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Fadel MG, Ahmed M, Shaw A, Fehervari M, Kontovounisios C, Brown G. Oncological outcomes of local excision versus radical surgery for early rectal cancer in the context of staging and surveillance: A systematic review and meta-analysis. Cancer Treat Rev 2024; 128:102753. [PMID: 38761791 DOI: 10.1016/j.ctrv.2024.102753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 05/09/2024] [Accepted: 05/11/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Local resection (LR) methods for rectal cancer are generally considered in the palliative setting or for patients deemed a high anaesthetic risk. This systematic review and meta-analysis aimed to compare oncological outcomes of LR and radical resection (RR) for early rectal cancer in the context of staging and surveillance assessment. METHODS A literature search of MEDLINE, Embase and Emcare databases was performed for studies that reported data on clinical outcomes for both LR and RR for early rectal cancer from January 1995 to April 2023. Meta-analysis was performed using random-effect models and between-study heterogeneity was assessed. The quality of assessment was assessed using the Newcastle-Ottawa Scale for observational studies and the Cochrane Risk of Bias 2.0 tool for randomised controlled trials. RESULTS Twenty studies with 12,022 patients were included: 6,476 patients had LR and 5,546 patients underwent RR. RR led to an improvement in 5-year overall survival (OR 1.84; 95 % CI 1.54-2.20; p < 0.0001; I2 20 %) and local recurrence (OR 3.06; 95 % CI 2.02-4.64; p < 0.0001; I2 39 %) when compared to LR. However, when staging and surveillance methods were clearly adopted in LR cases, there was an improvement in R0 rates (96.7 % vs 85.6 %), 5-year disease-free survival (93.0 % vs 77.9 %) and overall survival (81.6 % vs 79.0 %) compared to when staging and surveillance was not reported/performed. CONCLUSIONS LR may be appropriate for selected patients without poor prognostic factors in early rectal cancer. This study also highlights that there is currently no single standardised staging or surveillance approach being adopted in the management of early rectal cancer. A more specified and standardised preoperative staging for patient selection as well as clinical and image-based surveillance protocols is needed.
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Affiliation(s)
- Michael G Fadel
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom; Department of Colorectal and General Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Mosab Ahmed
- Department of Colorectal and General Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Annabel Shaw
- Department of Colorectal and General Surgery, Epsom and St. Helier University Hospitals NHS Trust, London, United Kingdom
| | - Matyas Fehervari
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom; Department of Gastrointestinal Surgery, Maidstone and Tunbridge Wells NHS Trust, Kent, United Kingdom
| | - Christos Kontovounisios
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom; Department of Colorectal and General Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom; Department of Colorectal Surgery, Royal Marsden NHS Foundation Trust, London, United Kingdom; 2nd Surgical Department Evaggelismos Athens General Hospital, Athens, Greece.
| | - Gina Brown
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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Saini S, Nandi S, Arora A, Chhebbi M, Mukherjee C. Revisiting the Trans-Sacral Approach for Large Rectal Adenomas, Surgical Technique, and Oncological Outcome: a Case Series. Indian J Surg Oncol 2024; 15:172-176. [PMID: 38511024 PMCID: PMC10948643 DOI: 10.1007/s13193-023-01855-0] [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: 10/05/2023] [Accepted: 11/24/2023] [Indexed: 03/22/2024] Open
Abstract
The standard oncologic surgeries for rectal carcinoma are radical trans abdominal procedures, However, these radical procedures are not suitable for large rectal adenomas. The transsacral approach for rectal adenoma was first described by Kraske and since then it has been utilized for various benign conditions of low and mid-rectum as well as for certain cancers. We are presenting a series of 5 consecutive cases of trans-sacral resection done in the past 7 years between January, 2016, until June, 2023, at the Department of Surgical Oncology, Cancer Research Institute, HIMS Dehradun, for large mid- and lower rectal adenoma. There were 5 patients who underwent transsacral excision of rectal adenoma. Three patients were male and 2 were female. All the patients underwent surgery after confirming the diagnosis of adenoma and metastatic work up. The postoperative histopathological examination showed adenocarcinoma infiltrating submucosa (T1) in one patient; however, other 4 patients had adenoma reconfirmed. The transsacral approach may not be the method of choice for the rectal carcinoma but it is a very useful surgical alternative to the large rectal adenoma where there is no invasive component and which cannot be managed by any other methods.
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Affiliation(s)
- Sunil Saini
- Department of Surgical Oncology, Himalayan Institute of Medical Sciences, Dehradun, India
| | - Sourabh Nandi
- Department of Surgical Oncology, Himalayan Institute of Medical Sciences, Dehradun, India
| | - Anshika Arora
- Department of Surgical Oncology, Himalayan Institute of Medical Sciences, Dehradun, India
| | - Madiwalesh Chhebbi
- Department of Surgical Oncology, Himalayan Institute of Medical Sciences, Dehradun, India
| | - Chiranjit Mukherjee
- Department of Surgical Oncology, Himalayan Institute of Medical Sciences, Dehradun, India
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Hochberger J, Loss M, Kruse E. [Endoscopic Resection Techniques for Precancerous and Early Cancerous Lesions in the Rectum]. Zentralbl Chir 2024; 149:46-55. [PMID: 38442883 PMCID: PMC10914494 DOI: 10.1055/a-2256-6724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/23/2024] [Indexed: 03/07/2024]
Abstract
Today, endoscopy plays a decisive role not only in the detection of colorectal adenomas and carcinomas, but also in the treatment of precancerous lesions, in particular flat adenomas and early carcinomas. In recent years, endoscopic submucosal dissection (ESD) has become increasingly important alongside classic polypectomy and mucosal resection after saline injection using a snare (EMR). Using ESD the lesion is marked, injected submucosally using viscous substances and the mucosa incised and tunneled with a transparent cap and a fine diathermy knife. Particularly in the case of widespread and high-risk lesions ESD enables a quasi-surgical "en bloc" resection almost regardless of size, with a histological R0 resection rate of far over 90% in specialized centers. ESD enables an excellent histopathological evaluation and has a low recurrence risk of 1-3%. Endoscopic full-thickness resection using a dedicated device (FTRD system) represents another addition to the armamentarium. It can be used for circumscribed submucosal, suspicious or scarred changes up to 2 cm in the middle and upper rectum. Endoscopic intermuscular dissection (EID) enables histopathological analysis of the complete submucosa beyond the mucosa and upper submucosal layer by including the circular inner muscle layer within the resection specimen. It reduces basal R1 situations and offers a new perspective for T1 carcinomas through curative, organ-preserving endoscopic therapy, especially in the case of deep submucosal infiltration alone, without other risk factors for metastases. Indications, the procedure itself and significance of the various techniques for premalignant and early malignant lesions in the rectum are presented.
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Affiliation(s)
- Jürgen Hochberger
- Klinikum Friedrichshain, Abteilung für Gastroenterologie, Interdisziplinäres Darmkrebszentrum, Vivantes Netzwerk für Gesundheit GmbH, Berlin, Deutschland
- Lehrkrankenhaus Vivantes Friedrichshain, Gastroenterologie, Charité Universitätsmedizin Berlin, Berlin, Deutschland
- Med. Klinik I - Gastroenterologie, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Deutschland
| | - Martin Loss
- Abteilung für Allgemein- und Viszeralchirurgie, Interdisziplinäres Darmkrebszentrum, Vivantes Klinikum im Friedrichshain, Berlin, Deutschland
| | - Elena Kruse
- Westklinikum Hamburg Suurheid, Abteilung für Gastroenterologie und Hepatologie, Asklepios Kliniken Hamburg GmbH, Hamburg, Deutschland
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Maeda K, Koide Y, Katsuno H, Tajima Y, Hanai T, Masumori K, Matsuoka H, Shiota M. Long-term results of minimally invasive transanal surgery for rectal tumors in 249 consecutive patients. Surg Today 2023; 53:306-315. [PMID: 35962290 PMCID: PMC9950212 DOI: 10.1007/s00595-022-02570-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 06/27/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE To delineate the long-term results of minimally invasive transanal surgery (MITAS) for selected rectal tumors. METHODS We analyzed data, retrospectively, on consecutive patients who underwent MITAS between 1995 and 2015, to establish the feasibility, excision quality, and perioperative and oncological outcomes of this procedure. RESULTS MITAS was performed on 243 patients. The final histology included 142 cancers, 47 adenomas, and 52 neuroendocrine tumors (NET G1). A positive margin of 1.6% and 100% en bloc resection were achieved. The mean operative time was 27.4 min. Postoperative morbidity occurred in 7% of patients, with 0% mortality. The median follow-up was 100 months (up to ≥ 5 years or until death in 91.8% of patients). Recurrence developed in 2.9% of the patients. The 10-year overall survival rate was 100% for patients with NET G1 and 80.3% for those with cancer. The 5-year DFS was 100% for patients with Tis cancer, 90.6% for those with T1 cancer, and 87.5% for those with T2 or deeper cancers. MITAS for rectal tumors ≥ 3 cm resulted in perioperative and oncologic outcomes equivalent to those for tumors < 3 cm. CONCLUSION MITAS is feasible for the local excision (LE) of selected rectal tumors, including tumors ≥ 3 cm. It reduces operative time and secures excision quality and long-term oncological outcomes.
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Affiliation(s)
- Kotaro Maeda
- Department of Surgery, Medical Corporation Kenikukai Shonan Keiiku Hospital, 4360 Endo, Fujisawa, Kanagawa 252-0816 Japan
| | - Yoshikazu Koide
- Department of Surgery, Fujita Health University Hospital, Toyoake, 470-1192 Japan
| | - Hidetoshi Katsuno
- Department of Surgery, Fujita Health University Okazaki Medical Center, Okazaki, 444-0827 Japan
| | - Yosuke Tajima
- Department of Surgery, Fujita Health University Hospital, Toyoake, 470-1192 Japan
| | - Tsunekazu Hanai
- Department of Surgery, Fujita Health University Hospital, Toyoake, 470-1192 Japan
| | - Koji Masumori
- Department of Surgery, Fujita Health University Hospital, Toyoake, 470-1192 Japan
| | - Hiroshi Matsuoka
- Department of Surgery, Fujita Health University Hospital, Toyoake, 470-1192 Japan
| | - Miho Shiota
- Department of Surgery, Kaisei Hospital, Sakaide, 657-0068 Japan
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Khalid A, Aloul Z, Chouhan H. Radical vs. Local Excision in Rectal Carcinoma T1N0M0: Recurrence and Mortality Rates. Cureus 2022; 14:e25433. [PMID: 35663694 PMCID: PMC9154048 DOI: 10.7759/cureus.25433] [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] [Accepted: 05/28/2022] [Indexed: 11/21/2022] Open
Abstract
Local transanal excision of early rectal carcinoma is an appealing treatment because of its low morbidity rates and better functional results than radical resection. However, this treatment approach is controversial due to its association with local recurrence when compared to the latter. This review aims to compare the local recurrence and mortality rates of local vs. radical excision in patients with T1N0M0 rectal carcinoma, based on data in the literature in the last 20 years. A PubMed, Cochrane, and Google Scholar search of published literature in the last 20 years was performed. A total of 12 studies were identified. Three were prospective, one was a population-based propensity matching study, one was a nationwide cohort study, one was a meta-analysis, and the remaining studies were retrospective/observational. The mean local recurrence rate within five years from the studies selected for local excision (LE: 12.8%) was nearly double that of radical excision (RAD: 5.0%). The five-year mean survival rate for both LE and RAD groups from the studies selected was 86%, which was equal for both groups. The main predictors of poor outcomes were older age and the presence of two or more comorbid conditions. There is a consensus amongst studies that LE is associated with inferior oncological outcomes such as postoperative complications and recurrence when compared to RAD. The higher local recurrence rates in LE are attributed to occult lymph node disease and inadequate adjunctive therapy due to suboptimal staging. There is no difference in the five-year survival rate when compared to RAD. A longer follow-up period is needed to determine whether the survival rates diverge after five years.
