nodes was constructed. All treatments required imaging follow-up to assess for local control. Cox proportional hazards analysis was implemented before the decision tree analysis. The data were split into training (70%), validation (10%), and testing (20%) sets for RPA to optimize the training set. Results In the study, 361 treatments were included in the local control analysis. Two-year local control was 71%. A decision tree analysis was used and the resulting model demonstrated 93.10% fidelity for the validation set and 87.67% for the test set. RPA class 3 was composed of patients with non-small cell lung cancer (NSCLC) primary tumors and treatment targets other than the cervical, thoracic, and lumbar spines. RPA class 2 included patients with primary cancers other than NSCLC or breast and treatments targets of the sacral spine or liver. RPA class 1 consisted of all other patients (including lymph node targets and patients with primary breast cancer). Classes 3, 2, and 1 demonstrated 3-year local controls rates of 29%, 50%, and 83%, respectively. On subgroup analysis using the Kaplan-Meier method, treatments for lymph nodes and primary ovarian disease demonstrated improved local control relative to other treatment targets (P < .005) and primary disease sites (P < .005), respectively. Conclusions A local control risk stratification model for SBRT to sites of metastatic disease was developed. Treatment target and primary tumor were identified as critical factors determining local control. NSCLC primary lesions have increased local failure for targets other than the cervical, thoracic, or lumbar spines, and improved local control was identified for lymph node sites and breast or ovarian primary tumors.
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16
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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Rectal Cancer. Dis Colon Rectum 2020; 63:1191-1222. [PMID: 33216491 DOI: 10.1097/dcr.0000000000001762] [Citation(s) in RCA: 152] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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17
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Peng Y, Tang H, Meng X, Shen Y, Hu D, Kamel I, Li Z. Histological grades of rectal cancer: whole-volume histogram analysis of apparent diffusion coefficient based on reduced field-of-view diffusion-weighted imaging. Quant Imaging Med Surg 2020; 10:243-256. [PMID: 31956546 DOI: 10.21037/qims.2019.11.17] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background To explore the role of whole-lesion histogram analysis of apparent diffusion coefficient (ADC) derived from reduced field-of-view (rFOV) diffusion-weighted imaging (DWI) technique in discriminating histological grades of rectal carcinoma. Methods Altogether, 49 patients with rectal cancer were enrolled in this retrospective study. All patients received preoperative 3.0 T MR scan. Histogram parameters from rFOV DWI were calculated and correlated with histological differentiation of rectal cancer. The parameters were compared between different histological grades of rectal cancer by independent Student's t-test or Man-Whitney U-test. The Spearman correlation test analyzed correlations between histological grade and histogram parameters. The diagnostic performance of individual parameters for distinguishing poorly from well-/moderately differentiated tumors was assessed by receiver operating characteristic curve (ROC) analysis. Results There were significant differences for ADCmean, 25th, 50th, 75th, 90th, 95th percentiles, skewness, and kurtosis of rFOV DWI sequence between well-, moderately, and poorly differentiated rectal cancers (P<0.05). Significant correlations were noted between histological grades and the above histogram parameters (r=0.679, 0.540, 0.701, 0.730, 0.669, 0.574, -0.730, and -0.760 respectively, P<0.001). Among the individual histogram parameter, kurtosis achieved the highest AUC of 0.882 with an optimal cutoff value of 1.934 in distinguishing poorly from well-/moderately differentiated rectal cancers. The combination of ADCmean, 75th percentile, and kurtosis yielded the highest AUC of 0.927 with a sensitivity of 88.00% and a sensitivity of 91.7% using logistic regression. Conclusions Quantitative whole-lesion ADC histogram analysis based on the rFOV DWI technique could help differentiate histological grades of rectal cancer. The combination of ADCmean, 75th percentile, and kurtosis may be the best choice.
