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Yatabe Y, Hanaoka M, Hanazawa R, Hirakawa A, Mukai T, Kimura K, Yamanoi K, Kono J, Yokota M, Takahashi H, Kobayashi A, Kobayashi K, Ichikawa N, Yasui M, Nakane K, Yamamoto M, Takenaka A, Nakamura Y, Takemasa I, Yabusaki N, Akamoto S, Tatarano S, Murata K, Manabe T, Fujimura T, Kawamura M, Egi H, Yamaguchi S, Terai Y, Inoue S, Ito A, Kinugasa Y. Robotic versus open and laparoscopic pelvic exenterations for pelvic cancer: a multicenter propensity-matched analysis in Japan. Surg Endosc 2024:10.1007/s00464-024-10966-w. [PMID: 38886231 DOI: 10.1007/s00464-024-10966-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 05/26/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Pelvic exenteration (PE) is the last resort for achieving a complete cure for pelvic cancer; however, it is burdensome for patients. Minimally invasive surgeries, including robot-assisted surgery, have been widely used to treat malignant tumors and have also recently been used in PE. This study aimed to evaluate the safety and efficacy of robot-assisted PE (RPE) by comparing the outcomes of open PE (OPE) with those of conventional laparoscopic PE (LPE) for treating pelvic tumors. METHODS Following the ethics committee approval, a multicenter retrospective analysis of patients who underwent pelvic exenteration between January 2012 and October 2022 was conducted. Data on patient demographics, tumor characteristics, and perioperative outcomes were collected. A 1:1 propensity score-matched analysis was performed to minimize group selection bias. RESULTS In total, 261 patients met the study criteria, of whom 61 underwent RPE, 90 underwent OPE, and 110 underwent LPE. After propensity score matching, 50 pairs were created for RPE and OPE and 59 for RPE and LPE. RPE was associated with significantly less blood loss (RPE vs. OPE: 408 mL vs. 2385 ml, p < 0.001), lower transfusion rate (RPE vs. OPE: 32% vs. 82%, p < 0.001), and lower rate of complications over Clavien-Dindo grade II (RPE vs. OPE: 48% vs. 74%, p = 0.013; RPE vs. LPE: 48% vs. 76%, p = 0.002). CONCLUSION This multicenter study suggests that RPE reduces blood loss and transfusion compared with OPE and has a lower rate of complications compared with OPE and LPE in patients with locally advanced and recurrent pelvic tumors.
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Affiliation(s)
- Yusuke Yatabe
- Department of Gastrointestinal Surgery, Tokyo Medical and Dental University (TMDU), 1-5-45, Yushima, Bunkyo-ku, Tokyo, Japan
| | - Marie Hanaoka
- Department of Gastrointestinal Surgery, Tokyo Medical and Dental University (TMDU), 1-5-45, Yushima, Bunkyo-ku, Tokyo, Japan
| | - Ryoichi Hanazawa
- Department of Clinical Biostatistics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Akihiro Hirakawa
- Department of Clinical Biostatistics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Toshiki Mukai
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Kei Kimura
- Division of Lower Gastrointestinal Surgery, Department of Gastroenterological Surgery, Hyogo Medical University, Hyogo, Japan
| | - Koji Yamanoi
- Department of Gynecology and Obstetrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Jin Kono
- Department of Urology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Mitsuru Yokota
- Department of General Surgery, Kurashiki Central Hospital, Okayama, Japan
| | - Hiroki Takahashi
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | | | - Kenji Kobayashi
- Department of Gastroenterological Surgery, Kariya Toyota General Hospital, Aichi, Japan
| | - Nobuki Ichikawa
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Hokkaido, Japan
| | - Masayoshi Yasui
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Keita Nakane
- Department of Urology, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Manabu Yamamoto
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Atsushi Takenaka
- Division of Urology, Department of Surgery, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Yuya Nakamura
- Department of Surgery, National Hospital Organization, Himeji Medical Center, Hyogo, Japan
| | - Ichiro Takemasa
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Hokkaido, Japan
| | | | | | - Shuichi Tatarano
- Department of Urology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Kohei Murata
- Department of Surgery, Kansai Rosai Hospital, Hyogo, Japan
| | - Tatsuya Manabe
- Department of Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | | | - Mikio Kawamura
- Department of Gastrointestinal and Pediatric Surgery, Institute of Life Sciences, Mie University Graduate School of Medicine, Mie, Japan
| | - Hiroyuki Egi
- Department of Gastrointestinal Surgery and Surgical Oncology, Ehime University Hospital, Ehime, Japan
| | - Shigeki Yamaguchi
- Division of Colorectal Surgery, Department of Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Yoshito Terai
- Department of Obstetrics and Gynecology, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Shigetaka Inoue
- Department of Surgery, Fukuoka Red Cross Hospital, Fukuoka, Japan
| | - Akihiro Ito
- Department of Urology, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Yusuke Kinugasa
- Department of Gastrointestinal Surgery, Tokyo Medical and Dental University (TMDU), 1-5-45, Yushima, Bunkyo-ku, Tokyo, Japan.
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Webb SP, Ahmad I. Novel and Innovative Surgical Strategies for Recurrent Rectal Cancer: Uncommon Resections, Local Interventions for Pelvic Reoccurrence, and Intraoperative Radiation Therapy. Clin Colon Rectal Surg 2024; 37:66-70. [PMID: 38322600 PMCID: PMC10843878 DOI: 10.1055/s-0043-1761473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
The frequency of recurrent rectal cancer has dropped significantly with improved surgical approaches and adjunctive therapies. These recurrences have proven challenging to obtain R0 resection with salvage operations. Meticulous planning, clear understanding of anatomy with imaging, and multispecialty support have become essential in local control and long-term survival with pelvic recurrence of rectal cancer. Technical considerations and prognosis indicators along with role of intraoperative radiation or boost radiation are discussed within.
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Affiliation(s)
- Shawn Philip Webb
- Division of Colon and Rectal Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Imran Ahmad
- Division of Colon and Rectal Surgery, Henry Ford Hospital, Detroit, Michigan
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Sakata S, Karim SM, Martinez-Jorge J, Larson DW, Mathis KL, Kelley SR, Rose PS, Dozois EJ. Improving R0 Resection Rates With a Posterior-First, 2-Stage Approach for En Bloc Resection of Locally Advanced Primary and Recurrent Anorectal Cancers Involving the Deep Pelvic Sidewall. Dis Colon Rectum 2024; 67:90-96. [PMID: 38091415 DOI: 10.1097/dcr.0000000000003035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
BACKGROUND Using standard anterior approaches, consistent R0 resection of locally advanced primary and recurrent rectal and anal cancer involving the deep pelvic sidewall may be unattainable. Therefore, to improve R0 resection rates, we have used a posterior-first, then anterior 2-stage approach to resection of tumors in this location. OBJECTIVE To assess the R0 resection rate and surgical outcomes of the first 10 patients operated on using this approach. DESIGN We conducted a retrospective case series review of our prospectively maintained surgical pathology and tumor registries. SETTING This study was conducted at the Mayo Clinic in Rochester, Minnesota. PATIENTS Ten patients (6 female individuals, median age 53.5 years) with primary or recurrent anal or rectal cancer treated with a posterior-first, then anterior 2-stage approach were identified. MAIN OUTCOME MEASURES The primary outcome measures were the R0 resection rate and surgical outcomes. RESULTS An R0 resection was achieved in all 10 patients. Nine patients developed 1 or more 30-day Clavien-Dindo grade III complications. Nine patients developed gluteal wound complications ranging from superficial wound dehiscence to flap necrosis. During the follow-up period, 4 patients were found to have metastatic disease and 1 patient had local re-recurrence. LIMITATIONS Small cohort with heterogeneous tumors and a short follow-up duration. CONCLUSION A posterior-first, then anterior 2-stage approach has allowed us to achieve consistent R0 resection margins in locally advanced primary and recurrent rectal and anal cancers involving the deep pelvic sidewall. Poor wound healing of the posterior gluteal incision is a common complication. See Video Abstract. MEJORANDO LAS TASAS DE RESECCIN R CON UN ABORDAJE DE DOS ETAPAS PRIMERO POSTERIOR PARA LA RESECCIN EN BLOQUE DE CNCERES ANORRECTALES PRIMARIOS Y RECURRENTES LOCALMENTE AVANZADOS QUE AFECTAN LA PARED LATERAL PLVICA PROFUNDA ANTECEDENTES:Utilizando abordajes anteriores estándares, la resección R0 consistente del cáncer de recto y ano primario y recurrente localmente avanzado involucrando la pared lateral pélvica profunda puede ser inalcanzable. Por lo tanto, para mejorar las tasas de resección R0, hemos empleado un abordaje de 2 etapas primero posterior y luego anterior para la resección de tumores en esta ubicación.OBJETIVO:Este estudio tuvo como objetivo evaluar la tasa de resección R0 y los resultados quirúrgicos de los primeros 10 pacientes operados con este abordaje.DISEÑO:Realizamos una revisión retrospectiva de series de casos de nuestros registros de patología quirúrgica y tumores mantenidos prospectivamente.AJUSTE:Este estudio se realizó en la Clínica Mayo en Rochester, Minnesota, EE. UU.PACIENTES:Se identificaron diez pacientes (6 mujeres, mediana de edad 53.5 años) con cáncer anal o rectal primario o recurrente tratados con un abordaje de dos etapas, primero posterior y luego anterior.PRINCIPALES MEDIDAS DE RESULTADO:Las medidas de resultado primarias fueron la tasa de resección R0 y los resultados quirúrgicos.RESULTADOS:Se logró una resección R0 en los 10 pacientes. Nueve pacientes desarrollaron una o más complicaciones de grado III de Clavien-Dindo a los 30 días. Nueve pacientes desarrollaron complicaciones de la herida del glúteo que variaron desde dehiscencia superficial de la herida hasta necrosis del colgajo. Durante el período de seguimiento, se encontró que 4 pacientes tenían enfermedad metastásica y un paciente tuvo recurrencia local.LIMITACIONES:Cohorte pequeño con tumores heterogéneos y corta duración de seguimiento.CONCLUSIÓN:Un abordaje en 2 etapas, primero posterior y luego anterior, nos ha permitido lograr márgenes de resección R0 consistentes en cánceres de recto y anal primarios y recurrentes localmente avanzados que afectan la pared lateral pélvica profunda. La mala cicatrización de la incisión glútea posterior es una complicación común. (Traducción-Dr. Aurian Garcia Gonzalez).
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Affiliation(s)
- Shinichiro Sakata
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - S Mohammed Karim
- Division of Orthopedic Oncology, Mayo Clinic, Rochester, Minnesota
| | - Jorys Martinez-Jorge
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Scott R Kelley
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Peter S Rose
- Division of Orthopedic Oncology, Mayo Clinic, Rochester, Minnesota
| | - Eric J Dozois
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
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van Kessel CS, Waller J, Steffens D, Lee PJ, Austin KKS, Stalley PD, Solomon MJ. Improving Surgical Outcomes in Pelvic Exenteration Surgery: Comparison of Prone Sacrectomy With Anterior Cortical Sacrectomy Techniques. Ann Surg 2023; 278:945-953. [PMID: 37485983 DOI: 10.1097/sla.0000000000006040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
OBJECTIVE To assess the effect of changing our sacrectomy approach from prone to anterior on surgical and oncological outcomes. BACKGROUND In patients with advanced pelvic malignancy involving the sacrum, pelvic exenteration (PE) with en-bloc sacrectomy is the only potential curative option but morbidity is high. Over time sacrectomy techniques have evolved from prone sacrectomy (PS) to abdominolithotomy sacrectomy (ALS, ≤S3) and high anterior cortical sacrectomy (HACS, >S3) to optimize surgical outcomes. METHODS A retrospective, single institution analysis of prospectively collected data for patients undergoing PE with en-bloc sacrectomy between 1994 and 2021 was performed. RESULTS A total of 363 patients were identified and divided into PS (n=77, 21.2%), ALS (n=247, 68.0%), and HACS (n=39, 10.7%). Indications were: locally advanced (n=92) or recurrent (n=177) rectal cancer, primary other (n=31), recurrent other (n=60), and benign disease (n=3). PS resulted in longer operating time ( P <0.01) and more blood loss ( P <0.01). Patients with HACS had more major nerve (87.2%) and vascular (25.6%) resections ( P <0.01). Vertical rectus abdominis myocutaneous flap repair was less common following HACS (7.7%) than ALS (25.5%) and PS (27.3%) ( P =0.040). R0 rate was 80.8%, 65.8%, and 76.9% following ALS, PS, and HACS, respectively ( P =0.024). Wound-related complications and re-operations were significantly reduced following ALS and HACS compared with PS. CONCLUSIONS Changing our practice from PS to an anterior approach with ALS or HAS has been safe and improved overall surgical and perioperative outcomes, while maintaining good oncological outcomes. Given the improved perioperative and surgical outcomes, it would be important for surgeons to learn and adopt the anterior sacrectomy approaches.
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Affiliation(s)
- Charlotte S van Kessel
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Jacob Waller
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Peter J Lee
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Kirk K S Austin
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Paul D Stalley
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, NSW, Australia
| | - Michael J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
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Gould LE, Pring ET, Moorghen M, Burns EM, Antoniou A, Steele CW, Roxburgh CS, Jenkins JT. Pathological determinants of outcome following resection of locally advanced or locally recurrent rectal cancer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106971. [PMID: 37442715 DOI: 10.1016/j.ejso.2023.06.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/17/2023] [Accepted: 06/25/2023] [Indexed: 07/15/2023]
Abstract
INTRODUCTION Pathological factors that influence and predict survival following pelvic exenteration (PE) for locally advanced (LARC) or locally recurrent rectal cancer (LRRC), especially LRRC, remain poorly understood. A clear resection margin has previously been demonstrated to be of most significance. MATERIALS AND METHODS A retrospective cohort study was performed for all patients undergoing a curative PE for LARC or LRRC between 2008 and 2021 at a tertiary referral UK specialist colorectal hospital. Cox regression analysis was planned to identify pathological factors associated with overall (OS), disease free (DFS) and local recurrence free survival (LRFS). RESULTS 388 patients were included in the analysis with 256 resections for LARC and 132 for LRRC. 62.4% of patients were male with a median age of 59 years (IQR 49-67). 247 (64%) partial pelvic exenterations and 141 (36%) total pelvic exenterations performed. Overall R0 rate 86.6%. Poorly differentiated tumours and a positive resection margin independently influenced OS, DFS and LRFS on multivariate analysis in LARC. On multivariate analysis venous invasion negatively influenced DFS and poorly differentiated lesions negatively influenced LRFS in LRRC. CONCLUSIONS A positive resection margin and poorly differentiated tumours are significant negative prognostic markers for survival and recurrence in LARC. The results of this study support the need to look for alternative prognostic markers beyond that in the existing standard reporting dataset for rectal cancers. With increasing R0 rates, novel prognostic pathological markers are required to help guide treatment and surveillance for patients with LRRC.
