Accurate staging, selective preoperative therapy and optimal surgery improves outcome in rectal cancer: a review of the recent evidence

Tumor size impact on TNM staging which define post-operative complications in rectal cancer

The purpose of this study was to see how accurate tumor size was at predicting T and N stages in rectal malignancies. Tumor sizes of 40 mm and greater than 40 mm were used to assess post-operative challenges in related to T1-T2 and T3-T4 stages, as well as between node N0 and node N1 and N2 patients. A total of 131 patients were treated for colorectal cancer, with 54 patients < 40 mm and 77 patients > 40 mm receiving Da Vinci colorectal surgery. Conferring to the Clavien-Dindo classification grade III, there's an increase in the percentage of tumors > 40 mm, which also impacts the percentage of intestinal obstruction, anastomotic leakage, GERD, and sepsis with a P < 0.05. A tumor size of more than 40 mm is strongly associated with advanced pT stages. Tumor size may serve in addition to clinical staging and improve the management of rectal cancer.

Robotic male and laparoscopic female sphincter-preserving total mesorectal excision of mid-low rectal cancer share similar specimen quality, complication rates and long-term oncological outcomes

The aim of this study was to compare perioperative and long-term oncological outcomes between laparoscopic sphincter-preserving total mesorectal excision in female patients (F-Lap-TME) and robotic sphincter-preserving total mesorectal excision in male patients (M-Rob-TME) with mid-low rectal cancer (RC). A retrospective analysis of a prospectively maintained database was performed. 170 cases (F-Lap-TME: 60 patients; M-Rob-TME: 110 patients) were performed by a single surgeon (January 2011-January 2020). Clinical characteristics did not differ significantly between the two groups. Operating time was longer in M-Rob-TME than in F-Lap-TME group (185.3 ± 28.4 vs 124.5 ± 35.8 min, p < 0.001). There was no conversion to open surgery in both groups. Quality of mesorectum was complete/near-complete in 58 (96.7%) and 107 (97.3%) patients of F-Lap-TME and M-Rob-TME (p = 0.508), respectively. Circumferential radial margin involvement was observed in 2 (3.3%) and 3 (2.9%) in F-Lap-TME and M-Rob-TME patients (p = 0.210), respectively. Median length of follow-up was 62 (24-108) months in the F-Lap-TME and 64 (24-108) months in the M-Rob-TME group. Five-year overall survival rates were 90.5% in the F-Lap-TME and 89.6% in the M-Rob-TME groups (p = 0.120). Disease-free survival rates in F-Lap-TME and M-Rob-TME groups were 87.5% and 86.5% (p = 0.145), respectively. Local recurrence rates were 5% (n = 3) and 5.5% (n = 6) (p = 0.210), in the F-Lap-TME and M-Rob-TME groups, respectively. The robotic technique can potentially overcome some technical challenges related to the pelvic anatomical difference between sex compared to laparoscopy. Laparoscopic and robotic approach, respectively in female and male patients provide similar surgical specimen quality, perioperative outcomes, and long-term oncological results.

Long recurrence-free survival of localized rectal melanoma after abdominoperineal resection in comparison to partial excision and highlighting the place of immunotherapy: A case report

Rectal malignant melanomas (RMM) are remarkably uncommon, the rectal location represents less than one percent of all rectal cancer. Because of its low global survival rate, the surgical strategy is a subject of controversy for attaining a r0 resection. the palliative treatment is also debateable, but recently; radiotherapy and immunotherapy became the preferred treatment and offer the best outcome. to ensure r0 resection, abdominoperineal resection (apr) is considered the main surgical option, but because of its morbidity and functional limitations, local excision techniques such as endoscopic mucosal resection (emr) combined with chemoradiotherapy are being increasingly performed to preserve the quality of life and reduce local recurrence rate. In this report, we evaluate the place that apr still keeps as surgical procedure in comparison to partial excision. we report a case of a 72 years old patient, who presented rectal syndrome with rectorrhagia for 2 months, the diagnosis of localized rectal melanoma was confirmed by endoscopy, magnetic resonance imaging, histological analysis tissue with immunohistochemistry. the procedure strategy was a surgical treatment with apr. After a long recurrence-free survival period, the patient develops local recurrence and immunotherapy-resistant metastasis.

A Way to Start Transanal Total Mesorectal Excision for Rectal Cancer

Introduction The optimal rectal cancer care is achieved by a multidisciplinary approach, with a high-quality surgical resection, with complete mesorectal excision and adequate margins. New approaches like the transanal total mesorectal excision (TaTME) aim to achieve these goals, maximizing the sphincter preservation ratio, with good oncologic and functional results. This report describes a way to implement TaTME without a proctor, presents the first case series of this approach in a center experienced in rectal cancer, and compares the results with those of the international literature.

Methods We performed a retrospective study of the first 10 consecutive patients submitted to TaTME for rectal cancer at our institution. The primary outcomes were postoperative complications, pathological specimen quality and local recurrence rate. The results and performance were compared with the outcomes of a known structured program with proctorship and with the largest meta-analysis on this topic.

Results All patients had locally advanced cancer; therefore, all underwent neoadjuvant therapy. A total of 30% had postoperative complications, without mortality or re-admissions. In comparison with the structured training program referred, no differences were found in postoperative complications and reintervention rates, resulting in a similar quality of resection. Comparing these results with those of the largest meta-analysis on the subject, no differences in the postoperative complication rates were found, and very similar outcomes regarding anastomotic leaks and oncological quality of resection were registered.

Conclusion The results of this study validate the safety and effectiveness of our pathway regarding the implementation of the TaTME approach, highlighting the fact that it should be done in a center with proficiency in minimally invasive rectal surgery.

Is robotic da Vinci Xi® superior to the da Vinci Si® for sphincter-preserving total mesorectal excision? Outcomes in 150 mid-low rectal cancer patients

The aim of this study was to determine the superiority between the robotic da Vinci Si® (Si group) and da Vinci Xi® (Xi group) generation in patients with mid-low rectal cancer. Between December 2011 and December 2017, 88 patients with mid-low rectal cancer were operated on using the Si robotic system, from January 2018 to May 2021, 62 more patients with mid-low rectal cancer were operated on using the Xi robotic system. Perioperative and postoperative short-term outcomes were compared between the two groups. Univariate and multivariate Cox-regression analysis were performed to determine factors affecting operating time. A cumulative sum (CUSUM) analysis was also performed to determine the learning curve of the primary surgeon. All patients underwent sphincter saving total mesorectal excision (TME). The overall operating time was significantly shorter in the Xi group (181.3 ± 31.8 min in Si group vs 123.6 ± 25.7 min in the Xi group, p < 0.001). There were no significant differences in terms of conversion rates, mean hospital stays, complications and histopathologic data. CUSUM analysis show completion of learning curve in 44th case of Si group. Univariate and multivariate analysis demonstrated that the learning curve of the primary surgeon (p < 0.001) and the type of robotic system (Xi) are only two factors associated with operating time (OR, 95% CI p; 3.656, 0.665-9.339, p < 0.001). Our study found that the robotic da Vinci Xi systems provide significantly shorter operating time comparing with Si systems, when performing sphincter-preserving TME in mid-low rectal cancer patients. Surgical system (da Vinci Xi) and primary surgeon learning curve are two independent risk factors which associated shortened operating time. Postoperative complication rates and histopathologic outcomes are similar in both groups.

Sphincter-Saving Robotic Total Mesorectal Excision Provides Better Mesorectal Specimen and Good Oncological Local Control Compared with Laparoscopic Total Mesorectal Excision in Male Patients with Mid-Low Rectal Cancer

INTRODUCTION

Laparoscopic rectal resection with total mesorectal excision is a technically challenging procedure, and there are limitations in conventional laparoscopy. A surgical robotic system may help to overcome some of the limitations. The aim of our study was to compare long-term oncological outcomes of robotic and laparoscopic sphincter-saving total mesorectal excision in male patients with mid-low rectal cancer.

MATERIALS AND METHODS

The study was conducted as a retrospective review of a prospectively maintained database. One-hundred-three robotic and 84 laparoscopic sphincter-saving total mesorectal excisions were performed by a single surgeon between January 2011 and January 2020. Patient characteristics, perioperative recovery, postoperative complications, pathology results, and oncological outcomes were compared between the two groups.

RESULTS

The patients' characteristics did not differ significantly between the two groups. Median operating time was longer in the robotic than in the laparoscopic group (180 minutes versus 140 minutes, p=0.033). Macroscopic grading of the specimen in the robotic group was complete in 96 (93.20%), near complete in four (3.88%) and incomplete in three (2.91%) patients. In the laparoscopic group, grading was complete in 37 (44.04%), near complete in 40 (47.61%) and incomplete in seven (8.33%) patients (p=0.03). The median length of follow up was 48 (9-102) months in the robotic, and 75.6 (11-113) months in the laparoscopic group. Overall, five-year survival was 87% in the robotic and 85.3% in the laparoscopic groups. Local recurrence rates were 3.8% and 7.14%, respectively, in the robotic and laparoscopic groups (p<0.05).

CONCLUSION

Sphincter-saving robotic total mesorectal excision is a safe and feasible tool, which provides good mesorectal integrity and better local control in male patients with mid-low rectal cancer.

