1
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Donohue K, Rossi A, Deek MP, Feingold D, Patel NM, Jabbour SK. Local Excision for Early-Stage Rectal Adenocarcinomas. Cancer J 2024; 30:245-250. [PMID: 39042775 DOI: 10.1097/ppo.0000000000000734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Abstract
ABSTRACT Although total mesorectal excision (TME) remains the standard of care for rectal cancer, including early-stage T1/T2 rectal adenocarcinoma, local excision may be warranted for these early-stage tumors in a select group of patients who may decline surgery or may be nonoptimal surgical candidates. Operative approaches for transanal local excision include transanal endoscopic microsurgery or transanal minimally invasive surgery for tumors <4 cm, occupying <40% of the rectal circumference and <10 cm from the dentate line. The use of preoperative chemoradiation therapy may help to downstage tumors and allow for more limited resections, and chemoradiation may also be employed postoperatively. Local excision approaches appear to result in improved quality of life compared with TME, but limited resections may also compromise survival rates compared with TME. Multidisciplinary management and shared decision-making can allow for the desired patient outcomes.
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Affiliation(s)
| | | | - Matthew P Deek
- Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ
| | | | | | - Salma K Jabbour
- Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ
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2
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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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Piozzi GN, Przedlacka A, Duhoky R, Ali O, Ghanem Y, Beable R, Higginson A, Khan JS. Robotic transanal minimally invasive surgery (r-TAMIS): perioperative and short-term outcomes for local excision of rectal cancers. Surg Endosc 2024; 38:3368-3377. [PMID: 38710889 PMCID: PMC11133047 DOI: 10.1007/s00464-024-10829-4] [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: 01/09/2024] [Accepted: 03/23/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND Transanal minimally invasive surgery (TAMIS) is an advanced technique for excision of early rectal cancers. Robotic TAMIS (r-TAMIS) has been introduced as technical improvement and potential alternative to total mesorectal excision (TME) in early rectal cancers and in frail patients. This study reports the perioperative and short-term oncological outcomes of r-TAMIS for local excision of early-stage rectal cancers. METHODS Retrospective analysis of a prospectively collected r-TAMIS database (July 2021-July 2023). Demographics, clinicopathological features, short-term outcomes, recurrences, and survival were investigated. RESULTS Twenty patients were included. Median age and body mass index were 69.5 (62.0-77.7) years and 31.0 (21.0-36.5) kg/m2. Male sex was prevalent (n = 12, 60.0%). ASA III accounted for 66.7%. Median distance from anal verge was 7.5 (5.0-11.7) cm. Median operation time was 90.0 (60.0-112.5) minutes. Blood loss was minimal. There were no conversions. Median postoperative stay was 2.0 (1.0-3.0) days. Minor and major complication rates were 25.0% and 0%, respectively. Seventeen (85.0%) patients had an adenocarcinoma whilst three patients had an adenoma. R0 rate was 90.0%. Most tumours were pT1 (55.0%), followed by pT2 (25.0%). One patient (5.0%) had a pT3 tumour. Specimen and tumour maximal median diameter were 51.0 (41.0-62.0) mm and 21.5 (17.2-42.0) mm, respectively. Median specimen area was 193.1 (134.3-323.3) cm2. Median follow-up was 15.5 (10.0-24.0) months. One patient developed local recurrence (5.0%). CONCLUSIONS r-TAMIS, with strict postoperative surveillance, is a safe and feasible approach for local excision of early rectal cancer and may have a role in surgically unfit and elderly patients who refuse or cannot undergo TME surgery. Future prospective multicentre large-scale studies are needed to report the long-term oncological outcomes.
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Affiliation(s)
| | - Ania Przedlacka
- Department of Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Rauand Duhoky
- Department of Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Oroog Ali
- Department of Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
- Department of General Surgery, Gateshead Health NHS Foundation Trust, Gateshead, UK
| | - Yasser Ghanem
- Department of General Surgery, Isle of Wight NHS Trust, Newport, UK
| | - Richard Beable
- Department of Radiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Antony Higginson
- Department of Radiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Jim S Khan
- Department of Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK.
- University of Portsmouth, Portsmouth, UK.
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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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Khalifa M, Gingold-Belfer R, Issa N. The Outcome of Local Excision of Rectal Adenomas with High-Grade Dysplasia by Transanal Endoscopic Microsurgery: A Single-Center Experience. J Clin Med 2024; 13:1419. [PMID: 38592246 PMCID: PMC10934864 DOI: 10.3390/jcm13051419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 02/20/2024] [Accepted: 02/26/2024] [Indexed: 04/10/2024] Open
Abstract
Background: Local excision by transanal endoscopic microsurgery (TEM) is considered an acceptable treatment for rectal adenomas with high-grade dysplasia (HGD). This study aims to assess the likelihood of harboring an invasive carcinoma in preoperatively diagnosed HGD polyps and evaluate the risk factors for tumor recurrence in patients with final HGD pathology. Methods: Data from patients who underwent TEM procedures for adenomatous lesions with HGD from 2005 to 2018 at the Rabin Medical Center, Hasharon Hospital, were analyzed. Collected data included patient demographics, preoperative workup, tumor characteristics and postoperative results. Follow-up data including recurrence assessment and further treatments were reviewed. The analysis included two subsets: preoperative pathology of HGD (sub-group 1) and postoperative final pathology of HGD (sub-group 2) patients. Results: Forty-five patients were included in the study. Thirty-six patients had a preoperative diagnosis of HGD, with thirteen (36%) showing postoperative invasive carcinoma. Thirty-two patients had a final pathology of HGD, and three (9.4%) experienced tumor recurrence. Large tumor size (>5 cm) was significantly associated with recurrence (p = 0.03). Conclusions: HGD rectal polyps are associated with a significant risk of invasive cancer. Tumor size was a significant factor in predicting tumor recurrence in patients with postoperative HGD pathology. The TEM procedure is an effective first-line treatment for such lesions.
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Affiliation(s)
- Muhammad Khalifa
- Department of Surgery, Rabin Medical Center-Hasharon Hospital, Faculty of Medicine, Tel Aviv University, Petach Tikva 49100, Israel;
| | - Rachel Gingold-Belfer
- Department of Gastroenterology, Rabin Medical Center-Hasharon Hospital, Tel Aviv University, Petach Tikva 49100, Israel;
| | - Nidal Issa
- Department of Surgery, Rabin Medical Center-Hasharon Hospital, Faculty of Medicine, Tel Aviv University, Petach Tikva 49100, Israel;
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El-Nakeep S, Madala S, Chidharla A, Surapaneni BK, Saha S, Martin B, Kasi A. Radical versus Local Surgical Excision for Early Rectal Cancer: A Systematic Review and Meta-Analysis. ARCHIVES OF INTERNAL MEDICINE RESEARCH 2024; 7:1-11. [PMID: 38605826 PMCID: PMC11008054 DOI: 10.26502/aimr.0160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
Background Radical excision (RE) for rectal cancer carries a higher risk of mortality and morbidity, while local excision (LE) could decrease these postoperative risks. However, the long-term benefit of LE is still debatable. Aim To study the effectiveness of LE versus RE in T1 and T2 rectal cancer. Methods A systematic review and meta-analysis was conducted using key databases like PubMed and ClinicalTrials.gov. Only cohort studies and randomized controlled trials were included. RevMan 5.4 tool was used for data analysis. Both clinical and statistical heterogeneity of the studies were assessed, and I2 >75% was considered as highly heterogeneous. The primary outcomes being measured were 5-year overall survival (OS) and 5-year disease free survival (DFS). A subgroup analysis of patients with T1-only was also conducted, without adjuvant chemo/radiotherapy. Results A total of 18 studies were included for final meta-analysis. Four were RCTs, while the other 15 were retrospective cohort studies. One included study had data from both RCT and non-RCT study groups. Nine studies were multicentered or national studies while nine were unicentral.There was no difference in risk ratio (RR) between OS: RR 0.95, 95% Confidence Interval (CI) [0.91, 0.99] and DFS: RR 0.93, 95% CI [0.87, 1.01]. There were lower hazards ratios in OS: RR 1.41, 95% CI [1.14, 1.74] and DFS: RR 1.95, 95% CI [1.36, 2.78] with radical, as compared to LE. Lower recurrence rate was associated with RE. Random effect model was used due to clinical heterogeneity between studies (different surgical procedures, tumor staging, adjuvant chemo or radiotherapy). Conclusions LE for early-stage rectal cancer has lower 5-year OS and DFS than RE, with higher local recurrence rate. However, LE is associated with lower early postoperative mortality, morbidity and length of stay as compared to RE.
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Affiliation(s)
| | - Samragnyi Madala
- University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, United States; 52242
| | - Anusha Chidharla
- Division of Medical Oncology, University of Kansas Cancer Center, 2650 Shawnee Mission Pkwy, Westwood, KS, United States 66205
| | | | - Subhrajit Saha
- Division of Radiation Oncology, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS, United States: 66160
| | - Benjamin Martin
- Division of Colorectal Surgery, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS, United States: 66160
| | - Anup Kasi
- Division of Medical Oncology, University of Kansas Cancer Center, 2650 Shawnee Mission Pkwy, Westwood, KS, United States 66205
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7
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Loria A, Tejani MA, Temple LK, Justiniano CF, Melucci AD, Becerra AZ, Monson JRT, Aquina CT, Fleming FJ. Practice Patterns for Organ Preservation in US Patients With Rectal Cancer, 2006-2020. JAMA Oncol 2024; 10:79-86. [PMID: 37943566 PMCID: PMC10636650 DOI: 10.1001/jamaoncol.2023.4845] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/08/2023] [Indexed: 11/10/2023]
Abstract
Importance In March 2023, the National Comprehensive Cancer Network endorsed watch and wait for those with complete clinical response to total neoadjuvant therapy. Neoadjuvant therapy is highly efficacious, so this recommendation may have broad implications, but the current trends in organ preservation in the US are unknown. Objective To describe organ preservation trends among patients with rectal cancer in the US from 2006 to 2020. Design, Setting, and Participants This retrospective, observational case series included adults (aged ≥18 years) with rectal adenocarcinoma managed with curative intent from 2006 to 2020 in the National Cancer Database. Exposure The year of treatment was the primary exposure. The type of therapy was chemotherapy, radiation, or surgery (proctectomy, transanal local excision, no tumor resection). The timing of therapy was classified as neoadjuvant or adjuvant. Main Outcomes and Measures The primary outcome was the absolute annual proportion of organ preservation after radical treatment, defined as chemotherapy and/or radiation without tumor resection, proctectomy, or transanal local excision. A secondary analysis examined complete pathologic responses among eligible patients. Results Of the 175 545 patients included, the mean (SD) age was 63 (13) years, 39.7% were female, 17.4% had clinical stage I disease, 24.7% had stage IIA to IIC disease, 32.1% had stage IIIA to IIIC disease, and 25.7% had unknown stage. The absolute annual proportion of organ preservation increased by 9.8 percentage points (from 18.4% in 2006 to 28.2% in 2020; P < .001). From 2006 to 2020, the absolute rate of organ preservation increased by 13.0 percentage points for patients with stage IIA to IIC disease (19.5% to 32.5%), 12.9 percentage points for patients with stage IIIA to IIC disease (16.2% to 29.1%), and 10.1 percentage points for unknown stages (16.5% to 26.6%; all P < .001). Conversely, patients with stage I disease experienced a 6.1-percentage point absolute decline in organ preservation (from 26.4% in 2006 to 20.3% in 2020; P < .001). The annual rate of transanal local excisions decreased for all stages. In the subgroup of 80 607 eligible patients, the proportion of complete pathologic responses increased from 6.5% in 2006 to 18.8% in 2020 (P < .001). Conclusions and Relevance This case series shows that rectal cancer is increasingly being managed medically, especially among patients whose treatment historically relied on proctectomy. Given the National Comprehensive Cancer Network endorsement of watch and wait, the increasing trends in organ preservation, and the nearly 3-fold increase in complete pathologic responses, international professional societies should urgently develop multidisciplinary core outcome sets and care quality indicators to ensure high-quality rectal cancer research and care delivery accounting for organ preservation.