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Affiliation(s)
- Laura E Gould
- School of Cancer Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, UK; St Mark's Academic Institute, St Mark's- The National Bowel Hospital, Harrow, UK.
| | - Edward T Pring
- St Mark's Academic Institute, St Mark's- The National Bowel Hospital, Harrow, UK
| | - Morgan Moorghen
- St Mark's Academic Institute, St Mark's- The National Bowel Hospital, Harrow, UK
| | - Elaine M Burns
- St Mark's Academic Institute, St Mark's- The National Bowel Hospital, Harrow, UK; Complex Cancer Clinic, St Mark's- The National Bowel Hospital, Harrow, UK
| | - Anthony Antoniou
- St Mark's Academic Institute, St Mark's- The National Bowel Hospital, Harrow, UK; Complex Cancer Clinic, St Mark's- The National Bowel Hospital, Harrow, UK
| | - Colin W Steele
- School of Cancer Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, UK; Department of Surgery, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - Campbell Sd Roxburgh
- School of Cancer Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, UK; Department of Surgery, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - John T Jenkins
- St Mark's Academic Institute, St Mark's- The National Bowel Hospital, Harrow, UK; Complex Cancer Clinic, St Mark's- The National Bowel Hospital, Harrow, UK
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Ali Uraiqat A, Al Nsour D, Mestareehy KM, Allababdeh MS, Naffa´ MF, Alrabee MM, Al-Hammouri F. Curative pelvic exenteration: initial experience and clinical outcome. Pan Afr Med J 2023; 44:170. [PMID: 37455871 PMCID: PMC10349634 DOI: 10.11604/pamj.2023.44.170.37182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 03/10/2023] [Indexed: 07/18/2023] Open
Abstract
Introduction in patients with advanced primary or recurrent gynecologic, urologic, or rectal cancers without metastatic disease, extensive aggressive surgery such as pelvic exenteration may be necessary for curative intent treatment. This study aims to present the initial experience and clinical outcome of curative pelvic exenteration procedures for advanced or recurrent pelvic cancer in our center. Methods a retrospective cross-sectional study was conducted at the colorectal unit at King Hussein Medical Center in Amman, Jordan, between March 2014 and December 2021. All patients who underwent pelvic exenteration procedures were included in this study. Demographic characteristics, type of procedure, completeness of excision, postoperative complications, morbidity, and mortality were analyzed. Results a total of 30 patients underwent thirty-one operations. There were 22 females and eight males with a median age of 55 (range 25-86) years. Twenty-six surgeries were for advanced primary and 5 for recurrent malignancies. Twenty-nine operations were performed for colorectal and 2 for gynecological tumors. There were 19 posterior pelvic exenterations, 2 posterior pelvic exenterations with sacrectomy, and ten total pelvic exenterations. Completeness of tumor excision R0 was observed in 21 specimens, incomplete (R1/R2) in 6 specimens. The overall complication rate was 67.7% and 30-day mortality was 16.7%. Ten (33.3%) patients are disease free at a median follow-up of 22 months. Conclusion in our study, pelvic exenteration provides above 40% overall survival at a median follow-up of two years. Gaining experience in this type of procedure, a multidisciplinary approach, careful patients' selection, and preoperative counseling will reduce postoperative morbidity and mortality.
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Affiliation(s)
- Ahmad Ali Uraiqat
- Colorectal Unit, King Hussein Medical Center, Royal Medical Services, Amman, Jordan
| | - Dania Al Nsour
- Colorectal Unit, King Hussein Medical Center, Royal Medical Services, Amman, Jordan
| | | | | | - Mo´taz Fawzat Naffa´
- Colorectal Unit, King Hussein Medical Center, Royal Medical Services, Amman, Jordan
| | | | - Firas Al-Hammouri
- Prince Hussein Center for Kidney Diseases, Royal Medical Services, Amman, Jordan
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Paku M, Uemura M, Kitakaze M, Miyoshi N, Takahashi H, Mizushima T, Doki Y, Eguchi H. Clinical Significance of Preoperative and Postoperative Serum CEA and Carbohydrate Antigen 19-9 Levels in Patients Undergoing Curative Resection of Locally Recurrent Rectal Cancer. Dis Colon Rectum 2023; 66:392-400. [PMID: 36649161 DOI: 10.1097/dcr.0000000000002655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Local recurrence is common after curative resection for rectal cancer. Although one expects radical resection of locally recurrent rectal cancer to be curative, the postoperative re-recurrence rate is relatively high. Therefore, identifying risk factors for recurrence may improve the prognosis of locally recurrent rectal cancer with early therapeutic intervention. OBJECTIVE This study aimed to evaluate the relationship between perioperative serum CEA/carbohydrate antigen 19-9 levels and prognosis in locally recurrent rectal cancer to validate their usefulness for postoperative surveillance in locally recurrent rectal cancer. DESIGN This was a single-center retrospective cohort study. SETTING The study is based on data obtained from procedures at the Osaka University Hospital. PATIENTS Ninety patients underwent radical resection for locally recurrent rectal cancer between January 2000 and January 2015. MAIN OUTCOME MEASURES We evaluated the correlation between perioperative serum CEA/carbohydrate antigen 19-9 levels and prognosis after complete resection of locally recurrent rectal cancer and the serum CEA and carbohydrate antigen 19-9 levels at the diagnosis of postoperative re-recurrence. RESULTS The median preoperative serum CEA level was 4 ng/mL and carbohydrate antigen 19-9 level was 12 U/mL. Of the 90 patients, 43.3% had serum CEA ≥5 ng/mL, and 15.6% had serum carbohydrate antigen 19-9 ≥37 U/mL. Preoperatively, this serum carbohydrate antigen 19-9 level strongly correlated with poorer prognoses regarding cancer-specific survival. Postoperatively, serum CEA ≥5 ng/mL significantly correlated with a worse prognosis. At the time of diagnosis of re-recurrence after resection of locally recurrent rectal cancer, 53.2% of patients had serum CEA ≥5 ng/mL, and 23.4% of patients had serum carbohydrate antigen 19-9 ≥37 U/mL. LIMITATIONS The study was limited by its single-center retrospective design, an insufficient sample size, and a relatively long study period. CONCLUSIONS High serum levels of carbohydrate antigen 19-9 preoperatively and CEA postoperatively are associated with poor prognosis after locally recurrent rectal cancer. Furthermore, we found a high rate of serum CEA elevation in the diagnosis of postoperative re-recurrence. See Video Abstract at http://links.lww.com/DCR/C106 . IMPORTANCIA CLNICA DE LOS NIVELES SRICOS PREOPERATORIOS Y POSOPERATORIOS DE CEA Y CA EN PACIENTES SOMETIDOS A RESECCIN CURATIVA DE CNCER DE RECTO LOCALMENTE RECURRENTE ANTECEDENTES:La recurrencia local es común después de la resección curativa del cáncer de recto. Aunque se espera que la resección radical del cáncer rectal localmente recurrente sea curativa, la tasa de recurrencia posoperatoria es relativamente alta. Por lo tanto, la identificación de los factores de riesgo de recurrencia puede mejorar el pronóstico del cáncer de recto localmente recurrente con una intervención terapéutica temprana.OBJETIVO:Evaluamos la relación entre los niveles séricos perioperatorios de CEA/CA19-9 y el pronóstico en el cáncer de recto localmente recurrente para validar su utilidad para la vigilancia posoperatoria en el cáncer de recto localmente recurrente.DISEÑO:Este fue un estudio de cohorte retrospectivo de un solo centro.AJUSTE:El estudio se basa en datos obtenidos de procedimientos en el Hospital Universitario de Osaka.PACIENTES:Noventa pacientes fueron sometidos a resección radical por cáncer de recto localmente recurrente entre Enero de 2000 y Enero de 2015.PRINCIPALES MEDIDAS DE RESULTADOS:Evaluamos la correlación entre los niveles séricos perioperatorios de CEA/CA19-9 y el pronóstico después de la resección completa del cáncer de recto localmente recurrente y los niveles séricos de CEA y CA19-9 en el diagnóstico de recurrencia posoperatoria.RESULTADOS:La mediana de los niveles séricos preoperatorios de CEA y CA19-9 fueron de 4 ng/mL y 12 U/mL, respectivamente. De los 90 pacientes, el 43,3 % tenía CEA sérico ≥5 ng/mL y el 15,6 % tenía CA19-9 sérico ≥37 U/mL. Antes de la operación, este nivel sérico de CA19-9 se correlacionó fuertemente con peores pronósticos con respecto a la supervivencia específica del cáncer. Después de la operación, el CEA sérico ≥5 ng/mL se correlacionó significativamente con un peor pronóstico. En el momento del diagnóstico de recurrencia después de la resección del cáncer de recto localmente recurrente, el 53,2 % de los pacientes tenían CEA sérico ≥5 ng/mL y el 23,4 % de los pacientes tenían CA19-9 sérico ≥37 U/mL.LIMITACIONES:El estudio estuvo limitado por su diseño retrospectivo de un solo centro, un tamaño de muestra insuficiente y un período de estudio relativamente largo.CONCLUSIONES:Los niveles séricos altos de CA19-9 antes de la operación y de CEA después de la operación están asociados con un mal pronóstico después del cáncer de recto localmente recurrente. Además, encontramos una alta tasa de elevación del CEA sérico en el diagnóstico de recurrencia posoperatoria. Consulte el Video Resumen en http://links.lww.com/DCR/C106 . (Traducción-Dr. Yesenia Rojas-Khalil ).
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Affiliation(s)
- Masakatsu Paku
- Department of Gastroenterological Surgery, Graduated School of Medicine, Osaka University, Osaka, Japan
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Gomez Ruiz M, Ballestero Diego R, Tejedor P, Cagigas Fernandez C, Cristobal Poch L, Suarez Pazos N, Castillo Diego J. Robotic surgery for locally advanced T4 rectal cancer: feasibility and oncological quality. Updates Surg 2023; 75:589-597. [PMID: 36763301 DOI: 10.1007/s13304-023-01450-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 02/03/2023] [Indexed: 02/11/2023]
Abstract
For T4 rectal tumours and local recurrences (LR) of rectal cancer, a radical resection beyond TME, sometimes by multi-visceral resection, is important to obtain safe margins and improve survival. The use of the laparoscopic approach (LA) for these cases is still controversial and associated with a high rate of conversion. However, robotic surgery might offer some advantages that can overcome some of the limitations of LA. Therefore, we aimed to analyse the postoperative outcomes and medium-term oncological results of robotic surgery for locally advanced rectal cancer (pathological T4) and LR. A retrospective analysis was performed including patients who had undergone robotic rectal resection in a single institution over an 11-year period, and had a T4 tumour confirmed in the pathological report. Primary endpoint was to analyse postoperative complications (30-day) and the rate of conversion. Secondary endpoints include pathological assessment of the quality of the specimen, local recurrence and survival [2-year disease-free survival (DFS) and overall survival (OS)]. A total of 41 patients were analysed, including a total of 24 patients (60%) that required a multivisceral resection. The median distance from the tumour to the anorectal junction was 7 (4-12) cm. Conversion to open surgery was necessary in 2 cases (5%). The overall morbidity rate was 78% (n = 32), with 37% of major complications, most of them urinary (n = 7). Median length of hospital stay (LOS) was 13 (7-27) days. The 30-day mortality rate was 7% (n = 3). An R0 resection was achieved in 85.4% of the cases (n = 35) due to 6 cases of the positive circumferential resection margin. 2-year disease-free survival (DFS) and overall survival (OS) for the T4 tumours were 72% and 85%, respectively. There were 8 cases of local recurrence (22.2%); 6 of them met the selection criteria for salvage surgery. Robotic surgery for locally advanced T4 rectal cancer and multi-visceral resections is safe and feasible, with a low rate of conversion and an acceptable rate of postoperative morbidity in this subgroup of patients. Oncological results have shown to be comparable with the laparoscopic series published, preserving a good quality of the resected specimen. However, comparative studies and a longer follow-up period is needed to confirm the oncologic findings and to support the general adoption of the robotic system for these complex interventions.
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Affiliation(s)
- Marcos Gomez Ruiz
- Colorectal Surgery Unit, General Surgery Department, Marqués de Valdecilla University Hospital, 39008, Santander, Spain
- Valdecilla Biomedical Research Institute (IDIVAL), 39010, Santander, Spain
| | - Roberto Ballestero Diego
- Urology, Marqués de Valdecilla University Hospital, 39008, Santander, Spain
- Valdecilla Biomedical Research Institute (IDIVAL), 39010, Santander, Spain
| | - Patricia Tejedor
- Colorectal Surgery Unit, General Surgery Department, Gregorio Marañón University Hospital, Madrid, Spain.
| | - Carmen Cagigas Fernandez
- Colorectal Surgery Unit, General Surgery Department, Marqués de Valdecilla University Hospital, 39008, Santander, Spain
- Valdecilla Biomedical Research Institute (IDIVAL), 39010, Santander, Spain
| | - Lidia Cristobal Poch
- Colorectal Surgery Unit, General Surgery Department, Marqués de Valdecilla University Hospital, 39008, Santander, Spain
- Valdecilla Biomedical Research Institute (IDIVAL), 39010, Santander, Spain
| | - Natalia Suarez Pazos
- Colorectal Surgery Unit, General Surgery Department, Marqués de Valdecilla University Hospital, 39008, Santander, Spain
- Valdecilla Biomedical Research Institute (IDIVAL), 39010, Santander, Spain
| | - Julio Castillo Diego
- Colorectal Surgery Unit, General Surgery Department, Marqués de Valdecilla University Hospital, 39008, Santander, Spain
- Valdecilla Biomedical Research Institute (IDIVAL), 39010, Santander, Spain
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Yan S, Liu Y, Chen G, Yang Y. Defining early recurrence of locally recurrent rectal cancer. Am J Cancer Res 2022; 12:5095-5104. [PMID: 36504890 PMCID: PMC9729890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 10/12/2022] [Indexed: 12/15/2022] Open
Abstract
Despite advances in rectal cancer treatments, its local recurrence rate is still 4-10 percent. And an evidence-based definition of early recurrence is lacking. Our study hopes to establish a clear threshold to distinguish early and late recurrence, and analyze risk and prognostic factors for them. Rectal cancer patients who underwent proctectomy from 2009 to 2019 were included. Patients who received neoadjuvant treatment and with incomplete records were excluded. The optimal interval was obtained using the minimum P value approach. Risk factors for early recurrence were analyzed by logistic regression models, and prognostic factors associated with additional surgery were assessed by Cox proportional hazards models. The optimal interval for the definition of early recurrence was 26 months based on the subsequent prognosis (P < 0.001). The 5-year survival rate of early and late recurrence cohort was 32.5% and 57.1%, respectively (P < 0.001). Adjuvant radiotherapy was the independent protective factor for early recurrence. And the presence of lymphovascular invasion, positive surgical margin, and no re-neoadjuvant radiotherapy were independent prognostic factors for the survival of LRRC patients under additional surgery.
