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Ebrahimi N, Brown KGM, Ng KS, Solomon MJ, Lee PJ. Impact of Intraoperative Decision-Making on Pathological Margin Status in Patients Undergoing Pelvic Exenteration for Locally Recurrent Rectal Cancer. Dis Colon Rectum 2024; 67:1024-1029. [PMID: 38380808 DOI: 10.1097/dcr.0000000000003131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
BACKGROUND A key component of preoperative preparation for pelvic exenteration surgery is the development of an operative plan in a multidisciplinary setting based on the extent of local tumor invasion on preoperative imaging. Changes to the extent of resection or operative plan may occur intraoperatively based on intraoperative findings. OBJECTIVE To report the frequency and extent of intraoperative deviation from the planned extent of resection during pelvic exenteration for locally recurrent rectal cancer and determine whether this resulted in a more or less radical resection. DESIGN Retrospective observational study. SETTINGS A high-volume pelvic exenteration center. PATIENTS Patients who underwent pelvic exenteration for locally recurrent rectal cancer between January 2015 and December 2020. MAIN OUTCOME MEASURES Frequency and extent of intraoperative deviation from the planned extent of resection, R0 resection rate. RESULTS One hundred thirty-six patients underwent pelvic exenteration for locally recurrent rectal cancer, of whom 110 (81%) had R0 resection margins. Twelve patients were excluded because of missing information, and 49 patients (40%) had a change to the operative plan. Operative changes were major in 30 patients (61%), more radical in 40 patients (82%), and margin relevant in 24 patients (49%). In patients in whom there was a change to the operative plan and R0 resection was achieved, the median distance to a relevant margin was 2.5 mm (range, 0.1-10 mm). Of 8 patients with a change in operative plan and R1 resection, 3 were margin relevant, of whom all were considered major, and 2 were more radical and 1 was less radical. LIMITATIONS Generalizability outside of specialist units may be limited. CONCLUSIONS Intraoperative changes to the planned extent of resection occur commonly and most often result in an unanticipated major or more radical resection. Such changes may contribute to high rates of R0 resection margins in specialist pelvic exenteration units that use an ultraradical approach in these patients. See Video Abstract . IMPACTO DE LA TOMA DE DECISIONES INTRAOPERATORIA SOBRE EL ESTADO DEL MARGEN PATOLGICO EN PACIENTES SOMETIDOS A EXENTERACIN PLVICA POR RECURRENCIA LOCAL EN CNCER DE RECTO ANTECEDENTES:Un componente clave de la preparación preoperatoria para exenteración pélvica es el desarrollo de un plan quirúrgico en un entorno multidisciplinario, basado en el grado de invasión tumoral local en las imágenes preoperatorias. Es posible que se produzcan cambios intraoperatorios en la extensión de la resección o en el plan quirúrgico según los hallazgos intraoperatorios.OBJETIVO:Informar la frecuencia y la extensión de la desviación intraoperatoria de la extensión planificada de la resección durante la exenteración pélvica para el cáncer de recto localmente recurrente, y si esto resultó en una resección más o menos radical.DISEÑO:Estudio observacional retrospectivo.ESCENARIO:Un centro de exenteración pélvica de alto volumen.PACIENTES:Pacientes sometidos a exenteración pélvica por cáncer de recto localmente recurrente entre enero de 2015 y diciembre de 2020.PRINCIPALES MEDIDAS DE RESULTADO:Frecuencia y extensión de desviación intraoperatoria de la extensión planeada de resección, tasa de resección R0.RESULTADOS:136 pacientes fueron sometidos a exenteración pélvica por cáncer de recto localmente recurrente, de los cuales 110 (81%) tuvieron márgenes de resección R0. 12 pacientes fueron excluidos por falta de información y 49 pacientes (40%) tuvieron un cambio en el plan quirúrgico. Los cambios operatorios fueron mayores en 30 pacientes (61%), más radicales en 40 pacientes (82%) y con relevancia sobre márgenes en 24 pacientes (49%). En los pacientes en los que hubo un cambio en el plan quirúrgico y se logró la resección R0, la distancia mediana hasta un margen relevante fue de 2.5 mm (rango 0.1-10 mm). De ocho pacientes con un cambio en el plan quirúrgico y resección R1, tres tuvieron relevancia sobre márgenes de los cuales todos se consideraron mayores, dos fueron más radicales y uno fue menos radical.LIMITACIONES:La generalización fuera de las unidades especializadas puede ser limitada.CONCLUSIONES:Los cambios intraoperatorios en la extensión planificada de la resección ocurren comúnmente y con mayor frecuencia resultan en una resección mayor imprevista y más radical. Dichos cambios pueden contribuir a altas tasas de márgenes de resección R0 en unidades especializadas en EP que emplean un enfoque ultrarradical en estos pacientes. (Traducción-Dr. Jorge Silva Velazco ).
