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Wang X, Jiang W, Deng Y, Chen Z, Zheng Z, Sun Y, Xie Z, Lu X, Huang S, Lin Y, Huang Y, Chi P. Unraveling variations and enhancing prediction of successful sphincter-preserving resection for low rectal cancer: a post hoc analysis of the multicentre LASRE randomized clinical trial. Int J Surg 2024; 110:4031-4042. [PMID: 38652133 PMCID: PMC11254249 DOI: 10.1097/js9.0000000000001014] [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: 08/18/2023] [Accepted: 12/11/2023] [Indexed: 04/25/2024]
Abstract
BACKGROUND Accurate prediction of successful sphincter-preserving resection (SSPR) for low rectal cancer enables peer institutions to scrutinize their own performance and potentially avoid unnecessary permanent colostomy. The aim of this study is to evaluate the variation in SSPR and present the first artificial intelligence (AI) models to predict SSPR in low rectal cancer patients. STUDY DESIGN This was a retrospective post hoc analysis of a multicenter, non-inferiority randomized clinical trial (LASRE, NCT01899547) conducted in 22 tertiary hospitals across China. A total of 604 patients who underwent neoadjuvant chemoradiotherapy (CRT) followed by radical resection of low rectal cancer were included as the study cohort, which was then split into a training set (67%) and a testing set (33%). The primary end point of this post hoc analysis was SSPR, which was defined as meeting all the following criteria: (1) sphincter-preserving resection; (2) complete or nearly complete TME, (3) a clear CRM (distance between margin and tumour of 1 mm or more), and (4) a clear DRM (distance between margin and tumour of 1 mm or more). Seven AI algorithms, namely, support vector machine (SVM), logistic regression (LR), extreme gradient boosting (XGB), light gradient boosting (LGB), decision tree classifier (DTC), random forest (RF) classifier, and multilayer perceptron (MLP), were employed to construct predictive models for SSPR. Evaluation of accuracy in the independent testing set included measures of discrimination, calibration, and clinical applicability. RESULTS The SSPR rate for the entire cohort was 71.9% (434/604 patients). Significant variation in the rate of SSPR, ranging from 37.7 to 94.4%, was observed among the hospitals. The optimal set of selected features included tumour distance from the anal verge before and after CRT, the occurrence of clinical T downstaging, post-CRT weight and clinical N stage measured by magnetic resonance imaging. The seven different AI algorithms were developed and applied to the independent testing set. The LR, LGB, MLP and XGB models showed excellent discrimination with area under the receiver operating characteristic (AUROC) values of 0.825, 0.819, 0.819 and 0.805, respectively. The DTC, RF and SVM models had acceptable discrimination with AUROC values of 0.797, 0.766 and 0.744, respectively. LR and LGB showed the best discrimination, and all seven AI models had superior overall net benefits within the range of 0.3-0.8 threshold probabilities. Finally, we developed an online calculator based on the LGB model to facilitate clinical use. CONCLUSIONS The rate of SSPR exhibits substantial variation, and the application of AI models has demonstrated the ability to predict SSPR for low rectal cancers with commendable accuracy.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Ying Huang
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, Fuzhou, People’s Republic of China
| | - Pan Chi
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, Fuzhou, People’s Republic of China
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Goffredo P, Hart AA, Tran CG, Kahl AR, Gao X, Del Vecchio NJ, Charlton ME, Hassan I. Patterns of Care and Outcomes of Rectal Cancer Patients from the Iowa Cancer Registry: Role of Hospital Volume and Tumor Location. J Gastrointest Surg 2023; 27:1228-1237. [PMID: 36949239 PMCID: PMC11283177 DOI: 10.1007/s11605-023-05656-2] [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: 12/03/2022] [Accepted: 02/09/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Centralization of rectal cancer surgery has been associated with high-quality oncologic care. However, several patient, disease and system-related factors can impact where patients receive care. We hypothesized that patients with low rectal tumors would undergo treatment at high-volume centers and would be more likely to receive guideline-based multidisciplinary treatment. METHODS Adults who underwent proctectomy for stage II/III rectal cancer were included from the Iowa Cancer Registry and supplemented with tumor location data. Multinomial logistic regression was employed to analyze factors associated with receiving care in high-volume hospital, while logistic regression for those associated with ≥ 12 lymph node yield, pre-operative chemoradiation and sphincter-preserving surgery. RESULTS Of 414 patients, 38%, 39%, and 22% had low, mid, and high rectal cancers, respectively. Thirty-two percent were > 65 years, 38% female, and 68% had stage III tumors. Older age and rural residence, but not tumor location, were associated with surgical treatment in low-volume hospitals. Higher tumor location, high-volume, and NCI-designated hospitals had higher nodal yield (≥ 12). Hospital-volume was not associated with neoadjuvant chemoradiation rates or circumferential resection margin status. Sphincter-sparing surgery was independently associated with high tumor location, female sex, and stage III cancer, but not hospital volume. CONCLUSIONS Low tumor location was not associated with care in high-volume hospitals. High-volume and NCI-designated hospitals had higher nodal yields, but not significantly higher neoadjuvant chemoradiation, negative circumferential margin, or sphincter preservation rates. Therefore, providing educational/quality improvement support in lower volume centers may be more pragmatic than attempting to centralize rectal cancer care among high-volume centers.
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Affiliation(s)
- P Goffredo
- Division of Colon & Rectal Surgery, University of Minnesota, Minneapolis, MN, USA
| | - A A Hart
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - C G Tran
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - A R Kahl
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA
- Iowa Cancer Registry, University of Iowa College of Public Health, Iowa City, IA, USA
| | - X Gao
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - N J Del Vecchio
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - M E Charlton
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA
- Iowa Cancer Registry, University of Iowa College of Public Health, Iowa City, IA, USA
| | - I Hassan
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
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Kim MJ, Park S, Park JW, Choi J, Kim HJ, Lim HK, Ryoo SB, Park KJ, Ji Y, Jeong SY. Gut microbiome associated with low anterior resection syndrome after rectal cancer surgery. Sci Rep 2023; 13:8578. [PMID: 37237024 DOI: 10.1038/s41598-023-34557-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 05/03/2023] [Indexed: 05/28/2023] Open
Abstract
This study aimed to assess the likely association of gut microbiome with low anterior resection syndrome (LARS) symptoms. Postoperative stool samples from patients with minor or major LARS after sphincter-preserving surgery (SPS) for rectal cancer were collected and analyzed using 16S ribosomal RNA sequencing method. The symptom patterns of LARS were classified into two groups (PC1LARS, PC2LARS) using principal component analysis. The dichotomized sum of questionnaire items (sub1LARS, sub2LARS) was used to group patients according to the main symptoms. According to microbial diversity, enterotype, and taxa, PC1LARS and sub1LARS were associated with frequency-dominant LARS symptoms and patients, while PC2LARS and sub2LARS were grouped as incontinence-dominant LARS symptoms and patients. Butyricicoccus levels decreased while overall LARS scores increased. The α-diversity richness index Chao1 showed a significantly negative correlation in sub1LARS and a positive correlation in sub2LARS. In sub1LARS, the severe group showed a lower Prevotellaceae enterotype and higher Bacteroidaceae enterotype than the mild group. Subdoligranulum and Flavonifractor showed a negative and a positive correlation with PC1LARS, respectively, while showing a negative relationship with PC2LARS. Lactobacillus and Bifidobacterium were negatively correlated to PC1LARS. Frequency-dominant LARS had decreased diversity of gut microbiome and showed lower levels of lactic acid-producing bacteria.
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Affiliation(s)
- Min Jung Kim
- Department of Surgery, Seoul National College of Medicine, Seoul, Republic of Korea
- Colorectal Cancer Center, Seoul National University Cancer Hospital, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University, Seoul, Republic of Korea
| | - Soyoung Park
- Bioinformatics Center, HEMpharma, Suwon-si, Gyeonggi-do, Republic of Korea.
| | - Ji Won Park
- Department of Surgery, Seoul National College of Medicine, Seoul, Republic of Korea
- Colorectal Cancer Center, Seoul National University Cancer Hospital, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University, Seoul, Republic of Korea
| | - Jinsun Choi
- Department of Surgery, Seoul National College of Medicine, Seoul, Republic of Korea
| | - Hyo Jun Kim
- Department of Surgery, Seoul National College of Medicine, Seoul, Republic of Korea
| | - Han-Ki Lim
- Department of Surgery, Seoul National College of Medicine, Seoul, Republic of Korea
- Colorectal Cancer Center, Seoul National University Cancer Hospital, Seoul, Republic of Korea
| | - Seung-Bum Ryoo
- Department of Surgery, Seoul National College of Medicine, Seoul, Republic of Korea
- Colorectal Cancer Center, Seoul National University Cancer Hospital, Seoul, Republic of Korea
| | - Kyu Joo Park
- Department of Surgery, Seoul National College of Medicine, Seoul, Republic of Korea
- Colorectal Cancer Center, Seoul National University Cancer Hospital, Seoul, Republic of Korea
| | - Yosep Ji
- Bioinformatics Center, HEMpharma, Suwon-si, Gyeonggi-do, Republic of Korea
| | - Seung-Yong Jeong
- Department of Surgery, Seoul National College of Medicine, Seoul, Republic of Korea
- Colorectal Cancer Center, Seoul National University Cancer Hospital, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University, Seoul, Republic of Korea
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Michel-Ruddy JA, Tom CM, Parrish AB, Kaji AH, Chen FC, Petrie BA. Sphincter Preservation Surgery in Patients With Rectal Cancer: Does Surgical Subspecialization Matter? Am Surg 2023; 89:1189-1190. [PMID: 33377811 DOI: 10.1177/0003134820982563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | | | | | - Amy H Kaji
- Harbor-UCLA Medical Center, Torrance, CA, USA
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Pappou EP, Temple LK, Patil S, Smith JJ, Wei IH, Nash GM, Guillem JG, Widmar M, Weiser MR, Paty PB, Schrag D, Garcia-Aguilar J. Quality of life and function after rectal cancer surgery with and without sphincter preservation. Front Oncol 2022; 12:944843. [PMID: 36353560 PMCID: PMC9639454 DOI: 10.3389/fonc.2022.944843] [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: 05/15/2022] [Accepted: 08/23/2022] [Indexed: 01/12/2023] Open
Abstract
Despite improvements in surgical techniques, functional outcomes and quality of life after therapy for rectal cancer remain suboptimal. We sought to prospectively evaluate the effect of bowel, bladder, and sexual functional outcomes on health-related quality of life (QOL) in patients with restorative versus non-restorative resections after rectal cancer surgery. A cohort of 211 patients with clinical stage I-III rectal cancer who underwent open surgery between 2006 and 2009 at Memorial Sloan Kettering were included. Subjects were asked to complete surveys preoperatively and at 6, 12, and 24 months after surgery. Validated instruments were used to measure QOL, bowel, bladder, and sexual function. Univariable and multivariable regression analyses evaluated predictors of 24- month QOL. In addition, longitudinal trends over the study period were evaluated using repeated measures models. In total, 180 patients (85%) completed at least 1 survey, and response rates at each time point were high (>70%). QOL was most impaired at 6 and 12 months and returned to baseline levels at 24 months. Among patients who underwent sphincter-preserving surgery (SPS; n=153 [85%]), overall bowel function at 24 months was significantly impaired and never returned to baseline. There were no differences in QOL at 24 months between patients who underwent SPS and those who did not (p=.29). Bowel function was correlated with QOL at 24 months (Pearson correlation,.41; p<.001). QOL among patients who have undergone SPS for rectal cancer is good despite poor function. Patients with ostomies are able to adjust to the functional changes and, overall, have good global QOL. Patients with low anastomoses had lower global QOL at 24 months than patients with permanent stomas. Our findings can help patients set expectations about function and quality of life after surgery for rectal cancer with and without a permanent stoma.