Circumferential Resection Margin Status as a Predictive Factor for Recurrence in Preoperative MRI for Advanced Lower Rectal Cancer Without Preoperative Therapy

BACKGROUND

In Japan, total mesorectal excision plus lateral lymph node dissection without preoperative therapy is the standard treatment for advanced lower rectal cancer. Although long-term oncologic outcomes with preoperative therapy based on circumferential resection margin status in preoperative MRI has been reported, outcomes without preoperative therapy are unknown.

OBJECTIVE

This study evaluated long-term oncologic outcomes of radical surgery without preoperative therapy in advanced lower rectal cancer based on circumferential resection margin status in preoperative MRI, with the aim of defining appropriate patient populations for preoperative therapy.

DESIGN

This retrospective analysis compared long-term oncologic outcomes with preoperative MRI in patients with lower rectal cancer.

SETTINGS

Patients were identified through a database managed by our institute.

PATIENTS

In total, 338 patients with lower rectal cancer who underwent radical surgery between 2000 and 2014 at the National Cancer Center Hospital without preoperative therapy were included.

MAIN OUTCOME MEASURES

The main outcome was relapse-free survival.

RESULTS

The median follow-up period was 61.7 months (range, 3-153 months). Five-year relapse-free survival rates in MRI-predicted circumferential resection margin negative patients and positive patients were 76.0% and 55.6% (p < 0.001). Univariate and multivariate analyses revealed pN stage (HR, 2.35; 95% CI, 1.470-3.770; p < 0.001), lymphatic invasion (HR, 2.03; 95% CI, 1.302-3.176; p = 0.002), venous invasion (HR, 2.15; 95% CI, 1.184-3.9; p = 0.01), surgical procedure (HR, 1.72; 95% CI, 1.115-2.665; p = 0.01), and MRI-predicted circumferential resection margin (HR, 1.850; 95% CI, 1.206-2.838; p = 0.0051) to be independent risk factors for postoperative recurrence.

LIMITATIONS

This study was retrospective in design.

CONCLUSIONS

Magnetic resonance imaging-predicted circumferential resection margin was associated with relapse-free survival without preoperative therapy, indicating its potential for use in selecting optimal preoperative therapy. See Video Abstract at http://links.lww.com/DCR/B335. ESTADO DEL MARGEN DE RESECCIÓN CIRCUNFERENCIAL COMO FACTOR PREDICTIVO DE RECURRENCIA EN LA RESONANCIA MAGNÉTICA PREOPERATORIA, PARA EL CÁNCER RECTAL BAJO AVANZADO SIN TERAPIA PREOPERATORIA: En Japón, la escisión mesorrectal total con disección de ganglios linfáticos laterales y sin terapia preoperatoria, es el tratamiento estándar para el cáncer rectal bajo avanzado. Aunque se han reportado resultados oncológicos a largo plazo con terapia preoperatoria, basada en el estado del margen de resección circunferencial en la resonancia magnética preoperatoria, se desconocen los resultados sin terapia preoperatoria.Este estudio evaluó los resultados oncológicos a largo plazo de cirugía radical sin terapia preoperatoria, en cáncer rectal bajo avanzado, basado en el estado del margen de resección circunferencial en la resonancia magnética preoperatoria, con el objetivo de definir poblaciones de pacientes apropiadas para terapia preoperatoria.Este análisis retrospectivo comparó los resultados oncológicos a largo plazo con resonancia magnética preoperatoria, en pacientes con cáncer rectal bajo.Los pacientes fueron identificados a través de una base de datos administrada por nuestro instituto.Se incluyeron un total de 338 pacientes con cáncer rectal bajo, que se sometieron a cirugía radical entre 2000 y 2014 en el Hospital Nacional del Centro de Cáncer, sin terapia preoperatoria.El resultado principal fue la supervivencia libre de recaídas.La mediana del período de seguimiento fue de 61,7 meses (rango, 3-153 meses). Las tasas de supervivencia sin recaídas a cinco años, con margen de resección circunferencial predicho por resonancia magnética, en pacientes negativos y pacientes positivos fueron 76.0% y 55.6% (p <0.001), respectivamente. Los análisis univariados y multivariados revelaron estadio pN (razón de riesgo [HR], 2.35; intervalo de confianza [IC] del 95%, 1.470-3.770; p <0.001), invasión linfática (HR, 2.03; IC del 95%, 1.302-3.176; p = 0.002), invasión venosa (HR, 2.15; IC 95%, 1.184-3.9; p = 0.01), procedimiento quirúrgico (HR, 1.72; IC 95%, 1.115-2.665; p = 0.01) y circunferencial predicho por resonancia magnética en margen de resección (HR, 1.850; IC 95%, 1.206-2.838; p = 0.0051), como factores de riesgo independientes, para la recurrencia postoperatoria.Este estudio fue retrospectivo en diseño.El margen de resección circunferencial predicho de resonancia magnética, se asoció con una supervivencia libre de recaída sin terapia preoperatoria, lo que indica su potencial para uso en la selección de la terapia óptima preoperatoria. Consulte Video Resumen en http://links.lww.com/DCR/B335.

Impact of a multidisciplinary training programme on outcome of upper rectal cancer by critical appraisal of the extent of mesorectal excision with postoperative MRI

BACKGROUND

Optimal management of patients with upper rectal cancer remains unclear. Partial mesorectal excision (PME) without neoadjuvant therapy is currently advocated for the majority of patients. Recent studies, however, reported a high risk of local recurrence and suboptimal surgery. The aim of this study was to evaluate the effects of a quality assurance initiative with postoperative MRI to improve outcomes in these patients.

METHODS

Patients who underwent mesorectal excision with curative intent for rectal cancer in 2007-2013 were included. Postoperative MRI of the pelvis was performed 1 year after surgery. In 2011, a multidisciplinary workshop with focus on extent and completeness of surgery was held for training surgeons, pathologists and radiologists involved in treatment planning. Images of residual mesorectum and histopathological reports were reviewed with regard to the distal resection margin. Local recurrence after a minimum of 3 years' follow-up was compared between two cohorts from 2007-2010 and 2011-2013.

RESULTS

A total of 627 patients were included; postoperative MRI of the pelvis was done in 381 patients. The 3-year actuarial local recurrence rate in patients with upper rectal cancer improved from 12·9 to 5·0 per cent (P = 0·012). After the workshop, fewer patients with cancer of the upper rectum were selected to have PME (90·8 per cent in 2007-2010 versus 80·2 per cent in 2011-2013; P = 0·023), and fewer patients who underwent PME had an insufficient distal resection margin (61·7 versus 31 per cent respectively; P < 0·001).

CONCLUSION

Quality assessment of surgical practice may have a major impact on oncological outcome after surgery for upper rectal cancer.

The long-term oncological outcomes of the 140 robotic sphincter-saving total mesorectal excision for rectal cancer: a single surgeon experience

Robotic surgery became more popularly in the colorectal surgical field. The aim of the study was to evaluate of the oncological outcomes which patients who underwent the robotic total mesorectal excision for rectal cancer. A series of 140 consecutive patients who underwent robotic rectal surgery between January 2012 and June 2019 was analyzed retrospectively in terms of demographics, pathological data, and surgical and oncological outcomes. There were 104 (74.28%) male and 36 (25.71%) female patients. The tumor was located in the lower rectum in 84 (60%) cases, in the mid rectum in 38 (27.14%) cases, and in the upper rectum in 18 (12.85%) cases. Ninety-eight (70%) of the patients has received neoadjuvant chemoradiotherapy. All the patients underwent robotic sphincter-preserving surgery, 101 (72.14%) patients low-anterior resection, and 39 (27.85%) patients underwent intersphincteric resection with colo-anal anastomosis. There were no conversions. The circumferential resection margin was positive in five (3.57%) patients. The median distal resection margin of the operative specimen was 3.2 (0.2-7) cm. The median number of retrieved lymph nodes was 22 (16-42). TME quality in the in our study was rated as complete in 88.57% (n124) of patients, nearly complete in 7.14% (n10) of patients; and 4.28% (n6) of incomplete. The median hospital stay was 3.5 (3-12) days. In-hospital and 1-month mortality was zero. The median length of follow-up was 40 (2-80) months. The 5-year overall survival rate was 92.78%. The 5-year disease-free survival rate was 90%. Locally recurrence and distance recurrence rate was 3.57% (n5/140) and 2.85% (n4/140), respectively. Robotic rectal cancer surgery has a good oncological outcomes and feasible tool in the field of the rectal surgery, but required a steep learning curve.

Transanal total mesorectal excision for low rectal cancer: a case-matched study comparing TaTME versus standard laparoscopic TME

Background

Transanal total mesorectal excision (TaTME) is emerging as a novel alternative to laparoscopic total mesorectal excision (LaTME). The aim of this study was to compare clinical and pathological results from these two techniques in patients undergoing rectal resections because of low rectal cancer.

Materials and methods

Thirty-five patients undergoing TaTME were matched with 35 patients operated on using LaTME. Composite primary endpoint (complete TME, negative circumferential resection margin [pCRM], and distal resection margin [pDRM]) was used to assess pathological quality specimens. Secondary outcomes included operative and postoperative parameters (operative time, total blood loss, postoperative morbidity, length of stay, 30-day mortality).