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Affiliation(s)
- Nargus Ebrahimi
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia
| | - Kilian G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, New South Wales, Australia
| | - Kheng-Seong Ng
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, New South Wales, Australia
- Department of Colorectal Surgery, Concord Repatriation General Hospital, Sydney, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, New South Wales, Australia
| | - Peter J Lee
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, Australia
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Risbey CWG, Brown KGM, Solomon MJ, Koh C, Karunaratne S, Steffens D. Impact of geographical health disparities on outcomes following pelvic exenteration at a centralised quaternary referral centre. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:107082. [PMID: 37738872 DOI: 10.1016/j.ejso.2023.107082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/22/2023] [Accepted: 09/13/2023] [Indexed: 09/24/2023]
Abstract
INTRODUCTION Pelvic exenteration (PE) is an ultra-radical procedure performed for primary or recurrent malignancies confined to the pelvis. Health outcomes for rural Australian populations are generally inferior compared to those from metropolitan centres, however, the effect of geographical location on outcomes following PE is poorly defined. The aim of this study was to investigate how geographical location affects oncological, quality of life (QoL) and survival outcomes following PE. METHODS Consecutive patients undergoing PE between 1994 and 2022 at a single centre were included. Patient post codes were linked with the Australian Statistical Geography Standard Remoteness Structure to stratify patients into five groups based on the geographical location of their residence. Primary outcome measures included patient survival, QoL and oncological outcomes. RESULTS A total of 953 patients were included, of which 626 (65.7%) were from major cities, 227 (23.8%) inner regional, 84 (8.8%) outer regional, 9 (0.9%) remote, and 7 (0.7%) very remote areas. Rural patients were more likely to undergo PE for primary rectal cancer (p = 002) and less likely for recurrent, non-rectal carcinoma (p = 0.027). Rural patients less frequently had health insurance (p < 0.001) but were more likely to have undergone neoadjuvant radiotherapy (p = 0.022). No difference in length-of-admission, in-hospital complication rates, QoL at 36 months or survival was observed between groups. CONCLUSIONS Despite geographical disparities, rural populations undergoing PE achieved equally favourable outcomes as populations from metropolitan areas. Enhancing access to specialised care may facilitate better outcomes of patients residing in regional and remote areas.
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Affiliation(s)
- Charles W G Risbey
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia
| | - Kilian G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Australia
| | - Cherry Koh
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Australia
| | - Sascha Karunaratne
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Australia.
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Huang Y, Wang X, Steffens D, Young J, Solomon M, Koh C. Grading Complications in Pelvic Exenteration: Limitations of Current Classification Systems. Dis Colon Rectum 2023; 66:e1023-e1031. [PMID: 35067502 DOI: 10.1097/dcr.0000000000002396] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To comprehensively report complications associated with pelvic exenteration and to determine the strength of associations between 3 different grading methodologies and length of stay, quality of life, and physical outcomes. BACKGROUND It is generally accepted that pelvic exenteration is associated with high rates of surgical morbidity. However, methods of reporting in the literature are inconsistent, making it difficult to compare surgical outcomes across studies to determine the impact of surgery on patients. DESIGN A retrospective study. SETTINGS This study was conducted at Royal Prince Alfred Hospital, Sydney, Australia. PATIENTS It included patients who underwent pelvic exenteration between December 2016 and August 2019. MAIN OUTCOME MEASURES Complications were classified according to the Clavien-Dindo classification, Comprehensive Complication Index, and number of postoperative complications. Correlations between length of stay, physical component score, 6-minute walk test, and sit-to-stand test, and complications as graded using the Clavien-Dindo classification, Comprehensive Complication Index, and the number of complications were explored using Pearson's or point biserial correlation tests. RESULTS In this study, 198 patients were included. The Clavien-Dindo classification was moderately positively correlated with length of stay ( r = 0.519; p < 0.0001), whereas Comprehensive Complication Index ( r = 0.744; p < 0.0001) and the number of complications ( r = 0.751; p < 0.0001) showed a strong correlation with length of stay. All these methodologies were moderately inversely correlated with a predischarge 6-minute walk test (Clavien-Dindo classification: r = -0.359, p = 0.008; Comprehensive Complication Index: r = -0.388, p = 0.007; number of complications: r = -0.467, p < 0.0001). LIMITATIONS This single-center retrospective study involves a small sample size. Classification of grade I and II complications in this cohort of patients who tend to have complex postoperative recovery was challenging and therefore incomplete. The incomplete data may have affected the correlations. CONCLUSIONS Comprehensive Complication Index and the number of postoperative complications were more strongly correlated with length of stay than the Clavien-Dindo classification in patients undergoing pelvic exenteration. Comprehensive Complication Index may be a better grading system to classify postoperative complications following pelvic exenteration. See Video Abstract at http://links.lww.com/DCR/B906 . CLASIFICACIN DE LAS COMPLICACIONES EN LA EXENTERACIN PLVICA LIMITACIONES DE LOS SISTEMAS DE CLASIFICACIN ACTUALES OBJETIVO:Este estudio tuvo