Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up

Advancing mid-rectal cancer surgery: Unveiling the potential of natural orifice specimen extraction surgery in comparison to conventional laparoscopic-assisted resection

BACKGROUND

Mid-rectal cancer treatment traditionally involves conventional laparoscopic-assisted resection (CLAR). This study aimed to assess the clinical and therapeutic advantages of Natural Orifice Specimen Extraction Surgery (NOSES) over CLAR.

AIMS

To compare the clinical outcomes, intraoperative metrics, postoperative recovery, complications, and long-term prognosis between NOSES and CLAR groups.

MATERIALS & METHODS

A total of 136 patients were analyzed, with 92 undergoing CLAR and 44 undergoing NOSES. Clinical outcomes were evaluated, and propensity score matching (PSM) was employed to control potential biases.

RESULTS

The NOSES group exhibited significant improvements in postoperative recovery, including lower pain scores on days 1, 3, and 5 (p < .001), reduced need for additional analgesics (p = .02), shorter hospital stays (10.8 ± 2.3 vs. 14.2 ± 5.3 days; p < .001), and decreased intraoperative blood loss (48.1 ± 52.7 mL vs. 71.0 ± 55.0 mL; p = .03). Patients undergoing NOSES also reported enhanced satisfaction with postoperative abdominal appearance and better quality of life. Additionally, the NOSES approach resulted in fewer postoperative complications.

CONCLUSION

While long-term outcomes (overall survival, disease-free survival, and local recurrence rates) were comparable between the two methods, NOSES demonstrated superior postoperative outcomes compared to CLAR in mid-rectal cancer treatment, while maintaining similar long-term oncological safety. These findings suggest that NOSES could serve as an effective alternative to CLAR without compromising long-term results.

The Outcome of Local Excision of Rectal Adenomas with High-Grade Dysplasia by Transanal Endoscopic Microsurgery: A Single-Center Experience

Background: Local excision by transanal endoscopic microsurgery (TEM) is considered an acceptable treatment for rectal adenomas with high-grade dysplasia (HGD). This study aims to assess the likelihood of harboring an invasive carcinoma in preoperatively diagnosed HGD polyps and evaluate the risk factors for tumor recurrence in patients with final HGD pathology. Methods: Data from patients who underwent TEM procedures for adenomatous lesions with HGD from 2005 to 2018 at the Rabin Medical Center, Hasharon Hospital, were analyzed. Collected data included patient demographics, preoperative workup, tumor characteristics and postoperative results. Follow-up data including recurrence assessment and further treatments were reviewed. The analysis included two subsets: preoperative pathology of HGD (sub-group 1) and postoperative final pathology of HGD (sub-group 2) patients. Results: Forty-five patients were included in the study. Thirty-six patients had a preoperative diagnosis of HGD, with thirteen (36%) showing postoperative invasive carcinoma. Thirty-two patients had a final pathology of HGD, and three (9.4%) experienced tumor recurrence. Large tumor size (>5 cm) was significantly associated with recurrence (p = 0.03). Conclusions: HGD rectal polyps are associated with a significant risk of invasive cancer. Tumor size was a significant factor in predicting tumor recurrence in patients with postoperative HGD pathology. The TEM procedure is an effective first-line treatment for such lesions.

Endoluminal ultrasound versus magnetic resonance imaging in assessment of rectal cancer after neoadjuvant therapy

BACKGROUND

Accurate rectal tumor staging guides the choice of treatment options. EUS and MRI are the main modalities for staging.

AIM OF THE WORK

To compare the performance of EUS and MRI for loco-regional staging of anorectal cancer after neo-adjuvant therapy.

METHODS

Seventy-three (37 male, 36 female) patients with rectal cancer after neo-adjuvant chemoradiotherapy were enrolled. Histopathological staging after surgery were used as reference for comparing the yield of loco-regional staging for EUS and MRI. EUS and MRI were done 1 month after completion of neo-adjuvant therapy.

RESULTS

Regarding post-surgical T staging, eight patients had early tumor (T2 = 16 and T1 = 9) and thirty six were locally advanced (T3 = 36), while N staging, forty patients with negative nodes and 33 were positive (N1 = 22 and N2 = 11). Comparing EUS to MRI, it showed a higher sensitivity (95.7% vs. 78.7%), specificity (84.6% vs. 68.0%) and accuracy (91.8% vs. 75.3%) for staging early and locally advanced tumor. Also, it had a higher sensitivity (78.8% vs. 69.7%), specificity (75.0% vs. 65.0%) and accuracy (76.7% vs. 67.1%) for detection of lymph nodes.

CONCLUSION

EUS appears to be more accurate than MRI in loco-regional staging of rectal carcinoma after neo-adjuvant therapy.

The effects of neoadjuvant chemoradiotherapy and an in-hospital exercise training programme on physical fitness and quality of life in locally advanced rectal cancer patients: a randomised controlled trial (The EMPOWER Trial)

BACKGROUND

The EMPOWER trial aimed to assess the effects of a 9-week exercise prehabilitation programme on physical fitness compared with a usual care control group. Secondary aims were to investigate the effect of (1) the exercise prehabilitation programme on psychological health; and (2) neoadjuvant chemoradiotherapy (NCRT) on physical fitness and psychological health.

METHODS

Between October 2013 and December 2016, adults with locally advanced rectal cancer undergoing standardised NCRT and surgery were recruited to a multi-centre trial. Patients underwent cardiopulmonary exercise testing (CPET) and completed HRQoL questionnaires (EORTC-QLQ-C30 and EQ-5D-5L) pre-NCRT and post-NCRT (week 0/baseline). At week 0, patients were randomised to exercise prehabilitation or usual care (no intervention). CPET and HRQoL questionnaires were assessed at week 0, 3, 6 and 9, whilst semi-structured interviews were assessed at week 0 and week 9. Changes in oxygen uptake at anaerobic threshold (VO2 at AT (ml kg-1 min-1)) between groups were compared using linear mixed modelling.

RESULTS

Thirty-eight patients were recruited, mean age 64 (10.4) years. Of the 38 patients, 33 were randomised: 16 to usual care and 17 to exercise prehabilitation (26 males and 7 females). Exercise prehabilitation significantly improved VO2 at AT at week 9 compared to the usual care. The change from baseline to week 9, when adjusted for baseline, between the randomised groups was + 2.9 ml kg -1 min -1; (95% CI 0.8 to 5.1), p = 0.011.

CONCLUSION

A 9-week exercise prehabilitation programme significantly improved fitness following NCRT. These findings have informed the WesFit trial (NCT03509428) which is investigating the effects of community-based multimodal prehabilitation before cancer surgery.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01914068 . Registered 1 August 2013.

High resolution MRI-based radiomic nomogram in predicting perineural invasion in rectal cancer

BACKGROUND

To establish and validate a high-resolution magnetic resonance imaging (HRMRI)-based radiomic nomogram for prediction of preoperative perineural invasion (PNI) of rectal cancer (RC).

METHODS

Our retrospective study included 140 subjects with RC (99 in the training cohort and 41 in the validation cohort) who underwent a preoperative HRMRI scan between December 2016 and December 2019. All subjects underwent radical surgery, and then PNI status was evaluated by a qualified pathologist. A total of 396 radiomic features were extracted from oblique axial T2 weighted images, and optimal features were selected to construct a radiomic signature. A combined nomogram was established by incorporating the radiomic signature, HRMRI findings, and clinical risk factors selected by using multivariable logistic regression.

RESULTS

The predictive nomogram of PNI included a radiomic signature, and MRI-reported tumor stage (mT-stage). Clinical risk factors failed to increase the predictive value. Favorable discrimination was achieved between PNI-positive and PNI-negative groups using the radiomic nomogram. The area under the curve (AUC) was 0.81 (95% confidence interval [CI], 0.71-0.91) in the training cohort and 0.75 (95% CI, 0.58-0.92) in the validation cohort. Moreover, our result highlighted that the radiomic nomogram was clinically beneficial, as evidenced by a decision curve analysis.

CONCLUSIONS

HRMRI-based radiomic nomogram could be helpful in the prediction of preoperative PNI in RC patients.