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Affiliation(s)
- Yang Peng
- Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan 430030, China
| | - Hao Tang
- Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan 430030, China
| | - Xiaoyan Meng
- Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan 430030, China
| | - Yaqi Shen
- Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan 430030, China
| | - Daoyu Hu
- Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan 430030, China
| | - Ihab Kamel
- Russell H. Morgan Department of Radiology and Radiological Science, the Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Zhen Li
- Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan 430030, China
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18
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Russo S, Anker CJ, Abdel-Wahab M, Azad N, Das P, Dragovic J, Goodman KA, Herman JM, Jones W, Kennedy T, Konski A, Kumar R, Lee P, Patel NM, Sharma N, Small W, Suh WW, Jabbour SK. Executive Summary of the American Radium Society Appropriate Use Criteria for Local Excision in Rectal Cancer. Int J Radiat Oncol Biol Phys 2019; 105:977-993. [PMID: 31445109 PMCID: PMC11101014 DOI: 10.1016/j.ijrobp.2019.08.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 08/02/2019] [Accepted: 08/11/2019] [Indexed: 02/07/2023]
Abstract
The goal of treatment for early stage rectal cancer is to optimize oncologic outcome while minimizing effect of treatment on quality of life. The standard of care treatment for most early rectal cancers is radical surgery alone. Given the morbidity associated with radical surgery, local excision for early rectal cancers has been explored as an alternative approach associated with lower rates of morbidity. The American Radium Society Appropriate Use Criteria presented in this manuscript are evidence-based guidelines for the use of local excision in early stage rectal cancer that include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) used by a multidisciplinary expert panel to rate the appropriateness of imaging and treatment procedures. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. These guidelines are intended for the use of all practitioners and patients who desire information regarding the use of local excision in rectal cancer.
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Affiliation(s)
- Suzanne Russo
- Case Western Reserve University School of Medicine and University Hospitals, Cleveland, Ohio.
| | | | - May Abdel-Wahab
- International Atomic Energy Agency, Division of Human Health, New York, New York
| | - Nilofer Azad
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Prajnan Das
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | | | - Joseph M Herman
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - William Jones
- UT Health Cancer Center, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | | | - Andre Konski
- University of Pennsylvania Perelman School of Medicine, Chester County Hospital, West Chester, Pennsylvania
| | - Rachit Kumar
- Banner MD Anderson Cancer Center, Gilbert, Arizona
| | - Percy Lee
- University of California, Los Angeles, Jonsson Comprehensive Cancer Center, Los Angeles, California
| | | | - Navesh Sharma
- Milton S. Hershey Cancer Institute, Hershey, Pennsylvania
| | | | - W Warren Suh
- Ridley-Tree Cancer Center Santa Barbara @ Sansum Clinic, Santa Barbara California
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Xu X, Zhang C, Ni X, Wu J, Pan C, Wang S, Yu J. Population-based analysis on predictors for lymph node metastasis in T1 colon cancer. Surg Endosc 2019; 34:4030-4040. [PMID: 31620912 PMCID: PMC7395001 DOI: 10.1007/s00464-019-07192-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 10/01/2019] [Indexed: 12/16/2022]
Abstract
Background In this study, we aimed to identify independent predictive factors for lymph node metastasis (LNM) in T1 colon cancer. Methods Data of 8056 eligible patients were retrospectively collected from the Surveillance, Epidemiology, and End Results (SEER) database during 2004–2012. We performed logistic regression analysis to identify predictive factors for LNM. Both unadjusted and adjusted Cox regression analyses were used to determine the association between LNM and patient survival. Finally, we used competing risks analysis and the cumulative incidence function (CIF) to further confirm the prognostic role of LNM in cancer-specific survival (CSS). Results The overall risk of LNM in patients with T1 colon cancer was 12.0% (N = 967). Adjusted logistic regression models revealed that mucinous carcinoma [odds ratio (OR) = 2.26, P < 0.001], moderately differentiated (OR 1.74, P < 0.001), poorly differentiated (OR 5.16, P < 0.001), and undifferentiated carcinoma (OR 3.01, P = 0.003); older age (OR 0.66, P < 0.001 for age 65–79 years, OR 0.44, P < 0.001 for age over 80 years); and carcinoma located in the ascending colon (OR 0.77, P = 0.018) and sigmoid colon (OR 1.24, P = 0.014) were independent predictive factors for LNM. Adjusted Cox regression analysis showed that positive lymph node involvement was significantly associated with CSS [hazard ratio (HR) = 3.02, P < 0.001], which was further robustly confirmed using a competing risks model and the CIF. Conclusions This population-based study showed that mucinous carcinoma, tumor grade, age, and primary tumor location were independent predictive factors for LNM in T1 colon cancer. The risk of LNM should be carefully evaluated in patients with T1 colon cancer, before clinical management.
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Affiliation(s)
- Xin Xu
- Department of General Surgery, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiao Tong University, 280 Mohe Road, Shanghai, 201999, China
| | - Chihao Zhang
- Department of General Surgery, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiao Tong University, 280 Mohe Road, Shanghai, 201999, China
| | - Xiaochun Ni
- Department of General Surgery, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiao Tong University, 280 Mohe Road, Shanghai, 201999, China
| | - Jugang Wu
- Department of General Surgery, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiao Tong University, 280 Mohe Road, Shanghai, 201999, China
| | - Chunpeng Pan
- Department of General Surgery, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiao Tong University, 280 Mohe Road, Shanghai, 201999, China
| | - Shoulian Wang
- Department of General Surgery, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiao Tong University, 280 Mohe Road, Shanghai, 201999, China
| | - Jiwei Yu
- Department of General Surgery, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiao Tong University, 280 Mohe Road, Shanghai, 201999, China.