Results

Composite primary endpoint was achieved by 85% of subjects in the TaTME group and 82% of subjects in the LaTME group (P=0.66). Mean pCRM was 1.1±1.29 vs 0.99±0.78 mm (P=0.25). Distal pDRM was 1.57±0.92 and 1.98±1.22 cm (P=0.15). In the TaTME and LaTME groups, respectively, complete mesorectal excision was achieved in 89% and 83% of subjects, while excision was nearly complete for the remaining 11% and 17% (P=0.23).

Conclusion

TaTME appears to be a noninferior alternative to laparoscopic surgery. TaTME allows for quality retrieval of surgical specimens with comparable clinical outcomes with LaTME.

Impact of a Multidisciplinary Team Approach for Managing Advanced and Recurrent Colorectal Cancer

BACKGROUND

The wide variety of treatment strategies makes clinical decision-making difficult in advanced and recurrent colorectal cancer cases. Many hospitals have started multidisciplinary team (MDT) meetings comprising a team of dedicated specialists for discussing cases. MDTs for selected cases that are difficult to diagnose and treat are alternatives to regular MDTs. This study's aim was to determine the impact of a MDT for colorectal cancer on clinical decision-making.

METHODS

Cases were discussed when clinical specialists had difficulty making decisions alone. All processes done by the MDT were then recorded in prospectively designed medical case forms.

RESULTS

From Jan 2011 to Dec 2014, 1383 cases were discussed. A total of 549 (39.8%) case forms were completed for patients with newly diagnosed colorectal cancer, whereas 833 (60.2%) were completed for those with recurrent diseases. The MDT altered the proposed treatment of the referring physician in 179 (13%) cases. In 85 of the 179 (47.5%) altered cases, the radiologist's review of clinical information affected the diagnosis and decision. Furthermore, 152 of the 1383 MDT decisions were not implemented. Treatment intent, therapeutic plan, and alteration of decision were important reasons for not following the MDT's recommendation.

CONCLUSION

Case discussions in MDT meetings resulted in altered clinical decisions in >10% cases. Implementation rates after MDT discussions might be affected by the treatment decision-making process. Imperfect decisions made by individual physicians can be decreased by the multidisciplinary decision-making process.

Evolution of Surgical Treatment for Rectal Cancer: a Review

Surgery that produces an optimal total mesorectal excision (TME) resection specimen remains the cornerstone of curative rectal cancer management. In the modern era, despite the results of recent randomised trials, laparoscopic TME is a crucial technique in the TME surgery armamentarium. Laparoscopic surgery offers the benefit of magnified views that aid sharp and precise dissection. However operating in the confines of a narrow pelvis, particularly when the mesorectum is bulky, requires significant technical skill. This is compounded by limited angulation of laparoscopic instruments and staplers. The final challenge is to preserve the integrity of the mesorectum during delivery of the specimen. The principles of TME surgery, on which Bill Heald founded the Basingstoke Colorectal unit, can equally be applied to laparoscopic, transanal and robotic TME, but great care must be taken to preserve the key principle-that no steps are taken that have the potential to shed tumour cells or compromise the quality of the mesorectal specimen.

Diagnostic Accuracy of MRI for Assessment of T Category and Circumferential Resection Margin Involvement in Patients With Rectal Cancer: A Meta-Analysis

BACKGROUND

The prognosis of rectal cancer is directly related to the stage of the tumor at diagnosis. Accurate preoperative staging is essential for selecting patients to receive optimal treatment.

OBJECTIVE

The purpose of this study was to evaluate the diagnostic performance of MRI in tumor staging and circumferential resection margin involvement in rectal cancer.

DATA SOURCES

A systematic literature search was performed in MEDLINE, EMBASE, PubMed, Cochrane Database of Systematic Reviews, and Web of Science database.

STUDY SELECTION

Original articles from 2000 to 2016 on the diagnostic performance of MRI in the staging of rectal cancer and/or assessment of mesorectal fascia status were eligible.

MAIN OUTCOME MEASURES

Pooled diagnostic statistics including sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio were calculated for invasion of muscularis propria, perirectal tissue, and adjacent organs and for circumferential resection margin involvement through bivariate random-effects modeling. Summary receiver operating characteristic curves were fitted, and areas under summary receiver operating characteristic curves were counted to evaluate the diagnostic performance of MRI for each outcome.

RESULTS

Thirty-five studies were eligible for this meta-analysis. Preoperative MRI revealed the highest sensitivity of 0.97 (95% CI, 0.96-0.98) and specificity of 0.97 (95% CI, 0.96-0.98) for muscularis propria invasion and adjacent organ invasion. Areas under summary receiver operating characteristic curves indicated good diagnostic accuracy for each outcome, with the highest of 0.9515 for the assessment of adjacent organ invasion. Significant heterogeneity existed among studies. There was no notable publication bias for each outcome.

LIMITATIONS

This meta-analysis revealed relatively high diagnostic accuracy for preoperative MRI, although significant heterogeneity existed. Therefore, exploration should be focused on standardized interpretation criteria and optimal MRI protocols for future studies.

CONCLUSIONS

MRI showed relatively high diagnostic accuracy for preoperative T staging and circumferential resection margin assessment and should be reliable for clinical decision making.

Incidence of Metachronous Distant Metastasis and ypN Classification Influence Patient Survival in Endosonographically Confirmed uT3 Rectal Cancer after Neoadjuvant Therapy and R0 Resection: A Historical Cohort Analysis

BACKGROUND

Tumor response after neoadjuvant radiochemotherapy (NRC) prior to surgery and other parameters are likely to have an influence on the survival rate of patients suffering from T3 rectal cancer.

METHODS

51 patients (17 female, 34 male; 59.0 years; Apache < 9 points: 95.1%; ASA I-II 88.3% and ASA III 11.8%) were treated with NRC (50.4 Gy; 5-fluorouracil/folinic acid) 4-6 weeks prior to surgery because of uT3 rectal cancer (G2: 96%; adenocarcinoma 86.3%; cUICC II 62.7%). NRC led to a tumor response (TR) (ypT0-ypT2) in 45.1% (ypT0N0M0 7.8%).

RESULTS

Neither the age of patients nor Apache/ASA score, histology, UICC staging, ypTNM, Dukes staging, infiltration of vessels, surgical procedure, local recurrence nor TR had a significant influence on the patients' survival time. Patients with metachronous distant metastasis (MDM) during the follow-up period (mean: 8.2 years; 1 month to 14.5 years) and patients with ypN1-ypN2 had a significantly shorter survival time.

CONCLUSIONS

NRC prior to surgery leads to a remarkable TR rate but has no significant impact of TR on the patients' survival time. Occurrence of MDM during the follow-up period and ypN1/N2 status do have a greater influence. It is necessary to investigate larger cohorts of patients in the future to obtain more conclusive results and to define factors with influence on survival.

The effect of multidisciplinary teams for rectal cancer on delivery of care and patient outcome: has the use of multidisciplinary teams for rectal cancer affected the utilization of available resources, proportion of patients meeting the standard of care, and does this translate into changes in patient outcome?

BACKGROUND

We hypothesized that mandatory multidisciplinary team (MDT) participation improves process evaluation, outcomes, and technical aspects of surgery for rectal cancer in a stable practice of colorectal surgery.

METHODS

A retrospective review of MDT data was conducted of all patients with colorectal cancer since 2010. Demographic, clinical stage, process evaluation, quality of surgery, and outcome data were collected. Total mesorectal excision and MDT required participation started 2013.

RESULTS

One hundred thirty patients were included in this study: 47 patients in 2014; 41 patients in 2013; and 42 patients pre-MDT. Improvements were seen in 12 of the 14 preoperative process variables, 6 significantly. Improvement in the completeness of total mesorectal excision (0% to 76%) was significant. Local recurrence occurred in 10% of the pre-MDT group, and follow-up is ongoing in the MDT groups.

CONCLUSIONS

MDT participation improves care of patients with rectal cancer. Preoperative clinical staging, multimodality treatment, pathologic staging, and technical aspects of surgery have improved.

Time trends, improvements and national auditing of rectal cancer management over an 18-year period

AIM

The main aims were to explore time trends in the management and outcome of patients with rectal cancer in a national cohort and to evaluate the possible impact of national auditing on overall outcomes. A secondary aim was to provide population-based data for appraisal of external validity in selected patient series.

METHOD

Data from the Swedish ColoRectal Cancer Registry with virtually complete national coverage were utilized in this cohort study on 29 925 patients with rectal cancer diagnosed between 1995 and 2012. Of eligible patients, nine were excluded.

RESULTS

During the study period, overall, relative and disease-free survival increased. Postoperative mortality after 30 and 90 days decreased to 1.7% and 2.9%. The 5-year local recurrence rate dropped to 5.0%. Resection margins improved, as did peri-operative blood loss despite more multivisceral resections being performed. Fewer patients underwent palliative resection and the proportion of non-operated patients increased. The proportions of temporary and permanent stoma formation increased. Preoperative radiotherapy and chemoradiotherapy became more common as did multidisciplinary team conferences. Variability in rectal cancer management between healthcare regions diminished over time when new aspects of patient care were audited.