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Affiliation(s)
- Aisha Khalid
- Research, Harvard Medical School, Boston, USA
- Cardiothoracic Surgery, The Alfred, Melbourne, AUS
| | - Zaina Aloul
- General Surgery, Cardiff University, Wales, GBR
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Hudson EM, Noutch S, Brown S, Adapala R, Bach SP, Burnett C, Burrage A, Gilbert A, Hawkins M, Howard D, Jefford M, Kochhar R, Saunders M, Seligmann J, Smith A, Teo M, Webb EJ, Webster A, West N, Sebag-Montefiore D, Gollins S, Appelt AL. A Phase II trial of Higher RadiOtherapy Dose In The Eradication of early rectal cancer (APHRODITE): protocol for a multicentre, open-label randomised controlled trial. BMJ Open 2022; 12:e049119. [PMID: 35487526 PMCID: PMC9052059 DOI: 10.1136/bmjopen-2021-049119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 02/18/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The standard of care for patients with localised rectal cancer is radical surgery, often combined with preoperative neoadjuvant (chemo)radiotherapy. While oncologically effective, this treatment strategy is associated with operative mortality risks, significant morbidity and stoma formation. An alternative approach is chemoradiotherapy to try to achieve a sustained clinical complete response (cCR). This non-surgical management can be attractive, particularly for patients at high risk of surgical complications. Modern radiotherapy techniques allow increased treatment conformality, enabling increased radiation dose to the tumour while reducing dose to normal tissue. The objective of this trial is to assess if radiotherapy dose escalation increases the cCR rate, with acceptable toxicity, for treatment of patients with early rectal cancer unsuitable for radical surgery. METHODS AND ANALYSIS APHRODITE (A Phase II trial of Higher RadiOtherapy Dose In The Eradication of early rectal cancer) is a multicentre, open-label randomised controlled phase II trial aiming to recruit 104 participants from 10 to 12 UK sites. Participants will be allocated with a 2:1 ratio of intervention:control. The intervention is escalated dose radiotherapy (62 Gy to primary tumour, 50.4 Gy to surrounding mesorectum in 28 fractions) using simultaneous integrated boost. The control arm will receive 50.4 Gy to the primary tumour and surrounding mesorectum. Both arms will use intensity-modulated radiotherapy and daily image guidance, combined with concurrent chemotherapy (capecitabine, 5-fluorouracil/leucovorin or omitted). The primary endpoint is the proportion of participants with cCR at 6 months after start of treatment. Secondary outcomes include early and late toxicities, time to stoma formation, overall survival and patient-reported outcomes (European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaires QLQ-C30 and QLQ-CR29, low anterior resection syndrome (LARS) questionnaire). ETHICS AND DISSEMINATION The trial obtained ethical approval from North West Greater Manchester East Research Ethics Committee (reference number 19/NW/0565) and is funded by Yorkshire Cancer Research. The final trial results will be published in peer-reviewed journals and adhere to International Committee of Medical Journal Editors guidelines. TRIAL REGISTRATION NUMBER ISRCTN16158514.
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Affiliation(s)
- Eleanor M Hudson
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Samantha Noutch
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Sarah Brown
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Ravi Adapala
- Department of Radiology, Wrexham Maelor Hospital, Wrexham, UK
| | - Simon P Bach
- Academic Department of Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Carole Burnett
- Leeds Cancer Centre, St James's University Hospital, Leeds, UK
| | | | - Alexandra Gilbert
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - Maria Hawkins
- Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Debra Howard
- National Radiotherapy Trials QA (RTTQA) Group, Mount Vernon Cancer Centre, Northwood, UK
| | | | - Rohit Kochhar
- Department of Radiology, The Christie NHS Foundation Trust, Manchester, UK
| | - Mark Saunders
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Jenny Seligmann
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - Alexandra Smith
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Mark Teo
- Leeds Cancer Centre, St James's University Hospital, Leeds, UK
| | - Edward Jd Webb
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Amanda Webster
- National Radiotherapy Trials QA (RTTQA) Group, Mount Vernon Cancer Centre, Northwood, UK
| | - Nicholas West
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | | | - Simon Gollins
- North Wales Cancer Treatment Centre, Glan Clwyd Hospital, Bodelwyddan, UK
| | - Ane L Appelt
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
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Kim S, Huh JW, Lee WY, Yun SH, Kim HC, Cho YB, Park YA, Shin JK. Can CCRT/RT Achieve Favorable Oncologic Outcome in Rectal Cancer Patients With High Risk Feature After Local Excision? Front Oncol 2022; 12:767838. [PMID: 35402222 PMCID: PMC8986033 DOI: 10.3389/fonc.2022.767838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 02/18/2022] [Indexed: 12/08/2022] Open
Abstract
PurposeThe oncologic outcome of concurrent chemoradiotherapy (CCRT) after local excision in patients with high-risk early rectal cancer as compared with radical operation has not been reported. The aim of this study is to compare the oncologic outcome between radical operation and adjuvant CCRT after local excision for high-risk early rectal cancer.Materials and MethodsFrom January 2005 to December 2015, 266 patients diagnosed with early rectal cancer and treated with local excision who showed high-risk characteristics were retrospectively analyzed. Propensity score matching was applied in a ratio of 1:4, comparing the CCRT/radiotherapy (RT) (n = 34) and radical operation (n = 91) groups. Univariate and multivariate analyses were performed to identify prognostic factors for survival.ResultsThe median follow-up period was 112 months. The 5-year disease-free survival rate and the 5-year overall survival of the radical operation group were significantly higher than those of the CCRT/RT group after propensity score matching (96.7% vs. 70.6%, p <0.001; 100% vs. 91.2%, p = 0.005, respectively). In a multivariate analysis, salvage therapy type and preoperative carcinoembryonic antigen (CEA) were prognostic factors for 5-year disease-free survival (p <0.001 and p = 0.021, respectively). The type of salvage therapy, the preoperative CEA, and the pT were prognostic factors for 5-year overall survival (p = 0.009, p = 0.024, and p = 0.046, respectively).ConclusionsPatients who undergo radical operations after local excision with a high-risk early rectal cancer had better survival than those treated with adjuvant CCRT/RT. Therefore, radical surgery may be recommended to high-risk early rectal cancer patients who have undergone local excision for more favorable oncologic outcomes.
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Verseveld M, Verver D, Noordman BJ, Pouwels S, Elferink MAG, de Graaf EJR, Verhoef C, Doornebosch PG, de Wilt JHW. Treatment of clinical T1 rectal cancer in the Netherlands; a population-based overview of clinical practice. Eur J Surg Oncol 2021; 48:1153-1160. [PMID: 34799230 DOI: 10.1016/j.ejso.2021.11.002] [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: 05/31/2021] [Revised: 10/22/2021] [Accepted: 11/01/2021] [Indexed: 10/19/2022] Open
Abstract
INTRODUCTION Local excision is increasingly used as an alternative treatment for radical surgery in patients with early stage clinical T1 (cT1) rectal cancer. This study provides an overview of incidence, staging accuracy and treatment strategies in patients with cT1 rectal cancer in the Netherlands. MATERIALS AND METHODS Patients with cT1 rectal cancer diagnosed between 2005 and 2018 were included from the Netherlands Cancer Registry. An overview per time period (2005-2009, 2010-2014 and 2015-2018) of the incidence and various treatment strategies used, e.g. local excision (LE) or major resection, with/without neoadjuvant treatment (NAT), were given and trends over time were analysed using the Chi Square for Trend test. In addition, accuracy of tumour staging was described, compared and analysed over time. RESULTS In total, 3033 patients with cT1 rectal cancer were diagnosed. The incidence of cT1 increased from 540 patients in 2005-2009 to 1643 patients in 2015-2018. There was a significant increased use of LE. In cT1N0/X patients, 9.2% received NAT, 25.5% were treated by total mesorectal excision (TME) and 11.4% received a completion TME (cTME) following prior LE. Overall accuracy in tumour staging (cT1 = pT1) was 77.3%, yet significantly worse in cN1/2 patients, as compared to cN0 patients (44.8% vs 77.9%, respectively, p < 0.001). CONCLUSION Over time, there was an increase in the incidence of cT1 tumours. Both the use of neoadjuvant therapy and TME surgery in clinically node negative patients decreased significantly. Clinical accuracy in T1 tumour staging improved over time, but remained significantly worse in clinical node positive patients.
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Affiliation(s)
- M Verseveld
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, Schiedam, the Netherlands; Department of Surgery, division of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands.
| | - D Verver
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, Schiedam, the Netherlands
| | - B J Noordman
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, Schiedam, the Netherlands; Department of Surgery, division of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - S Pouwels
- Department of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, the Netherlands
| | - M A G Elferink
- Department of Research & Development, Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands
| | - E J R de Graaf
- Department of Surgery, IJsselland Hospital, Capelle aan den IJssel, the Netherlands
| | - C Verhoef
- Department of Surgery, division of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - P G Doornebosch
- Department of Surgery, IJsselland Hospital, Capelle aan den IJssel, the Netherlands
| | - J H W de Wilt
- Department of Surgery, division of Surgical Oncology, Radboud University Medical Centre, Nijmegen, the Netherlands
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Kim MJ, Lee TG. Transanal minimally invasive surgery using laparoscopic instruments of the rectum: A review. World J Gastrointest Surg 2021; 13:1149-1165. [PMID: 34754384 PMCID: PMC8554714 DOI: 10.4240/wjgs.v13.i10.1149] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 07/18/2021] [Accepted: 09/16/2021] [Indexed: 02/06/2023] Open
Abstract
Transanal minimally invasive surgery (TAMIS) was first described in 2010 as an alternative to transanal endoscopic microsurgery (TEM). The TAMIS technique can be access to the proximal and mid-rectum for resection of benign and early-stage malignant rectal lesions and also used for noncurative intent surgery of more advanced lesions in patients who are not candidates for radical surgery. TAMIS has a shorter learning curve, reduced device setup time, flexibility in instrument use, and versatility in application than TEM. Also, TAMIS shows similar results in a view of the operation time, conversion rate, reoperation rate, and complication to TEM. For these reasons, TAMIS is an easily accessible, technically feasible, and cost-effective alternative to TEM. Overall, TAMIS has enabled the performance of high-quality local excision of rectal lesions by many colorectal surgeons. As TAMIS becomes more broadly utilized such as pelvic abscess drainage, rectal stenosis, and treatment of anastomotic dehiscence, the acquisition of appropriate training must be ensured, and the continued assessment and assurance of outcome must be maintained.
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Affiliation(s)
- Myung Jo Kim
- Department of Surgery, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju 28644, South Korea
| | - Taek-Gu Lee
- Department of Surgery, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju 28644, South Korea
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Westrich G, Mykoniatis I, Stefan S, Siddiqi N, Ahmed Y, Cross M, Nissan A, Khan JS. Robotic surgery for colorectal cancer in the Octogenarians. Int J Med Robot 2021; 17:e2268. [PMID: 33928752 DOI: 10.1002/rcs.2268] [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: 02/20/2021] [Revised: 04/03/2021] [Accepted: 04/21/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND We evaluated the short-term outcomes of robotic colorectal cancer surgery in octogenarian patients, focussing on postoperative morbidity and survival. METHODS All patients ≥80 years in a prospective colorectal cancer database undergoing robotic curative colorectal cancer resection were included. Patient demographics, intraoperative findings, postoperative and oncological outcomes were recorded. Patients were further subdivided into two groups named: old (OG 80-85 years) and very old (VOG ≥ 86 years). RESULTS Fifty-eight consecutive patients were included (median age, 83 years; male, 53.4%; median BMI, 26.5). Median total operative time was 230 min, median blood loss 20 ml, median length of stay 7 days. Major complications were seen in 12% of patients; and the 90-day mortality rate was 1.7%. Complete R0 resection achieved in 93% of cases, average lymph node harvest was 22. Overall and disease-free survival was 81% and 87.3%, respectively (median follow-up 24.5 months). We noticed a trend towards more advanced lesion staging in the VOG, but only N2 stage was significant (p = 0.03). There was a statistically significant difference in overall survival in favour of the OG (p = 0.024). CONCLUSIONS Robotic surgery is feasible in octogenarian patients undergoing curative colorectal cancer resection and is associated with good post-operative outcomes and overall survival.