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Affiliation(s)
- Anthony Loria
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | | | - Larissa K. Temple
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Carla F. Justiniano
- Division of Colon and Rectal Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Alexa D. Melucci
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Adan Z. Becerra
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - John R. T. Monson
- Departments of Colorectal Surgery and Surgical Oncology, AdventHealth Orlando, Orlando, Florida
| | - Christopher T. Aquina
- Departments of Colorectal Surgery and Surgical Oncology, AdventHealth Orlando, Orlando, Florida
| | - Fergal J. Fleming
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, New York
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Kwik C, El-Khoury T, Pathma-Nathan N, Toh JWT. Endoscopic and trans-anal local excision vs. radical resection in the treatment of early rectal cancer: A systematic review and network meta-analysis. Int J Colorectal Dis 2023; 39:13. [PMID: 38157077 DOI: 10.1007/s00384-023-04584-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2023] [Indexed: 01/03/2024]
Abstract
PURPOSE The management of early-stage rectal cancer in clinical practice is controversial. The aim of this network meta-analysis was to compare oncological and postoperative outcomes for T1T2N0M0 rectal cancers managed with local excision in comparison to conventional radical resection. METHODS A systematic review of Medline, Embase and Cochrane electronic databases was performed. Relevant studies were selected using PRISMA guidelines. The primary outcomes measured were 5-year local recurrence and overall survival. Secondary outcomes included rates of postoperative complication, 30-day mortality, positive margin and permanent stoma formation. RESULTS Three randomized controlled trials and 27 observational studies contributed 8570 patients for analysis. Radical resection was associated with reduced 5-year local recurrence in comparison to local excision. This was statistically significant in comparison to trans-anal local excision (odds ratio (OR) 0.23; 95% confidence interval 0.16-0.30) and favourable in comparison to endoscopic techniques (OR 0.40; 95% confidence interval 0.13-1.23) although this did not reach clinical significance. Positive margin rates were lowest for radical resection. However, 30-day mortality rates, perioperative complications and permanent stoma rates all favoured local excision with no statistically significant difference between endoscopic and trans-anal techniques. CONCLUSION Radical resection of early rectal cancer is associated with the lowest 5-year local recurrence rates and the lowest rate of positive margins. However, this must be balanced with its higher 30-day mortality and complication rates as well as the increased risk of permanent stoma. The emerging potential role of neoadjuvant therapy prior to local resection, and the heterogeneity of its use, as an alternative treatment for early rectal cancer further complicates the treatment paradigm and adds to controversy in this field.
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Affiliation(s)
- Charlotte Kwik
- Department of Colorectal Surgery, Westmead Hospital, Cnr Hawkesbury Road and Darcy Road, Westmead, NSW, Australia.
| | - Toufic El-Khoury
- Department of Colorectal Surgery, Westmead Hospital, Cnr Hawkesbury Road and Darcy Road, Westmead, NSW, Australia
| | - Nimalan Pathma-Nathan
- Department of Colorectal Surgery, Westmead Hospital, Cnr Hawkesbury Road and Darcy Road, Westmead, NSW, Australia
| | - James Wei Tatt Toh
- Department of Colorectal Surgery, Westmead Hospital, Cnr Hawkesbury Road and Darcy Road, Westmead, NSW, Australia.
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
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Mavrogenis G, Ntourakis D, Kritikos N, Kasapidis P, Kaklamanis L, Kouloulias V, Bazerbachi F. Salvage endoscopic wide-field full-thickness resection of T2 rectal cancer with endoscopic submucosal dissection instruments, without defect closure. Endoscopy 2023; 55:E751-E752. [PMID: 37286179 PMCID: PMC10247307 DOI: 10.1055/a-2081-9081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Georgios Mavrogenis
- Unit of Hybrid Interventional Endoscopy, Department of Gastroenterology, Mediterraneo Hospital, Athens, Greece
| | - Dimitrios Ntourakis
- School of Medicine, European University Cyprus, Nicosia, Cyprus
- Department of Surgery, Mediterraneo Hospital, Athens, Greece
| | | | - Panagiotis Kasapidis
- Unit of Hybrid Interventional Endoscopy, Department of Gastroenterology, Mediterraneo Hospital, Athens, Greece
| | | | | | - Fateh Bazerbachi
- CentraCare, Interventional Endoscopy Program, St. Cloud Hospital, St. Cloud, Minnesota, USA
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10
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Moynihan A, Hardy N, Dalli J, Aigner F, Arezzo A, Hompes R, Knol J, Tuynman J, Cucek J, Rojc J, Rodríguez-Luna MR, Cahill R. CLASSICA: Validating artificial intelligence in classifying cancer in real time during surgery. Colorectal Dis 2023; 25:2392-2402. [PMID: 37932915 DOI: 10.1111/codi.16769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 09/14/2023] [Accepted: 09/16/2023] [Indexed: 11/08/2023]
Abstract
AIM Treatment pathways for significant rectal polyps differ depending on the underlying pathology, but pre-excision profiling is imperfect. It has been demonstrated that differences in fluorescence perfusion signals following injection of indocyanine green (ICG) can be analysed mathematically and, with the assistance of artificial intelligence (AI), used to classify tumours endoscopically as benign or malignant. This study aims to validate this method of characterization across multiple clinical sites regarding its generalizability, usability and accuracy while developing clinical-grade software to enable it to become a useful method. METHODS The CLASSICA study is a prospective, unblinded multicentre European observational study aimed to validate the use of AI analysis of ICG fluorescence for intra-operative tissue characterization. Six hundred patients undergoing transanal endoscopic evaluation of significant rectal polyps and tumours will be enrolled in at least five clinical sites across the European Union over a 4-year period. Video recordings will be analysed regarding dynamic fluorescence patterns centrally as software is developed to enable analysis with automatic classification to happen locally. AI-based classification and subsequently guided intervention will be compared with the current standard of care including biopsies, final specimen pathology and patient outcomes. DISCUSSION CLASSICA will validate the use of AI in the analysis of ICG fluorescence for the purposes of classifying significant rectal polyps and tumours endoscopically. Follow-on studies will compare AI-guided targeted biopsy or, indeed, AI characterization alone with traditional biopsy and AI-guided local excision versus traditional excision with regard to marginal clearance and recurrence.
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Affiliation(s)
- A Moynihan
- University College Dublin, Dublin, Ireland
| | - N Hardy
- University College Dublin, Dublin, Ireland
| | - J Dalli
- University College Dublin, Dublin, Ireland
| | - F Aigner
- Krankenhaus der Barmherzigen Brüder Graz, Graz, Austria
| | - A Arezzo
- Department of Surgical Sciences, University of Torino, Torino, Italy
- European Association for Endoscopic Surgery, Eindhoven, The Netherlands
| | - R Hompes
- Ziekenhuis Oost-Limburg Autonome Verzorgingsinstelling, Genk, Belgium
| | - J Knol
- Ziekenhuis Oost-Limburg Autonome Verzorgingsinstelling, Genk, Belgium
| | - J Tuynman
- Stitching VUMC, Amsterdam, The Netherlands
| | - J Cucek
- Arctur, Nova Gorica, Slovenia
| | - J Rojc
- Arctur, Nova Gorica, Slovenia
| | | | - R Cahill
- University College Dublin, Dublin, Ireland
- Mater Misericordiae University Hospital, Dublin, Ireland
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11
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Motamedi MAK, Mak NT, Brown CJ, Raval MJ, Karimuddin AA, Giustini D, Phang PT. Local versus radical surgery for early rectal cancer with or without neoadjuvant or adjuvant therapy. Cochrane Database Syst Rev 2023; 6:CD002198. [PMID: 37310167 PMCID: PMC10264720 DOI: 10.1002/14651858.cd002198.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Total mesorectal excision is the standard of care for stage I rectal cancer. Despite major advances and increasing enthusiasm for modern endoscopic local excision (LE), uncertainty remains regarding its oncologic equivalence and safety relative to radical resection (RR). OBJECTIVES To assess the oncologic, operative, and functional outcomes of modern endoscopic LE compared to RR surgery in adults with stage I rectal cancer. SEARCH METHODS We searched CENTRAL, Ovid MEDLINE, Ovid Embase, Web of Science - Science Citation Index Expanded (1900 to present), four trial registers (ClinicalTrials.gov, ISRCTN registry, the WHO International Clinical Trials Registry Platform, and the National Cancer Institute Clinical Trials database), two thesis and proceedings databases, and relevant scientific societies' publications in February 2022. We performed handsearching and reference checking and contacted study authors of ongoing trials to identify additional studies. SELECTION CRITERIA We searched for randomized controlled trials (RCTs) in people with stage I rectal cancer comparing any modern LE techniques to any RR techniques with or without the use of neo/adjuvant chemoradiotherapy (CRT). DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. We calculated hazard ratios (HR) and standard errors for time-to-event data and risk ratios for dichotomous outcomes, using generic inverse variance and random-effects methods. We regrouped surgical complications from the included studies into major and minor according to the standard Clavien-Dindo classification. We assessed the certainty of evidence using the GRADE framework. MAIN RESULTS Four RCTs were included in data synthesis with a combined total of 266 participants with stage I rectal cancer (T1-2N0M0), if not stated otherwise. Surgery was performed in university hospital settings. The mean age of participants was above 60, and median follow-up ranged from 17.5 months to 9.6 years. Regarding the use of co-interventions, one study used neoadjuvant CRT in all participants (T2 cancers); one study used short-course radiotherapy in the LE group (T1-T2 cancers); one study used adjuvant CRT selectively in high-risk patients undergoing RR (T1-T2 cancers); and the fourth study did not use any CRT (T1 cancers). We assessed the overall risk of bias as high for oncologic and morbidity outcomes across studies. All studies had at least one key domain with a high risk of bias. None of the studies reported separate outcomes for T1 versus T2 or for high-risk features. Low-certainty evidence suggests that RR may result in an improvement in disease-free survival compared to LE (3 trials, 212 participants; HR 1.96, 95% confidence interval (CI) 0.91 to 4.24). This would translate into a three-year disease-recurrence risk of 27% (95% CI 14 to 50%) versus 15% after LE and RR, respectively. Regarding sphincter function, only one study provided objective results and reported short-term deterioration in stool frequency, flatulence, incontinence, abdominal pain, and embarrassment about bowel function in the RR group. At three years, the LE group had superiority in overall stool frequency, embarrassment about bowel function, and diarrhea. Local excision may have little to no effect on cancer-related survival compared to RR (3 trials, 207 participants; HR 1.42, 95% CI 0.60 to 3.33; very low-certainty evidence). We did not pool studies for local recurrence, but the included studies individually reported comparable local recurrence rates for LE and RR (low-certainty evidence). It is unclear if the risk of major postoperative complications may be lower with LE compared with RR (risk ratio 0.53, 95% CI 0.22 to 1.28; low-certainty evidence; corresponding to 5.8% (95% CI 2.4% to 14.1%) risk for LE versus 11% for RR). Moderate-certainty evidence shows that the risk of minor postoperative complications is probably lower after LE (risk ratio 0.48, 95% CI 0.27 to 0.85); corresponding to an absolute risk of 14% (95% CI 8% to 26%) for LE compared to 30.1% for RR. One study reported an 11% rate of temporary stoma after LE versus 82% in the RR group. Another study reported a 46% rate of temporary or permanent stomas after RR and none after LE. The evidence is uncertain about the effect of LE compared with RR on quality of life. Only one study reported standard quality of life function, in favor of LE, with a 90% or greater probability of superiority in overall quality of life, role, social, and emotional functions, body image, and health anxiety. Other studies reported a significantly shorter postoperative period to oral intake, bowel movement, and off-bed activities in the LE group. AUTHORS' CONCLUSIONS Based on low-certainty evidence, LE may decrease disease-free survival in early rectal cancer. Very low-certainty evidence suggests that LE may have little to no effect on cancer-related survival compared to RR for the treatment of stage I rectal cancer. Based on low-certainty evidence, it is unclear if LE may have a lower major complication rate, but probably causes a large reduction in minor complication rate. Limited data based on one study suggest better sphincter function, quality of life, or genitourinary function after LE. Limitations exist with respect to the applicability of these findings. We identified only four eligible studies with a low number of total participants, subjecting the results to imprecision. Risk of bias had a serious impact on the quality of evidence. More RCTs are needed to answer our review question with greater certainty and to compare local and distant metastasis rates. Data on important patient outcomes such as sphincter function and quality of life are very limited. Results of currently ongoing trials will likely impact the results of this review. Future trials should accurately report and compare outcomes according to the stage and high-risk features of rectal tumors, and evaluate quality of life, sphincter, and genitourinary outcomes. The role of neoadjuvant or adjuvant therapy as an emerging co-intervention for improving oncologic outcomes after LE needs to be further defined.