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Affiliation(s)
- Emmanouil P. Pappou
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States,*Correspondence: Emmanouil P. Pappou,
| | - Larissa K. Temple
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Sujata Patil
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, United States
| | - J. Joshua Smith
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Iris H. Wei
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Garrett M. Nash
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - José G. Guillem
- Department of Surgery, UNC School of Medicine, Chapel Hill, NC, United States
| | - Maria Widmar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Martin R. Weiser
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Philip B. Paty
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Deborah Schrag
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Julio Garcia-Aguilar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
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Nie K, Hu P, Zheng J, Zhang Y, Yang P, Jabbour SK, Yue N, Dong X, Xu S, Shen B, Niu T, Hu X, Cai X, Sun J. Incremental Value of Radiomics in 5-Year Overall Survival Prediction for Stage II-III Rectal Cancer. Front Oncol 2022; 12:779030. [PMID: 35847948 PMCID: PMC9279662 DOI: 10.3389/fonc.2022.779030] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 05/30/2022] [Indexed: 11/13/2022] Open
Abstract
Although rectal cancer comprises up to one-third of colorectal cancer cases and several prognosis nomograms have been established for colon cancer, statistical tools for predicting long-term survival in rectal cancer are lacking. In addition, previous prognostic studies did not include much imaging findings, qualitatively or quantitatively. Therefore, we include multiparametric MRI information from both radiologists' readings and quantitative radiomics signatures to construct a prognostic model that allows 5-year overall survival (OS) prediction for advance-staged rectal cancer patients. The result suggested that the model combined with quantitative imaging findings might outperform that of conventional TNM staging or other clinical prognostic factors. It was noteworthy that the identified radiomics signature consisted of three from dynamic contrast-enhanced (DCE)-MRI, four from anatomical MRI, and one from functional diffusion-weighted imaging (DWI). This highlighted the importance of multiparametric MRI to address the issue of long-term survival estimation in rectal cancer. Additionally, the constructed radiomics signature demonstrated value to the conventional prognostic factors in predicting 5-year OS for stage II-III rectal cancer. The presented nomogram also provides a practical example of individualized prognosis estimation and may potentially impact treatment strategies.
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Affiliation(s)
- Ke Nie
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Radiation Oncology, Rutgers-Cancer Institute of New Jersey, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Peng Hu
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jianjun Zheng
- Department of Radiology, Hwa Mei Hospital, Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, University of Chinese Academy of Sciences, Ningbo, China
| | - Yang Zhang
- Department of Radiation Oncology, Rutgers-Cancer Institute of New Jersey, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Pengfei Yang
- Institute of Translational Medicine, Zhejiang University, Hangzhou, China
| | - Salma K. Jabbour
- Department of Radiation Oncology, Rutgers-Cancer Institute of New Jersey, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Ning Yue
- Department of Radiation Oncology, Rutgers-Cancer Institute of New Jersey, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Xue Dong
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shufeng Xu
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Bo Shen
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Tianye Niu
- Institute of Translational Medicine, Zhejiang University, Hangzhou, China
| | - Xiaotong Hu
- Biomedical Research Center and Key Laboratory of Biotherapy of Zhejiang Province, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiujun Cai
- Department of General Surgery, Innovation Center for Minimally Invasive Techniques and Devices, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jihong Sun
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Innovation Center for Minimally Invasive Techniques and Devices, Zhejiang University, Hangzhou, China
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Thomas F, Bouvier AM, Cariou M, Bouvier V, Jooste V, Pouchucq C, Gardy J, Queneherve L, Launoy G, Alves A, Eid Y, Dejardin O. Influence of non-clinical factors on restorative rectal cancer surgery: An analysis of four specialized population-based digestive cancer registries in France. Dig Liver Dis 2022; 54:258-267. [PMID: 34301489 DOI: 10.1016/j.dld.2021.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/03/2021] [Accepted: 06/24/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND This study aims to measure the association between deprivation, health care accessibility and health care system with the likelihood of receiving non-restorative rectal cancer surgery (NRRCS). METHODS All adult patients who had rectal resection for invasive adenocarcinoma diagnosed between 2007 and 2016 in four French specialised cancer registries were included. A multilevel logistic regression with random effect was used to assess the link between patient and health care structure characteristics on the probability of NRRCS. RESULTS 2997 patients underwent rectal cancer resection in 68 health care structures: 708 (23.63%) had NRRCS. The likelihood of receiving NRCCS was associated with patients' characteristics (97%): age, sub peritoneal rectal tumors, neoadjuvant therapy, residual tumour and stage III . There was no impact of European Deprivation Index or remoteness on NRRCS. Inter-health care structure variability was modest (3%), of which 50% was explained by the high group volume of colorectal procedures and the type of health care structure which were associated with less NRRCS (p<0.01). CONCLUSION There is an influence of operating volume and type of structure on the probability of NRRCS, but it has truly little importance in explaining differences in performances. The probability of NRRCS is mainly affected by clinical determinant.
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Affiliation(s)
- Flavie Thomas
- Department of Digestive Surgery, University Hospital of Caen, Caen, France; UMR INSERM U1086 Anticipe, Centre François Baclesse, Caen, France
| | - Anne-Marie Bouvier
- Digestive Cancers Registry of Burgundy, University Hospital Dijon, France; INSERM UMR 1231, University of Burgundy, Dijon, France
| | - Mélanie Cariou
- Finistère Digestive Cancer Registry, University Hospital of Brest, France; EA7479 SPURBO, University of Western Brittany, Brest, France
| | - Véronique Bouvier
- UMR INSERM U1086 Anticipe, Centre François Baclesse, Caen, France; Department of Research: Epidemiology Research and Evaluation Unit, University Hospital of Caen, Caen, France; Calvados Digestive Cancer Registry, Epidemiology Research and Evaluation Unit, University Hospital of Caen, Caen, France
| | - Valérie Jooste
- Digestive Cancers Registry of Burgundy, University Hospital Dijon, France; INSERM UMR 1231, University of Burgundy, Dijon, France
| | - Camille Pouchucq
- Department of Digestive Surgery, University Hospital of Caen, Caen, France; UMR INSERM U1086 Anticipe, Centre François Baclesse, Caen, France
| | - Joséphine Gardy
- UMR INSERM U1086 Anticipe, Centre François Baclesse, Caen, France; Calvados Digestive Cancer Registry, Epidemiology Research and Evaluation Unit, University Hospital of Caen, Caen, France
| | - Lucille Queneherve
- Finistère Digestive Cancer Registry, University Hospital of Brest, France; EA7479 SPURBO, University of Western Brittany, Brest, France; Gastroenterology Department, University Hospital, Brest, France
| | - Guy Launoy
- UMR INSERM U1086 Anticipe, Centre François Baclesse, Caen, France; Department of Research: Epidemiology Research and Evaluation Unit, University Hospital of Caen, Caen, France; Calvados Digestive Cancer Registry, Epidemiology Research and Evaluation Unit, University Hospital of Caen, Caen, France
| | - Arnaud Alves
- Department of Digestive Surgery, University Hospital of Caen, Caen, France; UMR INSERM U1086 Anticipe, Centre François Baclesse, Caen, France; Calvados Digestive Cancer Registry, Epidemiology Research and Evaluation Unit, University Hospital of Caen, Caen, France
| | - Yassine Eid
- Department of Digestive Surgery, University Hospital of Caen, Caen, France; UMR INSERM U1086 Anticipe, Centre François Baclesse, Caen, France
| | - Olivier Dejardin
- UMR INSERM U1086 Anticipe, Centre François Baclesse, Caen, France; Department of Research: Epidemiology Research and Evaluation Unit, University Hospital of Caen, Caen, France.
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Bananzadeh A, Hafezi AA, Nguyen N, Omidvari S, Mosalaei A, Ahmadloo N, Ansari M, Mohammadianpanah M. Efficacy and safety of sequential neoadjuvant chemotherapy and short-course radiation therapy followed by delayed surgery in locally advanced rectal cancer: a single-arm phase II clinical trial with subgroup analysis between the older and young patients. Radiat Oncol J 2022; 39:270-278. [PMID: 34986548 PMCID: PMC8743455 DOI: 10.3857/roj.2021.00654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 07/22/2021] [Indexed: 12/18/2022] Open
Abstract
Purpose This study was performed to investigate the efficacy and safety of short-course radiation therapy (SCRT) and sequential chemotherapy followed by delayed surgery in locally advancer rectal cancer with subgroup analysis between the older and young patients. Materials and Methods In this single-arm phase II clinical trial, eligible patients with locally advanced rectal cancer (T3–4 and/or N1–2) were enrolled. All the patients received a median three sequential cycles of neoadjuvant CAPEOX (capecitabine + oxaliplatin) chemotherapy. A total dose of 25 Gy in five fractions during 1 week was prescribed to the gross tumor and regional lymph nodes. Surgery was performed about 8 weeks following radiotherapy. Pathologic complete response rate (pCR) and grade 3–4 toxicity were compared between older patients (≥65 years) and younger patients (<65 years). Results Ninety-six patients with locally advanced rectal cancer were enrolled. There were 32 older patients and 64 younger patients. Overall pCR was 20.8% for all the patients. Older patients achieved similar pCR rate (18.7% vs. 21.8; p = 0.795) compared to younger patients. There was no statistically significance in terms of the tumor and the node downstaging or treatment-related toxicity between older patients and younger ones; however, the rate of sphincter-saving surgery was significantly more frequent in younger patients (73% vs. 53%; p=0.047) compared to older ones. All treatment-related toxicities were manageable and tolerable among older patients. Conclusion Neoadjuvant SCRT and sequential chemotherapy followed by delayed surgery was safe and effective in older patients compared to young patients with locally advanced rectal cancer.