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Affiliation(s)
- Gal Westrich
- Colorectal Surgery, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK.,Department of General and Oncological Surgery - Surgery C, Sheba Medical Center, Ramat Gan, Israel
| | - Ioannis Mykoniatis
- Colorectal Surgery, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Samuel Stefan
- Colorectal Surgery, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Najaf Siddiqi
- Colorectal Surgery, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK.,School of Health and Care Professions, University of Portsmouth, Portsmouth, UK
| | - Yousra Ahmed
- Colorectal Surgery, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Matthew Cross
- Colorectal Surgery, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Aviram Nissan
- Department of General and Oncological Surgery - Surgery C, Sheba Medical Center, Ramat Gan, Israel
| | - Jim S Khan
- Colorectal Surgery, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK.,School of Health and Care Professions, University of Portsmouth, Portsmouth, UK
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Fields AC, Lu P, Hu F, Hirji S, Irani J, Bleday R, Melnitchouk N, Goldberg JE. Lymph Node Positivity in T1/T2 Rectal Cancer: a Word of Caution in an Era of Increased Incidence and Changing Biology for Rectal Cancer. J Gastrointest Surg 2021; 25:1029-1035. [PMID: 32246393 DOI: 10.1007/s11605-020-04580-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 03/23/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND The evaluation of lymph nodes in rectal cancer dictates treatment. The goals of this study are to characterize the contemporary rate of lymph node metastasis in early stage rectal cancer and to re-investigate histologic factors that predict positive lymph nodes. MATERIALS AND METHODS Using the National Cancer Database, we identified patients with clinical stage I rectal adenocarcinoma. Multivariable logistic regression was used to determine risk factors for lymph node positivity. RESULTS 12.2% of patients with T1 tumors and 18.0% of patients with T2 tumors had positive lymph nodes. For T1 tumors, positive lymph nodes were present in 9.3% with neither poor differentiation nor lymphovascular invasion (LVI), 17.3% with poor differentiation alone, 34.7% with LVI alone, and 45.0% with both poor differentiation and LVI. For T2 tumors, positive lymph nodes were present in 11.7% with neither poor differentiation nor LVI, 25.3% with poor differentiation alone, 47.3% with LVI alone, and 41.5% with both poor differentiation and LVI. LVI was an independent predictor of positive lymph nodes (OR;4.75,95%CI;3.17-7.11,p < 0.001) for T1 and (OR;6.20,95%CI;4.53-8.51,p < 0.001) T2 tumors. CONCLUSIONS T1/T2 tumors have higher rates of positive lymph nodes when poor differentiation and LVI are present. These results should be taken into consideration prior to surgical treatment.
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Affiliation(s)
- Adam C Fields
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
| | - Pamela Lu
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Frances Hu
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Sameer Hirji
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Jennifer Irani
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Ronald Bleday
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Nelya Melnitchouk
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Joel E Goldberg
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
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12
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Keller DS, de Lacy FB, Hompes R. Education and Training in Transanal Endoscopic Surgery and Transanal Total Mesorectal Excision. Clin Colon Rectal Surg 2021; 34:163-171. [PMID: 33814998 DOI: 10.1055/s-0040-1718682] [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] [Indexed: 01/03/2023]
Abstract
There is a paradigm shift in surgical training, and new tool and technology are being used to facilitate mastery of the content and technical skills. The transanal procedures for rectal cancer-transanal endoscopic surgery (TES) and transanal total mesorectal excision (TaTME)-have a distinct learning curve for competence in the procedures, and require special training for familiarity with the "bottom-up" anatomy, procedural risks, and managing complex cases. These procedures have been models for structured education and training, using multimodal tools, to ensure safe implementation of TES and TaTME into clinical practice. The goal of this work was to review the current state of surgical education, the introduction and learning curve of the TES and TaTME procedures, and the established and future models for education of the transanal procedures for rectal cancer.
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Affiliation(s)
- Deborah S Keller
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - F Borja de Lacy
- Department of Gastrointestinal Surgery, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Roel Hompes
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherland
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13
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Mathew R. Radical surgery versus organ preservation for early-stage rectal cancer. Lancet Gastroenterol Hepatol 2021; 6:263. [PMID: 33714365 DOI: 10.1016/s2468-1253(21)00015-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/07/2021] [Accepted: 01/07/2021] [Indexed: 12/30/2022]
Affiliation(s)
- Ronnie Mathew
- Department of Colorectal Surgery, Singapore General Hospital, Singapore 169856.
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14
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Aguirre-Allende I, Enriquez-Navascues JM, Elorza-Echaniz G, Etxart-Lopetegui A, Borda-Arrizabalaga N, Saralegui Ansorena Y, Placer-Galan C. Early-rectal Cancer Treatment: A Decision-tree Making Based on Systematic Review and Meta-analysis. Cir Esp 2020; 99:89-107. [PMID: 32993858 DOI: 10.1016/j.ciresp.2020.05.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 05/27/2020] [Accepted: 05/30/2020] [Indexed: 02/07/2023]
Abstract
Local excision (LE) has arisen as an alternative to total mesorectal excision for the treatment of early rectal cancer. Despite a decreased morbidity, there are still concerns about LE outcomes. This systematic-review and meta-analysis design is based on the "PICO" process, aiming to answer to three questions related to LE as primary treatment for early-rectal cancer, the optimal method for LE, and the potential role for completion treatment in high-risk histology tumors and outcomes of salvage surgery. The results revealed that reported overall survival (OS) and disease-specific survival (DSS) were 71%-91.7% and 80%-94% for LE, in contrast to 92.3%-94.3% and 94.4%-97% for radical surgery. Additional analysis of National Database studies revealed lower OS with LE (HR: 1.26; 95%CI, 1.09-1.45) and DSS (HR: 1.19; 95%CI, 1.01-1.41) after LE. Furthermore, patients receiving LE were significantly more prone develop local recurrence (RR: 3.44, 95%CI, 2.50-4.74). Analysis of available transanal surgical platforms was performed, finding no significant differences among them but reduced local recurrence compared to traditional transanal LE (OR:0.24;95%CI, 0.15-0.4). Finally, we found poor survival outcomes for patients undergoing salvage surgery, favoring completion treatment (chemoradiotherapy or surgery) when high-risk histology is present. In conclusion, LE could be considered adequate provided a full-thickness specimen can be achieved that the patient is informed about risk for potential requirement of completion treatment. Early-rectal cancer cases should be discussed in a multidisciplinary team, and patient's preferences must be considered in the decision-making process.
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Affiliation(s)
- Ignacio Aguirre-Allende
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain.
| | - Jose Maria Enriquez-Navascues
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain
| | - Garazi Elorza-Echaniz
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain
| | - Ane Etxart-Lopetegui
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain
| | - Nerea Borda-Arrizabalaga
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain
| | - Yolanda Saralegui Ansorena
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain
| | - Carlos Placer-Galan
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain
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15
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O'Connell E, Galvin R, McNamara DA, Burke JP. The utility of preoperative radiological evaluation of early rectal neoplasia: a systematic review and meta-analysis. Colorectal Dis 2020; 22:1076-1084. [PMID: 32052545 DOI: 10.1111/codi.15015] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 02/05/2020] [Indexed: 12/12/2022]
Abstract
AIM The diagnostic role for preoperative imaging of clinically benign rectal adenomas is unclear. The objective of this systematic review and meta-analysis was to examine the diagnostic accuracy of preoperative imaging in distinguishing benign adenomas from rectal cancer. METHOD A systematic search was performed for all studies published that correlated staging of clinically benign rectal adenomas with endorectal ultrasound (ERUS) or MRI and histology. Imaging was compared with postoperative histology and data on the numbers of true positives, false positives, true negatives and false negatives were extracted. Summary estimates of sensitivity and specificity with 95% CIs were calculated using a bivariate random effects model. The QUADAS2 tool was used to determine the methodological quality of included studies. RESULTS Eleven studies describing 1511 patients were retrieved. A total of 1134 patients underwent local excision and 377 had a formal proctectomy. A benign rectal adenoma was diagnosed in 840 and 214 had a T1 rectal cancer. For confirming benign adenomas, the pooled sensitivity of ERUS was 0.81 (95% CI 0.69-0.89) and specificity was 0.85 (95% CI 0.68-0.93). For detecting occult T1 tumours, the pooled sensitivity of ERUS was 0.50 (95% CI 0.33-0.66) and specificity was 0.89 (95% CI 0.82-0.94). Quantitative analysis of MRI could not be performed due to insufficient studies. CONCLUSION This study demonstrates the limited accuracy of preoperative ERUS in distinguishing benign adenomas from T1 rectal cancer. Preoperative imaging must be interpreted with caution to prevent over-staging and unnecessary proctectomy. We propose that clinically benign lesions may undergo local excision, with subsequent management based on final histology.
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Affiliation(s)
- E O'Connell
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland
| | - R Galvin
- School of Allied Health, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - D A McNamara
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland.,Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - J P Burke
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland.,Royal College of Surgeons in Ireland, Dublin 2, Ireland
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16
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Carmichael H, Sylla P. Evolution of Transanal Total Mesorectal Excision. Clin Colon Rectal Surg 2020; 33:113-127. [PMID: 32351334 PMCID: PMC7188508 DOI: 10.1055/s-0039-3402773] [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: 10/24/2022]
Abstract
Minimally invasive techniques continue to transform the field of colorectal surgery. Because traditional surgical approaches for rectal cancer are associated with significant mortality and morbidity, developing less invasive approaches to this disease is paramount. Natural orifice transluminal endoscopic surgery (NOTES), commonly known as "no incision surgery," represents the ultimate minimally invasive approach to disease. Although transgastric and transvaginal approaches for NOTES surgery were the initially explored, a transrectal approach for colorectal disease is intuitive given that it makes use of the resected organ for transluminal access. Furthermore, the transanal approach allows for improved, precise visualization of the presacral mesorectal plane compared with an abdominal viewpoint, particularly in the narrow, male pelvis. Finally, experience with existing transanal platforms that have been used for decades for local excision of rectal disease made the development of a transanal approach to total mesorectal excision (TME) feasible. Here, we will review the evolution of minimally invasive and transanal surgical techniques that allowed for the development of transanal TME and its introduction into clinical practice.
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Affiliation(s)
- Heather Carmichael
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Patricia Sylla
- Icahn School Medicine at Mount Sinai, New York, New York
- Division of Colon and Rectal Surgery, Department of Surgery, Mount Sinai Hospital, New York, New York
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17
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Peters FP, Teo MT, Appelt AL, Bach S, Baatrup G, de Wilt JH, Jensenius Kronborg C, Garm Spindler KL, Marijnen CA, Sebag-Montefiore D. Mesorectal radiotherapy for early stage rectal cancer: A novel target volume. Clin Transl Radiat Oncol 2020; 21:104-111. [PMID: 32099912 PMCID: PMC7031087 DOI: 10.1016/j.ctro.2020.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 02/02/2020] [Indexed: 02/07/2023] Open
Abstract
With the introduction of population-based bowel cancer screening, rectal cancer is diagnosed at earlier stages, yet standard treatment still requires the same extensive surgery that is used for more advanced stages. Organ preserving treatment is rapidly developing and is subject of investigation in numerous clinical trials. The STAR-TREC trial is an international, multi-centre randomised trial investigating organ preservation using (chemo)radiotherapy. Patients with small mrT1-3bN0V0M0 tumours are randomized between three arms: standard TME, organ preservation with SCRT or with CRT. In this trial, the clinical target volume has been tailored to the early staged disease of the included patients. This mesorectal irradiation volume includes the mesorectum and pre-sacral lymph nodes at the level of the tumour, two centimetres below and cranially up to the S2-3 interspace level. In contrast to conventional irradiation volumes, the lateral lymph nodes and the nodes along the superior rectal artery are excluded. As a result, the dose to the bowel, bladder, anal sphincter and the neurovascular plexus in the lower pelvis is substantially decreased, especially when combined with modern irradiation techniques, such as dynamic arc therapy. These lower doses are expected to lead to decreasing acute and late toxicity and beneficial functional outcomes. The implementation of this novel target volume will be accompanied by an extensive quality assurance program in the STAR-TREC trial. We describe the rationale behind the novel, mesorectal only radiotherapy treatment used in the STAR-TREC trial specifically tailored for early stage disease, with the goal of organ preservation.