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Affiliation(s)
- Shen Yan
- Key Laboratory of Shaanxi Province for Craniofacial Precision Medicine Research, College of Stomatology, Xi’an Jiaotong UniversityXi’an, China,Clinical Research Center of Shaanxi Province for Dental and Maxillofacial Diseases, College of Stomatology, Xi’an Jiaotong UniversityXi’an, China,Department of Cariology & Endodontics, College of Stomatology, Xi’an Jiaotong UniversityXi’an, China
| | - Yucun Liu
- Department of Gastroenterology, Peking University First HospitalBeijing, China
| | - Guowei Chen
- Department of Gastroenterology, Peking University First HospitalBeijing, China
| | - Yanpeng Yang
- Department of Gastroenterology, Peking University First HospitalBeijing, China
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Re-resection of Microscopically Positive Margins Found on Intraoperative Frozen Section Analysis Does Not Result in a Survival Benefit in Patients Undergoing Surgery and Intraoperative Radiation Therapy for Locally Recurrent Rectal Cancer. Dis Colon Rectum 2022; 65:1094-1102. [PMID: 35714345 DOI: 10.1097/dcr.0000000000002349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Intraoperative frozen-section analysis provides real-time margin resection status that can guide intraoperative decisions made by the surgeon and radiation oncologist. For patients with locally recurrent rectal cancer undergoing surgery and intraoperative radiation therapy, intraoperative re-resection of positive margins to achieve negative margins is common practice. OBJECTIVE This study aimed to assess whether re-resection of positive margins found on intraoperative frozen-section analysis improves oncologic outcomes. DESIGN This is a retrospective cohort study. SETTINGS This study was an analysis of a prospectively maintained multicenter database. PATIENTS All patients who underwent surgical resection of locally recurrent rectal cancer with intraoperative radiation therapy between 2000 and 2015 were included and followed for 5 years. Three groups were compared: initial R0 resection, initial R1 converted to R0 after re-resection, and initial R1 that remained R1 after re-resection. Grossly positive margin resections (R2) were excluded. MAIN OUTCOME MEASURES The primary outcome measures were 5-year overall survival, recurrence-free survival, and local re-recurrence. RESULTS A total of 267 patients were analyzed (initial R0 resection, n = 94; initial R1 converted to R0 after re-resection, n = 95; initial R1 that remained R1 after re-resection, n = 78). Overall survival was 4.4 years for initial R0 resection, 2.7 years for initial R1 converted to R0 after re-resection, and 2.9 years for initial R1 that remained R1 after re-resection ( p = 0.01). Recurrence-free survival was 3.0 years for initial R0 resection and 1.8 years for both initial R1 converted to R0 after re-resection and initial R1 that remained R1 after re-resection ( p ≤ 0.01). Overall survival did not differ for patients with R1 and re-resection R1 or R0 ( p = 0.62). Recurrence-free survival and freedom from local re-recurrence did not differ between groups. LIMITATIONS This study was limited by the heterogeneous patient population restricted to those receiving intraoperative radiation therapy. CONCLUSIONS Re-resection of microscopically positive margins to obtain R0 status does not appear to provide a significant survival advantage or prevent local re-recurrence in patients undergoing surgery and intraoperative radiation therapy for locally recurrent rectal cancer. See Video Abstract at http://links.lww.com/DCR/B886 . LA RERESECCIN DE LOS MRGENES MICROSCPICAMENTE POSITIVOS ENCONTRADOS DE MANERA INTRAOPERATORIA MEDIANTE LA TCNICA DE CRIOSECCIN, NO DA COMO RESULTADO UN BENEFICIO DE SUPERVIVENCIA EN PACIENTES SOMETIDOS A CIRUGA Y RADIOTERAPIA INTRAOPERATORIA PARA EL CNCER RECTAL LOCALMENTE RECIDIVANTE ANTECEDENTES:El análisis de la ténica de criosección para los margenes positivos encontrados de manera intraoperatoria proporciona el estado de la resección del margen en tiempo real que puede guiar las decisiones intraoperatorias tomadas por el cirujano y el oncólogo radioterapeuta. Para los pacientes con cáncer de recto localmente recurrente que se someten a cirugía y radioterapia intraoperatoria, la re-resección intraoperatoria de los márgenes positivos para lograr márgenes negativos es una práctica común.OBJETIVO:Evaluar si la re-resección de los márgenes positivos encontrados en el análisis de la ténica por criosecciónde manera intraoperatorios mejora los resultados oncológicos.DISEÑO:Estudio de cohorte retrospectivo.AJUSTES:Análisis de una base de datos multicéntrica mantenida de forma prospectiva.POBLACIÓN:Todos los pacientes que se sometieron a resección quirúrgica de cáncer de recto localmente recurrente con radioterapia intraoperatoria entre 2000 y 2015 fueron incluidos y seguidos durante 5 años. Se compararon tres grupos: resección inicial R0, R1 inicial convertido en R0 después de la re-resección y R1 inicial que permaneció como R1 después de la re-resección. Se excluyeron las resecciones de márgenes macroscópicamente positivos (R2).PRINCIPALES MEDIDAS DE RESULTADO:Supervivencia global a cinco años, supervivencia sin recidiva y recidiva local.RESULTADOS:Se analizaron un total de 267 pacientes (resección inicial R0 n = 94, R1 inicial convertido en R0 después de la re-resección n = 95, R1 inicial que permaneció como R1 después de la re-resección n = 78). La supervivencia global fue de 4,4 años para la resección inicial R0, 2,7 años para la R1 inicial convertida en R0 después de la re-resección y 2,9 años para la R1 inicial que permaneció como R1 después de la re-resección ( p = 0,01). La supervivencia libre de recurrencia fue de 3,0 años para la resección inicial R0 y de 1,8 años para el R1 inicial convertido en R0 después de la re-resección y el R1 inicial que permaneció como R1 después de la re-resección ( p ≤ 0,01). La supervivencia global no difirió para los pacientes con R1 y re-resección R1 o R0 ( p = 0,62). La supervivencia libre de recurrencia y la ausencia de recurrencia local no difirieron entre los grupos.LIMITACIONES:Población de pacientes heterogénea, restringida a aquellos que reciben radioterapia intraoperatoria.CONCLUSIONES:La re-resección de los márgenes microscópicamente positivos para obtener el estado R0 no parece proporcionar una ventaja de supervivencia significativa o prevenir la recurrencia local en pacientes sometidos a cirugía y radioterapia intraoperatoria para el cáncer de recto localmente recurrente. Consulte Video Resumen en http://links.lww.com/DCR/B886 . (Traducción-Dr. Daniel Guerra ).
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Gould LE, Pring ET, Drami I, Moorghen M, Naghibi M, Jenkins JT, Steele CW, Roxburgh CS. A systematic review of the pathological determinants of outcome following resection by pelvic exenteration of locally advanced and locally recurrent rectal cancer. Int J Surg 2022; 104:106738. [PMID: 35781038 DOI: 10.1016/j.ijsu.2022.106738] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/07/2022] [Accepted: 06/16/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Despite multimodal therapy 5-15% of patients who undergo resection for advanced rectal cancer (LARC) will develop local recurrence. Management of locally recurrent rectal cancer (LRRC) presents a significant therapeutic challenge and even with modern exenterative surgery, 5-year survival rates are poor at 25-50%. High rates of local and systemic recurrence in this cohort are reflective of the likely biological aggressiveness of these tumour types. This review aims to appraise the current literature identifying pathological factors associated with survival and tumour recurrence in patients undergoing exenterative surgery. METHODS A systematic review was carried out searching MEDLINE, EMBASE and COCHRANE Trials database for all studies assessing pathological factors influencing survival following pelvic exenteration for LARC or LRRC from 2010 to July 2021 following PRISMA guidelines. Risk of bias was assessed using QUIPS tool. RESULTS Nine cohort studies met inclusion criteria, reporting outcomes for 2864 patients. Meta-analysis was not possible due to significant heterogeneity of reported outcomes. Resection margin status and nodal disease were the most commonly reported factors. A positive resection margin was demonstrated to be a negative prognostic marker in six studies. Involved lymph nodes and lymphovascular invasion also appear to be negative prognostic markers with tumour stage to be of lesser importance. No studies assessed other adverse tumour features that would not otherwise be included in a standard histopathology report. CONCLUSION Pathological resection margin status is widely demonstrated to influence disease free and overall survival following pelvic exenteration for rectal cancer. With increasing R0 rates, other adverse tumour features must be explored to help elucidate differences in survival and potentially guide tailored oncological treatment.
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Affiliation(s)
- Laura E Gould
- University of Glasgow College of Medical Veterinary and Life Sciences, Academic Unit of Surgery, School of Medicine, United Kingdom; St Mark's Academic Institute, St Mark's Hospital, United Kingdom.
| | - Edward T Pring
- St Mark's Academic Institute, St Mark's Hospital, United Kingdom; Imperial College London, United Kingdom
| | - Ioanna Drami
- St Mark's Academic Institute, St Mark's Hospital, United Kingdom; Imperial College London, United Kingdom
| | - Morgan Moorghen
- St Mark's Academic Institute, St Mark's Hospital, United Kingdom
| | - Mani Naghibi
- St Mark's Academic Institute, St Mark's Hospital, United Kingdom
| | - John T Jenkins
- St Mark's Academic Institute, St Mark's Hospital, United Kingdom; Imperial College London, United Kingdom
| | - Colin W Steele
- University of Glasgow College of Medical Veterinary and Life Sciences, Academic Unit of Surgery, School of Medicine, United Kingdom
| | - Campbell Sd Roxburgh
- University of Glasgow College of Medical Veterinary and Life Sciences, Academic Unit of Surgery, School of Medicine, United Kingdom
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12
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Laparoscopic Versus Open Surgery for Locally Advanced Rectal Cancer: Five-Year Survival Outcomes in a Large, Multicenter, Propensity Score-Matched Cohort Study. Dis Colon Rectum 2022; 65:1005-1014. [PMID: 34775411 DOI: 10.1097/dcr.0000000000002196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND There is a paucity of evidence pertaining to long-term survival outcomes of laparoscopic versus open surgery for locally advanced rectal cancer. OBJECTIVE This study aimed to evaluate the long-term survival outcomes of laparoscopic surgery for locally advanced rectal cancer and to investigate the recurrence pattern. DESIGN This was a prospective analysis of a registered cohort. SETTINGS This study was conducted at 69 institutions across Japan. PATIENTS A total of 1500 patients with clinical stage II-III rectal cancer located below the peritoneal reflection between January 2010 and December 2011 were included. After propensity score matching, all eligible patients, including the matched patients registered in 2014, were prospectively followed up. MAIN OUTCOME MEASURES Five-year relapse-free survival was the primary outcome. RESULTS The median follow-up period was 5.6 years. Among the 964 matched patients, the 5-year relapse-free survival was 65.1% in the open group versus 63.5% in the laparoscopic group (HR 1.04; p = 0.71). Distant recurrences at rare sites, which were more frequently observed in the laparoscopic group, were significantly less salvaged (adjusted OR 0.74; p = 0.045). Postrecurrence 5-year overall survival was significantly better for patients who underwent salvage surgery than for those who did not; 55.3% vs 29.5% for patients with initial local recurrence ( p = 0.03) and 64.4% vs 30.7% for patients with distant recurrence alone ( p < 0.001). LIMITATIONS Potential heterogeneity and influence of unknown confounding. CONCLUSIONS Five-year follow-up data demonstrated that laparoscopic surgery for locally advanced rectal cancer was safely performed in terms of long-term prognosis. In addition, salvage surgery for recurrent lesions was associated with prolonged postrecurrence survival, both in patients with local and distant recurrence. However, recurrence at rare sites may require further investigation. See Video Abstract at http://links.lww.com/DCR/B793 . CIRUGA LAPAROSCPICA VERSUS CIRUGA ABIERTA EN CNCER DE RECTO LOCALMENTE AVANZADO RESULTADOS DE SUPERVIVENCIA A CINCO AOS EN UN ESTUDIO DE COHORTE DE GRAN MAGNITUD, MULTICNTRICO Y DE PAREAMIENTO POR PUNTAJE DE PROPENSIN ANTECEDENTES:Existe una escasez de pruebas relacionadas con los resultados de supervivencia a largo plazo de la cirugía laparoscópica versus abierta para el cáncer de recto localmente avanzado.OBJETIVO:Este estudio tuvo como objetivo evaluar los resultados de supervivencia a largo plazo de la cirugía laparoscópica para el cáncer de recto localmente avanzado e investigar el patrón de recurrencia.DISEÑO:Fue un análisis prospectivo de una cohorte registrada.ENTORNO CLÍNICO:El estudio se llevó a cabo en 69 instituciones en todo Japón.PACIENTES:Se incluyó un total de 1500 pacientes con cáncer de recto en estadio clínico II-III ubicados por debajo de la reflección peritoneal, entre enero del 2010 y diciembre del 2011. Después del pareamiento por puntaje de propensión, se realizó un seguimiento prospectivo de todos los pacientes elegibles, incluidos los pacientes emparejados registrados en 2014.PRINCIPALES MEDIDAS DE VALORACIÓN:La supervivencia sin recaídas a cinco años fue el resultado primario.RESULTADOS:El período de seguimiento medio fue de 5,6 años. Entre los 964 pacientes emparejados, la supervivencia libre de recaída a 5 años fue del 65,1% en el grupo abierto frente al 63,5% en el grupo laparoscópico (cociente de riesgo 1,04; p = 0,71). Las recurrencias a distancia en sitios raros, que se observaron con mayor frecuencia en el grupo laparoscópico, tuvieron menor sobrevida (razón de posibilidades ajustada 0,74; p = 0,045). La supervivencia general a los 5 años después de la recidiva fue significativamente menor en los pacientes sometidos a una cirugía de rescate; 55,3% frente al 29,5% para los pacientes con recidiva local inicial ( p = 0,03) y 64,4% frente al 30,7% para los pacientes con recidiva a distancia sola ( p < 0,001).LIMITACIONES:Potencial heterogeneidad e influencia de factores de confusión desconocidos.CONCLUSIONES:El seguimiento a cinco años demostró que la cirugía laparoscópica para el cáncer de recto localmente avanzado es segura en términos de pronóstico a largo plazo. Además, la cirugía de rescate de las lesiones recurrentes se asoció con una mayor supervivencia posrecurrencia, tanto en pacientes con recurrencia local como a distancia. Sin embargo, la recurrencia en sitios raros puede requerir una mayor investigación. Consulte Video Resumen en http://links.lww.com/DCR/B793 . (Traducción- Dr. Ingrid Melo ).
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Dumont F, Loaec C, Wernert R, Maurel B, Thibaudeau E, Vilcot L. Surgery of resectable local recurrence following colorectal cancer: Compartmental surgery improves local control. J Surg Oncol 2022; 126:1048-1057. [PMID: 35779039 DOI: 10.1002/jso.26990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 05/14/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND This study aims to identify prognostic factors and define the best extent of surgery for optimizing treatment of local recurrence (LR) following colorectal cancer (CRC). METHODS An institutional database of consecutive patients who underwent radical resection (R0/R1) of LR following CRC was analyzed prospectively from 2010 to 2021 at one tertiary cancer center. RESULTS In this study, 75 patients were included with LR following CRC and analyzed. Patients were categorized as compartmental resections (CompRe) (n = 47) if all adjacent organs were systematically removed, with or without tumor involvement, or noncompartmental resections (NoCompRe) (n = 28) if only contiguously involved organs were resected. NoCompRe were mainly related to contact between major vessels or bone and the tumor, with only 8/19 (42.1%) resections. Five-year overall survival and locoregional-free survival were 37.5% and 38.8% respectively. Local control was better in the CompRe than the NocompRe group (61.4% vs. 11%; p < 0.01). CompRe (hazard ratio: 2.34 [1.16-4.68]; p = 0.017) and absence of peritoneal metastasis (3.05 [1.03-9.02]; p = 0.044) were the two factors associated with decreased abdominal recurrences in multivariate analysis. CONCLUSION Complete compartmental surgery is safe and improves local control. Optimal LR resection needs to remove all contiguous organs, with or without tumor involvement.
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Affiliation(s)
- Frédéric Dumont
- Department of Surgical Oncology, Comprehensive Cancer Center, Institut de Cancérologie de l'Ouest, Saint-Herblain, France
| | - Cécile Loaec
- Department of Surgical Oncology, Comprehensive Cancer Center, Institut de Cancérologie de l'Ouest, Saint-Herblain, France
| | - Romuald Wernert
- Department of Surgical Oncology, Comprehensive Cancer Center, Institut de Cancérologie de l'Ouest, Angers, France
| | - Blandine Maurel
- Department of Vascular Surgery, Hopital Laennec, Saint Herblain, France
| | - Emilie Thibaudeau
- Department of Surgical Oncology, Comprehensive Cancer Center, Institut de Cancérologie de l'Ouest, Saint-Herblain, France
| | - Laurence Vilcot
- Department of Radiology, Comprehensive Cancer Center, Institut de Cancérologie de l'Ouest, Saint-Herblain, France
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Rokan Z, Simillis C, Kontovounisios C, Moran B, Tekkis P, Brown G. Locally Recurrent Rectal Cancer According to a Standardized MRI Classification System: A Systematic Review of the Literature. J Clin Med 2022; 11:jcm11123511. [PMID: 35743581 PMCID: PMC9224654 DOI: 10.3390/jcm11123511] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/11/2022] [Accepted: 06/16/2022] [Indexed: 12/15/2022] Open
Abstract
(1) Background: The classification of locally recurrent rectal cancer (LRRC) is not currently standardized. The aim of this review was to evaluate pelvic LRRC according to the Beyond TME (BTME) classification system and to consider commonly associated primary tumour characteristics. (2) Methods: A systematic review of the literature prior to April 2020 was performed through electronic searches of the Science Citation Index Expanded, EMBASE, MEDLINE, and CENTRAL databases. The primary outcome was to assess the location and frequency of previously classified pelvic LRRC and translate this information into the BTME system. Secondary outcomes were assessing primary tumour characteristics. (3) Results: A total of 58 eligible studies classified 4558 sites of LRRC, most commonly found in the central compartment (18%), following anterior resection (44%), in patients with an 'advanced' primary tumour (63%) and following neoadjuvant radiotherapy (29%). Most patients also classified had a low rectal primary tumour. The lymph node status of the primary tumour leading to LRRC was comparable, with 52% node positive versus 48% node negative tumours. (4) Conclusions: This review evaluates the largest number of LRRCs to date using a single classification system. It has also highlighted the need for standardized reporting in order to optimise perioperative treatment planning.
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Affiliation(s)
- Zena Rokan
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK; (C.S.); (P.T.); (G.B.)
- Pelican Cancer Foundation, Basingstoke RG24 9NN, UK;
- Correspondence: (Z.R.); (C.K.)
| | - Constantinos Simillis
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK; (C.S.); (P.T.); (G.B.)
