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Somashekhar SP, Saklani A, Dixit J, Kothari J, Nayak S, Sudheer OV, Dabas S, Goud J, Munikrishnan V, Sugoor P, Penumadu P, Ramachandra C, Mehendale S, Dahiya A. Clinical Robotic Surgery Association (India Chapter) and Indian rectal cancer expert group’s practical consensus statements for surgical management of localized and locally advanced rectal cancer. Front Oncol 2022; 12:1002530. [PMID: 36267970 PMCID: PMC9577482 DOI: 10.3389/fonc.2022.1002530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 09/16/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction There are standard treatment guidelines for the surgical management of rectal cancer, that are advocated by recognized physician societies. But, owing to disparities in access and affordability of various treatment options, there remains an unmet need for personalizing these international guidelines to Indian settings. Methods Clinical Robotic Surgery Association (CRSA) set up the Indian rectal cancer expert group, with a pre-defined selection criterion and comprised of the leading surgical oncologists and gastrointestinal surgeons managing rectal cancer in India. Following the constitution of the expert Group, members identified three areas of focus and 12 clinical questions. A thorough review of the literature was performed, and the evidence was graded as per the levels of evidence by Oxford Centre for Evidence-Based Medicine. The consensus was built using the modified Delphi methodology of consensus development. A consensus statement was accepted only if ≥75% of the experts were in agreement. Results Using the results of the review of the literature and experts’ opinions; the expert group members drafted and agreed on the final consensus statements, and these were classified as “strong or weak”, based on the GRADE framework. Conclusion The expert group adapted international guidelines for the surgical management of localized and locally advanced rectal cancer to Indian settings. It will be vital to disseminate these to the wider surgical oncologists and gastrointestinal surgeons’ community in India.
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Affiliation(s)
- S. P. Somashekhar
- Department of Surgical Oncology, Manipal Hospital, Bengaluru, Karnataka, India
- *Correspondence: S. P. Somashekhar,
| | - Avanish Saklani
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Jagannath Dixit
- Department of GI Surgery, HCG Hospital, Bengaluru, Karnataka, India
| | - Jagdish Kothari
- Department of Surgical Oncology HCG Hospital, Ahmedabad, Gujarat, India
| | - Sandeep Nayak
- Department of Surgical Oncology, Fortis Hospital, Bengaluru, Karnataka, India
| | - O. V. Sudheer
- Department of GI Surgery and Surgical Oncology, Amrita Institute of Medical Science, Kochi, Kerala, India
| | - Surender Dabas
- Department of Surgical Oncology, BL Kapur-Max Superspeciality Hospital, Delhi, India
| | - Jagadishwar Goud
- Department of Surgical Oncology, AOI Hospital, Hyderabad, Telangana, India
| | | | - Pavan Sugoor
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
| | | | - C. Ramachandra
- Director and Head, Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
| | - Shilpa Mehendale
- Director and Head, Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
| | - Akhil Dahiya
- Department of Clinical and Medical Affairs, Intuitive Surgical, California, CA, United States
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Acem I, Schultze BT, Schoonbeek A, van Houdt WJ, van de Sande MA, Visser JJ, Grünhagen DJ, Verhoef C. The added value of chest imaging after neoadjuvant radiotherapy for soft tissue sarcoma of the extremities and trunk wall: A retrospective cohort study. Eur J Surg Oncol 2022; 48:1543-1549. [DOI: 10.1016/j.ejso.2022.03.231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 03/28/2022] [Indexed: 10/18/2022] Open
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Hendrick LE, Buckner JD, Guerrero WM, Shibata D, Hinkle NM, Monroe JJ, Glazer ES, Deneve JL, Dickson PV. What Is the Utility of Restaging Imaging for Patients With Clinical Stage II/III Rectal Cancer After Completion of Neoadjuvant Chemoradiation and Prior to Proctectomy? Am Surg 2020; 87:242-247. [PMID: 32927959 DOI: 10.1177/0003134820950298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND In the United States, patients with clinical stage II or III rectal cancer typically receive neoadjuvant chemoradiation therapy (chemo/XRT) over a 5-6 week period followed by a 6-10 week break prior to proctectomy. In the current study, we evaluate the utilization of restaging studies performed and detection of disease progression during this window. METHODS A retrospective review of patients with clinical stage II/III rectal cancer was performed. Medical records were analyzed to collect clinicopathologic data and the performance and results of preoperative, early postoperative, and first surveillance CT and/or PET/CT in patients completing long course neoadjuvant chemo/XRT and undergoing proctectomy. RESULTS Between 2005 and 2017, 176 patients with clinical stage II or III rectal adenocarcinoma completed neoadjuvant chemo/XRT and underwent proctectomy. Preoperative restaging with CT CAP and/or CT/PET was performed in 72 (40.9%) patients with no detection of disease progression. Of the 104 patients without preoperative restaging, 1 had intraoperative detection of liver metastases and 31 had early postoperative reimaging (within 30 days of proctectomy) of which 2 had detection of new pulmonary metastases. Among 72 patients with no preoperative or early postoperative reimaging, first surveillance imaging was available in 47 and detected new metastases in 8 (17%). DISCUSSION In patients with clinical stage II/III rectal cancer who undergo long course neoadjuvant chemo/XRT, perioperative reimaging with CT CAP and/or PET/CT detects new metastases in a small percentage of patients. A multi-institutional, prospective analysis using standardized staging protocols is warranted to better determine the value of preoperative restaging in these patients.