Preoperative nomogram to predict survival following colorectal cancer liver metastasis simultaneous resection

Background

Simultaneous resection for patients with synchronous colorectal cancer liver metastases (CRLM) remains an optimal option for the sake of curability. However, few studies so far focus on outcome of this subgroup of patients (who receive simultaneous resection for CRLM). Substantial heterogeneity exists among such patients and more precise categorization is needed preoperatively to identify those who may benefit more from surgery. In this study, we formulated this internally validated scoring system as an option.

Methods

Clinicopathological and follow-up data of 234 eligible CRLM patients undergoing simultaneous resection from January 2010 to March 2019 in our center were included for analysis. Patients were randomized to either a training or validation cohort. We performed multivariable Cox regression analysis to determine preoperative factors with prognostic significance using data in training cohort, and a nomogram scoring system was thus established. Time-dependent receiver operating characteristic (ROC) curve and calibration plot were adopted to evaluate the predictive power of our risk model.

Results

In the multivariable Cox regression analysis, five factors including presence of node-positive primary defined by enhanced CT/MR, preoperative CEA level, primary tumor location, tumor grade and number of liver metastases were identified as independent prognostic indicators of overall survival (OS) and adopted to formulate the nomogram. In the training cohort, calibration plot graphically showed good fitness between estimated and actual 1- and 3-year OS. Time-dependent ROC curve by Kaplan-Meier method showed that our nomogram model was superior to widely used Fong's score in prediction of 1- and 3-year OS (AUC 0.702 vs. 0.591 and 0.848 vs. 0.801 for 1- and 3-year prediction in validation cohort, respectively). Kaplan-Meier curves for patients stratified by the assessment of nomogram showed great discriminability (P<0.001).

Conclusions

In this retrospective analysis we identified several preoperative factors affecting survival of synchronous CRLM patients undergoing simultaneous resection. We also constructed and validated a risk model which showed high accuracy in predicting 1- and 3-year survival after surgery. Our risk model is expected to serve as a predictive tool for CRLM patients receiving simultaneous resection and assist physicians to make treatment decision.

Long-term outcomes of real world 'watch and wait' data for rectal cancer after neoadjuvant chemoradiotherapy

AIM

A 'watch and wait' (W&W) strategy after neoadjuvant long-course chemoradiotherapy (NACRT) remains controversial. Whilst encouraging short-term data exist, the strategy will be judged on long-term data. We present long-term, real-world UK data from a single National Health Service trust.

METHODS

An analysis was performed of a prospectively maintained W&W database over 9 years between 2010 and 2018. Outcome measures include incidence and time to regrowth and overall and disease-free survival.

RESULTS

We diagnosed 563 rectal cancers in 9 years. In all, 283 patients underwent rectal resection (50.3%). NACRT was used in 155 patients for margin-threatened tumours on staging MRI. Forty-nine patients (31.6%) experienced either a 'near complete' or a complete clinical response (cCR) at their 10 weeks post-NACRT assessment (MRI and endoscopy). The median age was 69 years (range 44-83), and the male to female ratio was 32:17. The median follow-up was 38 months (range 12-96). The median tumour distance from the anal verge was 7 cm (1-15 cm). Twenty-two patients had a cCR on initial assessment and 27 patients had a 'near' cCR. Of those 27 who experienced a 'near' cCR, 17 (63%) progressed to cCR on repeat assessment and 10 (37%) did not. Of these 10 patients, seven underwent standard surgical resection and three were unfit for surgery. R0 for the seven with delayed resection was 100%. Of 39 patients (22 cCR and 17 'near' cCR who progressed to cCR) (25.2% of those receiving NACRT), six patients experienced local regrowth (15.4%). The median time to local regrowth was 29 months (15-60 months). One of these six patients underwent salvage abdominoperineal resection, one was advised to have contact radiotherapy and four opted against surgery and also had contact radiotherapy. The overall survival was 100% at 2 years and 90% at 5 years. Disease-free survival was 90.47% at 2 years and 74.8% at 5 years.

CONCLUSION

A W&W treatment strategy was employed safely in this patient cohort with acceptable rates of local regrowth and survival.

The utility of preoperative radiological evaluation of early rectal neoplasia: a systematic review and meta-analysis

AIM

The diagnostic role for preoperative imaging of clinically benign rectal adenomas is unclear. The objective of this systematic review and meta-analysis was to examine the diagnostic accuracy of preoperative imaging in distinguishing benign adenomas from rectal cancer.

METHOD

A systematic search was performed for all studies published that correlated staging of clinically benign rectal adenomas with endorectal ultrasound (ERUS) or MRI and histology. Imaging was compared with postoperative histology and data on the numbers of true positives, false positives, true negatives and false negatives were extracted. Summary estimates of sensitivity and specificity with 95% CIs were calculated using a bivariate random effects model. The QUADAS2 tool was used to determine the methodological quality of included studies.

RESULTS

Eleven studies describing 1511 patients were retrieved. A total of 1134 patients underwent local excision and 377 had a formal proctectomy. A benign rectal adenoma was diagnosed in 840 and 214 had a T1 rectal cancer. For confirming benign adenomas, the pooled sensitivity of ERUS was 0.81 (95% CI 0.69-0.89) and specificity was 0.85 (95% CI 0.68-0.93). For detecting occult T1 tumours, the pooled sensitivity of ERUS was 0.50 (95% CI 0.33-0.66) and specificity was 0.89 (95% CI 0.82-0.94). Quantitative analysis of MRI could not be performed due to insufficient studies.

CONCLUSION

This study demonstrates the limited accuracy of preoperative ERUS in distinguishing benign adenomas from T1 rectal cancer. Preoperative imaging must be interpreted with caution to prevent over-staging and unnecessary proctectomy. We propose that clinically benign lesions may undergo local excision, with subsequent management based on final histology.

Two-Stage Turnbull-Cutait Pull-Through Coloanal Anastomosis for Low Rectal Cancer: A Randomized Clinical Trial

Importance

Two-stage Turnbull-Cutait pull-through hand-sewn coloanal anastomosis seems to provide benefits in terms of postoperative morbidity compared with standard hand-sewn coloanal anastomosis associated with diverting ileostomy and further ileostomy reversal in patients operated on for low rectal cancer.

Objective

To compare 30-day postoperative and 1-year follow-up results of Turnbull-Cutait pull-through hand-sewn coloanal anastomosis and standard hand-sewn coloanal anastomosis after ultralow rectal resection for rectal cancer.

Design, Setting, and Participants

Multicenter randomized clinical trial. Neither patients nor surgeons were blinded for technique. Patients were recruited in 3 centers, Bellvitge University Hospital and Valle d'Hebron University Hospital in Spain and Instituto Nazionale Tumori Fondazione G. Pascale-Istituto di Ricovero e Cura a Carattere Scientifico in Italy. Patients undergoing ultralow anterior rectal resection needing hand-sewn coloanal anastomosis were randomly assigned to 2-stage Turnbull-Cutait pull-through hand-sewn coloanal anastomosis or standard hand-sewn coloanal anastomosis associated with diverting ileostomy. Data were analyzed between June 2012 and October 2018.

Interventions

All patients underwent ultralow anterior resection. Patients assigned to the 2-stage Turnbull-Cutait pull-through group underwent exteriorization of a segment of left colon through the anal canal and, after 6 to 10 days, the exteriorized colon was resected and a delayed hand-sewn coloanal anastomosis was performed. For patients assigned to standard coloanal anastomosis, the hand-sewn coloanal anastomosis was performed with diverting ileostomy at first operation. Closure of the ileostomy was planned after 6 to 8 months.

Main Outcomes and Measures

Primary outcome was 30-day postoperative morbidity. For the standard hand-sewn coloanal anastomosis with diverting ileostomy group, overall postoperative morbidity includes 30-day postoperative complications of the ileostomy closure.

Results

Ninety-two white patients, 72 men and 20 women, with a median age of 62 years, were randomized and included in the analysis. Forty-six patients received standard hand-sewn coloanal anastomosis with diverting ileostomy and 46 received the 2-stage pull-through hand-sewn coloanal anastomosis. Seven patients (15.2%) in the standard hand-sewn coloanal anastomosis group did not undergo reversal ileostomy, and 1 patient (2.2%) in the 2-stage pull-through hand-sewn coloanal anastomosis group did not undergo delayed coloanal anastomosis. The 30-day overall composite postoperative complications rate was similar between the 2 groups (34.8% in 2-stage pull-through hand-sewn coloanal anastomosis group vs 45.7% in standard hand-sewn coloanal anastomosis group; P = .40), with a difference of -10.9 (95% CI, -29.5 to 8.9).

