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Motamedi MAK, Mak NT, Brown CJ, Raval MJ, Karimuddin AA, Giustini D, Phang PT. Local versus radical surgery for early rectal cancer with or without neoadjuvant or adjuvant therapy. Cochrane Database Syst Rev 2023; 6:CD002198. [PMID: 37310167 PMCID: PMC10264720 DOI: 10.1002/14651858.cd002198.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Total mesorectal excision is the standard of care for stage I rectal cancer. Despite major advances and increasing enthusiasm for modern endoscopic local excision (LE), uncertainty remains regarding its oncologic equivalence and safety relative to radical resection (RR). OBJECTIVES To assess the oncologic, operative, and functional outcomes of modern endoscopic LE compared to RR surgery in adults with stage I rectal cancer. SEARCH METHODS We searched CENTRAL, Ovid MEDLINE, Ovid Embase, Web of Science - Science Citation Index Expanded (1900 to present), four trial registers (ClinicalTrials.gov, ISRCTN registry, the WHO International Clinical Trials Registry Platform, and the National Cancer Institute Clinical Trials database), two thesis and proceedings databases, and relevant scientific societies' publications in February 2022. We performed handsearching and reference checking and contacted study authors of ongoing trials to identify additional studies. SELECTION CRITERIA We searched for randomized controlled trials (RCTs) in people with stage I rectal cancer comparing any modern LE techniques to any RR techniques with or without the use of neo/adjuvant chemoradiotherapy (CRT). DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. We calculated hazard ratios (HR) and standard errors for time-to-event data and risk ratios for dichotomous outcomes, using generic inverse variance and random-effects methods. We regrouped surgical complications from the included studies into major and minor according to the standard Clavien-Dindo classification. We assessed the certainty of evidence using the GRADE framework. MAIN RESULTS Four RCTs were included in data synthesis with a combined total of 266 participants with stage I rectal cancer (T1-2N0M0), if not stated otherwise. Surgery was performed in university hospital settings. The mean age of participants was above 60, and median follow-up ranged from 17.5 months to 9.6 years. Regarding the use of co-interventions, one study used neoadjuvant CRT in all participants (T2 cancers); one study used short-course radiotherapy in the LE group (T1-T2 cancers); one study used adjuvant CRT selectively in high-risk patients undergoing RR (T1-T2 cancers); and the fourth study did not use any CRT (T1 cancers). We assessed the overall risk of bias as high for oncologic and morbidity outcomes across studies. All studies had at least one key domain with a high risk of bias. None of the studies reported separate outcomes for T1 versus T2 or for high-risk features. Low-certainty evidence suggests that RR may result in an improvement in disease-free survival compared to LE (3 trials, 212 participants; HR 1.96, 95% confidence interval (CI) 0.91 to 4.24). This would translate into a three-year disease-recurrence risk of 27% (95% CI 14 to 50%) versus 15% after LE and RR, respectively. Regarding sphincter function, only one study provided objective results and reported short-term deterioration in stool frequency, flatulence, incontinence, abdominal pain, and embarrassment about bowel function in the RR group. At three years, the LE group had superiority in overall stool frequency, embarrassment about bowel function, and diarrhea. Local excision may have little to no effect on cancer-related survival compared to RR (3 trials, 207 participants; HR 1.42, 95% CI 0.60 to 3.33; very low-certainty evidence). We did not pool studies for local recurrence, but the included studies individually reported comparable local recurrence rates for LE and RR (low-certainty evidence). It is unclear if the risk of major postoperative complications may be lower with LE compared with RR (risk ratio 0.53, 95% CI 0.22 to 1.28; low-certainty evidence; corresponding to 5.8% (95% CI 2.4% to 14.1%) risk for LE versus 11% for RR). Moderate-certainty evidence shows that the risk of minor postoperative complications is probably lower after LE (risk ratio 0.48, 95% CI 0.27 to 0.85); corresponding to an absolute risk of 14% (95% CI 8% to 26%) for LE compared to 30.1% for RR. One study reported an 11% rate of temporary stoma after LE versus 82% in the RR group. Another study reported a 46% rate of temporary or permanent stomas after RR and none after LE. The evidence is uncertain about the effect of LE compared with RR on quality of life. Only one study reported standard quality of life function, in favor of LE, with a 90% or greater probability of superiority in overall quality of life, role, social, and emotional functions, body image, and health anxiety. Other studies reported a significantly shorter postoperative period to oral intake, bowel movement, and off-bed activities in the LE group. AUTHORS' CONCLUSIONS Based on low-certainty evidence, LE may decrease disease-free survival in early rectal cancer. Very low-certainty evidence suggests that LE may have little to no effect on cancer-related survival compared to RR for the treatment of stage I rectal cancer. Based on low-certainty evidence, it is unclear if LE may have a lower major complication rate, but probably causes a large reduction in minor complication rate. Limited data based on one study suggest better sphincter function, quality of life, or genitourinary function after LE. Limitations exist with respect to the applicability of these findings. We identified only four eligible studies with a low number of total participants, subjecting the results to imprecision. Risk of bias had a serious impact on the quality of evidence. More RCTs are needed to answer our review question with greater certainty and to compare local and distant metastasis rates. Data on important patient outcomes such as sphincter function and quality of life are very limited. Results of currently ongoing trials will likely impact the results of this review. Future trials should accurately report and compare outcomes according to the stage and high-risk features of rectal tumors, and evaluate quality of life, sphincter, and genitourinary outcomes. The role of neoadjuvant or adjuvant therapy as an emerging co-intervention for improving oncologic outcomes after LE needs to be further defined.
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Affiliation(s)
| | - Nicole T Mak
- Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Carl J Brown
- Head, Division of General Surgery, St. Paul's Hospital, Vancouver, Canada
| | - Manoj J Raval
- Department of Surgery, St. Paul's Hospital, University of British Columbia, Vancouver, Canada
| | - Ahmer A Karimuddin
- Department of Surgery, St. Paul's Hospital, University of British Columbia, Vancouver, Canada
| | - Dean Giustini
- Faculty of Medicine, University of British Columbia Library, Vancouver, Canada
| | - Paul Terry Phang
- Department of Surgery, St. Paul's Hospital, University of British Columbia, Vancouver, Canada
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Maeda K, Koide Y, Katsuno H, Tajima Y, Hanai T, Masumori K, Matsuoka H, Shiota M. Long-term results of minimally invasive transanal surgery for rectal tumors in 249 consecutive patients. Surg Today 2023; 53:306-315. [PMID: 35962290 PMCID: PMC9950212 DOI: 10.1007/s00595-022-02570-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 06/27/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE To delineate the long-term results of minimally invasive transanal surgery (MITAS) for selected rectal tumors. METHODS We analyzed data, retrospectively, on consecutive patients who underwent MITAS between 1995 and 2015, to establish the feasibility, excision quality, and perioperative and oncological outcomes of this procedure. RESULTS MITAS was performed on 243 patients. The final histology included 142 cancers, 47 adenomas, and 52 neuroendocrine tumors (NET G1). A positive margin of 1.6% and 100% en bloc resection were achieved. The mean operative time was 27.4 min. Postoperative morbidity occurred in 7% of patients, with 0% mortality. The median follow-up was 100 months (up to ≥ 5 years or until death in 91.8% of patients). Recurrence developed in 2.9% of the patients. The 10-year overall survival rate was 100% for patients with NET G1 and 80.3% for those with cancer. The 5-year DFS was 100% for patients with Tis cancer, 90.6% for those with T1 cancer, and 87.5% for those with T2 or deeper cancers. MITAS for rectal tumors ≥ 3 cm resulted in perioperative and oncologic outcomes equivalent to those for tumors < 3 cm. CONCLUSION MITAS is feasible for the local excision (LE) of selected rectal tumors, including tumors ≥ 3 cm. It reduces operative time and secures excision quality and long-term oncological outcomes.