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Affiliation(s)
- Alimohammad Bananzadeh
- Colorectal Research Center, Department of Colorectal Surgery, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali Akbar Hafezi
- Department of Radiation Oncology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - NamPhong Nguyen
- Department of Radiation Oncology, Howard University Hospital, Washington, DC, USA
| | - Shapour Omidvari
- Breast Diseases Research Center, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ahmad Mosalaei
- Breast Diseases Research Center, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Niloofar Ahmadloo
- Breast Diseases Research Center, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mansour Ansari
- Breast Diseases Research Center, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Mohammadianpanah
- Colorectal Research Center, Department of Colorectal Surgery, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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Can Pre-Treatment Inflammatory Parameters Predict the Probability of Sphincter-Preserving Surgery in Patients with Locally Advanced Low-Lying Rectal Cancer? Diagnostics (Basel) 2021; 11:diagnostics11060946. [PMID: 34070592 PMCID: PMC8226544 DOI: 10.3390/diagnostics11060946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/07/2021] [Accepted: 05/24/2021] [Indexed: 11/29/2022] Open
Abstract
There is evidence suggesting that pre-treatment clinical parameters can predict the probability of sphincter-preserving surgery in rectal cancer; however, to date, data on the predictive role of inflammatory parameters on the sphincter-preservation rate are not available. The aim of the present cohort study was to investigate the association between inflammation-based parameters and the sphincter-preserving surgery rate in patients with low-lying locally advanced rectal cancer (LARC). A total of 848 patients with LARC undergoing radiotherapy from 2004 to 2019 were retrospectively reviewed in order to identify patients with rectal cancer localized ≤6 cm from the anal verge, treated with neo-adjuvant radiochemotherapy (nRCT) and subsequent surgery. Univariable and multivariable analyses were used to investigate the role of pre-treatment inflammatory parameters, including the C-reactive protein (CRP), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) for the prediction of sphincter preservation. A total of 363 patients met the inclusion criteria; among them, 210 patients (57.9%) underwent sphincter-preserving surgery, and in 153 patients (42.1%), an abdominoperineal rectum resection was performed. Univariable analysis showed a significant association of the pre-treatment CRP value (OR = 2.548, 95% CI: 1.584–4.097, p < 0.001) with sphincter preservation, whereas the pre-treatment NLR (OR = 1.098, 95% CI: 0.976–1.235, p = 0.120) and PLR (OR = 1.002, 95% CI: 1.000–1.005, p = 0.062) were not significantly associated with the type of surgery. In multivariable analysis, the pre-treatment CRP value (OR = 2.544; 95% CI: 1.314–4.926; p = 0.006) was identified as an independent predictive factor for sphincter-preserving surgery. The findings of the present study suggest that the pre-treatment CRP value represents an independent parameter predicting the probability of sphincter-preserving surgery in patients with low-lying LARC.
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10
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Partl R, Magyar M, Hassler E, Langsenlehner T, Kapp KS. Clinical parameters predictive for sphincter-preserving surgery and prognostic outcome in patients with locally advanced low rectal cancer. Radiat Oncol 2020; 15:99. [PMID: 32375894 PMCID: PMC7203844 DOI: 10.1186/s13014-020-01554-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 04/27/2020] [Indexed: 02/06/2023] Open
Abstract
Background Although controversial, there are data suggesting that clinical parameters can predict the probability of sphincter preserving procedures in rectal cancer. The purpose of this study was to investigate the association between clinical parameters and the sphincter-preserving surgery rate in patients who had undergone neoadjuvant combination therapy for advanced low rectal cancer. Methods In this single center study, the charts of 540 patients with locally advanced rectal cancer who had been treated with induction chemotherapy-and/or neoadjuvant concomitant radiochemotherapy (nRCT) over an 11-year period were reviewed in order to identify patients with rectal cancer ≤6 cm from the anal verge, who had received the prescribed nRCT only. Univariate and multivariate analyses were used to identify pretreatment patient- and tumor associated parameters correlating with sphincter preservation. Survival rates were calculated using Kaplan-Meier analyses. Results Two hundred eighty of the 540 patients met the selection criteria. Of the 280 patients included in the study, 158 (56.4%) underwent sphincter-preserving surgery. One hundred sixty-four of 280 patients (58.6%) had a downsizing of the primary tumor (ypT < cT) and 39 (23.8%) of these showed a complete histopathological response (ypT0 ypN0). In univariate analysis, age prior to treatment, Karnofsky performance status, clinical T-size, relative lymphocyte value, CRP value, and interval between nRCT and surgery, were significantly associated with sphincter-preserving surgery. In multivariate analysis, age (hazard ratio (HR) = 1.05, CI95%: 1.02–1.09, p = 0.003), relative lymphocyte value (HR = 0.94, CI95%: 0.89–0.99, p = 0.029), and interval between nRCT and surgery (HR = 2.39, CI95%: 1.17–4.88, p = 0.016) remained as independent predictive parameters. Conclusions These clinical parameters can be considered in the prognostication of sphincter-preserving surgery in case of low rectal adenocarcinoma. More future research is required in this area.
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Affiliation(s)
- Richard Partl
- Department of Therapeutic Radiology and Oncology, Medical University of Graz, Comprehensive Cancer Center Graz (CCC), Auenbruggerplatz 32, 8036, Graz, Austria.
| | - Marton Magyar
- Division of Neuroradiology, Vascular and Interventional Radiology, Medical University of Graz, Comprehensive Cancer Center Graz (CCC), Auenbruggerplatz 9, 8036, Graz, Austria
| | - Eva Hassler
- Division of Neuroradiology, Vascular and Interventional Radiology, Medical University of Graz, Comprehensive Cancer Center Graz (CCC), Auenbruggerplatz 9, 8036, Graz, Austria
| | - Tanja Langsenlehner
- Department of Therapeutic Radiology and Oncology, Medical University of Graz, Comprehensive Cancer Center Graz (CCC), Auenbruggerplatz 32, 8036, Graz, Austria
| | - Karin Sigrid Kapp
- Department of Therapeutic Radiology and Oncology, Medical University of Graz, Comprehensive Cancer Center Graz (CCC), Auenbruggerplatz 32, 8036, Graz, Austria
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11
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MRI predicts increased eligibility for sphincter preservation after CRT in low rectal cancer. Radiother Oncol 2020; 145:223-228. [DOI: 10.1016/j.radonc.2020.01.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 09/25/2019] [Accepted: 01/12/2020] [Indexed: 11/22/2022]
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12
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Kim S, Kim MH, Oh JH, Jeong SY, Park KJ, Oh HK, Kim DW, Kang SB. Predictors of permanent stoma creation in patients with mid or low rectal cancer: results of a multicentre cohort study with preoperative evaluation of anal function. Colorectal Dis 2020; 22:399-407. [PMID: 31698537 DOI: 10.1111/codi.14898] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 10/08/2019] [Indexed: 12/24/2022]
Abstract
AIM Preoperative factors predictive of permanent stoma creation were investigated in a long-term follow-up of patients with mid or low rectal cancer. METHOD We included patients who underwent radical resection for mid or low rectal cancer with available data for preoperative anal function measured by manometry and Faecal Incontinence Severity Index questionnaire between January 2005 and December 2015 in three tertiary referral hospitals. A permanent stoma was defined as a stoma present until the patient's last follow-up visit or death. Preoperative factors that predicted permanent stoma creation were analysed. RESULTS Over a median follow-up of 57.4 months (range 12-143 months), a permanent stoma was created in 144/577 (25.0%) patients, including 89 (15.4%) who underwent abdominoperineal resection, one (0.2%) who underwent Hartmann's operation without reversal, 15 (2.6%) with a diverting ileostomy at the time of initial sphincter-preserving surgery without undergoing stoma reversal, and 39 (6.8%) who underwent permanent ileostomy formation after sphincter-preserving surgery. Patients with permanent stoma creation had a shorter tumour distance from the anal verge (P < 0.001), larger tumour size (P = 0.020) and higher preoperative Faecal Incontinence Severity Index score (P = 0.020). On multivariable analysis, tumour distance from the anal verge predicted permanent stoma formation (relative risk 0.53 per centimetre increase; 95% confidence interval 0.46-0.60; P < 0.001) but preoperative anal function did not. CONCLUSION Tumour distance from the anal verge was the only preoperative determinant of permanent stoma creation in rectal cancer patients. These data may help mid and low rectal cancer patients understand the need for permanent stoma.
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Affiliation(s)
- S Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Surgery, Armed Forces Capital Hospital, Seongnam, Korea
| | - M H Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - J H Oh
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - S-Y Jeong
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - K J Park
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - H-K Oh
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - D-W Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - S-B Kang
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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13
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Trends and outcomes of sphincter-preserving surgery for rectal cancer: a national cancer database study. Int J Colorectal Dis 2019; 34:239-245. [PMID: 30280252 DOI: 10.1007/s00384-018-3171-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE Previous studies have shown that sphincter-preserving surgery is associated with better quality of life in postsurgical rectal cancer patients. However, the factors predicting the likelihood of undergoing sphincter-preserving surgery have not been well-described. The aim of this study was to report the factors that determined the likelihood of undergoing sphincter-preserving surgery. METHODS Characteristics of 24,018 rectal cancer patients undergoing sphincter-preserving surgery and abdominoperineal resection diagnosed from 2008 to 2012 from the National Cancer Database were investigated retrospectively for rate, pattern, and differences in mortality. Cox proportional hazards models were used to calculate hazard ratios for assessing mortality. Odds ratios were calculated using logistic regressions models for outcome sphincter-preserving surgery. RESULTS Eighteen thousand four hundred fifty-two (77%) patients had sphincter-preserving surgery. Majority of sphincter-preserving surgery patients were aged < 70 (74%), had private insurance (52%), and got treatment at a comprehensive community cancer program (54%). Multivariable analysis showed that patients with age ≥ 70 (OR 0.87, 95% CI 0.80-0.95), male gender (OR 0.90, 95% CI 0.84-0.96), having Medicare (OR 0.83, 95% CI 0.76-0.90), Medicaid (OR 0.72, 95% CI 0.63-0.81), and poorly differentiated grade (OR 0.78, 95% CI 0.71-0.85) were less likely to undergo sphincter-preserving surgery. Multivariable analysis showed that patients having abdominoperineal resection have higher likelihood of mortality than sphincter-preserving surgery (HR 1.26, 95% CI 1.16-1.36). CONCLUSIONS We were able to identify several patient and tumor-related factors impacting the likelihood of undergoing sphincter-preserving surgery. Patients undergoing non-sphincter sparing surgery had a higher mortality that sphincter preservation.