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Affiliation(s)
- Leah E Hendrick
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jacob D Buckner
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Whitney M Guerrero
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - David Shibata
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Nathan M Hinkle
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Justin J Monroe
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Evan S Glazer
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jeremiah L Deneve
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Paxton V Dickson
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, TN, USA
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Caturegli I, Molin MD, Laird C, Molitoris JK, Bafford AC. Limited Role for Routine Restaging After Neoadjuvant Therapy in Locally Advanced Rectal Cancer. J Surg Res 2020; 256:317-327. [PMID: 32712447 DOI: 10.1016/j.jss.2020.06.050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/26/2020] [Accepted: 06/16/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although many patients with locally advanced rectal cancer undergo restaging imaging after neoadjuvant chemoradiotherapy and before surgery, the benefit of this practice is unclear. The purpose of this study was to examine the impact of reimaging on outcomes. MATERIALS AND METHODS We performed a retrospective analysis of consecutive patients with stage 2 and 3 rectal adenocarcinoma treated with neoadjuvant chemoradiotherapy between May 2005 and April 2018. Patient and disease characteristics, imaging, treatment, and oncologic outcomes were compared between those who underwent restaging and those who went directly to surgery. Predictors of outcomes and cost effectiveness of restaging were determined. RESULTS Of 224 patients, 146 underwent restaging. Six restaged patients had findings leading to a change in management. There was no difference in freedom from recurrence (P = 0.807) and overall survival (P = 0.684) based on restaging. Pretreatment carcinoembryonic antigen level >3 ng/mL (P = 0.010), clinical T stage 4 (P = 0.016), and pathologic T4 (P = 0.047) and N2 (P = 0.002) disease increased the risk of death, whereas adjuvant chemotherapy decreased the risk of death (P < 0.001) on multivariate analysis. Disease recurrence was lower with pelvic exenteration (P = 0.005) and in females (P = 0.039) and higher with pathologic N2 (P = 0.003) and N3 (P = 0.002) disease. The average cost of reimaging is $40,309 per change in management; however, $45 is saved per patient when downstream surgical costs are considered. CONCLUSIONS Imaging restaging after neoadjuvant chemoradiotherapy in patients with locally advanced rectal cancer rarely changes treatment and does not improve survival. In a subset of patients at higher risk for worse outcome, reimaging may be beneficial.
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Affiliation(s)
- Ilaria Caturegli
- The University of Maryland School of Medicine, Baltimore, Maryland
| | - Marco Dal Molin
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Christopher Laird
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jason K Molitoris
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Andrea C Bafford
- Division of General and Oncologic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland.
