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Anker CJ, Tchelebi LT, Selfridge JE, Jabbour SK, Akselrod D, Cataldo P, Abood G, Berlin J, Hallemeier CL, Jethwa KR, Kim E, Kennedy T, Lee P, Sharma N, Small W, Williams VM, Russo S. Executive Summary of the American Radium Society on Appropriate Use Criteria for Nonoperative Management of Rectal Adenocarcinoma: Systematic Review and Guidelines. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00673-4. [PMID: 38797496 DOI: 10.1016/j.ijrobp.2024.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 04/15/2024] [Accepted: 05/17/2024] [Indexed: 05/29/2024]
Abstract
For patients with rectal cancer, the standard approach of chemotherapy, radiation therapy, and surgery (trimodality therapy) is associated with significant long-term toxicity and/or colostomy for most patients. Patient options focused on quality of life (QOL) have dramatically improved, but there remains limited guidance regarding comparative effectiveness. This systematic review and associated guidelines evaluate how various treatment strategies compare to each other in terms of oncologic outcomes and QOL. Cochrane and Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) methodology were used to search for prospective and retrospective trials and meta-analyses of adequate quality within the Ovid Medline database between January 1, 2012, and June 15, 2023. These studies informed the expert panel, which rated the appropriateness of various treatments in 6 clinical scenarios through a well-established consensus methodology (modified Delphi). The search process yielded 197 articles that advised voting. Increasing data have shown that nonoperative management (NOM) and primary surgery result in QOL benefits noted over trimodality therapy without detriment to oncologic outcomes. For patients with rectal cancer for whom total mesorectal excision would result in permanent colostomy or inadequate bowel continence, NOM was strongly recommended as usually appropriate. Restaging with tumor response assessment approximately 8 to 12 weeks after completion of radiation therapy/chemoradiation therapy was deemed a necessary component of NOM. The panel recommended active surveillance in the setting of a near-complete or complete response. In the setting of NOM, 54 to 56 Gy in 27 to 31 fractions concurrent with chemotherapy and followed by consolidation chemotherapy was recommended. The panel strongly recommends primary surgery as usually appropriate for a T3N0 high rectal tumor for which low anterior resection and adequate bowel function is possible, with adjuvant chemotherapy considered if N+. Recent data support NOM and primary surgery as important options that should be offered to eligible patients. Considering the complexity of multidisciplinary management, patients should be discussed in a multidisciplinary setting, and therapy should be tailored to individual patient goals/values.
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Affiliation(s)
- Christopher J Anker
- Division of Radiation Oncology, University of Vermont Cancer Center, Burlington, Vermont
| | - Leila T Tchelebi
- Northwell, New Hyde Park, New York; Department of Radiation Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York.
| | - J Eva Selfridge
- Division of Solid Tumor Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio
| | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute, New Brunswick, New Jersey
| | - Dmitriy Akselrod
- Department of Radiology, University of Vermont Larner College of Medicine, Burlington, Vermont
| | - Peter Cataldo
- Department of Surgery, University of Vermont Larner College of Medicine, Burlington, Vermont
| | - Gerard Abood
- Department of Surgery, Loyola University Stritch School of Medicine, Maywood, Illinois
| | - Jordan Berlin
- Division of Hematology Oncology, Department of Medicine Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | | | - Krishan R Jethwa
- Department of Radiation Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Ed Kim
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Timothy Kennedy
- Department of Surgery, Rutgers Cancer Institute, New Brunswick, New Jersey
| | - Percy Lee
- Department of Radiation Oncology, City of Hope National Medical Center, Los Angeles, California
| | - Navesh Sharma
- Department of Radiation Oncology, WellSpan Cancer Center, York, Pennsylvania
| | - William Small
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, Illinois
| | - Vonetta M Williams
- Department of Radiation Oncology, Memorial Sloan Kettering, New York, New York
| | - Suzanne Russo
- Department of Radiation Oncology, MetroHealth, Case Western Reserve University School of Medicine, Cleveland, Ohio
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Serra-Aracil X, Pericay C, Golda T, Mora L, Targarona E, Delgado S, Reina A, Vallribera F, Enriquez-Navascues JM, Serra-Pla S, Garcia-Pacheco JC. Non-inferiority multicenter prospective randomized controlled study of rectal cancer T 2-T 3s (superficial) N 0, M 0 undergoing neoadjuvant treatment and local excision (TEM) vs total mesorectal excision (TME). Int J Colorectal Dis 2018; 33:241-249. [PMID: 29234923 DOI: 10.1007/s00384-017-2942-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/28/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE The standard treatment of rectal adenocarcinoma is total mesorectal excision (TME), in many cases requires a temporary or permanent stoma. TME is associated with high morbidity and genitourinary alterations. Transanal endoscopic microsurgery (TEM) allows access to tumors up to 20 cm from the anal verge, achieves minimal postoperative morbidity and mortality rates, and does not require an ostomy. The treatment of T2, N0, and M0 cancers remains controversial. Preoperative chemoradiotherapy (CRT) in association with TEM reduces local recurrence and increases survival. The TAU-TEM study aims to demonstrate the non-inferiority of the oncological outcomes and the improvement in morbidity and quality of life achieved with TEM compared with TME. METHODS Prospective, multicenter, randomized controlled non-inferiority trial includes patients with rectal adenocarcinoma less than 10 cm from the anal verge and up to 4 cm in size, staged as T2 or T3-superficial N0-M0. Patients will be randomized to two areas: CRT plus TEM or radical surgery (TME). Postoperative morbidity and mortality will be recorded and patients will complete the quality of life questionnaires before the start of treatment, after CRT in the CRT/TEM arm, and 6 months after surgery in both arms. The estimated sample size for the study is 173 patients. Patients will attend follow-up controls for local and systemic relapse. CONCLUSIONS This study aims to demonstrate the preservation of the rectum after preoperative CRT and TEM in rectal cancer stages T2-3s, N0, M0 and to determine the ability of this strategy to avoid the need for radical surgery (TME). TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01308190. Número de registro del Comité de Etica e Investigación Clínica (CEIC) del Hospital universitario Parc Taulí: TAU-TEM-2009-01.