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Baral J, Schön MR, Ruppert R, Ptok H, Strassburg J, Brosi P, Kreis ME, Lewin A, Sauer J, Sawicki S, Schiffmann L, Winde G, Junginger T, Merkel S, Hermanek P. [Spincter preservation after selective chemoradiotherapy of rectal cancer. Interim results of the OCUM study]. Chirurg 2016; 86:1138-44. [PMID: 26347011 DOI: 10.1007/s00104-015-0083-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND In a prospective multicenter observational study (OCUM) neoadjuvant chemoradiotherapy (nRCT) was selectively administered depending on the risk of local recurrence and based on the distance between tumor and mesorectal fascia in pretherapeutic high-resolution magnetic resonance imaging (MRI). OBJECTIVE Frequency and quality of abdominoperineal excision (APE) and sphincter preserving operations. PATIENTS AND METHODS Of 642 patients treated in 13 hospitals 389 received surgery alone and 253 nRCT followed by surgery. By univariate and multivariate analysis risk factors for APE were determined. Quality parameters were the quality grade of mesorectal excision, the pathohistological involvement of the circumferential resection margin and intraoperative local dissemination of tumor cells. RESULTS AND DISCUSSION In 12.8 % of the patients APE was performed. Independent risk factors for APE were tumor location in the lower third of the rectum and the individual hospitals, where APE varied between 0 and 32 %. This variation was chiefly caused by the different case mix. Hospitals with a high APE rate (> 30 %) treated significantly more patients with very low lying carcinomas (< 3 cm above the anal verge) and more advanced tumors. The median height of the tumor in cases of APE was nearly equal in all participating hospitals. Independent on the number of cases the quality of rectal surgery was high. Within the patient groups of primary surgery and nRCT the oncological quality parameter did not significantly differ between sphincter preservation and APE. As far as sphincter preservation is concerned the results justify a selective application of nRCT in patients with rectal carcinoma. The long-term results still have to be awaited.
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Affiliation(s)
- J Baral
- Chirurgische Klinik, Städtisches Klinikum, Karlsruhe, Deutschland
| | - M R Schön
- Chirurgische Klinik, Städtisches Klinikum, Karlsruhe, Deutschland
| | - R Ruppert
- Klinik Neuperlach, Klinik für Allgemein- und Viszeralchirurgie, Endokrine Chirurgie und Coloproktologie, Städtische Kliniken München, München, Deutschland
| | - H Ptok
- Klinik für Chirurgie, Carl-Thiem-Klinik, Cottbus, Deutschland
| | - J Strassburg
- Abteilung für Allgemein- und Viszeralchirurgie, Vivantes-Klinik im Friedrichshain, Berlin, Deutschland
| | - P Brosi
- Chirurgische Klinik, Kantonspital Liestal, Liestal, Schweiz
| | - M E Kreis
- Chirurgische Klinik I, Charité Campus Benjamin Franklin, Berlin, Deutschland
| | - A Lewin
- Allgemein- und Viszeralchirurgie, Sanaklinikum Berlin Lichtenberg, Berlin, Deutschland
| | - J Sauer
- Klinik für Allgemein-, Viszeral- und Minimalinvasive Chirurgie, Klinikum Arnsberg, Arnsberg, Deutschland
| | - S Sawicki
- Franziskus Hospital Bielefeld, Bielefeld, Deutschland
| | - L Schiffmann
- Klinik für Allgemein-, Unfall- Viszeral- und Plastische Chirurgie, Ev. Krankenhaus Lippstadt, Lippstadt, Deutschland
| | - G Winde
- Klinik für Allgemein- und Viszeralchirurgie, Thoraxchirurgie und Proktologie, Klinikum Herford, Herford, Deutschland
| | - T Junginger
- Klinik für Allgemein- und Abdominalchirurgie, Universitätsmedizin Mainz, Langenbeckstr.1, 55131, Mainz, Deutschland.
| | - S Merkel
- Chirurgische Klinik, Friedrich-Alexander-Universität, Erlangen-Nürnberg, Deutschland
| | - P Hermanek
- Chirurgische Klinik, Friedrich-Alexander-Universität, Erlangen-Nürnberg, Deutschland
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Abstract
Abdominoperineal resection (APR) and sphincter-preserving resection (SPR) are the two primary surgical options for rectal cancer. Retrospectively we collected rectal cancer patients for SPR and APR observation between 2005 and 2007. The patient-related, tumor-related, and surgery-related variables of the SPR and APR groups were analyzed by using logistic regression techniques. The mean distance from the anal verge (DAV) of cancer is significantly higher in SPR than that in APR (P<0.001). In cancers with DAV<40 mm (SPR, 40 versus APR, 110), multivariate analysis shows that surgeon procedure volume (odds ratio [OR]=0.244; 95% confidence interval [CI]: 0.077-0.772; P=0.016) and neoadjuvant radiotherapy (OR=0.031; 95% CI: 0.002-0.396; P=0.008) are factors influencing SPR. In cancers with DAV ranging from 40 mm to 59 mm (SPR 190 versus APR 50), analysis shows that patient age (OR=2.139; 95% CI: 1.124-4.069; P=0.021), diabetes (OR=2.657; 95% CI: 0.872-8.095; P=0.086), and colorectal surgeon (OR=0.122, 95% CI: 0.020-0.758; P=0.024), are influencing factors for SPR. The local recurrence and disease-free survival reveal no significant difference. A significant difference exists in DAV, surgeon specialization, procedure volume, age, diabetes, and neoadjuvant radiotherapy between SPR and APR.
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16
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Hou XT, Pang D, Lu Q, Yang P, Jin SL, Zhou YJ, Tian SH. Validation of the Chinese version of the low anterior resection syndrome score for measuring bowel dysfunction after sphincter-preserving surgery among rectal cancer patients. Eur J Oncol Nurs 2015; 19:495-501. [DOI: 10.1016/j.ejon.2015.02.009] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Revised: 02/11/2015] [Accepted: 02/13/2015] [Indexed: 12/25/2022]
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Surgeon perspectives on the use and effects of neoadjuvant chemoradiation in the treatment of rectal cancer: a comprehensive review of the literature. Langenbecks Arch Surg 2015; 400:661-73. [PMID: 26250144 DOI: 10.1007/s00423-015-1328-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 07/27/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite screening initiatives, rectal cancer remains one of the most prevalent malignancies diagnosed in patients worldwide with a high mortality. The introduction of neoadjuvant therapy has resulted in a paradigm shift in the treatment and outcomes of rectal cancer. Surgeons play an intricate role in the pre-operative, operative, and post-operative management of these patients. PURPOSE The purpose of this comprehensive literature review was to summarize the evolution of the use chemotherapy and radiation and the process of differentiation into specific neoadjuvant chemoradiation protocols in the treatment of locally advanced rectal cancer. This will provide a concise summary for practicing surgeons of the current evidence for neoadjuvant chemoradiation as well as the various implications of therapy on operative outcomes. CONCLUSION The initial benefit of adjuvant therapy in the treatment of rectal cancer patients became evident with prospective studies demonstrating improvements in various oncologic survival outcomes. Due to the improved compliance and reduced toxicity, as well as the potential for tumor down-staging and sphincter preservation, neoadjuvant approaches became the preferred method of administering chemotherapy and radiation. Furthermore, a subgroup of patients has been shown to present with complete clinical response to neoadjuvant therapy. This has resulted in the development of the non-operative "watch and wait" approach, which has initiated discussions on changing the interval from the completion of neoadjuvant therapy to surgical resection. The continued development of the multidisciplinary approach will only further improve our ability to provide patients with the best possible oncologic outcomes.
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Sun Z, Yu X, Wang H, Ma M, Zhao Z, Wang Q. Factors affecting sphincter-preserving resection treatment for patients with low rectal cancer. Exp Ther Med 2015; 10:484-490. [PMID: 26622341 DOI: 10.3892/etm.2015.2552] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Accepted: 03/17/2015] [Indexed: 01/07/2023] Open
Abstract
The aim of the present study was to identify the factors associated with the use of sphincter-preserving resection (SPR) surgery for the treatment of low rectal cancer. A total of 330 patients with histopathologically confirmed low rectal cancer were divided into two groups, namely the abdominoperineal resection (APR) and sphincter-preserving (SP) groups. For SPR factor analysis, the χ2 test was performed as the univariate analysis, while a logistic regression test was conducted as the multivariate analysis. Of the 330 patients, 192 cases (58.18%) received SPR surgery and 138 cases (41.82%) underwent an APR. Univariate analysis results revealed that the sphincter-preserving factor was significantly associated with age, gender, ethnicity, body mass index (BMI), total infiltrated circumference, distance of the tumor from the anal verge (DTAV), depth of invasion and tumor grade (P<0.05). However, there were no statistically significant associations with family medical history, diabetes history, venous tumor embolism, growth type, tumor length, lymphatic metastasis and level of preoperative carcinoembryonic antigen (P>0.05). Multivariate analysis indicated that the sphincter-preserving factor was strongly associated with DTAV and the depth of invasion, with significant statistical difference (P<0.05). Therefore, selecting SPR surgery for patients with low rectal cancer is dependent on age, gender, ethnicity, BMI, the total infiltrated circumference, DTAV, depth of invasion and tumor grade. In addition, DTAV and the depth of invasion are independent risk factors for the selection of SPR surgery.