Conclusions and Relevance

The 2-stage pull-through hand-sewn coloanal anastomosis after ultralow anterior resection for low rectal cancer is safe and does not increase the postoperative morbidity rate compared with standard coloanal anastomosis with covering ileostomy followed by ileostomy closure.

Trial Registration

ClinicalTrials.gov Identifier: NCT01766661.

Adjuvant chemotherapy in curatively resected rectal cancer: How valid are the data?

BACKGROUND

According to the result of the Cochrane review published in 2012, postoperative adjuvant chemotherapy (CTx) is associated with a survival benefit for rectal cancer patients operated for cure in comparison to patients who underwent only the surgical resection.

AIM

To analyze the quality of the data supporting the advantage of adjuvant CTx after surgery for rectal cancer. In the times of increasing health care costs, it is imperative to offer the patient an evidence-based therapy that justifies potential side effects as well as costs.

METHODS

Overall survival was selected as endpoint of interest. Among the 21 included papers which analyzed this endpoint, we identified those three publications which have the highest weights to influence the final result. The validity of these papers was analyzed using the CONSORT checklist for randomized controlled trials. We performed a second meta-analysis excluding the three analyzed studies (n = 18) in order to assess their impact on the overall result of the original meta-analysis. Finally, we performed a third meta-analysis excluding all studies (n = 16) which showed a statistically improved overall survival.

RESULTS

The detailed analysis of the three most relevant RCTs according to the items of the CONSORT checklist showed several pitfalls. In up to 47% of the items, inappropriate answers were found. Generally, a lack of information regarding the randomization procedure as well as the absence of allocation concealment, blinded set-up, of intention-to-treat analysis and omission of sample size calculation were common problems of the analyzed studies. The exclusion of these three studies from the meta-analysis did not affect the general result of the meta-analysis, still confirming a survival advantage after adjuvant chemotherapy. After exclusion of single studies with a statistically significant outcome improvement, the meta-analysis of the remaining 16 studies again shows a statistically significant result due in part to a large remaining sample size.

CONCLUSION

The three most powerful publications show substantial deficits. We suggest a more critical appraisal regarding the validity of single studies because a meta-analysis cannot overcome the limitations of individual trials by pooling treatment effect estimates to generate a single best estimate.

Use of magnetic resonance imaging in rectal cancer patients: Society of Abdominal Radiology (SAR) rectal cancer disease-focused panel (DFP) recommendations 2017

PURPOSE

To propose guidelines based on an expert-panel-derived unified approach to the technical performance, interpretation, and reporting of MRI for baseline and post-treatment staging of rectal carcinoma.

METHODS

A consensus-based questionnaire adopted with permission and modified from the European Society of Gastrointestinal and Abdominal Radiologists was sent to a 17-member expert panel from the Rectal Cancer Disease-Focused Panel of the Society of Abdominal Radiology containing 268 question parts. Consensus on an answer was defined as ≥ 70% agreement. Answers not reaching consensus (< 70%) were noted.

RESULTS

Consensus was reached for 87% of items from which recommendations regarding patient preparation, technical performance, pulse sequence acquisition, and criteria for MRI assessment at initial staging and restaging exams and for MRI reporting were constructed.

CONCLUSION

These expert consensus recommendations can be used as guidelines for primary and post-treatment staging of rectal cancer using MRI.

Rates of metachronous adenoma after curative resection for left-sided or right-sided colon cancer

Background/Aims

We determined the rates of metachronous colorectal neoplasm in colorectal cancer (CRC) patients after resection for right (R)-sided or left (L)-sided cancer.

Methods

Consecutive CRC patients who had undergone surgical resection for curative intent in our hospital between 2001 and 2004 were identified. R-sided colonic cancers refer to cancer proximal to splenic flexure whereas L-sided cancers include rectal cancers. Patients were included only if they had a clearing colonoscopy performed either before or within 6 months after the operation. Findings of surveillance colonoscopy performed up to 5 years after colonic resection were included in the analysis.

Results

Eight hundred and sixty-three CRC patients underwent curative surgical resection during the study period. Three hundred and twenty-seven patients (107 R-sided and 220 L-sided) fulfilled the inclusion criteria and had at least 1 postoperative surveillance colonoscopy performed. The proportion of patients who had polyp and adenoma on surveillance colonoscopy was significantly higher among patients with L-sided than R-sided cancers (polyps: 30.9% vs. 19.6%, P=0.03; adenomas: 25.5% vs. 13.1%, P=0.01). The mean number of adenoma per patient on surveillance colonoscopy was also higher for patients with L-sided than R-sided tumors (0.52; 95% confidence interval [CI], 0.37–0.68 vs. 0.22; 95% CI, 0.08–0.35; P<0.01). Multivariate analysis showed that L-sided cancers, age, male gender and longer follow-up were independent predictors of adenoma detection on surveillance colonoscopy.

Conclusions

Patients with Lsided cancer had a higher rate of metachronous polyps and adenoma than those with R-sided cancer on surveillance colonoscopy.

Impact of adjuvant chemotherapy on patients with ypT0-2 ypN0 rectal cancer after neoadjuvant chemoradiation: a cohort study from a tertiary referral hospital

Background

To investigate the importance of adjuvant chemotherapy in locally advanced rectal cancer (≥ cT3 or N+) staged ypT0–2 ypN0 on final histological work-up after neoadjuvant chemoradiation and radical resection.

Methods

The clinical course of patients with rectal cancer and ypT0–2 ypN0 stages after neoadjuvant chemoradiation and radical resection was analyzed from 1999 to 2012. Patients were divided into two groups depending on whether adjuvant chemotherapy was administered or not. Overall survival, distant metastases, and local recurrence were compared between both groups.

Results

Fifty-four patients with adjuvant (ACT) and 50 patients without adjuvant chemotherapy (NACT) after neoadjuvant chemoradiation followed by radical resection for rectal cancer were included in the analysis. Mean follow-up was 68 ± 33.7 months. One patient without adjuvant chemotherapy and none in the ACT group developed a local recurrence. Five patients in the NACT group and three patients in the ACT group had distant recurrences. Median disease-free survival for all patients was 65.5 ± 34.5 months. Multivariate analysis showed adjuvant chemotherapy to be the most relevant factor for disease-free and overall survival. Patients staged ypT2 ypN0 showed a significantly better disease-free survival after application of adjuvant chemotherapy. Disease-free survival in ypT0–1 ypN0 patients showed no correlation to the administration of adjuvant chemotherapy.

Conclusion

Administration of adjuvant chemotherapy after neoadjuvant chemoradiation and radical resection in rectal cancer improved disease-free and overall survival of patients with ypT0–2 ypN0 tumor stages in our study. In particular, ypT2 ypN0 patients seem to profit from adjuvant treatment.

CXCR4 overexpression is correlated with poor prognosis in colorectal cancer

AIMS

Colorectal cancer threatens human health due to its high mortality resulting from metastatic progression. The expression of C-X-C chemokine receptor type 4 (CXCR4) is absent or low in most healthy tissues but high in various types of tumours. In this study, we aim to determine the prognostic significance of CXCR4 in colorectal cancer.

MAIN METHODS

We retrospectively examined a total of 72 tissue samples, that qRT-PCR and immunohistochemistry were performed to detect the expression of CXCR4 as well as univariate and multivariate analyses were performed to explore the overall survival.

KEY FINDINGS

Our data demonstrated that CXCR4 expression was associated with lymph node metastasis (P = 0.049), histological differentiation (P = 0.01), distant metastasis (P = 0.02) and DNA mismatch repair (MMR) index (P = 0.0002). However, CXCR4 expression was not associated with age, sex, tumour diameter or depth of invasion. Furthermore, both univariate and multivariate analyses confirmed that CXCR4 was an independent factor in predicting unfavourable overall survival (hazard ratio, 0.188; 95% confidence interval, 0.038-0.757).