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Restaging Patients with Rectal Cancer Following Neoadjuvant Chemoradiation: A Systematic Review. World J Surg 2019; 44:973-979. [PMID: 31788724 DOI: 10.1007/s00268-019-05309-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND In the USA, most patients with clinical stage II/III rectal cancer receive neoadjuvant chemoradiation (chemo/XRT) over 5-6 weeks followed by a 6-10-week break before proctectomy. As chemotherapy is delivered at radio-sensitizing doses, there is essentially a 3-month window during which potential systemic disease is untreated. Evidence regarding the utility of restaging patients prior to proctectomy is limited. METHODS PubMed, Scopus, Web of Science, and the Cochrane Library were searched for studies evaluating the utility of restaging patients with rectal cancer after completion of long-course chemo/XRT, and reporting associated changes in management. Studies that were non-English, included <50 patients, or examining the diagnostic accuracy of imaging modalities were excluded. Study quality was evaluated using the modified Newcastle Ottawa Scale. RESULTS Eight studies were identified including a total of 1251 patients restaged between completion of chemo/XRT and proctectomy. All studies were retrospective. Restaging identified new metastatic disease in 72 (6.0%) patients, with 4 studies reporting specific sites: liver (n = 28), lung (n = 8), adrenal (n = 1), bone (n = 1), and multiple sites (n = 7). Overall progression (distant or local) was detected in 88 (7.0%) patients and resulted in a change in management in 77 (87.5%) of these patients. Tumor-related prognostic characteristics were inconsistently reported among studies, precluding meta-analysis. CONCLUSIONS Although restaging between completion of neoadjuvant chemo/XRT and proctectomy detects disease progression in only a small percentage of patients, findings alter the treatment plan in the vast majority of these patients. Multi-institutional collaboration with analysis of well-defined prognostic variables may better identify patients most likely to benefit from restaging.
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Park HJ, Jang JK, Park SH, Park IJ, Kim JH, Baek S, Hong YS. Restaging Abdominopelvic Computed Tomography Before Surgery After Preoperative Chemoradiotherapy in Patients With Locally Advanced Rectal Cancer. JAMA Oncol 2019; 4:259-262. [PMID: 29181529 DOI: 10.1001/jamaoncol.2017.4596] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Hyo Jung Park
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Songpa-gu, Seoul, South Korea
| | - Jong Keon Jang
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Songpa-gu, Seoul, South Korea
| | - Seong Ho Park
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Songpa-gu, Seoul, South Korea
| | - In Ja Park
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Songpa-gu, Seoul, South Korea
| | - Jong Hoon Kim
- Department of Radiation Oncology, University of Ulsan College of Medicine, Asan Medical Center, Songpa-gu, Seoul, South Korea
| | - Seunghee Baek
- Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Songpa-gu, Seoul, South Korea
| | - Yong Sang Hong
- Department of Oncology, University of Ulsan College of Medicine, Asan Medical Center, Songpa-gu, Seoul, South Korea
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Choi T, Baek SJ, Kwak JM, Kim J, Kim SH. Early Systemic Failure After Preoperative Chemoradiotherapy for the Treatment of Patients With Rectal Cancer. Ann Coloproctol 2019; 35:94-99. [PMID: 31113174 PMCID: PMC6529755 DOI: 10.3393/ac.2018.08.28] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 08/28/2018] [Indexed: 12/13/2022] Open
Abstract
Purpose Distant metastasis can occur early after neoadjuvant chemoradiotherapy (CRT) in patients with rectal cancer. This study was conducted to evaluate the clinical characteristics of patients who developed early systemic failure. Methods The patients who underwent neoadjuvant CRT for a rectal adenocarcinoma between June 2007 and July 2015 were included in this study. Patients who developed distant metastasis within 6 months after CRT were identified. We compared short- and long-term clinicopathologic outcomes of patients in the early failure (EF) group with those of patients in the control group. Results Of 107 patients who underwent neoadjuvant CRT for rectal cancer, 7 developed early systemic failure. The lung was the most common metastatic site. In the EF group, preoperative carcinoembryonic antigen was higher (5 mg/mL vs. 2 mg/mL, P = 0.010), and capecitabine as a sensitizer of CRT was used more frequently (28.6% vs. 3%, P = 0.002). Of the 7 patients in the EF group, only 4 underwent a primary tumor resection (57.1%), in contrast to the 100% resection rate in the control group (P < 0.001). In terms of pathologic outcomes, ypN and TNM stages were more advanced in the EF group (P < 0.001 and P = 0.047, respectively), and numbers of positive and retrieved lymph nodes were much higher (P < 0.001 and P = 0.027, respectively). Conclusion Although early distant metastasis after CRT for rectal cancer is very rare, patients who developed early metastasis showed a poor nodal response with a low primary tumor resection rate and poor oncologic outcomes.