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Affiliation(s)
| | - Nicole T Mak
- Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Carl J Brown
- Head, Division of General Surgery, St. Paul's Hospital, Vancouver, Canada
| | - Manoj J Raval
- Department of Surgery, St. Paul's Hospital, University of British Columbia, Vancouver, Canada
| | - Ahmer A Karimuddin
- Department of Surgery, St. Paul's Hospital, University of British Columbia, Vancouver, Canada
| | - Dean Giustini
- Faculty of Medicine, University of British Columbia Library, Vancouver, Canada
| | - Paul Terry Phang
- Department of Surgery, St. Paul's Hospital, University of British Columbia, Vancouver, Canada
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Freund MR, Horesh N, Emile SH, Garoufalia Z, Gefen R, Wexner SD. Predictors and outcomes of positive surgical margins after local excision of clinical T1 rectal cancer: A National Cancer Database analysis. Surgery 2023; 173:1359-1366. [PMID: 36959073 DOI: 10.1016/j.surg.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 02/09/2023] [Accepted: 02/11/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Transanal local excision and the use of specialized platforms has become increasingly popular for early-stage rectal cancer. Predictors and outcomes of positive resection margins following transanal local excision for early-stage rectal cancer have yet to be explored. METHODS This was a retrospective analysis of the National Cancer Database of all patients with clinical nonmetastatic node negative T1 rectal adenocarcinoma who underwent transanal local excision from 2004 to 2017. Patients with positive surgical margins were compared to those with negative resection margins to determine factors associated with predictors and outcomes of positive surgical margins after transanal local excision. The main outcome measure was overall survival. RESULTS Of 318,548 patients with rectal adenocarcinoma in the National Cancer Database, 9,078 (2.8%) met the inclusion criteria. The positive surgical margins rate was 7.4%. Predictors of positive surgical margins were older age (odds ratio, 1.03; P < .001), higher Charlson comorbidity index (odds ratio, 1.24; P = .004), poorly differentiated carcinomas (odds ratio, 1.89; P < .001), mucinous (odds ratio, 2.36; P = .003) and signet-ring cell carcinomas (odds ratio, 4.7; P = .048). Independent predictors of reduced survival were older age (hazard ratio, 1.062; P < .001), male sex (hazard ratio, 1.214; P = .011), Charlson comorbidity index 3 (hazard ratio, 1.94; P < .001), pathologic T2 (hazard ratio, 1.27; P = .036) and T3 stages (hazard ratio, 1.77; P = .006), poorly differentiated carcinomas (hazard ratio, 1.47; P = .008), and positive surgical margins (hazard ratio, 1.374; P = .018). The positive surgical margins group's median overall survival was significantly shorter (88 vs 159.3 months, P < .001). CONCLUSION Positive surgical margins after transanal local excision for early-stage node-negative rectal cancer adversely affects prognosis. Older male patients with higher Charlson comorbidity index scores and poorly differentiated mucinous or signet cell histology tumors are at risk for positive surgical margins. Patient selection according to these suggested criteria may help avoid positive surgical margins.
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Affiliation(s)
- Michael R Freund
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Department of General Surgery, Shaare Zedek Medical Center, the Hebrew University Faculty of Medicine, Jerusalem, Israel. https://twitter.com/mikifreund
| | - Nir Horesh
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Department of Surgery and Transplantations, Sheba Medical Center, Ramat Gan, Israel. https://twitter.com/Nirhoresh1
| | - Sameh Hany Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Colorectal Surgery Unit, Mansoura University, Faculty of Medicine, Egypt. https://twitter.com/dr_samehhany81
| | - Zoe Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL. https://twitter.com/ZGaroufalia
| | - Rachel Gefen
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Department of General Surgery, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Israel. https://twitter.com/RachellGefen
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL.
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Roat-Shumway S, Tonelli C, Singer M, Cohn T, Luchette FA, Abdelsattar Z, Baker MS. Is local excision an appropriate treatment modality in patients presenting with early-stage (cT1 N0 M0) rectal adenocarcinoma? Surgery 2023; 173:665-673. [PMID: 36273975 DOI: 10.1016/j.surg.2022.08.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/29/2022] [Accepted: 08/05/2022] [Indexed: 02/11/2023]
Abstract
BACKGROUND Prior studies evaluating the safety and efficacy of local excision relative to surgical resection in early-stage rectal adenocarcinoma have primarily included low rectal cancers treated with abdominoperineal resection as control comparison cohorts. The role of local excision in early-stage rectal adenocarcinoma is incompletely defined. METHODS We queried the National Cancer Database to identify patients with cT1 N0 M0 rectal adenocarcinoma between 2004 and 2019. Patients undergoing abdominoperineal resection were excluded. Multivariable regression was used to identify factors associated with use of local excision instead of low anterior resection. Patients undergoing local excision were propensity score matched for age, sex, demographic characteristics, Charlson-Deyo comorbidity class score, and tumor grade and size to those undergoing low anterior resection. Short-term clinical outcomes and 5-year overall survival for matched cohorts were compared by standard methods. RESULTS A total of 5,693 patients met inclusion criteria; 1,973 patients underwent local excision and 3,720 low anterior resection. Age (adjusted odds ratio 1.26; 95% confidence interval, 1.17-1.37), tumor histology (poorly differentiated histology: adjusted odds ratio 0.66; 95% confidence interval, 0.51-0.86), and size (>4 cm: adjusted odds ratio 0.20; 95% confidence interval, 0.16-0.25) were associated with choice of intervention. On comparison of matched cohorts, patients undergoing LE demonstrated shorter hospital stay (2.4 ±9.8 vs 5.6 ±8.1 days; P < .001) and lower readmission rate (4% vs 7%; P = .002) but higher margin-positive resection rates (8% vs 2%; P < .001). Overall survival profiles for patients undergoing local excision were comparable with those for low anterior resection. CONCLUSION In patients with cT1 N0 M0 rectal adenocarcinoma, local excision is associated with a higher margin-positive resection rate than low anterior resection but affords accelerated postprocedure recovery and comparable rates of overall survival.
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Affiliation(s)
- Siena Roat-Shumway
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL. https://twitter.com/sroatshumway
| | - Celsa Tonelli
- Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Marc Singer
- Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Tyler Cohn
- Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Fred A Luchette
- Department of Surgery, Loyola University Medical Center, Maywood, IL; Edward Hines, Jr. Veterans Administration Hospital, Maywood, IL
| | - Zaid Abdelsattar
- Department of Surgery, Loyola University Medical Center, Maywood, IL; Edward Hines, Jr. Veterans Administration Hospital, Maywood, IL
| | - Marshall S Baker
- Department of Surgery, Loyola University Medical Center, Maywood, IL; Edward Hines, Jr. Veterans Administration Hospital, Maywood, IL.
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Stijns RCH, Leijtens J, de Graaf E, Bach SP, Beets G, Bremers AJA, Beets-Tan RGH, de Wilt JHW. Endoscopy and MRI for restaging early rectal cancer after neoadjuvant treatment. Colorectal Dis 2023; 25:211-221. [PMID: 36104011 DOI: 10.1111/codi.16341] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 05/30/2022] [Accepted: 07/01/2022] [Indexed: 02/08/2023]
Abstract
AIM Chemoradiotherapy (CRT) has great potential to downstage rectal cancer. Response assessment has been investigated in locally advanced rectal cancer but not in early stage rectal cancer. The aim is to characterize the diagnostic accuracy of endoscopy performed by surgical endoscopists compared to (diffusion-weighted, DWI) MRI only and a multimodal approach combining (DWI-)MRI and endoscopic information both analysed by an abdominal radiologist for response assessment in early rectal cancer after neoadjuvant CRT. MATERIALS AND METHODS Patients treated with neoadjuvant CRT for early distal rectal cancer (cT1-3 N0) followed by transanal endoscopic microsurgery were included. Three separate reassessment groups were analysed for response assessment using endoscopic evaluation alone versus (DWI-)MRI alone versus the combination of endoscopy with (DWI-)MRI with a focus on sensitivity and specificity and analysis using receiver operating characteristic curves. RESULTS Three cohorts (N = 36, N = 25 and N = 25, respectively) were analysed for response assessment. Of the endoscopy cohort, 16 of the 36 patients had a complete response. Area under the curve was 0.69 (0.66-0.74; pooled sensitivity 55.3%, pooled specificity 80.0%). Agreement for scoring separate endoscopic features was poor to moderate. Of the (DWI-)MRI cohort, 11 of the 25 patients had a complete response. Area under the curve for (DWI-)MRI alone was 0.55 (sensitivity 72.7%, specificity 42.9%). The areas under the receiver operating characteristic curve improved to 0.68 (sensitivity 90.9%, specificity 75.0%) when (DWI-)MRI was combined with endoscopic information, with 11 out of 25 patients with a complete response. The most accurate response assessment was made by combining endoscopy and (DWI-)MRI with a high negative predictive value (90.9%). CONCLUSION Good and complete responders after chemoradiation of early stage rectal cancer can be best assessed using a multimodality approach combining endoscopy and (DWI-)MRI.
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Affiliation(s)
- Rutger C H Stijns
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Jeroen Leijtens
- Department of Surgery, Laurentius Hospital, Roermond, The Netherlands
| | - Eelco de Graaf
- Department of Surgery, IJsselland Hospital, Capelle aan de Ijssel, The Netherlands
| | - Simon P Bach
- Department of Surgery, University Hospitals Birmingham, Birmingham, UK
| | - Geerard Beets
- Department of Surgery, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Andre J A Bremers
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Regina G H Beets-Tan
- Department of Radiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
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15
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Robot-assisted TAMIS: a systematic review of feasibility and outcomes. Surg Endosc 2023; 37:3398-3409. [PMID: 36707419 PMCID: PMC9882737 DOI: 10.1007/s00464-022-09853-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 12/27/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND In the advancement of transanal local excision, robot-assisted transanal minimal invasive surgery is the newest development. In the confined area of the rectum, robot-assisted surgery should, theoretically, be superior due to articulated utensils, video enhancement, and tremor reduction, however, this has not yet been investigated. The aim of this study was to review the evidence reported to-date on experience of using robot-assisted transanal minimal invasive surgery for treatment of rectal neoplasms. METHODS A comprehensive literature search of Embase and PubMed from May to August 2021were performed. Studies including patients diagnosed with rectal neoplasia or benign polyps who underwent robot-assisted transanal minimal invasive surgery were included. All studies were assessed for risk of bias through assessment tools. Main outcome measures were feasibility, excision quality, and complications. RESULTS Twenty-five studies with a total of 322 local excisions were included. The studies included were all retrospective, primarily case-reports, -series, and cohort studies. The median distance from the anal verge ranged from 3.5 to 10 cm and the median size was between 2.5 and 5.3 cm. Overall, 4.6% of the resections had a positive resection margin. The overall complication rate was at 9.5% with severe complications (Clavien-Dindo score III) at 0.9%. CONCLUSION Based on limited, retrospective data, with a high risk of bias, robot-assisted transanal minimal invasive surgery seems feasible and safe for local excisions in the rectum.