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Affiliation(s)
- Femke P. Peters
- Department of Radiotherapy, Leiden University Medical Center, Postbus 9600, 2300 RC Leiden, the Netherlands
| | - Mark T.W. Teo
- Leeds Cancer Centre, St James’s University Hospital, Beckett Street, Leeds LS9 7TF, UK
| | - Ane L. Appelt
- Leeds Institute of Medical Research at St James’s, University of Leeds and Leeds Cancer Centre, St James’s University Hospital, Beckett Street, Leeds LS9 7TF, UK
| | - Simon Bach
- Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2GW, UK
| | - Gunnar Baatrup
- Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense C, Denmark
| | - Johannes H.W. de Wilt
- Radboud University Nijmegen Medical Centre, Postbus 9101, 6500 HB Nijmegen, the Netherlands
| | - Camilla Jensenius Kronborg
- Department of Oncology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200 Aarhus N, Denmark
| | - Karen-Lise Garm Spindler
- Department of Oncology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200 Aarhus N, Denmark
| | - Corrie A.M. Marijnen
- Department of Radiotherapy, Leiden University Medical Center, Postbus 9600, 2300 RC Leiden, the Netherlands
| | - David Sebag-Montefiore
- Leeds Institute of Medical Research at St James’s, University of Leeds and Leeds Cancer Centre, St James’s University Hospital, Beckett Street, Leeds LS9 7TF, UK
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18
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The risk of distant metastases in rectal cancer managed by a watch-and-wait strategy – A systematic review and meta-analysis. Radiother Oncol 2020; 144:1-6. [DOI: 10.1016/j.radonc.2019.10.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 10/12/2019] [Accepted: 10/15/2019] [Indexed: 12/18/2022]
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19
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van den Ende RPJ, Peters FP, Harderwijk E, Rütten H, Bouwmans L, Berbee M, Canters RAM, Stoian G, Compagner K, Rozema T, de Smet M, Intven MPW, Tijssen RHN, Theuws J, van Haaren P, van Triest B, Eekhout D, Marijnen CAM, van der Heide UA, Kerkhof EM. Radiotherapy quality assurance for mesorectum treatment planning within the multi-center phase II STAR-TReC trial: Dutch results. Radiat Oncol 2020; 15:41. [PMID: 32070386 PMCID: PMC7027245 DOI: 10.1186/s13014-020-01487-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 02/10/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The STAR-TReC trial is an international multi-center, randomized, phase II study assessing the feasibility of short-course radiotherapy or long-course chemoradiotherapy as an alternative to total mesorectal excision surgery. A new target volume is used for both (chemo)radiotherapy arms which includes only the mesorectum. The treatment planning QA revealed substantial variation in dose to organs at risk (OAR) between centers. Therefore, the aim of this study was to determine the treatment plan variability in terms of dose to OAR and assess the effect of a national study group meeting on the quality and variability of treatment plans for mesorectum-only planning for rectal cancer. METHODS Eight centers produced 25 × 2 Gy treatment plans for five cases. The OAR were the bowel cavity, bladder and femoral heads. A study group meeting for the participating centers was organized to discuss the planning results. At the meeting, the values of the treatment plan DVH parameters were distributed among centers so that results could be compared. Subsequently, the centers were invited to perform replanning if they considered this to be necessary. RESULTS All treatment plans, both initial planning and replanning, fulfilled the target constraints. Dose to OAR varied considerably for the initial planning, especially for dose levels below 20 Gy, indicating that there was room for trade-offs between the defined OAR. Five centers performed replanning for all cases. One center did not perform replanning at all and two centers performed replanning on two and three cases, respectively. On average, replanning reduced the bowel cavity V20Gy by 12.6%, bowel cavity V10Gy by 22.0%, bladder V35Gy by 14.7% and bladder V10Gy by 10.8%. In 26/30 replanned cases the V10Gy of both the bowel cavity and bladder was lower, indicating an overall lower dose to these OAR instead of a different trade-off. In addition, the bowel cavity V10Gy and V20Gy showed more similarity between centers. CONCLUSIONS Dose to OAR varied considerably between centers, especially for dose levels below 20 Gy. The study group meeting and the distribution of the initial planning results among centers resulted in lower dose to the defined OAR and reduced variability between centers after replanning. TRIAL REGISTRATION The STAR-TReC trial, ClinicalTrials.gov Identifier: NCT02945566. Registered 26 October 2016, https://clinicaltrials.gov/ct2/show/NCT02945566).
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Affiliation(s)
- Roy P. J. van den Ende
- Department of Radiation Oncology, Leiden University Medical Center, P.O. Box 9600 2300, RC, Leiden, the Netherlands
| | - Femke P. Peters
- Department of Radiation Oncology, Leiden University Medical Center, P.O. Box 9600 2300, RC, Leiden, the Netherlands
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Ernst Harderwijk
- Department of Radiation Oncology, Leiden University Medical Center, P.O. Box 9600 2300, RC, Leiden, the Netherlands
| | - Heidi Rütten
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Liza Bouwmans
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Maaike Berbee
- Department of Radiation Oncology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Richard A. M. Canters
- Department of Radiation Oncology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Georgiana Stoian
- Department of Radiation Oncology, Isala Clinics, Zwolle, the Netherlands
| | - Kim Compagner
- Department of Radiation Oncology, Isala Clinics, Zwolle, the Netherlands
| | - Tom Rozema
- Department of Radiation Oncology, Verbeeten Institute, Tilburg, the Netherlands
| | - Mariska de Smet
- Department of Radiation Oncology, Verbeeten Institute, Tilburg, the Netherlands
| | - Martijn P. W. Intven
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Rob H. N. Tijssen
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jacqueline Theuws
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - Paul van Haaren
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - Baukelien van Triest
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Dave Eekhout
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Corrie A. M. Marijnen
- Department of Radiation Oncology, Leiden University Medical Center, P.O. Box 9600 2300, RC, Leiden, the Netherlands
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Uulke A. van der Heide
- Department of Radiation Oncology, Leiden University Medical Center, P.O. Box 9600 2300, RC, Leiden, the Netherlands
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Ellen M. Kerkhof
- Department of Radiation Oncology, Leiden University Medical Center, P.O. Box 9600 2300, RC, Leiden, the Netherlands
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20
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Sevak S, Gregoir T, Wolthuis A, Albert M. How can we utilize local excision to help, not harm, geriatric patients with rectal cancer? Eur J Surg Oncol 2020; 46:344-348. [PMID: 31983488 DOI: 10.1016/j.ejso.2019.12.013] [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: 06/01/2019] [Revised: 09/12/2019] [Accepted: 12/13/2019] [Indexed: 01/24/2023] Open
Abstract
A majority of the morbidity and mortality burden of rectal cancer is distributed within the geriatric age group. Current surgical and medical treatment modalities pose significant challenges in treating complications specifically in the already pre-disposed senior population with baseline dysfunction. This chapter reviews the work-up, management, current data and oncologic outcomes of treating rectal cancer in the senior adult.
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Affiliation(s)
- Shruti Sevak
- Center for Colon and Rectal Surgery, AdventHealth, Orlando, FL, USA.
| | - Tine Gregoir
- Department of Abdominal Surgery, University Hospital Leuven, Herestraat 48, 3000, Leuven, Belgium
| | - Albert Wolthuis
- Department of Abdominal Surgery, University Hospital Leuven, Herestraat 48, 3000, Leuven, Belgium
| | - Matthew Albert
- Center for Colon and Rectal Surgery, AdventHealth, Orlando, FL, USA
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21
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Rouleau-Fournier F, Brown CJ. Can less be more? Organ preservation strategies in the management of rectal cancer. ACTA ACUST UNITED AC 2019; 26:S16-S23. [PMID: 31819706 DOI: 10.3747/co.26.5841] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background Total mesorectal excision (tme) is the current standard of care for the treatment of rectal cancer. However, that surgery is associated with significant morbidity and mortality. Clinicians and patients are seeking alternatives to radical resection. Currently, prevalent organ-sparing strategies under investigation include local excision and nonoperative management (nom). Methods We reviewed the current evidence in the literature to create an overview of the use of transanal endoscopic surgery and watch-and-wait strategies in the modern management of rectal cancer. Results Compared with radical resection, transanal endoscopic surgery in patients with early rectal cancer (cT1) having favourable histopathologic features is associated with an increased risk of local recurrence, but no difference in 5-year survival. In patients with T2 or early T3 cancer, strategies that use neoadjuvant or adjuvant therapy as adjuncts to local excision are under evaluation. Nonoperative management is a new option for patients who experience a complete clinical response after neoadjuvant chemoradiotherapy (ncrt). The selection criteria that will appropriately identify patients for whom nom will succeed are not established. Conclusions Local excision is appropriate for early rectal cancer with favourable histopathologic features. Although organ-preserving strategies are promising, the quality of the evidence to date is insufficient to replace the current standard care in most patients. Patients should be offered nom in the safe setting of a clinical trial or registry. Rigorous follow-up, including endoscopy and imaging at frequent intervals is recommended when radical resection is forgone.
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Affiliation(s)
- F Rouleau-Fournier
- Department of Surgery, St. Paul's Hospital, Providence Health Care, Vancouver, BC
| | - C J Brown
- Department of Surgery, St. Paul's Hospital, Providence Health Care, Vancouver, BC
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22
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Westrich G, Venturero M, Schtrechman G, Hazzan D, Khaikin M, Nissan A, Shapiro R, Segev L. Transanal Minimally Invasive Surgery for Benign and Malignant Rectal Lesions: Operative and Oncological Outcomes of a Single Center Experience. J Laparoendosc Adv Surg Tech A 2019; 29:1122-1127. [DOI: 10.1089/lap.2019.0329] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Gal Westrich
- Department of Surgical Oncology-Surgery C, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Tel Aviv University, Sackler Medical School, Tel Aviv, Israel
| | - Moris Venturero
- Department of Surgical Oncology-Surgery C, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Tel Aviv University, Sackler Medical School, Tel Aviv, Israel
| | - Gal Schtrechman
- Department of Surgical Oncology-Surgery C, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - David Hazzan
- Department of Surgical Oncology-Surgery C, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Tel Aviv University, Sackler Medical School, Tel Aviv, Israel
| | - Marat Khaikin
- Department of Surgical Oncology-Surgery C, Chaim Sheba Medical Center, Tel Hashomer, Israel
- General Surgery and Transplantation-Surgery B, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Aviram Nissan
- Department of Surgical Oncology-Surgery C, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Tel Aviv University, Sackler Medical School, Tel Aviv, Israel
| | - Ron Shapiro
- Department of Surgical Oncology-Surgery C, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Tel Aviv University, Sackler Medical School, Tel Aviv, Israel
| | - Lior Segev
- Department of Surgical Oncology-Surgery C, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Tel Aviv University, Sackler Medical School, Tel Aviv, Israel
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Hwang Y, Yoon YS, Bong JW, Choi HY, Song IH, Lee JL, Kim CW, Park IJ, Lim SB, Yu CS, Kim JC. Long-term Transanal Excision Outcomes in Patients With T1 Rectal Cancer: Comparative Analysis of Radical Resection. Ann Coloproctol 2019; 35:194-201. [PMID: 31487767 PMCID: PMC6732326 DOI: 10.3393/ac.2018.10.18.2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 10/18/2018] [Indexed: 12/20/2022] Open
Abstract
Purpose Transanal excision (TAE) is an alternative surgical procedure for early rectal cancer. This study compared long-term TAE outcomes, in terms of survival and local recurrence (LR), with total mesorectal excision (TME) in patients with pathologically confirmed T1 rectal cancer. Methods T1 rectal adenocarcinoma patients who underwent surgery from 1990 to 2011 were retrospectively reviewed. Patients that were suspected to have preoperative lymph node metastasis were excluded. Demographics, recurrence, and survival were analyzed based on TAE and TME surgery. Results Of 268 individuals, 61 patients (26%) underwent TAE, which was characterized by proximity to the anus, submucosal invasion depth, and lesion infiltration, compared with TME patients (P < 0.001–0.033). During a median follow-up of 10.4 years, 12 patients had systemic and/or LR. Ten-year cancer-specific survival in the TAE and TME groups was not significantly different (98% vs. 100%). However, the 10-year LR rate in the TAE group was greater than that of TME group (10% vs. 0%, P < 0.001). Although 5 of the 6 TAE patients with LR underwent salvage surgery, one of the patients eventually died. The TAE surgical procedure (hazard ratio, 19.066; P = 0.007) was the only independent risk factor for LR. Conclusion Although long-term survival after TAE was comparable to that after TME, TAE had a greater recurrence risk than TME. Thus, TAE should only be considered as an alternative surgical option for early rectal cancer in selected patients.