- Cambridge Colorectal Unit, Addenbrookes Hospital, Cambridge CB2 0QQ, UK
| | - Christos Kontovounisios
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK; (C.S.); (P.T.); (G.B.)
- Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
- Chelsea & Westminster Hospital, London SW10 9NH, UK
- Correspondence: (Z.R.); (C.K.)
| | - Brendan Moran
- Pelican Cancer Foundation, Basingstoke RG24 9NN, UK;
- Basingstoke & North Hampshire Hospital, Basingstoke RG24 9NA, UK
| | - Paris Tekkis
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK; (C.S.); (P.T.); (G.B.)
- Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Gina Brown
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK; (C.S.); (P.T.); (G.B.)
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15
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Fadel MG, Ahmed M, Malietzis G, Pellino G, Rasheed S, Brown G, Tekkis P, Kontovounisios C. Oncological outcomes of multimodality treatment for patients undergoing surgery for locally recurrent rectal cancer: A systematic review. Cancer Treat Rev 2022; 109:102419. [PMID: 35714574 DOI: 10.1016/j.ctrv.2022.102419] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/01/2022] [Accepted: 06/05/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND There are several strategies in the management of locally recurrent rectal cancer (LRRC) with the optimum treatment yet to be established. This systematic review aims to compare oncological outcomes in patients undergoing surgery for LRRC who underwent neoadjuvant radiotherapy or chemoradiotherapy (CRT), adjuvant CRT, surgery only or surgery and intraoperative radiotherapy (IORT). METHODS A literature search of MEDLINE, EMBASE and CINAHL was performed for studies that reported data on oncological outcomes for the different treatment modalities in patients with LRRC from January 1990 to January 2022. Weighted means were calculated for the following outcomes: postoperative resection status, local control, and overall survival at 3 and 5 years. RESULTS Fifteen studies of 974 patients were included and they received the following treatment: 346 neoadjuvant radiotherapy, 279 neoadjuvant CRT, 136 adjuvant CRT, 189 surgery only, and 24 surgery and IORT. The highest proportion of R0 resection was found in the neoadjuvant CRT group followed by neoadjuvant radiotherapy and adjuvant CRT groups (64.07% vs 52.46% vs 47.0% respectively). The neoadjuvant CRT group had the highest mean 5-year local control rate (49.50%) followed by neoadjuvant radiotherapy (22.0%). Regarding the 5-year overall survival rate, the neoadjuvant CRT group had the highest mean of 34.92%, followed by surgery only (29.74%), neoadjuvant radiotherapy (28.94%) and adjuvant CRT (20.67%). CONCLUSIONS The findings of this systematic review suggest that neoadjuvant CRT followed by surgery can lead to improved resection status, long-term disease control and survival in the management of LRRC. However, treatment strategies in LRRC are complex and further comparisons, particularly taking into account previous treatments for the primary rectal cancer, are required.
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Affiliation(s)
- Michael G Fadel
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK; Department of Surgery and Cancer, Imperial College, London, UK.
| | - Mosab Ahmed
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK
| | - George Malietzis
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK; Department of Surgery and Cancer, Imperial College, London, UK; Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy; Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Shahnawaz Rasheed
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK; Department of Surgery and Cancer, Imperial College, London, UK; Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
| | - Gina Brown
- Department of Surgery and Cancer, Imperial College, London, UK
| | - Paris Tekkis
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK; Department of Surgery and Cancer, Imperial College, London, UK; Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
| | - Christos Kontovounisios
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK; Department of Surgery and Cancer, Imperial College, London, UK; Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
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16
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Kitakaze M, Uemura M, Kobayashi Y, Paku M, Miyo M, Takahashi Y, Miyake M, Kato T, Ikeda M, Fujino S, Ogino T, Miyoshi N, Takahashi H, Yamamoto H, Mizushima T, Sekimoto M, Doki Y, Eguchi H. Postoperative pain management after concomitant sacrectomy for locally recurrent rectal cancer. Surg Today 2022; 52:1599-1606. [PMID: 35661260 DOI: 10.1007/s00595-022-02522-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 02/22/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE To assess pain management in patients post-sacrectomy, focusing on opioid use, and to identify the factors associated with postoperative pain. METHODS Patients who underwent resection of locally recurrent rectal cancer (LRRC) with concomitant sacrectomy at one of two hospitals between 2007 and 2020 were reviewed retrospectively. We examined the use of opioids preoperatively and postoperatively. Patients were classified into high and low sacrectomy groups based on the sacral bone resection level passing through the S3 vertebra. RESULTS Sixty-four patients were enrolled. Opioid use was significantly higher in the high sacrectomy group than in the low sacrectomy group at all times assessed: on postoperative days 7, 14, 30, 90, 180, and 365. Opioid use 3 months after locally recurrent rectal cancer surgery was significantly higher in patients with local re-recurrence of the tumor than in those without re-recurrence (p < 0.05), and the median morphine-equivalent opioid use 3 months postoperatively was significantly higher in the high sacrectomy group (30 vs. 0 mg/day; p < 0.05). CONCLUSIONS Opioid use after concomitant sacrectomy for LRRC was higher in the high sacrectomy group. Prolonged postoperative pain or increasing pain was associated with local recurrence.
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Affiliation(s)
- Masatoshi Kitakaze
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Mamoru Uemura
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan.
| | - Yuta Kobayashi
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Masakatsu Paku
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Masaaki Miyo
- Department of Surgery, National Hospital Organization Osaka National Hospital, Osaka, 5400006, Japan
| | - Yusuke Takahashi
- Department of Surgery, National Hospital Organization Osaka National Hospital, Osaka, 5400006, Japan
| | - Masakazu Miyake
- Department of Surgery, National Hospital Organization Osaka National Hospital, Osaka, 5400006, Japan
| | - Takeshi Kato
- Department of Surgery, National Hospital Organization Osaka National Hospital, Osaka, 5400006, Japan
| | - Masataka Ikeda
- Division of Lower GI Surgery, Department of Surgery, Hyogo College of Medicine, Hyogo, 6638501, Japan
| | - Shiki Fujino
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Takayuki Ogino
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Norikatsu Miyoshi
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Hidekazu Takahashi
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Hirofumi Yamamoto
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Tsunekazu Mizushima
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Mitsugu Sekimoto
- Department of Surgery, Kansai Medical University, Osaka, 5731010, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
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17
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A novel inflammation-related prognostic biomarker for predicting the disease-free survival of patients with colorectal cancer. World J Surg Oncol 2022; 20:79. [PMID: 35277188 PMCID: PMC8917685 DOI: 10.1186/s12957-022-02550-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/03/2022] [Indexed: 12/24/2022] Open
Abstract
Background To develop and evaluate the prognostic value of a comprehensive inflammatory biomarker for postoperative colorectal cancer (CRC) patients. Methods A total of 646 CRC patients were recruited between August 2017 and December 2019 from Fujian Medical University Union Hospital, with follow-up data up to 2021. The least absolute shrinkage and selection operator method (LASSO) was used to select inflammation indicators in order to construct a comprehensive biomarker (named NSAP). The Cox regression model was utilized to analyze the association between the NSAP and the disease-free survival (DFS) of CRC. Predictive performance and clinical utility of prognostic models were evaluated by area under the curve (AUC) and decision curve analyses (DCAs). Results During a median follow-up of 23 months, 95 clinical outcomes were observed, with a 1-year survival rate is 89.47%. A comprehensive inflammatory biomarker (NSAP) was established based on four blood indicators (including neutrophil-to-lymphocyte ratio (NLR), neutrophil×monocyte-to-lymphocyte ratio (SIRI), albumin-to-globulin ratio (AGR), and platelet-to-lymphocytes ratio (PLR)). Patients with a lower NSAP had significantly associated with better DFS of CRC (HR=0.53, 95%CI 0.32–0.89). Moreover, compared to a previously established model, the traditional TNM staging system or/and tumor markers, the nomogram based on NSAP displayed more excellent predictive ability (0.752 vs 0.597, 0.711 and 0.735, P < 0.05). DCAs also demonstrated that the established nomogram had better utility for decision making. Conclusions Our study suggests that NSAP may be a useful comprehensive prognostic biomarker for predicting the DFS of CRC patients. The nomogram based on NSAP can be considered a valuable tool to estimate the prognosis of patients with CRC. Supplementary Information The online version contains supplementary material available at 10.1186/s12957-022-02550-0.
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18
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Posterior-First Two-Stage Approach to En Bloc Resection of Locally Recurrent Rectal Cancer Involving the Pelvic Sidewall. Dis Colon Rectum 2021; 64:e465-e470. [PMID: 34214058 DOI: 10.1097/dcr.0000000000002091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Using standard anterior-only or anterior then posterior approaches can make an R0 resection difficult to achieve in patients with pelvic sidewall recurrences because of confined working spaces and poor visibility. TECHNIQUE Given the limitations of standard approaches, we have used a novel posterior-first then anterior 2-stage approach allowing us to widely expose and secure deep margins and control vessels under direct visualization. RESULTS We present a technical note describing this approach in patients with recurrent rectal cancer involving the pelvic sidewall with extrapelvic extension. CONCLUSION The posterior-first approach may assist in achieving a higher number of R0 resections in patients with locally recurrent rectal cancer involving the pelvic sidewall.
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19
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A prospective investigation of pain and fatigue following pelvic exenteration. Eur J Surg Oncol 2021; 47:3137-3143. [PMID: 34366173 DOI: 10.1016/j.ejso.2021.07.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 07/01/2021] [Accepted: 07/25/2021] [Indexed: 11/23/2022] Open
Abstract
AIM To describe the long-term course of pain and fatigue in patients undergoing pelvic exenteration and to evaluate potential prognostic factors for these outcomes. DESIGN Prospective cohort study. SETTINGS Royal Prince Alfred Hospital, Sydney, Australia. PATIENTS Consecutive patients undergoing pelvic exenteration surgery between July 2008 and December 2017. MAIN OUTCOME MEASURES Pain and fatigue scores collected via SF-36v2 Health surveys pre-operatively and at eight time-points post-operatively for a period of 5-years. The course of pain and fatigue were described according to the following prognostic factors; bone resection (yes/no), cancer type (primary/recurrent), margin status (R0/R1-2) and extent of exenteration (complete/partial). RESULTS 345 of 459 eligible patients (75 %) consented to the study. The course of pain and fatigue over the 5 year follow-up was favourable. Patients undergoing pelvic exenteration with an R0 resection margin or without bone resection presented lower pain levels throughout the follow-up period. Bone resection, positive surgical margin (R1/R2) and type of cancer did not influence fatigue trajectories. Patients undergoing complete pelvic exenteration were more likely to report a higher level of pain and fatigue in the initial follow-up period, however this difference was not observed in the longer-term. CONCLUSIONS Patients undergoing PE (Austin and Solomon, 2015) [1] can expect improvement but an incomplete recovery in the levels of pain and fatigue postoperatively over the 5-year follow-up period. Bone resection as part of exenteration demonstrated higher levels of pain and fatigue.
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20
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Rokan Z, Simillis C, Kontovounisios C, Moran BJ, Tekkis P, Brown G. Systematic review of classification systems for locally recurrent rectal cancer. BJS Open 2021; 5:6272170. [PMID: 33963369 PMCID: PMC8105621 DOI: 10.1093/bjsopen/zrab024] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 02/13/2021] [Indexed: 01/08/2023] Open
Abstract
Background Classification of pelvic local recurrence (LR) after surgery for primary rectal cancer is not currently standardized and optimal imaging is required to categorize anatomical site and plan treatment in patients with LR. The aim of this review was to evaluate the systems used to classify locally recurrent rectal cancer (LRRC) and the relevant published outcomes. Methods A systematic review of the literature prior to April 2020 was performed through electronic searches of the Science Citation Index Expanded, EMBASE, MEDLINE and CENTRAL databases. The primary outcome was to review the classifications currently in use; the secondary outcome was the extraction of relevant information provided by these classification systems including prognosis, anatomy and prediction of R0 after surgery. Results A total of 21 out of 58 eligible studies, classifying LR in 2086 patients, were reviewed. Studies used at least one of the following eight classification systems proposed by institutions or institutional groups (Mayo Clinic, Memorial Sloan-Kettering – original and modified, Royal Marsden and Leeds) or authors (Yamada, Hruby and Kusters). Negative survival outcomes were associated with increased pelvic fixity, associated symptoms of LR, lateral compared with central LR and involvement of three or more pelvic compartments. A total of seven studies used MRI with specifically defined anatomical compartments to classify LR. Conclusion This review highlights the various imaging systems in use to classify LRRC and some of the prognostic indicators for survival and oncological clearance based on these systems. Implementation of an agreed classification system to document pelvic LR consistently should provide more detailed information on anatomical site of recurrence, burden of disease and standards for comparative outcome assessment.
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Affiliation(s)
- Z Rokan
- Department of Radiology, Royal Marsden Hospital, London, UK.,Pelican Cancer Foundation, Basingstoke, UK.,Cambridge Colorectal Unit, Addenbrookes Hospital, Cambridge, UK
| | - C Simillis
- Cambridge Colorectal Unit, Addenbrookes Hospital, Cambridge, UK.,Department of Surgery & Cancer, Imperial College, London, UK
| | - C Kontovounisios
- Department of Surgery & Cancer, Imperial College, London, UK.,Department of Colorectal Surgery, Royal Marsden Hospital, London, UK.,Department of Colorectal Surgery, Chelsea & Westminster Hospital, London, UK
| | - B J Moran
- Pelican Cancer Foundation, Basingstoke, UK.,Department of Peritoneal Malignancy, Basingstoke & North Hampshire Hospital, Basingstoke, UK
| | - P Tekkis
- Department of Surgery & Cancer, Imperial College, London, UK.,Department of Colorectal Surgery, Royal Marsden Hospital, London, UK.,Department of Colorectal Surgery, Chelsea & Westminster Hospital, London, UK
| | - G Brown
- Department of Radiology, Royal Marsden Hospital, London, UK.,Department of Surgery & Cancer, Imperial College, London, UK
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21
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Dijkstra EA, Mul VEM, Hemmer PHJ, Havenga K, Hospers GAP, Kats-Ugurlu G, Beukema JC, Berveling MJ, El Moumni M, Muijs CT, van Etten B. Clinical selection strategy for and evaluation of intra-operative brachytherapy in patients with locally advanced and recurrent rectal cancer. Radiother Oncol 2021; 159:91-97. [PMID: 33741470 DOI: 10.1016/j.radonc.2021.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 03/05/2021] [Accepted: 03/08/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE A radical resection of locally advanced rectal cancer (LARC) or recurrent rectal cancer (RRC) can be challenging. In case of increased risk of an R1 resection, intra-operative brachytherapy (IOBT) can be applied. We evaluated the clinical selection strategy for IOBT. MATERIALS AND METHODS Between February 2007 and May 2018, 132 LARC/RRC patients who were scheduled for surgery with IOBT standby, were evaluated. By intra-operative inspection of the resection margin and MR imaging, it was determined whether a resection was presumed to be radical. Frozen sections were taken on indication. In case of a suspected R1 resection, IOBT (1 × 10 Gy) was applied. Histopathologic evaluation, treatment and toxicity data were collected from medical records. RESULTS Tumour was resected in 122 patients. IOBT was given in 42 patients of whom 54.8% (n = 23) had a histopathologically proven R1 resection. Of the 76 IOBT-omitted R0 resected patients, 17.1% (n = 13) had a histopathologically proven R1 resection. In 4 IOBT-omitted patients, a clinical R1/2 resection was seen. In total, correct clinical judgement occurred in 72.6% (n = 88) of patients. In LARC, 58.3% (n = 14) of patients were overtreated (R0, with IOBT) and 10.9% (n = 5) were undertreated (R1, without IOBT). In RRC, 26.5% (n = 9) of patients were undertreated. CONCLUSION In total, correct clinical judgement occurred in 72.6% (n = 88). However, in 26.5% (n = 9) RRC patients, IOBT was unjustifiedly omitted. IOBT is accompanied by comparable and acceptable toxicity. Therefore, we recommend IOBT to all RRC patients at risk of an R1 resection as their salvage treatment.