SIGNIFICANCE

In conclusion, our findings suggest that CXCR4 might contribute to clinical tumour progression and may be a valuable prognostic biomarker in colorectal cancer treatment.

Protein phosphatase 2A (PP2A) inhibitor CIP2A indicates resistance to radiotherapy in rectal cancer

Preoperative (chemo)radiotherapy, (C)RT, is an essential part of the treatment of rectal cancer patients, but tumor response to this therapy among patients is variable. Thus far, there are no clinical biomarkers that could be used to predict response to (C)RT or to stratify patients into different preoperative treatment groups according to their prognosis. Overexpression of cancerous inhibitor of protein phosphatase 2A (CIP2A) has been demonstrated in several cancers and is frequently associated with reduced survival. Recently, high CIP2A expression has also been indicated to contribute to radioresistance in head and neck squamous cell carcinoma, but few studies have examined the connection between CIP2A and radiation response regarding other malignancies. We have evaluated CIP2A protein expression levels in relation to tumor regression after preoperative (C)RT and survival of rectal adenocarcinoma patients. The effects of CIP2A knockdown by siRNA on cell survival were further investigated in colorectal cancer cells exposed to radiation. Patients with low‐CIP2A‐expressing tumors had more frequently moderate or excellent response to long‐course (C)RT than patients with high‐CIP2A‐expressing tumors. They also had higher 36‐month disease‐specific survival (DSS) rate in categorical analysis. In the multivariate analysis, low CIP2A expression level remained as an independent predictive factor for increased DSS. Suppression of CIP2A transcription by siRNA was found to sensitize colorectal cancer cells to irradiation and decrease their survival in vitro. In conclusion, these results suggest that by contributing to radiosensitivity of cancer cells, low CIP2A protein expression level associates with a favorable response to long‐course (C)RT in rectal cancer patients.

Looking at Differences in Stage and Treatment of Colorectal Cancers across Italy: A EUROCARE-5 High Resolution Study

Aims and background

The high incidence and the estimate of a five-year relative survival of 59% for colorectal cancer in Italy were the main reasons to investigate the management of Italian patients with colorectal cancer diagnosed in the early 2000s.

Methods

Samples of adult (≥15 years) patients diagnosed in 2003–2005 with a colorectal cancer were randomly selected in 8 Italian population-based cancer registries. The z test was used to evaluate differences in proportions of Dukes stage, patients with at least 12 examined lymph nodes, and of cases treated with curative surgery plus chemotherapy or plus radiotherapy and diagnosed with colon or rectal tumors, respectively. Logistic regression models were used to estimate odds ratios of receiving the selected treatment in each cancer registry, age group and stage category, by anatomical subsite.

Results

A total of 3,938 colorectal cancer patients were analyzed. About 40% of the cases were over 75 years of age at diagnosis and at Dukes A + B stages. Higher proportions of early stages were found in the northern cancer registries. High percentages of resection with a curative intent were observed in Reggio Emilia (northern Italy), in 15 to 74-year-old patients, and at Dukes B stage. At least 12 lymph nodes were more frequently examined in the north of the country. After adjusting for age and stage, no significant differences were seen in the odds ratios of receiving surgery plus chemotherapy between cancer registries, whereas surgery plus radiotherapy was more frequent in Napoli (southern Italy) and less frequent in Biella (northern Italy).

Conclusions

Some disparities in staging and treatment of colorectal cancer patients persist across Italy. National oncological plans still need to reduce inequalities in provision and access to proper care.

Has the role of EUS in rectal cancer staging changed in the last decade?

The need for effective diagnosis, staging, and treatment of rectal cancer cannot be overstated. Accurate staging of rectal cancer has wide-ranging implications, including therapeutic strategy and prognosis. A change in stage may lead to the need for preoperative neoadjuvant therapy to decrease the risk of recurrence. The modalities commonly used for the primary staging of rectal cancer include EUS, computed tomography, and magnetic resonance imaging. EUS may be accompanied by the use of EUS-fine-needle aspiration to provide cytological confirmation. In this review, we take a deeper look into the role of EUS in the accurate staging of rectal cancer, how it compares to other modalities for the same, and how its role has changed in the last decade.

Two-stage Turnbull-Cutait pull-through coloanal anastomosis versus coloanal anastomosis with protective loop ileostomy for low rectal cancer. Protocol for a randomized controlled trial (Turnbull-BCN)

PURPOSE

The aim of this study was to determine whether patients that underwent ultra-low rectal resection for cancer can benefit from the recently reintroduced two-stage Turnbull-Cutait abdominoperineal pull-through procedure.

METHODS

Patients with low rectal tumors undergoing radical sphincter-sparing resection are eligible for inclusion in a randomized multicenter study. Whether two-stage Turnbull-Cutait coloanal anastomosis provides significant benefits over hand-sewn coloanal anastomosis and associated lateral ileostomy in terms of postoperative morbidity is the primary endpoint. In addition, the study aims to assess secondary endpoints such as quality of life, fecal incontinence, and locoregional recurrence of the neoplasm. Patients with adenocarcinoma of the lower rectum diagnosed by rigid proctoscopy, with histological confirmation of malignancy, and who are candidates of rectal removal and coloanal anastomosis will be included in a randomized controlled and multicenter trial. Postoperative morbidity is defined as complications that occur within 30 days of the data of the second surgical procedure of the last patient included in the trial. Patients will be followed for a minimum period of 3 years.

CONCLUSIONS

The two-stage Turnbull-Cutait coloanal anastomosis may constitute an effective surgical alternative in the current approach to the treatment of low rectal cancer without the need of a temporary loop colostomy, preventing the wide range of complications related to stoma surgery.

TRIAL REGISTRATION

This trial is registered at clinicaltrials.gov (trial number: NCT01766661). This trial is registered in January 10, 2013.

Tumor size, tumor location, and antitumor inflammatory response are associated with lymph node size in colorectal cancer patients

Lymph node size affects lymph node retrieval in surgical specimen and is used as criterion for pre-operative radiological estimation of metastatic disease. However, factors determining lymph node size remain to be established. Therefore, the association between lymph node size and presence of metastatic cancer deposits as well as different primary tumor characteristics was analyzed in a prospective cross-sectional study. Visible and palpable nodes were harvested, and conventional histology, immunohistochemistry, and molecular analysis were performed. The study cohort comprised 148 patients (median age 69 years, range 36-92). Lymph node dissection rendered 4167 nodes. Mean lymph node count was 28 (median 26, range 9-67). Metastatic disease was detected in 320 (8%) nodes and was associated with lymph node size (P<0.001). Positive nodes measuring ≤2 mm caused upstaging within the N category in one third of cases, but did not identify patients as node-positive as all patients also had positive larger nodes. Large tumor size (P=0.001), right tumor location (P<0.001), and deep tumor penetration (P=0.024) were all independently associated with lymph node size, whereas high lymphocytic antitumor reaction just missed statistical significance (P=0.053) in multivariable analysis. Microsatellite instability had no influence on lymph node size when analysis was restricted to right-sided tumors. In conclusion, analysis of small lymph nodes may lead to upstaging within the N category, but they do not identify a patient as node-positive and do therefore not influence clinical decision-making in the adjuvant setting. The majority of enlarged lymph nodes, including those measuring >1 cm, are not involved by cancer. Different tumor characteristics, such as large primary tumor size, right tumor location, and deep tumor penetration are independently associated with lymph node size and need to be considered when interpreting enlarged nodes detected by radiological imaging.

OLFM4, KNG1 and Sec24C identified by proteomics and immunohistochemistry as potential markers of early colorectal cancer stages

Background

Despite recent advances in colorectal cancer (CRC) diagnosis and population screening programs, the identification of patients with preneoplastic lesions or with early CRC stages remains challenging and is important for reducing CRC incidence and increasing patient’s survival.

Methods

We analysed 76 colorectal tissue samples originated from early CRC stages, normal or inflamed mucosa by label-free proteomics. The characterisation of three selected biomarker candidates was performed by immunohistochemistry on an independent set of precancerous and cancerous lesions harbouring increasing CRC stages.