CONCLUSION

There have been substantial changes over time in the management of patients with rectal cancer, reflected in improved outcome. Much indirect evidence indicates that auditing matters, but without a control group it is not possible to draw firm conclusions regarding the possible impact of a quality control registry on faster shifts in time trends, decreased variability and improvements. Registry data were made available for reference.

Role of intraoperative frozen section for assessing distal resection margin after anterior resection

BACKGROUND AND AIMS

The use of neoadjuvant long-course chemoradiotherapy (LCRT), shorter distal safety margins (DSMs) and stapled or intersphincteric resections has increased sphincter preservation rates. While intraoperative frozen section (IOFS) is not mandatory, it helps achieve negative distal resection margins (DRMs). Our aim was to audit the role of IOFS for DRM assessment while performing sphincter-saving rectal surgery and to identify those subgroups that would benefit the most from IOFS analysis.

METHODS

Patients who underwent rectal cancer surgery between 2009 and 2013 were identified from a prospectively maintained database. Patients who intraoperatively underwent an IOFS for DRM assessment were included in the study. Factors associated with a positive margin on IOFS were analysed. The sensitivity and specificity of IOFS were also assessed.

RESULTS

Of 250 patients, who had an anterior resection with an IOFS, 12 had an involved DRM. Of these patients, eight were involved by adenocarcinoma, two by acellular mucin, one by moderate dysplasia and one by adenoma confirmed on paraffin section. Positive margins had a 100 % intervention rate. There were two false negative on IOFS. IOFS had a sensitivity of 85.17 % with a specificity of 100 % and a negative predictive value of 99.16 %. Specimens with a positive IOFS were lower rectal (P < 0.05), poorly differentiated and post LCRT locally advanced tumours.

CONCLUSIONS

IOFS to confirm negative DRM is recommended in lower rectal tumours irrespective of DSM. It can be considered for locally advanced post LCRT poorly differentiated mid rectal tumours and avoided for upper rectal tumours.

Robotic versus laparoscopic surgery for mid or low rectal cancer in male patients after neoadjuvant chemoradiation therapy: comparison of short-term outcomes

The aim of our study was to compare short-term outcomes of robotic and laparoscopic sphincter-saving total mesorectal excision (TME) in male patients with mid-low rectal cancer (RC) after neadjuvant chemoradiotherapy (NCRT). The study was conducted as a retrospective review of a prospectively maintained database, and we analyzed 14 robotic and 65 laparoscopic sphincter saving TME (R-TME and L-TME, respectively) performed by one surgeon between 2005 and 2013. Patient characteristics, perioperative recovery, postoperative complications and and pathology results were compared between the two groups. The patient characteristics did not differ significantly between the two groups. Median operating time was longer in the R-TME than in the L-TME group (182 min versus 140 min). Only two conversions occurred in the L-TME group. No difference was found between groups regarding perioperative recovery and postoperative complication rates. The median number of harvested lymph nodes was higher in the RTME than in the L-TME group (32 versus 23, p = 0.008). The median circumferential margin (CRM) was 10 mm in the R-TME group, 6.5 mm in the L-TME group (p = 0.047. The median distal resection margin (DRM) was 27.5 mm in the R-TME, 15 mm in the L-TME group (p = 0.014). Macroscopic grading of the specimen in the R-TME group was complete in all patients. In the L-TME group, grading was complete in 52 (80%) and incomplete in 13 (20%) cases (p = 0.109). R-TME is a safe and feasible procedure that facilitates performing of TME in male patients with mid-low RC after NCRT.

Global DNA methylation is altered by neoadjuvant chemoradiotherapy in rectal cancer and may predict response to treatment - A pilot study

AIM

In rectal cancer, not all tumours display a response to neoadjuvant treatment. An accurate predictor of response does not exist to guide patient-specific treatment. DNA methylation is a distinctive molecular pathway in colorectal carcinogenesis. Whether DNA methylation is altered by neoadjuvant treatment and a potential response predictor is unknown. We aimed to determine whether DNA methylation is altered by neoadjuvant chemoradiotherapy (CRT) and to determine its role in predicting response to treatment.

PATIENTS AND METHODS

Fifty-three (n = 53) patients with locally advanced rectal cancers treated with neoadjuvant CRT followed by surgery were identified from the pathology databases of 2 tertiary referral centres over a 4-year period. Immunohistochemical staining of treatment specimens was carried out using the 5-Methylcytidine (Eurogentec, Seraing, Belgium) antibody. Quantitative analysis of staining was performed using an automated image analysis platform. The modified tumour regression grading system was used to assess tumour response to neoadjuvant therapy.

RESULTS

Seven (13%) patients showed complete pathological response while 46 (87%) patients were partial responders to neoadjuvant treatment. In 38 (72%) patients, significant reduction in methylation was observed in post-treatment resection specimens compared to pre-treatment specimens (171.5 vs 152.7, p = 0.01); in 15 (28%) patients, methylation was increased. Pre-treatment methylation correlated significantly with tumour regression (p < 0.001), T-stage (p = 0.005), and was able to predict complete and partial pathological responders (p = 0.01).

CONCLUSION

Neoadjuvant CRT appears to alter the rectal cancer epigenome. The significant correlation between pre-treatment DNA methylation with tumour response suggests a potential role for methylation as a biomarker of response.

Robotic versus laparoscopic surgery for mid-low rectal cancer after neoadjuvant chemoradiation therapy: comparison of oncologic outcomes

PURPOSE

Minimal invasive surgery for mid and low rectal cancer after neoadjuvant long-course chemoradiotherapy (LCRT) can be challenging. The aim of our study was to compare outcomes of laparoscopic and robotic resections in mid and low rectal cancers after LCRT.

METHODS

Between Jan 2006 and Dec 2010, all patients who underwent robotic or laparoscopic resections for mid and low rectal cancers after LCRT were identified from a prospective database. These patients received treatment (5FU-based chemotherapy, 50.4 Gy radiotherapy), as they were T3 or T4 and/or node + ve. Patients in the two groups were compared with respect to demographics, clinical safety, and oncological outcomes.

RESULTS

One hundred thirty-eight patients underwent rectal cancer resection after LCRT, either robotic (n = 74) or laparoscopic (n = 64). The patients in both groups were comparable in terms of demographics, distance of tumor from anal verge, and type of procedures. There were four (6.3 %) conversions in laparoscopic group and one (1.4 %) in the robotic group (p = 0.183). The morbidity rates in the laparoscopic and robotic group were 26.6 % and 16.2 %, respectively (p = 0.137). With a median follow up of 3 years, the local recurrence in the laparoscopic and robotic group was four (6.3 %) and two (2.7 %), respectively (p = 0.420). The 3-year overall survival rate for laparoscopic and robotic group was 92.1 and 90.0 %, respectively (p = 0.803). The 3-year disease-free survival was also comparable, 78.8 % (laparoscopic) versus 77.7 % (robotic) (p = 0.390).

CONCLUSION

With a median follow up of 3 years, robotic surgery for mid and low rectal cancer was associated with oncological outcomes comparable to laparoscopic surgery.

Changing patterns of recurrent disease in colorectal cancer

BACKGROUND

Due to changes in staging, (neo)-adjuvant treatment and surgical techniques for colorectal cancer (CRC), it is expected that the recurrence pattern will change as well. This study aims to report the current incidence of, and time to recurrent disease (RD), further the localization(s) and the eligibility for successive curative treatment.

METHODS

A consecutive cohort of CRC patients, whom were routinely staged with CT and underwent curative treatment according to the national guidelines, was analyzed (n = 526).

RESULTS

After a mean and median FU of 39 months, 20% of all patients and 16% of all AJCC stage 0-III patients had developed RD. The annual incidences were the highest in the first two years but tend to retain in the succeeding years for stage 0-III patients. The majority of RD was confined to one organ (58%) and 28% of these patients were again treated with curative intent.

CONCLUSIONS

In follow-up nowadays, less recurrences are found than reported in historical studies but these can more often be treated with curative intent. A main cause for the decreased incidence of RD, next to improvements in treatment, is probably stage shift elicited by pre-operative staging. The outcomes support continuation of follow-up in colorectal cancer.

Tailored rectal cancer treatment--a time for implementing contemporary prognostic factors?

AIM

To report data supporting the development of tailored treatment strategies for rectal cancer.

METHOD

A comprehensive review of the literature on the impact of prognostic factors cur-rently not included in international guidelines in rectal cancer management.

RESULTS

There is considerable variation in treatment guidelines for rectal cancer worldwide, especially for Stage II and Stage III disease. Long-term side effects of chemoradiotherapy are not considered in any guideline. Detailed knowledge, and the prognostic impact, of the circumferential resection margin, tumour grade and venous invasion should be factored into the development of a treatment strategy.

CONCLUSION

Factors additional to the TNM system should improve decision making for contemporary rectal cancer treatment. Optimized radiological and pathological evaluations, and a focus on detailed clinical factors, should be the basis for treatment decisions. International guidelines should consider all known prognostic factors for long-term oncological and functional outcomes.