como objetivo informar de manera integral las complicaciones asociadas con la exanteración pélvica y determinar la rlacion de las asociaciones entre tres metodologías de clasificación diferentes y la duración de la estadía, la calidad de vida y los resultados físicos.ANTECEDENTES:En general, se acepta que la exanteración pélvica se asocia con altas tasas de morbilidad quirúrgica. Sin embargo, los métodos de notificación en la literatura son inconsistentes, lo que dificulta la comparación de los resultados quirúrgicos entre estudios para determinar el impacto de la cirugía en los pacientes.DISEÑO:Este fue un estudio retrospectivo.AJUSTES:Este estudio se realizó en el Royal Prince Alfred Hospital, Sydney. Australia.PACIENTES:Se incluyeron pacientes a las que se les realizó exenteración pélvica entre diciembre de 2016 y agosto de 2019.PRINCIPALES MEDIDAS DE RESULTADO:Las complicaciones se clasificaron de acuerdo con la Clasificación de Clavien-Dindo, el Índice Integral de Complicaciones y el número de complicaciones posoperatorias. Correlaciones entre la duración de la estadía, la puntuación del componente físico, la prueba de caminata de 6 minutos y la prueba de sentarse y levantarse; y las complicaciones según la clasificación de Clavien-Dindo, el CCI y el número de complicaciones se exploraron mediante las pruebas de correlación biserial de Pearson o Point.RESULTADOS:Un total de 198 pacientes fueron incluidos en este estudio. La clasificación de Clavien-Dindo se correlacionó moderadamente positivamente con la duración de la estancia ( r = 0,519, p < 0,0001), mientras que el índice de complicaciones integrales ( r = 0,744, p < 0,0001) y el número de complicaciones ( r = 0,751, p < 0,0001) mostraron una fuerte correlación con la duración de la estancia. Todas estas metodologías se correlacionaron moderadamente inversamente con la prueba de caminata de 6 minutos antes del alta (Clasificación de Clavien-Dindo: r = -0,359, p = 0,008; Índice de Complicaciones Integrales: r = -0,388, p = 0,007; número de complicaciones: r = -0,467, p < 0,0001).LIMITACIONES:Un estudio retrospectivo de un solo centro incluye un tamaño de muestra pequeño. La clasificación de las complicaciones de grado I y II en esta cohorte de pacientes que tienden a tener una recuperación postoperatoria compleja fue un desafío y, por lo tanto, incompleta. Los datos incompletos pueden haber afectado las correlaciones.CONCLUSIONES:El Índice Integral de Complicaciones y el número de complicaciones postoperatorias se correlacionaron más con la duración de la estancia que la Clasificación de Clavien-Dindo en pacientes con exenteración pélvica. El Índice Integral de Complicaciones puede ser un mejor sistema de clasificación para clasificar las complicaciones posoperatorias después de la exenteración pélvica. Consulte Video Resumen en http://links.lww.com/DCR/B906 . (Traducción-Dr. Yolanda Colorado ).
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Affiliation(s)
- Yeqian Huang
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown. New South Wales, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Xiaomeng Wang
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown. New South Wales, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Jane Young
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael Solomon
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown. New South Wales, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Cherry Koh
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown. New South Wales, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
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Wang T, Fu X, Zhang L, Liu S, Tao Z, Wang F. Prognostic Factors and a Predictive Nomogram of Cancer-Specific Survival of Epithelial Ovarian Cancer Patients with Pelvic Exenteration Treatment. Int J Clin Pract 2023; 2023:9219067. [PMID: 37637510 PMCID: PMC10449593 DOI: 10.1155/2023/9219067] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/16/2023] [Accepted: 08/03/2023] [Indexed: 08/29/2023] Open
Abstract
Objective The aim of this study was to explore prognostic factors, develop and internally validate a prognostic nomogram model, and predict the cancer-specific survival (CCS) of epithelial ovarian cancer (EOC) patients with pelvic exenteration (PE) treatment. Methods A total of 454 EOC patients from the Surveillance, Epidemiology, and End Results (SEER) database were collected according to the inclusion criteria and randomly divided into the training (n = 317) and validation (n = 137) cohorts. Prognostic factors of EOC patients with PE treatment were explored by univariate and multivariate stepwise Cox regression analyses. A predictive nomogram was constructed based on selected risk factors. The predictive power of the constructed nomogram was assessed by the time-dependent receiver operating characteristic (ROC) curve. Kaplan-Meier (KM) curve stratified by patients' nomoscore was also plotted to assess the risk stratification of the established nomogram. In internal validation, the C index, calibration curve, and decision curve analysis (DCA) were employed to assess the discrimination, calibration, and clinical utility of the models, respectively. Results In the training cohort, age, histological type, Federation of Gynecology and Obstetrics (FIGO) stage, number of examined lymph nodes, and number of positive lymph nodes were found to be independent prognostic factors of postoperative CSS. A practical nomogram model of EOC patients with PE treatment was constructed based on these selected risk factors. Time-dependent ROC curves and KM curves showed the superior predictive capability and excellent clinical stratification of the nomogram in both training and validation cohorts. In the internal validation, the C index, calibration plots, and DCA in the training and validation cohorts confirmed that the nomogram presents a high level of prediction accuracy and clinical applicability. Conclusion Our nomogram exhibited satisfactory survival prediction and prognostic discrimination. It is a user-friendly tool with high clinical pragmatism for estimating prognosis and guiding the long-term management of EOC patients with PE treatment.