Results

Out of 5258 proteins identified, we obtained 561 proteins with a significant differential distribution among groups of patients and controls. KNG1, OLFM4 and Sec24C distributions were validated in tissues and showed different expression levels especially in the two early CRC stages compared to normal and preneoplastic tissues.

Conclusion

We highlighted three proteins that require further investigations to better characterise their role in early CRC carcinogenesis and their potential as early CRC markers.

Electronic supplementary material

The online version of this article (doi:10.1186/s12014-017-9143-3) contains supplementary material, which is available to authorized users.

Diffusion-weighted magnetic resonance imaging in colorectal cancer

Magnetic resonance imaging (MRI) plays now a major role in patients with colorectal cancer regarding tumor staging, surgical planning, therapeutic decision, assessment of tumor response to chemoradiotherapy and surveillance of rectal cancer, and detection and characterization of liver or peritoneal metastasis of colorectal cancers. Diffusion-weighted MRI (DW-MRI) is a functional imaging tool that is now part of the standard MRI protocol for the investigation of patients with colorectal cancer. DW-MRI reflects micro-displacements of water molecules in tissues and conveys high degrees of accuracy to discriminate between benign and malignant colorectal conditions. Thus, in addition to morphological imaging, DW-MRI has an important role to accurately detect colorectal neoplasms and peritoneal implants, to differentiate benign focal liver lesions from metastases and to detect tumor relapse within fibrotic changes. This review provides a comprehensive overview of basic principles, clinical applications and future trends of DW-MRI in colorectal cancers.

Comparative effectiveness of postoperative chemotherapy among older patients with non-metastatic rectal cancer treated with preoperative chemoradiotherapy

OBJECTIVE

Postoperative chemotherapy is standard following preoperative chemoradiation therapy (CRT) and curative resection for clinically staged II/III rectal cancer. Recent trials have questioned whether postoperative chemotherapy improves overall survival. The objective of the study was to evaluate the comparative effectiveness of postoperative chemotherapy following CRT or radiation therapy (RT) with specific attention to the impact of age on postoperative chemotherapy effectiveness.

MATERIALS AND METHODS

Patients treated with CRT or RT then resection of pathologically staged 0-III rectal cancer diagnosed from 2004 to 2009 were identified from the Surveillance, Epidemiology and End Results program-Medicare database. Propensity score weighted Cox proportional hazards models and Kaplan Meier methods were used to compare the effectiveness of 1) postoperative 5-fluorouracil (5-FU) or capecitabine to no treatment and 2) postoperative oxaliplatin+5-FU/capecitabine to 5-FU/capecitabine alone on mortality. Results were stratified by age.

RESULTS

We identified 1316 patients; 49% received postoperative chemotherapy, 341 (52%) included oxaliplatin. After weighting, postoperative 5-FU/capecitabine alone was associated with decreased mortality in patients aged 66-74 (adjusted hazard ratio (aHR)=0.46, 95% CI: 0.30, 0.72), corresponding to a 5-year risk difference of -0.23, (95% CI: -0.33, -0.12). No further mortality reduction from adding oxaliplatin to 5-FU/capecitabine was seen in patients aged 66-74 (aHR=1.57, 95% CI: 0.93, 2.65). No mortality reduction for 5-FU/capecitabine alone was observed among patients aged 75+ (aHR=1.11, 95% CI: 0.76, 1.63).

CONCLUSIONS

Among patients <75years, postoperative 5-FU/capecitabine was associated with reduced mortality after preoperative CRT/RT and surgical resection; however, the addition of oxaliplatin was not associated with further mortality reduction. Decisions regarding postoperative chemotherapy after age 75 warrant consideration of individual patient risks and preferences, as benefits may be limited.

The accuracy of endorectal ultrasonography in rectal cancer staging

Background and aims

The incidence of rectal cancer in the European Union is about 35% of the total colorectal cancer incidence. Staging rectal cancer is important for planning treatment. It is essential for the management of rectal cancer to have adequate preoperative imaging, because accurate staging can influence the therapeutic strategy, type of resection, and candidacy for neoadjuvant therapy. The aim of this work is to evaluate the accuracy of endorectal ultrasound (ERUS) in rectal cancer staging.

Methods

A retrospective study was performed to assess the accuracy of ERUS by analyzing patients discharged from Regional Institute of Gastroenterology and Hepatology (IRGH) Cluj-Napoca, Romania, diagnosed with rectal cancer between 01 January 2011 and 31 December 2013. Patients who were preoperatively staged by other imaging methods and those who had ERUS performed in another service were excluded from the analysis. As inclusion criteria remained ERUS performed for patients with rectal cancer in IRGH Cluj-Napoca where they were also operated. We analyzed preoperative T stage obtained by ERUS and it was compared with the histopathology findings.

Results

The number of patients discharged with a diagnosis of rectal cancer were 200 (operated – 157) in 2011, 193 (operated – 151) in 2012, and 198 (operated – 142) in 2013. We analyzed a total of 51 cases diagnosed with rectal cancer who performed ERUS in IRGH Cluj-Napoca. The results according to the T stage obtained by ERUS and histopathology test were:

Conclusions

ERUS is a method of staging rectal cancer which is human dependent. ERUS is less accurate for T staging of stenotic tumours, but the accuracy may still be within acceptable limits. Surgeons use ERUS to adopt a treatment protocol, knowing the risk of under-staging and over-staging of this method. The accuracy of ERUS is higher in diagnosing rectal cancer in stages T1, T2 and even in stage T3 with malignant tumor which is not occlusive. ERUS is less accurate for T staging of locally advanced and stenotic tumours.

Practice parameters for early rectal cancer management: Italian Society of Colorectal Surgery (Società Italiana di Chirurgia Colo-Rettale; SICCR) guidelines

The introduction of new technologies for diagnosis and screening programs led to an increasing rate of early detection of colorectal cancer. This, associated with the evolution of endoscopic techniques of local excision, led to the assessment of new strategies to reduce morbidity related to treatment, especially for early rectal cancer (ERC). Nevertheless, the definition of ERC and its staging and treatment algorithm are still under debate. The Italian Society of Colorectal Surgery developed practice guidelines to provide recommendations on the diagnosis, staging and treatment of ERC. A systematic review on the topic was performed by a multidisciplinary group of experts selected based on their clinical and scientific expertise in endoscopy, endoscopic ultrasound, magnetic resonance and surgery, with the aid of an external international audit.

Protein phosphatase methylesterase-1 (PME-1) expression predicts a favorable clinical outcome in colorectal cancer

Colorectal cancer (CRC) accounts for high mortality. So far, there is lack of markers capable of predicting which patients are at risk of aggressive course of the disease. Protein phosphatase-2A (PP2A) inhibitor proteins have recently gained interest as markers of more aggressive disease in certain cancers. Here, we report the role of PP2A inhibitor PME-1 in CRC. PME-1 expression was assessed from a rectal cancer patient cohort by immunohistochemistry, and correlations were performed for various clinicopathological variables and patient survival. Rectal cancer patients with higher cytoplasmic PME-1 protein expression (above median) had less recurrences (P = 0.003, n = 195) and better disease-free survival (DFS) than the patients with low cytoplasmic PME-1 protein expression (below median). Analysis of PPME-1 mRNA expression from TCGA dataset of colon and rectal adenocarcinoma (COADREAD) patient cohort confirmed high PPME1 expression as an independent protective factor predicting favorable overall survival (OS) (P = 0.005, n = 396) compared to patients with low PPME1 expression. CRC cell lines were used to study the effect of PME-1 knockdown by siRNA on cell survival. Contrary to other cancer types, PME-1 inhibition in CRC cell lines did not reduce the viability of cells or the expression of active phosphorylated AKT and ERK proteins. In conclusion, PME-1 expression predicts for a favorable outcome of CRC patients. The unexpected role of PME-1 in CRC in contrast with the oncogenic role of PP2A inhibitor proteins in other malignancies warrants further studies of cancer-specific function for each of these proteins.

Radiographic staging practices of newly diagnosed colorectal cancer vary according to medical specialty

BACKGROUND

Since 2008, multiple guidelines have endorsed incorporation of chest CT in the radiographic staging assessment of newly diagnosed colorectal cancer (CRC). Radiographic staging practices performed after CRC is detected have not been studied.