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Affiliation(s)
- Yunghuyn Hwang
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong Sik Yoon
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jun Woo Bong
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hye Yun Choi
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In Ho Song
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Lyul Lee
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chan Wook Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In Ja Park
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seok-Byung Lim
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang Sik Yu
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Cheon Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Verseveld M, de Wilt JH, Elferink MA, de Graaf EJ, Verhoef C, Pouwels S, Doornebosch PG. Survival after local excision for rectal cancer: a population-based overview of clinical practice and outcome. Acta Oncol 2019; 58:1163-1166. [PMID: 31106636 DOI: 10.1080/0284186x.2019.1616816] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Maria Verseveld
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam/Schiedam, The Netherlands
- Department of Surgery, Division of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Johannes H.W. de Wilt
- Department of Surgery, Division of Surgical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Eelco J.R. de Graaf
- Department of Surgery, IJsselland Hospital, Capelle aan den IJssel, The Netherlands
| | - Cees Verhoef
- Department of Surgery, Division of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Sjaak Pouwels
- Department of Surgery, Haaglanden Medical Center, Den Haag, The Netherlands
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Abstract
BACKROUND A common consensus for the definition for early rectal cancer does not exist. This item is used in cases of histological findings including pTis, pT1 or pT2 tumors. The term early rectal cancer is not mentioned in the German S3 guidelines on colorectal cancer. The pTis tumors are located at the mucosa level of the intestinal wall and they have nearly no tendency to develop metastases but pT2 tumors have a high risk of local metastases; therefore, the term early rectal cancer is not adequate for pT2 tumors. OBJECTIVE This focus of this article is exclusively on pT1 rectal cancer. Following the histological definition, pT1 tumors of the rectum are located at the level of the mucosa and submucosa of the intestinal wall. CONCLUSION With respect to the nature of the tumor (e.g. size, grading, invasion of lymphatic and/or blood vessels, Kikuchi classification) local methods (endoscopic procedure, surgical techniques) or radical resections are recommended. Tumor budding is of increasing interest and importance. Depending on the severity of the tumor budding classification (bd1-bd3) there is an association with a more frequent occurrence of lymph node metastases and should therefore be taken into consideration in treatment decisions in the future.
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Coton C, Lefevre JH, Debove C, Creavin B, Chafai N, Tiret E, Parc Y. Does transanal local resection increase morbidity for subsequent total mesorectal excision for early rectal cancer? Colorectal Dis 2019; 21:15-22. [PMID: 30300969 DOI: 10.1111/codi.14445] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 07/30/2018] [Indexed: 02/06/2023]
Abstract
AIM Local excision is recommended for early rectal cancer (pT1). Complementary total mesorectal excision (cTME) is warranted when bad pathological features are present. The impact of a prior local resection on the outcome remains unclear. The aim of this study was to assess if prior local excision increases the morbidity of a subsequent cTME compared with primary TME. METHODS From 2001 to 2016 all patients who underwent TME after local excision for rectal adenocarcinoma were studied. All were matched (1:1) with patients who underwent primary TME, without neoadjuvant radiochemotherapy. The matching factors included age, sex, body mass index, American Society of Anesthesiologists score and type of surgery. Short-term morbidity and pathological examination of the resected specimen were compared. RESULTS Forty-one patients were included (14 women, 34%, mean age 65 ± 11 years), comprising classic transanal excision (66%) and transanal endoscopic microsurgery (34%), and were matched to 41 patients who had primary TME. cTME was significantly longer (315 min ± 87 vs 275 min ± 58, P = 0.03). The overall morbidity was 48.8% in the local excision group vs 31.7% in the control group (P = 0.18). Surgical morbidity was 31.7% vs 26.8% (P = 0.8). Anastomotic related morbidity was similar (local excision 17% vs TME 14.6%, P = 0.84) and the mean length of stay was similar (14 days) in both groups. There was a tendency to a worse quality of mesorectal excision in the cTME group (17% vs 5%, P = 0.15). CONCLUSION Local excision prior to TME for early rectal cancer tends to increase overall morbidity and may worsen the quality of the mesorectal plane but should be considered as a surgical approach in select cases.
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Affiliation(s)
- C Coton
- Department of Digestive and General Surgery, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - J H Lefevre
- Department of Digestive and General Surgery, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - C Debove
- Department of Digestive and General Surgery, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - B Creavin
- Department of Colorectal Surgery, St Vincent's University Hospital, Dublin 4, Ireland
| | - N Chafai
- Department of Digestive and General Surgery, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - E Tiret
- Department of Digestive and General Surgery, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - Y Parc
- Department of Digestive and General Surgery, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
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Raynaud L, Mege D, Zappa M, Guedj N, Vilgrain V, Panis Y. Is magnetic resonance imaging useful for the management of patients with rectal villous adenoma? A study of 45 consecutive patients treated by transanal endoscopic microsurgery. Int J Colorectal Dis 2018; 33:1695-1701. [PMID: 30136172 DOI: 10.1007/s00384-018-3148-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/14/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE Very few data are available about the clinical relevance of magnetic resonance (MR) imaging in preoperative evaluation of rectal villous adenoma. The aim is to evaluate the impact of MR imaging for the surgical management of rectal villous adenoma treated by transanal endoscopic microsurgery (TEM). METHODS All patients with histologically proven rectal villous tumours operated by TEM who had a preoperative MR imaging between 2009 and 2017 were retrospectively reviewed. All patients underwent TEM because preoperative evaluation suggested systematically usT0 or usT1 tumour. Pathological stage was blindly compared to preoperative MR imaging (location according to the anal verge and the peritoneal reflection, amount of circumferential involvement, tumour size and staging) and preoperative transrectal ultrasonography (TRUS) results. RESULTS Forty-five patients were included (24 men, mean age 65 ± 8 years) with TRUS data available only in 37. Pathologic results were pT0-pTis in 32, pT1 in 10 and pT2 in 3. TRUS diagnosed correctly 36/37 lesions (97%) and understaged one pT2 tumour. A significant correlation between TRUS and pathologic results was noted (r = 0.99; p = 0.01). MR imaging diagnosed correctly 19/42 pTis-T1 and 1/3 pT2 tumours (46%). Overstaging by MR imaging was noted in 25 cases (54%). No correlation between MR imaging and pathologic results was noted (r = 0.7; p = 0.3). CONCLUSION Preoperative evaluation of rectal villous adenoma is overstaged by MRI in more than half of the patients. This study suggests that the indication of local excision by TEM for rectal villous adenoma should be based on TRUS rather than on MRI.
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Affiliation(s)
- Lucas Raynaud
- Department of Radiology, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France
| | - Diane Mege
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Magaly Zappa
- Department of Radiology, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France.,University Paris Diderot, Sorbonne Paris Cité, 75018, Paris, France.,UMR1149 CRI, INSERM, 75018, Paris, France
| | - Nathalie Guedj
- Department of Pathology, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France
| | - Valérie Vilgrain
- Department of Radiology, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France.,University Paris Diderot, Sorbonne Paris Cité, 75018, Paris, France.,UMR1149 CRI, INSERM, 75018, Paris, France
| | - Yves Panis
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, 100 Boulevard du Général Leclerc, 92110, Clichy, France. .,University Paris Diderot, Sorbonne Paris Cité, 75018, Paris, France.
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Clermonts SHEM, van Loon YT, Stijns J, Pottel H, Wasowicz DK, Zimmerman DDE. The effect of proctoring on the learning curve of transanal minimally invasive surgery for local excision of rectal neoplasms. Tech Coloproctol 2018; 22:965-975. [PMID: 30560322 DOI: 10.1007/s10151-018-1910-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 12/12/2018] [Indexed: 01/15/2023]
Abstract
BACKGROUND The current method of choice for local resection of benign and selected malignant rectal tumors is transanal endoscopic microsurgery. Transanal minimally invasive surgery (TAMIS) yields similar oncological results and better patient reported outcomes when compared to transanal endoscopic micro surgery. However, due to the technical complexity of TAMIS, a significant learning curve has been suggested. Data on the surgical learning curve are limited. The aim of our study was to investigate surgeon specific learning curves for TAMIS procedures for the local excision of selected rectal tumors, and analyze the effects of proctoring on operating time and outcome. METHODS The current study was prospective of all TAMIS procedures performed by two surgeons from October 2010 to November 2017. Margin positivity, specimen fragmentation, adverse events and operative time were evaluated with a cumulative sum analysis to determine the number of procedures required to reach proficiency. Cumulative sum (CUSUM) analysis was used to determine trends in changes over time. RESULTS The earliest adopter, surgeon A, performed 103 procedures, was not proctored and developed the standardized institutional program. Surgeon B, performed 26 cases, had the benefit of a proctorship and availability of a standardized program. The CUSUM curve for operative time showed a change after 36 cases for surgeon A and after 10 cases for surgeon B. For margin positivity proficiency was reached after 31 and 6 cases for surgeon A and B, respectively. The complications curve for surgeon A showed a three-phase learning curve with a decrease after the 26th case whereas surgeon B only had one (3.8%) complication in the learning phase with no change point in the CUSUM curve. Comparing pre- and post-proficiency periods there was a decrease in operating time for both surgeon A (84.4 ± 47.3 to 55.9 ± 30.1 min) and surgeon B (90.6 ± 64.to 53 ± 26.5 min; p < 0.001). Overall margin positivity rates decreased non significantly from 21.7 to 4.8% (p = 0.23). Complications were higher in the pre-proficiency period (21.7% vs. 13.0%; p = 0.02). Surgeon A had significantly more postoperative complications in pre-proficiency phase when compared to surgeon B (25% vs. none, p < 0.001), in the post-proficiency phase there was no statistically significant difference between both surgeons (p = 0.08). CONCLUSIONS Our results suggest that to reach satisfactory results for TAMIS, 18-31 procedures are required. Standardized institutional operative protocols together with proficient proctorship may contribute to a shorter learning curve with fewer cases (6-10) required to reach proficiency.
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Affiliation(s)
- S H E M Clermonts
- Department of Surgery, Elisabeth-TweeSteden Hospital, 5042 AD, Tilburg, The Netherlands.
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.
| | - Y T van Loon
- Department of Surgery, Elisabeth-TweeSteden Hospital, 5042 AD, Tilburg, The Netherlands
| | - J Stijns
- Department of Surgery, Elisabeth-TweeSteden Hospital, 5042 AD, Tilburg, The Netherlands
| | - H Pottel
- Department of Public Health and Primary Care, Catholic University Leuven, Kortrijk, Belgium
| | - D K Wasowicz
- Department of Surgery, Elisabeth-TweeSteden Hospital, 5042 AD, Tilburg, The Netherlands
| | - D D E Zimmerman
- Department of Surgery, Elisabeth-TweeSteden Hospital, 5042 AD, Tilburg, The Netherlands
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Suzuki T, Sadahiro S, Tanaka A, Okada K, Saito G, Miyakita H, Akiba T, Yamamuro H. Outcomes of Local Excision plus Chemoradiotherapy in Patients with T1 Rectal Cancer. Oncology 2018; 95:246-250. [PMID: 29909419 DOI: 10.1159/000489930] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 05/08/2018] [Indexed: 01/03/2023]
Abstract
OBJECTIVE The National Comprehensive Cancer Network (NCCN) guidelines recommend local excision and observation as standard treatment for selected patients with clinical T1N0M0 rectal cancer. In patients with pathological T1 (pT1) rectal cancer who received local excision, the local recurrence rate is at least 10%. We studied oncological outcomes in patients with pT1 rectal cancer who received chemoradiotherapy (CRT) after local excision. METHODS Local excision was performed in 65 patients with clinical T1N0M0 rectal cancer (≤8 cm from the anal verge, tumor size < 30 mm, well or moderately differentiated adenocarcinoma). The patients received CRT (40 or 45 Gy in 1.8-2.0 fractions with concurrent oral UFT [tegafur/uracil] or S-1 [tegafur/gimeracil/ote-racil]) after confirmation of pT1 and negative margins. RESULTS Patients who had pT2 cancer or who did not provide informed consent were excluded. The remaining 50 patients additionally received CRT. The CRT was completed in 48 patients (96%). The median follow-up period was 71 months. Local recurrence occurred in 1 patient (2%). Distant metastases occurred in 3 patients (6%). The 5-year disease-free survival rate was 86%, and the 5-year overall survival rate was 92%. CONCLUSIONS Our study suggested that multidisciplinary treatment with local excision plus CRT can be used as a treatment option in selected patients with clinical T1N0M0 rectal cancer.