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Kennecke HF, O'Callaghan CJ, Loree JM, Moloo H, Auer R, Jonker DJ, Raval M, Musselman R, Ma G, Caycedo-Marulanda A, Simianu VV, Patel S, Pitre LD, Helewa R, Gordon VL, Neumann K, Nimeiri H, Sherry M, Tu D, Brown CJ. Neoadjuvant Chemotherapy, Excision, and Observation for Early Rectal Cancer: The Phase II NEO Trial (CCTG CO.28) Primary End Point Results. J Clin Oncol 2023; 41:233-242. [PMID: 35981270 PMCID: PMC9839227 DOI: 10.1200/jco.22.00184] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
PURPOSE Organ-sparing therapy for early-stage I/IIA rectal cancer is intended to avoid functional disturbances or a permanent ostomy associated with total mesorectal excision (TME). The objective of this phase II trial was to determine the outcomes and organ-sparing rate of patients with early-stage rectal cancer treated with neoadjuvant chemotherapy followed by transanal excision surgery (TES). METHODS This phase II trial included patients with clinical T1-T3abN0 low- or mid-rectal adenocarcinoma eligible for endoscopic resection who were treated with 3 months of chemotherapy (modified folinic acid-fluorouracil-oxaliplatin 6 or capecitabine-oxaliplatin). Those with evidence of response proceeded to transanal endoscopic surgery 2-6 weeks later. The primary end point was protocol-specified organ preservation rate, defined as the proportion of patients with tumor downstaging to ypT0/T1N0/X and who avoided radical surgery. RESULTS Of 58 patients enrolled, all commenced chemotherapy and 56 proceeded to surgery. A total of 33/58 patients had tumor downstaging to ypT0/1N0/X on the surgery specimen, resulting in an intention-to-treat protocol-specified organ preservation rate of 57% (90% CI, 45 to 68). Of 23 remaining patients recommended for TME surgery on the basis of protocol requirements, 13 declined and elected to proceed directly to observation resulting in 79% (90% CI, 69 to 88) achieving organ preservation. The remaining 10/23 patients proceeded to recommended TME of whom seven had no histopathologic residual disease. The 1-year and 2-year locoregional relapse-free survival was, respectively, 98% (95% CI, 86 to 100) and 90% (95% CI, 58 to 98), and there were no distant recurrences or deaths. Minimal change in quality of life and rectal function scores was observed. CONCLUSION Three months of induction chemotherapy may successfully downstage a significant proportion of patients with early-stage rectal cancer, allowing well-tolerated organ-preserving surgery.
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Affiliation(s)
- Hagen F. Kennecke
- Providence Cancer Institute and Earle A Chiles Research Institute, Portland, OR,Hagen F. Kennecke, MD, MHA, Providence Cancer Institute, 4805 NE Glisan St, Portland, OR 97213; Twitter: @HKENNECKE; e-mail:
| | | | | | - Hussein Moloo
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Rebecca Auer
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Manoj Raval
- Providence-St. Paul's Hospital, Vancouver, BC, Canada
| | | | - Grace Ma
- Health Sciences North, Sudbury, ON, Canada
| | | | | | - Sunil Patel
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | | | | | | | | | | | - Max Sherry
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | - Dongsheng Tu
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | - Carl J. Brown
- Providence-St. Paul's Hospital, Vancouver, BC, Canada
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Maeda K, Koide Y, Katsuno H, Tajima Y, Hanai T, Masumori K, Matsuoka H, Shiota M. Long-term results of minimally invasive transanal surgery for rectal tumors in 249 consecutive patients. Surg Today 2023; 53:306-315. [PMID: 35962290 PMCID: PMC9950212 DOI: 10.1007/s00595-022-02570-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 06/27/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE To delineate the long-term results of minimally invasive transanal surgery (MITAS) for selected rectal tumors. METHODS We analyzed data, retrospectively, on consecutive patients who underwent MITAS between 1995 and 2015, to establish the feasibility, excision quality, and perioperative and oncological outcomes of this procedure. RESULTS MITAS was performed on 243 patients. The final histology included 142 cancers, 47 adenomas, and 52 neuroendocrine tumors (NET G1). A positive margin of 1.6% and 100% en bloc resection were achieved. The mean operative time was 27.4 min. Postoperative morbidity occurred in 7% of patients, with 0% mortality. The median follow-up was 100 months (up to ≥ 5 years or until death in 91.8% of patients). Recurrence developed in 2.9% of the patients. The 10-year overall survival rate was 100% for patients with NET G1 and 80.3% for those with cancer. The 5-year DFS was 100% for patients with Tis cancer, 90.6% for those with T1 cancer, and 87.5% for those with T2 or deeper cancers. MITAS for rectal tumors ≥ 3 cm resulted in perioperative and oncologic outcomes equivalent to those for tumors < 3 cm. CONCLUSION MITAS is feasible for the local excision (LE) of selected rectal tumors, including tumors ≥ 3 cm. It reduces operative time and secures excision quality and long-term oncological outcomes.
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Affiliation(s)
- Kotaro Maeda
- Department of Surgery, Medical Corporation Kenikukai Shonan Keiiku Hospital, 4360 Endo, Fujisawa, Kanagawa 252-0816 Japan
| | - Yoshikazu Koide
- Department of Surgery, Fujita Health University Hospital, Toyoake, 470-1192 Japan
| | - Hidetoshi Katsuno
- Department of Surgery, Fujita Health University Okazaki Medical Center, Okazaki, 444-0827 Japan
| | - Yosuke Tajima
- Department of Surgery, Fujita Health University Hospital, Toyoake, 470-1192 Japan
| | - Tsunekazu Hanai
- Department of Surgery, Fujita Health University Hospital, Toyoake, 470-1192 Japan
| | - Koji Masumori
- Department of Surgery, Fujita Health University Hospital, Toyoake, 470-1192 Japan
| | - Hiroshi Matsuoka
- Department of Surgery, Fujita Health University Hospital, Toyoake, 470-1192 Japan
| | - Miho Shiota
- Department of Surgery, Kaisei Hospital, Sakaide, 657-0068 Japan
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Lynn PB, Van der Valk MJM, Claassen YHM, Shi Q, Widmar M, Bastiaannet E, Van de Velde CJH, Garcia-Aguilar J. Chemoradiation and Local Excision Versus Total Mesorectal Excision for T2N0 Rectal Cancer: Comparison of Short- and Long-Term Outcomes From 2 Prospective Studies. Ann Surg 2023; 277:e96-e102. [PMID: 34225302 PMCID: PMC8658950 DOI: 10.1097/sla.0000000000005052] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Compare oncological long-term and short-term outcomes between patients with distal cT2NO rectal cancer treated with chemoradio-therapy and local excision (CRT + LE) and patients treated with total mesorectal excision (TME). SUMMARY BACKGROUND DATA Previous studies showed that CRT + LE is equivalent to TME in local tumor control and survival for T2N0 rectal cancer. METHODS Seventy-nine patients with cT2N0 rectal adenocarcinoma treated with CRT + LE in the ACOSOG Z6041 trial were compared to a cohort of 79 patients with pT2N0 tumors treated with upfront TME in the Dutch TME trial. Survival, short-term outcomes, and health-related quality of life (HRQOL) were compared between groups. RESULTS Three patients (4%) in the CRT + LE group required abdominoperineal resection, compared with 31 (40%) in the TME group. Forty TME patients (51%) required a permanent stoma. CRT-related toxicity occurred in 43% of the CRT + LE patients; however, TME patients had a higher rate of complications requiring reoperation (1 vs 9%; P = 0 .03). Five-year disease-free survival {88.2% [confidence interval (CI), 77.7%-93.9%] vs 88.3% [CI, 78.7%-93.7%]; P = 0.88} and overall survival [90.3% (CI, 80.8%-95.3%) vs 88.4% (CI, 78.9%-93.8%); P = 0 .82] were similar in the 2 groups. Compared to baseline, overall HRQOL decreased in the CRT + LE group and improved in the TME group. In both groups, patients with sphincter preservation had worse HRQOL scores 1 year after surgery. Conclusions: In patients who underwent CRT + LE, oncological outcomes were similar to those of patients who underwent TME, with fewer complications requiring reoperation but significant CRT toxicity. Although overall HRQOL decreased in the CRT + LE group and improved in TME patients, when considering anorectal function, results were worse in both groups.
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Affiliation(s)
- Patricio B Lynn
- Department of General Surgery, NYU Langone Health, New York, NY
| | | | | | - Qian Shi
- Department of Health Science Research, Mayo Clinic, Rochester, MN
| | - Maria Widmar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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Liu PL, Wang DD, Pang CJ, Zhang LZ. Impact of adequate lymph nodes dissection on survival in patients with stage I rectal cancer. Front Oncol 2022; 12:985324. [DOI: 10.3389/fonc.2022.985324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 10/28/2022] [Indexed: 11/21/2022] Open
Abstract
Background and AimsThe NCCN guidelines recommended an assessment of ≥ 12 lymph nodes (LN) as an adequate LN dissection (LND) for rectal cancer (RC). However, the impact of adequate LND on survival in stage I RC patients remained unclear. Thus, we aimed to compare the survival between stage I RC patients with adequate and inadequate LND.MethodsA total of 1,778 stage I RC patients in the SEER database from 2010 to 2017 treated with radical proctectomy were identified. The association between ≥ 12 LND and survival was examined using the multivariate Cox regression and the multivariate competing risk model referenced to < 12 LND.ResultsStage I RC patients with ≥ 12 LND experienced a significantly lower hazard of cancer-specific death compared with those with < 12 LND in both multivariate Cox regression model (adjusted HR [hazard ratio], 0.44, 95% CI, 0.29-0.66; P < 0.001) and the multivariate competing risk model (adjusted subdistribution HR [SHR], 0.45, 95% CI, 0.30-0.69; P < 0.001). Further, subgroup analyses performed by pT stage. No positive association between ≥ 12 LND and survival was found in pT1N0 RC patients (adjusted HR: 0.62, 95%CI, 0.32-1.19; P = 0.149; adjusted SHR: 0.63, 95%CI, 0.33-1.20; P = 0.158), whereas a positive association between ≥ 12 LND and survival was found in pT2N0 RC patients (adjusted HR: 0.35, 95%CI, 0.21-0.58; P < 0.001; adjusted SHR: 0.36, 95%CI, 0.21-0.62; P < 0.001).ConclusionsThe long-term survival benefit of adequate LND was not found in pT1N0 but in pT2N0 RC patients, which suggested that pT2N0 RC patients should be treated with adequate LND and those with inadequate LND might need additional therapy.