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Affiliation(s)
- Kotaro Maeda
- Department of Surgery, Medical Corporation Kenikukai Shonan Keiiku Hospital, 4360 Endo, Fujisawa, Kanagawa 252-0816 Japan
| | - Yoshikazu Koide
- Department of Surgery, Fujita Health University Hospital, Toyoake, 470-1192 Japan
| | - Hidetoshi Katsuno
- Department of Surgery, Fujita Health University Okazaki Medical Center, Okazaki, 444-0827 Japan
| | - Yosuke Tajima
- Department of Surgery, Fujita Health University Hospital, Toyoake, 470-1192 Japan
| | - Tsunekazu Hanai
- Department of Surgery, Fujita Health University Hospital, Toyoake, 470-1192 Japan
| | - Koji Masumori
- Department of Surgery, Fujita Health University Hospital, Toyoake, 470-1192 Japan
| | - Hiroshi Matsuoka
- Department of Surgery, Fujita Health University Hospital, Toyoake, 470-1192 Japan
| | - Miho Shiota
- Department of Surgery, Kaisei Hospital, Sakaide, 657-0068 Japan
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Long-term outcomes of transanal endoscopic microsurgery for clinical complete response after neoadjuvant treatment in T2-3 rectal cancer. Surg Endosc 2021; 36:2906-2913. [PMID: 34231071 DOI: 10.1007/s00464-021-08583-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 06/02/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Organ sparing by the transanal endoscopic microsurgery (TEM) procedure is a treatment for patients with locally advanced rectal cancer after chemoradiotherapy (CRT) and complete clinical response (cCR). AIMS To assess the surgical and long-term oncological outcomes of TEM for the treatment in T2-3 rectal cancer after CRT and cCR. METHODS This study was a retrospective review of a prospective database of patients with rectal cancer who underwent TEM after CRT and cCR from April 2011 to March 2020. RESULTS 52 patients underwent TEM during a period of 9 years. This group of patients included 27 females and 25 males. The median age was 62 (32-86) years, lesion size was 2.5 (1-4) cm, and lesion distance from the anal verge 7.3 (4-10) cm. Median operative time was 79.5 (25-120) min and hospital stay was 1 day (14 h-4 days). Morbidity rate was 13.5% and reoperation rate due to major complications was 3.8%. Final histological findings confirmed 34 (65.4%) patients with ypT0, 7 (13.5%), 6 (11.5%), and 5 (9.6%) patients with carcinoma ypT1, ypT2, and ypT3, respectively. After a median follow-up period of 86 (5-107) months, 1 (2.4%) patient had local recurrences and 3 (7.3%) distant metastases. The 5-year disease-free survival was 91.7% and 5-year overall survival 89.5%. CONCLUSION Our experience has shown significant rates of ypT0 and ypT1 associated with excellent long-term results. Performing TEM to treat T2-3N0 rectal cancer after CRT and cCR appears to be an oncologically safe and effective procedure.
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Transanal minimally invasive surgery (TAMIS) for local excision of selected rectal neoplasms: efficacy and outcomes in the first 11 patients. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1016/j.jcol.2014.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AbstractDisposable single-port surgery devices have been used for transanal minimally invasive surgery (TAMIS) with benefits, when compared to local resection and transanal endoscopic microsurgery (TEM).
Objective To show outcomes and details of the technique.
Method A series of patients with indication for local resection of rectal tumors were submitted to surgery using the TAMIS platform.
Results Eleven patients have been submitted to TAMIS. Distance from anal verge was from 1.5 to 8 cm and maximum tumor diameter was 6 cm. Initial diagnosis of adenoma was the most frequent indication for resection. One partial dehiscence was the only complication seen. Minimal setup time, low cost and the possibility of using regular laparoscopic instruments make TAMIS a good option for transanal resection. The results of this technique are encouraging, concerning the feasibility, maneuverability, upfront cost, setup time, resectability and complication rate. Because of its simplicity and similarity with conventional laparoscopic surgery, it can be learned easily. Although at the present time the appropriate use of local excision is still under debate, TAMIS is a technique that still expects a lot of growing and much remains to be learned.
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Aguirre-Allende I, Enriquez-Navascues JM, Elorza-Echaniz G, Etxart-Lopetegui A, Borda-Arrizabalaga N, Saralegui Ansorena Y, Placer-Galan C. Early-rectal Cancer Treatment: A Decision-tree Making Based on Systematic Review and Meta-analysis. Cir Esp 2020; 99:89-107. [PMID: 32993858 DOI: 10.1016/j.ciresp.2020.05.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 05/27/2020] [Accepted: 05/30/2020] [Indexed: 02/07/2023]
Abstract
Local excision (LE) has arisen as an alternative to total mesorectal excision for the treatment of early rectal cancer. Despite a decreased morbidity, there are still concerns about LE outcomes. This systematic-review and meta-analysis design is based on the "PICO" process, aiming to answer to three questions related to LE as primary treatment for early-rectal cancer, the optimal method for LE, and the potential role for completion treatment in high-risk histology tumors and outcomes of salvage surgery. The results revealed that reported overall survival (OS) and disease-specific survival (DSS) were 71%-91.7% and 80%-94% for LE, in contrast to 92.3%-94.3% and 94.4%-97% for radical surgery. Additional analysis of National Database studies revealed lower OS with LE (HR: 1.26; 95%CI, 1.09-1.45) and DSS (HR: 1.19; 95%CI, 1.01-1.41) after LE. Furthermore, patients receiving LE were significantly more prone develop local recurrence (RR: 3.44, 95%CI, 2.50-4.74). Analysis of available transanal surgical platforms was performed, finding no significant differences among them but reduced local recurrence compared to traditional transanal LE (OR:0.24;95%CI, 0.15-0.4). Finally, we found poor survival outcomes for patients undergoing salvage surgery, favoring completion treatment (chemoradiotherapy or surgery) when high-risk histology is present. In conclusion, LE could be considered adequate provided a full-thickness specimen can be achieved that the patient is informed about risk for potential requirement of completion treatment. Early-rectal cancer cases should be discussed in a multidisciplinary team, and patient's preferences must be considered in the decision-making process.