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Affiliation(s)
- Ting Wang
- Department of Laboratory Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
- Branch of National Clinical Research Center for Laboratory Medicine, Nanjing 210029, China
- Jiangsu Provincial Medical Key Discipline, Nanjing 210029, China
| | - Xin Fu
- Clinical Laboratory, Baoshan People's Hospital, Baoshan, Yunnan 678000, China
| | - Lei Zhang
- Department of Laboratory Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
- Department of Gynecology, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, Huaian 223300, China
| | - Shuna Liu
- Department of Laboratory Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
- Branch of National Clinical Research Center for Laboratory Medicine, Nanjing 210029, China
- Jiangsu Provincial Medical Key Discipline, Nanjing 210029, China
| | - Ziqi Tao
- Department of Laboratory Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
- Branch of National Clinical Research Center for Laboratory Medicine, Nanjing 210029, China
- Jiangsu Provincial Medical Key Discipline, Nanjing 210029, China
| | - Fang Wang
- Department of Laboratory Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
- Branch of National Clinical Research Center for Laboratory Medicine, Nanjing 210029, China
- Jiangsu Provincial Medical Key Discipline, Nanjing 210029, China
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Fitzsimmons T, Thomas M, Tonkin D, Murphy E, Hollington P, Solomon M, Sammour T, Luck A. Establishing a state-wide pelvic exenteration multidisciplinary team meeting in South Australia. ANZ J Surg 2022; 93:1227-1231. [PMID: 36567641 DOI: 10.1111/ans.18220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/04/2022] [Accepted: 12/13/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Pelvic exenteration surgery is complex, necessitating co-ordinated multidisciplinary input and improved referral pathways. A state-wide pelvic exenteration multidisciplinary team (MDT) meeting was established in SA and the outcomes of this were audited and compared with historical data. METHODS All patients referred for discussion between August 2021 and July 2022 to the SA State-wide Pelvic Exenteration MDT were included in this study. MDT discussion centred around disease resectability, risk versus benefit of surgery, and need for local or interstate referral. Prospective data collection included patient demographics and MDT recommendations of surgery, palliation, or referral. Patients referred for surgery locally or interstate were compared with a retrospective patient cohort treated previously between January and December 2020. RESULTS Over 12 months, 91 patients were discussed (including nine multiple times), by a mean of 18 meeting participants each month. Forty-eight patients (58.5%) had primary malignancy, 25 (30.5%) recurrent malignancy, and 9 (11.0%) had non-malignant disease. Colorectal cancer was the most common presentation (56.1%), followed by gynaecological (30.5%) and urological (6.1%) malignancy. Pelvic exenteration surgery was recommended to be performed locally in 53.7% of patients and the remainder for non-surgical treatment, palliation, or re-discussion. During this time, 44 patients underwent surgery locally (versus 34 in 2020) and only 4 referred interstate (versus 8 in 2020). CONCLUSION The establishment of a dedicated state-wide pelvic exenteration MDT has resulted in better coordination of care for patients with locally advanced pelvic malignancy in SA, and significantly reduced the need for interstate referral.
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Affiliation(s)
- Tracy Fitzsimmons
- Surgical Specialties, Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia.,Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Michelle Thomas
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Darren Tonkin
- Colorectal Unit, Department of Surgery, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Elizabeth Murphy
- Colorectal Unit, Division of Surgery, Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Paul Hollington
- Flinders Medical Centre, Division of Surgery and Perioperative Medicine, Flinders University, Adelaide, South Australia, Australia
| | - Michael Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Tarik Sammour
- Surgical Specialties, Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia.,Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Andrew Luck
- Colorectal Unit, Division of Surgery, Lyell McEwin Hospital, Adelaide, South Australia, Australia
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Differences in Surgical Outcomes and Quality-of-Life Outcomes in Pelvic Exenteration Between Locally Advanced Versus Locally Recurrent Rectal Cancers. Dis Colon Rectum 2022; 65:1475-1482. [PMID: 35913831 DOI: 10.1097/dcr.0000000000002401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Although pelvic exenteration remains the only curative option for locally advanced rectal cancer and locally recurrent rectal cancer, only limited evidence is available on the differences in surgical and quality-of-life outcomes between the two. OBJECTIVE This study aimed to compare surgical outcomes and identify any differences or predictors of quality of life of patients with locally advanced rectal cancer and locally recurrent rectal cancer undergoing pelvic exenteration. DESIGN This was a cohort study. SETTING This study was conducted at Royal Prince Alfred Hospital, Sydney, Australia. PATIENTS This study included patients with locally advanced rectal cancer and locally recurrent rectal cancer who underwent pelvic exenteration between July 2008 and March 2019. MAIN