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Peltrini R, Imperatore N, Di Nuzzo MM, Pellino G. Towards personalized treatment of T2N0 rectal cancer: A systematic review of long-term oncological outcomes of neoadjuvant therapy followed by local excision. J Gastroenterol Hepatol 2022; 37:1426-1433. [PMID: 35614027 PMCID: PMC9545053 DOI: 10.1111/jgh.15898] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 05/17/2022] [Accepted: 05/19/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIM Total mesorectal excision (TME) remains the treatment of choice in T2N0 tumors. However, evidence suggest that one-size-fits-all approach is not always beneficial for this group of patients. The aim of this study is to synthesize data on long-term outcomes after neoadjuvant therapy (NAT) followed by local excision (LE) in T2N0 rectal cancer patients in the perspective of a rectal-preserving strategy. METHODS A systematic search of PubMed/MEDLINE, SCOPUS, and Web of Science databases was conducted until October 2021 to identify studies comparing LE after NAT and TME or reporting oncologic outcomes after conservative approach. A pooled analysis was conducted using a fixed-effect model in the case of non-significant heterogeneity (P > 0.1), and a random effect model (DerSimonian-Laird method) when significant heterogeneity was present (P < 0.1) CRD42022300344. RESULTS Nine studies were included in the analysis. Three of them were comparative studies. The pooled 3-year DFS, 5-year DFS, 3-year OS, 5-year OS, local and distant recurrence rates were 92.8% (95% CI 81.6-99.5%), 91.3% (95% CI 88.3-94.3%), 96.1% (95% CI 90.5-100%), 72.6% (95% CI 57.5-87.7%), 4% (95% CI 18-63%), and 4.9% (95% CI 2-7.8%), respectively, in subjects treated with NAT followed by LE. No heterogeneity was found for all these analyses, except for the 5-year OS sub-analysis (I2 95.5%, P < 0.001). Complete pathological response (ypT0) rate after NAT and LE ranges from 26.7% to 59%. CONCLUSION LE following neoadjuvant CRT may provide comparable survival benefit to radical surgery for patients with clinical stage T2N0 in selected patients although the evidence is still limited to provide solid recommendations. A personalized therapeutic approach taking into account tumor and patient-related factors should be considered.
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Affiliation(s)
- Roberto Peltrini
- Department of Public Health, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Nicola Imperatore
- Gastroenterology and Endoscopy Unit, AORN Antonio Cardarelli, Naples, Italy
| | - Maria Michela Di Nuzzo
- Department of Public Health, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitell", Naples, Italy.,Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
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Read M, Felder S. Transanal Approaches to Rectal Neoplasia. SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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22
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Neoadjuvant and Adjuvant Therapy for Local Excision of Rectal Cancer. SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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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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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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Berger NF, Sylla P. The Role of Transanal Endoscopic Surgery for Early Rectal Cancer. Clin Colon Rectal Surg 2022; 35:113-121. [PMID: 35237106 PMCID: PMC8885158 DOI: 10.1055/s-0041-1742111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Transanal endoscopic surgery (TES), which is performed through a variety of transanal endoluminal multitasking surgical platforms, was developed to facilitate endoscopic en bloc excision of rectal lesions as a minimally invasive alternative to radical proctectomy. Although the oncologic safety of TES in the treatment of malignant rectal tumors has been an area of vigorous controversy over the past two decades, TES is currently accepted as an oncologically safe approach for the treatment of carefully selected early and superficial rectal cancers. TES can also serve as both a diagnostic and potentially curative treatment of partially resected unsuspected malignant polyps. In this article, indications and contraindications for transanal endoscopic excision of early rectal cancer lesions are reviewed, as well as selection criteria for the most appropriate transanal excisional approach. Preoperative preparation and surgical technique for complications of TES will be reviewed, as well as recommended surveillance and management of upstaged tumors.
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Affiliation(s)
| | - Patricia Sylla
- Icahn School of Medicine at Mount Sinai, New York, New York,Division of Colon and Rectal Surgery, Department of Surgery, Mount Sinai Hospital, New York, New York,Address for correspondence Patricia Sylla, MD, FACS, FASCRS Division of Colon and Rectal Surgery, Department of Surgery, Mount Sinai Hospital5 East 98th Street, Box 1259, New York, NY 10029
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Wlodarczyk JR, Lee SW. New Frontiers in Management of Early and Advanced Rectal Cancer. Cancers (Basel) 2022; 14:938. [PMID: 35205685 PMCID: PMC8870151 DOI: 10.3390/cancers14040938] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 01/29/2022] [Accepted: 02/08/2022] [Indexed: 02/04/2023] Open
Abstract
It is important to understand advances in treatment options for rectal cancer. We attempt to highlight advances in rectal cancer treatment in the form of a systematic review. Early-stage rectal cancer focuses on minimally invasive endoluminal surgery, with importance placed on patient selection as the driving factor for improved outcomes. To achieve a complete pathologic response, various neoadjuvant chemoradiation regimens have been employed. Short-course radiation therapy, total neoadjuvant chemotherapy, and others provide unique advantages with select patient populations best suited for each. With a clinical complete response, a "watch and wait" non-operative surveillance has been introduced with preliminary equivalency to radical resection. Various modalities for total mesorectal excision, such as robotic or transanal, have advantages and can be utilized in select patient populations. Tumors demonstrating solid organ or peritoneal spread, traditionally defined as unresectable lesions conveying a terminal diagnosis, have recently undergone advances in hepatic and pulmonary metastasectomy. Hepatic and pulmonary metastasectomy has demonstrated clear advantages in 5-year survival over standard chemotherapy. With the peritoneal spread of colorectal cancer, HIPEC with cytoreductive therapy has emerged as the preferred treatment. Understanding the various therapeutic interventions will pave the way for improved patient outcomes.
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Affiliation(s)
| | - Sang W. Lee
- Division of Colorectal Surgery, Norris Cancer Center, Keck School of Medicine, University of Southern California, 1441 Eastlake Avenue, Suite NTT-7418, Los Angeles, CA 90033, USA;
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Stitzenberg KB. Advances in Rectal Cancer Surgery. Clin Colorectal Cancer 2022; 21:55-62. [DOI: 10.1016/j.clcc.2022.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 01/18/2022] [Accepted: 01/20/2022] [Indexed: 12/16/2022]
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Tang J, Zhang Y, Zhang D, Zhang C, Jin K, Ji D, Peng W, Feng Y, Sun Y. Total Mesorectal Excision vs. Transanal Endoscopic Microsurgery Followed by Radiotherapy for T2N0M0 Distal Rectal Cancer: A Multicenter Randomized Trial. Front Surg 2022; 9:812343. [PMID: 35178428 PMCID: PMC8844472 DOI: 10.3389/fsurg.2022.812343] [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: 11/10/2021] [Accepted: 01/10/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction Transanal endoscopic microsurgery (TEM) is an organ-preserving treatment alternative for patients with early rectal cancer. However, TEM alone is associated with greater risk of local recurrence and inferior survival in comparison with total meso-rectal excision (TME). As an important adjuvant therapy, radiotherapy can effectively reduce the local recurrence rate of rectal cancer. This study aimed to investigate whether TEM followed by radiotherapy can be a valid alternative to TME in T2N0M0 distal rectal cancer treatment. Methods We plan to recruit 168 participants meeting established inclusion criteria. Following informed consent, participants will randomly receive treatment protocols of TEM followed by radiotherapy (a total dose of 45–50.4 Gy given in 25–28 factions) or TME. Depending on post-operative pathology, the participants will receive either long-term follow-up or further treatment. The primary endpoint of this trial is 3-year local recurrence rate. The secondary end points include 3-year disease-free survival rate, 3-year overall survival rate, 3-year mortality rate, post-operative quality of life, post-operative safety index, intraoperative evaluation index and post-operative short-term evaluation index. Discussion This trial is the first prospective randomized trial to investigate the rectum preserving treatment by using transanal local excision followed by radiotherapy. Clinical trial registration The trial was prospectively registered at ClinicalTrials.gov NCT04098471 on September 20, 2019.
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Al-Sawat A, Bae JH, Kim HH, Lee CS, Han SR, Lee YS, Cho HM, Jang HS, Lee IK. Short- and long-term outcomes of local excision with adjuvant radiotherapy in high-risk T1 rectal cancer patients. Ann Surg Treat Res 2022; 102:36-45. [PMID: 35071118 PMCID: PMC8753379 DOI: 10.4174/astr.2022.102.1.36] [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: 10/07/2021] [Revised: 10/28/2021] [Accepted: 11/12/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose Methods Results Conclusion
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Affiliation(s)
- Abdullah Al-Sawat
- Department of Surgery, College of Medicine, Taif University, Taif, Saudi Arabia
| | - Jung Hoon Bae
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyun Ho Kim
- Division of Colorectal Surgery, Department of Surgery, St. Vincent Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chul Seung Lee
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung Rim Han
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yoon Suk Lee
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyeon-Min Cho
- Division of Colorectal Surgery, Department of Surgery, St. Vincent Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hong Seok Jang
- Department of Radiation Oncology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - In Kyu Lee
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Whelan S, Burneikis D, Kalady MF. Rectal cancer: Maximizing local control and minimizing toxicity. J Surg Oncol 2021; 125:46-54. [PMID: 34897711 DOI: 10.1002/jso.26743] [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: 10/07/2021] [Accepted: 10/11/2021] [Indexed: 12/31/2022]
Abstract
Adoption of multimodality treatment approach for rectal cancer has resulted in significant improvements in oncologic outcomes. The roles of chemotherapy, radiation, and surgery in rectal cancer treatment are continuously evolving with the goal of achieving the best possible oncologic and functional outcome while minimizing treatment toxicity. The aim of this review is to summarize the most recent trials focusing on organ-sparing treatment strategies and the optimal selection of patients for neoadjuvant radiation therapy.
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Affiliation(s)
- Sean Whelan
- Department of Surgery, Division of Colon and Rectal Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Dominykas Burneikis
- Department of Surgery, Division of Colon and Rectal Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Matthew F Kalady
- Department of Surgery, Division of Colon and Rectal Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Gramellini M, Carrano FM, Spinelli A. Role of surgical approach on LARS: LAR vs. TEM, TAMIS, transanal excision, TaTME. SEMINARS IN COLON AND RECTAL SURGERY 2021. [DOI: 10.1016/j.scrs.2021.100846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Smits LJH, van Lieshout AS, Grüter AAJ, Horsthuis K, Tuynman JB. Multidisciplinary management of early rectal cancer - The role of surgical local excision in current and future clinical practice. Surg Oncol 2021; 40:101687. [PMID: 34875460 DOI: 10.1016/j.suronc.2021.101687] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/30/2021] [Accepted: 11/22/2021] [Indexed: 12/14/2022]
Abstract
The implementation of bowel cancer screening programs has led to a rise in the incidence of early rectal cancer. The combination of increased incidence and the growing interest in organ-sparing treatment options has led to an amplified importance of local excision techniques in treatment strategies for early rectal cancer. In addition, developments in new technologies of single-port surgery have popularized surgical techniques. Although local treatment of early rectal cancer seems promising, a multidisciplinary approach is necessary and awareness of the oncological robustness is warranted to enable shared decision-making. This review illustrates the position of surgical local excision in the treatment of early rectal cancer and reflects on its role in current and future clinical practice.
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Affiliation(s)
- Lisanne J H Smits
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, the Netherlands.
| | - Annabel S van Lieshout
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, the Netherlands
| | - Alexander A J Grüter
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, the Netherlands
| | - Karin Horsthuis
- Department of Radiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, the Netherlands
| | - Jurriaan B Tuynman
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, the Netherlands.