Clinical impact of PET/MR imaging in patients with cancer undergoing same-day PET/CT: initial experience in 134 patients--a hypothesis-generating exploratory study

PURPOSE

To compare the clinical impact of combined positron emission tomography (PET) and magnetic resonance (MR) imaging to that of combined PET and computed tomography (CT) performed on the same day in patients with cancer.

MATERIALS AND METHODS

This HIPAA-compliant retrospective study was approved by the institutional review board. Patients gave written informed consent for study enrollment, including the possibility to use their imaging and clinical data in future evaluations. A total of 134 patients with cancer with a non-central nervous system primary neoplasm underwent same-day fluorodeoxyglucose (FDG) PET/CT and FDG PET/MR imaging. PET/CT and PET/MR studies were independently interpreted by teams of radiologists and nuclear medicine physicians. Four readers, divided into two teams composed of one radiologist and one nuclear medicine physician each, read all 134 studies. The referring physician classified discordance between PET/CT and PET/MR observations either as findings affecting clinical management or as findings not affecting clinical management. Data were compared with the χ(2) test.

RESULTS

Findings affecting clinical management were noted for PET/CT studies but not for PET/MR studies in two (1.5%) of 134 patients and for PET/MR studies but not for PET/CT studies in 24 (17.9%) of 134 patients. The discrepancies between findings affecting clinical management detected with PET/MR imaging over those detected with PET/CT were significant (P < .001).

CONCLUSION

In these patients, PET/MR imaging alone contributed to clinical management more often than did PET/CT alone. PET/MR imaging provides information that affects the care of patients with cancer and is unavailable from PET/CT. Online supplemental material is available for this article.

Stage and size using magnetic resonance imaging and endosonography in neoadjuvantly-treated rectal cancer

AIM: To assess the stage and size of rectal tumours using 1.5 Tesla (1.5T) magnetic resonance imaging (MRI) and three-dimensional (3D) endosonography (ERUS).

METHODS: In this study, patients were recruited in a phase I/II trial of neoadjuvant chemotherapy for biopsy-proven rectal cancer planned for surgical resection with or without preoperative radiotherapy. The feasibility and accuracy of 1.5T MRI and 3D ERUS were compared with the histopathology of the fixed surgical specimen (pathology) to determine the stage and size of the rectal cancer before and after neoadjuvant chemotherapy. A Philips Intera 1.5T with a cardiac 5-channel synergy surface coil was used for the MRI, and a B-K Medical Falcon 2101 EXL 3D-Probe was used at 13 MHz for the ERUS. Our hypothesis was that the staging accuracy would be the same when using MRI, ERUS and a combination of MRI and ERUS. For the combination, MRI was chosen for the assessment of the lymph nodes, and ERUS was chosen for the assessment of perirectal tissue penetration. The stage was dichotomised into stage I and stage II or greater. The size was measured as the supero-inferior length and the maximal transaxial area of the tumour.

RESULTS: The staging feasibility was 37 of 37 for the MRI and 29 of 36 for the ERUS, with stenosis as a limiting factor. Complete sets of investigations were available in 18 patients for size and 23 patients for stage. The stage accuracy by MRI, ERUS and the combination of MRI and ERUS was 0.65, 0.70 and 0.74, respectively, before chemotherapy and 0.65, 0.78 and 0.83, respectively, after chemotherapy. The improvement of the post-chemotherapy staging using the combination of MRI and ERUS compared with the staging using MRI alone was significant (P = 0.046). The post-chemotherapy understaging frequency by MRI, ERUS and the combination of MRI and ERUS was 0.18, 0.14 and 0.045, respectively, and these differences were non-significant. The measurements of the supero-inferior length by ERUS compared with MRI were within 1.96 standard deviations of the difference between the methods (18 mm) for tumours smaller than 50 mm. The agreement with pathology was within 1.96 standard deviations of the difference between imaging and pathology for all tumours with MRI (15 mm) and for tumours that did not exceed 50 mm with ERUS (22 mm). Tumours exceeding 50 mm in length could not be reliably measured by ERUS due to the limit in the length of each recording.

CONCLUSION: MRI is preferable to use when assessing the size of large or stenotic rectal tumours. However, staging accuracy is improved by combining MRI with ERUS.

Perioperative outcomes after ultra low anterior resection in the era of neoadjuvant chemoradiotherapy

PURPOSE

Data on perioperative outcomes of sphincter preserving ultra low anterior resections (ULAR) following neoadjuvant chemoradiotherapy (NA-CTRT) is sparsely reported in literature.

METHODS

Prospective data of 68 patients was reviewed retrospectively. Patients who received preoperative chemoradiotherapy (CTRT, Group A, n = 45) were compared with those who were operated upfront (Group B, n = 23).

RESULTS

Overall, mean distance of the tumor from anal verge was 5.1 cm (range 3-8). In Groups A and B, it was 5.2 and 5.1 cm, respectively. In Group A, 3 patients had complete response, 40 had partial response and 2 had progressive disease. Overall, the mean distance of the anastomosis performed from the anal verge was 2.8 cm (range 1-4). In Groups A and B, it was 2.7 and 2.9 cm, respectively (NS). Mean blood loss in Groups A and B was 510.5 (range 200-2,200) and 345 mL (range 50-800), respectively (p = 0.037). Two patients in Group A required blood transfusion (range 1-2) compared to none in Group B. The overall complication rate was 26.5 % (18/68); in Groups A and B, it was 22.2 % and 34.8 %, respectively. There was no postoperative mortality. Postoperative stay for Groups A and B was 8 and 9.5 days (p = 0.009), respectively. In Group A, 23/45 patients, earlier planned for abdominoperineal resection, ultimately received sphincter-preserving ULAR.

CONCLUSION

ULAR can be performed safely without added morbidity or mortality after neoadjuvant chemoradiation. In some cases, earlier deemed to be suitable for APR, the neoadjuvant approach improved chances of sphincter conservation.

Increased use of multidisciplinary treatment modalities adds little to the outcome of rectal cancer treated by optimal total mesorectal excision

PURPOSE

Total mesorectal excision (TME) is the standard surgical treatment for rectal cancer. The roles of chemotherapy and radiotherapy have become more defined, accompanied by improvements in preoperative staging and histopathological assessment. We analyse our ongoing results in the light of changing patterns of treatment over consecutive time periods.

METHODS

In total, 151 consecutive patients underwent potentially curative rectal excision for cancer in a single institution. Management and outcomes were compared between 1993-1999 and 2000-2007 which corresponded with the restructuring of the regional oncological services.

RESULTS

We found an increase in patients treated with neoadjuvant chemoradiotherapy after 1999 (20/89 vs 1/62, p < 0.001). There was an increase in the mean number of lymph nodes examined (11.9 vs 9.4, p = 0.037). The locoregional recurrence rate was 5.3%. The rates were not significantly different between the two study periods [4/89 (4.5%) 1999-2007 vs 4/62 (6.5%) 1993-1999, p = 0.597]. There was no statistical difference in overall or disease-free survival in the time periods examined.

CONCLUSIONS

Increasing use of neoadjuvant therapy and concomitant improvement in lymph node assessment did not translate into a concurrent reduction in the local recurrence, disease-free and overall survival rates. Our results demonstrate the enduring benefit of specialist training in TME in the outcome of rectal cancer surgery. This observational study suggests that low local recurrence rates are surrogate markers for improved overall and disease-free survival. Multidisciplinary team practice should be examined and made cost effective according to the individual unit's local recurrence rate in the light of this and other reports.

Expression of the phosphorylated MEK5 protein is associated with TNM staging of colorectal cancer

BACKGROUND

Activation of MEK5 in many cancers is associated with carcinogenesis through aberrant cell proliferation. In this study, we determined the level of phosphorylated MEK5 (pMEK5) expression in human colorectal cancer (CRC) tissues and correlated it with clinicopathologic data.

METHODS

pMEK5 expression was examined by immunohistochemistry in a tissue microarray (TMA) containing 335 clinicopathologic characterized CRC cases and 80 cases of nontumor colorectal tissues. pMEK5 expression of 19 cases of primary CRC lesions and paired with normal mucosa was examined by Western blotting. The relationship between pMEK5 expression in CRC and clinicopathologic parameters, and the association of pMEK5 expression with CRC survival were analyzed respectively.

RESULTS

pMEK5 expression was significantly higher in CRC tissues (185 out of 335, 55.2%) than in normal tissues (6 out of 80, 7.5%; P < 0.001). Western blotting demonstrated that pMEK5 expression was upregulated in 12 of 19 CRC tissues (62.1%) compared to the corresponding adjacent nontumor colorectal tissues. Overexpression of pMEK5 in CRC tissues was significantly correlated to the depth of invasion (P = 0.001), lymph node metastasis (P < 0.001), distant metastasis (P < 0.001) and high preoperative CEA level (P < 0.001). Consistently, the pMEK5 level in CRC tissues was increased following stage progression of the disease (P < 0.001). Analysis of the survival curves showed a significantly worse 5-year disease-free (P = 0.002) and 5-year overall survival rate (P < 0.001) for patients whose tumors overexpressed pMEK5. However, in multivariate analysis, pMEK5 was not an independent prognostic factor for CRC (DFS: P = 0.139; OS: P = 0.071).