OBJECTIVE

To evaluate radiographic staging practices for newly diagnosed CRC between gastroenterologists versus non-gastroenterologists.

DESIGN

Observational cohort study.

SETTING

Single, tertiary-care referral center.

PATIENTS

Patients newly diagnosed with a T1 or higher stage CRC at time of colonoscopy between 2008 and 2013.

INTERVENTIONS

Radiographic staging.

MAIN OUTCOME MEASUREMENTS

Radiographic preoperative staging examinations ordered by gastroenterologists in comparison to those ordered by non-gastroenterology specialists.

RESULTS

This study included 277 patients with CRC newly diagnosed by colonoscopy. There were 141 total ordering physicians (68 gastroenterologists and 73 non-gastroenterologists). The majority of preoperative radiographic staging was performed by gastroenterologists (59.2% of patients, n = 164). Colorectal surgeons managed staging in 28.7% of patients (n = 47). Gastroenterologists were more likely to omit a staging chest CT than were non-gastroenterologists (64.6% vs 46.9%; P < .001). Physician practice setting, rectal location of tumor, and advanced endoscopic appearance of tumors were predictors of chest CT inclusion.

LIMITATIONS

Single center, moderate sample size of both providers and patients.

CONCLUSION

Gastroenterologists more frequently ordered the initial radiographic staging studies in newly diagnosed CRC patients. However, gastroenterologists were less likely to include chest CT in the initial staging of CRC despite current guideline recommendations to do so. If confirmed with further studies, educational efforts to improve compliance and standardization may be needed.

Higher adenoma recurrence rate after left- versus right-sided colectomy for colon cancer

BACKGROUND

Patients with history of colonic resection for cancer have an increased risk of the development of metachronous malignant and premalignant lesions. Scanty data are reported on detection rates of premalignant lesions during colonoscopy surveillance in this setting.

OBJECTIVE

To assess the risk of metachronous precancerous lesions developing in patients with previous colonic surgery for cancer according to the resection type.

DESIGN

Retrospective study.

SETTING

Two academic centers in Italy.

PATIENTS

A total of 441 patients; 256 with previous left-sided colectomy (LCR) (LCR group) and 185 with previous right-sided colectomy (RCR) (RCR group).

INTERVENTIONS

Second surveillance colonoscopy.

MAIN OUTCOME MEASUREMENTS

Polyp and adenoma detection rates.

RESULTS

At least 1 adenoma was diagnosed in 76 of 256 patients (30% adenoma detection rate) and in 35 of 185 patients (19% adenoma detection rate) in the LCR and RCR groups, respectively (P=.014), yielding an odds ratio of 1.83 (95% confidence interval, 1.16-2.89). Corresponding figures for the polyp detection rate were 39% and 25%, respectively (P=.002; odds ratio 1.97; 95% confidence interval, 1.30-3.00).

LIMITATIONS

Retrospective study with colonoscopy baseline information missing.

CONCLUSIONS

Patients who have undergone LCR are at higher risk of the development of adenomas than those who have undergone RCR. If this result is confirmed by large prospective studies, surveillance programs could be targeted according to the type of colonic resection, with longer intervals for patients with previous RCR compared with LCR.

Role of endoscopic ultrasonography in the loco-regional staging of patients with rectal cancer

The prognosis of rectal cancer (RC) is strictly related to both T and N stage of the disease at the time of diagnosis. RC staging is crucial for choosing the best multimodal therapy: patients with high risk locally advanced RC (LARC) undergo surgery after neoadjuvant chemotherapy and radiotherapy (NAT); those with low risk LARC are operated on after a preoperative short-course radiation therapy; finally, surgery alone is recommended only for early RC. Several imaging methods are used for staging patients with RC: computerized tomography, magnetic resonance imaging, positron emission tomography, and endoscopic ultrasound (EUS). EUS is highly accurate for the loco-regional staging of RC, since it is capable to evaluate precisely the mural infiltration of the tumor (T), especially in early RC. On the other hand, EUS is less accurate in restaging RC after NAT and before surgery. Finally, EUS is indicated for follow-up of patients operated on for RC, where there is a need for the surveillance of the anastomosis. The aim of this review is to highlight the impact of EUS on the management of patients with RC, evaluating its role in both preoperative staging and follow-up of patients after surgery.

Optimizing the selection of patients with low rectal cancer for intersphincteric resection by evaluating vertical invasion to the levator and external sphincter

AIM

The indications for intersphincteric (ISR) anterior resection are not clearly defined. The aim of this study was to evaluate vertical extension of T2 or T3 low rectal cancer treated by rectal amputation to optimize patient selection for ISR.

METHOD

The abdominoperineal excision specimens of T2 or T3 low rectal cancer from 53 patients treated between 1992 and 2004 were retrospectively reviewed. Vertical invasion was quantified by measuring the shortest distance between the tumour and the striated muscle (T-SM), assuming that this represented the surgical margin that would have be achieved had an ISR been performed.

RESULTS

Involvement of the dentate line (DL) and intramural distal spread were independent risk factors for T-SM ≤ 2 mm. The T-SM was less when the inferior border of the tumour was on the distal side of the DL (r = 0.572, P < 0.001). The probability of involvement of the DL, intramural distal spread or either one of these being associated with T-SM ≤ 2 mm was 43, 46 and 43%, respectively. All patients without both intramural distal spread and involvement of the DL had T-SM > 2.

CONCLUSION

We recommend that ISR should only be performed for patients with T2 or T3 low rectal cancer in whom the lowest edge of the tumour is above the DL and there is no intramural distal spread. Such patients are relatively unlikely to have a T-SM ≤ 2 mm.

Incidence and survival in late liver metastases of colorectal cancer

BACKGROUND AND AIMS

Data concerning the risk of long-term liver metastasis following surgery of colorectal cancer in the general population are scarce. The 10-year incidence and prognosis of metachronous liver metastases remain unknown.

METHODS

Among 4584 patients resected for cure for colorectal cancer recorded in two French digestive population-based cancer registries between 1985 and 2000, 602 presented metastases including liver metastases.

RESULTS

The cumulated incidence of liver metastasis was 15% at 5 years and 17% at 10 years, and was mainly related to stage at diagnosis. The 10-year cumulative incidence was 6% for stage I and 30% for stage III. The hazard ratio was 3.2 [2.4-4.3] for stage II and 6.9 [5.1-9.2] for stage III compared with stage I. Among survivors with no recurrence five years after diagnosis, 2.2% developed liver metastasis between 5 and 10 years. Resection for cure of liver metastases was performed in 35% of patients aged under 75 years and in 10% of patients over 75 (P < 0.001). After resection for cure, 10-year relative survival improved from 21% during the period 1985-1997 to 34% during the period 1998-2011 (P = 0.023). Survival in patients with liver metastasis diagnosed between six and 12 months after surgery was less than half that in patients with metastasis diagnosed later (HR: 0.6 [0.4-1.0]).

CONCLUSION

Liver metastases from colorectal cancer remain a substantial problem and continue to occur long after five years. This study furnishes unbiased figures that can be used as a reference. Liver metastases that appear late have a better prognosis.

Risk factors of synchronous inguinal lymph nodes metastasis for lower rectal cancer involving the anal canal

Purpose

The aim of the study is to identify the risk factors of synchronous ILN metastasis for lower rectal cancer involving the anal canal.

Methods

Patients with lower rectal cancer who underwent radical resection at the Fudan University Shanghai Cancer Center were retrospectively analyzed. The synchronous ILN metastasis was defined as the metastasis occurring within 6 months after the diagnosis of rectal cancer. Patients’ gender, age, tumor diameter, dentate line invasion, differentiation level, histological type, depth of invasion, perirectal LN metastasis, lymphovascular invasion or perineural invasion were analyzed in the study. The correlation between synchronous ILN involvement and clinicopathological features were analyzed with Chi-square test/fisher’s exact test. Variables with p<0.05 in univariate analysis were then analyzed in a multivariate logistic model. Odds ratio (OR) along with 95% confidence intervals (95% CI) were calculated.