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Affiliation(s)
- Toshiyuki Suzuki
- Department of Surgery, Tokai University School of Medicine, Kanagawa, Japan
| | - Sotaro Sadahiro
- Department of Surgery, Tokai University School of Medicine, Kanagawa, Japan
| | - Akira Tanaka
- Department of Surgery, Tokai University School of Medicine, Kanagawa, Japan
| | - Kazutake Okada
- Department of Surgery, Tokai University School of Medicine, Kanagawa, Japan
| | - Gota Saito
- Department of Surgery, Tokai University School of Medicine, Kanagawa, Japan
| | - Hiroshi Miyakita
- Department of Surgery, Tokai University School of Medicine, Kanagawa, Japan
| | - Takeshi Akiba
- Department of Radiology, Tokai University School of Medicine, Kanagawa, Japan
| | - Hiroshi Yamamuro
- Department of Radiology, Tokai University School of Medicine, Kanagawa, Japan
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Read J, Tekkis P, Rullier E, Nicholls J, Mortensen N, Marks J, Steele RJC, Brown G. Session 3: Many ways to organ preserve the rectum but which is correct? Colorectal Dis 2018; 20 Suppl 1:82-87. [PMID: 29878680 DOI: 10.1111/codi.14085] [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: 02/08/2023]
Abstract
From the patient's perspective, cancer cure with full preservation of function is a crucial goal. There are many advances that have emerged which may make this possible in a greater proportion of patients without compromising oncological outcomes. Professor Tekkis reviews the options and evidence to date for 'organ preservation' and the expert panel discuss the implications for current and future patient care.
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Affiliation(s)
- J Read
- The Royal Marsden NHS Foundation Trust, London, UK
| | - P Tekkis
- The Royal Marsden NHS Foundation Trust, London, UK
| | - E Rullier
- Saint-Andre Hospital, University of Bordeaux, Bordeaux, France
| | | | | | - J Marks
- Lankenau Hospital, Wynnewood, Pennsylvania, USA
| | - R J C Steele
- Prevention, Early Detection and Treatment of Colorectal Cancer, University of Dundee, Dundee, UK
| | - G Brown
- The Royal Marsden NHS Foundation Trust, London, UK.,Imperial College London, London, UK
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Park SM, Kye BH, Kim MK, Jalloun HE, Cho HM, Lee IK. Are we doing too much?: local excision before radical surgery in early rectal cancer. Int J Colorectal Dis 2018; 33:383-391. [PMID: 29445871 DOI: 10.1007/s00384-018-2982-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/08/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE In early rectal cancer cases, the use of local excision is increasing. The general indication for local excision is based on the preoperative stage, but there is often a discrepancy between pre and postoperative stages. We sought to determine the indications for local excision in T1 rectal adenocarcinoma patients by comparing the preoperative clinical and postoperative pathological stages. A second aim was to compare the oncologic outcomes between local excision and radical resection. METHODS Between 2004 and 2014, 152 T1 rectal adenocarcinoma patients were enrolled. We divided the subjects into two groups, local excision and radical resection, depending on the modality of treatment the patients initially received. The group of patients who underwent radical resection was subsequently subdivided into "excisable" and "non-excisable" groups based on the postoperative pathology. RESULTS Of 152 patients, 28 patients (18.4%) underwent local excision, while 124 patients (81.6%) underwent radical resection. Of 124 patients, in clinically suspected T2 or less and N0 (93) cases, 50 patients (53.8%) needed treatment beyond local excision, and local excision was sufficient for 43 patients (46.2%). The 3-year overall survival (p = 0.393) and 3-year disease-free survival (p = 0.076) between the local excision and radical resection groups showed no significant difference. CONCLUSIONS The clinical T stage was overestimated in more than half of the cases. Therefore, if cT1/2 tumors with cN0 are suspected preoperatively, local excision is initially recommended and will allow for determination of underlying pathology. The clinician can then decide whether to monitor or intervene with radical resection.
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Affiliation(s)
- Sun Min Park
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Korea
| | - Bong-Hyeon Kye
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Korea
| | - Min Ki Kim
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Korea
| | - Heba E Jalloun
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Korea
| | - Hyeon-Min Cho
- Division of Colorectal Surgery, Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - In Kyu Lee
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Korea.
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32
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Rombouts AJM, Al-Najami I, Abbott NL, Appelt A, Baatrup G, Bach S, Bhangu A, Garm Spindler KL, Gray R, Handley K, Kaur M, Kerkhof E, Kronborg CJ, Magill L, Marijnen CAM, Nagtegaal ID, Nyvang L, Peters FP, Pfeiffer P, Punt C, Quirke P, Sebag-Montefiore D, Teo M, West N, de Wilt JHW. Can we Save the rectum by watchful waiting or Trans Anal microsurgery following (chemo) Radiotherapy versus Total mesorectal excision for early REctal Cancer (STAR-TREC study)?: protocol for a multicentre, randomised feasibility study. BMJ Open 2017; 7:e019474. [PMID: 29288190 PMCID: PMC5770914 DOI: 10.1136/bmjopen-2017-019474] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 10/20/2017] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Total mesorectal excision (TME) is the highly effective standard treatment for rectal cancer but is associated with significant morbidity and may be overtreatment for low-risk cancers. This study is designed to determine the feasibility of international recruitment in a study comparing organ-saving approaches versus standard TME surgery. METHODS AND ANALYSIS STAR-TREC trial is a multicentre international randomised, three-arm parallel, phase II feasibility study in patients with biopsy-proven adenocarcinoma of the rectum. The trial is coordinated from Birmingham, UK with national hubs in Radboudumc (the Netherlands) and Odense University Hospital Svendborg UMC (Denmark). Patients with rectal cancer, staged by CT and MRI as ≤cT3b (up to 5 mm of extramural spread) N0 M0 can be included. Patients will be randomised to either standard TME surgery (control), organ-saving treatment using long-course concurrent chemoradiation or organ-saving treatment using short-course radiotherapy. For patients treated with an organ-saving strategy, clinical response to (chemo)radiotherapy determines the next treatment step. An active surveillance regime will be performed in the case of a complete clinical regression. In the case of incomplete clinical regression, patients will proceed to local excision using an optimised platform such as transanal endoscopic microsurgery or other transanal techniques (eg, transanal endoscopic operation or transanal minimally invasive surgery). The primary endpoint of this phase II study is to demonstrate sufficient international recruitment in order to sustain a phase III study incorporating pelvic failure as the primary endpoint. Success in phase II is defined as randomisation of at least four cases per month internationally in year 1, rising to at least six cases per month internationally during year 2. ETHICS AND DISSEMINATION The medical ethical committees of all the participating countries have approved the study protocol. Results of the primary and secondary endpoints will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER ISRCTN14240288, 20 October 2016. NCT02945566; Pre-results, October 2016.
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Affiliation(s)
- Anouk J M Rombouts
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Issam Al-Najami
- Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Natalie L Abbott
- Radiotheraphy Trials Quality Assurance Group, Velindre Cancer Centre, Cardiff, UK
| | - Ane Appelt
- Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
- Leeds Cancer Centre, St. James' University Hospital, Leeds, UK
| | - Gunnar Baatrup
- Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Simon Bach
- Department of Surgery, University Hospitals Birmingham, Birmingham, UK
| | - Aneel Bhangu
- Department of Surgery, University Hospitals Birmingham, Birmingham, UK
| | - Karen-Lise Garm Spindler
- Department of Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Richard Gray
- Clinical Trial Services Unit, University of Oxford, Oxford, UK
| | - Kelly Handley
- Institue of Applied Health Research, University of Birmingham Clinical Trials Unit, Birmingham, UK
| | - Manjinder Kaur
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Ellen Kerkhof
- Department of Radiotherapy, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Laura Magill
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Corrie A M Marijnen
- Department of Radiotherapy, Leiden University Medical Center, Leiden, The Netherlands
| | - Iris D Nagtegaal
- Department of Pathology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Lars Nyvang
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Femke P Peters
- Department of Radiotherapy, Leiden University Medical Center, Leiden, The Netherlands
| | - Per Pfeiffer
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Cornelis Punt
- Department of Medical Oncology, Academic Medical Center, Amsterdam, The Netherlands
| | - Philip Quirke
- Department of Pathology, School of Medicine, University of Leeds, Leeds, UK
| | - David Sebag-Montefiore
- Department of Clinical Oncology, Leeds Radiotherapy Research Group, University of Leeds, Leeds, UK
| | - Mark Teo
- Department of Clinical Oncology, Leeds Radiotherapy Research Group, University of Leeds, Leeds, UK
- Department of Clinical Oncology, Leeds Cancer Centre, St James University Hospital, Leeds, UK
| | - Nick West
- Department of Pathology, School of Medicine, University of Leeds, Leeds, UK
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
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Stijns RCH, Tromp MSR, Hugen N, de Wilt JHW. Advances in organ preserving strategies in rectal cancer patients. Eur J Surg Oncol 2017; 44:209-219. [PMID: 29275912 DOI: 10.1016/j.ejso.2017.11.024] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 10/23/2017] [Accepted: 11/19/2017] [Indexed: 02/06/2023] Open
Abstract
Treatment of rectal cancer patients has been subjected to change over the past thirty years. Total mesorectal excision is considered the cornerstone of rectal cancer treatment, but is also associated with significant morbidity resulting in an impaired quality of life. The addition of neoadjuvant chemoradiotherapy to surgery has shown to improve survival and local control and may lead to a partial or even complete response (CR). This raises questions regarding the necessity for subsequent radical surgery. After careful patient selection local excision and wait-and-see approaches are explored, aiming to improve quality of life without compromising oncological outcome. A multimodality diagnostic approach for optimal staging is crucial in determining the appropriate neoadjuvant treatment regimen. Adequate endoscopic restaging of rectal tumours after multimodality treatment will aid in selecting patients who are eligible for an organ preserving approach. The role and accuracy of imaging in the detection of the primary tumour, residual rectal cancer or local recurrence seems vital. Alternative neoadjuvant regimens are currently explored to increase the rate of clinical CRs, which may support organ preserving approaches. This review aims to generate insight into the advances in diagnostics and treatment modalities in all stages of rectal cancer and will highlight future studies that may support further implementation of organ preservation treatment in rectal cancer.
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Affiliation(s)
- Rutger C H Stijns
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Mike-Stephen R Tromp
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Niek Hugen
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
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Jones HJS, Cunningham C, Nicholson GA, Hompes R. Outcomes following completion and salvage surgery for early rectal cancer: A systematic review. Eur J Surg Oncol 2017; 44:15-23. [PMID: 29174708 DOI: 10.1016/j.ejso.2017.10.212] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 10/14/2017] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVES To establish outcomes after completion and salvage surgery following local excision in literature published since 2005, to inform decision-making when offering local excision. BACKGROUND Local excision of early rectal cancer aims to offer cure while maintaining quality of life through organ preservation. However, some patients will require radical surgery, prompted by unexpected poor pathology or local recurrence. Consistent definition and reporting of these scenarios is poor. We propose the term "salvage surgery" for recurrence after local excision and "completion surgery" for poor pathology. METHODS Electronic databases were searched in February 2016. Studies since 2005 describing outcomes for radical surgery following local excision of rectal cancer were included. Pooled and average values were obtained. RESULTS A total of 23 studies included 262 completion and 165 salvage operations. Most completion operations were done within 4 weeks; local recurrence rate was 5% and overall disease recurrence rate was 14%. The majority of salvage operations for local recurrence were within 15 months of local excision, often following adjuvant treatment. Re-do local excision was used in 15%; APR was the most common radical procedure. Further local recurrence was uncommon (3%) but overall disease recurrence rate was 13%. Estimated 5-year survival was in the order of 50%. Heterogeneity was high among the studies. CONCLUSIONS Patients undergoing local excision must be informed of risks and expected outcomes, but better data on completion and salvage surgery are required to achieve this. SYSTEMATIC REVIEW REGISTRATION NUMBER CRD42014014758.