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Affiliation(s)
- Ignacio Aguirre-Allende
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain.
| | - Jose Maria Enriquez-Navascues
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain
| | - Garazi Elorza-Echaniz
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain
| | - Ane Etxart-Lopetegui
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain
| | - Nerea Borda-Arrizabalaga
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain
| | - Yolanda Saralegui Ansorena
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain
| | - Carlos Placer-Galan
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain
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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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Park J, Kim HG, Jeong SO, Jo HG, Song HY, Kim J, Ryu S, Cho Y, Youn HJ, Jeon SR, Kim JO, Ko BM, Jeen YM, Jin SY. Clinical outcomes of positive resection margin after endoscopic mucosal resection of early colon cancers. Intest Res 2019; 17:516-526. [PMID: 31129949 PMCID: PMC6821942 DOI: 10.5217/ir.2018.00169] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 04/22/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND/AIMS When determining the subsequent management after endoscopic resection of the early colon cancer (ECC), various factors including the margin status should be considered. This study assessed the subsequent management and outcomes of ECCs according to margin status. METHODS We examined the data of 223 ECCs treated by endoscopic mucosal resection (EMR) from 215 patients during 2004 to 2014, and all patients were followed-up at least for 2 years. RESULTS According to histological analyses, the margin statuses of all lesions after EMR were as follows: 138 cases (61.9%) were negative, 65 cases (29.1%) were positive for dysplastic cells on the resection margins, and 20 cases (8.9%) were uncertain. The decision regarding subsequent management was affected not only by pathologic outcomes but also by the endoscopist's opinion on whether complete resection was obtained. Surgery was preferred if the lesion extended to the submucosa (odds ratio [OR], 25.46; 95% confidence interval [CI], 7.09-91.42), the endoscopic resection was presumed incomplete (OR, 15.55; 95% CI, 4.28-56.56), or the lymph system was invaded (OR, 13.69; 95% CI, 1.76-106.57). Fourteen patients (6.2%) had residual or recurrent malignancies at the site of the previous ECC resection and were significantly associated with presumed incomplete endoscopic resection (OR, 4.59; 95% CI, 1.21-17.39) and submucosal invasion (OR, 5.14; 95% CI, 1.18-22.34). CONCLUSIONS Subsequent surgery was associated with submucosa invasion, lymphatic invasion, and cancer-positive margins. Presumed completeness of the resection may be helpful for guiding the subsequent management of patients who undergo endoscopic resection of ECC.
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Affiliation(s)
- Junseok Park
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Hyun Gun Kim
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Shin Ok Jeong
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Hoon Gil Jo
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Hyo Yeop Song
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jeeyeon Kim
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Seri Ryu
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Youngyun Cho
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Hyun Jin Youn
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Seong Ran Jeon
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jin-Oh Kim
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Bong Min Ko
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Yoon Mi Jeen
- Department of Pathology, Soonchunhyang University College of Medicine, Seoul, Korea
| | - So-Young Jin
- Department of Pathology, Soonchunhyang University College of Medicine, Seoul, Korea
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Treatment and survival of rectal cancer patients over the age of 80 years: a EURECCA international comparison. Br J Cancer 2018; 119:517-522. [PMID: 30057408 PMCID: PMC6134121 DOI: 10.1038/s41416-018-0215-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 07/09/2018] [Accepted: 07/12/2018] [Indexed: 12/18/2022] Open
Abstract
Background The optimal treatment strategy for older rectal cancer patients
remains unclear. The current study aimed to compare treatment and survival of
rectal cancer patients aged 80+. Methods Patients of ≥80 years diagnosed with rectal cancer between 2001 and
2010 were included. Population-based cohorts from Belgium (BE), Denmark (DK), the
Netherlands (NL), Norway (NO) and Sweden (SE) were compared side by side for
neighbouring countries on treatment strategy and 5-year relative survival (RS),
adjusted for sex and age. Analyses were performed separately for stage I–III
patients and stage IV patients. Results Overall, 19 634 rectal cancer patients were included. For stage
I–III patients, 5-year RS varied from 61.7% in BE to 72.3% in SE. Proportion of
preoperative radiotherapy ranged between 7.9% in NO and 28.9% in SE. For stage IV
patients, 5-year RS differed from 2.8% in NL to 5.6% in BE. Rate of patients
undergoing surgery varied from 22.2% in DK to 40.8% in NO. Conclusions Substantial variation was observed in the 5-year relative survival
between European countries for rectal cancer patients aged 80+, next to a wide
variation in treatment, especially in the use of preoperative radiotherapy in
stage I–III patients and in the rate of patients undergoing surgery in stage IV
patients.
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Borstlap WAA, Coeymans TJ, Tanis PJ, Marijnen CAM, Cunningham C, Bemelman WA, Tuynman JB. Meta-analysis of oncological outcomes after local excision of pT1-2 rectal cancer requiring adjuvant (chemo)radiotherapy or completion surgery. Br J Surg 2016; 103:1105-16. [PMID: 27302385 DOI: 10.1002/bjs.10163] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 02/16/2016] [Accepted: 02/17/2016] [Indexed: 01/29/2023]
Abstract
BACKGROUND Completion total mesorectal excision (TME) is advised for high-risk early (pT1/pT2) rectal cancer following transanal removal. The main objective of this meta-analysis was to determine oncological outcomes of adjuvant (chemo)radiotherapy as a rectum-preserving alternative to completion TME. METHODS A literature search using PubMed, Embase and the Cochrane Library was performed in February 2015. Studies had to include at least ten patients with pT1/pT2 adenocarcinomas that were removed transanally and followed by either adjuvant chemoradiotherapy or completion surgery. A weighted average of the logit proportions was determined for the pooled analyses of subgroups according to treatment modality and pT category. RESULTS In total, 14 studies comprising 405 patients treated with adjuvant (chemo)radiotherapy and seven studies comprising 130 patients treated with completion TME were included. Owing to heterogeneity it was not possible to compare the two strategies directly. However, the weighted average local recurrence rate for locally excised pT1/pT2 rectal cancer treated with adjuvant (chemo)radiotherapy was 14 (95 per cent c.i. 11 to 18) per cent, and 7 (4 to 14) per cent following completion TME. The weighted averages for distance recurrence were 9 (6 to 14) and 9 (5 to 16) per cent respectively. Weighted averages for local recurrence rate after adjuvant chemo(radiotherapy) and completion TME for pT1 were 10 (4 to 21) and 6 (3 to 15) per cent respectively. Corresponding averages for pT2 were 15 (11 to 21) and 10 (4 to 22) per cent respectively. CONCLUSION A higher recurrence rate after transanal excision and adjuvant (chemo)radiotherapy must be balanced against the morbidity and mortality associated with mesorectal excision. A reasonable approach is close follow-up and salvage mesorectal surgery as needed.
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Affiliation(s)
- W A A Borstlap
- Departments of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - T J Coeymans
- Departments of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - P J Tanis
- Departments of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - C A M Marijnen
- Department of Radiotherapy, Leiden University Medical Centre, Leiden, The Netherlands
| | - C Cunningham
- Department of Surgery, Oxford University Hospital, Oxford, UK
| | - W A Bemelman
- Departments of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - J B Tuynman
- VU University Medical Centre, Amsterdam, The Netherlands
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Bartel MJ, Brahmbhatt BS, Wallace MB. Management of colorectal T1 carcinoma treated by endoscopic resection from the Western perspective. Dig Endosc 2016; 28:330-41. [PMID: 26718885 DOI: 10.1111/den.12598] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 12/21/2015] [Accepted: 12/25/2015] [Indexed: 12/13/2022]
Abstract
Detection of early colorectal cancer is expected to rise in light of national colorectal cancer screening programs. This The present review article delineates current endoscopic risk assessments, differentiating invasive from non-invasive neoplasia, for high likelihood of lymph node metastasis in early colorectal cancer, also termed high-risk early colorectal cancer, and endoscopic and surgical resection methods from a Western hemisphere perspective.