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Affiliation(s)
- X Serra-Aracil
- Coloproctology Unit, General and Digestive Surgery Department, Parc Tauli University Hospital, Universitat Autònoma de Barcelona, Parc Tauli s/n. 08208, Sabadell, Spain.
| | - C Pericay
- Medical Oncology Department, Parc Tauli University Hospital, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - T Golda
- Coloproctology Unit, General and Digestive Surgery Department, Bellvitge University Hospital, Barcelona, Spain
| | - L Mora
- Coloproctology Unit, General and Digestive Surgery Department, Parc Tauli University Hospital, Universitat Autònoma de Barcelona, Parc Tauli s/n. 08208, Sabadell, Spain
| | - E Targarona
- General and Digestive Surgery Department, Santa Creu and Sant Pau University Hospital, Barcelona, Spain
| | - S Delgado
- General and Digestive Surgery Department, Clinic University Hospital, Barcelona, Spain
| | - A Reina
- Coloproctology Unit, General and Digestive Surgery Department, Torrecardenas University Hospital, Almeria, Spain
| | - F Vallribera
- Coloproctology Unit, General and Digestive Surgery Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - S Serra-Pla
- Coloproctology Unit, General and Digestive Surgery Department, Parc Tauli University Hospital, Universitat Autònoma de Barcelona, Parc Tauli s/n. 08208, Sabadell, Spain
| | - J C Garcia-Pacheco
- Coloproctology Unit, General and Digestive Surgery Department, Parc Tauli University Hospital, Universitat Autònoma de Barcelona, Parc Tauli s/n. 08208, Sabadell, Spain
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Dapri G, Yi LQ, Ng CWA, Enjiu PT, Lin SH, Lee DJK, Tan KY, Mantoo S. Transanal minimally invasive full-thickness anterior middle rectum polyp resection - video vignette. Colorectal Dis 2017; 20:257-259. [PMID: 29205783 DOI: 10.1111/codi.13981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 11/09/2017] [Indexed: 02/08/2023]
Abstract
Rectal preservation is gaining popularity in the surgical treatment of degenerated rectal polyps or early rectal cancer (1,2). Tis/T1 rectal lesions can be safely treated without chemoradiation (3). Treatment by transanal minimally invasive surgery (TAMIS) offers more advantages than endoscopic submucosal dissection (ESD) (4). The authors report a 60 year-old woman who underwent TAMIS for a large polyp located anteriorly in the middle 1/3 of the rectum, 7 cm from the dentate line and staged preoperatively as uTisN0M0. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Giovanni Dapri
- Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, Brussels, Belgium
- Laboratory of Anatomy, Faculty of Medicine and Pharmacy, University of Mons, Mons, Belgium
| | - Lee Qin Yi
- Department of Surgery, Khoo Teck Puat University Hospital, Singapore
| | - Chin Wei Adele Ng
- Department of Surgery, Khoo Teck Puat University Hospital, Singapore
| | - Pauleon Tan Enjiu
- Department of Surgery, Khoo Teck Puat University Hospital, Singapore
| | - Sim Hsein Lin
- Department of Surgery, Khoo Teck Puat University Hospital, Singapore
| | | | - Kok Yang Tan
- Department of Surgery, Khoo Teck Puat University Hospital, Singapore
| | - Surendra Mantoo
- Department of Surgery, Khoo Teck Puat University Hospital, Singapore
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Oliva Perez R, Pagin São Julião G, Borba Vailati B. Time to rethink transanal endoscopic microsurgery for rectal cancer after neoadjuvant chemoradiation for highly selected patients. Cir Esp 2017; 95:179-180. [PMID: 28411890 DOI: 10.1016/j.ciresp.2017.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 03/13/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Rodrigo Oliva Perez
- Angelita & Joaquim Gama Institute, São Paulo, Brasil; Colorectal Surgery Division, University of São Paulo School of Medicine, São Paulo, Brasil.
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