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Penman D, Keogh A, Ahmed S, Ahmed S, Farrell C, Andrews T, Javed A, Sarkar S. Substratifying the risk of covert malignancy in significant rectal polyps: Outcomes from a specialist multidisciplinary team (MDT). Colorectal Dis 2024; 26:1145-1152. [PMID: 38702861 DOI: 10.1111/codi.17007] [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] [Received: 10/10/2022] [Revised: 04/06/2023] [Accepted: 05/30/2023] [Indexed: 05/06/2024]
Abstract
AIM A treatment strategy for patients with a significant polyp or early colon cancer (SPECC) of the rectum presents a challenge due to the significant rate of covert malignancy and lack of standardized assessment. For this reason, NICE recommends multidisciplinary meetings to improve outcomes. The primary aim of the present study was to report the performance of our specialist early rectal cancer (SERC) multidisciplinary team (MDT) in correctly substratifying the risk of cancer and to discuss the limitations of staging investigations in those patients with "poor outcomes". METHOD This was a retrospective review of patients referred to our SERC MDT from 2014 to 2019. Lesions were assigned by the MDT to three pre-resection categories (low, intermediate, high) according to the risk of covert malignancy. Resection method and final histology were compared to the pre-resection categories. RESULTS Of 350 SPECC lesions, 174 were assessed as low-risk, 108 intermediate-risk and 68 high-risk. The cancer incidence was 4.8%, 8.3% and 53%, respectively (15.5% overall). Eight lesions were categorized as low-risk but following piecemeal resection were found to be malignant. Five lesions, three of which were categorized as high-risk, were ultimately benign following conventional surgery. One pT1sm1 cancer, removed by anterior resection, may have been treated by local excision. CONCLUSION A total of 83% of malignant polyps were triaged to an en bloc resection technique and surgical resection avoided for nearly all benign lesions. However, 12 patients from this cohort were deemed to have a poor outcome because of miscategorization. Further comparative research is needed to establish the optimum strategy for rectal SPECC lesion assessment. ORIGINALITY STATEMENT There is currently no consensus for staging significant polyps of the rectum. This paper reports the effectiveness of a specialist early rectal cancer MDT to correctly risk-stratify significant rectal polyps. It underscores the importance of accurate categorization for treatment decision-making, while acknowledging the limitations of current staging modalities.
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Affiliation(s)
- Douglas Penman
- The Department of Colorectal Surgery, Liverpool University Hospitals Foundation Trust, Liverpool, UK
| | - Ashley Keogh
- The Department of Colorectal Surgery, Liverpool University Hospitals Foundation Trust, Liverpool, UK
| | - Shakil Ahmed
- The Department of Colorectal Surgery, Liverpool University Hospitals Foundation Trust, Liverpool, UK
| | - Suhail Ahmed
- The Department of Colorectal Surgery, Liverpool University Hospitals Foundation Trust, Liverpool, UK
| | - Catriona Farrell
- The Department of Colorectal Surgery, Liverpool University Hospitals Foundation Trust, Liverpool, UK
| | - Timothy Andrews
- The Department of Colorectal Surgery, Liverpool University Hospitals Foundation Trust, Liverpool, UK
| | - Ahsan Javed
- The Department of Colorectal Surgery, Liverpool University Hospitals Foundation Trust, Liverpool, UK
| | - Sanchoy Sarkar
- The Department of Colorectal Surgery, Liverpool University Hospitals Foundation Trust, Liverpool, UK
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Pinto RA, Kawaguti FS, Kimura CMS, Corrêa Neto IJF, Nahas CSR, Marques CFS, Bustamante-Lopez LA, Ribeiro-Jr U, Maluf-Filho F, Nahas SC. Comparing three-dimensional endorectal ultrasound and magnification chromoendoscopy for early rectal neoplasia invasion depth assessment. J Gastroenterol Hepatol 2024; 39:346-352. [PMID: 37931782 DOI: 10.1111/jgh.16382] [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] [Received: 06/11/2023] [Revised: 09/29/2023] [Accepted: 10/02/2023] [Indexed: 11/08/2023]