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Bianco F, Arezzo A, Agresta F, Coco C, Faletti R, Krivocapic Z, Rotondano G, Santoro GA, Vettoretto N, De Franciscis S, Belli A, Romano GM. Practice parameters for early colon cancer management: Italian Society of Colorectal Surgery (Società Italiana di Chirurgia Colo-Rettale; SICCR) guidelines. Tech Coloproctol 2015; 19:577-85. [PMID: 26403233 DOI: 10.1007/s10151-015-1361-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 05/22/2015] [Indexed: 02/08/2023]
Abstract
Early colon cancer (ECC) has been defined as a carcinoma with invasion limited to the submucosa regardless of lymph node status and according to the Royal College of Pathologists as TNM stage T1 NX M0. As the potential risk of lymph node metastasis ranges from 6 to 17% and the preoperative assessment of lymph node metastasis is not reliable, the management of ECC is still controversial, varying from endoscopic to radical resection. A meeting on recent advances on the management of colorectal polyps endorsed by the Italian Society of Colorectal Surgery (SICCR) took place in April 2014, in Genoa (Italy). Based on this material the SICCR decided to issue guidelines updating the evidence and to write a position statement paper in order to define the diagnostic and therapeutic strategy for ECC treatment in context of the Italian healthcare system.
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Affiliation(s)
- F Bianco
- Department of Surgical Oncology, Istituto Nazionale Tumori, "Fondazione G. Pascale"-IRCCS, Naples, Italy
| | - A Arezzo
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - F Agresta
- Department of General Surgery, Ulss1 9 of the Veneto, Civic Hospital, Adria (TV), Italy
| | - C Coco
- Department of Surgical Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - R Faletti
- Department of Surgical Sciences, Radiology Institute University Hospital City of Health and Science, Turin University, Turin, Italy
| | - Z Krivocapic
- Clinical Center of Serbia, Institute for Digestive Disease, University of Belgrade, Belgrade, Serbia and Montenegro
| | - G Rotondano
- Department of Gastroenterology, Maresca Hospital, Torre del Greco (NA), Italy
| | - G A Santoro
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - N Vettoretto
- Department of General Surgery, Montichiari Hospital, Civic Hospitals of Brescia, Brescia, Italy
| | - S De Franciscis
- Department of Surgical Oncology, Istituto Nazionale Tumori, "Fondazione G. Pascale"-IRCCS, Naples, Italy
| | - A Belli
- Department of Surgical Oncology, Istituto Nazionale Tumori, "Fondazione G. Pascale"-IRCCS, Naples, Italy
| | - G M Romano
- Department of Surgical Oncology, Istituto Nazionale Tumori, "Fondazione G. Pascale"-IRCCS, Naples, Italy.
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Verseveld M, de Graaf EJR, Verhoef C, van Meerten E, Punt CJA, de Hingh IHJT, Nagtegaal ID, Nuyttens JJME, Marijnen CAM, de Wilt JHW. Chemoradiation therapy for rectal cancer in the distal rectum followed by organ-sparing transanal endoscopic microsurgery (CARTS study). Br J Surg 2015; 102:853-60. [PMID: 25847025 DOI: 10.1002/bjs.9809] [Citation(s) in RCA: 131] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2014] [Revised: 02/15/2015] [Accepted: 02/18/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND This prospective multicentre study was performed to quantify the number of patients with minimal residual disease (ypT0-1) after neoadjuvant chemoradiotherapy and transanal endoscopic microsurgery (TEM) for rectal cancer. METHODS Patients with clinically staged T1-3 N0 distal rectal cancer were treated with long-course chemoradiotherapy. Clinical response was evaluated 6-8 weeks later and TEM performed. Total mesorectal excision was advocated in patients with residual disease (ypT2 or more). RESULTS The clinical stage was cT1 N0 in ten patients, cT2 N0 in 29 and cT3 N0 in 16 patients. Chemoradiotherapy-related complications of at least grade 3 occurred in 23 of 55 patients, with two deaths from toxicity, and two patients did not have TEM or major surgery. Among 47 patients who had TEM, ypT0-1 disease was found in 30, ypT0 N1 in one, ypT2 in 15 and ypT3 in one. Local recurrence developed in three of the nine patients with ypT2 tumours who declined further surgery. Postoperative complications grade I-IIIb occurred in 13 of 47 patients after TEM and in five of 12 after (completion) surgery. After a median follow-up of 17 months, four local recurrences had developed overall, three in patients with ypT2 and one with ypT1 disease. CONCLUSION TEM after chemoradiotherapy enabled organ preservation in one-half of the patients with rectal cancer.
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Affiliation(s)
- M Verseveld
- Department of Surgery, IJsselland Hospital, Capelle aan den IJssel, Rotterdam, The Netherlands; Division of Surgical Oncology, Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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Platz J, Cataldo P. Functional outcomes following transanal rectal surgery. SEMINARS IN COLON AND RECTAL SURGERY 2015. [DOI: 10.1053/j.scrs.2014.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Local resection compared with radical resection in the treatment of T1N0M0 rectal adenocarcinoma: a systematic review and meta-analysis. Dis Colon Rectum 2015; 58:122-40. [PMID: 25489704 DOI: 10.1097/dcr.0000000000000293] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Local resection for early rectal cancer is thought to be less invasive but oncologically inferior to radical resection. OBJECTIVE The aim of this study was to compare local with radical resection in terms of oncologic control (survival and local recurrence), postoperative complications, and the need for a permanent stoma in adult patients with T1N0M0 rectal adenocarcinoma. DATA SOURCES Data were retrieved from Medline, Embase, Central, www.clinicaltrials.gov, and conference proceedings. STUDY SELECTION Two reviewers independently screened studies and assessed the risk of bias. INTERVENTIONS Local resection (transanal procedures, excluding endoscopic polypectomy) versus radical resection were considered. MAIN OUTCOME MEASURES The primary outcomes measured were overall survival, major postoperative complications, and the 'need for permanent stoma.' RESULTS : One randomized controlled trial and 12 observational studies contributed 2855 patients for analysis. The randomized controlled trial was inadequately powered. Observational study meta-analysis showed that local resection was associated with significantly lower 5-year overall survival (72 more deaths per 1000 patients; 95%CI 30-120). However, the transanal endoscopic microsurgery subgroup did not yield significantly lower overall survival than radical resection. Local resection was associated with higher local recurrence but with lower perioperative mortality (relative risk 0.31, 95% CI 0.14-0.71), major postoperative complications (relative risk 0.20, 95% CI 0.10-0.41), and need for a permanent stoma (relative risk 0.17, 95% CI 0.09-0.30). Findings were robust to sensitivity analyses. Meta-regression suggests that the higher overall survival associated with radical resection may be explained by increased use of local resection on tumors in the lower third of the rectum, which have poorer prognosis. LIMITATIONS This systematic review of nonrandomized studies had inherent biases that may persist despite our rigorous use of systematic review methodology and sensitivity analyses. CONCLUSIONS Local resection does not offer oncologic control comparable to radical surgery. However, this finding may be driven by the higher prevalence of cancers with poorer prognosis in local resection groups. Local resection is associated with lower postoperative complications, mortality, and the need for a permanent stoma. Local resection with transanal endoscopic microsurgery appears to offer oncologic control similar to that of radical resection while offering all the benefits of local resection.
