Progress in the multidisciplinary treatment of gastrointestinal cancer and the impact on clinical practice: perioperative management of rectal cancer

Chinese guidelines for the diagnosis and comprehensive treatment of colorectal liver metastases (version 2018)

The liver is the most common anatomical site for hematogenous metastases of colorectal cancer, and colorectal liver metastases is one of the most difficult and challenging points in the treatment of colorectal cancer. To improve the diagnosis and comprehensive treatment in China, the Guidelines have been edited and revised several times since 2008, including the overall evaluation, personalized treatment goals and comprehensive treatments, to prevent the occurrence of liver metastases, improve the resection rate of liver metastases and survival. The revised Guideline includes the diagnosis and follow-up, prevention, MDT effect, surgery and local ablative treatment, neoadjuvant and adjuvant therapy, and comprehensive treatment, and with advanced experience, latest results, detailed content, and strong operability.

Correlation of standard diffusion-weighted imaging and diffusion kurtosis imaging with distant metastases of rectal carcinoma

PURPOSE

To investigate the correlation of standard diffusion-weighted imaging (DWI) and diffusion kurtosis imaging (DKI) with distant metastases of rectal carcinoma.

MATERIALS AND METHODS

Fifty-eight patients with rectal carcinoma (27 with distant metastasis and 31 with no metastasis) were included in this study. The apparent diffusion coefficient (ADC) value from standard DWI (b values of 0 and 1000 sec/mm(2) ), Dapp , and Kapp from DKI (b values of 0, 700, 1400, and 2000 sec/mm(2) ) were acquired with a 3.0T magnetic resonance imaging (MRI) scanner. These quantitative parameters were calculated from the entire tumors. Receiver operating characteristic curve analyses were conducted to assess the utility for discrimination of tumor with distant metastasis and those without metastasis. Parameters were compared using the independent-samples t-test.

RESULTS

The histogram metrics 10th percentile of Dapp (Dapp-10th ) and ADC values (ADC10th ) were significantly lower in the distant metastasis group than those without metastasis (972.5 ± 118.8 vs. 1121.3 ± 133.8 × 10(-6) mm(2) /s, P = 0.03; 809.2 ± 67.1 vs. 856.2 ± 72.1 × 10(-6) mm(2) /s, P = 0.03). Dapp-10th showed relatively higher area under the curve (AUC) (0.856 vs. 0.669, P = 0.024), and higher specificity (100% vs. 68%) than ADC10th did for differentiation of lesions with distant metastasis from those without metastasis.

CONCLUSION

DKI was relatively better than standard DWI in discriminating rectal carcinoma with distant metastasis from those without metastasis. J. Magn. Reson. Imaging 2016;44:221-229.

Management of rectal cancers in relation to treatment guidelines: a population-based study comparing Italian and French patients

BACKGROUND

Few studies have investigated rectal cancer management at the population level. We compared how rectal cancers diagnosed in Italy (2003-2005) and France (2005) were managed, and evaluated the extent to which management adhered to European guidelines.

METHODS

Samples of 3938 Italian and 2287 French colorectal cancer patients were randomly extracted from 8 and 12 cancer registries respectively. Rectal cancer patients (860 Italian, 559 French) were analysed. Logistic regression models estimated odds ratios (ORs) of being treated with curative intent, receiving sphincter-saving surgery, and receiving preoperative radiotherapy.

RESULTS

Similar proportions of Italian and French patients were treated with curative intent (70% vs. 67%; OR=0.92 [0.73-1.16]); the respective proportions receiving sphincter-saving surgery were 21% and 33% (OR=1.15 [0.86-1.53]). In about 50% of those treated with curative intent, ≥ 12 lymph nodes were harvested in both countries. The proportion receiving postoperative radiotherapy was higher in Italy than in France (25% vs. 11%, p<0.01), but French patients were more likely to receive preoperative radiotherapy (52% vs. 21%; OR=4.06 [2.79-5.91]).

CONCLUSION

The proportions of patients receiving preoperative radiotherapy and the numbers of lymph nodes sampled were low in both countries. Centralising treatment and potentiating screening would be practical ways of improving outcomes and adhering to guidelines.

Cancer survival in Europe 1999-2007 by country and age: results of EUROCARE--5-a population-based study

BACKGROUND

Cancer survival is a key measure of the effectiveness of health-care systems. EUROCARE-the largest cooperative study of population-based cancer survival in Europe-has shown persistent differences between countries for cancer survival, although in general, cancer survival is improving. Major changes in cancer diagnosis, treatment, and rehabilitation occurred in the early 2000s. EUROCARE-5 assesses their effect on cancer survival in 29 European countries.