OUTCOME MEASURES The main outcome measures included Short Form 36 version 2 and Functional Assessment of Cancer Therapy-Colorectal score. RESULTS A total of 271 patients were included in this study. Locally advanced rectal cancer patients had higher rates of R0 resection ( p = 0.003), neoadjuvant chemoradiotherapy ( p < 0.001), and had greater median overall survival (75.1 vs. 45.8 months), although the latter was clinically but not statistically significant. There was a higher blood loss ( p < 0.001), longer length of stay ( p = 0.039), and longer operative time ( p = 0.002) in the locally recurrent rectal cancer group. This group also had a higher mean baseline physical component summary score and Functional Assessment of Cancer Therapy-Colorectal score; however, there were no significant differences in complications or quality-of-life outcomes between with the two groups at any time points postoperatively up to 12 months. LIMITATION The study was from a specialized experienced center, which could limit its generalizability. CONCLUSIONS Patients with locally recurrent rectal cancer tend to require a more extensive surgery with a longer operative time and more blood loss and longer recovery from surgery, but despite this, their quality of life is comparable to those with locally advanced rectal cancer. See Video Abstract at http://links.lww.com/DCR/B1000 . DIFERENCIAS EN LOS RESULTADOS QUIRRGICOS Y LOS RESULTADOS DE LA CALIDAD DE VIDA EN LA EXENTERACIN PLVICA ENTRE EL CNCER DE RECTO LOCALMENTE AVANZADO Y EL CNCER DE RECTO LOCALMENTE RECIDIVANTE ANTECEDENTES:Aunque la exenteración pélvica sigue siendo la única opción curativa para el cáncer de recto localmente avanzado y el cáncer de recto localmente recurrente, solo hay evidencia limitada disponible sobre las diferencias en los resultados quirúrgicos y de calidad de vida entre los dos.OBJETIVO:Este estudio tuvo como objetivo comparar los resultados quirúrgicos e identificar cualquier diferencia o predictor de la calidad de vida de los pacientes con cáncer de recto localmente avanzado y cáncer de recto localmente recurrente sometidos a exenteración pélvica.DISEÑO:Este fue un estudio de cohorte.AJUSTE:Este estudio se realizó en el Royal Prince Alfred Hospital, Sydney, Australia.PACIENTES:Este estudio incluyó pacientes con cáncer de recto localmente avanzado y cáncer de recto localmente recurrente que se sometieron a exenteración pélvica entre julio de 2008 y marzo de 2019.PRINCIPALES MEDIDAS DE RESULTADO:Las principales medidas de resultado incluyeron el formulario corto 36 versión 2 y la puntuación de la evaluación funcional de la terapia del cáncer colorrectal.RESULTADOS:Un total de 271 pacientes fueron incluidos en este estudio. Los pacientes con cáncer de recto localmente avanzado tuvieron tasas más altas de resección R0 ( p = 0,003), quimiorradioterapia neoadyuvante ( p < 0,001) y una mediana de supervivencia general más alta (75,1 frente a 45,8 meses),a pesar de que esta última fue clínica pero no estadísticamente significativa. Hubo una mayor pérdida de sangre ( p < 0,001), una estancia más prolongada ( p = 0,039) y un tiempo operatorio más prolongado ( p = 0,002) en el grupo de cáncer de recto localmente recurrente. También tenían una puntuación de componente físico inicial media más alta y una puntuación de Evaluación funcional de la terapia del cáncer colorrectal; sin embargo, no hubo diferencias significativas en las complicaciones o los resultados de la calidad de vida entre los dos grupos en ningún momento después de la operación hasta los 12 meses.LIMITACIÓN:El estudio fue de un centro especializado con experiencia, lo que podría limitar su generalización.CONCLUSIONES:Los pacientes con cáncer de recto localmente recurrente tienden a requerir una cirugía más extensa con un tiempo operatorio más largo y más pérdida de sangre y una recuperación más prolongada de la cirugía, pero a pesar de esto, su calidad de vida es comparable a aquellos con cáncer de recto localmente avanzado. Consulte Video Resumen en http://links.lww.com/DCR/B1000 . (Traducción-Dr. Yolanda Colorado ).
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Ciulla S, Celli V, Aiello AA, Gigli S, Ninkova R, Miceli V, Ercolani G, Dolciami M, Ricci P, Palaia I, Catalano C, Manganaro L. Post treatment imaging in patients with local advanced cervical carcinoma. Front Oncol 2022; 12:1003930. [PMID: 36465360 PMCID: PMC9710522 DOI: 10.3389/fonc.2022.1003930] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/26/2022] [Indexed: 10/29/2023] Open
Abstract
Cervical cancer (CC) is the fourth leading cause of death in women worldwide and despite the introduction of screening programs about 30% of patients presents advanced disease at diagnosis and 30-50% of them relapse in the first 5-years after treatment. According to FIGO staging system 2018, stage IB3-IVA are classified as locally advanced cervical cancer (LACC); its correct therapeutic choice remains still controversial and includes neoadjuvant chemo-radiotherapy, external beam radiotherapy, brachytherapy, hysterectomy or a combination of these modalities. In this review we focus on the most appropriated therapeutic options for LACC and imaging protocols used for its correct follow-up. We explore the imaging findings after radiotherapy and surgery and discuss the role of imaging in evaluating the response rate to treatment, selecting patients for salvage surgery and evaluating recurrence of disease. We also introduce and evaluate the advances of the emerging imaging techniques mainly represented by spectroscopy, PET-MRI, and radiomics which have improved diagnostic accuracy and are approaching to future direction.