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Sanders M, Vabi BW, Cole PA, Kulaylat MN. Local Excision of Early-Stage Rectal Cancer. Surg Oncol 2015. [DOI: 10.1007/978-1-4939-1423-4_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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16
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Papamichael D, Audisio RA, Glimelius B, de Gramont A, Glynne-Jones R, Haller D, Köhne CH, Rostoft S, Lemmens V, Mitry E, Rutten H, Sargent D, Sastre J, Seymour M, Starling N, Van Cutsem E, Aapro M. Treatment of colorectal cancer in older patients: International Society of Geriatric Oncology (SIOG) consensus recommendations 2013. Ann Oncol 2014; 26:463-76. [PMID: 25015334 DOI: 10.1093/annonc/mdu253] [Citation(s) in RCA: 275] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Colorectal cancer (CRC) is one of the most commonly diagnosed cancers in Europe and worldwide, with the peak incidence in patients >70 years of age. However, as the treatment algorithms for the treatment of patients with CRC become ever more complex, it is clear that a significant percentage of older CRC patients (>70 years) are being less than optimally treated. This document provides a summary of an International Society of Geriatric Oncology (SIOG) task force meeting convened in Paris in 2013 to update the existing expert recommendations for the treatment of older (geriatric) CRC patients published in 2009 and includes overviews of the recent data on epidemiology, geriatric assessment as it relates to surgery and oncology, and the ability of older CRC patients to tolerate surgery, adjuvant chemotherapy, treatment of their metastatic disease including palliative chemotherapy with and without the use of the biologics, and finally the use of adjuvant and palliative radiotherapy in the treatment of older rectal cancer patients. An overview of each area was presented by one of the task force experts and comments invited from other task force members.
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Affiliation(s)
- D Papamichael
- Department of Medical Oncology, B.O. Cyprus Oncology Centre, Nicosia, Cyprus
| | | | - B Glimelius
- Department of Radiology, Oncology and Radiation Science, University of Uppsala, Uppsala, Sweden
| | | | | | - D Haller
- Abramson Cancer Center at the University of Pennsylvania, Philadelphia, USA
| | - C-H Köhne
- Klinikum Oldenburg, Oldenburg, Germany
| | - S Rostoft
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - V Lemmens
- Erasmus MC University Medical Centre, Rotterdam Eindhoven Cancer Registry, Comprehensive Cancer Centre South (IKZ), Eindhoven, The Netherlands
| | - E Mitry
- Department of Medical Oncology, Institut Curie, Paris Université Versailles Saint-Quentin, Guyancourt, France
| | - H Rutten
- Catharina Hospital Eindhoven, Eindhoven Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - J Sastre
- Department of Medical Oncology, Hospital Clinico San Carlos, Madrid, Spain
| | - M Seymour
- Cancer Medicine and Pathology, University of Leeds, Leeds
| | - N Starling
- Gastrointestinal Unit, Royal Marsden Hospital, London, UK
| | - E Van Cutsem
- Digestive Oncology, Leuven Cancer Institute, Leuven, Belgium
| | - M Aapro
- SIOG Office, Clinique de Genolier, Genolier, Switzerland
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Glimelius B, Tiret E, Cervantes A, Arnold D. Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2014; 24 Suppl 6:vi81-8. [PMID: 24078665 DOI: 10.1093/annonc/mdt240] [Citation(s) in RCA: 337] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- B Glimelius
- Dept of Radiology, Oncology and Radiation Science, Akademiska sjukhuset, Uppsala University, SE-751 85 Uppsala, Sweden
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Glimelius B. Neo-adjuvant radiotherapy in rectal cancer. World J Gastroenterol 2013; 19:8489-8501. [PMID: 24379566 PMCID: PMC3870494 DOI: 10.3748/wjg.v19.i46.8489] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 10/18/2013] [Accepted: 11/03/2013] [Indexed: 02/06/2023] Open
Abstract
In rectal cancer treatment, attention has focused on the local primary tumour and the regional tumour cell deposits to diminish the risk of a loco-regional recurrence. Several large randomized trials have also shown that combinations of surgery, radiotherapy and chemotherapy have markedly reduced the risk of a loco-regional recurrence, but this has not yet had any major influence on overall survival. The best results have been achieved when the radiotherapy has been given preoperatively. Preoperative radiotherapy improves loco-regional control even when surgery has been optimized to improve lateral clearance, i.e., when a total mesorectal excision has been performed. The relative reduction is then 50%-70%. The value of radiotherapy has not been tested in combination with more extensive surgery including lateral lymph node clearance, as practised in some Asian countries. Many details about how the radiotherapy is performed are still open for discussion, and practice varies between countries. A highly fractionated radiation schedule (5 Gy × 5), proven efficacious in many trials, has gained much popularity in some countries, whereas a conventionally fractionated regimen (1.8-2.0 Gy × 25-28), often combined with chemotherapy, is used in other countries. The additional therapy adds morbidity to the morbidity that surgery causes, and should therefore be administered only when the risk of loco-regional recurrence is sufficiently high. The best integration of the weakest modality, to date the drugs (conventional cytotoxics and biologicals) is not known. A new generation of trials exploring the best sequence of treatments is required. Furthermore, there is a great need to develop predictors of response, so that treatment can be further individualized and not solely based upon clinical factors and anatomic imaging.
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Lirici MM, Kanehira E, Melzer A, Schurr MO. The outburst age: how TEM ignited the MIS revolution. MINIM INVASIV THER 2013; 23:1-4. [PMID: 24328982 DOI: 10.3109/13645706.2013.871294] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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20
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Maeda K, Koide Y, Katsuno H. When is local excision appropriate for "early" rectal cancer? Surg Today 2013; 44:2000-14. [PMID: 24254058 PMCID: PMC4194025 DOI: 10.1007/s00595-013-0766-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Accepted: 09/30/2013] [Indexed: 12/20/2022]
Abstract
Local excision is increasingly performed for “early stage” rectal cancer in the US; however, local recurrence after local excision has become a controversial issue in Western countries. Local recurrence is considered to originate based on the type of tumor and procedure performed, and in surgical margin-positive cases. This review focuses on the inclusion criteria of “early” rectal cancers for local excision from the Western and Japanese points of view. “Early” rectal cancer is defined as T1 cancer in the rectum. Only the tumor grade and depth of invasion are the “high risk” factors which can be evaluated before treatment. T1 cancers with sm1 or submucosal invasion <1,000 μm are considered to be “low risk” tumors with less than 3.2 % nodal involvement, and are considered to be candidates for local excision as the sole curative surgery. Tumors with a poor tumor grade should be excluded from local excision. Digital examination, endoscopy or proctoscopy with biopsy, a barium enema study and endorectal ultrasonography are useful for identifying “low risk” or excluding “high risk” factors preoperatively for a comprehensive diagnosis. The selection of an initial local treatment modality is also considered to be important according to the analysis of the nodal involvement rate after initial local treatment and after radical surgery.