Abstract
INTRODUCTION Accurate assessment of invasion depth of early rectal neoplasms is essential for optimal therapy. We aimed to compare three-dimensional endorectal ultrasound (3D-ERUS) with magnification chromoendoscopy (MCE) regarding their accuracy in assessing parietal invasion depth (T). METHODS Patients with middle and distal rectum neoplasms were prospectively included. Two providers blinded to each other's assessment performed 3D-ERUS and MCE, respectively. The T stage assessed through ERUS was compared to the MCE evaluation. The results were compared to the surgical specimen anatomopathological report. Sensitivity, specificity, accuracy, positive (PPV), and negative (NPV) predictive values were calculated for the T stage and for the final therapy (local excision or radical surgery). RESULTS In 8 years, 70 patients were enrolled, and all underwent both exams. MCE and ERUS showed an accuracy of 94.3% and 85.7%, sensitivity of 83.7 and 93.3%, specificity of 96.4 and 83.6%, PPV of 86.7 and 60.9%, and NPV of 96.4 and 97.9%, respectively. Kappa for T stage assessed through ERUS was 0.64 and 0.83 for MCE. CONCLUSION MCE and 3D-ERUS had good diagnostic performance, but the endoscopic method had higher accuracy. Both methods reliably assessed lesion extension, circumferential involvement, and distance from the anal verge.
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Affiliation(s)
- Rodrigo Ambar Pinto
- Division of Colon and Rectal Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Cintia Mayumi Sakurai Kimura
- Division of Colon and Rectal Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- Department of Surgery, Stanford School of Medicine, Stanford, California, USA
| | - Isaac José Felippe Corrêa Neto
- Division of Colon and Rectal Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Caio Sérgio Rizkallah Nahas
- Division of Colon and Rectal Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Carlos Frederico Sparapan Marques
- Division of Colon and Rectal Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Leonardo Alfonso Bustamante-Lopez
- Division of Colon and Rectal Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Ulysses Ribeiro-Jr
- Division of Gastrointestinal Surgery, Instituto do Câncer do Estado de São Paulo, São Paulo, Brazil
| | - Fauze Maluf-Filho
- Division of Endoscopy, Instituto do Câncer do Estado de São Paulo, São Paulo, Brazil
| | - Sérgio Carlos Nahas
- Division of Colon and Rectal Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Haji A. Endoscopic Submucosal Dissection in the Colon and Rectum: Indications, Techniques, and Outcomes. Gastrointest Endosc Clin N Am 2023; 33:83-97. [PMID: 36375889 DOI: 10.1016/j.giec.2022.08.001] [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] [Indexed: 11/12/2022]
Abstract
Multimodal assessment of colorectal polyps is needed before decision-making for endoscopic mucosal resection or endoscopic submucosal dissection (ESD). Assessment should include morphology according to Paris classification, magnification endoscopy for vascular pattern, and Kudo pit pattern analysis. ESD should be offered to patients that have Vi pit pattern, lateral spreading tumors (LST) granular multinodular and LST nongranular, lesions with fibrosis and those in patients with inflammatory bowel disease. A defined strategy for resection and planning is crucial for successful and efficient resection with a clear audit of outcomes aiming for a perforation and bleeding rate of less than 1% and R0 resection greater than 90%.
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Affiliation(s)
- Amyn Haji
- Department of Colorectal Surgery, King's College Hospital, Denmark Hill, London SE5 9RS, United Kingdom.