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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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Pacevicius J, Petrauskas V, Pilipavicius L, Dulskas A. Local Excision ± Chemoradiotherapy vs. Total Mesorectal Excision for Early Rectal Cancer: Case-Matched Analysis of Long-Term Results. Front Surg 2021; 8:746784. [PMID: 34733880 PMCID: PMC8558343 DOI: 10.3389/fsurg.2021.746784] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 09/07/2021] [Indexed: 12/14/2022] Open
Abstract
Background: Our aim was to compare the bowel function and oncologic outcomes following these two treatment modalities. Materials and methods: This was a single-center study with 67 patients included between 2009 and 2018. A total of 32 patients underwent total mesorectal excision (TME) group and 35 transanal local excisions (LE) ± chemoradiation. We performed a case-matched analysis: we matched the patients by age, cancer stage, and comorbidities. Duration of operation, postoperative complications, length of hospital stay, and long-term functional and oncological outcomes were compared. We calculated oncological outcomes using Kaplan-Meier Cox diagrams. In addition, we used a low anterior resection syndrome (LARS) score for the bowel function assessment. Results: Mean operation time in the LE group was 58.8 ± 45 min compared with the TME group that was 121.1 ± 42 min (p = 0.032). Complications were seen in 5.7% in LE group and 15.62% in TME group (p = 0.043). ~85.2% of the patients had no LARS in LE group compared with 54.5% in TME group (p = 0.018). Minor LARS was 7.4% in LE group compared with 31.8% in TME group (p = 0.018); major LARS was 7.4 and 13.7%, respectively (p = 0.474). Hospital stay was 2.77 days in LE group compared with 9.21 days in TME group (p = 0.036). The overall survival was 68.78 months in LE group compared with 74.81 months in TME group (p = 0.964). Conclusion: Our results of a small sample size showed that local excision ± chemoradiation is a rather safe method for early rectal cancer compared with gold standard treatment. In addition, better bowel function is preserved with less postoperative complications and shorter hospital stays.
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Affiliation(s)
- Julius Pacevicius
- Department of Abdominal and General Surgery and Oncology, National Cancer Institute, Vilnius, Lithuania
| | - Vidas Petrauskas
- Department of Abdominal and General Surgery and Oncology, National Cancer Institute, Vilnius, Lithuania
| | - Lukas Pilipavicius
- Department of Abdominal and General Surgery and Oncology, National Cancer Institute, Vilnius, Lithuania
| | - Audrius Dulskas
- Department of Abdominal and General Surgery and Oncology, National Cancer Institute, Vilnius, Lithuania
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Jeon YW, Park IJ, Kim JE, Park JH, Lim SB, Kim CW, Yoon YS, Lee JL, Yu CS, Kim JC. Evaluating the benefit of adjuvant chemotherapy in patients with ypT0–1 rectal cancer treated with preoperative chemoradiotherapy. World J Gastrointest Surg 2021; 13:1000-1011. [PMID: 34621476 PMCID: PMC8462088 DOI: 10.4240/wjgs.v13.i9.1000] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 05/22/2021] [Accepted: 08/02/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Adjuvant chemotherapy (ACTx) is recommended in rectal cancer patients after preoperative chemoradiotherapy (PCRT), but its efficacy in patients in the early post-surgical stage who have a favorable prognosis is controversial.
AIM To evaluate the long-term survival benefit of ACTx in patients with ypT0–1 rectal cancer after PCRT and surgical resection.
METHODS We identified rectal cancer patients who underwent PCRT followed by surgical resection at the Asan Medical Center from 2005 to 2014. Patients with ypT0–1 disease and those who received ACTx were included. The 5-year overall survival (OS) and 5-year recurrence-free survival (RFS) were analyzed according to the status of the ACTx.
RESULTS Of 520 included patients, 413 received ACTx (ACTx group) and 107 did not (no ACTx group). No significant difference was observed in 5-year RFS (ACTx group, 87.9% vs no ACTx group, 91.4%, P = 0.457) and 5-year OS (ACTx group, 90.5% vs no ACTx group, 86.2%, P = 0.304) between the groups. cT stage was associated with RFS and OS in multivariate analysis [hazard ratio (HR): 2.57, 95% confidence interval (CI): 1.07–6.16, P = 0.04 and HR: 2.27, 95%CI: 1.09–4.74, P = 0.03, respectively]. Furthermore, ypN stage was associated with RFS and OS (HR: 4.74, 95%CI: 2.39–9.42, P < 0.00 and HR: 4.33, 95%CI: 2.20–8.53, P < 0.00, respectively), but only in the radical resection group.
CONCLUSION Oncological outcomes of patients with ypT0–1 rectal cancer who received ACTx after PCRT showed no improvement, regardless of the radicality of resection. Further trials are needed to evaluate the efficacy of ACTx in these group of patients.
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Affiliation(s)
- Ye Won Jeon
- Department of Surgery, Asan Medical Center and University of Ulsan College of Medicine, Seoul 05505, South Korea
| | - In Ja Park
- Department of Colon and Rectal Surgery, Asan Medical Center and University of Ulsan College of Medicine, Seoul 05505, South Korea
| | - Jeong Eun Kim
- Department of Oncology, Asan Medical Center and University of Ulsan College of Medicine, Seoul 05505, South Korea
| | - Jin-Hong Park
- Department of Radiation Oncology, Asan Medical Center and University of Ulsan College of Medicine, Seoul 05505, South Korea
| | - Seok-Byung Lim
- Department of Colon and Rectal Surgery, Asan Medical Center and University of Ulsan College of Medicine, Seoul 05505, South Korea
| | - Chan Wook Kim
- Department of Colon and Rectal Surgery, Asan Medical Center and University of Ulsan College of Medicine, Seoul 05505, South Korea
| | - Yong Sik Yoon
- Department of Colon and Rectal Surgery, Asan Medical Center and University of Ulsan College of Medicine, Seoul 05505, South Korea
| | - Jong Lyul Lee
- Department of Colon and Rectal Surgery, Asan Medical Center and University of Ulsan College of Medicine, Seoul 05505, South Korea
| | - Chang Sik Yu
- Department of Colon and Rectal Surgery, Asan Medical Center and University of Ulsan College of Medicine, Seoul 05505, South Korea
| | - Jin Cheon Kim
- Department of Colon and Rectal Surgery, Asan Medical Center and University of Ulsan College of Medicine, Seoul 05505, South Korea
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Khoury W, Dauod M, Khalefah M, Duek SD, Issa N. The outcome of transanal endoscopic microsurgery and adjuvant radiotherapy in patients with high-risk T1 rectal cancer. J Minim Access Surg 2021; 18:212-217. [PMID: 35313431 PMCID: PMC8973482 DOI: 10.4103/jmas.jmas_67_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction: Transanal endoscopic microsurgery (TEM) is considered the technique of choice for adenoma and low-risk T1 rectal cancer. The adequacy of such treatment for high-risk T1 tumours, however, is still controversial. The aim of the study is to evaluate our results with local excision of high-risk T1 cancers. Materials and Methods: Demographic, clinical data pertaining to patients undergoing TEM for T1 rectal cancer between 1999 and 2015 was retrospectively collected. Long-term outcomes were assessed for the entire cohort. Patients were classified into two groups: favourable and high-risk cancer features. Results: Three hundred and fifty-five TEM procedures were recorded in the study period. Forty-three patients were included in the present study. There were 20 females and 23 males, the median age was 69 ± 9. The median tumour distance from the anal verge was 6 cm (range 1–13 cm). Post-operative histopathology showed well/moderately differentiated T1 adenocarcinoma in 30 patients and poorly differentiated in 13. The overall survival for patients with favourable and high-risk features groups were 93.5% and 77%, respectively, while the local recurrence (LR) was 3.5% and 23.1%, respectively. Nine patients with high-risk features received adjuvant radiotherapy; one (11.1%) of them experienced LR. Conclusions: Local excision by TEM augmented by adjuvant radiotherapy may be a feasible alternative for selected patients with high-risk T1 rectal cancer. The addition of radiotherapy seems to decrease the rates of LR.
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Affiliation(s)
- Wisam Khoury
- Department of General Surgery A, Carmel Medical Center, Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Mai Dauod
- Department of General Surgery, Rambam Health Care Campus, Ruth and Bruce Rappaport Faculty of Medicine,Technion-Israel Institute of Technology, Haifa, Israel
| | - Mohamed Khalefah
- Department of General Surgery, Rambam Health Care Campus, Ruth and Bruce Rappaport Faculty of Medicine,Technion-Israel Institute of Technology, Haifa, Israel
| | - Simon D Duek
- Department of General Surgery, Rambam Health Care Campus, Ruth and Bruce Rappaport Faculty of Medicine,Technion-Israel Institute of Technology, Haifa, Israel
| | - Nidal Issa
- Department of General Surgery, HaSharon Medical Center, Petah-Tikva; Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Javed MA, Shamim S, Slawik S, Andrews T, Montazeri A, Ahmed S. Long-term outcomes of patients with poor prognostic factors following transanal endoscopic microsurgery for early rectal cancer. Colorectal Dis 2021; 23:1953-1960. [PMID: 33900004 DOI: 10.1111/codi.15693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 02/24/2021] [Accepted: 03/23/2021] [Indexed: 12/11/2022]
Abstract
AIM Management of early rectal cancer following transanal microscopic anal surgery poses a management dilemma when the histopathology reveals poor prognostic features, due to high risk of local recurrence. The aim of this study is to evaluate the oncological outcomes of such patients who undergo surgery with total mesorectal excision (TME), receive adjuvant chemo/radiotherapy (CRDT/RT) or receive close surveillance only (no further treatment). METHODS We identified patients with poor prognostic factors-pT2 adenocarcinoma, poor differentiation, deep submucosal invasion (Kikuchi SM3), lymphovascular invasion, tumour budding or R1 resection margin-between 1 September 2012 and 31 January 2020 and report their oncological outcomes. RESULTS Of the 53 patients, 18 had TME, 14 had CRDT and 14 had RT; seven patients did not have any further treatment. The median follow-up was 48 months, 12 developed recurrence and six died. Overall, 5-year survival (OS) was 88.9% and disease-free survival (DFS) was 79.2%. Compared to the surgical group, in which there were eight recurrences and two deaths, there were zero recurrences or deaths in the CRDT group, log-rank test P = 0.206 for OS and P = 0.005 for DFS. The 5-year survival rates in the RT and surveillance only groups were OS 78.6%, DFS 85.7% and OS 71.5%, DFS 71% respectively. TME assessment in the surgical group revealed Grade 3 quality in seven of the 16 available reports. CONCLUSION These findings support the strategy of adjuvant CRDT as first line treatment for patients undergoing transanal endoscopic microsurgery for early rectal cancer with poor prognostic factors on initial histological assessment.
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Affiliation(s)
- Muhammad A Javed
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Sarah Shamim
- Health Education England-North West, Manchester, UK
| | - Simone Slawik
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Timothy Andrews
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Amir Montazeri
- Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK
| | - Shakil Ahmed
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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Bilkhu A, Robinson JM, Steward MA. Preservation of the rectum is possible in early rectal cancer with neoadjuvant radiotherapy, delay and local excision-a 12-year single-centre experience of the evolution of early rectal cancer treatment. Colorectal Dis 2021; 23:1765-1776. [PMID: 33724612 DOI: 10.1111/codi.15631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 02/11/2021] [Accepted: 03/07/2021] [Indexed: 12/18/2022]
Abstract
AIM Treatment of early rectal cancer (ERC) is undergoing a revolution towards rectum preservation. Adjuvant and neoadjuvant therapy alongside local excision (LE) means that organ preservation is a real possibility for most patients and a viable alternative for frailer patients. This study presents our 12-year experience as a specialist regional ERC unit, evolving towards organ preservation. METHOD Data were collected prospectively between 2006 and 2018 for all patients referred to the regional ERC multidisciplinary team with suspected or confirmed ERC. Patients considered suitable for LE, or those declining radical surgery, were offered LE or neoadjuvant short-course radiotherapy (SCRT), delay and LE with subsequent rescue surgery or contact brachytherapy for unfavourable histopathology. RESULTS In all, 102 patients underwent LE. Ten patients were excluded (N = 92). 45 patients underwent LE directly and 47 patients received SCRT and LE. After SCRT and LE, a pathological complete response was achieved in 44.7%. This approach also resulted in a lower rate of lymphovascular invasion (22.2% vs. 6.4%), fewer distant recurrences (4.4% vs. 0%) and a better disease-specific mortality (11.1% vs. 0%) (P < 0.05). Although statistically insignificant, fewer patients required rescue surgery after SCRT (15.6% vs. 4.3%). CONCLUSION Organ preservation with a good oncological outcome is better achieved by neoadjuvant radiotherapy, delay and LE. To achieve this, careful patient selection, thorough preoperative investigation, experienced surgical technique and a deep appreciation of tumour biology managed via a dedicated ERC network is paramount.