CONCLUSIONS

pMEK5 expression is correlated with the staging of CRC and its expression might be helpful to the TNM staging system of CRC.

What is a safe distal resection margin in rectal cancer patients treated by low anterior resection without preoperative radiotherapy?

AIM

The aim of this study was to examine what constitutes an acceptable distal resection margin (DRM) when performing sphincter-saving surgery for rectal cancer without preoperative radiotherapy.

METHOD

This national study consisted of 3571 patients for whom information on DRM was available and who were radically treated by anterior resection between 1993 and 2004. Of these, 3342 (93.5%) patients had not received preoperative radiotherapy. The DRM was measured on fixed specimens.

RESULTS

The 5-year local recurrence rate was 14.5% for patients with a DRM of 0-10 mm compared to 9.6% for patients with a DRM of 11-20 mm, 8.9% for a DRM of 21-30 mm, 7.0% for a DRM of 31-40 mm, 7.7% for a DRM of 41-50 mm and 8.7% for a DRM of > 50 mm. After adjustment for other independent prognostic factors, a DRM of 0-10 mm was found to have significant impact on local recurrence. The DRM had no impact on distant metastases or overall survival.

CONCLUSION

For rectal cancer patients treated without radiotherapy, a DRM of > 10 mm is recommended.

Intratumoral budding as a potential parameter of tumor progression in mismatch repair-proficient and mismatch repair-deficient colorectal cancer patients

In colorectal cancer, tumor budding at the invasive front (peritumoral budding) is an established prognostic parameter and decreased in mismatch repair-deficient tumors. In contrast, the clinical relevance of tumor budding within the tumor center (intratumoral budding) is not yet known. The aim of the study was to determine the correlation of intratumoral budding with peritumoral budding and mismatch repair status and the prognostic impact of intratumoral budding using 2 independent patient cohorts. Following pancytokeratin staining of whole-tissue sections and multiple-punch tissue microarrays, 2 independent cohorts (group 1: n = 289; group 2: n = 222) with known mismatch repair status were investigated for intratumoral budding and peritumoral budding. In group 1, intratumoral budding was strongly correlated to peritumoral budding (r = 0.64; P < .001) and less frequent in mismatch repair-deficient versus mismatch repair-proficient cases (P = .177). Sensitivity and specificity for lymph node positivity were 72.7% and 72.1%. In mismatch repair-proficient cancers, high-grade intratumoral budding was associated with right-sided location (P = .024), advanced T stage (P = .001) and N stage pN (P < .001), vascular invasion (P = .041), infiltrating tumor margin (P = .003), and shorter survival time (P = .014). In mismatch repair-deficient cancers, high intratumoral budding was linked to higher tumor grade (P = .004), vascular invasion (P = .009), infiltrating tumor margin (P = .005), and more unfavorable survival time (P = .09). These associations were confirmed in group 2. High-grade intratumoral budding was a poor prognostic factor in univariate (P < .001) and multivariable analyses (P = .019) adjusting for T stage, N stage distant metastasis, and adjuvant therapy. These preliminary results on 511 patients show that intratumoral budding is an independent prognostic factor, supporting the future investigation of intratumoral budding in larger series of both preoperative and postoperative rectal and colon cancer specimens.

The effects of short-course preoperative irradiation on local recurrence rate and survival in rectal cancer: a population-based nationwide study

BACKGROUND

Preoperative irradiation with 5 × 5 Gy in randomized trials reduces local recurrence rate and may improve survival in patients with resectable rectal cancer.

OBJECTIVE

The aim of this study was to determine whether the same favorable effects could be observed in a population-based study.

DESIGN

This study was conducted via a retrospective analysis of prospectively collected data from the Swedish Rectal Cancer Registry.

SETTINGS

This study examined population-based data from Sweden.

PATIENTS

All newly diagnosed rectal cancers in Sweden are reported to the Swedish Rectal Cancer Registry.

INTERVENTIONS

Between 1995 and 2001, 6878 patients (stages I-III) were operated on with an anterior resection, an abdominoperineal resection, or a Hartmann's procedure. Short-course irradiation was given to 41% of patients preoperatively. To reduce bias, patients operated on with a Hartmann procedure or older than 75 years were excluded when 5-year survival was analyzed (n = 3466). Tumors were analyzed according to height (0-5 cm, 6-10 cm, 11-15 cm).

MAIN OUTCOME MEASURES

Five-year cumulative local recurrence and survival rates.

RESULTS

The 5-year cumulative local recurrence rate was 6.3% (95% CI 5.4-7.4) for patients receiving preoperative irradiation and 12.1% (95% CI 10.8-13.5) for patients not receiving preoperative irradiation. Multivariate analyses indicated the risk of local recurrence was 50% lower for patients receiving preoperative irradiation compared with patients not receiving irradiation (hazard ratio = 0.50; 95% CI 0.40-0.62). Among patients younger than 76 years and operated on with an anterior resection or abdominoperineal resection, the 5-year cumulative survival rate was 0.70 (95% CI 0.69-0.72). Disease-free and overall survivals were higher in irradiated patients, and the difference was statistically significant in low tumors.

CONCLUSIONS

In this population-based analysis, the favorable effect of preoperative short-course irradiation on local recurrence rates, seen in randomized trials, was confirmed for the entire Swedish population irrespective of tumor height and stage. Data also suggested an effect on 5-year survival, especially in patients with low tumors (0-5 cm).

Laparoscopic total mesorectal excision following long course chemoradiotherapy for locally advanced rectal cancer

PURPOSE

Laparoscopic total mesorectal excision (TME) of locally advanced rectal cancer after long-course chemoradiotherapy (LCRT) is surgically and oncologically challenging. We have assessed the feasibility, timing, and short-term oncological outcome of laparoscopic TME after LCRT.

METHODS

Between 2004 and 2006, 30 patients were selected for LCRT based on clinical examination and MRI. Patients received 3/4 field radiotherapy, 45-50.4 Gy in 25-28 fractions during 5 weeks with either 5-fluorouracil or Uftoral. Clinical assessments were made 4 weeks after completion of radiotherapy and then 2 weekly with sequential 4 weekly MRI, to individualize the timing of surgery at maximal response. Laparoscopic TME was performed using a standard technique.

RESULTS

Thirty patients received LCRT and 26 patients (21 men; median age, 63 years) underwent laparoscopic TME at 11 weeks (median) after LCRT. Median operating time was 270 min. Sixteen patients had LAR and ten had APR. There were three conversions. Three patients developed anastomotic leak (18.7%): one was managed conservatively and one patient died of septicemia. Morbidity was seen in 19% of patients. There were 25 (96%) R0 resections with a complete response in 5 (19%) cases and microscopic tumor in lakes of mucin (Tmic) in another 6 (23%). Two patients (7.6%) developed local recurrence (median follow up, 34 months). The median time interval between radiotherapy and surgery was 11 (range, 7-13) weeks, which was based on serial MRI scans after LCRT.

CONCLUSIONS

Laparoscopic TME after LCRT is feasible and safe both oncologically and surgically. Serial MRI helps to determine the optimum timing of surgery.

MRI-based indications for neoadjuvant radiochemotherapy in rectal carcinoma: interim results of a prospective multicenter observational study

BACKGROUND

This study evaluated use of circumferential resection margin status in preoperative MRI (mrCRM) as an indication for neoadjuvant radiochemotherapy (nRCT) in rectal carcinoma patients.

MATERIALS AND METHODS

In a multicenter prospective study, nRCT was given to patients with carcinoma of the middle rectum with positive mrCRM (≤1 mm), with cT3 low rectal carcinoma, and all patients with cT4 tumors. The short-term endpoints were pathologic pCRM (≤1 mm) as a strong predictor of local recurrence rate and the quality of total mesorectal excision according to the plane of surgery. These endpoints were compared in patients with and without nRCT.

RESULTS

Of 230 patients that met the inclusion criteria, 96 (41.7%) received a long course of nRCT and 134 (58.3%) were primarily operated on. The pCRM was positive in 13 of 230 (5.7%) (primarily operated on, 2 of 134 [1.5%]; after nRCT, 11 of 96 [11%]). In 1 of 134 (0.7%) case, the mrCRM was falsely negative. Patients at participating centers varied in terms of preoperative stage but not in pCRM positivity (0%-13%, P = .340). The plane of surgery was mesorectal (good) in 209 of 230 (90.9%), intramesorectal (moderate) in 16 of 230 (7%), and the muscularis propria plane (poor) in 2.2% (5 of 230).

CONCLUSIONS

Low pCRM positivity and the high quality of mesorectal excision support use of MRI-based nRCT in rectal carcinoma. nRCT was avoidable in 45% of patients with stage II and III disease without significant risk of undertreatment. Preoperative MRI thus allows identification of patients with high risk of local recurrence and use of selective nRCT.

Stage-to-stage comparison of preoperative and postoperative chemoradiotherapy for T3 mid or distal rectal cancer

PURPOSE

To investigate, in a comparative analysis, the prognostic implications of postchemoradiotherapy (post-CRT) pathologic stage (ypStage) vs. postoperative pathologic stage (pStage) in rectal cancer.