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20
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Hu DY, Cao B, Li SH, Li P, Zhang ST. Incidence, risk factors, and a predictive model for lymph node metastasis of submucosal (T1) colon cancer: A population-based study. J Dig Dis 2019; 20:288-293. [PMID: 31021492 DOI: 10.1111/1751-2980.12754] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 03/21/2019] [Accepted: 04/22/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE This study aimed to assess the incidence, identify independent factors, and develop a lymph node metastasis (LNM) prediction model for patients with T1 colon cancer. METHODS Statistics were drawn from the Surveillance, Epidemiology, and End Results database between 2004 and 2014. A multivariate logistic regression analysis was performed to determine independent predictors of LNM. A nomogram for predicting the possibility of LNM was developed based on those factors. RESULTS A total of 5397 patients with T1 colon cancer were identified. The overall LNM rate was 15.0% (808/5397). A multivariate analysis showed that age (odds ratio [OR] 0.97, P < 0.001), tumor size (OR 1.01, P < 0.001), moderate (OR 1.77, P = 0.001) or poorly differentiated/undifferentiated tumor (OR 5.60, P < 0.001), right colon cancer (OR 1.39, P = 0.008), and a positive carcinoembryonic antigen level (OR 1.51, P = 0.004) were independent predictive factors for LNM. The area under the receiver operating characteristic curve was 0.68 (95% confidence interval [CI] 0.65-0.71) in the training set and 0.65 (95% CI 0.61-0.67) in the validation set. A calibration plot showed good consistency between the bias-corrected prediction and the ideal reference line with 1000 additional bootstraps (mean absolute error = 0.007). CONCLUSIONS The incidence of LNM was high in patients with T1 colon cancer. A nomogram for predicting the probability of LNM for T1 colon cancer may be used to help determine the optimal treatment for these patients.
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Affiliation(s)
- Dong Ya Hu
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory for Precancerous Lesion of Digestive Diseases, National Clinical Research Center for Digestive Diseases, Beijing Digestive Disease Center, Beijing, China
| | - Bin Cao
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory for Precancerous Lesion of Digestive Diseases, National Clinical Research Center for Digestive Diseases, Beijing Digestive Disease Center, Beijing, China
| | - Shi Han Li
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory for Precancerous Lesion of Digestive Diseases, National Clinical Research Center for Digestive Diseases, Beijing Digestive Disease Center, Beijing, China
| | - Peng Li
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory for Precancerous Lesion of Digestive Diseases, National Clinical Research Center for Digestive Diseases, Beijing Digestive Disease Center, Beijing, China
| | - Shu Tian Zhang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory for Precancerous Lesion of Digestive Diseases, National Clinical Research Center for Digestive Diseases, Beijing Digestive Disease Center, Beijing, China
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21
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Cao B, Min L, Zhu S, Shi H, Zhang S. Long-term oncological outcomes of local excision versus radical resection for early colorectal cancer in young patients without preoperative chemoradiotherapy: a population-based propensity matching study. Cancer Med 2018; 7:2415-2422. [PMID: 29726125 PMCID: PMC6010790 DOI: 10.1002/cam4.1508] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 03/22/2018] [Accepted: 03/27/2018] [Indexed: 12/15/2022] Open
Abstract
The incidence and mortality of colorectal carcinoma are rising in young adults. This population-based propensity matching study aimed to compare long-term oncological outcomes of local excision with radical resection for early localized colorectal cancer (CRC) in young patients without preoperative chemoradiotherapy. Patients under 45 years old with T1 colon or rectal adenocarcinoma who underwent local excision or radical resection were included from the Surveillance, Epidemiology, and End Results (SEER) database between 1998 and 2014. Survival curves were plotted using the Kaplan-Meier method. Cancer-specific survival (CSS) was compared using adjusted hazard ratios (HRs) between local excision and radical resection. After propensity score matching procedure, total of 1719 patients were included in the analysis, among which 573 treated with local excision and 1146 treated with radical resection. The median follow-up was 80 months (interquartile range(IQR): 37-132), with 1074 patients followed for ≥5 years and 508 patients followed for ≥10 years. Five-year CSS of local excision versus radical resection was 93.4% versus 96.7% for colon cancer and 96.6% versus 98.4% for rectal cancer. Ten-year CSS of local excision versus radical resection was 91.4% versus 94.0% for colon cancer and 92.8% versus 96.7% for rectal cancer. On multivariable analysis, compared with radical resection, local excision was not associated with inferior CSS for colon (HR 1.74, 95% CI: 0.92-3.29, P = 0.090) and rectal cancer (HR 2.16, 95% CI: 0.99-4.71, P = 0.052). There is no evidence of differential long-term oncological outcomes between local excision and radical resection. These findings supported clinical application of local excision for early colon and rectal cancer in young adults.