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Affiliation(s)
- Kotaro Maeda
- Department of Surgery, Fujita Health University School of Medicine, 1-98 Kutsukake, Toyoake, Aichi, 470-1192, Japan,
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21
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van Gijn W, Brehm V, de Graaf E, Neijenhuis PA, Stassen LPS, Leijtens JWA, Van De Velde CJH, Doornebosch PG. Unexpected rectal cancer after TEM: outcome of completion surgery compared with primary TME. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2013; 39:1225-9. [PMID: 23972571 DOI: 10.1016/j.ejso.2013.08.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 07/27/2013] [Accepted: 08/05/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND Transanal endoscopic microsurgery (TEM) has gained wide-spread acceptance as a safe and useful technique for the resection of rectal adenomas and selected T1 malignant lesions. If the lesion appears >T1 rectal cancer after resection with TEM, a completion TME resection is recommended. The aim of this study was to investigate the results of TME surgery after TEM for rectal cancer. METHODS In four tertiary referral hospitals for TEM, all patients with completion TME surgery after initial TEM were selected. All eligible patients who were treated with 5 × 5 Gy radiotherapy followed by TME surgery from the Dutch TME trial were selected as reference group. A multivariate logistic regression model was used to calculate odds ratio's (OR) for colostomies and for colo- and ileostomies combined. Local recurrence and survival rates were compared in hazard ratio's (HR) using the multivariate Cox proportional hazard model. RESULTS Fifty-nine patients were included in the TEM-COMPLETION group and 881 patients from the TME trial. In the TEM-COMPLETION group, 50.8% of the patients had a colostomy compared to 45.9% in the TME trial, OR 2.51 (p < 0.006). There is no significant difference when ileo- and colostomies are analyzed together. In the TEM-COMPLETION group, 10.2% developed a local recurrence compared to 5.2% in the TME trial, HR 6.8 (p < 0.0001). CONCLUSIONS Completion TME surgery after TEM for unexpected rectal adenocarcinoma results in more colostomies and higher local recurrence rates compared to one stage TME surgery preceded with preoperative 5 × 5 Gy radiotherapy. Pre-operative investigations must be optimized to distinguish malignant and benign lesions and prevent avoidable local recurrence and colostomies.
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Affiliation(s)
- W van Gijn
- Netherlands Cancer Institute, Surgery Department, The Netherlands.
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22
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Williams JG, Pullan RD, Hill J, Horgan PG, Salmo E, Buchanan GN, Rasheed S, McGee SG, Haboubi N. Management of the malignant colorectal polyp: ACPGBI position statement. Colorectal Dis 2013; 15 Suppl 2:1-38. [PMID: 23848492 DOI: 10.1111/codi.12262] [Citation(s) in RCA: 123] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- J G Williams
- Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK.
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24
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Bianchi V, Spitale A, Ortelli L, Mazzucchelli L, Bordoni A. Quality indicators of clinical cancer care (QC3) in colorectal cancer. BMJ Open 2013; 3:bmjopen-2013-002818. [PMID: 23869102 PMCID: PMC3717445 DOI: 10.1136/bmjopen-2013-002818] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES Assessing the quality of cancer care (QoCC) has become increasingly important to providers, regulators and purchasers of care worldwide. The aim of this study was to develop evidence-based quality indicators (QIs) for colorectal cancer (CRC) to be applied in a population-based setting. DESIGN A comprehensive evidence-based literature search was performed to identify the initial list of QIs, which were then selected and developed using a two-step-modified Delphi process involving two multidisciplinary expert panels with expertise in CRC care, quality of care and epidemiology. SETTING The QIs of the clinical cancer care (QC3) population-based project, which involves all the public and private hospitals and clinics present on the territory of Canton Ticino (South Switzerland). PARTICIPANTS Ticino Cancer Registry, The Colorectal Cancer Working Group (CRC-WG) and the external academic Advisory Board (AB). MAIN OUTCOME MEASURES Set of QIs which encompass the whole diagnostic-treatment process of CRC. RESULTS Of the 149 QIs that emerged from 181 sources of literature, 104 were selected during the in-person meeting of CRC-WG. During the Delphi process, CRC-WG shortened the list to 89 QI. AB finally validated 27 QIs according to the phase of care: diagnosis (N=6), pathology (N=3), treatment (N=16) and outcome (N=2). CONCLUSIONS Using the validated Delphi methodology, including a literature review of the evidence and integration of expert opinions from local clinicians and international experts, we were able to develop a list of QIs to assess QoCC for CRC. This will hopefully guarantee feasibility of data retrieval, as well as acceptance and translation of QIs into the daily clinical practice to improve QoCC. Moreover, evidence-based selected QIs allow one to assess immediate changes and improvements in the diagnostic-therapeutic process that could be translated into a short-term benefit for patients with a possible gain both in overall and disease-free survival.
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Affiliation(s)
- Valentina Bianchi
- Cantonal Institute of Pathology, Ticino Cancer Registry, Locarno, Switzerland
| | - Alessandra Spitale
- Cantonal Institute of Pathology, Ticino Cancer Registry, Locarno, Switzerland
| | - Laura Ortelli
- Cantonal Institute of Pathology, Ticino Cancer Registry, Locarno, Switzerland
| | - Luca Mazzucchelli
- Cantonal Institute of Pathology, Clinical Pathology, Locarno, Switzerland
| | - Andrea Bordoni
- Cantonal Institute of Pathology, Ticino Cancer Registry, Locarno, Switzerland
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Kogler P, Kafka-Ritsch R, Öfner D, Sieb M, Augustin F, Pratschke J, Zitt M. Is limited surgery justified in the treatment of T1 colorectal cancer? Surg Endosc 2012; 27:817-25. [DOI: 10.1007/s00464-012-2518-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Accepted: 07/24/2012] [Indexed: 01/13/2023]
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26
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Léonard D, Remue C, Kartheuser A. The transanal endoscopic microsurgery procedure: standards and extended indications. Dig Dis 2012. [PMID: 23207938 DOI: 10.1159/000342033] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Transanal endoscopic microsurgery (TEM) was developed in the early 1980s as a minimally invasive technique allowing the resection of benign rectal adenomas. For this indication, TEM was reported to be safe and effective and even exceeded the results compared to classical local excision. Unsurprisingly, the indication expanded to small rectal cancer. There is still much debate, though, whether it is oncologically safe to perform TEM for rectal cancer. Much has been published about the need for proper patient selection, i.e. patients presenting a low-risk T1 rectal cancer seem to be the most adequate subgroup for this technique. Nevertheless, TEM remains controversial concerning high-risk T1 rectal adenocarcinomas and deeper infiltrating tumors. Several retrospective case series and a small prospective study suggest that radiochemotherapy before local excision reduces recurrence to a level comparable with classic radical surgery (total mesorectal excision). However, these studies are collectively limited, and prospective data from larger multicenter trials are awaited. Reports about functional results after TEM have shown that the procedure has no permanent impact on anorectal function. Even if transient anal resting pressure weakening has been repeatedly described, patients do not suffer from any long-term functional sequelae. Nor do they complain of quality of life impairment.