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Affiliation(s)
- Esmée A Dijkstra
- University of Groningen, University Medical Centre Groningen, Department of Medical Oncology, the Netherlands
| | - Véronique E M Mul
- University of Groningen, University Medical Centre Groningen, Department of Radiation Oncology, the Netherlands
| | - Patrick H J Hemmer
- University of Groningen, University Medical Centre Groningen, Department of Surgery, the Netherlands
| | - Klaas Havenga
- University of Groningen, University Medical Centre Groningen, Department of Surgery, the Netherlands
| | - Geke A P Hospers
- University of Groningen, University Medical Centre Groningen, Department of Medical Oncology, the Netherlands
| | - Gursah Kats-Ugurlu
- University of Groningen, University Medical Centre Groningen, Department of Pathology and Medical Biology, the Netherlands
| | - Jannet C Beukema
- University of Groningen, University Medical Centre Groningen, Department of Radiation Oncology, the Netherlands
| | - Maaike J Berveling
- University of Groningen, University Medical Centre Groningen, Department of Radiation Oncology, the Netherlands
| | - Mostafa El Moumni
- University of Groningen, University Medical Centre Groningen, Department of Surgery, the Netherlands
| | - Christina T Muijs
- University of Groningen, University Medical Centre Groningen, Department of Radiation Oncology, the Netherlands
| | - Boudewijn van Etten
- University of Groningen, University Medical Centre Groningen, Department of Surgery, the Netherlands.
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22
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Blake J, Koh CE, Steffens D, De Robles MS, Brown K, Lee P, Austin K, Solomon MJ. Outcomes following repeat exenteration for locally advanced pelvic malignancy. Colorectal Dis 2021; 23:646-652. [PMID: 33058495 DOI: 10.1111/codi.15402] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 09/06/2020] [Accepted: 09/21/2020] [Indexed: 12/27/2022]
Abstract
AIM This study aims to assess surgical outcomes and survival following first, second and third pelvic exenterations for pelvic malignancy. METHOD Consecutive patients undergoing pelvic exenteration for pelvic malignancy at a quaternary referral centre from January 1994 and December 2017 were included. Demographics and surgical outcomes were compared between patients who underwent first, second and third pelvic exenterations by generalized mixed modelling with repeated measures. Survival was assessed using Cox proportional hazards models and Kaplan-Meier plots. RESULTS Of the 642 exenterations reviewed, 29 (4.5%) were second and 6 (0.9%) were third exenterations. Patients selected for repeat exenteration were more likely to have asymptomatic local recurrences detected on routine surveillance (P < 0.001). Postoperative wound complications increased with repeat exenteration (6%, 17%, 33%; P = 0.003, respectively). Additionally, postoperative length of stay increased from 27 to 38 and 48 days, respectively (P = 0.004). Median survival from first exenteration was 4.75, 5.30 and 8.14 years respectively amongst first, second and third exenteration cohorts (P = 0.849). Median survival from the most recent exenteration was 4.75 years after a first exenteration, 2.02 years after a second exenteration and 1.45 years after a third exenteration (P = 0.0546). CONCLUSION This study demonstrates that repeat exenteration for recurrent pelvic malignancy is feasible but is associated with increased complication rates and length of admission and reduced likelihood of attaining R0 margin. Moreover, these data indicate that repeat exenteration does not afford a survival advantage compared with patients having a single exenteration. These data suggest that repeat exenteration for recurrent pelvic malignancy may be of questionable therapeutic value.
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Affiliation(s)
- Joshua Blake
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Cherry E Koh
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia.,RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Marie Shella De Robles
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Kilian Brown
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia.,RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Peter Lee
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Kirk Austin
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Michael J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia.,RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
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23
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Pelvic exenteration for colorectal and non-colorectal cancer: a comparison of perioperative and oncological outcome. Int J Colorectal Dis 2021; 36:1701-1710. [PMID: 33677655 PMCID: PMC8279979 DOI: 10.1007/s00384-021-03893-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/12/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Pelvic exenteration (PE) is the only option for long-term cure of advanced cancer originating from different types of tumor or recurrent disease in the lower pelvis. The aim was to show differences between colorectal and non-colorectal cancer in survival and postoperative morbidity. METHODS Retrospective data of 63 patients treated with total pelvic exenteration between 2013 and 2018 are reported. Pre-, intra-, and postoperative parameters, survival data, and risk factors for complications were analyzed. RESULTS A total of 57.2% (n = 37) of the patients had colorectal cancer, 22.3% had gynecological malignancies (vulvar (n = 6) or cervical (n = 8) cancer), 11.1% (n = 7) had anal cancer, and 9.5% had other primary tumors. A total of 30.2% (n = 19) underwent PE for a primary tumor and 69.8% (n = 44) for recurrent cancer. The 30-day in-hospital mortality was 0%. Neoadjuvant treatment was administered to 65.1% (n = 41) of the patients and correlated significantly with postoperative complications (odds ratio 4.441; 95% CI: 1.375-14.342, P > 0.05). R0, R1, R2, and Rx resections were achieved in 65.1%, 19%, 1.6%, and 14.3% of the patients, respectively. In patients undergoing R0 resection, 2-year OS and RFS were 73.2% and 52.4%, respectively. Resection status was a significant risk factor for recurrence-free and overall survival (OS) in univariate analysis. Multivariate analysis revealed age (P = 0.021), ASA ≥ 3 (P = 0.005), high blood loss (P = 0.028), low preoperative hemoglobin level (P < 0.001), nodal positivity (P < 0.001), and surgical complications (P = 0.003) as independent risk factors for OS. CONCLUSION Pelvic exenteration is a procedure with high morbidity rates but remains the only curative option for advanced or recurrent colorectal and non-colorectal cancer in the pelvis.
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24
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Wang L, Wang H, Jiang Y, Ji Z, Guo F, Jiang P, Li X, Chen Y, Sun H, Fan J, Li W, Li X, Wang J. The efficacy and dosimetry analysis of CT-guided 125I seed implantation assisted with 3D-printing non-co-planar template in locally recurrent rectal cancer. Radiat Oncol 2020; 15:179. [PMID: 32711542 PMCID: PMC7382046 DOI: 10.1186/s13014-020-01607-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 06/30/2020] [Indexed: 01/31/2023] Open
Abstract
Background Locally recurrent rectal cancer (LRRC) after surgery or external beam radiotherapy (EBRT) is a serious challenge for which no standard treatment is defined. In the present study, we investigated the feasibility of computed tomography (CT)-guided radioactive 125I seed (RIS) implantation assisted with three-dimensional printing non-coplanar template (3D-PNCT) in LRRC patients who previously received surgery or EBRT. Methods Sixty-six patients with LRRC treated by CT-guided RIS implantation in our institute from December 2015 to May 2019 were included. The treatment procedure included: preoperative CT localization, planning design, the printing of 3D individualized template, CT-guided RIS implantation assisted with 3D-PNCT, and postoperative dose evaluation. Therapeutic outcomes including local control (LC) and overall survival (OS) were retrospectively evaluated, as well as side effects. Results All the patients had previously received surgery or EBRT. The median follow-up time was 12.2 (range, 2.5–35.9) months. The median radioactive activity of a single RIS was 0.6 (range, 0.43–0.72) mCi. The median number of RIS was 60, ranging from 10 to 175. The dosimetric parameters included D90 (140.7 ± 33.1) Gy, D100 (90.3 ± 138.6) Gy, and V100 (91.0 ± 13.3) %. Pain relief was achieved in 85.1% (40/47) of patients. Besides, 9.1% (6/66) of patients had severe side effects (≥grade 3), including perianal skin ulcer in 1 case, fistula, radiation proctitis, and intestinal obstruction each in two cases. Median OS time was 14.7 (95% confidence interval (CI): 13.0–16.3) months, and median LC time was 12.2 (95% CI: 9.1–15.2) months. Univariate analysis revealed that when D90 > 130 Gy or D100 > 55 Gy or V100 > 90%, the LC time was remarkably prolonged. However, none of the parameters significantly affected OS. Conclusions CT-guided RIS implantation assisted with 3D-PNCT is an effective and safe salvage treatment strategy for patients with LRRC after EBRT or surgery. D90, D100, and V100 can be used as prognostic predictors. Trial registration NCT03890926.
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Affiliation(s)
- Lu Wang
- Department of Radiation Oncology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Hao Wang
- Department of Radiation Oncology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Yuliang Jiang
- Department of Radiation Oncology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Zhe Ji
- Department of Radiation Oncology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Fuxin Guo
- Department of Radiation Oncology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Ping Jiang
- Department of Radiation Oncology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Xuemin Li
- Department of Radiation Oncology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Yi Chen
- Department of Radiation Oncology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Haitao Sun
- Department of Radiation Oncology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Jinghong Fan
- Department of Radiation Oncology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Weiyan Li
- Department of Radiation Oncology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Xu Li
- Department of Radiation Oncology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Junjie Wang
- Department of Radiation Oncology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China.
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25
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Kok END, van Veen R, Groen HC, Heerink WJ, Hoetjes NJ, van Werkhoven E, Beets GL, Aalbers AGJ, Kuhlmann KFD, Nijkamp J, Ruers TJM. Association of Image-Guided Navigation With Complete Resection Rate in Patients With Locally Advanced Primary and Recurrent Rectal Cancer: A Nonrandomized Controlled Trial. JAMA Netw Open 2020; 3:e208522. [PMID: 32639566 PMCID: PMC7344384 DOI: 10.1001/jamanetworkopen.2020.8522] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
IMPORTANCE The percentage of tumor-positive surgical resection margin rates in patients treated for locally advanced primary or recurrent rectal cancer is high. Image-guided navigation may improve complete resection rates. OBJECTIVE To ascertain whether image-guided navigation during rectal cancer resection improves complete resection rates compared with surgical procedures without navigation. DESIGN, SETTING, AND PARTICIPANTS This prospective single-center nonrandomized controlled trial was conducted at the Netherlands Cancer Institute-Antoni van Leeuwenhoek in Amsterdam, the Netherlands. The prospective or navigation cohort included adult patients with locally advanced primary or recurrent rectal cancer who underwent resection with image-guided navigation between February 1, 2016, and September 30, 2019, at the tertiary referral hospital. Clinical results of this cohort were compared with results of the historical cohort, which was composed of adult patients who received rectal cancer resection without image-guided navigation between January 1, 2009, and December 31, 2015. INTERVENTION Rectal cancer resection with image-guided navigation. MAIN OUTCOMES AND MEASURES The primary end point was the complete resection rate, measured by the amount of tumor-negative resection margin rates. Secondary outcomes were safety and usability of the system. Safety was evaluated by the number of navigation system-associated surgical adverse events. Usability was assessed from responses to a questionnaire completed by the participating surgeons after each procedure. RESULTS In total, 33 patients with locally advanced or recurrent rectal cancer were included (23 men [69.7%]; median [interquartile range] age at start of treatment, 61 [55.0-69.0] years). With image-guided navigation, a radical resection (R0) was achieved in 13 of 14 patients (92.9%; 95% CI, 66.1%-99.8%) after primary resection of locally advanced tumors and in 15 of 19 patients (78.9%; 95% CI, 54.4%-94.0%) after resection of recurrent rectal cancer. No navigation system-associated complications occurred before or during surgical procedures. In the historical cohort, 142 patients who underwent resection without image-guided navigation were included (95 men [66.9%]; median [interquartile range] age at start of treatment, 64 [55.0-70.0] years). In these patients, an R0 resection was accomplished in 85 of 101 patients (84.2%) with locally advanced rectal cancer and in 20 of 41 patients (48.8%) with recurrent rectal cancer. A significant difference was found between the navigation and historical cohorts after recurrent rectal cancer resection (21.1% vs 51.2%; P = .047). For locally advanced primary tumor resection, the difference was not significant (7.1% vs 15.8%; P = .69). Surgeons stated in completed questionnaires that the navigation system improved decisiveness and helped with tumor localization. CONCLUSIONS AND RELEVANCE Findings of this study suggest that image-guided navigation used during rectal cancer resection is safe and intuitive and may improve tumor-free resection margin rates in recurrent rectal cancer. TRIAL REGISTRATION Netherlands Trial Register Identifier: NTR7184.
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Affiliation(s)
- Esther N. D. Kok
- Department of Surgical Oncology, the Netherlands Cancer Institute—Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Ruben van Veen
- Department of Surgical Oncology, the Netherlands Cancer Institute—Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Harald C. Groen
- Department of Surgical Oncology, the Netherlands Cancer Institute—Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Wouter J. Heerink
- Department of Surgical Oncology, the Netherlands Cancer Institute—Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Nikie J. Hoetjes
- Department of Surgical Oncology, the Netherlands Cancer Institute—Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Erik van Werkhoven
- Department of Biometrics, the Netherlands Cancer Institute—Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Geerard L. Beets
- Department of Surgical Oncology, the Netherlands Cancer Institute—Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Arend G. J. Aalbers
- Department of Surgical Oncology, the Netherlands Cancer Institute—Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Koert F. D. Kuhlmann
- Department of Surgical Oncology, the Netherlands Cancer Institute—Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Jasper Nijkamp
- Department of Surgical Oncology, the Netherlands Cancer Institute—Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Theo J. M. Ruers
- Department of Surgical Oncology, the Netherlands Cancer Institute—Antoni van Leeuwenhoek, Amsterdam, the Netherlands
- Faculty Applied Sciences, Group Nanobiophysics, Twente University, Enschede, the Netherlands
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Cyr DP, Zih FS, Wells BJ, Swett-Cosentino J, Burkes RL, Brierley JD, Cummings B, Smith AJ, Swallow CJ. Long-term outcomes following salvage surgery for locally recurrent rectal cancer: A 15-year follow-up study. Eur J Surg Oncol 2020; 46:1131-1137. [PMID: 32224071 DOI: 10.1016/j.ejso.2020.02.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 02/20/2020] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Locally recurrent rectal cancer (LRRC) is a complex problem requiring multidisciplinary consultation and specialized surgical care. Given the paucity of published longer-term survival data, skepticism persists regarding the benefit of major extirpative surgery. We investigated ultra-long-term (~15 years) outcomes following radical resection of LRRC and sought relevant clinicopathologic prognostic variables. METHODS A cohort of 52 consecutive patients who underwent resection of LRRC at our institution between 1997 and 2005 were followed with serial exams and imaging up to the point of death, or 30/06/2019. RESULTS Median follow-up time was 16.5 years (9.9-18.3) for patients who were alive at last follow-up; only one patient was lost to follow-up, at 9.9 years. For the entire cohort of 52 patients, disease-specific survival (DSS) at 5, 10, and 15 years following salvage surgery was 41%, 33%, and 31%, respectively. All patients who had distant metastatic disease at the time of LRRC resection (n = 6) subsequently died of cancer, at a median of 21 months (4-46). In those without distant metastases at time of salvage surgery (n = 46), DSS at 5, 10, and 15 years was 47%, 38%, and 35%, respectively, median 60 months. Negative resection margin (R0) was independently predictive of superior outcomes. In patients with M0 disease who had R0 resection (n = 37), DSS at 5, 10 and 15 years was 58%, 47%, and 44%, respectively, median 73 months. No patient developed re-recurrence after 5.5 years. CONCLUSIONS This study demonstrates exceptionally durable long-term cancer-free survival following salvage surgery for LRRC, indicating that cure is possible.
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Affiliation(s)
- David P Cyr
- Department of Surgical Oncology, Princess Margaret Cancer Centre and Mount Sinai Hospital, Toronto, Canada; Division of General Surgery, Department of Surgery, University of Toronto, Canada; Institute of Medical Science, University of Toronto, Toronto, Canada; Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Canada
| | - Francis Sw Zih
- Department of Surgery, Surrey Memorial Hospital, Surrey, Canada; Division of General Surgery, Department of Surgery, University of British Columbia, Canada
| | - Bryan J Wells
- Division of General Surgery, Nanaimo Regional General Hospital, Nanaimo, Canada
| | | | - Ronald L Burkes
- Department of Medical Oncology, Mount Sinai Hospital and Princess Margaret Cancer Centre, Department of Medicine, University of Toronto, Canada
| | - James D Brierley
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Canada
| | - Bernard Cummings
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Canada
| | - Andrew J Smith
- Sunnybrook Health Sciences Centre and Odette Cancer Centre, Toronto, Canada
| | - Carol J Swallow
- Department of Surgical Oncology, Princess Margaret Cancer Centre and Mount Sinai Hospital, Toronto, Canada; Division of General Surgery, Department of Surgery, University of Toronto, Canada; Institute of Medical Science, University of Toronto, Toronto, Canada; Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Canada.