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Affiliation(s)
- Bin Cao
- Beijing Key Laboratory for Precancerous Lesion of Digestive Diseases, Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing Digestive Disease Center, NO. 95, Yong'an Road, Xicheng District, Beijing, China
| | - Li Min
- Beijing Key Laboratory for Precancerous Lesion of Digestive Diseases, Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing Digestive Disease Center, NO. 95, Yong'an Road, Xicheng District, Beijing, China
| | - Shengtao Zhu
- Beijing Key Laboratory for Precancerous Lesion of Digestive Diseases, Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing Digestive Disease Center, NO. 95, Yong'an Road, Xicheng District, Beijing, China
| | - Haiyun Shi
- Beijing Key Laboratory for Precancerous Lesion of Digestive Diseases, Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing Digestive Disease Center, NO. 95, Yong'an Road, Xicheng District, Beijing, China
| | - Shutian Zhang
- Beijing Key Laboratory for Precancerous Lesion of Digestive Diseases, Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing Digestive Disease Center, NO. 95, Yong'an Road, Xicheng District, Beijing, China
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22
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Ozawa T, Kandimalla R, Gao F, Nozawa H, Hata K, Nagata H, Okada S, Izumi D, Baba H, Fleshman J, Wang X, Watanabe T, Goel A. A MicroRNA Signature Associated With Metastasis of T1 Colorectal Cancers to Lymph Nodes. Gastroenterology 2018; 154:844-848.e7. [PMID: 29199088 PMCID: PMC5847452 DOI: 10.1053/j.gastro.2017.11.275] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 11/14/2017] [Accepted: 11/20/2017] [Indexed: 12/26/2022]
Abstract
Most T1 colorectal cancers treated by radical surgery can now be cured by endoscopic submucosal dissection. Although 70%-80% of T1 colorectal cancers are classified as high risk, <16% of these patients actually have lymph node metastases. Biomarkers are needed to identify patients with T1 cancers with the highest risk of metastasis, to prevent unnecessary radical surgery. We collected data from The Cancer Genome Atlas and identified 5 microRNAs (MIR32, MIR181B, MIR193B, MIR195, and MIR411) with significant changes in expression in T1 and T2 colorectal cancers with vs without lymph node metastases. Levels of the 5 microRNAs identified patients with lymph node invasion by T1 or T2 cancers with an area under the receiver operating characteristic curve (AUROC) value of 0.84. We validated these findings in 2 cohorts of patients with T1 cancers, using findings from histology as the reference. The 5-microRNA signature identified T1 cancers with lymph node invasion in cohort 1 with an AUROC value of 0.83, and in cohort 2 with an AUROC value of 0.74. When we analyzed biopsy samples from untreated patients, the 5-microRNA signature identified cancers with lymph node metastases with an AUROC value of 0.77. The 5-microRNA therefore identifies high-risk T1 colorectal cancers with a greater degree of accuracy than currently used pathologic features.
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Affiliation(s)
- Tsuyoshi Ozawa
- Center for Gastrointestinal Research and Center for Translational Genomics and Oncology, Baylor Scott & White Research Institute, Charles A Sammons Cancer Center, Baylor University Medical Center, Dallas, Texas
| | - Raju Kandimalla
- Center for Gastrointestinal Research and Center for Translational Genomics and Oncology, Baylor Scott & White Research Institute, Charles A Sammons Cancer Center, Baylor University Medical Center, Dallas, Texas
| | - Feng Gao
- Department of Biomedical Sciences, City University of Hong Kong, Hong Kong, China
| | - Hiroaki Nozawa
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Keisuke Hata
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroshi Nagata
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Satoshi Okada
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Daisuke Izumi
- Center for Gastrointestinal Research and Center for Translational Genomics and Oncology, Baylor Scott & White Research Institute, Charles A Sammons Cancer Center, Baylor University Medical Center, Dallas, Texas
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - James Fleshman
- Department of Colorectal Surgery, Baylor University Medical Center, Dallas, Texas
| | - Xin Wang
- Department of Biomedical Sciences, City University of Hong Kong, Hong Kong, China
| | - Toshiaki Watanabe
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ajay Goel
- Center for Gastrointestinal Research and Center for Translational Genomics and Oncology, Baylor Scott & White Research Institute, Charles A Sammons Cancer Center, Baylor University Medical Center, Dallas, Texas.