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Affiliation(s)
- Zhenqiang Sun
- Department of Gastrointestinal Surgery, Affiliated Tumor Hospital, Xinjiang Medical University, Ürümqi, Xinjiang 830011, P.R. China ; Research Laboratory of Disease Genomics, Cancer Research Institute, Central South University, Changsha, Hunan 410078, P.R. China
| | - Xianbo Yu
- Department of Gastrointestinal Surgery, Affiliated Tumor Hospital, Xinjiang Medical University, Ürümqi, Xinjiang 830011, P.R. China
| | - Haijiang Wang
- Department of Gastrointestinal Surgery, Affiliated Tumor Hospital, Xinjiang Medical University, Ürümqi, Xinjiang 830011, P.R. China
| | - Ming Ma
- Department of Hepatobiliary Surgery, Xinjiang Uygur Autonomous Region People's Hospital, Ürümqi, Xinjiang 830001, P.R. China
| | - Zeliang Zhao
- Department of Gastrointestinal Surgery, Affiliated Tumor Hospital, Xinjiang Medical University, Ürümqi, Xinjiang 830011, P.R. China
| | - Qisan Wang
- Department of Gastrointestinal Surgery, Affiliated Tumor Hospital, Xinjiang Medical University, Ürümqi, Xinjiang 830011, P.R. China
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Beppu N, Matsubara N, Kakuno A, Doi H, Kamikonya N, Yamanaka N, Yanagi H, Tomita N. Feasibility of modified short-course radiotherapy combined with a chemoradiosensitizer for T3 rectal cancer. Dis Colon Rectum 2015; 58:479-87. [PMID: 25850834 DOI: 10.1097/dcr.0000000000000323] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND 5-Fluorouracil-based chemotherapy is considered to be a radiosensitizer; however, conventional short-course radiotherapy combined with chemotherapy is generally thought to not be feasible because of the prevalence of side effects. OBJECTIVE The aim of this study was to evaluate the feasibility of modified short-course radiotherapy combined with a chemoradiosensitizer for T3 rectal cancer. DESIGN AND SETTINGS This study was retrospective in nature and used a prospectively collected database. PATIENTS Patients with T3 rectal cancer located below the peritoneum reflection were selected. INTERVENTIONS A total dose of 25 Gy of radiotherapy was administered in 10 fractions of 2.5 Gy each for 5 days. Radiotherapy was performed with S-1 as a radiosensitizer from day 1 to day 10. Surgery was targeted to be performed 4 weeks after radiotherapy. MAIN OUTCOME MEASUREMENTS The morbidity, sphincter-preserving rate, anal function, and long-term outcomes were assessed. RESULTS All patients (n = 170) completed the radiotherapy regimen and 166 (97.6%) completed the combination regimen with chemotherapy. A total of 149 patients (87.6%) had sphincter-preserving surgery (double stapling technique (DST), 58 patients; intersphincteric resection (ISR), 91 patients), and postoperative complications were relatively mild (anastomotic leakage, 15.4%; intra-abdominal infection, 8.2%). Among those undergoing sphincter preserving surgery, the 5-year local relapse-free survival rate was 94.3% in the DST group, and 89.8% in the ISR group. With respect to the anal function, the Wexner score the first year after stoma closure for the double-stapling technique group was 6 and that for intersphincteric resection was 15; however, the score for the intersphincteric resection group was improved to 8 at 4 years after stoma closure. LIMITATIONS This study had limitations because it was an uncontrolled, 1-arm, retrospective review with a small sample size. CONCLUSIONS Modified short-course radiotherapy combined with chemoradiosensitizer is a feasible approach for treating T3 rectal cancer. With the use of the short-course approach, efforts to reduce the incidence of side effects by appropriately prolonging the waiting period enable the administration of combination treatment with short-course radiotherapy and chemotherapy.
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Affiliation(s)
- Naohito Beppu
- 1 Department of Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan 2 Department of Pathology, Meiwa Hospital, Nishinomiya, Hyogo, Japan 3 Department of Radiology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan 4 Department of Surgery, Meiwa Hospital, Nishinomiya, Hyogo, Japan
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20
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Yeo H, Niland J, Milne D, ter Veer A, Bekaii-Saab T, Farma JM, Lai L, Skibber JM, Small W, Wilkinson N, Schrag D, Weiser MR. Incidence of minimally invasive colorectal cancer surgery at National Comprehensive Cancer Network centers. J Natl Cancer Inst 2014; 107:362. [PMID: 25527640 DOI: 10.1093/jnci/dju362] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Laparoscopic colectomy has been shown to have equivalent oncologic outcomes to open colectomy for the management of colon cancer, but its adoption nationally has been slow. This study investigates the prevalence and factors associated with laparoscopic colorectal resection at National Comprehensive Cancer Network (NCCN) centers. METHODS Data on patients undergoing surgery for colon and rectal cancer at NCCN centers from 2005 to 2010 were obtained from chart review of medical records for the NCCN Outcomes Project and included information on socioeconomic status, insurance coverage, comorbidity, and physician-reported Eastern Cooperative Oncology Group (ECOG) performance status. Associations between receipt of minimally invasive surgery and patient and clinical variables were analyzed with univariate and multivariable logistic regression. All statistical tests were two-sided. RESULTS A total of 4032 patients, diagnosed between September 2005 and December 2010, underwent elective colon or rectal resection for cancer at NCCN centers. Median age of colon cancer patients was 62.6 years, and 49% were men. The percent of colon cancer patients treated with minimally invasive surgery (MIS) increased from 35% in 2006 to 51% in 2010 across all centers but varied statistically significantly between centers. On multivariable analysis, factors associated with minimally invasive surgery for colon cancer patients who had surgery at an NCCN institution were older age (P = .02), male sex (P = .006), fewer comorbidities (P ≤ .001), lower final T-stage (P < .001), median household income greater than or equal to $80000 (P < .001), ECOG performance status = 0 (P = .02), and NCCN institution (P ≤ .001). CONCLUSIONS The use of MIS increased at NCCN centers. However, there was statistically significant variation in adoption of MIS technique among centers.
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Affiliation(s)
- Heather Yeo
- Memorial Sloan Kettering Cancer Center, New York, NY (HY, MRW); City of Hope Comprehensive Cancer Center, Duarte, CA (JN, AtV, LL, DS); Dana-Farber/Brigham and Women's Cancer Center, Boston, MA (DM, LL); The Ohio State University Comprehensive Cancer Center-James Cancer Hospital and Solove Research Institute, Columbus, OH (TBS); Fox Chase Cancer Center, Philadelphia, PA (JMF); The University of Texas M.D. Anderson Cancer Center, Houston, TX (JMS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (WS Jr); Roswell Park Cancer Institute, Buffalo, NY (NW)
| | - Joyce Niland
- Memorial Sloan Kettering Cancer Center, New York, NY (HY, MRW); City of Hope Comprehensive Cancer Center, Duarte, CA (JN, AtV, LL, DS); Dana-Farber/Brigham and Women's Cancer Center, Boston, MA (DM, LL); The Ohio State University Comprehensive Cancer Center-James Cancer Hospital and Solove Research Institute, Columbus, OH (TBS); Fox Chase Cancer Center, Philadelphia, PA (JMF); The University of Texas M.D. Anderson Cancer Center, Houston, TX (JMS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (WS Jr); Roswell Park Cancer Institute, Buffalo, NY (NW)
| | - Dana Milne
- Memorial Sloan Kettering Cancer Center, New York, NY (HY, MRW); City of Hope Comprehensive Cancer Center, Duarte, CA (JN, AtV, LL, DS); Dana-Farber/Brigham and Women's Cancer Center, Boston, MA (DM, LL); The Ohio State University Comprehensive Cancer Center-James Cancer Hospital and Solove Research Institute, Columbus, OH (TBS); Fox Chase Cancer Center, Philadelphia, PA (JMF); The University of Texas M.D. Anderson Cancer Center, Houston, TX (JMS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (WS Jr); Roswell Park Cancer Institute, Buffalo, NY (NW)
| | - Anna ter Veer
- Memorial Sloan Kettering Cancer Center, New York, NY (HY, MRW); City of Hope Comprehensive Cancer Center, Duarte, CA (JN, AtV, LL, DS); Dana-Farber/Brigham and Women's Cancer Center, Boston, MA (DM, LL); The Ohio State University Comprehensive Cancer Center-James Cancer Hospital and Solove Research Institute, Columbus, OH (TBS); Fox Chase Cancer Center, Philadelphia, PA (JMF); The University of Texas M.D. Anderson Cancer Center, Houston, TX (JMS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (WS Jr); Roswell Park Cancer Institute, Buffalo, NY (NW)
| | - Tanios Bekaii-Saab
- Memorial Sloan Kettering Cancer Center, New York, NY (HY, MRW); City of Hope Comprehensive Cancer Center, Duarte, CA (JN, AtV, LL, DS); Dana-Farber/Brigham and Women's Cancer Center, Boston, MA (DM, LL); The Ohio State University Comprehensive Cancer Center-James Cancer Hospital and Solove Research Institute, Columbus, OH (TBS); Fox Chase Cancer Center, Philadelphia, PA (JMF); The University of Texas M.D. Anderson Cancer Center, Houston, TX (JMS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (WS Jr); Roswell Park Cancer Institute, Buffalo, NY (NW)
| | - Jeffrey M Farma
- Memorial Sloan Kettering Cancer Center, New York, NY (HY, MRW); City of Hope Comprehensive Cancer Center, Duarte, CA (JN, AtV, LL, DS); Dana-Farber/Brigham and Women's Cancer Center, Boston, MA (DM, LL); The Ohio State University Comprehensive Cancer Center-James Cancer Hospital and Solove Research Institute, Columbus, OH (TBS); Fox Chase Cancer Center, Philadelphia, PA (JMF); The University of Texas M.D. Anderson Cancer Center, Houston, TX (JMS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (WS Jr); Roswell Park Cancer Institute, Buffalo, NY (NW)
| | - Lily Lai
- Memorial Sloan Kettering Cancer Center, New York, NY (HY, MRW); City of Hope Comprehensive Cancer Center, Duarte, CA (JN, AtV, LL, DS); Dana-Farber/Brigham and Women's Cancer Center, Boston, MA (DM, LL); The Ohio State University Comprehensive Cancer Center-James Cancer Hospital and Solove Research Institute, Columbus, OH (TBS); Fox Chase Cancer Center, Philadelphia, PA (JMF); The University of Texas M.D. Anderson Cancer Center, Houston, TX (JMS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (WS Jr); Roswell Park Cancer Institute, Buffalo, NY (NW)
| | - John M Skibber
- Memorial Sloan Kettering Cancer Center, New York, NY (HY, MRW); City of Hope Comprehensive Cancer Center, Duarte, CA (JN, AtV, LL, DS); Dana-Farber/Brigham and Women's Cancer Center, Boston, MA (DM, LL); The Ohio State University Comprehensive Cancer Center-James Cancer Hospital and Solove Research Institute, Columbus, OH (TBS); Fox Chase Cancer Center, Philadelphia, PA (JMF); The University of Texas M.D. Anderson Cancer Center, Houston, TX (JMS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (WS Jr); Roswell Park Cancer Institute, Buffalo, NY (NW)
| | - William Small
- Memorial Sloan Kettering Cancer Center, New York, NY (HY, MRW); City of Hope Comprehensive Cancer Center, Duarte, CA (JN, AtV, LL, DS); Dana-Farber/Brigham and Women's Cancer Center, Boston, MA (DM, LL); The Ohio State University Comprehensive Cancer Center-James Cancer Hospital and Solove Research Institute, Columbus, OH (TBS); Fox Chase Cancer Center, Philadelphia, PA (JMF); The University of Texas M.D. Anderson Cancer Center, Houston, TX (JMS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (WS Jr); Roswell Park Cancer Institute, Buffalo, NY (NW)
| | - Neal Wilkinson
- Memorial Sloan Kettering Cancer Center, New York, NY (HY, MRW); City of Hope Comprehensive Cancer Center, Duarte, CA (JN, AtV, LL, DS); Dana-Farber/Brigham and Women's Cancer Center, Boston, MA (DM, LL); The Ohio State University Comprehensive Cancer Center-James Cancer Hospital and Solove Research Institute, Columbus, OH (TBS); Fox Chase Cancer Center, Philadelphia, PA (JMF); The University of Texas M.D. Anderson Cancer Center, Houston, TX (JMS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (WS Jr); Roswell Park Cancer Institute, Buffalo, NY (NW)
| | - Deborah Schrag
- Memorial Sloan Kettering Cancer Center, New York, NY (HY, MRW); City of Hope Comprehensive Cancer Center, Duarte, CA (JN, AtV, LL, DS); Dana-Farber/Brigham and Women's Cancer Center, Boston, MA (DM, LL); The Ohio State University Comprehensive Cancer Center-James Cancer Hospital and Solove Research Institute, Columbus, OH (TBS); Fox Chase Cancer Center, Philadelphia, PA (JMF); The University of Texas M.D. Anderson Cancer Center, Houston, TX (JMS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (WS Jr); Roswell Park Cancer Institute, Buffalo, NY (NW)
| | - Martin R Weiser
- Memorial Sloan Kettering Cancer Center, New York, NY (HY, MRW); City of Hope Comprehensive Cancer Center, Duarte, CA (JN, AtV, LL, DS); Dana-Farber/Brigham and Women's Cancer Center, Boston, MA (DM, LL); The Ohio State University Comprehensive Cancer Center-James Cancer Hospital and Solove Research Institute, Columbus, OH (TBS); Fox Chase Cancer Center, Philadelphia, PA (JMF); The University of Texas M.D. Anderson Cancer Center, Houston, TX (JMS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (WS Jr); Roswell Park Cancer Institute, Buffalo, NY (NW).