METHODS AND MATERIALS

Between May 2001 and December 2006, 487 patients with T3 mid or distal rectal cancer were analyzed retrospectively. Concurrent CRT was administered preoperatively (n = 364, 74.7%) or postoperatively (n = 123, 25.3%). The radiation dose was 50.4 Gy in 28 fractions. All patients underwent a total mesorectal excision and received adjuvant chemotherapy. Disease-free survival (DFS) was estimated using the Kaplan-Meier method. Differences in DFS, stratified by ypStage and pStage, were compared using the log-rank test.

RESULTS

For surviving patients, the median follow-up period was 68 months (range, 12-105 months). The 5-year local recurrence-free survival rate was not different, at 95.3% and 92.1% in preoperative and postoperative CRT groups, respectively (p = 0.402), but the 5-year distant metastasis-free survival rate was significantly different, at 81.6% (preoperative CRT) vs. 65.4% (postoperative CRT; p = 0.001). The 5-year DFS rate of 78.8% in the preoperative CRT group was significantly better than the 63.0% rate in the postoperative CRT group (p = 0.002). Post-CRT pathologic Stage 0-I occurred in 42.6% (155 of 364) of the patients with preoperative CRT. The 5-year DFS rates were 90.2% (ypStage 0-I), 83.5% (ypStage II), 77.3% (pStage II), 58.6% (ypStage III), and 54.7% (pStage III). The DFS rate of ypStage 0-I was significantly better than that of ypStage II or pStage II. Post-CRT pathologic Stage II and III had similar DFS, compared with pStage II and III, respectively.

CONCLUSIONS

Disease-free survival predicted by each ypStage was similar to that predicted by the respective pStage. Improved DFS with preoperative vs. postoperative CRT was associated with the ypStage 0-I group that showed a similarly favorable outcome to pStage I rectal cancer.

Anorectal malignant melanomas: Retrospective experience with surgical management

AIM: To present the experience and outcomes of the surgical treatment for the patients with anorectal melanoma from the Cancer Hospital, Chinese Academy of Medical Sciences.

METHODS: Medical records of the diagnosis, surgery, and follow-up of 56 patients with anorectal melanoma who underwent surgery between 1975 and 2008 were retrospectively reviewed. The factors predictive for the survival rate of these patients were identified using multivariate analysis.

RESULTS: The 5-year survival rate of the 56 patients with anorectal melanoma was 20%, 36 patients underwent abdominoperineal resection (APR) and 20 patients underwent wide local excision (WLE). The rates of local recurrence of the APR and WLE groups were 16.13% (5/36) and 68.75% (13/20), (P = 0.001), and the median survival time was 22 mo and 21 mo, respectively (P = 0.481). Univariate survival analysis demonstrated that the number of tumor and the depth of invasion had significant effects on the survival (P < 0.05). Multivariate analysis showed that the number of tumor [P = 0.017, 95% confidence interval (CI) = 1.273-11.075] and the depth of invasion (P = 0.015, 95% CI = 1.249-7.591) were independent prognostic factors influencing the survival rate.

CONCLUSION: Complete or R0 resection is the first choice of treatment for anorectal melanoma, prognosis is poor regardless of surgical approach, and early diagnosis is the key to improved survival rate for patients with anorectal melanoma.

Clinicopathological staging of colorectal cancer: Evolution and consensus-an Australian perspective

In 1991 this journal published the report of an international working party to the World Congress of Gastroenterology regarding the clinicopathological staging of colorectal cancer. Since that time staging has continued to evolve as further prognostic factors in colorectal cancer have been elucidated in studies of increasingly large databases in several countries. This review summarizes several of the key issues that have arisen during this evolutionary process and raises matters which still remain controversial in staging at the present time.

International preoperative rectal cancer management: staging, neoadjuvant treatment, and impact of multidisciplinary teams

BACKGROUND

Little is known regarding variations in preoperative treatment and practice for rectal cancer (RC) on an international level, yet practice variation may result in differences in recurrence and survival rates.

METHODS

One hundred seventy-three international colorectal centers were invited to participate in a survey of preoperative management of rectal cancer.

RESULTS

One hundred twenty-three (71%) responded, with a majority of respondents from North America, Europe, and Asia. Ninety-three percent have more than 5 years' experience with rectal cancer surgery. Fifty-five percent use CT scan, 35% MRI, 29% ERUS, 12% digital rectal examination and 1% PET scan in all RC cases. Seventy-four percent consider threatened circumferential margin (CRM) an indication for neoadjuvant treatment. Ninety-two percent prefer 5-FU-based long-course neoadjuvant chemoradiation therapy (CRT). A significant difference in practice exists between the US and non-US surgeons: poor histological differentiation as an indication for CRT (25% vs. 7.0%, p = 0.008), CRT for stage II and III rectal cancer (92% vs. 43%, p = 0.0001), MRI for all RC patients (20% vs. 42%, p = 0.03), and ERUS for all RC patients (43% vs. 21%, p = 0.01). Multidisciplinary team meetings significantly influence decisions for MRI (RR = 3.62), neoadjuvant treatment (threatened CRM, RR = 5.67, stage II + III RR = 2.98), quality of pathology report (RR = 4.85), and sphincter-saving surgery (RR = 3.81).

CONCLUSIONS

There was little consensus on staging, neoadjuvant treatment, and preoperative management of rectal cancer. Regular multidisciplinary team meetings influence decisions about neoadjuvant treatment and staging methods.

Magnetic resonance imaging (MRI) in rectal cancer: a comprehensive review

Magnetic resonance imaging (MRI) has established itself as the primary method for local staging in patients with rectal cancer. This is due to several factors, most importantly because of the ability to assess the status of circumferential resection margin. There are several newer developments being introduced continuously, such as diffusion-weighted imaging and imaging with 3 T. Assessment of loco-regional lymph nodes has also been investigated extensively using different approaches, but more work needs to be done. Finally, evaluation of tumours during or after preoperative treatment is becoming an everyday reality. All these new aspects prompt a review of the most recent advances and opinions. In this review, a comprehensive overview of the current status of MRI in the loco-regional assessment and management of rectal cancer is presented. The findings on MRI and their accuracy are reviewed based on the most up-to-date evidence. Optimisation of MRI acquisition and relevant regional anatomy are also presented, based on published literature and our own experience.

Sphincter preservation in rectal cancer is associated with patients' socioeconomic status

Background

Decision making regarding the choice of surgical procedure in rectal cancer is complex. It was hypothesized that, in addition to clinical factors, several aspects of patients' socioeconomic background influence this process.

Methods

Individually attained data on civil status, education and income were linked to the Swedish Rectal Cancer Registry 1995–2005 (16 713 patients) and analysed by logistic regression.

Results

Anterior resection (AR) was performed in 7433 patients (44·5 per cent), abdominoperineal resection (APR) in 3808 (22·8 per cent) and Hartmann's procedure in 1704 (10·2 per cent). Unmarried patients were least likely (odds ratio (OR) 0·76, 95 per cent confidence interval (c.i.) 0·64 to 0·88) and university-educated men were most likely (OR 1·30, 1·04 to 1·62) to have an AR. Patients with the highest income were more likely to undergo AR (OR 0·80, 0·85 and 0·86 respectively for first, second and third income quartiles). Socioeconomic differences in the use of AR were smallest among the youngest patients. Unmarried patients were more likely (OR 1·21, 95 per cent c.i. 1·00 to 1·48) and university-educated patients less likely (OR 0·78, 95 per cent c.i. 0·63 to 0·98) to have an APR.

Conclusion

The choice of surgical strategy in rectal cancer is not socioeconomically neutral. Confounding factors, such as co-morbidity or smoking, may explain some of the differences but inequality in treatment is also plausible.

[Pre-operative sera levels of CEA and CA19-9 and tissular distribution of tumor marker CA19-9 in colorectal carcinoma: correlation with morphological features of neoplasia]

OBJECTIVE

To compare sera levels of CEA and CA19-9 and tissular expression of the CA19-9 and to correlate these with morphological features of the colorectal carcinoma.

METHODS

Forty five patients with colorectal carcinoma underwent surgical treatment following measurement of pre-operative levels of CA19-9 and CEA. Sera levels of CEA = 5.0ng/ml and CA19-9 = 37UI were deemed high values. Evaluation of CA19-9 immunoexpression in neoplastic tissue was carried through by means of immunohistochemical study with monoclonal antibody anti-CA19-9. The intensity of expression of CA19-9 in neoplastic areas was semi-quantified in each area of tumor differentiation into mild(+/+++), moderate(++/+++), intense(+++/+++) or absent.

RESULTS

Sera CA19-9 values were progressively higher in the presence of elevated CA19-9 immunoexpression in colorectal carcinoma tissue, although not significant (p=0.06). Increased sera CA19-9 levels were found to be associated with significantly elevated (p<0.001) sera CEA levels. Levels of sera CA19-9, tissular immunoexpression of CA19-9 and sera levels of CEA presented no significant association with morphological features of the colorectal carcinoma.

CONCLUSION

Sera and tissular levels of the CA19-9 marker exhibited, each other, a directly proportional relationship. The morphological features of the neoplasia had no influence on sera CEA or CA19-9 levels or tissular immunoexpression of CA19-9.