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23
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Abstract
PUPRPOSE Benign polyps that are technically challenging and unsafe to remove via polypectomy are known as complex polyps. Concerns regarding safety and completeness of resection dictate they undergo advanced endoscopic techniques, such as endoscopic mucosal resection or surgery. We provide a comprehensive overview of complex polyps and current treatment options. METHODS A review of the English literature was conducted to identifyarticles describing the management of complex polyps of the colon and rectum. RESULTS Endoscopic mucosal resection is the standard of care for the majority of complex polyps. Only polyps that fail endoscopic mucosal resection or are highly suspicious of invasive cancer but which cannot be removed endoscopically warrant surgery. CONCLUSION Several factors influence the treatment of a complex polyp; therefore, there cannot be a "one-size-fitsall" approach. Treatment should be tailored to the lesion's characteristics, the risk of adverse events, and the resources available to the treating physician.
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24
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Lee KC, Chung KC, Chen HH, Liu CC, Lu CC. Prognostic factors of overall survival and cancer-specific survival in patients with resected early-stage rectal adenocarcinoma: a SEER-based study. J Investig Med 2017; 65:1148-1154. [PMID: 28735257 DOI: 10.1136/jim-2017-000496] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2017] [Indexed: 12/21/2022]
Abstract
The benefits of radiotherapy for colorectal cancer are well documented, but the impact of adjuvant radiotherapy on early-stage rectal adenocarcinoma remains unclear. This study aimed to identify predictors of overall survival (OS) and cancer-specific survival (CSS) in patients with stage II rectal adenocarcinoma treated with preoperative or postoperative radiation therapy. Patients with early-stage rectal adenocarcinoma in the postoperative state were identified using the Surveillance, Epidemiology, and End Results database. The primary endpoints were OS and overall CSS. Stage IIA patients without radiotherapy had significantly lower OS and CSS compared with those who received radiation before or after surgery. Stage IIB patients with radiotherapy before surgery had significantly higher OS and CSS compared with patients in the postoperative or no radiotherapy groups. Patients with signet ring cell carcinoma had the poorest OS among all the groups. Multivariable analysis showed that ethnicity (HR, 0.388, p=0.006) and radiation before surgery (HR, 0.614, p=0.006) were favorable prognostic factors for OS, while age (HR, 1.064, p<0.001), race (HR, 1.599, p=0.041), stage IIB (HR, 3.011, p=0.011), and more than one tumor deposit (TD) (HR, 2.300, p=0.001) were unfavorable prognostic factors for OS. Old age (HR, 1.047, p<0.00 L), stage IIB (HR, 8.619, p=0.005), circumferential resection margin between 0.1 mm and 10 mm (HR, 1.529, p=0.039), and more than one TD (HR, 2.688, p=0.001) were unfavorable prognostic factors for CSS. This population-based study identified predictors of OS and CSS in patients with early-stage resected rectal adenocarcinoma, which may help to guide future management of this patient population.
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Affiliation(s)
- Ko-Chao Lee
- Division of Colorectal Surgery, Department of Surgery, Chang Gung Memorial Hospital - Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Kuan-Chih Chung
- Department of Anesthesiology, Chang Gung Memorial Hospital - Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hong-Hwa Chen
- Division of Colorectal Surgery, Department of Surgery, Chang Gung Memorial Hospital - Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chia-Cheng Liu
- Department of Surgery, Pingtung Christian Hospital, Pingtung, Taiwan
| | - Chien-Chang Lu
- Division of Colorectal Surgery, Department of Surgery, Chang Gung Memorial Hospital - Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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25
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Abstract
Local excision (LE) of early-stage rectal cancer avoids the morbidity associated with radical surgery but has historically been associated with inferior oncologic outcomes. Newer techniques, including transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS), have been developed to improve the quality of LE and extend the benefits of LE to tumors in the more proximal rectum. This article provides an overview of conventional LE, TEM, and TAMIS techniques, including indications for their use and pertinent literature on their associated outcomes for rectal cancer.
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Affiliation(s)
- Daniel Owen Young
- Colorectal Surgery Program, Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, 1100 9th Avenue Seattle, WA 98101, USA
| | - Anjali S Kumar
- Colorectal Surgery Program, Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, 1100 9th Avenue Seattle, WA 98101, USA.
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