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Affiliation(s)
- Daniel Léonard
- Colorectal Surgery Unit, Department of Abdominal Surgery and Transplantation, Université catholique de Louvain, Cliniques universitaires Saint-Luc, Brussels, Belgium
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27
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Glimelius B. Multidisciplinary treatment of patients with rectal cancer: Development during the past decades and plans for the future. Ups J Med Sci 2012; 117:225-36. [PMID: 22512246 PMCID: PMC3339554 DOI: 10.3109/03009734.2012.658974] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
In rectal cancer treatment, both the local primary and the regional and systemic tumour cell deposits must be taken care of in order to improve survival. The three main treatments, surgery, radiotherapy, and chemotherapy, each with their own advantages and limitations, must then be combined to improve results. Several large randomized trials have shown that combinations of the modalities have markedly reduced the loco-regional recurrences, but have not yet had any major influence on overall survival. The best integration of the weakest modality, to date the drugs (conventional cytotoxics and biologicals), is not known. A new generation of trials exploring the best sequence of treatments is required. Furthermore, treatment of rectal cancer is administered to populations of individuals, based upon clinical factors and imaging, and can presently not be further individualized. There is an urgent need to develop response predictors.
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Affiliation(s)
- Bengt Glimelius
- Department of Radiology, Oncology and Radiation Science, Uppsala University, Akademiska Sjukhuset, Uppsala, Sweden.
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Bökkerink GMJ, de Graaf EJR, Punt CJA, Nagtegaal ID, Rütten H, Nuyttens JJME, van Meerten E, Doornebosch PG, Tanis PJ, Derksen EJ, Dwarkasing RS, Marijnen CAM, Cats A, Tollenaar RAEM, de Hingh IHJT, Rutten HJT, van der Schelling GP, Ten Tije AJ, Leijtens JWA, Lammering G, Beets GL, Aufenacker TJ, Pronk A, Manusama ER, Hoff C, Bremers AJA, Verhoef C, de Wilt JHW. The CARTS study: Chemoradiation therapy for rectal cancer in the distal rectum followed by organ-sparing transanal endoscopic microsurgery. BMC Surg 2011; 11:34. [PMID: 22171697 PMCID: PMC3295682 DOI: 10.1186/1471-2482-11-34] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2011] [Accepted: 12/15/2011] [Indexed: 12/15/2022] Open
Abstract
Background The CARTS study is a multicenter feasibility study, investigating the role of rectum saving surgery for distal rectal cancer. Methods/Design Patients with a clinical T1-3 N0 M0 rectal adenocarcinoma below 10 cm from the anal verge will receive neoadjuvant chemoradiation therapy (25 fractions of 2 Gy with concurrent capecitabine). Transanal Endoscopic Microsurgery (TEM) will be performed 8 - 10 weeks after the end of the preoperative treatment depending on the clinical response. Primary objective is to determine the number of patients with a (near) complete pathological response after chemoradiation therapy and TEM. Secondary objectives are the local recurrence rate and quality of life after this combined therapeutic modality. A three-step analysis will be performed after 20, 33 and 55 patients to ensure the feasibility of this treatment protocol. Discussion The CARTS-study is one of the first prospective multicentre trials to investigate the role of a rectum saving treatment modality using chemoradiation therapy and local excision. The CARTS study is registered at clinicaltrials.gov (NCT01273051)
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Affiliation(s)
- Guus M J Bökkerink
- Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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Abstract
The staging process in a newly diagnosed rectal cancer is divided into three parts. One essential part is the local staging, in which both endorectal ultrasound and MRI are used to disclose the size of the tumor and its correlation to the perirectal fascia, and to identify lymph node deposits and vascular invasion. This local staging process will guide clinicians to decide upon not only the type of surgery (local excision or radical surgery) but also whether or not some type of neoadjuvant treatment, such as radiotherapy and/or chemotherapy, is indicated. The second part is to evaluate whether or not the tumor has already metastasized at diagnosis. The most important organs to evaluate are the liver and lungs, and imaging techniques such as ultrasound, CT-scan, or sometimes PET-CT, and MRI can be used. The third important part is to investigate the rest of the large bowel for synchronous adenomas or cancers. This will preferably be done with colonoscopy or CT-colonography and sometimes barium enema. This article discusses the imaging techniques used for local staging and distant metastases.
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Affiliation(s)
- Lars Påhlman
- Radiology Department of Oncology, Radiology & Clinical Immunology, Section of Radiology, Uppsala University, Uppsala, Sweden.
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Sgourakis G, Lanitis S, Gockel I, Kontovounisios C, Karaliotas C, Tsiftsi K, Tsiamis A, Karaliotas CC. Transanal Endoscopic Microsurgery for T1 and T2 Rectal Cancers: A Meta–Analysis and Meta-Regression Analysis of Outcomes. Am Surg 2011. [DOI: 10.1177/000313481107700635] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective of this study is to assess transanal endoscopic microsurgery (TEM) as a surgical strategy for stage I rectal cancer. The literature lacks level I and level II evidence of the oncologic competence of TEM. Three randomized controlled, one prospective, and seven retrospective comparative studies were evaluated. End-points included perioperative outcomes, margin involvement, disease-free and overall survival, and recurrence. The number of patients with major (odds ratio (OR) = 0.24,95% confidence interval (CI) 0.07–0.91) and overall postoperative complications (OR = 0.16, 95% CI 0.06-0.38) were significantly lower in TEM. The disease-free survival was higher in standard resection (SR) group compared with TEM (OR = 0.46, 95% CI 0.24-0.88). The number of patients with positive margins were less in the SR group (OR = 6.49, 95% CI 1.49-24.91), which was associated with lower local recurrence (OR = 4.92,95% CI 1.81-13.41) and overall recurrence rate (OR = 2.03, 95% CI 1.15-3.57). No survival advantage was observed in favor of either procedure. TEM had lower rate of positive margins and longer disease-free survival when compared with transanal excision (TAE). TEM seems to be superior to SR concerning morbidity whilst less effective in obtaining negative surgical margins, and it is associated with higher local and overall recurrence. No survival advantage was observed in favor of either procedure. Unfavorable tumor preoperative histology does not seem to influence the selection between TEM and SR. TEM is more effective than TAE in obtaining negative surgical margins and shows a greater disease-free survival.