Role of tumor size in the pre-operative management of rectal cancer patients

Background

Clinical management of rectal cancer patients relies on pre-operative staging. Studies however continue to report moderate degrees of over/understaging as well as inter-observer variability. The aim of this study was to determine the sensitivity, specificity and accuracy of tumor size for predicting T and N stages in pre-operatively untreated rectal cancers.

Methods

We examined a test cohort of 418 well-documented patients with pre-operatively untreated rectal cancer admitted to the University Hospital of Basel between 1987 and 1996. Classification and regression tree (CART) and logistic regression analysis were carried out to determine the ability of tumor size to discriminate between early (pT1-2) and late (pT3-4) T stages and between node-negative (pN0) and node-positive (pN1-2) patients. Results were validated by an external patient cohort (n = 28).

Results

A tumor diameter threshold of 34 mm was identified from the test cohort resulting in a sensitivity and specificity for late T stage of 76.3%, and 67.4%, respectively and an odds ratio (OR) of 6.67 (95%CI:3.4-12.9). At a threshold value of 29 mm, sensitivity and specificity for node-positive disease were 94% and 15.5%, respectively with an OR of 3.02 (95%CI:1.5-6.1). Applying these threshold values to the validation cohort, sensitivity and specificity for T stage were 73.7% and 77.8% and for N stage 50% and 75%, respectively.

Conclusions

Tumor size at a threshold value of 34 mm is a reproducible predictive factor for late T stage in rectal cancers. Tumor size may help to complement clinical staging and further optimize the pre-operative management of patients with rectal cancer.

Factors influencing local failure in rectal cancer: analysis of 2315 patients from a population-based series

PURPOSE

This study aimed to identify risk factors for local failure in an effort to optimize treatment for rectal cancer.

METHODS

A total of 154 patients with local failure after abdominal resection were identified from a population-based consecutive series of 2315 patients who underwent operations for rectal cancer in the Stockholm region between January 1995 and December 2004. Surgeons trained in total mesorectal excision performed the surgery, and preoperative radiotherapy was given according to defined protocols. Data from the 9 hospitals in the region, prospectively registered in a database, were reviewed with regard to tumor location and stage, radiation therapy, surgical treatment, and follow-up.

RESULTS

In a multivariable analysis, independent risk factors for local failure were distal tumor location and advanced tumor and nodal stage, omission of preoperative radiation, residual disease, and hospitals with lower caseload. Low anterior resection and total mesorectal excision were deployed more often in centers with low failure rates. Discriminators for radiation therapy were patients with male gender, less advanced age, and tumors situated <6 cm from the anal verge.

CONCLUSION

The variability of patient outcome according to local failure depends on tumor stage, nodal stage, and location. Omission of radiation therapy and surgical performance are important additional risk factors to consider when optimizing treatment for rectal cancer.

Actionable indicators for short and long term outcomes in rectal cancer

AIM OF THE STUDY

Although patient and tumour characteristics are the most important determinants for outcomes in rectal cancer care, actionable factors for improving these are still unclear. Therefore, the purpose of this study was to assess the impact of surgeon and hospital factors which can actually be influenced to improve on postoperative complications, disease-free survival (DFS) and relative survival (RS) in rectal cancer.

METHODS

For 819 curatively operated rectal cancer patients, staged I-III and diagnosed between 2001 and 2005, data were derived from the population-based Cancer Registry of the Comprehensive Cancer Centre North East and supplemented by medical record examination. (Multilevel) Logistic regression analysis was performed to examine the influence of relevant factors on postoperative complications and time from diagnosis to first treatment. Besides, Cox regression analysis for DFS and relative survival analysis was performed.

RESULTS

Postoperative complications were dependent on type of surgery (p=0.024) and hospital volume (p=0.029). DFS was mainly influenced by stage (p<0.001) and time to treatment (p=0.018). Actionable indicators related to RS were type of surgery (p=0.011) and time to treatment (p=0.048). Time to treatment was found to be related to co-morbidity (p=0.007), preoperative radiotherapy (p=0.003) and referral for operation (p=0.048). Nevertheless, 18.2% unexplained variation in time to treatment remained on hospital level.

CONCLUSIONS

We conclude that optimal outcomes for rectal cancer care can be achieved by focusing on early detection and timely diagnosis, as well as adequate choice and timeliness of treatment in hospitals with optimal logistics for rectal cancer patients.

Modified neoadjuvant short-course radiation therapy in uT3 rectal carcinoma: low local recurrence rate with unchanged overall survival and frequent morbidity

PURPOSE

The purpose of this study is to investigate the value of a modified neoadjuvant short-course radiation therapy (SCRT) in uT3 rectal carcinoma, which, despite local R0 resectability, carries a greater risk of local recurrence than less invasive carcinomas.

METHODS

Sixty-three patients with uT3 rectal carcinoma < or =10 cm above the anal verge received a modified 8 x 3 Gy pre-operative SCRT. Radiation-associated and peri-operative complications were recorded, and the patients were followed up for long-term oncological outcome and morbidity.

RESULTS

In the study group, there were no severe adverse radiation-associated effects; the rate of peri-operative morbidity was 54.0% and that of in-hospital mortality is 4.8%. The probability (Kaplan-Meier estimate) of local recurrence was 3.9% with a probability of metachronic distant metastases of 26.8% (5-year rates). We found the probability of 5-year disease-free survival to be 70.5% and that of 5-year overall survival, 59.5%. Long-term complications were reported for 31.7% of patients.

CONCLUSIONS

Compared to the literature-modified 8 x 3 Gy neoadjuvant SCRT and surgery in uT3, rectal carcinoma was associated with low local recurrence but frequent peri-operative complications. The decisive prognostic factor, distant metastasis, was unaffected. Difficulties included overestimation of tumour invasion depth by endosonography. Possible clinical consequences of the results are discussed.

Importance of clear resection margins in anorectal malignant melanoma

BACKGROUND

Anorectal melanoma is rare and surgery is the recommended primary treatment. There has been some debate whether abdominoperineal resection (APR) or local excision is most appropriate. The aim of this study was to provide a population-based analysis of symptoms, treatment and outcome.

METHODS

From the Swedish National Cancer Registry, 251 patients with anorectal melanoma were identified from 1960 to 1999. Medical reports were collected and reviewed retrospectively. R0 resection was defined by clear macroscopic margins and a pathology report showing a margin greater than 10 mm. Survival was compared with the log rank test, and Cox multivariable analysis was performed.

RESULTS

APR and local excision was performed in 66 and 86 patients respectively. Median survival after surgery was 14 months, with no statistically significant difference between the two groups. Seventy-two patients in whom an R0 resection was achieved, irrespective of approach, had a significantly better overall 5-year survival rate than patients with involved margins (19 versus 6 per cent; P < 0.001). Multivariable analysis showed resection status and tumour stage to be independent prognostic variables.

CONCLUSION

Both APR and LE seem appropriate for anorectal melanoma provided clear margins can be achieved; prognosis is poor regardless of surgical approach.

Preoperative radiotherapy is associated with worse functional results after coloanal anastomosis for rectal cancer

PURPOSE

This study was designed to evaluate functional outcome in patients treated with preoperative radiotherapy after low anterior resection and a coloanal anastomosis for low rectal cancer.

METHODS

Functional outcome data from patients enrolled in a prospective randomized trial comparing 3 reconstructive procedures were evaluated with respect to administration of preoperative radiotherapy. Incontinence was assessed with a questionnaire on bowel function including the Fecal Incontinence Severity Index; sexual function was assessed with the Sexual Health Inventory for Men and a gender-specific questionnaire for women. Quality of life was assessed with SF-36 scores.

RESULTS

Of 364 patients enrolled, 153 (42%) had no radiotherapy or chemotherapy, and 211 (58%) had preoperative radiotherapy; 186 (51%) had chemotherapy in addition to radiotherapy. Comparison of irradiated vs. nonirradiated patients showed no significant differences in postoperative morbidity (29.9% vs. 35.3%; P = 0.27). Two-year follow-up of 297 patients showed greater impairment of bowel function in irradiated patients (n = 170) vs. nonirradiated patients (n = 127): e.g., mean number of daily bowel movements at 12 months, 4.2 +/- 3.5 vs. 3.5 +/- 2.6, P = 0.032; urgency, 85% vs. 67%, P = 0.002). Antidiarrheal use was significantly higher in irradiated patients vs. nonirradiated patients at 4 (P = 0.043), 12 (P = 0.002), and 24 (P = 0.001) months. Sexual Health Inventory for Men scores indicated poorer function in irradiated patients at 24 months (P = 0.039). Preoperative radiotherapy had no deleterious effects on quality of life. Multivariate analyses showed that negative effects of preoperative radiotherapy on urgency at 4 months (P = 0.002) and antidiarrheal use at 24 months were independent of reconstruction technique, but a positive effect of reconstruction with a J-pouch was still observed in patients who received radiotherapy.

CONCLUSION

Preoperative radiotherapy does not increase overall morbidity but is associated with poorer functional outcome after low anterior resection with coloanal anastomosis. Preoperative radiotherapy and the J-pouch are nonconfounding predictors of functional outcome up to 24 months after surgery.