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Son GM, Lee IY, Cho SH, Park BS, Kim HS, Park SB, Kim HW, Oh SB, Kim TU, Shin DH. Multidisciplinary treatment strategy for early rectal cancer A review. PRECISION AND FUTURE MEDICINE 2021. [DOI: 10.23838/pfm.2021.00163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2022] Open
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Golia Pernicka JS, Bates DDB, Fuqua JL, Knezevic A, Yoon J, Nardo L, Petkovska I, Paroder V, Nash GM, Markowitz AJ, Gollub MJ. Meaningful words in rectal MRI synoptic reports: How "polypoid" may be prognostic. Clin Imaging 2021; 80:371-376. [PMID: 34517303 DOI: 10.1016/j.clinimag.2021.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 08/02/2021] [Accepted: 08/18/2021] [Indexed: 01/13/2023]
Abstract
PURPOSE This study explored the clinicopathologic outcomes of rectal tumor morphological descriptors used in a synoptic rectal MRI reporting template and determined that prognostic differences were observed. METHODS This retrospective study was conducted at a comprehensive cancer center. Fifty patients with rectal tumors for whom the synoptic descriptor "polypoid" was chosen by three experienced radiologists were compared with ninety comparator patients with "partially circumferential" and "circumferential" rectal tumors. Two radiologists re-evaluated all cases. The outcome measures were agreement among two re-interpreting radiologists, clinical T staging with MRI (mrT) and descriptive nodal features, and degrees of wall attachment of tumors (on MRI) compared with pathological (p) T and N stage when available. RESULTS Re-evaluation by two radiologists showed moderate to excellent agreement in tumor morphology, presence of a pedicle, and degree of wall attachment (k = 0.41-0.76) and excellent agreement on lymph node presence and size (ICC = 0.83-0.91). Statistically significant lower mrT stage was noted for polypoid morphology, wherein 98% were mrT1/2, while only 7% and 2% of partially circumferential and circumferential tumors respectively were mrT1/2. Pathologic T and N stages among the three morphologies also differed significantly, with only 14% of polypoid cases higher than stage pT2 compared to 48% of partially circumferential cases and 60% of circumferential cases. CONCLUSION Using a "polypoid" morphology in rectal cancer MRI synoptic reports revealed a seemingly distinct phenotype with lower clinical and pathologic T and N stages when compared with alternative available descriptors. PRECIS "Polypoid" morphology in rectal cancer confers a lower clinical and pathologic T and N stage and may be useful in determining whether to proceed with surgery versus neoadjuvant treatment.
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Affiliation(s)
- Jennifer S Golia Pernicka
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 530 East 74th Street, New York, NY 10065, USA.
| | - David D B Bates
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 530 East 74th Street, New York, NY 10065, USA
| | - James L Fuqua
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 530 East 74th Street, New York, NY 10065, USA
| | - Andrea Knezevic
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Joongchul Yoon
- Department of Radiology, Hôpital Saint-Eustache, 520 Boulevard Arthur-Sauvé, Saint-Eustache, QC J7R 5B1, Canada
| | - Lorenzo Nardo
- Department of Radiology, University of California-Davis, 4860 Y Street, Sacramento, CA 95817, USA
| | - Iva Petkovska
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 530 East 74th Street, New York, NY 10065, USA
| | - Viktoriya Paroder
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 530 East 74th Street, New York, NY 10065, USA
| | - Garrett M Nash
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Arnold J Markowitz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Marc J Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 530 East 74th Street, New York, NY 10065, USA
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Dhadda A, Sun Myint A, Thamphya B, Hunter I, Hershman M, Gerard JP. A multi-centre analysis of adjuvant contact X-ray brachytherapy (CXB) in rectal cancer patients treated with local excision - Preliminary results of the CONTEM1 study. Radiother Oncol 2021; 162:195-201. [PMID: 34329654 DOI: 10.1016/j.radonc.2021.07.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 07/19/2021] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Early rectal cancers are increasingly diagnosed through screening programmes and are often treated using local excision (LE). In the case of adverse pathological features completion total mesorectal excision surgery (TME) is the standard recommendation. The morbidity and mortality risks of TME have stimulated the use of adjunctive treatments following LE to achieve organ preservation. MATERIAL AND METHODS Patients treated with adjuvant CXB following local excision between 2004 and 2017 in three centres were identified (Clatterbridge, Hull, Nice). All patients had adverse pathological features including: lymphovacular invasion, Sm2-3 Kikuchi level, tumour budding, pT2, positive resection margins (R1). CXB was performed with the Papillon50 tm machine to a dose of 40-60 Gy in 2 or 3 fractions over 2-4 weeks preceding/following external beam chemo/radiotherapy. Kaplan Meier survival estimates were used for outcomes measures. RESULTS 194 patients were identified. Median age was 70 years. pT staging was: pT1:143, pT2:45, pT3:6. CXB alone was given in 24 pts and combined with EBRT in 170. Median follow-up time was 77 months (range 7-122 months). Local relapse rate was 8% and distant metastases 9%. Organ preservation was achieved in 95%. 6 year local recurrence free and overall survival was 91% and 81% respectively. Cancer specific survival was 97%. No treatment related mortality was seen. CONCLUSION This large multi-centre cohort study using adjuvant CXB following local excision suggests excellent oncological outcomes for these patients without completion TME. This treatment approach can be considered as an alternative for selective patients compliant with long term follow up.