Results

A total of 325 patients (182 men and 143 women) with lower rectal cancer met the criteria and were enrolled in the study. Among them, 20 patients (6.2%) had synchronous ILN metastasis. Both univariate and multivariate analysis showed the invasion of the dentate line had a strong correlation with synchronous ILN metastasis with the odds ratio (OR) of 23.558 [95% confidence interval (CI) 6.380–86.982] (p<0.001). The presence of lymphovascular invasion also showed a significant correlation synchronous ILN metastasis with odds ratio (OR) of 5.260 [95% confidence interval (CI) 1.818–15.212] (p = 0.002).

Conclusions

The invasion of dentate line and lymphovascular invasion are two independent risk factors of inguinal lymph node metastasis for lower rectal cancer involving the anal canal.

Multimodal therapy in treatment of rectal cancer is associated with improved survival and reduced local recurrence - a retrospective analysis over two decades

Background

The management of rectal cancer (RC) has substantially changed over the last decades with the implementation of neoadjuvant chemoradiotherapy, adjuvant therapy and improved surgery such as total mesorectal excision (TME). It remains unclear in which way these approaches overall influenced the rate of local recurrence and overall survival.

Methods

Clinical, histological and survival data of 658 out of 662 consecutive patients with RC were analyzed for treatment and prognostic factors from a prospectively expanded single-institutional database. Findings were then stratified according to time of diagnosis in patient groups treated between 1993 and 2001 and 2002 and 2010.

Results

The study population included 658 consecutive patients with rectal cancer between 1993 and 2010. Follow up data was available for 99.6% of all 662 treated patients. During the time period between 2002 and 2010 significantly more patients underwent neoadjuvant chemoradiotherapy (17.6% vs. 60%) and adjuvant chemotherapy (37.9% vs. 58.4%). Also, the rate of reported TME during surgery increased. The rate of local or distant metastasis decreased over time, and tumor related 5-year survival increased significantly with from 60% to 79%.

Conclusion

In our study population, the implementation of treatment changes over the last decade improved the patient’s outcome significantly. Improvements were most evident for UICC stage III rectal cancer.

National and international guidelines for rectal cancer

AIM

Rectal cancer is a common malignancy. Differences in daily practice may influence the morbidity and mortality, and many national and international organizations have created guidelines for staging and treatment of rectal cancer. Even though consensus is reached within individual guidelines, this might not be the case between guidelines. No formal evaluation of the contrasting guidance has been reported.

METHOD

A systematic search for national and international guidelines on rectal cancer was performed. Eleven guidelines were identified for further analysis.

RESULTS

There was no consensus concerning the definition of rectal cancer. Ten of the 11 guidelines use the TNM staging system and there was general agreement regarding the recommendation of MRI and CT in rectal cancer. There was consensus concerning a multidisciplinary approach, preoperative chemoradiotherapy (CRT) and total mesorectal excision (TME). There was no consensus concerning local treatment of T1 tumours and adjuvant therapy, and not all guidelines included metastatic disease and recurrence. There was no consensus on the protocol for follow up. The guidelines had different approaches to evidence. All referred to evidence but not all considered the level of evidence.

CONCLUSION

The intention of the study was to provide an overview of international guidelines for rectal cancer based on the underlying evidence, but despite hard evidence it was very difficult to reach general conclusions. Despite much knowledge, there is no international consensus on guidelines for the staging and treatment of rectal cancer.

Incremental value of liver MR imaging in patients with potentially curable colorectal hepatic metastasis detected at CT: a prospective comparison of diffusion-weighted imaging, gadoxetic acid-enhanced MR imaging, and a combination of both MR techniques

PURPOSE

To prospectively compare diagnostic performance of diffusion-weighted (DW) imaging, gadoxetic acid-enhanced magnetic resonance (MR) imaging, both techniques combined (combined MR imaging), and computed tomography (CT) for detecting colorectal hepatic metastases and evaluate incremental value of MR for patients with potentially curable colorectal hepatic metastases detected with CT.

MATERIALS AND METHODS

In this institutional review board-approved prospective study, with informed consent, 51 patients (39 men, 12 women; mean age, 62 years) with potentially resectable hepatic metastases detected with CT underwent liver MR, including DW imaging and gadoxetic acid-enhanced MR. Two independent readers reviewed DW, gadoxetic acid-enhanced, combined MR, and CT image sets to detect hepatic metastases. The figure-of-merit (FOM) value representing overall diagnostic performance, sensitivity, and positive predictive value (PPV) for each image set were analyzed by using free-response receiver operating characteristic analysis and generalized estimating equations.

RESULTS

There were 104 hepatic metastases in 47 patients. The pooled FOM values, sensitivities, and PPVs of combined MR (FOM value, 0.93; sensitivity, 98%; and PPV, 88%) and gadoxetic acid-enhanced MR (FOM value, 0.92; sensitivity, 95%; and PPV, 90%) were significantly higher than those of CT (FOM value, 0.82; sensitivity, 85%; and PPV, 73%) (P < .006). The pooled FOM value and sensitivity of combined MR (FOM value, 0.92; sensitivity, 95%) was also significantly higher than that of DW imaging (FOM value, 0.82; sensitivity, 79%) for metastases (≤1-cm diameter) (P ≤ .003). DW imaging showed significantly higher pooled sensitivity (79%) and PPV (60%) than CT (sensitivity, 50%; PPV, 33%) for the metastases (≤1-cm diameter) (P ≤ .004). In 47 patients with hepatic metastases, combined MR depicted more metastases than CT in 10 and 14 patients, respectively, according to both readers.

CONCLUSION

Gadoxetic acid-enhanced MR and combined MR are more accurate than CT in detecting colorectal hepatic metastases, have an incremental value when added to CT alone for detecting additional metastases, and can be routinely performed in patients with potentially curable hepatic metastases detected with CT.

Neoadjuvant chemoradiation therapy with gemcitabine/cisplatin and surgery versus immediate surgery in resectable pancreatic cancer: results of the first prospective randomized phase II trial

Background

In nonrandomized trials, neoadjuvant treatment was reported to prolong survival in patients with pancreatic cancer. As neoadjuvant chemoradiation is established for the treatment of rectal cancer we examined the value of neoadjuvant chemoradiotherapy in pancreatic cancer in a randomized phase II trial. Radiological staging defining resectability was basic information prior to randomization in contrast to adjuvant therapy trials resting on pathological staging.

Patients and methods

Patients with resectable adenocarcinoma of the pancreatic head were randomized to primary surgery (Arm A) or neoadjuvant chemoradiotherapy followed by surgery (Arm B), which was followed by adjuvant chemotherapy in both arms. A total of 254 patients were required to detect a 4.33-month improvement in median overall survival (mOS).

Results

The trial was stopped after 73 patients; 66 patients were eligible for analysis. Twenty nine of 33 allocated patients received chemoradiotherapy. Radiotherapy was completed in all patients. Chemotherapy was changed in 3 patients due to toxicity. Tumor resection was performed in 23 vs. 19 patients (A vs. B). The R0 resection rate was 48 % (A) and 52 % (B, P = 0.81) and (y)pN0 was 30 % (A) vs. 39 % (B, P = 0.44), respectively. Postoperative complications were comparable in both groups. mOS was 14.4 vs. 17.4 months (A vs. B; intention-to-treat analysis; P = 0.96). After tumor resection, mOS was 18.9 vs. 25.0 months (A vs. B; P = 0.79).

Conclusion

This worldwide first randomized trial for neoadjuvant chemoradiotherapy in pancreatic cancer showed that neoadjuvant chemoradiation is safe with respect to toxicity, perioperative morbidity, and mortality. Nevertheless, the trial was terminated early due to slow recruiting and the results were not significant. ISRCTN78805636; NCT00335543.

Electronic supplementary material

The online version of this article (doi: 10.1007/s00066-014-0737-7) contains supplementary material, which is available to authorized users.

Advances in the management of colorectal cancer: from biology to treatment

BACKGROUND

Colorectal cancer (CRC) is the third most common malignant neoplasm worldwide and the fourth leading cause of cancer-related deaths. This article reviews the epidemiology, risk factors, pathogenesis, and prognosis of CRC with special emphasis on advances in the management of CRC over the past decade.

METHODS

A review of the published English literature was conducted using the search engines PubMed, Medline, EMBASE, and Google Scholar. A total of 127 relevant publications were identified for further review.