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Affiliation(s)
- S Ciulla
- Department of Radiological, Oncological and Pathological Sciences, Sapienza, University of Rome, Rome, Italy
| | - V Celli
- Department of Radiological, Oncological and Pathological Sciences, Sapienza, University of Rome, Rome, Italy
| | - A A Aiello
- Department of Medical Sciences, University of Cagliari, Cagliari, Italy
| | - S Gigli
- Department of Radiological, Oncological and Pathological Sciences, Sapienza, University of Rome, Rome, Italy
| | - R Ninkova
- Department of Radiological, Oncological and Pathological Sciences, Sapienza, University of Rome, Rome, Italy
| | - V Miceli
- Department of Radiological, Oncological and Pathological Sciences, Sapienza, University of Rome, Rome, Italy
| | - G Ercolani
- Department of Radiological, Oncological and Pathological Sciences, Sapienza, University of Rome, Rome, Italy
| | - M Dolciami
- Department of Radiological, Oncological and Pathological Sciences, Sapienza, University of Rome, Rome, Italy
| | - P Ricci
- Department of Radiological, Oncological and Pathological Sciences, Sapienza, University of Rome, Rome, Italy
| | - I Palaia
- Department of Maternal and Child Health and Urological Sciences, Sapienza, University of Rome, Rome, Italy
| | - C Catalano
- Department of Radiological, Oncological and Pathological Sciences, Sapienza, University of Rome, Rome, Italy
| | - L Manganaro
- Department of Radiological, Oncological and Pathological Sciences, Sapienza, University of Rome, Rome, Italy
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Traeger L, Bedrikovetski S, Oehler MK, Cho J, Wagstaff M, Harbison J, Lewis M, Vather R, Sammour T. Short-term outcomes following development of a dedicated pelvic exenteration service in a tertiary centre. ANZ J Surg 2022; 92:2620-2627. [PMID: 35866328 PMCID: PMC9795898 DOI: 10.1111/ans.17921] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/05/2022] [Accepted: 07/08/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Pelvic exenteration surgery (PE) offers potentially curative resection for locally advanced malignancy but is associated with significant complexity and morbidity. Specialised teams are recommended to achieve optimal patient outcomes. This study aims to analyse short-term outcomes at a tertiary setting before and after creating a dedicated PE service. METHODS Patients undergoing PE between 2008 and October 2021 at the Royal Adelaide Hospital and St. Andrews Hospital in South Australia were included, with prospective data collection since June 2017. Patients operated on prior and post the creation of the PE service were compared via univariate analyses. RESULTS In total, 113 patients were included, with a significant increase in volume of cases post creation of the PE service, (n = 46 pre versus n = 67 post). There were significant differences in the type of neoadjuvant therapy and patient co-morbidity, with more advanced disease stage and a higher likelihood of bone involvement (P < 0.05) in the latter period. An increased proportion of patients had flap reconstruction (40.3 versus 33.9%, P = 0.010) as well as lateral lymph node dissection (13.4 versus 2.2%, P = 0.046). Despite this, peri-operative outcomes such as urosepsis (11.9 versus 28.3%, P = 0.028) and Clavien-Dindo grade of complications grade improved. R0 resections were achieved in 93.9% of curative cases (93.9 versus 84.2%, P = 0.171). CONCLUSION The development of a PE service significantly improved short term patient outcomes, despite the inclusion of patients with more advanced disease and comorbidity.
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Affiliation(s)
- Luke Traeger
- Colorectal Unit, Department of SurgeryRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia,Adelaide Medical School, Faculty of Health and Medical SciencesUniversity of AdelaideAdelaideSouth AustraliaAustralia
| | - Sergei Bedrikovetski
- Colorectal Unit, Department of SurgeryRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia,Adelaide Medical School, Faculty of Health and Medical SciencesUniversity of AdelaideAdelaideSouth AustraliaAustralia
| | - Martin K. Oehler
- Department of Gynaecological OncologyRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Jonathan Cho
- Urology Unit, Department of SurgeryRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Marcus Wagstaff
- Adelaide Medical School, Faculty of Health and Medical SciencesUniversity of AdelaideAdelaideSouth AustraliaAustralia,Department of Plastic and Reconstructive SurgeryRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Jack Harbison
- Department of Plastic and Reconstructive SurgeryRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Mark Lewis
- Colorectal Unit, Department of SurgeryRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Ryash Vather
- Colorectal Unit, Department of SurgeryRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia,Adelaide Medical School, Faculty of Health and Medical SciencesUniversity of AdelaideAdelaideSouth AustraliaAustralia
| | - Tarik Sammour
- Colorectal Unit, Department of SurgeryRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia,Adelaide Medical School, Faculty of Health and Medical SciencesUniversity of AdelaideAdelaideSouth AustraliaAustralia
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Harji DP, Houston F, Cutforth I, Hawthornthwaite E, McKigney N, Sharpe A, Coyne P, Griffiths B. The impact of multidisciplinary team decision-making in locally advanced and recurrent rectal cancer. Ann R Coll Surg Engl 2022; 104:611-617. [PMID: 35639482 PMCID: PMC9680687 DOI: 10.1308/rcsann.2022.0045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2022] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Appropriate patient selection within the context of a multidisciplinary team (MDT) is key to good clinical outcomes. The current evidence base for factors that guide the decision-making process in locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LRRC) is limited to anatomical factors. METHODS A registry-based, prospective cohort study was undertaken of patients referred to our specialist MDT between 2015 and 2019. Data were collected on patients and disease characteristics including performance status, Charlson Comorbidity Index, the English Index of Multiple Deprivation quintiles and MDT treatment decision. Curative treatment was defined as neoadjuvant treatment and surgical resection that would achieve a R0 resection, and/or complete treatment of distant metastatic disease. Palliative treatment was defined as non-surgical treatment. RESULTS In total, 325 patients were identified; 72.7% of patients with LARC and 63.6% of patients with LRRC were offered treatment with curative intent (p = 0.08). Patients with poor performance status (PS > 2; p < 0.001), severe comorbidity (p < 0.001), socio-economic deprivation (p = 0.004), a positive predictive circumferential resection margin (p = 0.005) and metastatic disease (p < 0.001) were associated with palliative treatment. Overall survival in the curative cohort was 49 months (95% confidence interval [CI] 32.4-65.5) compared with 12 months (95% CI 9.1-14.9) in the palliative cohort (p < 0.001). The presence of metastatic disease was identified as a prognostic factor for patients undergoing curative treatment (p = 0.05). The only prognostic factor identified in patients treated palliatively was performance status (p < 0.001). CONCLUSIONS Our study identifies a number of preoperative, prognostic factors that affect MDT decision-making and overall survival.