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Affiliation(s)
- Amandeep Dhadda
- Queen's Centre for Oncology & Haematology, Hull University Teaching Hospitals NHS Trust, Hull, United Kingdom.
| | | | - Brice Thamphya
- Service de Radiotherapie, Centre Antoine-Lacassagne, Nice, France
| | - Iain Hunter
- Queen's Centre for Oncology & Haematology, Hull University Teaching Hospitals NHS Trust, Hull, United Kingdom
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Seifert H, Fusaroli P, Arcidiacono PG, Braden B, Herth F, Hocke M, Larghi A, Napoleon B, Rimbas M, Ungureanu BS, Sãftoiu A, Sahai AV, Dietrich CF. Controversies in EUS: Do we need miniprobes? Endosc Ultrasound 2021; 10:246-269. [PMID: 34380805 PMCID: PMC8411553 DOI: 10.4103/eus-d-20-00252] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
This is the fifth in a series of papers entitled "Controversies in EUS." In the current paper, we deal with high-resolution catheter probes, otherwise known as EUS miniprobes (EUS-MPs). The application of miniprobes for early carcinomas in the entire intestinal tract, for subepithelial lesions, and for findings in the bile duct and pancreatic duct as well as endobronchial use is critically discussed. Submucous lesions, especially in the colon, but also early carcinomas in special cases are considered the most important indications. The argument is illustrated by numerous examples.
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Affiliation(s)
- Hans Seifert
- Department of Gastroenterology, Evangelisches Krankenhaus, Oldenburg; Universitatsklinik fur Innere Medizin - Gastroneterologie, Hepatologie; Klinikum Oldenburg, Germany
| | - Pietro Fusaroli
- Department of Medical and Surgical Sciences, Gastroenterology Unit, University of Bologna/Imola Hospital, Imola, Italy
| | - Paolo Giorgio Arcidiacono
- Research Center, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
| | - Barbara Braden
- Translational Gastroenterology Unit I, John Radcliffe Hospital I, Oxford, OX3 9DU, UK
| | - Felix Herth
- 2nd Department of Pneumology and Critical Care Medicine, Thoraxklinik and Translational Lung Research Center (TLRCH), Member of the German Lung Research Foundation (DZL), University of Heidelberg, Heidelberg, Germany
| | - Michael Hocke
- Department of Medicine, Helios Klinikum Meiningen, Meiningen, Germany
| | - Alberto Larghi
- Digestive Endoscopy Unit, IRCCS Foundation University Hospital, Policlinico A. Gemelli, Rome, Italy
| | - Bertrand Napoleon
- 2nd Digestive Endoscopy Unit, HopitalPrivé J Mermoz Ramsay Générale de Santé, Lyon, France
| | - Mihai Rimbas
- Department of Gastroenterology, Colentina Clinical Hospital, Bucharest; Department of Internal Medicine, Carol Davila University of Medicine Bucharest, Romania
| | - Bogdan Silvio Ungureanu
- Research Center of Gastroenterology and Hepatology Craiova, University of Medicine and Pharmacy Craiova, Craiova, Romania
| | - Adrian Sãftoiu
- Research Center of Gastroenterology and Hepatology Craiova, University of Medicine and Pharmacy Craiova, Craiova, Romania
| | - Anand V Sahai
- Center Hospitalier de l'Université de Montréal, Montreal, Canada
| | - Christoph F Dietrich
- Department of Allgemeine Innere Medizin, Kliniken Hirslanden, Beau Site, Salem und Permanence, Bern, Switzerland; Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
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