RESULTS

Most CRC are sporadic and are due to genetic instability and multiple somatic mutations. Approximately 80% of cancers are diagnosed at the early stage and are curable. The pathologic stage at presentation is the most important predictor of outcome after resection of early stage cancer. Surgery is the primary treatment modality for localized CRC. Advances in (neo)adjuvant chemotherapy and radiation have reduced the disease recurrence and increased survival in high risk diseases. Although recent advancements in combination chemotherapy and target agents have increased the survival of incurable CRC, it is remarkable that only selected patients with advanced CRC can be cured with multimodality therapy.

CONCLUSION

Over the past decade, there has seen substantial progress in our understanding of and in the management of CRC.

Endorectal ultrasound in the diagnosis of rectal cancer: accuracy and criticies

INTRODUCTION

Endorectal ultrasound (ERU) is used for locoregional staging of rectal cancer. Our work compares the data in the literature regarding diagnostic accuracy of the technique and results of routine use of the technique in two centers in Piedmont.

MATERIAL AND METHODS

77 reports ultrasound with the final diagnosis of rectal cancer from the period 2008-2012 were examined. The echographies were performed by two experienced operators, using two ultrasound device with the same technical characteristics.

RESULTS

Sensitivity levels are high, with the exception of stage T3. Specificity is always high. The relationships of verisimilitude, both negative and positive, showing that the accuracy of the test is still high. The risk of overstaging is higher for pT1, while most important the risk of understaging concerns the stage T3 (23.5%); on the contrary the ERU is able to exclude infiltration of perirectal organs with a good accuracy (NPV of 99.3%).

CONCLUSION

Although our study was a retrospective study, likewise some literature's reports, the interpretation of our analysis results shows a significant risk of downstaging T3 and N+ tumors. ERU represents in our experience a very important radiological staging methods to evaluate T1 and T2 rectal cancer.

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.

Primary rectal cancer local staging

The treatment of patients with a malignant rectal tumor has evolved over the past few years. The role of medical imaging techniques, notably MRI, has become increasingly important in the preoperative assessment of rectal tumors. Radiologists are finding that their presence is requested more and more frequently at multidisciplinary team meetings for decision-making on the treatment of these tumors and therefore they must have a grounding in the therapeutic issues involved. Locoregional assessment of malignant rectal tumors may be performed prior to initiating treatment or as a re-evaluation following neoadjuvant therapy. We are interested in the assessment of the initial locoregional extension of these rectal tumors and we place much emphasis on the ability to identify MRI criteria which determine the patient's prognosis and treatment. We will also examine the advantages of MRI as well as its limits in this assessment.

Dosimetric evaluation of Tomotherapy and four-box field conformal radiotherapy in locally advanced rectal cancer

Purpose

To report the results of dosimetric comparison between intensity-modulated radiotherapy (IMRT) using Tomotherapy and four-box field conformal radiotherapy (CRT) for pelvic irradiation of locally advanced rectal cancer.

Materials and Methods

Twelve patients with locally advanced rectal cancer who received a short course preoperative chemoradiotherapy (25 Gy in 5 fractions) on the pelvis using Tomotherapy, between July 2010 and December 2010, were selected. Using their simulation computed tomography scans, Tomotherapy and four-box field CRT plans with the same dose schedule were evaluated, and dosimetric parameters of the two plans were compared. For the comparison of target coverage, we analyzed the mean dose, V_{n Gy}, D_min, D_max, radical dose homogeneity index (rDHI), and radiation conformity index (RCI). For the comparison of organs at risk (OAR), we analyzed the mean dose.

Results

Tomotherapy showed a significantly higher mean target dose than four-box field CRT (p = 0.001). But, V_{26.25 Gy} and V_{27.5 Gy}were not significantly different between the two modalities. Tomotherapy showed higher D_max and lower D_min. The Tomotherapy plan had a lower rDHI than four-box field CRT (p = 0.000). Tomotherapy showed better RCI than four-box field CRT (p = 0.007). For OAR, the mean irradiated dose was significantly lower in Tomotherapy than four-box field CRT.

Conclusion

In locally advanced rectal cancer, Tomotherapy delivers a higher conformal radiation dose to the target and reduces the irradiated dose to OAR than four-box field CRT.

Follow-Up Care, Surveillance Protocol, and Secondary Prevention Measures for Survivors of Colorectal Cancer: American Society of Clinical Oncology Clinical Practice Guideline Endorsement

Purpose

The American Society of Clinical Oncology (ASCO) has a policy and set of procedures for endorsing recent clinical practice guidelines that have been developed by other professional organizations.

Methods

The Cancer Care Ontario (CCO) Guideline on Follow-up Care, Surveillance Protocol, and Secondary Prevention Measures for Survivors of Colorectal Cancer was reviewed by ASCO for methodologic rigor and considered for endorsement.

Results

The ASCO Panel concurred with the CCO recommendations and recommended endorsement, with the addition of several qualifying statements.

Conclusion

Surveillance should be guided by presumed risk of recurrence and functional status of the patient (important within the first 2 to 4 years). Medical history, physical examination, and carcinoembryonic antigen testing should be performed every 3 to 6 months for 5 years. Patients at higher risk of recurrence should be considered for testing in the more frequent end of the range. A computed tomography scan (abdominal and chest) is recommended annually for 3 years, in most cases. Positron emission tomography scans should not be used for surveillance outside of a clinical trial. A surveillance colonoscopy should be performed 1 year after the initial surgery and then every 5 years, dictated by the findings of the previous one. If a colonoscopy was not preformed before diagnosis, it should be done after completion of adjuvant therapy (before 1 year). Secondary prevention (maintaining a healthy body weight and active lifestyle) is recommended. If a patient is not a candidate for surgery or systemic therapy because of severe comorbid conditions, surveillance tests should not be performed. A treatment plan from the specialist should have clear directions on appropriate follow-up by a nonspecialist.

When is local excision appropriate for "early" rectal cancer?

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.

Tailored rectal cancer treatment--a time for implementing contemporary prognostic factors?

AIM

To report data supporting the development of tailored treatment strategies for rectal cancer.

METHOD

A comprehensive review of the literature on the impact of prognostic factors cur-rently not included in international guidelines in rectal cancer management.

RESULTS

There is considerable variation in treatment guidelines for rectal cancer worldwide, especially for Stage II and Stage III disease. Long-term side effects of chemoradiotherapy are not considered in any guideline. Detailed knowledge, and the prognostic impact, of the circumferential resection margin, tumour grade and venous invasion should be factored into the development of a treatment strategy.

CONCLUSION

Factors additional to the TNM system should improve decision making for contemporary rectal cancer treatment. Optimized radiological and pathological evaluations, and a focus on detailed clinical factors, should be the basis for treatment decisions. International guidelines should consider all known prognostic factors for long-term oncological and functional outcomes.

Is follow-up CT imaging of the chest and abdomen necessary after preoperative neoadjuvant therapy in rectal cancer patients without evidence of metastatic disease at diagnosis?

AIM

Patients with rectal cancer often undergo multiple CT scans prior to surgical resection. We propose that in patients with locally advanced rectal cancer without evidence of metastatic disease at presentation, CT imaging of the chest and abdomen after preoperative neoadjuvant therapy does not change clinical information or surgical management.

METHOD

An institutional review board-approved medical record review identified patients with contrast enhanced CT of the chest, abdomen and pelvis alone or in conjunction with (18)F-fluoro-2-deoxy-d-glucose/positron emission tomography imaging for staging of rectal cancer prior to and after neoadjuvant therapy. Eighty-eight patients were included in the study. Scans were reviewed for the presence of metastatic disease on initial and follow-up imaging prior to surgical resection.

RESULTS

Seventy-six (86%) of 88 patients had no evidence of metastasis at presentation. None of these patients developed metastatic disease after neoadjuvant therapy. Twelve (14%) had metastases at presentation. No study patient developed metastatic disease in a new organ.

CONCLUSION

Imaging after preoperative neoadjuvant therapy in rectal cancer does not change the designation of metastatic disease. Patients with locally advanced rectal adenocarcinoma without evidence of metastases may not benefit from repeat imaging of the chest and abdomen after neoadjuvant therapy.