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Affiliation(s)
- Taesun Choi
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Se-Jin Baek
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Jung Myun Kwak
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Jin Kim
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Seon-Hahn Kim
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
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Singhal N, Vallam K, Engineer R, Ostwal V, Arya S, Saklani A. Restaging after neoadjuvant chemoradiation in rectal cancers: is histology the key in patient selection? J Gastrointest Oncol 2016; 7:360-4. [PMID: 27284467 DOI: 10.21037/jgo.2016.01.08] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Neoadjuvant chemoradiation is the standard of care for locally advanced rectal cancer. However, there is no clarity regarding the necessity for restaging scans to rule out systemic progression of disease post chemoradiation with existing literature being divided on the need for the same. METHODS Data from a prospectively maintained database was retrospectively analysed. All locally advanced rectal cancers (node positive/T4/T3 with threatened or involved CRM) were included. Biopsy proof of adenocarcinoma and CT scan of abdomen and chest were mandatory. Grade of tumor and response to CTRT on restaging magnetic resonance imaging (MRI) were documented. RESULTS Out of 119 patients subjected to CTRT, 72 underwent definitive total mesorectal excision while 13 patients progressed locoregionally on restaging MR pelvis and 15 other patients progressed systemically while the rest defaulted. Patients with poorly differentiated (PD) cancers were compared to those with well/moderately differentiated (WMD) tumors. PD tumors had a significantly higher rate of local progression (32.1% vs. 5.6% %, P=0.0011) and systemic progression (35.7% vs. 6.9%, P=0.0008) as compared to WMD tumors. Only one-third (9/28) of PD patients underwent TME while the rest progressed. CONCLUSIONS Selecting poorly differentiated tumors alone for restaging CECT abdomen and thorax will be a cost effective strategy as the rate of progression is very high. Also patients with PD tumors need to be consulted about the high probability of progression of disease.
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Affiliation(s)
- Nitin Singhal
- 1 Specialist Registrar Oncosurgery, 2 Department of Radiation Oncology, 3 Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India ; 4 Department of Radiodiagnosis, 5 Departmemt of GI Surgery, Tata Memorial Centre, Mumbai, India
| | - Karthik Vallam
- 1 Specialist Registrar Oncosurgery, 2 Department of Radiation Oncology, 3 Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India ; 4 Department of Radiodiagnosis, 5 Departmemt of GI Surgery, Tata Memorial Centre, Mumbai, India
| | - Reena Engineer
- 1 Specialist Registrar Oncosurgery, 2 Department of Radiation Oncology, 3 Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India ; 4 Department of Radiodiagnosis, 5 Departmemt of GI Surgery, Tata Memorial Centre, Mumbai, India
| | - Vikas Ostwal
- 1 Specialist Registrar Oncosurgery, 2 Department of Radiation Oncology, 3 Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India ; 4 Department of Radiodiagnosis, 5 Departmemt of GI Surgery, Tata Memorial Centre, Mumbai, India
| | - Supreeta Arya
- 1 Specialist Registrar Oncosurgery, 2 Department of Radiation Oncology, 3 Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India ; 4 Department of Radiodiagnosis, 5 Departmemt of GI Surgery, Tata Memorial Centre, Mumbai, India
| | - Avanish Saklani
- 1 Specialist Registrar Oncosurgery, 2 Department of Radiation Oncology, 3 Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India ; 4 Department of Radiodiagnosis, 5 Departmemt of GI Surgery, Tata Memorial Centre, Mumbai, India
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Routine preoperative restaging CTs after neoadjuvant chemoradiation for locally advanced rectal cancer are low yield: A retrospective case study. Int J Surg 2014; 12:1295-9. [DOI: 10.1016/j.ijsu.2014.10.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 10/01/2014] [Accepted: 10/25/2014] [Indexed: 02/06/2023]
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Multicenter Evaluation of Rectal cancer ReImaging POst Neoadjuvant (MERRION) Therapy. Ann Surg 2014; 262:e53. [PMID: 25409311 DOI: 10.1097/sla.0000000000000570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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