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27
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Denost Q, Bousser V, Morin-Porchet C, Vincent C, Pinon E, Collin F, Martin A, Colombani F, Digue L, Ravaud A, Harji DP, Saillour-Glénisson F. The development of a regional referral pathway for locally recurrent rectal cancer: A Delphi consensus study. Eur J Surg Oncol 2019; 46:470-475. [PMID: 31866109 DOI: 10.1016/j.ejso.2019.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 11/18/2019] [Accepted: 12/01/2019] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The management of patients with locally recurrent rectal cancer (LRRC) is often complex and requires multidisciplinary input whereas only few patients are referred to a specialist centre. The aim of this study was to design a regional referral pathway for LRRC, in Nouvelle Aquitaine (South-West, France). METHODS In 2016, we conducted with a Study Steering Committee (SC) a three phase mixed-methods study including identification of key factors, identification of key stakeholders and Delphi voting consensus. During three rounds of Delphi voting, a consensus was defined as favorable, if at least 80% of participating experts rate the factor, below or equal to 3/10 using a Likert scale, or consider it as "useful" using a binary scale (third round only). Finally, the SC drafted guidelines. RESULTS Among the 423 physicians involved in 29 regional digestive Multi-Disciplinary Team (MDT) meeting, 59 participants (from 26 MDT meeting) completed all three rounds of Delphi voting. Thirteen out of twenty initially selected factors reached a favorable consensus. All patients with a LRRC need to be included into a referral pathway. Patients with a central pelvic recurrence offered curative treatment in their local hospital and patients with unresectable metastatic disease were excluded of the referral. Key performance indicators were also agreed including the time to referral and completion of pelvic MRI-, CT-, PET-scan prior to MDT referral. CONCLUSION The development of this referral pathway represents an innovative health service, which will improve the management of patients with LRRC in France.
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Affiliation(s)
- Quentin Denost
- Department of Digestive Surgery, Haut-leveque Hospital, Bordeaux University Hospital, Pessac, France.
| | | | | | - Cecile Vincent
- Limousin Oncology-Hematology Network (ROHLim), 87000, Limoges, France.
| | - Elodie Pinon
- Aquitaine Regional Cancer Network, 33076, Bordeaux, France.
| | - Fideline Collin
- Department of Digestive Surgery, Haut-leveque Hospital, Bordeaux University Hospital, Pessac, France.
| | - Aurelie Martin
- INSERM, ISPED, Centre INSERM U1219-Bordeaux Population Health, Team EMOS, F-33000, Bordeaux, France.
| | | | - Laurence Digue
- Department of Medical Oncology, Saint-André Hospital, Bordeaux University Hospital-CHU Bordeaux, France; Aquitaine Regional Cancer Network, 33076, Bordeaux, France.
| | - Alain Ravaud
- Department of Medical Oncology, Saint-André Hospital, Bordeaux University Hospital-CHU, Bordeaux, France, University of Bordeaux, Bordeaux, France.
| | - Deena Pravin Harji
- Department of Digestive Surgery, Haut-leveque Hospital, Bordeaux University Hospital, Pessac, France.
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28
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Kumar B, Murali A, Bharath AB, Giri S. Guar gum modified upconversion nanocomposites for colorectal cancer treatment through enzyme-responsive drug release and NIR-triggered photodynamic therapy. NANOTECHNOLOGY 2019; 30:315102. [PMID: 30893650 DOI: 10.1088/1361-6528/ab116e] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Multimodal therapeutic approach towards colorectal cancer (CRC) holds great promise. There is, however, no convincing strategy reported to date that employs a multimodal strategy in CRC treatment. The present study reports an intense green-emitting core-shell photoluminescent upconversion (CSGU) nanocrystal engineered to synergistically perform photodynamic and enzyme-triggered delivery of the chemotherapeutic agent for an enhanced therapeutic outcome on HT-29 colon carcinoma cells in vitro. The photodynamic activity is achieved by the energy transfer between CSGU and the chemically conjugated Rose Bengal (RB) molecules that are further protected by a mesoporous silica (MS) layer. The chemical assay demonstrates a remarkable FRET mediated generation of 1O2 under NIR (980 nm) excitation. The outermost MS layer of the nanoplatform is utilized for the loading of the 5FU anticancer drug, which is further capped with a guar gum (GG) polysaccharide polymer. The release of the 5FU is specifically triggered by the degradation of the GG cap by specific enzymes secreted from colonic microflora, which otherwise showed 'zero-release behavior' in the absence of any enzymatic trigger in various simulated gastro-intestinal (GI) conditions. Furthermore, the enhanced therapeutic efficacy of the nanoplatform (CSGUR-MSGG/5FU) was evaluated through in vitro studies using HT-29 CRC cell lines by various biochemical and microscopic assays by the simultaneous triggering effect of colonic enzyme and 980 nm laser excitation. In addition, the strong visible emission from the nanoplatform has been utilized for NIR-induced cellular bioimaging.
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Affiliation(s)
- Balmiki Kumar
- Department of Chemistry, National Institute of Technology, Rourkela. Odisha-769008, India
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29
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Anatomical Variations of Iliac Vein Tributaries and Their Clinical Implications During Complex Pelvic Surgeries. Dis Colon Rectum 2019; 62:809-814. [PMID: 31188181 DOI: 10.1097/dcr.0000000000001335] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND During high sacrectomies and lateral pelvic compartment exenterations, isolating the external and internal iliac veins within the presacral area is crucial to avoid inadvertent injury and severe hemorrhage. Anatomical variations of external iliac vein tributaries have not been previously described, whereas multiple classifications of internal iliac vein tributaries exist. OBJECTIVE We sought to clarify the iliac venous system anatomy using soft-embalmed cadavers. DESIGN This is a descriptive study. SETTINGS This study was conducted in Chulalongkorn University, Thailand. PATIENTS We examined 40 iliac venous systems from 20 human cadavers (10 males, 10 females). INTERVENTIONS Blue resin dye infused into the inferior vena cava highlighted the iliac venous system, which was meticulously dissected and traced to their draining organs. MAIN OUTCOME MEASURES Iliac vein tributaries and their valvular system were documented and analyzed. RESULTS The external iliac vein classically receives 2 tributaries (inferior epigastric and deep circumflex iliac) near the inguinal ligament. However, external iliac vein tributaries in the presacral area were found in 20 venous systems among 15 cadavers (75%). The mean diameter of each tributary was 4.0 ± 0.35 mm, with 72% arising laterally. We propose a simplified classification for internal iliac vein variations: pattern 1 in 12 cadavers (60%) where a single internal iliac vein joins a single external iliac vein to drain into the common iliac vein; pattern 2 in 7 cadavers (35%) where the internal iliac vein is duplicated; and pattern 3 in 1 cadaver (5%) where bilateral internal iliac veins drain into a common trunk before joining the common iliac vein bifurcation. LIMITATIONS This study is limited by the number of cadavers included. CONCLUSIONS A comprehensive understanding of previously unreported highly prevalent external iliac vein tributaries in the presacral region is vital during complex pelvic surgery. A simplified classification of internal iliac vein variations is proposed. See Video Abstract at http://links.lww.com/DCR/A900.
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30
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Davis BR, Schlosser KA. Management of locally recurrent rectal cancer. SEMINARS IN COLON AND RECTAL SURGERY 2019. [DOI: 10.1053/j.scrs.2019.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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31
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Lau YC, Jongerius K, Wakeman C, Heriot AG, Solomon MJ, Sagar PM, Tekkis PP, Frizelle FA. Influence of the level of sacrectomy on survival in patients with locally advanced and recurrent rectal cancer. Br J Surg 2019; 106:484-490. [PMID: 30648734 DOI: 10.1002/bjs.11048] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Revised: 09/25/2018] [Accepted: 10/10/2018] [Indexed: 01/27/2023]
Abstract
BACKGROUND Exenterative surgery for locally advanced rectal cancer may involve partial sacrectomy to achieve complete resection. High sacrectomy is technically challenging, and can be associated with high morbidity and mortality rates. The aim of this study was to determine the influence of the level of sacrectomy on the survival of patients with locally advanced rectal cancer. METHODS This was an international multicentre retrospective analysis of patients undergoing exenterative abdominosacrectomy between July 2006 and June 2016. High sacrectomy was defined as resection at or above the junction of S2-S3; low sacrectomy was below the S2-S3 junction. Kaplan-Meier survival analysis was used to assess overall survival and cancer-specific survival. Predictive factors were determined using Cox regression analysis. RESULTS A total of 345 patients were identified, of whom 91 underwent high sacrectomy and 254 low sacrectomy. There was no difference in 5-year overall survival (53 versus 44·1 per cent; P = 0·216) or cancer-specific survival (60 versus 56·1 per cent; P = 0·526) between high and low sacrectomy. Negative margin rates were similar for primary and recurrent disease: 65 of 90 (72 per cent) versus 97 of 153 (63·4 per cent) (P = 0·143). Level of sacrectomy was not a significant predictor of mortality (P = 0·053). Positive resection margin and advancing age were the only significant predictors for death, with hazard ratios of 2·78 (P < 0·001) and 1·02 (P = 0·020) respectively. CONCLUSION There was no survival difference between patients who underwent high or low sacrectomy. In appropriately selected patients, high sacrectomy is feasible and safe.
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Affiliation(s)
- Y C Lau
- Department of General Surgery, Christchurch Public Hospital, Christchurch, New Zealand.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - K Jongerius
- Department of General Surgery, University of Otago, Christchurch, New Zealand
| | - C Wakeman
- Department of General Surgery, Christchurch Public Hospital, Christchurch, New Zealand.,Department of General Surgery, University of Otago, Christchurch, New Zealand
| | - A G Heriot
- Department of Colorectal Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - M J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - P M Sagar
- Department of Colorectal Surgery, Leeds General Infirmary, Leeds, UK
| | - P P Tekkis
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
| | - F A Frizelle
- Department of General Surgery, Christchurch Public Hospital, Christchurch, New Zealand.,Department of General Surgery, University of Otago, Christchurch, New Zealand
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32
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Brownstein JM, Wisdom AJ, Castle KD, Mowery YM, Guida P, Lee CL, Tommasino F, Tessa CL, Scifoni E, Gao J, Luo L, Campos LDS, Ma Y, Williams N, Jung SH, Durante M, Kirsch DG. Characterizing the Potency and Impact of Carbon Ion Therapy in a Primary Mouse Model of Soft Tissue Sarcoma. Mol Cancer Ther 2018; 17:858-868. [PMID: 29437879 PMCID: PMC5912881 DOI: 10.1158/1535-7163.mct-17-0965] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 12/28/2017] [Accepted: 02/01/2018] [Indexed: 12/11/2022]
Abstract
Carbon ion therapy (CIT) offers several potential advantages for treating cancers compared with X-ray and proton radiotherapy, including increased biological efficacy and more conformal dosimetry. However, CIT potency has not been characterized in primary tumor animal models. Here, we calculate the relative biological effectiveness (RBE) of carbon ions compared with X-rays in an autochthonous mouse model of soft tissue sarcoma. We used Cre/loxP technology to generate primary sarcomas in KrasLSL-G12D/+; p53fl/fl mice. Primary tumors were irradiated with a single fraction of carbon ions (10 Gy), X-rays (20 Gy, 25 Gy, or 30 Gy), or observed as controls. The RBE was calculated by determining the dose of X-rays that resulted in similar time to posttreatment tumor volume quintupling and exponential growth rate as 10 Gy carbon ions. The median tumor volume quintupling time and exponential growth rate of sarcomas treated with 10 Gy carbon ions and 30 Gy X-rays were similar: 27.3 and 28.1 days and 0.060 and 0.059 mm3/day, respectively. Tumors treated with lower doses of X-rays had faster regrowth. Thus, the RBE of carbon ions in this primary tumor model is 3. When isoeffective treatments of carbon ions and X-rays were compared, we observed significant differences in tumor growth kinetics, proliferative indices, and immune infiltrates. We found that carbon ions were three times as potent as X-rays in this aggressive tumor model and identified unanticipated differences in radiation response that may have clinical implications. Mol Cancer Ther; 17(4); 858-68. ©2018 AACR.
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Affiliation(s)
- Jeremy M Brownstein
- Department of Radiation Oncology, Duke University Health System, Durham, North Carolina
| | - Amy J Wisdom
- Department of Pharmacology & Cancer Biology, Duke University, Durham, North Carolina
| | - Katherine D Castle
- Department of Pharmacology & Cancer Biology, Duke University, Durham, North Carolina
| | - Yvonne M Mowery
- Department of Radiation Oncology, Duke University Health System, Durham, North Carolina
| | - Peter Guida
- Department of Biology, Brookhaven National Laboratory, Upton, New York
| | - Chang-Lung Lee
- Department of Radiation Oncology, Duke University Health System, Durham, North Carolina
| | - Francesco Tommasino
- Trento Institute for Fundamental Physics and Applications, National Institute for Nuclear Physics (INFN), Trento, Italy
- Department of Physics, University of Trento, Trento, Italy
| | - Chiara La Tessa
- Brookhaven National Laboratory, Upton, New York
- Trento Institute for Fundamental Physics and Applications, National Institute for Nuclear Physics (INFN), Trento, Italy
- Department of Physics, University of Trento, Trento, Italy
| | - Emanuele Scifoni
- Trento Institute for Fundamental Physics and Applications, National Institute for Nuclear Physics (INFN), Trento, Italy
| | - Junheng Gao
- Department of Biostatistics and Informatics, Duke University, Durham, North Carolina
| | - Lixia Luo
- Department of Radiation Oncology, Duke University Health System, Durham, North Carolina
| | | | - Yan Ma
- Department of Radiation Oncology, Duke University Health System, Durham, North Carolina
| | - Nerissa Williams
- Department of Radiation Oncology, Duke University Health System, Durham, North Carolina
| | - Sin-Ho Jung
- Department of Biostatistics and Informatics, Duke University, Durham, North Carolina
| | - Marco Durante
- Trento Institute for Fundamental Physics and Applications, National Institute for Nuclear Physics (INFN), Trento, Italy
| | - David G Kirsch
- Department of Radiation Oncology, Duke University Health System, Durham, North Carolina.
- Department of Pharmacology & Cancer Biology, Duke University, Durham, North Carolina
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Rao C, Smith F, Martin A, Dhadda A, Stewart A, Gollins S, Collins B, Athanasiou T, Sun Myint A. A Cost-Effectiveness Analysis of Contact X-ray Brachytherapy for the Treatment of Patients with Rectal Cancer Following a Partial Response to Chemoradiotherapy. Clin Oncol (R Coll Radiol) 2018; 30:166-177. [DOI: 10.1016/j.clon.2017.11.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 10/07/2017] [Accepted: 10/26/2017] [Indexed: 10/18/2022]
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Uemura M, Ikeda M, Kawai K, Nishimura J, Takemasa I, Mizushima T, Yamamoto H, Sekimoto M, Doki Y, Mori M. Laparoscopic surgery using a Gigli wire saw for locally recurrent rectal cancer with concomitant intraperitoneal sacrectomy. Asian J Endosc Surg 2018; 11:83-86. [PMID: 29485249 DOI: 10.1111/ases.12407] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 06/01/2017] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Previous reports indicated the effectiveness of surgical resection for locally recurrent rectal cancer (LRRC). Most cases with posterior invasion patterns require concomitant sacrectomy to secure negative histologic margins, although this is a highly invasive procedure. Here, we present a new minimally invasive laparoscopic surgical technique for LRRC with concomitant sacrectomy. MATERIALS AND SURGICAL TECHNIQUE A 64-year-old man presented with LRRC on the surface of the sacral bone. He underwent laparoscopic abdominoperineal resection with concomitant sacrectomy below the S4 vertebra. The surgical procedure, including sacrectomy, was performed laparoscopically. The distance between the estimated resection line (below the S4 vertebra) and sacral promontory was measured by preoperative imaging. Intraoperatively, a flexible ruler was employed to determine the resection line. Securing adequate space dorsal to the sacral bone was indispensable for placement of the Gigli wire saw. After the Gigli wire saw was positioned, bilateral caudal trocars were used to remove the ends of the wire. Then, the sacral bone was cut by the linear reciprocating motion of the Gigli wire saw. Pathologically confirmed curative resection was achieved. The procedure was successfully performed without transfusion or intraoperative complications. The operation time was 757 min, and blood loss volume was 890 ml. There were no severe postoperative complications. The patient is alive and well with no evidence of recurrence at 58 months after surgical resection of LRRC. DISCUSSION Our newly developed technique demonstrates that laparoscopic intraperitoneal sacrectomy using a Gigli wire saw is a safe and useful procedure to facilitate resection of LRRC.