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Wasserberg N, Kundel Y, Purim O, Keidar A, Kashtan H, Sadot E, Fenig E, Brenner B. Sphincter preservation in distal CT2N0 rectal cancer after preoperative chemoradiotherapy. Radiat Oncol 2014; 9:233. [PMID: 25338839 PMCID: PMC4215010 DOI: 10.1186/s13014-014-0233-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 10/08/2014] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Preoperative chemoradiotherapy is usually not indicated for cT2N0 rectal cancer. Abdominoperineal resection is the standard treatment for distal rectal tumors. The aim of the study was to evaluate the actual sphincter-preservation rate in patients with distal cT2N0 rectal cancer given neoadjuvant chemoradiotherapy. METHODS Data were retrospectively collected for all patients who were diagnosed with distal cT2N0 rectal cancer at a tertiary medical center in 2000-2008 and received chemoradiotherapy followed by surgery (5-7 weeks later). RESULTS Thirty-three patients (22 male) of median age 65 years (range, 32-88) were identified. Tumor distance from the anal verge ranged from 0 to 5 cm. R0 resection with sphincter preservation was accomplished in 22 patients (66%), with a 22% pathological complete response rate. Median follow-up time was 62 months (range 7-120). There were no local failures. Crude disease-free and overall survival were 82% and 86%, respectively. Factors associated with sphincter preservation were tumor location (OR=0.58, p=0.02, 95% CI=0.37-0.91) and pathological downstaging (OR=7.8, p=0.02, 95% CI=1.35-45.85). Chemoradiotherapy was well tolerated. CONCLUSION High rates of sphincter preservation can be achieved after preoperative chemoradiotherapy for distal cT2N0 rectal cancer, with tolerable toxicity, without compromising oncological outcome.
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Affiliation(s)
| | - Yulia Kundel
- Davidoff Cancer Center, Rabin Medical Center, Beilinson Campus, Petach Tikva, 49100, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 69978, Israel.
| | - Ofer Purim
- Davidoff Cancer Center, Rabin Medical Center, Beilinson Campus, Petach Tikva, 49100, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 69978, Israel.
| | - Andrei Keidar
- Department of Surgery B, Petach Tikva, 49100, Israel.
| | | | - Eran Sadot
- Department of Surgery B, Petach Tikva, 49100, Israel.
| | - Eyal Fenig
- Davidoff Cancer Center, Rabin Medical Center, Beilinson Campus, Petach Tikva, 49100, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 69978, Israel.
| | - Baruch Brenner
- Davidoff Cancer Center, Rabin Medical Center, Beilinson Campus, Petach Tikva, 49100, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 69978, Israel.
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Abdelsattar ZM, Wong SL, Birkmeyer NJ, Cleary RK, Times ML, Figg RE, Peters N, Krell RW, Campbell DA, Russell MM, Hendren S. Multi-institutional assessment of sphincter preservation for rectal cancer. Ann Surg Oncol 2014; 21:4075-80. [PMID: 25001097 DOI: 10.1245/s10434-014-3882-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND Sphincter-preserving surgery (SPS) has been proposed as a quality measure for rectal cancer surgery. However, previous studies on SPS rates lack critical clinical characteristics, rendering it unclear if variation in SPS rates is due to unmeasured case-mix differences or surgeons' selection criteria. In this context, we investigate the variation in SPS rates at various practice settings. METHODS Ten hospitals in the Michigan Surgical Quality Collaborative collected rectal cancer-specific data, including tumor location and reasons for non-SPS, of patients who underwent rectal cancer surgery from 2007 to 2012. Hospitals were divided into terciles of SPS rates (frequent, average, and infrequent). Patients were categorized as 'definitely SPS eligible' a priori if they did not have any of the following: sphincter involvement, tumor <6 cm from the anal verge, fecal incontinence, stoma preference, or metastatic disease. Fixed-effects logistic regression was used to evaluate for factors associated with SPS. RESULTS In total, 329 patients underwent rectal cancer surgery at 10 hospitals (5/10 higher volume, and 6/10 major teaching). Overall, 72 % had SPS (range by hospital 47-91 %). Patient and tumor characteristics were similar between hospital terciles. On multivariable analysis, only hospital ID, younger age, and tumor location were associated with SPS, but not sex, race, body mass index, American Joint Committee on Cancer (AJCC) stage, preoperative radiation, or American Society of Anesthesiologists (ASA) class. Analysis of the 181 (55 %) 'definitely-eligible' patients revealed an SPS rate of 90 % (65-100 %). CONCLUSIONS SPS rates vary by hospital, even after accounting for clinical characteristics using detailed chart review. These data suggest missed opportunities for SPS, and refute the general hypothesis that hospital variation in previous studies is due to unmeasured case-mix differences.
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Dodgion CM, Neville BA, Lipsitz SR, Schrag D, Breen E, Zinner MJ, Greenberg CC. Hospital variation in sphincter preservation for elderly rectal cancer patients. J Surg Res 2014; 191:161-8. [PMID: 24750983 DOI: 10.1016/j.jss.2014.03.047] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Revised: 02/24/2014] [Accepted: 03/14/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND The primary goal of an operation for rectal cancer is to cure cancer and, where possible, preserve continence. A wide range of sphincter preservation rates have been reported. This study evaluated hospital variation in the use of low anterior resection (LAR), local excision (LE), and abdominoperineal resection (APR) in the treatment of elderly rectal cancer patients. METHODS Using Surveillance, Epidemiology, and End Results-Medicare linked data, we identified 4959 patients older than 65 y with stage I-III rectal cancer diagnosed from 2000-2005 who underwent operative intervention at one of 370 hospitals. We evaluated the distribution of hospital-specific procedure rates and used generalized mixed models with random hospital effects to examine the influence of patient characteristics and hospital on operation type, using APR as a reference. RESULTS The median hospital performed APR on 33% of elderly patients with rectal cancer. Hospital was a stronger predictor of LAR receipt than any patient characteristic, explaining 32% of procedure choice, but not a strong predictor of LE, explaining only 3.8%. Receipt of LE was primarily related to tumor size and tumor stage, which combined explained 31% of procedure variation. CONCLUSIONS Receipt of LE is primarily determined by patient characteristics. In contrast, the hospital where surgery is performed significantly influences whether a patient undergoes an LAR or APR. Understanding the factors that cause this institutional variation is crucial to ensuring equitable availability of sphincter preservation.
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Affiliation(s)
- Christopher M Dodgion
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Bridget A Neville
- Center for Outcomes and Policy Research, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Stuart R Lipsitz
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Deborah Schrag
- Center for Outcomes and Policy Research, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Elizabeth Breen
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael J Zinner
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Caprice C Greenberg
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin, Madison, Wisconsin.
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Omidvari S, Hamedi SH, Mohammadianpanah M, Razzaghi S, Mosalaei A, Ahmadloo N, Ansari M, Pourahmad S. Comparison of abdominoperineal resection and low anterior resection in lower and middle rectal cancer. J Egypt Natl Canc Inst 2013; 25:151-60. [DOI: 10.1016/j.jnci.2013.06.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Revised: 06/12/2013] [Accepted: 06/15/2013] [Indexed: 01/23/2023] Open
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Population-based use of sphincter-preserving surgery in patients with rectal cancer: is there room for improvement? Dis Colon Rectum 2013; 56:704-10. [PMID: 23652743 DOI: 10.1097/dcr.0b013e3182758c2b] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Treatment of rectal cancer in North America has been associated with lower rates of sphincter-preserving surgery in comparison with other regions. It is unclear if these lower rates are due to patient, tumor, or treatment factors; thus, the potential to increase the use of sphincter-preserving surgery is unknown. OBJECTIVE The aim of this study is to identify the factors associated with the use of sphincter-preserving surgery and to quantify the potential for an increase in sphincter preservation. DESIGN This population-based retrospective cohort study used patient-level data collected through a comprehensive, standardized review of hospital inpatient and outpatient medical records and cancer center charts. SETTINGS This study was conducted in all hospitals providing rectal cancer surgery in a Canadian province. PATIENTS All patients with a new diagnosis of rectal cancer from July 1, 2002 to June 30, 2006 who underwent potentially curative radical surgery were included. MAIN OUTCOME MEASURES Logistic regression was used to identify factors associated with receiving a permanent colostomy. Patients were categorized as having received an appropriate or potentially inappropriate colostomy based on a priori determined patient, tumor, operative, and pathologic criteria. RESULTS Of 466 patients who underwent radical surgery, 48% received a permanent colostomy. There was significant variation in the rate of sphincter-preserving surgery among the 10 hospitals that provided rectal cancer care (12%-73%, p = 0.0001). On multivariate analysis, male sex, low tumor height, and increasing tumor stage were associated with the receipt of a permanent colostomy. Among patients who received a permanent stoma, 65 of 224 (29%) patients received a potentially inappropriate stoma. On multivariate analysis, male sex and treatment in a medium- or low-volume hospital was associated with the receipt of a potentially inappropriate colostomy. LIMITATIONS This study was limited by its retrospective design. CONCLUSIONS These data suggest that the receipt of a permanent colostomy by many patients with rectal cancer may be inappropriate, and there is potential to increase the use of sphincter-preserving surgery in patients with rectal cancer.