METHODS

In this retrospective observational study, we analysed data from 107 cancer registries for more than 10 million patients with cancer diagnosed up to 2007 and followed up to 2008. Uniform quality control procedures were applied to all datasets. For patients diagnosed 2000-07, we calculated 5-year relative survival for 46 cancers weighted by age and country. We also calculated country-specific and age-specific survival for ten common cancers, together with survival differences between time periods (for 1999-2001, 2002-04, and 2005-07).

FINDINGS

5-year relative survival generally increased steadily over time for all European regions. The largest increases from 1999-2001 to 2005-07 were for prostate cancer (73.4% [95% CI 72.9-73.9] vs 81.7% [81.3-82.1]), non-Hodgkin lymphoma (53.8% [53.3-54.4] vs 60.4% [60.0-60.9]), and rectal cancer (52.1% [51.6-52.6] vs 57.6% [57.1-58.1]). Survival in eastern Europe was generally low and below the European mean, particularly for cancers with good or intermediate prognosis. Survival was highest for northern, central, and southern Europe. Survival in the UK and Ireland was intermediate for rectal cancer, breast cancer, prostate cancer, skin melanoma, and non-Hodgkin lymphoma, but low for kidney, stomach, ovarian, colon, and lung cancers. Survival for lung cancer in the UK and Ireland was much lower than for other regions for all periods, although results for lung cancer in some regions (central and eastern Europe) might be affected by overestimation. Survival usually decreased with age, although to different degrees depending on region and cancer type.

INTERPRETATION

The major advances in cancer management that occurred up to 2007 seem to have resulted in improved survival in Europe. Likely explanations of differences in survival between countries include: differences in stage at diagnosis and accessibility to good care, different diagnostic intensity and screening approaches, and differences in cancer biology. Variations in socioeconomic, lifestyle, and general health between populations might also have a role. Further studies are needed to fully interpret these findings and how to remedy disparities.

FUNDING

Italian Ministry of Health, European Commission, Compagnia di San Paolo Foundation, Cariplo Foundation.

Rectal cancer staging: focus on the prognostic significance of the findings described by high-resolution magnetic resonance imaging

High-resolution (HR) magnetic resonance imaging (MRI) has become an indispensable tool for multidisciplinary teams (MDTs) addressing rectal cancer. It provides anatomic information for surgical planning and allows patients to be stratified into different groups according to the risk of local and distant recurrence. One of the objectives of the MDT is the preoperative identification of high-risk patients who will benefit from neoadjuvant treatment. For this reason, the correct evaluation of the circumferential resection margin (CRM), the depth of tumor spread beyond the muscularis propria, extramural vascular invasion and nodal status is of the utmost importance. Low rectal tumors represent a special challenge for the MDT, because decisions seek a balance between oncologic safety, in the pursuit of free resection margins, and the patient's quality of life, in order to preserve sphincter function. At present, the exchange of information between the different specialties involved in dealing with patients with rectal cancer can rank the contribution of colleagues, auditing their work and incorporating knowledge that will lead to a better understanding of the pathology. Thus, beyond the anatomic description of the images, the radiologist's role in the MDT makes it necessary to know the prognostic value of the findings that we describe, in terms of recurrence and survival, because these findings affect decision making and, therefore, the patients' life. In this review, the usefulness of HR MRI in the initial staging of rectal cancer and in the evaluation of neoadjuvant treatment, with a focus on the prognostic value of the findings, is described as well as the contribution of HR MRI in assessing patients with suspected or confirmed recurrence of rectal cancer.

General surgeons' views on Oncologic Multidisciplinary Group meetings as part of colorectal cancer care

This study aimed to assess the current effectiveness of Oncologic Multidisciplinary Groups (OMGs) meetings across central Tuscany through surgeons' reports and their individual perceived benefits on colorectal cancer management. One hundred and sixty-seven general surgeons received a questionnaire with 21 questions covering organizational characteristics of OMGs and the individual perceived benefits of OMGs. The responses were analyzed by hospital setting (teaching vs. community hospital). The reply rate was 62.8 %, and 82 respondent surgeons (49.1 %) were involved in the treatment of colorectal cancer patients. At community hospitals, there was a more frequent participation of medical oncologists, radiation oncologists and pathologists; a less selection of discussed cases was performed; and almost all decisions were inserted into official patient charts (p < 0.05). Community hospital surgeons perceived more of a benefit than academic surgeons: OMGs ensure that all treatment options are considered and improve timeliness of care, patient outcomes, patient satisfaction and communication with patients (p < 0.05). The surveyed surgeons reported that OMGs offer a modest degree of protection from malpractice but improve communications between colleagues and are an opportunity for personal professional development. Professionals regularly participating in well-conducted and well-organized OMGs for colorectal cancer felt that the multidisciplinary strategy may be advantageous to both patients and caregivers.