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Affiliation(s)
- Mamoru Uemura
- Department of Surgery, National Hospital Organization Osaka National Hospital, Osaka, Japan.,Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Masataka Ikeda
- Department of Surgery, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Kenji Kawai
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Junichi Nishimura
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Ichiro Takemasa
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan.,Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
| | - Tsunekazu Mizushima
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Hirofumi Yamamoto
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Mitsugu Sekimoto
- Department of Surgery, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Masaki Mori
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
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Time to local recurrence as a predictor of survival in unrecetable gastric cancer patients after radical gastrectomy. Oncotarget 2017; 8:89203-89213. [PMID: 29179512 PMCID: PMC5687682 DOI: 10.18632/oncotarget.19038] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 04/20/2017] [Indexed: 12/23/2022] Open
Abstract
Local recurrence is common after radical surgery. However, the factors that contribute to survival after local recurrence remain unclear. In this retrospective study we analyzed the relationship between time to recurrence and survival after recurrence in 74 patients with locally recurrent gastric cancer. All patients received palliative radiotherapy with or without chemotherapy. The patients were divided into two groups according to the time between gastrectomy and local recurrence: early local recurrence (ELR, < 12 months after primary surgery), and late local recurrence (LLR, ≥12 months after primary surgery). The median overall survival (OS) time was 15 months for patients with ELR and 25 months for LLR patients. Univariate and multivariate analysis revealed that time to local recurrence was significantly associated with OS after local recurrence (P = 0.001). The hazard ratio of ELR compared with LLR patients was 0.442 (95% confidence interval: 0.264-0.741). These results indicate that early local recurrence predicted poor prognosis in gastric cancer patients with unresectable local recurrence.
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36
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Lee DJK, Sagar PM, Sadadcharam G, Tan KY. Advances in surgical management for locally recurrent rectal cancer: How far have we come? World J Gastroenterol 2017; 23:4170-4180. [PMID: 28694657 PMCID: PMC5483491 DOI: 10.3748/wjg.v23.i23.4170] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 03/31/2017] [Accepted: 05/09/2017] [Indexed: 02/06/2023] Open
Abstract
Locally recurrent rectal cancer (LRRC) is a complex disease with far-reaching implications for the patient. Until recently, research was limited regarding surgical techniques that can increase the ability to perform an en bloc resection with negative margins. This has changed in recent years and therefore outcomes for these patients have improved. Novel radical techniques and adjuncts allow for more radical resections thereby improving the chance of negative resection margins and outcomes. In the past contraindications to surgery included anterior involvement of the pubic bone, sacral invasions above the level of S2/S3 and lateral pelvic wall involvement. However, current data suggests that previously unresectable cases may now be feasible with novel techniques, surgical approaches and reconstructive surgery. The publications to date have only reported small patient pools with the research conducted by highly specialised units. Moreover, the short and long-term oncological outcomes are currently under review. Therefore although surgical options for LRRC have expanded significantly, one should balance the treatment choices available against the morbidity associated with the procedure and select the right patient for it.
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Chew MH, Yeh YT, Toh EL, Sumarli SA, Chew GK, Lee LS, Tan MH, Hennedige TP, Ng SY, Lee SK, Chong TT, Abdullah HR, Goh TLH, Rasheed MZ, Tan KC, Tang CL. Critical evaluation of contemporary management in a new Pelvic Exenteration Unit: The first 25 consecutive cases. World J Gastrointest Oncol 2017; 9:218-227. [PMID: 28567186 PMCID: PMC5434389 DOI: 10.4251/wjgo.v9.i5.218] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 02/02/2017] [Accepted: 03/13/2017] [Indexed: 02/05/2023] Open
Abstract
AIM To critically appraise short-term outcomes in patients treated in a new Pelvic Exenteration (PE) Unit.
METHODS This retrospective observational study was conducted by analysing prospectively collected data for the first 25 patients (16 males, 9 females) who underwent PE for advanced pelvic tumours in our PE Unit between January 2012 and October 2016. Data evaluated included age, co-morbidities, American Society of Anesthesiologists (ASA) score, Eastern Cooperative Oncology Group (ECOG) status, preoperative adjuvant treatment, intra-operative blood loss, procedural duration, perioperative adverse event, lengths of intensive care unit (ICU) stay and hospital stay, and oncological outcome. Quantitative data were summarized as percentage or median and range, and statistically assessed by the χ2 test or Fisher’s exact test, as applicable.
RESULTS All 25 patients received comprehensive preoperative assessment via our dedicated multidisciplinary team approach. Long-course neoadjuvant chemoradiotherapy was provided, if indicated. The median age of the patients was 61.9-year-old. The median ASA and ECOG scores were 2 and 0, respectively. The indications for PE were locally invasive rectal adenocarcinoma (n = 13), advanced colonic adenocarcinoma (n = 5), recurrent cervical carcinoma (n = 3) and malignant sacral chordoma (n = 3). The procedures comprised 10 total PEs, 4 anterior PEs, 7 posterior PEs and 4 isolated lateral PEs. The median follow-up period was 17.6 mo. The median operative time was 11.5 h. The median volume of blood loss was 3306 mL, and the median volume of red cell transfusion was 1475 mL. The median lengths of ICU stay and of hospital stay were 1 d and 21 d, respectively. There was no case of mortality related to surgery. There were a total of 20 surgical morbidities, which occurred in 12 patients. The majority of the complications were grade 2 Clavien-Dindo. Only 2 patients experienced grade 3 Clavien-Dindo complications, and both required procedural interventions. One patient experienced grade 4a Clavien-Dindo complication, requiring temporary renal dialysis without long-term disability. The R0 resection rate was 64%. There were 7 post-exenteration recurrences during the follow-up period. No statistically significant relationship was found among histological origin of tumour, microscopic resection margin status and postoperative recurrence (P = 0.67). Four patients died from sequelae of recurrent disease during follow-up.
CONCLUSION By utilizing modern assessment and surgical techniques, our PE Unit can manage complex pelvic cancers with acceptable morbidities, zero-rate mortality and equivalent oncologic outcomes.
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Validation of MRI and Surgical Decision Making to Predict a Complete Resection in Pelvic Exenteration for Recurrent Rectal Cancer. Dis Colon Rectum 2017; 60:144-151. [PMID: 28059910 DOI: 10.1097/dcr.0000000000000766] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The main predictor of long-term survival in patients with recurrent rectal cancer is surgical resection with a clear resection margin. MRI plays a role in patient selection and surgical planning. OBJECTIVE This study aimed to validate MRI in determining pelvic involvement by comparing MRI to histological outcomes, to assess the effect of MRI on surgical planning by comparing MRI findings with the surgical procedure, and to compare MRI anatomical involvement with resection outcome to assess if MRI can predict a clear resection margin. DESIGN Retrospective study reviewing prepelvic exenteration MRI and correlating organ, involving an MRI with pathological involvement and surgical outcomes. SETTINGS Single quaternary referral center with a special interest in pelvic exenteration. PATIENTS The patients included 40 men and 22 women with median age of 60 years who had locally recurrent rectal cancer. MAIN OUTCOME MEASURES The accuracy of MRI as measured using sensitivity and specificity by correlating MRI involvement with pathological involvement was the primary outcome measured. RESULTS Recurrence in the anterior and central compartments was identified with accuracy on MRI and was likely to be associated with clear resection margins. MRI was less accurate at determining pelvic sidewall involvement. Lateral recurrence, high sacral, and nerve involvement were more likely to be associated with a positive resection margin. Sensitivity and specificity for pelvic sidewall structures was 46% and 91%. Involvement of nerve roots (60%-69%) and the upper sacrum (80%) on MRI was more likely to predict a positive resection margin than involvement of major pelvic viscera (22%). LIMITATIONS This study was limited by its retrospective nature. CONCLUSIONS MRI findings can be used to help predict resection margin. Prospective work with MRI interpretation and close correlation and involvement by pathologists is needed to address imaging and surgical limitations at the pelvic sidewall and high posterior margin.
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Abstract
BACKGROUND Radical surgery is associated with significant perioperative mortality in elderly and comorbid populations. Emerging data suggest for patients with a clinical complete response after neoadjuvant chemoradiotherapy that a watch-and-wait approach may provide equivalent survival and oncological outcomes. OBJECTIVE The purpose of this study was to compare the cost-effectiveness of watch and wait and radical surgery for patients with rectal cancer after a clinical complete response following chemoradiotherapy. DESIGN Decision analytical modeling and a Markov simulation were used to model long-term costs, quality-adjusted life-years, and cost-effectiveness after watch and wait and radical surgery. Sensitivity analysis was used to investigate the effect of uncertainty in model parameters. SETTINGS A third-party payer perspective was adopted. PATIENTS Patients included in the study were a 60-year-old male cohort with no comorbidities, 80-year-old male cohorts with no comorbidities, and 80-year-old male cohorts with significant comorbidities. INTERVENTIONS Radical surgery and watch-and-wait approaches were studied. MAIN OUTCOME MEASURES Incremental cost, effectiveness, and cost-effectiveness ratio over the entire lifetime of the hypothetical patient cohorts were measured. RESULTS Watch and wait was more effective (60-year-old male cohort with no comorbidities = 0.63 quality-adjusted life-years (95% CI, 2.48-3.65 quality-adjusted life-years); 80-year-old male cohort with no comorbidities = 0.56 quality-adjusted life-years (95% CI, 0.52-1.59 quality-adjusted life-years); 80-year-old male cohort with significant comorbidities = 0.72 quality-adjusted life-years (95% CI, 0.34-1.76 quality-adjusted life-years)) and less costly (60-year-old male cohort with no comorbidities = $11,332.35 (95% CI, $668.50-$23,970.20); 80-year-old male cohort with no comorbidities = $8783.93 (95% CI, $2504.26-$21,900.66); 80-year-old male cohort with significant comorbidities = $10,206.01 (95% CI, $2762.014-$24,135.31)) independent of patient cohort age and comorbidity. Consequently, watch and wait was more cost-effective with a high degree of certainty (range, 69.6%-89.2%) at a threshold of $50,000/quality-adjusted life-year. LIMITATIONS Long-term outcomes were derived from modeled cohorts. Analysis was performed for a United Kingdom third-party payer perspective, limiting generalizability to other healthcare contexts. CONCLUSIONS Watch and wait is likely to be cost-effective compared with radical surgery. These findings strongly support the discussion of organ-preserving strategies with suitable patients.
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González-Castillo A, Biondo S, García-Granero Á, Cambray M, Martínez-Villacampa M, Kreisler E. Resultados de la cirugía de la recidiva pélvica de cáncer de recto. Experiencia en un centro de referencia. Cir Esp 2016; 94:518-524. [DOI: 10.1016/j.ciresp.2016.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 08/02/2016] [Accepted: 08/02/2016] [Indexed: 01/14/2023]
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Holman FA, Bosman SJ, Haddock MG, Gunderson LL, Kusters M, Nieuwenhuijzen GAP, van den Berg H, Nelson H, Rutten HJ. Results of a pooled analysis of IOERT containing multimodality treatment for locally recurrent rectal cancer: Results of 565 patients of two major treatment centres. Eur J Surg Oncol 2016; 43:107-117. [PMID: 27659000 DOI: 10.1016/j.ejso.2016.08.015] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 07/13/2016] [Accepted: 08/09/2016] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Aim of this study is analysing the pooled results of Intra-Operative Electron beam Radiotherapy (IOERT) containing multimodality treatment of locally recurrent rectal cancer (LRRC) of two major treatment centres. METHODS AND MATERIALS Five hundred sixty five patients with LRRC who underwent multimodality-treatment up to 2010 were studied. The preferred treatment was preoperative chemo-radiotherapy, surgery and IOERT. In uni- and multivariate analyses risk factors for local re-recurrence, distant metastasis free survival, relapse free survival, cancer-specific survival and overall survival were studied. RESULTS Two hundred fifty one patients (44%) underwent a radical (R0) resection. In patients who had no preoperative treatment the R0 resection rate was 26%, and this was 43% and 50% for patients who respectively received preoperative re-(chemo)-irradiation or full-course radiotherapy (p < 0.0001). After uni- and multivariate analysis it was found that all oncologic parameters were influenced by preoperative treatment and radicality of the resection. Patients who were re-irradiated had a similar outcome compared to patients, who were radiotherapy naive and could undergo full-course treatment, except the chance of local re-recurrence was higher for re-irradiated patients. Waiting-time between preoperative radiotherapy and IOERT was inversely correlated with the chance of local re-recurrence, and positively correlated with the chance of a R0 resection. CONCLUSIONS R0 resection is the most important factor influencing oncologic parameters in treatment of LRRC. Preoperative (chemo)-radiotherapy increases the chance of achieving radical resections and improves oncologic outcomes. Short waiting-times between preoperative treatment and IOERT improves the effectiveness of IOERT to reduce the chance of a local re-recurrence.
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Affiliation(s)
- F A Holman
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - S J Bosman
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - M G Haddock
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - L L Gunderson
- Department of Radiation Oncology, Mayo Clinic, Scottsdale, AZ, USA
| | - M Kusters
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands; Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | | | - H van den Berg
- Department of Radiotherapy, Catharina Hospital, Eindhoven, The Netherlands
| | - H Nelson
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - H J Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands; GROW: School of Oncology and Developmental Biology, University of Maastricht, Maastricht, The Netherlands.
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Outcomes of Pelvic Exenteration with en Bloc Partial or Complete Pubic Bone Excision for Locally Advanced Primary or Recurrent Pelvic Cancer. Dis Colon Rectum 2016; 59:831-5. [PMID: 27505111 DOI: 10.1097/dcr.0000000000000656] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Neoplasms infiltrating the pubic bone have until recently been considered a contraindication to surgery. Paucity of existing published data in regard to surgical techniques and outcomes exist. OBJECTIVE This study aims to address outcomes of our recently published technique for en bloc composite pubic bone excision during pelvic exenteration. DESIGN A prospective database was reviewed to identify patients who underwent a partial or complete pubic bone composite excision over a 12-year period. SETTINGS This study was conducted at a tertiary level exenteration unit. MAIN OUTCOME MEASURES Primary outcomes measured were resection margin and survival. Secondary outcomes included patient and operative demographics, type of cancer, extent of pubic bone excision, morbidity, and 30-day mortality. RESULTS Twenty-nine of over 500 patients undergoing exenterations (mean age, 57.9; 20 males) underwent en bloc complete (11 patients) or partial (18 patients) composite pubic bone excision. Twenty-two patients (76%) underwent resection for recurrent as opposed to advanced primary malignant disease of which rectal adenocarcinoma was the most common followed by squamous-cell carcinoma. The median operating time was 10.5 (range, 6-15) hours, and median blood loss was 2971 (range, 300-8600) mL. Seventeen (59%) patients had a concurrent sacrectomy performed mainly S3 and below. A total cystectomy was performed in 26 patients (90%). Fifteen of 20 male patients (75%) had a perineal urethrectomy. A clear (R0) resection margin was achieved in 22 patients (76%) with a 5-year overall survival of 53% after a median follow-up of 3.2 years (r = 1.4-12.3 years). There was no 30-day mortality. Seventy percent of patients experienced morbidity with a pelvic collection the most common. LIMITATIONS This study was limited because it was a retrospective review, it occurred at a single site, and it used a small heterogeneous sample. CONCLUSION Within the realm of evolving exenteration surgery, en bloc composite pubic bone excision offers results comparable to central, lateral, and posterior compartment excisions, and, as such, is a reasonable strategy in the management of neoplasms infiltrating the pubic bone.