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Affiliation(s)
| | | | | | | | | | - A Sharpe
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - P Coyne
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - B Griffiths
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
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Ng KS, Lee PJ. Pelvic exenteration: Pre-, intra-, and post-operative considerations. Surg Oncol 2022. [DOI: 10.1016/j.suronc.2022.101787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Dinger TL, Kroon HM, Traeger L, Bedrikovetski S, Hunter A, Sammour T. Regional variance in treatment and outcomes of locally invasive (T4) rectal cancer in Australia and New Zealand: analysis of the Bi-National Colorectal Cancer Audit. ANZ J Surg 2022; 92:1772-1780. [PMID: 35502647 PMCID: PMC9541368 DOI: 10.1111/ans.17699] [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: 12/02/2021] [Revised: 03/05/2022] [Accepted: 03/30/2022] [Indexed: 12/09/2022]
Abstract
Backgrounds Locally invasive T4 rectal cancer often requires neoadjuvant treatment followed by multi‐visceral surgery to achieve a radical resection (R0), and referral to a specialized exenteration quaternary centre is typically recommended. The aim of this study was to explore regional variance in treatment and outcomes of patients with locally advanced rectal cancer in Australia and New Zealand (ANZ). Methods Data were collected from the Bi‐National Colorectal Cancer Audit (BCCA) database. Rectal cancer patients treated between 2007 and 2019 were divided into six groups based on region (state/country) using patient postcode. A subset analysis of patients with T4 cancer was performed. Primary outcomes were positive circumferential resection margin (CRM+), and positive circumferential and/or distal resection margin (CRM/DRM+). Results A total of 9385 patients with rectal cancer were identified, with an overall CRM+ rate of 6.4% and CRM/DRM+ rate of 8.6%. There were 1350 patients with T4 rectal cancer (14.4%). For these patients, CRM+ rate was 18.5%, and CRM/DRM+ rate was 24.1%. Significant regional variation in CRM+ (range 13.4–26.0%; p = 0.025) and CRM/DRM+ rates (range 16.1–29.3%; p = 0.005) was identified. In addition, regions with higher CRM+ and CRM/DRM+ rates reported lower rates of multi‐visceral resections: range 24.3–26.8%, versus 32.6–37.3% for regions with lower CRM+ and CRM/DRM+ rates (p < 0.0001). Conclusion Positive resection margins and rates of multi‐visceral resection vary between the different regions of ANZ. A small subset of patients with T4 rectal cancer are particularly at risk, further supporting the concept of referral to specialized exenteration centres for potentially curative multi‐visceral resection.
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Affiliation(s)
- Tessa L Dinger
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Faculty of Medical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Hidde M Kroon
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Luke Traeger
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Sergei Bedrikovetski
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Andrew Hunter
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Tarik Sammour
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
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Persson P, Chong P, Steele C, Quinn M. Prevention and management of complications in pelvic exenteration. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:2277-2283. [DOI: 10.1016/j.ejso.2021.12.470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 12/29/2021] [Indexed: 11/17/2022]
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Staging, recurrence and follow-up of uterine cervical cancer using MRI: Updated Guidelines of the European Society of Urogenital Radiology after revised FIGO staging 2018. Eur Radiol 2021; 31:7802-7816. [PMID: 33852049 DOI: 10.1007/s00330-020-07632-9] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 10/31/2020] [Accepted: 12/14/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVES The recommendations cover indications for MRI examination including acquisition planes, patient preparation, imaging protocol including multi-parametric approaches such as diffusion-weighted imaging (DWI-MR), dynamic contrast-enhanced imaging (DCE-MR) and standardised reporting. The document also underscores the value of whole-body 18-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (FDG-PET/CT) and highlights potential future methods. METHODS In 2019, the ESUR female pelvic imaging working group reviewed the revised 2018 FIGO staging system, the up-to-date clinical management guidelines, and the recent imaging literature. The RAND-UCLA Appropriateness Method (RAM) was followed to develop the current ESUR consensus guidelines following methodological steps: literature research, questionnaire developments, panel selection, survey, data extraction and analysis. RESULTS The updated ESUR guidelines are recommendations based on ≥ 80% consensus among experts. If ≥ 80% agreement was not reached, the action was indicated as optional. CONCLUSIONS The present ESUR guidelines focus on the main role of MRI in the initial staging, response monitoring and evaluation of disease recurrence. Whole-body FDG-PET plays an important role in the detection of lymph nodes (LNs) and distant metastases. KEY POINTS • T2WI and DWI-MR are now recommended for initial staging, monitoring of response and evaluation of recurrence. • DCE-MR is optional; its primary role remains in the research setting. • T2WI, DWI-MRI and whole-body FDG-PET/CT enable comprehensive assessment of treatment response and recurrence.