Effect of multidisciplinary team treatment on outcomes of patients with gastrointestinal malignancy

AIM: To evaluate the effect of multidisciplinary team (MDT) treatment modality on outcomes of patients with gastrointestinal malignancy in China.

METHODS: Data about patients with gastric and colorectal cancer treated in our center during the past 10 years were collected and divided into two parts. Part 1 consisted of the data collected from 516 consecutive complicated cases discussed at MDT meetings in Peking University School of Oncology (PKUSO) from December 2005 to July 2009. Part 2 consisted of the data collected from 263 consecutive cases of resectable locally advanced rectal cancer from January 2001 to January 2005. These 263 patients were divided into neoadjuvant therapy (NT) group and control group. Patients in NT group received MDT treatment, namely neoadjuvant therapy + surgery + postoperative adjuvant therapy. Patients in control group underwent direct surgery + postoperative adjuvant therapy. The outcomes in two groups were compared.

RESULTS: The treatment strategy was altered after discussed at MDT meeting in 76.81% of gastric cancer patients and in 58.33% of colorectal cancer patients before operation. The sphincter-preservation and local control of tumor were better in NT group than in control group. The 5-year overall survival rate was also higher in NT group than in control group (77.23% vs 69.75%, P = 0.049).

CONCLUSION: MDT treatment modality can significantly improve the outcomes of patients with gastrointestinal malignancy in China.

Radiotherapy in rectal cancer: development, adequacy and radiotherapy utilisation rate. A comparative analysis with the most frequent tumour sites

INTRODUCTION

Radiotherapy is a basic weapon in the local treatment of multiple solid tumors. The radiotherapy activity has been evaluated in our centre during the past eleven years. The study focused on rectal cancer.

MATERIALS AND METHODS

This is a descriptive study of all radiotherapy procedures performed between January 1998 and December 2008. It quantifies the workload of each pathology treated, the rate of irradiation and its adequacy with optimal rates of irradiation according to the best available scientific evidence.

RESULTS

We quantified 9,622 external radiotherapy procedures of which 6,009 were associated with the five pathologies that involved the highest workloads. Of these, 905 were performed in rectal cancer. The workloads due to cancers of the breast, prostate, lung, gynaecological pathologies and rectal cancers were 23.2%, 11.8%, 11.6%, 6.3% and 9.3% respectively. The real "radiotherapy utilisation rates" of these pathologies were 62%, 20.2%, 34.3%, 21% and 64% respectively, while the "rates of adequacy" were 74.7%, 33.6%, 45.1%, 60% and 104.8%.

CONCLUSIONS

The "radiotherapy utilisation rate" for rectal cancer was equivalent to the estimated optimum rate as defined on the basis of reference groups. The therapy utilised developed chronologically in parallel with the available scientific evidence. The radiotherapy utilisation rates for breast and prostate cancer gradually increased, with a tendency to reach optimal rates. Radiotherapy as a treatment for lung cancer was underutilised. In global terms, the rate of utilisation of radiation therapy was low, although it displayed a tendency to increase.

The role of the pathologist in rectal cancer diagnosis and staging and surgical quality assessment

Since the introduction of the total mesorectal excision by Heald, many changes in the therapeutic management of rectal cancer have been incorporated. The multidisciplinary approach to colorectal cancer, integrated in a team of different specialists, ensures individualised treatment for each patient with rectal cancer. Therefore the role of the pathologist has acquired an important relevance, not only in diagnosing but also managing and evaluating the surgical specimen. The knowledge of preoperative staging, distance between tumour and anal verge or in patients subjected to a neoadjuvant treatment is necessary for the pathologist to make a detailed, accurate and good-quality report. Parameters such as the macroscopic quality of the mesorectum, the status of the circumferential resection margin and the lymph node harvest are considered basic criteria recommended by the current guidelines for the multidisciplinary team audit.