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Yun JA, Huh JW, Kim HC, Park YA, Cho YB, Yun SH, Lee WY, Chun HK. Local recurrence after curative resection for rectal carcinoma: The role of surgical resection. Medicine (Baltimore) 2016; 95:e3942. [PMID: 27399067 PMCID: PMC5058796 DOI: 10.1097/md.0000000000003942] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Local recurrence of rectal cancer is difficult to treat, may cause severe and disabling symptoms, and usually has a fatal outcome. The aim of this study was to document the clinical nature of locally recurrent rectal cancer and to determine the effect of surgical resection on long-term survival.A retrospective review was conducted of the prospectively collected medical records of 2485 patients with primary rectal adenocarcinoma who underwent radical resection between September 1994 and December 2008.In total, 147 (5.9%) patients exhibited local recurrence. The most common type of local recurrence was lateral recurrence, whereas anastomotic recurrence was the most common type in patients without preoperative concurrent chemoradiotherapy (CCRT). Tumor location with respect to the anal verge significantly affected the local recurrence rate (P < 0.001), whereas preoperative CCRT did not affect the local recurrence rate (P = 0.433). Predictive factors for surgical resection of recurrent rectal cancer included less advanced tumor stage (P = 0.017, RR = 3.840, 95% CI = 1.271-11.597), axial recurrence (P < 0.001, RR = 5.772, 95% CI = 2.281-14.609), and isolated local recurrence (P = 0.006, RR = 8.679, 95% CI = 1.846-40.815). Overall survival after diagnosis of local recurrence was negatively influenced by advanced pathologic tumor stage (P = 0.040, RR = 1.867, 95% CI = 1.028-3.389), positive CRM (P = 0.001, RR = 12.939, 95% CI = 2.906-57.604), combined distant metastases (P = 0.001, RR = 2.086, 95% CI = 1.352-3.218), and nonsurgical resection of recurrent tumor (P < 0.001, RR = 4.865, 95% CI = 2.586-9.153).In conclusion, the clinical outcomes of local recurrence after curative resection of rectal cancer are diverse. Surgical resection of locally recurrent rectal cancer should be considered as an initial treatment, especially in patients with less advanced tumors and axial recurrence.
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Affiliation(s)
- Jung-A Yun
- Department of Surgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Jung Wook Huh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Correspondence: Jung Wook Huh, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, Korea (e-mail: ); Hee Cheol Kim, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, Korea (e-mail: )
| | - Hee Cheol Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Correspondence: Jung Wook Huh, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, Korea (e-mail: ); Hee Cheol Kim, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, Korea (e-mail: )
| | - Yoon Ah Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Beom Cho
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Hyeon Yun
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woo Yong Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ho-Kyung Chun
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicin, Seoul, Korea
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Abstract
The optimal management of rectal cancer is achieved through a shared multidisciplinary decision making process with accurate staging by imaging being critical for treatment planning. Good quality, high-resolution MRI has become the imaging gold standard as it allows consistent staging and stratification of patients into distinct prognostic groups according to MR-findings. Imaging features other than T and N have been proven to influence patient outcomes, and increasingly these features are taken into consideration when determining treatment options: distance of tumour to the potential circumferential margin (CRM), presence of tumour within the extramural rectal vessels (EMVI), discontinuous tumour deposits (N1c), relationship to the intersphincteric plane in low rectal tumours and to pelvic compartments in advanced disease. The presence or absence of proven adverse MR features should be included in the MRI report and shared with the patient when treatment choices are offered. MRI enables the identification of high risk tumours where the use of neoadjuvant therapy is justified and is a robust method of identifying patients with a strong likelihood of complete response after preoperative treatment.
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Affiliation(s)
- Svetlana Balyasnikova
- />Colorectal Imaging Group, The Royal Marsden Hospital, NHS Foundation Trust, Downs Road, Sutton, Surrey, SM2 5PT UK
- />Imperial College London, London, SW7 2AZ UK
- />The N. N. Blokhin Russian Cancer Research Center, Kashirskoye Shosse 24, Moscow, 15478 Russia
- />The State Scientific Center of Coloproctology, ul. Saliama Adilia 2, Moscow, 123423 Russia
| | - Gina Brown
- />Colorectal Imaging Group, The Royal Marsden Hospital, NHS Foundation Trust, Downs Road, Sutton, Surrey, SM2 5PT UK
- />Imperial College London, London, SW7 2AZ UK
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Intraoperative radiotherapy with low energy photons in recurrent colorectal cancer: a single centre retrospective study. Contemp Oncol (Pozn) 2016; 20:52-7. [PMID: 27095940 PMCID: PMC4829748 DOI: 10.5114/wo.2016.58500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 10/29/2015] [Indexed: 11/17/2022] Open
Abstract
AIM OF THE STUDY Intraoperative radiotherapy (IORT) may improve outcome of surgical treatment of recurrent colorectal cancer (CRC). The aim of this study is to determine the feasibility, safety and long-term results of surgical treatment of recurrent CRC with orthovolt IORT. MATERIAL AND METHODS Fifty-nine consecutive CRC patients with local recurrence (LR), undergoing surgery, were included in the retrospective analysis of prospectively collected data. The modified Wanebo classification was used to stage LR (Tr). Twenty-five (43%) patients received IORT using INTRABEAM(®) PRS 500. The complications were classified according to the Clavien-Dindo classification. RESULTS There were 32 males and 27 females, with a median age of 63 years. Multi-visceral resections were performed in 37 (63%) patients. Median hospitalization time after surgery with IORT was 7 days. One (1.7%) in-hospital postoperative death was reported. Grade 3/4 postoperative complications were found in 11 (19%) patients. Intraoperative radiotherapy had no effect on the postoperative hospitalization time, morbidity and mortality. Median survival after R0 resection was 32 months. Complete resection (R0), no synchronous liver metastases (M0), and no lateral and posterior pelvic wall involvement, were significant predictors of improved survival. Stage of LR was found to be an independent prognostic factor in the multivariate analysis (p = 0.03); Cox regression model). In patients with LR stage < Tr5, a 3-year overall survival (OS) rate was 52%. CONCLUSIONS Combination of surgical resection and orthovolt IORT is a safe and feasible procedure that does not increase the risk of postoperative complications or prolongs the hospital stay. Despite aggressive surgery supported by IORT, the advanced stage of LR is a limiting factor of long-term survival.
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Denost Q, Saillour F, Masya L, Martinaud HM, Guillon S, Kret M, Rullier E, Quintard B, Solomon M. Benchmarking trial between France and Australia comparing management of primary rectal cancer beyond TME and locally recurrent rectal cancer (PelviCare Trial): rationale and design. BMC Cancer 2016; 16:262. [PMID: 27044252 PMCID: PMC4820920 DOI: 10.1186/s12885-016-2286-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 03/18/2016] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Among patients with rectal cancer, 5-10% have a primary rectal cancer beyond the total mesorectal excision plane (PRC-bTME) and 10% recur locally following primary surgery (LRRC). In both cases, patients 'care remains challenging with a significant worldwide variation in practice regarding overall management and criteria for operative intervention. These variations in practice can be explained by structural and organizational differences, as well as cultural dissimilarities. However, surgical resection of PRC-bTME and LRRC provides the best chance of long-term survival after complete resection (R0). With regards to the organization of the healthcare system and the operative criteria for these patients, France and Australia seem to be highly different. A benchmarking-type analysis between French and Australian clinical practice, with regards to the care and management of PRC-bTME and LRRC, would allow understanding of patients' care and management structures as well as individual and collective mechanisms of operative decision-making in order to ensure equitable practice and improve survival for these patients. METHODS/DESIGN The current study is an international Benchmarking trial comparing two cohorts of 120 consecutive patients with non-metastatic PRC-bTME and LRRC. Patients with curative and palliative treatment intent are included. The study design has three main parts: (1) French and Australian cohorts including clinical, radiological and surgical data, quality of life (MOS SF36, FACT-C) and distress level (Distress thermometer) at the inclusion, 6 and 12 months; (2) experimental analyses consisting of a blinded inter-country reading of pelvic MRI to assess operatory decisions; (3) qualitative analyses based on MDT meeting observation, semi-structured interviews and focus groups of health professional attendees and conducted by a research psychologist in both countries using the same guides. The primary endpoint will be the clinical resection rate. Secondary end points will be concordance rate between French and Australian operative decisions based on the inter-country reading MRI, post-operative mortality and morbidity rates, oncological outcomes based on resection status and one-year overall and disease-free survival, patients' quality of life and distress level. Qualitative analysis will compare obstacles and facilitators of operative decision-making between both countries. DISCUSSION Benchmarking can be defined as a comparison and learning process which will allow, in the context of PRC-bTME and LRRC, to understand and to share the whole process management of these patientsbetween Farnce and Australia. TRIAL REGISTRATION NCT02551471 . (date of registration: 09/14/2015).
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Affiliation(s)
- Quentin Denost
- Department of Digestive Surgery, CHU Bordeaux, Saint André Hospital, Bordeaux, F-33075, France. .,Université Bordeaux Segalen, Bordeaux, F-33076, France. .,Service de Chirurgie Digestive, Hôpital Saint-André, 33075, Bordeaux, France.
| | - Florence Saillour
- Unité Méthodes Evaluation en Santé, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Lindy Masya
- Surgical Outcome Research Centre (SOuRCe), Royal Prince Alfred Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Helene Maillou Martinaud
- Department of Digestive Surgery, CHU Bordeaux, Saint André Hospital, Bordeaux, F-33075, France.,Université Bordeaux Segalen, Bordeaux, F-33076, France
| | - Stephanie Guillon
- Department of Digestive Surgery, CHU Bordeaux, Saint André Hospital, Bordeaux, F-33075, France.,Université Bordeaux Segalen, Bordeaux, F-33076, France
| | - Marion Kret
- Unité de Soutien Méthodologique à la Recherche Clinique et Epidémiologique du CHU de Bordeaux (USMR), Université Bordeaux Segalen, Case 75, 146 rue Léo Saignat, 33076, Bordeaux, France
| | - Eric Rullier
- Department of Digestive Surgery, CHU Bordeaux, Saint André Hospital, Bordeaux, F-33075, France.,Université Bordeaux Segalen, Bordeaux, F-33076, France
| | - Bruno Quintard
- Laboratory of Psychology, Université Victor Segalen Bordeaux 2, Bordeaux, France
| | - Michael Solomon
- Surgical Outcome Research Centre (SOuRCe), Royal Prince Alfred Hospital, University of Sydney, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
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Abstract
BACKGROUND Local recurrence after rectal cancer treatment occurs in ≈5% to 10% of patients. Neoadjuvant (chemo)radiotherapy for primary rectal cancer renders treatment of recurrent disease more difficult. OBJECTIVE The purpose of this study was to review contemporary multimodality therapies, including their outcome, for locally recurrent rectal carcinoma after (chemo)radiotherapy and complete surgical resection of primary rectal cancer. DATA SOURCES A comprehensive literature search of PubMed and EMBASE was performed. STUDY SELECTION All English language articles presenting original patient data regarding treatment and the respective outcome of previously irradiated locally recurrent rectal cancer were included. INTERVENTIONS All of the treatment modalities for locally recurrent rectal cancer were reviewed. MAIN OUTCOME MEASURES Primary outcome parameters were local control, metastasis-free survival, and overall survival. Secondary outcome parameters were perioperative morbidity and mortality, and prognostic factors for treatment outcome. RESULTS Of 854 studies, 9 studies and 474 patients with locally recurrent rectal carcinoma were included. Various treatment regimens were used, most with curative intent. Reirradiation was composed of (neo-)adjuvant external beam radiotherapy (with or without concurrent chemotherapy), additional intraoperative radiotherapy, or intraoperative radiotherapy only. Surgical technique highly varied, depending on the extent of the lesion. Radiation toxicity, perioperative morbidity, and mortality were generally acceptable. Outcome was better after curative intent treatment, any surgical resection, and R0 resections in particular. Moreover, reirradiation is associated with increased complete resection rates, which in turn positively affected local control and overall survival. LIMITATIONS Most studies were retrospectively designed, with highly variable therapies, patient populations, and duration of follow-up. CONCLUSIONS A complete resection is the most important prognostic factor and should be the goal of treatment in locally recurrent rectal carcinoma. Reirradiation seems safe and of additional value in reaching a complete resection. Considering the available evidence, at present reirradiation should be given on a case-specific basis, with all of the patients entering an international prospective database.
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Denost Q, Faucheron J, Lefevre J, Panis Y, Cotte E, Rouanet P, Jafari M, Capdepont M, Rullier E, Pezet, Tuech, Benchimol, Massard, Prudhomme, Gainant, Regimbeau, Chenet, Pautrat, Paineau, Peluchon, Elias, Dumont, Evrard, Beaulieu, Mabrut, Vaudois, Rio, Gouthi, Mauvais, Bresler, Boissel, Tiret, Parc, Glehen, Rohr, Sastre, Paineau, Chenet, Fancois, Singier, Voirin, Risse, Quenet, Joyeux, Saint-Aubert, Khalil. French current management and oncological results of locally recurrent rectal cancer. Eur J Surg Oncol 2015; 41:1645-52. [DOI: 10.1016/j.ejso.2015.09.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 08/26/2015] [Accepted: 09/22/2015] [Indexed: 12/18/2022] Open
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Pubic Bone Excision and Perineal Urethrectomy for Radical Anterior Compartment Excision During Pelvic Exenteration. Dis Colon Rectum 2015; 58:1114-9. [PMID: 26445189 DOI: 10.1097/dcr.0000000000000479] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Malignant infiltration of the pubic bone traditionally is considered inoperable. Consequently, there is little published on surgical approaches to resection of the anterior pelvic bone. En bloc partial or complete pubic bone excision can be performed depending on the degree of involvement. OBJECTIVE This article describes our surgical approach of pelvic exenteration with en bloc composite pubic bone excision. DESIGN The surgical technique describes 2 distinct aspects of the surgery, first, a perineal as opposed to abdominal transection of the urethra, and, second, varying extents of en bloc pubic bone excision. SETTINGS This study was conducted at a tertiary care hospital. MAIN OUTCOME MEASURES Pelvic tumors infiltrating the pubic bone require radical en bloc composite bone resection to achieve an R0 margin that should translate to longer-term survival versus nonoperative treatments. RESULTS Results of our study are currently under review. CONCLUSIONS As the magnitude of pelvic exenteration surgery continues to evolve for all compartments of the pelvis, malignant infiltration of the anterior pelvic bone should not be considered a contraindication to surgery.
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Solomon MJ, Brown KGM, Koh CE, Lee P, Austin KKS, Masya L. Lateral pelvic compartment excision during pelvic exenteration. Br J Surg 2015; 102:1710-7. [PMID: 26694992 DOI: 10.1002/bjs.9915] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 05/05/2015] [Accepted: 07/08/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Involvement of the lateral compartment remains a relative or absolute contraindication to pelvic exenteration in most units. Initial experience with exenteration in the authors' unit produced a 21 per cent clear margin rate (R0), which improved to 53 per cent by adopting a novel technique for en bloc resection of the iliac vessels and other side-wall structures. The objective of this study was to report morbidity and oncological outcomes in consecutive exenterations involving the lateral compartment. METHODS Patients undergoing pelvic exenteration between 1994 and 2014 were eligible for review. RESULTS Two hundred consecutive patients who had en bloc resection of the lateral compartment were included. R0 resection was achieved in 66·5 per cent of 197 patients undergoing surgery for cancer and 68·9 per cent of planned curative resections. For patients with colorectal cancer, a clear resection margin was associated with a significant overall survival benefit (P = 0·030). Median overall and disease-free survival in this group was 41 and 27 months respectively. Overall 1-, 3- and 5-year survival rates were 86, 46 and 35 per cent respectively. No predictors of survival were identified on univariable analysis other than margin status and operative intent. Excision of the common or external iliac vessels or sciatic nerve did not confer a survival disadvantage. CONCLUSION The continuing evolution of radical pelvic exenteration techniques has seen an improvement in R0 margin status from 21 to 66·5 per cent over a 20-year interval by routine adoption of a more lateral anatomical plane. Five-year overall survival rates are comparable with those for more centrally based tumours.
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Affiliation(s)
- M J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, New South Wales, Australia.,Institute of Academic Surgery at Royal Prince Alfred Hospital, Sydney Local Health District, New South Wales, Australia.,Discipline of Surgery, University of Sydney, Sydney, New South Wales, Australia
| | - K G M Brown
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, New South Wales, Australia
| | - C E Koh
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, New South Wales, Australia.,Institute of Academic Surgery at Royal Prince Alfred Hospital, Sydney Local Health District, New South Wales, Australia
| | - P Lee
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, New South Wales, Australia
| | - K K S Austin
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, New South Wales, Australia
| | - L Masya
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, New South Wales, Australia
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