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Ng KS, Lee PJM. Pelvic exenteration: Pre-, intra-, and post-operative considerations. Surg Oncol 2021; 37:101546. [PMID: 33799076 DOI: 10.1016/j.suronc.2021.101546] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 03/02/2021] [Indexed: 01/18/2023]
Abstract
This review outlines the role of pelvic exenteration (PE) in the management of certain locally-advanced primary and recurrent rectal cancers. PE has undergone significant evolution over the past decades. Advances in pre-, intra-, and post-operative care have been directed towards achieving the 'holy grail' of an R0 resection, which remains the most important predictor of survival, quality of life, morbidity, and cost effectiveness following PE. Patient selection for surgery is largely determined by assessment of resectability. Pelvic magnetic resonance imaging determines the extent of local disease, while positron emission tomography remains the most accurate tool for exclusion of distant metastases. PE in the setting of metastatic disease or with palliative intent remains controversial. The intra-operative approach is based on the anatomical division of the pelvis into five compartments (anterior, central, posterior, and two lateral). Within each compartment are various possible dissection planes which are elected depending on the extent of tumour involvement. Innovations in surgical technique have allowed 'higher and wider' dissection planes with resultant en bloc excision of major vessels, major nerves, and bone. Evidence of improved R0 resection and survival rates with these techniques justifies the radicality of these novel approaches. Post-operative care for PE patients is technically demanding with a substantial hospital resource burden. Unique considerations for PE patients include the 'empty pelvis syndrome', urological complications, and management of post-operative malnutrition. While undeniably a morbid procedure, quality of life largely returns to baseline at six months, and for long-term survivors is sustained for up to five years.
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Affiliation(s)
- Kheng-Seong Ng
- Royal Prince Alfred Hospital, Department of Colorectal Surgery, Sydney, Australia; Surgical Outcomes Research Centre, Royal Prince Alfred Hospital, Sydney, Australia
| | - Peter J M Lee
- Royal Prince Alfred Hospital, Department of Colorectal Surgery, Sydney, Australia; Surgical Outcomes Research Centre, Royal Prince Alfred Hospital, Sydney, Australia.
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Solomon MJ. Redefining the boundaries of advanced pelvic oncology surgery. Br J Surg 2021; 108:453-455. [PMID: 33608731 DOI: 10.1093/bjs/znab047] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 01/20/2021] [Indexed: 12/15/2022]
Affiliation(s)
- M J Solomon
- Surgical Outcomes Research Centre, Sydney, New South Wales, Australia.,Institute of Academic Surgery at Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health Sciences, Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
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Brown KGM, Ansari N, Solomon MJ, Austin KKS, Hamilton AER, Young CJ. Pelvic exenteration combined with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for advanced primary or recurrent colorectal cancer with peritoneal metastases. Colorectal Dis 2021; 23:186-191. [PMID: 32978813 DOI: 10.1111/codi.15378] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 07/25/2020] [Accepted: 09/10/2020] [Indexed: 02/06/2023]
Abstract
AIM The aim was to report early outcomes of six patients who underwent combined pelvic exenteration (PE), cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for advanced or recurrent colorectal cancer with colorectal peritoneal metastases at a single centre. The literature contains limited data on the safety and oncological outcomes of patients who undergo this combined procedure. METHODS Six patients who underwent combined PE, CRS and HIPEC at Royal Prince Alfred Hospital, Sydney, between January 2017 and February 2020 were identified and included. Data were extracted from prospectively maintained databases. RESULTS Three patients underwent surgery for advanced primary rectal cancer, while two patients had recurrent sigmoid cancer and one had recurrent rectal cancer. All patients had synchronous peritoneal metastases. Two patients required total PE and two patients had a central (bladder-sparing) PE. The median peritoneal carcinomatosis index was 6 (range 3-12) and all patients underwent a complete cytoreduction. The median operating time was 702 min (range 485-900) and the median blood loss was 1650 ml (range 700-12,000). The median length of intensive care unit and hospital stay was 4.5 and 25 days, respectively. There was no inpatient, 30-day or 90-day mortality. Three patients (50%) experienced a major (Clavien-Dindo III/IV) complication. At a median follow-up of 11.5 months (range 2-18 months), two patients died with recurrent disease, one patient was alive with recurrence, while three patients remain alive and disease-free. Of the three patients who developed recurrent disease, one had isolated pelvic recurrence, one had pelvic and peritoneal recurrences and one had bone metastases. CONCLUSION Early results from this initial experience with simultaneous PE, CRS and HIPEC suggest that this combined procedure is safe and feasible; however, the long-term oncological and quality of life outcomes require further investigation.
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Affiliation(s)
- Kilian G M Brown
- Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,The Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Nabila Ansari
- Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,The Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,The Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
| | - Kirk K S Austin
- Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,The Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Auerilius E R Hamilton
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Christopher J Young
- The Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
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