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Affiliation(s)
- Helen J S Jones
- Department of Colorectal Surgery, Oxford University Hospitals, United Kingdom.
| | - Chris Cunningham
- Department of Colorectal Surgery, Oxford University Hospitals, United Kingdom
| | - Gary A Nicholson
- Department of Colorectal Surgery, Oxford University Hospitals, United Kingdom
| | - Roel Hompes
- Department of Colorectal Surgery, Oxford University Hospitals, United Kingdom
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Lee L, Kelly J, Nassif GJ, Keller D, Debeche-Adams TC, Mancuso PA, Monson JR, Albert MR, Atallah SB. Establishing the learning curve of transanal minimally invasive surgery for local excision of rectal neoplasms. Surg Endosc 2017; 32:1368-1376. [PMID: 28812153 DOI: 10.1007/s00464-017-5817-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 08/03/2017] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Transanal minimally invasive surgery (TAMIS) is an endoscopic operating platform for local excision of rectal neoplasms. However, it may be technically demanding, and its learning curve has yet to be adequately defined. The objective of this study was to determine the number of TAMIS procedures for the local excision of rectal neoplasm required to reach proficiency. METHODS AND PROCEDURES All TAMIS cases performed from 07/2009 to 12/2016 at a single high-volume tertiary care institution for local excision of benign and malignant rectal neoplasia were identified from a prospective database. A cumulative summation (CUSUM) analysis was performed to determine the number of cases required to reach proficiency. The main proficiency outcome was rate of margin positivity (R1 resection). The acceptable and unacceptable R1 rates were defined as the R1 rate of transanal endoscopic microsurgery (TEM-10%) and traditional transanal excision (TAE-26%), which was obtained from previously published meta-analyses. Comparisons of patient, tumor, and operative characteristics before and after TAMIS proficiency were performed. RESULTS A total of 254 TAMIS procedures were included in this study. The overall R1 resection rate was 7%. The indication for TAMIS was malignancy in 57%. CUSUM analysis reported that TAMIS reached an acceptable R1 rate between 14 and 24 cases. Moving average plots also showed that the mean operative times stabilized by proficiency gain. The mean lesion size was larger after proficiency gain (3.0 cm (SD 1.5) vs. 2.3 cm (SD 1.3), p = 0.008). All other patient, tumor, and operative characteristics were similar before and after proficiency gain. CONCLUSIONS TAMIS for local excision of rectal neoplasms is a complex procedure that requires a minimum of 14-24 cases to reach an acceptable R1 resection rate and lower operative duration.
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Affiliation(s)
- Lawrence Lee
- Center for Colon and Rectal Surgery, Department of Surgery, Florida Hospital, 2501 North Orange Ave, suite 240, Orlando, FL, 32804, USA.
| | - Justin Kelly
- Center for Colon and Rectal Surgery, Department of Surgery, Florida Hospital, 2501 North Orange Ave, suite 240, Orlando, FL, 32804, USA
| | - George J Nassif
- Center for Colon and Rectal Surgery, Department of Surgery, Florida Hospital, 2501 North Orange Ave, suite 240, Orlando, FL, 32804, USA
| | - Deborah Keller
- Department of Surgery, Baylor University Medical Center, Dallas, TX, USA
| | - Teresa C Debeche-Adams
- Center for Colon and Rectal Surgery, Department of Surgery, Florida Hospital, 2501 North Orange Ave, suite 240, Orlando, FL, 32804, USA
| | - Paul A Mancuso
- Center for Colon and Rectal Surgery, Department of Surgery, Florida Hospital, 2501 North Orange Ave, suite 240, Orlando, FL, 32804, USA
| | - John R Monson
- Center for Colon and Rectal Surgery, Department of Surgery, Florida Hospital, 2501 North Orange Ave, suite 240, Orlando, FL, 32804, USA
| | - Matthew R Albert
- Center for Colon and Rectal Surgery, Department of Surgery, Florida Hospital, 2501 North Orange Ave, suite 240, Orlando, FL, 32804, USA
| | - Sam B Atallah
- Center for Colon and Rectal Surgery, Department of Surgery, Florida Hospital, 2501 North Orange Ave, suite 240, Orlando, FL, 32804, USA
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Abstract
Local excision (LE) of early-stage rectal cancer avoids the morbidity associated with radical surgery but has historically been associated with inferior oncologic outcomes. Newer techniques, including transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS), have been developed to improve the quality of LE and extend the benefits of LE to tumors in the more proximal rectum. This article provides an overview of conventional LE, TEM, and TAMIS techniques, including indications for their use and pertinent literature on their associated outcomes for rectal cancer.
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Affiliation(s)
- Daniel Owen Young
- Colorectal Surgery Program, Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, 1100 9th Avenue Seattle, WA 98101, USA
| | - Anjali S Kumar
- Colorectal Surgery Program, Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, 1100 9th Avenue Seattle, WA 98101, USA.
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Han J, Noh GT, Cheong C, Cho MS, Hur H, Min BS, Lee KY, Kim NK. Transanal Endoscopic Operation Versus Conventional Transanal Excision for Rectal Tumors: Case-Matched Study with Propensity Score Matching. World J Surg 2017; 41:2387-2394. [PMID: 28421262 DOI: 10.1007/s00268-017-4017-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUNDS Although transanal endoscopic surgery is practiced worldwide, there is no consensus on comparative outcomes between transanal endoscopic operation (TEO) and transanal excision (TAE). In this study, we reviewed our experiences with these techniques and compared patients who underwent TEO and TAE using propensity score matching (PSM). METHODS A total of 207 patients underwent local rectal tumor excision between January 2008 and November 2015. To overcome selection bias, we used PSM to achieve a one-to-one TEO: TAE ratio. We included baseline characteristics, age, sex, surgeon, American Society of Anesthesiologists score, tumor location (clockwise direction), involved circumference quadrants, tumor size, and pathology. RESULTS After PSM, 72 patients were included in each group. The tumor distance from the anal verge was higher in the TEO group (8.0 [5-10] vs. TAE: 4.0 [3-5], p < 0.001). Complication rates did not differ between the groups (TEO: 8.3% vs. TAE: 11.1%, p = 0.39). TEO was associated with a shorter hospital stay (3.01 vs. 4.68 days, p = 0.001), higher negative margin rate (95.8 vs. 86.1%, p = 0.039), and non-fragmented specimen rate vs. TAE (98.6 vs. 90.3%, p = 0.029). CONCLUSIONS TEO was more beneficial for patients with higher rectal tumors. Regardless of tumor location, involved circumference quadrants, and tumor size, TEO may more effectively achieve negative resection margins and non-fragmented specimens. Consequently, although local excision method according to tumor distance may be important, TEO will become the standard for rectal tumors.
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Affiliation(s)
- Jeonghee Han
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Gyoung Tae Noh
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Chinock Cheong
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Min Soo Cho
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Hyuk Hur
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Soh Min
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Kang Young Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Nam Kyu Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea. .,Division of Colon and Rectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Korea.
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Junginger T, Goenner U, Hitzler M, Trinh TT, Heintz A, Roth W, Blettner M, Wollschlaeger D. Analysis of local recurrences after transanal endoscopic microsurgery for low risk rectal carcinoma. Int J Colorectal Dis 2017; 32:265-271. [PMID: 27888300 DOI: 10.1007/s00384-016-2715-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/18/2016] [Indexed: 02/04/2023]
Abstract
AIM Rates of local recurrence (LR) after transanal endoscopic microsurgery (TEM) for rectal carcinoma vary; the reasons remain unclear. We analyzed LR after TEM for low-risk pT1 (G1/2/X, L0/X) rectal carcinoma to investigate the influence of completeness of resection and occult lymph node metastasis on risk of LR. METHOD LR location and stage, completeness of resection of primary carcinoma (minimal distance between tumor and resection line ≤1 mm vs >1 mm), and incidence of involved lymph nodes in resected LR specimens were collected, and tumor characteristics of LR were compared with primary carcinoma. Distant metastasis and overall and cancer-specific survival were determined. RESULTS LR developed in 14 patients; in 2/4 with R1/X resection, in 3/8 (38%) with clear margins (R0) but a minimal distance of ≤1 mm, and in 9/88 (10%) with formally complete resection. Six of nine patients with formally complete resection underwent radical surgery for LR; in five out of these six, lymph nodes were not involved. In 5/14 patients, LR was poorly differentiated compared to primary carcinoma. Main LR causes were incomplete tumor resection or tumor persistence after formally complete resection. Overall (p = 0.008) and cancer-specific (p < 0.001) survival was lower in LR patients compared to non-LR patients, even if lymph nodes were uninvolved. CONCLUSIONS The results suggest that most LRs after TEM for low-risk rectal cancer were caused by residual tumor at the previous excision site and not by undetected lymph node metastases. By improved standardization of surgical techniques to ensure complete resection of carcinomas and thorough pathological assessments, most LRs seem to be avoidable.
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Affiliation(s)
- Theodor Junginger
- Department of General and Abdominal Surgery, University Medical Centre of the Johannes Gutenberg-University, Langenbeckstr. 1, 55131, Mainz, Germany.
| | - Ursula Goenner
- Department of General and Abdominal Surgery, University Medical Centre of the Johannes Gutenberg-University, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Mirjam Hitzler
- Department of General, Visceral and Vascular Surgery, Catholic Hospital Mainz, Mainz, Germany
| | - Tong T Trinh
- Department of Heart, Chest and Vascular Surgery, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Achim Heintz
- Department of General, Visceral and Vascular Surgery, Catholic Hospital Mainz, Mainz, Germany
| | - Wilfried Roth
- Institute of Pathology, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Maria Blettner
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Daniel Wollschlaeger
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
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Riansuwan W, Lohsiriwat V. Local Excision Versus Total Mesorectal Excision for Clinical Stage I (cT1–cT2) Rectal Cancer. CURRENT COLORECTAL CANCER REPORTS 2017. [DOI: 10.1007/s11888-017-0350-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Debove C, Svrcek M, Dumont S, Chafai N, Tiret E, Parc Y, Lefèvre JH. Is the assessment of submucosal invasion still useful in the management of early rectal cancer? A study of 91 consecutive patients. Colorectal Dis 2017; 19:27-37. [PMID: 27253882 DOI: 10.1111/codi.13405] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 04/28/2016] [Indexed: 02/06/2023]
Abstract
AIM The only studies on the prognosis of T1 tumours are old and investigate colic and rectal cancers. Very few studies use Kikuchi's classification (of dividing submucosa into three strata) to evaluate the depth of the submucosal invasion. This study aimed to assess the pathological risk factors for lymph node metastasis (LNM), and the pathological and oncological results of patients with early rectal cancer (ERC, pT1 tumour). METHOD Between 2000 and 2014, 91 consecutive patients undergoing surgery [primary total mesorectal excision (TME) or local excision (LE) alone, or LE followed by TME] for ERC were included. RESULTS Eighteen patients underwent LE, 22 underwent LE followed by TME and 51 underwent primary total TME. After TME (n = 73), 16 (23%) patients had LNM. The LNM rate was 15% for Sm1 tumours, 14% for Sm2 tumours and 30% for Sm3 tumours. In multivariate analysis, lymphovascular invasion (P = 0.027) and high tumour budding (P = 0.037) were the only independent factors predictive of LNM. The depth of submucosal invasion was not associated with an increased risk of LNM. After a mean follow up of 56 ± 46 months, 5-year overall survival, specific survival and disease-free survival were, respectively, 82%, 93% and 75%. No significant difference of survival was found according to the depth of submucosal invasion or to the surgical management. CONCLUSION Histological features seem to be stronger risk factors for LNM than depth of submucosal invasion. Considering the LNM rate, TME should be discussed after LE in terms of one of these pathological criteria.