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Teste B, Rouanet P, Tuech JJ, Valverde A, Lelong B, Rivoire M, Faucheron JL, Jafari M, Portier G, Meunier B, Sielezneff I, Prudhomme M, Marchal F, Dubois A, Capdepont M, Denost Q, Rullier E. Early and late morbidity of local excision after chemoradiotherapy for rectal cancer. BJS Open 2021; 5:6294246. [PMID: 34097005 PMCID: PMC8183183 DOI: 10.1093/bjsopen/zrab043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 04/08/2021] [Indexed: 12/17/2022] Open
Abstract
Background Local excision (LE) after chemoradiotherapy is a new option in low rectal cancer, but morbidity has never been compared prospectively with total mesorectal excision (TME). Early and late morbidity were compared in patients treated either by LE or TME after neoadjuvant chemoradiotherapy for rectal cancer. Method This was a post-hoc analysis from a randomized trial. Patients with clinical T2/T3 low rectal cancer with good response to the chemoradiotherapy and having either LE, LE with eventual completion TME, or TME were considered. Early (1 month) and late (2 years) morbidities were compared between the three groups. Results There were no deaths following surgery in any of the three groups. Early surgical morbidity (20 per cent LE versus 36 per cent TME versus 43 per cent completion TME, P = 0.025) and late surgical morbidity (4 per cent versus 33 per cent versus 57 per cent, P < 0.001) were significantly lower in the LE group than in the TME or the completion TME group. of LE, was associated with the lowest rate of early (10 versus 18 versus 21 per cent, P = 0.217) and late medical morbidities (0 versus 7 versus 7 per cent, P = 0.154), although this did not represent a significant difference between the groups. The severity of overall morbidity was significantly lower at 2 years after LE compared with TME or completion TME (4 versus 28 versus 43 per cent grade 3–5, P < 0.001). Conclusion The rate of surgical complications after neoadjuvant chemoradiotherapy in the LE group was half that of TME group at 1 month and 10 times lower at 2 years. LE is a safe approach for organ preservation and should be considered as an alternative to watch-and-wait in complete clinical responders and to TME in subcomplete responders.
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Affiliation(s)
- B Teste
- Department of Colorectal Surgery, Magellan Centre, Haut-Leveque Hospital, University of Bordeaux, 33604 Pessac, France
| | - P Rouanet
- Département de Chirurgie Oncologique, ICM Val d'Aurelle, Montpellier, France
| | - J-J Tuech
- Service de Chirurgie Digestive, CHU Charles Nicolle, Rouen, France
| | - A Valverde
- Service de Chirurgie Digestive, Groupe Hospitalier Diaconesses Croix Saint-Simon, Paris, France
| | - B Lelong
- Département de Chirurgie Oncologique, Institut Paoli Calmette, Marseille, France
| | - M Rivoire
- Département de Chirurgie Oncologique, Centre Léon Bérard, Lyon, France
| | - J-L Faucheron
- Service de Chirurgie Digestive, Hôpital A. Michallon, La Tronche, France
| | - M Jafari
- Département de Chirurgie Oncologique, Centre Oscar Lambret, Lille, France
| | - G Portier
- Service de Chirurgie Digestive, Hôpital Purpan, Toulouse, France
| | - B Meunier
- Service de Chirurgie Viscérale, CHU Pontchaillou, Rennes, France
| | - I Sielezneff
- Service de Chirurgie Digestive, CHU Timone, Marseille, France
| | - M Prudhomme
- Département de Chirurgie Digestive et de Cancérologie Digestive, Hôpital Universitaire Carémeau, Nimes, France
| | - F Marchal
- Département de Chirurgie Oncologique, Institut de Cancérologie de Lorraine, Vandoeuvre les Nancy, France
| | - A Dubois
- Service de Chirurgie Générale et Digestive, Hôtel Dieu, Clermont-Ferrand, France
| | - M Capdepont
- Department of Colorectal Surgery, Magellan Centre, Haut-Leveque Hospital, University of Bordeaux, 33604 Pessac, France
| | - Q Denost
- Department of Colorectal Surgery, Magellan Centre, Haut-Leveque Hospital, University of Bordeaux, 33604 Pessac, France
| | - E Rullier
- Department of Colorectal Surgery, Magellan Centre, Haut-Leveque Hospital, University of Bordeaux, 33604 Pessac, France
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Rektumkarzinom. COLOPROCTOLOGY 2021. [DOI: 10.1007/s00053-021-00541-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Kim H, Pedersen K, Olsen JR, Mutch MG, Chin RI, Glasgow SC, Wise PE, Silviera ML, Tan BR, Wang-Gillam A, Lim KH, Suresh R, Amin M, Huang Y, Henke LE, Park H, Ciorba MA, Badiyan S, Parikh PJ, Roach MC, Hunt SR. Nonoperative Rectal Cancer Management With Short-Course Radiation Followed by Chemotherapy: A Nonrandomized Control Trial. Clin Colorectal Cancer 2021; 20:e185-e193. [PMID: 34001462 DOI: 10.1016/j.clcc.2021.03.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 02/19/2021] [Accepted: 03/28/2021] [Indexed: 01/18/2023]
Abstract
PURPOSE Short-course radiation therapy (SCRT) and nonoperative management are emerging paradigms for rectal cancer treatment. This clinical trial is the first to evaluate SCRT followed by chemotherapy as a nonoperative treatment modality. METHODS Patients with nonmetastatic rectal adenocarcinoma were treated on the single-arm, Nonoperative Radiation Management of Adenocarcinoma of the Lower Rectum study of SCRT followed by chemotherapy. Patients received 25 Gy in 5 fractions to the pelvis followed by FOLFOX ×8 or CAPOX ×5 cycles. Patients with clinical complete response (cCR) underwent nonoperative surveillance. The primary end point was cCR at 1 year. Secondary end points included safety profile and anorectal function. RESULTS From June 2016 to March 2019, 19 patients were treated (21% stage I, 32% stage II, and 47% stage III disease). At a median follow-up of 27.7 months for living patients, the 1-year cCR rate was 68%. Eighteen of 19 patients are alive without evidence of disease. Patients with cCR versus without had improved 2-year disease-free survival (93% vs 67%; P = .006), distant metastasis-free survival (100% vs 67%; P = .03), and overall survival (100% vs 67%; P = .03). Involved versus uninvolved circumferential resection margin on magnetic resonance imaging was associated with less initial cCR (40% vs 93%; P = .04). Anorectal function by Functional Assessment of Cancer Therapy-Colorectal cancer score at 1 year was not different than baseline. There were no severe late effects. CONCLUSIONS Treatment with SCRT and chemotherapy resulted in high cCR rate, intact anorectal function, and no severe late effects. NCT02641691.
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Affiliation(s)
- Hyun Kim
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO.
| | - Katrina Pedersen
- Department of Medicine, Division of Oncology, Section of Medical Oncology, Washington University School of Medicine, St. Louis, MO
| | - Jeffrey R Olsen
- Department of Radiation Oncology, University of Colorado School of Medicine, Denver, CO
| | - Matthew G Mutch
- Department of Surgery, Division of General Surgery, Section of Colon and Rectal Surgery
| | - Re-I Chin
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Sean C Glasgow
- Department of Surgery, Division of General Surgery, Section of Colon and Rectal Surgery
| | - Paul E Wise
- Department of Surgery, Division of General Surgery, Section of Colon and Rectal Surgery
| | - Matthew L Silviera
- Department of Surgery, Division of General Surgery, Section of Colon and Rectal Surgery
| | - Benjamin R Tan
- Department of Medicine, Division of Oncology, Section of Medical Oncology, Washington University School of Medicine, St. Louis, MO
| | - Andrea Wang-Gillam
- Department of Medicine, Division of Oncology, Section of Medical Oncology, Washington University School of Medicine, St. Louis, MO
| | - Kian-Huat Lim
- Department of Medicine, Division of Oncology, Section of Medical Oncology, Washington University School of Medicine, St. Louis, MO
| | - Rama Suresh
- Department of Medicine, Division of Oncology, Section of Medical Oncology, Washington University School of Medicine, St. Louis, MO
| | - Manik Amin
- Department of Medicine, Division of Oncology, Section of Medical Oncology, Washington University School of Medicine, St. Louis, MO
| | - Yi Huang
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Lauren E Henke
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Haeseong Park
- Department of Medicine, Division of Oncology, Section of Medical Oncology, Washington University School of Medicine, St. Louis, MO
| | - Matthew A Ciorba
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Shahed Badiyan
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Parag J Parikh
- Department of Radiation Oncology, Henry Ford Health System, Detroit, MI
| | - Michael C Roach
- Department of Radiation Oncology, Hawai'i Pacific Health, Honolulu, HI
| | - Steven R Hunt
- Department of Radiation Oncology, University of Colorado School of Medicine, Denver, CO
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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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Goshtasbi K, Abouzari M, Yasaka T, Soltanzadeh-Zarandi S, Sarna B, Lin HW, Djalilian HR. Treatment Analysis and Overall Survival Outcomes of Patients With Bilateral Vestibular Schwannoma. Otol Neurotol 2021; 42:592-597. [PMID: 33351555 PMCID: PMC8080845 DOI: 10.1097/mao.0000000000002984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To investigate the clinical presentation, treatment breakdown, and overall survival (OS) outcomes of patients with neurofibromatosis type 2 (NF2)-associated bilateral vestibular schwannoma (NVS). METHODS The 2004 to 2016 National Cancer Database was queried for patients with a diagnosis of VS. The "Laterality" code was used to stratify patients into sporadic unilateral vestibular schwannoma (UVS) and NVS. RESULTS Of the 33,839 patients with VS, 155 (0.46%) were coded for NVS with an average age and tumor size of 37.4 ± 20.5 years and 23.5 ± 18.2 mm. Patients underwent observation (45.3%), surgery (29.3%), and radiotherapy (20.0%), and had a 5.8% 5-year mortality rate. Compared with UVS, NVS was negatively associated with receiving surgery (40.2% versus 29.3%, p = 0.02) while watchful observation was more prevalent (30.1% versus 45.3%, p = 0.001). In NVS, undergoing surgery was associated with larger tumor size (34.5 ± 21.2 versus 17.8 ± 13.3 mm, p = 0.001) and shorter diagnosis-to-treatment time (49.1 ± 60.6 versus 87.0 ± 78.5 d, p = 0.02), radiotherapy was associated with older age (44.4 ± 18.9 versus 35.2 ± 20.6 yr, p = 0.02) and longer diagnosis-to-treatment time (85.9 ± 77.9 versus 53.9 ± 65.5 d, p = 0.04), and observation was associated with smaller tumor size (17.8 ± 15.9 versus 28.0 ± 19.2 mm, p = 0.01). Kaplan-Meier log-rank analysis demonstrated similar 10-year OS between NVS and UVS patients (p = 0.58) without factoring the earlier age of presentation. Furthermore, there were no temporal changes in presentation/management of NVS, and OS was not dependent on the received treatment (p = 0.30). CONCLUSIONS With younger age, larger tumors, and more conservative management, NVS's OS was not treatment-dependent and was similar to sporadic UVS, though the latter should not be interpreted as similar life expectancies due to the much earlier presentation.