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Pahlman L, Bujko K, Rutkowski A, Michalski W. Altering the therapeutic paradigm towards a distal bowel margin of < 1 cm in patients with low-lying rectal cancer: a systematic review and commentary. Colorectal Dis 2013; 15:e166-74. [PMID: 23331717 DOI: 10.1111/codi.12120] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Accepted: 09/04/2012] [Indexed: 12/13/2022]
Abstract
AIM The 1-cm rule of distal bowel clearance in patients with low-lying rectal cancer undergoing anterior resection is based mainly on pathological data showing distal intramural spread. Because clinical data are contradictory, a review that includes only cancers located ≤ 5 or ≤ 6 cm from the anal verge was carried out. METHOD A systematic review of the literature identified seven studies that presented results in relation to a margin of ≤ 1 cm (n = 293) vs > 1 cm (n = 315). In six studies, pre- or postoperative radiotherapy was implemented, and in one study patients were treated with surgery alone. Three studies, all implementing radiotherapy, reported results related to a margin of ≤ 5 mm (n = 51) vs > 5 mm (n = 125). RESULTS In none of the studies were the differences in local recurrence rate between the small and large margin groups statistically significant. The pooled analysis of six studies, in which patients received perioperative radiotherapy, showed a 1.2% [95% confidence interval (Cl) -4.5-7.0%] higher local recurrence rate in the ≤ 1 cm margin group compared with the > 1 cm margin group (P = 0.6). The corresponding figures for the ≤ 5 mm cut-off point were 0.5% (95% CI -7.6-8.7%, P = 0.9). The 5-year local recurrence rate in the only study in which radiotherapy had not been used was 8.6% higher in the ≤ 1 cm margin group compared with the > 1 cm margin group (P = 0.09). CONCLUSION Clinical evidence does not support the 1-cm rule in patients with low-lying rectal cancer undergoing pre- or postoperative radiotherapy.
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Affiliation(s)
- L Pahlman
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Do older Americans undergo stoma reversal following low anterior resection for rectal cancer? J Surg Res 2012; 183:238-45. [PMID: 23298948 DOI: 10.1016/j.jss.2012.11.057] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Revised: 11/21/2012] [Accepted: 11/30/2012] [Indexed: 12/12/2022]
Abstract
OBJECTIVE For low-lying rectal cancers, proximal diversion can reduce anastomotic leak after sphincter-preserving surgery; however, evidence suggests that such temporary diversions are often not reversed. We aimed to evaluate nonreversal and delayed stoma reversal in elderly patients undergoing low anterior resection (LAR). DESIGN SEER-Medicare-linked analysis from 1991-2007. SETTINGS AND PARTICIPANTS A total of 1179 primary stage I-III rectal cancer patients over age 66 who underwent LAR with synchronous diverting stoma. MAIN OUTCOME MEASURES (1) Stoma creation and reversal rates; (2) time to reversal; (3) characteristics associated with reversal and shorter time to reversal. RESULTS Within 18 mo of LAR, 51% of patients (603/1179) underwent stoma reversal. Stoma reversal was associated with age <80 y (P < 0.0001), male sex (P = 0.018), fewer comorbidities (P = 0.017), higher income (quartile 4 versus 1; P = 0.002), early tumor stage (1 versus 3; P < 0.001), neoadjuvant radiation (P < 0.0001), rectal tumor location (versus rectosigmoid; P = 0.001), more recent diagnosis (P = 0.021), and shorter length of stay on LAR admission (P = 0.021). Median time to reversal was 126 d (interquartile range: 79-249). Longer time to reversal was associated with older age (P = 0.031), presence of comorbidities (P = 0.014), more advanced tumor stage (P = 0.007), positive lymph nodes (P = 0.009), receipt of adjuvant radiation therapy (P = 0.008), more recent diagnosis (P = 0.004), and longer length of stay on LAR admission (P < 0.0001). CONCLUSIONS Half of elderly rectal cancer patients who undergo LAR with temporary stoma have not undergone stoma reversal by 18 mo. Identifiable risk factors predict both nonreversal and longer time to reversal. These results help inform preoperative discussions and promote realistic expectations for elderly rectal cancer patients.
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Abstract
BACKGROUND Local excision, alone or in combination with chemoradiation, is increasingly considered for rectal cancer. Higher risks of disease recurrence have been demonstrated after local excision. OBJECTIVE The aim of this study was to examine the outcomes of current-era multimodality salvage for recurrent rectal cancer after local excision. DESIGN This was a single-institutional retrospective study. SETTINGS This study was conducted at a tertiary-referral cancer center between 1993 and 2011. PATIENTS Forty-six patients with recurrent rectal cancer after initial local excision were included. INTERVENTION Multimodality salvage treatment was performed as appropriate. MAIN OUTCOME MEASURES The primary outcomes measured were the pattern of disease recurrence, salvage treatments, and resultant overall and re-recurrence-free survival. RESULTS After the initial local excision, recurrent disease was diagnosed after a median interval of 1.9 years: local/regionally in 67%, distantly in 18%, and both in 15%. Four patients (9%) had recurrence that was unsalvageable, 2 (4%) declined treatment, and 40 (87%) underwent surgical salvage. Preoperative chemoradiation was given in 30 (75%) patients. The R0 resection rate was 80%, requiring multivisceral resection (33%), total pelvic exenteration (5%), and metastasectomy (25%). The rate of sphincter preservation was 33%, and perioperative morbidity was 50%. The first site of failure after salvage was distant in 38% and was local only in 10%. The 5-year overall and 3-year re-recurrence-free survival were 63% and 43%. Pathologic stage at initial local excision, receipt of neoadjuvant chemoradiation before local excision, recurrence pattern after local excision, pathologic stage at salvage, and R0 resection at salvage influenced re-recurrence-free survival. LIMITATIONS This study was limited by the referral and selection biases inherent in a small study cohort. CONCLUSIONS Failure after local excision for rectal cancer may not be salvageable. When feasible, multimodality treatment, including multivisceral resection, pelvic irradiation, and chemotherapy, was associated with potentially lasting treatment-related morbidities and only modest success in long-term disease control. These findings should be compared with the expected stage-specific outcomes of standard proctectomy for early-stage rectal cancer, when local excision is being considered.
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Abstract
BACKGROUND Patients with rectal cancer who have a temporary ostomy report good quality of life despite identifying a number of stoma-related difficulties. OBJECTIVE This study aimed to qualitatively explore the experiences of patients with rectal cancer who have a temporary ileostomy to better understand the discordant findings of previous quantitative quality-of-life studies. DESIGN/SETTING We conducted in-depth qualitative interviews with patients with stage I to III rectal cancer who underwent sphincter-preserving surgery that resulted in a temporary ileostomy. PATIENTS Twenty-six patients (54% male, median age 54) participated. Sixty-five percent had stage III disease, and 88% received neoadjuvant therapy. MAIN OUTCOME MEASURES Interviews examined preoperative expectations, overall experience, and stoma impact on quality of life. With the use of grounded theory, 2 investigators independently performed line-by-line content analysis to identify key themes. Analysis continued until data saturation. RESULTS Two major themes were identified: stoma-related difficulties and perceived response shift. Patients reported difficulty in exercise, sleep, social activities, sexuality, and clothing. Patients' perception of quality of life with a temporary stoma appears to have undergone a response shift through recalibration of their standards for measuring quality of life (internal measurement scale altered by side effects of neoadjuvant/adjuvant treatment, temporary nature of stoma, and accommodation to stoma) and reconceptualization of what "good quality of life" is (stoma difficulties were felt to be less important in comparison with cancer-related mortality). LIMITATIONS Although qualitative research is, by design, not generalizable, these data support our previous quantitative work. This convergence of findings suggests that our data may be representative. CONCLUSIONS A temporary ileostomy represents significant difficulties for patients with rectal cancer. However, because of response shift, these difficulties may not be perceived as important to overall quality of life when considered within the context of the cancer experience. Our results can inform preoperative consultations with patients who have rectal cancer to assist in aligning patient expectations of what life with a temporary ileostomy may be like.
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Laforest A, Bretagnol F, Mouazan AS, Maggiori L, Ferron M, Panis Y. Functional disorders after rectal cancer resection: does a rehabilitation programme improve anal continence and quality of life? Colorectal Dis 2012; 14:1231-7. [PMID: 22268662 DOI: 10.1111/j.1463-1318.2012.02956.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM A poor functional outcome is often reported after total mesorectal excision (TME) for rectal cancer, especially when sphincter-saving resection with intersphincteric dissection is performed for low tumours. Anal sphincter rehabilitation is widely proposed for faecal incontinence. Very few studies have reported results to improve anal dysfunction following rectal surgery. This prospective study aimed to assess the benefits of sphincter training after TME in terms of functional outcome and quality of life. METHODS Anal sphincter training was performed in patients undergoing laparoscopic sphincter-saving TME for rectal cancer. Rehabilitation was performed after ileostomy closure. This group was compared with 24 matched patients. Assessment included one functional and two quality of life questionnaires (SF-36 Health Status and Faecal Incontinence Quality of Life score). RESULTS From 2007 to 2009, 22 patients underwent laparoscopic TME. The median follow-up after stoma closure was 21.2 (range 8-46) months. The mean stool frequency per day was significantly lower after sphincter training (2.6 in the training group vs 4.0 in the control group, P=0.025). Following rehabilitation, patients complained significantly less about dyschezia (22 vs 63%, P=0.008). Both groups had similar continence (Wexner score 8.3 after training vs 9.9 in controls, NS). Quality of life was significantly improved by sphincter training as measured by the vitality (P=0.004) and mental functioning (P=0.02) subscales on the SF-36 Health Status questionnaire and by the depression and self-perception (P = 0.005) categories of the Faecal Incontinence Quality of Life score. CONCLUSION This study suggests that anal sphincter training following TME could decrease stool frequency and improve both general and specific quality of life.
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Affiliation(s)
- A Laforest
- Department of Colorectal Surgery, Beaujon Hospital, University Paris VII, Clichy, France
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Baker B, Salameh H, Al-Salman M, Daoud F. How does preoperative radiotherapy affect the rate of sphincter-sparing surgery in rectal cancer? Surg Oncol 2012; 21:e103-9. [DOI: 10.1016/j.suronc.2012.03.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Revised: 03/27/2012] [Accepted: 03/28/2012] [Indexed: 01/03/2023]
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Risk of permanent stoma after resection of rectal cancer depending on the distance between the tumour lower edge and anal verge. POLISH JOURNAL OF SURGERY 2012; 83:588-96. [PMID: 22246091 DOI: 10.2478/v10035-011-0094-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The distance between the anal verge and lower edge of rectal cancer is one of the most important factors affecting the feasibility of sphincter-preserving resection.The aim of the study was to assess the risk of permanent stoma after resection of rectal tumour depending on the distance between the tumour and the anal verge.Material and methods. The retrospective analysis covered 884 patients after resection of rectal cancer. The distance between the anal verge and the lowest edge of the tumour was measured during endoscopic examination. Surgical technique was similar in all cases. For statistical analysis, the chi-square test and Fisher exact test were used.Results. The overall rate of sphincter-preserving procedures was 71.8%, 90.1% of which were anterior resections. The greatest differences between the rate of anterior resections were noted for the segment between the 4th and the 5th centimetres: 30.1% for 4 cm vs 66.7% for 5 cm, p = 0.005. Overall, in 328 patients (37.1%) surgical treatment resulted in a permanent stoma. The number included: 246 (75.0%) patients after abdominosacral resection, 44 (13.4%) patients after the Hartmann procedure, three (0.9%) patients after proctocolectomy, and 28 (8.5%) patients after anterior resection, with a permanent stoma as a result of anastomotic leak. The overall rate of anastomotic leak was 11.7%. Formation of a defunctioning stoma in patients with a low-lying (6 cm from the anal verge) tumour reduced the risk of symptomatic anastomotic leak: 6.3% vs 20.5%; p = 0.049.Conclusions. Anterior resection of tumours located 6 cm from the anal verge is feasible in 90%. Anastomotic leak that requires reoperation increases the risk of permanent colostomy. In selected cases, formation of a defunctioning stoma after resection of low-lying rectal cancer can reduce the risk of permanent colostomy.