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Affiliation(s)
- C Debove
- Department of Digestive Surgery, St Antoine Hospital (AP-HP), Paris VI University, Paris, France
| | - M Svrcek
- Department of Pathology, St Antoine Hospital (AP-HP), Paris VI University, Paris, France
| | - S Dumont
- Pierre et Marie Curie University, Paris VI University, Paris, France
| | - N Chafai
- Department of Digestive Surgery, St Antoine Hospital (AP-HP), Paris VI University, Paris, France
| | - E Tiret
- Department of Digestive Surgery, St Antoine Hospital (AP-HP), Paris VI University, Paris, France
| | - Y Parc
- Department of Digestive Surgery, St Antoine Hospital (AP-HP), Paris VI University, Paris, France
| | - J H Lefèvre
- Department of Digestive Surgery, St Antoine Hospital (AP-HP), Paris VI University, Paris, France
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Current Controversies in Transanal Surgery for Rectal Cancer. Surg Laparosc Endosc Percutan Tech 2016; 26:431-438. [DOI: 10.1097/sle.0000000000000357] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Abstract
The Ferguson Operating Anoscope (FOA) is a surgical instrument, which can facilitate transanal excision of appropriate rectal tumors within 15 cm of the anal verge. Previous work showed low recurrence (4.3%) for favorable T1 tumors (no lymphovascular invasion, well/moderate differentiation, negative margins). This follow-up study evaluates outcomes in rectal cancer excised with FOA at a tertiary care center. T1 rectal cancer patients were identified in a prospectively maintained database. Tumor pathology and patient characteristics were reviewed. Primary outcomes include tumor recurrence and patient and disease-free survival. Secondary outcomes are quality of excision (intact specimen). Twenty-eight patients had pathologic stage T1 rectal cancer (average 8 ± 2.6 cm from the anal verge). Final path demonstrated 14 per cent to be well differentiated, 82 per cent moderately differentiated, and 93 per cent without angiolymphatic invasion. All specimens removed were intact. One patient had a true local recurrence and underwent a salvage operation 24 months after her index operation. Patient survival was 96.4 per cent (n = one death from primary lung cancer) at median follow-up 64 ± 35 months. With appropriate tumor selection and quality of initial resection, FOA has demonstrated utility in achieving optimal oncologic resection of T1 rectal tumors.
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Jeong JU, Nam TK, Kim HR, Shim HJ, Kim YH, Yoon MS, Song JY, Ahn SJ, Chung WK. Adjuvant chemoradiotherapy instead of revision radical resection after local excision for high-risk early rectal cancer. Radiat Oncol 2016; 11:114. [PMID: 27595767 PMCID: PMC5011790 DOI: 10.1186/s13014-016-0692-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Accepted: 08/31/2016] [Indexed: 01/30/2023] Open
Abstract
Background After local excision of early rectal cancer, revision radical resection is recommended for patients with high-risk pathologic stage T1 (pT1) or pT2 cancer, but the revision procedure has high morbidity rates. We evaluated the efficacy of adjuvant concurrent chemoradiotherapy (CCRT) for reducing recurrence after local excision in these patients. Methods Eighty-three patients with high-risk pT1 or pT2 rectal cancer underwent postoperative adjuvant CCRT after local excision. We defined high-risk features as pT1 having tumor size ≤3 cm, and/or resection margin (RM) ≤3 mm, and/or lymphovascular invasion (LVI), and/or non-full thickness excision such as endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD), or unknown records regarding those features, or pT2 cancer. Radiotherapy was administered with a median dose of 50.4 Gy in 1.8 Gy fraction size over 5–7 weeks. Concurrent 5-fluorouracil and leucovorin were administered for 4 days in the first and fifth weeks of radiotherapy. Results The median interval between local excision and radiotherapy was 34 (range, 11–104) days. Fifteen patients (18.1 %) had stage pT2 tumors, 22 (26.5 %) had RM of ≥3 mm, and 21 (25.3 %) had tumors of ≥3 cm in size. Thirteen patients (15.7 %) had LVI. Transanal excision was performed in 58 patients (69.9 %) and 25 patients (30.1 %) underwent EMR or ESD. The median follow-up was 61 months. The 5-year overall survival (OS), locoregional relapse-free survival (LRFS), and disease-free survival (DFS) rates for all patients were 94.9, 91.0, and 89.8 %, respectively. Multivariate analysis did not identify any significant factors for OS or LRFS, but the only significant factor affecting DFS was the pT stage (p = 0.027). Conclusions In patients with high-risk pT1 rectal cancer, adjuvant CCRT after local excision could be an effective alternative treatment instead of revision radical resection. However, patients with pT2 stage showed inferior DFS compared to pT1.
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Affiliation(s)
- Jae-Uk Jeong
- Department of Radiation Oncology, Chonnam National University Medical School, Hwasun-eup, Hwasun-gun, Jeonnam, South Korea
| | - Taek-Keun Nam
- Department of Radiation Oncology, Chonnam National University Medical School, Hwasun-eup, Hwasun-gun, Jeonnam, South Korea.
| | - Hyeong-Rok Kim
- Department of Surgery, Chonnam National University Medical School, Hwasun-eup, Hwasun-gun, Jeonnam, South Korea
| | - Hyun-Jeong Shim
- Department of Hemato-Oncology, Chonnam National University Medical School, Hwasun-eup, Hwasun-gun, Jeonnam, South Korea
| | - Yong-Hyub Kim
- Department of Radiation Oncology, Chonnam National University Medical School, Hwasun-eup, Hwasun-gun, Jeonnam, South Korea
| | - Mee Sun Yoon
- Department of Radiation Oncology, Chonnam National University Medical School, Hwasun-eup, Hwasun-gun, Jeonnam, South Korea
| | - Ju-Young Song
- Department of Radiation Oncology, Chonnam National University Medical School, Hwasun-eup, Hwasun-gun, Jeonnam, South Korea
| | - Sung-Ja Ahn
- Department of Radiation Oncology, Chonnam National University Medical School, Hwasun-eup, Hwasun-gun, Jeonnam, South Korea
| | - Woong-Ki Chung
- Department of Radiation Oncology, Chonnam National University Medical School, Hwasun-eup, Hwasun-gun, Jeonnam, South Korea
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Mukkai Krishnamurty D, Wise PE. Importance of surgical margins in rectal cancer. J Surg Oncol 2016; 113:323-32. [DOI: 10.1002/jso.24136] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 11/18/2015] [Indexed: 12/14/2022]
Affiliation(s)
- Devi Mukkai Krishnamurty
- Section of Colon and Rectal Surgery; Washington University School of Medicine in St. Louis; St. Louis Missouri
| | - Paul E. Wise
- Section of Colon and Rectal Surgery; Washington University School of Medicine in St. Louis; St. Louis Missouri
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Bartel MJ, Brahmbhatt BS, Wallace MB. Management of colorectal T1 carcinoma treated by endoscopic resection from the Western perspective. Dig Endosc 2016; 28:330-41. [PMID: 26718885 DOI: 10.1111/den.12598] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 12/21/2015] [Accepted: 12/25/2015] [Indexed: 12/13/2022]
Abstract
Detection of early colorectal cancer is expected to rise in light of national colorectal cancer screening programs. This The present review article delineates current endoscopic risk assessments, differentiating invasive from non-invasive neoplasia, for high likelihood of lymph node metastasis in early colorectal cancer, also termed high-risk early colorectal cancer, and endoscopic and surgical resection methods from a Western hemisphere perspective.
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Transanal Local Excision for Patients With Rectal Cancer: Can Radiation Compensate for What Is Perceived as a Nondefinitive Surgical Approach? Dis Colon Rectum 2016; 59:173-8. [PMID: 26855390 DOI: 10.1097/dcr.0000000000000544] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Total mesorectal excision has long been the standard of care for patients with rectal cancer. However, in select patients, local excision is an appropriate alternative option. The role of adjuvant radiation therapy in patients treated with local excision is controversial and evidence is lacking. OBJECTIVE The purpose of this study was to report oncological outcomes of patients with rectal cancer treated with local excision and adjuvant radiation. DESIGN This study was a retrospective chart review. SETTINGS The study was conducted at the BC Cancer Agency, a tertiary referral hospital. PATIENTS A total of 93 patients with node-negative rectal cancer treated with local excision and adjuvant radiotherapy between 2001 and 2010 were included in the study. MAIN OUTCOME MEASURES Patient and tumor characteristics are reported. Five-year local control, progression-free survival, and overall survival were analyzed using Kaplan-Meier methods. RESULTS Five-year overall survival, local control, and progression-free survival for patients treated with local excision and adjuvant radiotherapy were 78.5%, 86.1%, and 83.8%. In T1 disease, local control was 92.5%. LIMITATIONS Referral bias, selection bias, lack of uniform surveillance, and retrospective analysis are the study limitations. CONCLUSIONS Local excision with adjuvant radiotherapy provides a good level of local control in T1 disease and remains a good treatment option for patients who are either medically not suitable for a more radical surgical approach or who refuse this procedure. Local excision and radiotherapy should not be advocated in T2/T3 disease; however, it can provide a good alternative in those patients who are not fit enough for a more radical operation.
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Martin BM, Cardona K, Sullivan PS. Management of Early (T1 or T2) Rectal Cancer. CURRENT COLORECTAL CANCER REPORTS 2016. [DOI: 10.1007/s11888-016-0315-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Cao YS, Ge HY. Survival after local excision or radical resection for early-stage colorectal cancer. Shijie Huaren Xiaohua Zazhi 2016; 24:801-807. [DOI: 10.11569/wcjd.v24.i5.801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AIM: To compare the overall survival after local excision or radical resection for early-stage colorectal cancer.
METHODS: Patients who met the criteria were screened from the SEER database between 1998 and 2008, and they were divided into a local excision group and a radical resection group according to the mode of surgery. Each group was further divided into colon or rectal cancer subgroup according to the location of tumor. Kaplan-Meier analysis was performed to determine the overall survival between the two groups and independent prognostic factors.
RESULTS: A total of 13975 cases were included in the study. Of 13647 cases receiving radical resection, 10389 had colon cancer and 3258 had rectal cancer. Of 148 cases receiving local excision, 62 had colon cancer and 86 had rectal cancer. Tumors at T1 stage tended to receive local excision, while tumors at T2 stage were more inclined to accept radical resection (P < 0.001). Univariate survival analysis showed that there were statistical differences between the two groups in 5-year and 10-year survival rates of patients with stage T1 colon cancer, althougn no significant differences were noted in patients with stage T2 colon cancer and those with both stages T1 and T2 rectal cancer. Multivariate survival factor analysis showed that gender, age, race, tumor size, tumor differentiation and mode of surgery were independent prognostic factors, but both colon cancer and rectal cancer had their own characteristics.
CONCLUSION: Local excision can obtain the same survival rate as radical surgery in patients with stages T1 and T2 rectal cancer. Compared to local excision, radical resection can offer better overall survival in patients with stage T1 colon cancer, while more cases are needed to analyze the difference in patients with stage T2 colon cancer.
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Keller DS, Haas EM. Transanal Minimally Invasive Surgery: State of the Art. J Gastrointest Surg 2016; 20:463-9. [PMID: 26608195 DOI: 10.1007/s11605-015-3036-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 11/17/2015] [Indexed: 01/31/2023]
Abstract
The treatment for rectal cancer and benign rectal lesions continues to progress in the arena of minimally invasive surgery. While surgical excision of the primary mass remains essential for eradication of disease, there has been a paradigm shift towards less invasive resection methods. Local excision is increasing in popularity for its low morbidity and excellent functional results in select patients. Transanal minimally invasive surgery (TAMIS) is a new technology developed to elevate the practice of local excision to state-of-the-art resection. The goal of this article is to evaluate the history, short-term outcomes, and evolution of the TAMIS technique for excision of benign and malignant rectal neoplasia.
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Affiliation(s)
- D S Keller
- Colorectal Surgical Associates, Houston, TX, USA
- Division of Colon and Rectal Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - E M Haas
- Colorectal Surgical Associates, Houston, TX, USA.
- Division of Minimally Invasive Colorectal Surgery, Department of Surgery, University of Texas Medical School at Houston, 7900 Fannin, Suite 2700, Houston, TX, 77054, USA.
- Division of Colon and Rectal Surgery, Houston Methodist Hospital, Houston, TX, USA.
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Local Failure After Conservative Treatment of Rectal Cancer. Updates Surg 2016. [DOI: 10.1007/978-88-470-5767-8_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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