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Affiliation(s)
- Khodayar Goshtasbi
- Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, USA
| | - Mehdi Abouzari
- Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, USA
| | - Tyler Yasaka
- Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, USA
| | | | - Brooke Sarna
- Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, USA
| | - Harrison W. Lin
- Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, USA
| | - Hamid R. Djalilian
- Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, USA
- Department of Biomedical Engineering, University of California, Irvine, USA
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Zhao S, Chen X, Wen D, Zhang C, Wang X. Oncologic Nomogram for Stage I Rectal Cancer to Assist Patient Selection for Adjuvant (Chemo)Radiotherapy Following Local Excision. Front Oncol 2021; 11:632085. [PMID: 33816269 PMCID: PMC8017267 DOI: 10.3389/fonc.2021.632085] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 02/08/2021] [Indexed: 12/16/2022] Open
Abstract
Background: Because of the low rate of lymph node metastasis in stage I rectal cancer (RC), local resection (LR) can achieve high survival benefits and quality of life. However, the indications for postoperative adjuvant therapy (AT) remain controversial. Methods: A retrospective analysis was performed in 6,486 patients with RC (pT1/T2) using the Surveillance, Epidemiology, and End Results (SEER) database. Patients were initially diagnosed from 2004 to 2016; following LR, 967 received AT and 5,519 did not. Propensity score matching (PSM) was used to balance the confounding factors of the two groups; the Kaplan-Meier method and the log-rank test were used for survival analysis. Cox proportional hazards regression analysis was used to screen independent prognostic factors and build a nomogram on this basis. X-tile software was used to divide the patients into low-, moderate-, and high-risk groups based on the nomogram risk score. Results: Multivariate analysis found that age, sex, race, marital status, tumor size, T stage, and carcinoembryonic antigen (CEA) in the non-AT group were independent prognostic factors for stage I RC and were included in the nomogram prediction model. The C-index of the model was 0.726 (95% CI, 0.689-0.763). We divided the patients into three risk groups according to the nomogram prediction score and found that patients with low and moderate risks did not show an improved prognosis after AT. However, high-risk patients did benefit from AT. Conclusion: The nomogram of this study can effectively predict the prognosis of patients with stage I RC undergoing LR. Our results indicate that high-risk patients should receive AT after LR; AT is not recommended for low-risk patients.
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Affiliation(s)
- Shutao Zhao
- Department of Gastrointestinal Nutrition and Hernia Surgery, The Second Hospital of Jilin University, Changchun, China
| | - Xin Chen
- Department of Gastrointestinal Nutrition and Hernia Surgery, The Second Hospital of Jilin University, Changchun, China
| | - Dacheng Wen
- Department of Gastrointestinal Nutrition and Hernia Surgery, The Second Hospital of Jilin University, Changchun, China
| | - Chao Zhang
- Department of Gastrointestinal Nutrition and Hernia Surgery, The Second Hospital of Jilin University, Changchun, China
| | - Xudong Wang
- Department of Gastrointestinal Nutrition and Hernia Surgery, The Second Hospital of Jilin University, Changchun, China
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Radical resection versus local excision for low rectal gastrointestinal stromal tumor: A multicenter propensity score-matched analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2021; 47:1668-1674. [PMID: 33581967 DOI: 10.1016/j.ejso.2021.01.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/18/2021] [Accepted: 01/27/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND The surgical approaches and resection extent for rectal gastrointestinal stromal tumors (GISTs) are controversial due to the low incidence of this disease. A multicenter retrospective cohort study was conducted to compare the postoperative and oncologic outcomes of local excision (LE) and radical resection (RR) in patients with low rectal GIST. PATIENTS AND METHODS The medical records of rectal GIST patients from 11 large-scale medical centers in China (January 2000-December 2019) were reviewed. All patients were divided into either the LE group or the RR group. Propensity score matching (PSM) was conducted to reduce confounders. RESULTS A total of 280 patients with low rectal GIST were enrolled. After PSM, 144 patients were included (72 in each group). The LE group showed a higher anal preservation rate (100.0% vs. 76.4%, P < 0.001), shorter operation time (77.1 ± 68.4 min vs. 159.1 ± 83.6 min, P < 0.001), fewer complications (8.3% vs. 22.2%, P = 0.021) and shorter postoperative hospital stay (4.9 ± 4.1 d vs. 10.7 ± 8.1 d, P < 0.001) than the RR group. There was no significant difference in recurrence-free survival (RFS) between the RR and LE groups among patients with tumors ≤2 cm (P = 0.220), and the RR group had a superior RFS than the LE group in patients with tumors >2 cm (P = 0.046). CONCLUSIONS LE resulted in improved postoperative outcomes and comparable oncological safety with a low rectal GIST of ≤2 cm. However, for patients with a low rectal GIST of >2 cm, RR might be a more appropriate option with better RFS.
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Atallah C, Taylor JP, Lo BD, Stem M, Brocke T, Efron JE, Safar B. Local excision for T1 rectal tumours: are we getting better? Colorectal Dis 2020; 22:2038-2048. [PMID: 32886836 DOI: 10.1111/codi.15344] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 08/17/2020] [Indexed: 12/13/2022]
Abstract
AIM The objective was to assess the effect of three different surgical treatments for T1 rectal tumours, radical resection (RR), open local excision (open LE) and laparoscopic local excision (laparoscopic LE), on overall survival (OS). METHODS Adults from the National Cancer Database (2008-2016) with a diagnosis of T1 rectal cancer were stratified by treatment type (LE vs RR). We assumed that laparoscopic LE equates to transanal minimally invasive surgery (TAMIS) or transanal endoscopic microsurgery. The primary outcome was 5-year OS. Subgroup analyses of the LE group stratified by time period [2008-2010 (before TAMIS) vs 2011-2016 (after TAMIS)] and approach (laparoscopic vs open) were performed. RESULTS Among 10 053 patients, 6623 (65.88%) underwent LE (74.33% laparoscopic LE vs 25.67% open LE) and 3430 (34.12%) RR. The use of LE increased from 52.69% in 2008 to 69.47% in 2016, whereas RR decreased (P < 0.001). In unadjusted analysis, there was no significant difference in 5-year OS between the LE and RR groups (P = 0.639) and between the two LE time periods (P = 0.509), which was consistent with the adjusted analysis (LE vs RR, hazard ratio 1.05, 95% CI 0.92-1.20, P = 0.468; 2008-2010 LE vs 2011-2016 LE, hazard ratio 1.09, 95% CI 0.92-1.29, P = 0.321). Laparoscopic LE was associated with improved OS in the unadjusted analysis only (P = 0.006), compared to the open LE group (hazard ratio 0.94, 95% CI 0.78-1.12, P = 0.495). CONCLUSIONS This study supports the use of a LE approach for T1 rectal tumours as a strategy to reduce surgical morbidity without compromising survival.
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Affiliation(s)
- C Atallah
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - J P Taylor
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - B D Lo
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - M Stem
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - T Brocke
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - J E Efron
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - B Safar
- Colorectal Research Unit, Ravitch Colorectal Division, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Nishizaki D, Hoshino N, Hida K, Nishikawa Y, Horimatsu T, Minamiguchi S, Sakanaka K, Sakai Y. Nonsurgical Management Following Local Resection for Early Rectal Cancer in Patients with High-risk Factors: A Single-institute Experience. JOURNAL OF THE ANUS RECTUM AND COLON 2020; 4:174-180. [PMID: 33134598 PMCID: PMC7595679 DOI: 10.23922/jarc.2020-019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/05/2020] [Indexed: 11/30/2022]
Abstract
Objective Additional surgery is considered for patients at high risk for lymph node metastasis (LNM) after local resection for early rectal cancer. Several factors are considered as indications for additional surgery, although there are currently no definitive criteria. This study aimed to clarify the need for additional surgery based on the number of risk factors for LNM and to evaluate the significance of submucosal invasion on recurrence. Methods Patients with early rectal cancer harboring risk factors for LNM who underwent local resection between March 2005 and December 2016 were retrospectively analyzed. Associations among the number of risk factors, prognosis, and additional treatment after local resection were investigated. Results A total of 29 eligible patients were classified into the surgery (n = 10), chemoradiotherapy (n = 7), and no-additional-treatment (NAT, n = 12) groups. Among the 29 patients, 15 patients (52%) with only one risk factor did not relapse. The NAT group harbored fewer risk factors for LNM, and 8 of the 12 patients (67%) had only deep submucosal invasion. Local recurrence occurred in one patient in the chemoradiotherapy group. The estimated 5-year overall survival rates were 88.9%, 75.0%, and 81.5% in the surgery, chemoradiotherapy, and NAT groups, respectively. There were no disease-specific deaths in the overall cohort. Conclusions In the present study, no recurrence occurred in patients who did not receive additional surgery with deep submucosal invasion as the only risk factor. A multicenter investigation is necessary to confirm the safety of nonsurgical options.
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Affiliation(s)
- Daisuke Nishizaki
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Nobuaki Hoshino
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan.,Department of Health Informatics, School of Public Health, Kyoto University, Kyoto, Japan
| | - Koya Hida
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yoshitaka Nishikawa
- Department of Health Informatics, School of Public Health, Kyoto University, Kyoto, Japan.,Department of Therapeutic Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takahiro Horimatsu
- Department of Therapeutic Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | | | - Katsuyuki Sakanaka
- Department of Radiation Oncology and Image-Applied Therapy, Kyoto University Hospital, Kyoto, Japan
| | - Yoshiharu Sakai
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
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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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van Oostendorp SE, Smits LJH, Vroom Y, Detering R, Heymans MW, Moons LMG, Tanis PJ, de Graaf EJR, Cunningham C, Denost Q, Kusters M, Tuynman JB. Local recurrence after local excision of early rectal cancer: a meta-analysis of completion TME, adjuvant (chemo)radiation, or no additional treatment. Br J Surg 2020; 107:1719-1730. [PMID: 32936943 PMCID: PMC7692925 DOI: 10.1002/bjs.12040] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 07/13/2020] [Accepted: 08/10/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The risks of local recurrence and treatment-related morbidity need to be balanced after local excision of early rectal cancer. The aim of this meta-analysis was to determine oncological outcomes after local excision of pT1-2 rectal cancer followed by no additional treatment (NAT), completion total mesorectal excision (cTME) or adjuvant (chemo)radiotherapy (aCRT). METHODS A systematic search was conducted in PubMed, Embase and the Cochrane Library. The primary outcome was local recurrence. Statistical analysis included calculation of the weighted average of proportions. RESULTS Some 73 studies comprising 4674 patients were included in the analysis. Sixty-two evaluated NAT, 13 cTME and 28 aCRT. The local recurrence rate for NAT among low-risk pT1 tumours was 6·7 (95 per cent c.i. 4·8 to 9·3) per cent. There were no local recurrences of low-risk pT1 tumours after cTME or aCRT. The local recurrence rate for high-risk pT1 tumours was 13·6 (8·0 to 22·0) per cent for local excision only, 4·1 (1·7 to 9·4) per cent for cTME and 3·9 (2·0 to 7·5) per cent for aCRT. Local recurrence rates for pT2 tumours were 28·9 (22·3 to 36·4) per cent with NAT, 4 (1 to 13) per cent after cTME and 14·7 (11·2 to 19·0) per cent after aCRT. CONCLUSION There is a substantial risk of local recurrence in patients who receive no additional treatment after local excision, especially those with high-risk pT1 and pT2 rectal cancer. The lowest recurrence risk is provided by cTME; aCRT has outcomes comparable to those of cTME for high-risk pT1 tumours, but shows a higher risk for pT2 tumours.
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Affiliation(s)
- S E van Oostendorp
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - L J H Smits
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - Y Vroom
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - R Detering
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - M W Heymans
- Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - L M G Moons
- Department of Gastroenterology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - P J Tanis
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - E J R de Graaf
- Department of Surgery, IJsselland Ziekenhuis, Capelle aan den Ijssel, the Netherlands
| | - C Cunningham
- Department of Surgery, Oxford University Hospitals, Oxford, UK
| | - Q Denost
- Department of Surgery, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - M Kusters
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - J B Tuynman
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Rectal Cancer. Dis Colon Rectum 2020; 63:1191-1222. [PMID: 33216491 DOI: 10.1097/dcr.0000000000001762] [Citation(s) in RCA: 152] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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