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Chen ZH, Song XM, Chen SC, Li MZ, Li XX, Zhan WH, He YL. Risk factors for adverse outcome in low rectal cancer. World J Gastroenterol 2012; 18:64-9. [PMID: 22228972 PMCID: PMC3251807 DOI: 10.3748/wjg.v18.i1.64] [Citation(s) in RCA: 8] [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: 04/08/2011] [Revised: 07/07/2011] [Accepted: 07/14/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: To demonstrate the oncologic outcomes of low rectal cancer and to clarify the risk factors for survival, focusing particularly on the type of surgery performed.
METHODS: Data from patients with low rectal carcinomas who underwent surgery, either sphincter-preserving surgery (SPS) or abdominoperineal resection (APR), at The First Affiliated Hospital of Sun Yat-sen University in China from August 1994 to December 2005 were retrospectively analyzed.
RESULTS: Of 331 patients with low rectal cancer, 159 (48.0%) were treated with SPS. A higher incidence of positive resection margins and a higher 5-year cumulative local recurrence rate (14.7% vs 6.8%, P = 0.041) were observed in patients after APR compared to SPS. The five-year overall survival (OS) was 54.6% after APR and 66.8% after SPS (P = 0.018), and the 5-year disease-free survival (DFS) was 52.9% after APR and 65.5% after SPS (P = 0.013). In multivariate analysis, poor OS and DFS were significantly related to positive resection margins, pT3-4, and pTNM III-IV but not to the type of surgery.
CONCLUSION: Despite a higher rate of positive resection margins after APR, the type of surgery was not identified as an independent risk factor for survival.
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Rutkowski A, Nowacki MP, Chwalinski M, Oledzki J, Bednarczyk M, Liszka-Dalecki P, Gornicki A, Bujko K. Acceptance of a 5-mm distal bowel resection margin for rectal cancer: is it safe? Colorectal Dis 2012; 14:71-8. [PMID: 21199273 DOI: 10.1111/j.1463-1318.2010.02542.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
AIM Acceptance of a short distal bowel margin results in a higher rate of anterior resection but may compromise oncological safety. This study aimed to evaluate the safety of a 5-mm distal margin. METHOD A retrospective analysis was carried out of 412 consecutive patients with rectal cancer treated with anterior resection with a negative circumferential resection margin. Radiotherapy was given to 63% of patients with an advanced tumour. The median follow up was 75 months. RESULTS Fewer patients in the group with a distal margin of ≤ 5 mm had a tumour with an advanced pT stage compared to patients in the group with a distal margin of > 5 mm (P = 0.033). Two patients were converted to abdominoperineal resection because of a positive 'doughnut', leaving 410 patients, in whom 5.4% (95% CI, 0-11.3%) of the group with a distal margin of ≤ 5 mm had local recurrence at 5 years compared with 4.2% (95% CI, 2.1-6.3%) of the group with a distal margin of > 5 mm (P = 0.726). The corresponding figures for the 5-year overall survival were 82.4% (95% CI, 72.6-92.2%) vs 76.3% (95% CI, 71.8-80.8%) (P = 0.581). All four anastomotic recurrences occurred in the group with a distal margin of > 5 mm. CONCLUSION A distal margin of ≤ 5 mm did not compromise oncological safety in patients undergoing preoperative radiation for an advanced rectal cancer.
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Affiliation(s)
- A Rutkowski
- Departments of Colorectal Cancer Radiotherapy, The Maria Sklodowska-Curie Memorial Cancer Centre, Warsaw, Poland.
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Abstract
BACKGROUND There is wide variation in surgical care for rectal cancer in the United States. OBJECTIVE This study aimed to assess the differences in individual surgeon procedural profiles that might explain variations in the rates of restorative vs nonrestorative proctectomy for rectal cancer. DESIGN This study was a retrospective examination of a cohort derived from trackable state hospital discharge data from 11 states. PATIENTS We identified all patients with rectal cancer that underwent restorative proctectomy (sphincter-sparing surgery) vs nonrestorative proctectomy (colostomy formation) over a 24-month study period (January 1, 2003 through December 31, 2004). INTERVENTION We developed an inpatient procedural profile of each treating surgeon's practice across general surgery procedure codes and summed the number of restorative vs nonrestorative proctectomies for rectal cancer by surgeon. MAIN OUTCOME MEASURES The primary outcome measures were nonrestorative proctectomy, mortality, and length of stay. RESULTS A total of 7519 proctectomies were performed for rectal cancer by 2588 surgeons. During the 24-month study period, 1003 (38.8%) surgeons performed only nonrestorative procedures for rectal cancer. On multivariate analysis, the likelihood that a surgeon performed only nonrestorative procedures was increased if that surgeon performed more integumentary procedures and decreased if the surgeon performed at least one ileoanal pouch procedure or more anorectal procedures. Patients who underwent proctectomy by surgeons who performed only nonrestorative procedures had significantly higher mortality (2.5 ± 0.7%) and longer length of stay (11.3 ± 8.8 days) in comparison with those patients treated by surgeons who performed both restorative and nonrestorative procedures (1.3 ± 0.3% mortality and 9.2 ± 6.9 days, P < .001 for both analyses). The volume of proctectomy performed significantly affected all analyses. LIMITATIONS : The retrospective design introduces potential selection bias. CONCLUSIONS Over a 24-month period, 38.8% of surgeons performed only nonrestorative procedures for rectal cancer. These surgeons did not regularly perform anorectal or ileoanal pouch procedures, suggesting that they may not have a focus on colorectal disease in their practice; they had significantly higher mortality and length of stay for their patients who underwent proctectomy for rectal cancer.
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Dumont F, Souadka A, Goéré D, Lasser P, Elias D. Impact of perineal pseudocontinent colostomy on perineal wound healing after abdominoperineal resection. J Surg Oncol 2011; 105:628-31. [DOI: 10.1002/jso.22105] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Accepted: 09/06/2011] [Indexed: 11/07/2022]
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Bujko K, Rutkowski A, Chang GJ, Michalski W, Chmielik E, Kusnierz J. Is the 1-cm rule of distal bowel resection margin in rectal cancer based on clinical evidence? A systematic review. Ann Surg Oncol 2011; 19:801-8. [PMID: 21879269 PMCID: PMC3278608 DOI: 10.1245/s10434-011-2035-2] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Indexed: 12/20/2022]
Abstract
Background Distal intramural spread is present within 1 cm from visible tumor in a substantial proportion of patients. Therefore, ≥1 cm of distal bowel clearance is recommended as minimally acceptable. However, clinical results are contradictory in answering the question of whether this rule is valid. The aim of this review was to evaluate whether in patients undergoing anterior resection, a distal bowel gross margin of <1 cm jeopardizes oncologic safety. Methods A systematic review of the literature identified 17 studies showing results in relation to margins of approximately <1 cm (948 patients) versus >1 cm (4626 patients); five studies in relation to a margin of ≤5 mm (173 patients) versus >5 mm (1277 patients), and five studies showing results in a margin of ≤2 mm (73 patients). In most studies, pre- or postoperative radiation was provided. Results A multifactorial process was identified resulting in selection of favorable tumors for anterior resection with the short bowel margin and unfavorable tumors for abdominoperineal resection or for anterior resection with the long margin. In total, the local recurrence rate was 1.0% higher in the <1-cm margin group compared to the >1-cm margin group (95% confidence interval [CI] −0.6 to 2.7; P = 0.175). The corresponding figures for ≤5 mm cutoff point were 1.7% (95% CI −1.9 to 5.3; P = 0.375). The pooled local recurrence rate in patients having ≤2 mm margin was 2.7% (95% CI 0 to 6.4). Conclusions In the selected group of patients, <1 cm margin did not jeopardize oncologic safety.
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Affiliation(s)
- Krzysztof Bujko
- Department of Radiotherapy, Maria Sklodowska-Curie Memorial Cancer Centre, Warsaw, Poland.
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Presence of specialty surgeons reduces the likelihood of colostomy after proctectomy for rectal cancer. Dis Colon Rectum 2011; 54:207-13. [PMID: 21228670 DOI: 10.1007/dcr.0b013e3181fb8903] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Geographic variability in the use of restorative proctectomy for rectal cancer has been described throughout the United States. We examined factors associated with high rates of colostomy formation after proctectomy for rectal cancer across US counties. METHODS We used state hospital discharge data from 21 states to determine county rates of restorative proctectomy vs nonrestorative proctectomy (ie, colostomy) for rectal cancer. We merged the county-level data with 1) tumor characteristics from Surveillance Epidemiology and End Results data; 2) number of specialty surgeons in the American Society of Colon and Rectal Surgeons and Society of Surgical Oncology; 3) county socioeconomic variables from census data; 4) colorectal cancer-screening rates from Medicare; and 5) hospital characteristics from the American Hospital Association. We then determined factors associated with high rates of colostomy formation (> 60%) after proctectomy for rectal cancer across counties. RESULTS From January 1, 2002, to December 31, 2004, a total of 19,912 proctectomies were performed for cancer in 1050 counties, of which 489 had adequate sample size for evaluation. Based on county of residence information, nonrestorative proctectomy with colostomy was performed in greater than 60% of all patients with rectal cancer in 26% (n = 125) of counties. On multivariate analysis, more specialty surgeons (OR = 0.70; CI = 0.51-0.96) were protective against colostomy formation at the county level. CONCLUSIONS The use of restorative techniques in rectal cancer surgery varies based on access to specialty colorectal cancer surgeons. Population-based directives are needed to standardize care for rectal cancer across the United States.
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Neuman HB, Patil S, Fuzesi S, Wong WD, Weiser MR, Guillem JG, Paty PB, Nash GM, Temple LK. Impact of a Temporary Stoma on the Quality of Life of Rectal Cancer Patients Undergoing Treatment. Ann Surg Oncol 2010; 18:1397-403. [DOI: 10.1245/s10434-010-1446-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2010] [Indexed: 01/09/2023]
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