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Affiliation(s)
- George Sgourakis
- Second Surgical Department and Surgical Oncology Unit of “Korgialenio – Benakio”, Red Cross Hospital, Athens, Greece
| | - Sophocles Lanitis
- Second Surgical Department and Surgical Oncology Unit of “Korgialenio – Benakio”, Red Cross Hospital, Athens, Greece
| | - Ines Gockel
- Department of General and Abdominal Surgery, Johannes Gutenberg University Hospital, Mainz, Germany
| | - Christos Kontovounisios
- Second Surgical Department and Surgical Oncology Unit of “Korgialenio – Benakio”, Red Cross Hospital, Athens, Greece
| | - Charilaos Karaliotas
- Second Surgical Department and Surgical Oncology Unit of “Korgialenio – Benakio”, Red Cross Hospital, Athens, Greece
| | - Katerina Tsiftsi
- Second Surgical Department and Surgical Oncology Unit of “Korgialenio – Benakio”, Red Cross Hospital, Athens, Greece
| | - Achilleas Tsiamis
- Department of Colorectal and Laparoscopic Surgery, James Paget University Hospital, Norfolk, UK
| | - Constantine C. Karaliotas
- Second Surgical Department and Surgical Oncology Unit of “Korgialenio – Benakio”, Red Cross Hospital, Athens, Greece
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Motamedi MAK, Mak NT, Brown CJ, Raval MJ, Karimuddin AA, Phang PT. Local versus radical surgery for early rectal cancer with or without neoadjuvant or adjuvant therapy. Hippokratia 2011. [DOI: 10.1002/14651858.cd002198.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- M Ali K Motamedi
- Surgery; St. Paul's Hospital, University of British Columbia; Vancouver Canada
| | - Nicole T Mak
- Surgery; University of British Columbia; Vancouver Canada
| | - Carl J Brown
- Head Division of General Surgery; St. Paul's Hospital; Vancouver Canada
| | - Manoj J Raval
- General Surgery; Providence Health Care - St. Paul's Hospital; Vancouver Canada
| | | | - Paul Terry Phang
- Surgery; St. Paul's Hospital, University of British Columbia; Vancouver Canada
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Evidence and research perspectives for surgeons in the European Rectal Cancer Consensus Conference (EURECA-CC2). ACTA ACUST UNITED AC 2010; 57:9-16. [PMID: 21066977 DOI: 10.2298/aci1003009v] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE Although surgery remains the most important treatment of rectal cancer, the management of this disease has evolved to become more multidisciplinary to offer the best clinical outcome. The International Conference on Multidisciplinary Rectal Cancer Treatment: Looking for an European Consensus' (EURECA-CC2) had the duty to identify the degree of consensus that could be achieved across a wide range of topics relating to the management of rectal cancer helping shape future programs, investigational protocols and guidelines for staging and treatment throughout Europe. MATERIALS AND METHODS Consensus was achieved using the Delphi method. Eight chapters were identified: epidemiology, diagnostics, pathology, surgery, radiotherapy and chemotherapy, treatment toxicity and quality of life, follow-up, and research questions. Each chapter was subdivided by topic, and a series of statements were developed. Each committee member commented and voted, sentence by sentence three times. Sentences which did not reach agreement after voting round #2 were openly debated during the Conference in Perugia (Italy) December 2008. The Executive Committee scored percentage consensus based on three categories: "large consensus", "moderate consensus", "minimum consensus". RESULTS The total number of the voted sentences was 207. Of the 207, 86% achieved large consensus, 13% achieved moderate consensus, and only 3 (1%) resulted in minimum consensus. No statement was disagreed by more than 50% of members. All chapters were voted on by at least 75% of the members, and the majority was voted on by 85%. CONCLUSIONS This Consensus Conference represents an expertise opinion process that may help shape future programs, investigational protocols, and guidelines for staging and treatment of rectal cancer throughout Europe. In spite of substantial progress, many research challenges remain.
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Glimelius B, Påhlman L, Cervantes A. Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2010; 21 Suppl 5:v82-6. [PMID: 20555109 DOI: 10.1093/annonc/mdq170] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- B Glimelius
- Department of Oncology, Radiology and Clinical Immunology, University of Uppsala, Sweden
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Abstract
BACKGROUND AND PURPOSE During the first decade of the 21st century several important European randomized studies in rectal cancer have been published. In order to help shape clinical practice based on best scientific evidence, the International Conference on 'Multidisciplinary Rectal Cancer Treatment: Looking for an European Consensus' (EURECA-CC2) was organized. This article summarizes the consensus about imaging and radiotherapy of rectal cancer and gives an update until May 2010. METHODS Consensus was achieved using the Delphi method. Eight chapters were identified: epidemiology, diagnostics, pathology, surgery, radiotherapy and chemotherapy, treatment toxicity and quality of life, follow-up, and research questions. Each chapter was subdivided by topic, and a series of statements were developed. Each committee member commented and voted, sentence by sentence three times. Sentences which did not reach agreement after voting round # 2 were openly debated during the Conference in Perugia (Italy) December 2008. The Executive Committee scored percentage consensus based on three categories: "large consensus", "moderate consensus", "minimum consensus". RESULTS The total number of the voted sentences was 207. Of the 207, 86% achieved large consensus, 13% achieved moderate consensus, and only three (1%) resulted in minimum consensus. No statement was disagreed by more than 50% of members. All chapters were voted on by at least 75% of the members, and the majority was voted on by >85%. Considerable progress has been made in staging and treatment, including radiation treatment of rectal cancer. CONCLUSIONS This Consensus Conference represents an expertise opinion process that may help shape future programs, investigational protocols, and guidelines for staging and treatment of rectal cancer throughout Europe. In spite of substantial progress, many research challenges remain.
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Magnetic resonance imaging (MRI) in rectal cancer: a comprehensive review. Insights Imaging 2010; 1:245-267. [PMID: 22347920 PMCID: PMC3259411 DOI: 10.1007/s13244-010-0037-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Revised: 07/11/2010] [Accepted: 07/26/2010] [Indexed: 02/07/2023] Open
Abstract
Magnetic resonance imaging (MRI) has established itself as the primary method for local staging in patients with rectal cancer. This is due to several factors, most importantly because of the ability to assess the status of circumferential resection margin. There are several newer developments being introduced continuously, such as diffusion-weighted imaging and imaging with 3 T. Assessment of loco-regional lymph nodes has also been investigated extensively using different approaches, but more work needs to be done. Finally, evaluation of tumours during or after preoperative treatment is becoming an everyday reality. All these new aspects prompt a review of the most recent advances and opinions. In this review, a comprehensive overview of the current status of MRI in the loco-regional assessment and management of rectal cancer is presented. The findings on MRI and their accuracy are reviewed based on the most up-to-date evidence. Optimisation of MRI acquisition and relevant regional anatomy are also presented, based on published literature and our own experience.
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Derwinger K, Kodeda K, Bexe-Lindskog E, Taflin H. Tumour differentiation grade is associated with TNM staging and the risk of node metastasis in colorectal cancer. Acta Oncol 2010; 49:57-62. [PMID: 20001500 DOI: 10.3109/02841860903334411] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
AIM The tumour differentiation grade has been shown by numerous multivariate analyses to be a stage-independent prognostic factor in colorectal cancer. The aim of this study was to explore the importance of differentiation grading for the staging of colorectal cancer and how it relates to the components of the TNM system. MATERIAL AND METHODS The study was a retrospective single-centre analysis of all patients undergoing surgical resection for colorectal cancer during the period 2002-2007 (n = 1239). The clinical parameters and pathology data of overall stage, differentiation grade, local tumour (T)-stage and metastasis status (M-stage) were included as well as the lymph node count of both assessed and metastatic nodes. The differentiation grade was correlated with demography, overall stage and each component of the TNM staging system. The correlation between differentiation grade and N-stage was also explored for the separate T-stages. RESULTS The tumour differentiation grade correlated significantly with the overall TNM stage (p < 0.0001). The grade significantly correlated with the T-stage and the risk of having lymph node metastasis (p < 0.0001). A high grade was associated with a higher positive lymph node count in stage III disease (p < 0.0002). For the T-stages, the risk of node metastasis was significantly linked to the tumour grade. A low grade (G1) T2 had a 17% risk of lymph node metastasis compared to a 44% risk for a high grade (G4) T2. CONCLUSION Tumour differentiation is an important prognostic factor. It correlates significantly with the overall stage of the TNM system and also to each of its components. The risk of having lymph node metastasis for each T-stage also correlates with the tumour grade. The findings can be of importance in postoperative risk assessment or when considering local resection procedures like TEM.
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