Oncologic outcomes after radical surgery following preoperative chemoradiotherapy for locally advanced lower rectal cancer: abdominoperineal resection versus sphincter-preserving procedure

Oncologic outcomes of intersphincteric resection versus abdominoperineal resection for lower rectal cancer: a systematic review and meta-analysis

BACKGROUND

The efficacy of intersphincteric resection (ISR) surgery for patients with lower rectal cancer remains unclear compared to abdominoperineal resection (APR). The aim of this study is to compare the oncologic outcomes for lower rectal cancer patients after ISR and APR through a systematic review and meta-analysis.

MATERIALS AND METHODS

A systematic electronic search of the Cochrane Library, PubMed, EMBASE, and MEDLINE was performed through January 12, 2022. The primary outcomes included 5-year disease-free survival (5y-DFS) and 5-year overall survival. Secondary outcomes included circumferential resection margin involvement, local recurrence, perioperative outcomes, and other long-term outcomes. The pooled odds ratios, mean difference, or hazard ratios (HRs) of each outcome measurement and their 95% CIs were calculated.

RESULTS

A total of 20 nonrandomized controlled studies were included in the qualitative analysis, with 1217 patients who underwent ISR and 1135 patients who underwent APR. There was no significant difference in 5y-DFS (HR: 0.84, 95% CI: 0.55-1.29; P =0.43) and 5-year overall survival (HR: 0.93, 95% CI: 0.60-1.46; P =0.76) between the two groups. Using the results of five studies that reported matched T stage and tumor distance, we performed another pooled analysis. Compared to APR, the ISR group had equal 5y-DFS (HR: 0.76, 95% CI: 0.45-1.30; P =0.31) and 5y-LRFS (local recurrence-free survival) (HR: 0.72, 95% CI: 0.29-1.78; P =0.48). Meanwhile, ISR had equivalent local control as well as perioperative outcomes while significantly reducing the operative time (mean difference: -24.89, 95% CI: -45.21 to -4.57; P =0.02) compared to APR.

CONCLUSIONS

Our results show that the long-term survival and safety of patients is not affected by ISR surgery, although this result needs to be carefully considered and requires further study due to the risk of bias and limited data.

Long-term Outcomes of Minimally Invasive Versus Open Abdominoperineal Resection for Rectal Cancer: A Single Specialized Center Experience

BACKGROUND

Randomized studies have validated laparoscopic proctectomy for the treatment of rectal cancer as noninferior to an open proctectomy, but most of those studies have included sphincter-preserving resections along with abdominoperineal resection.

OBJECTIVE

This study aimed to compare perioperative and long-term oncological outcomes between minimally invasive and open abdominoperineal resection.

DESIGN

This study is a retrospective analysis of a prospectively maintained database.

SETTINGS

The study was conducted in a single specialized colorectal surgery department.

PATIENTS

All patients who underwent abdominoperineal resection for primary rectal cancer between 2000 and 2016 were included.

MAIN OUTCOME MEASURES

The primary outcomes measured were the perioperative and long-term oncological outcomes.

RESULTS

We included 452 patients, 372 in the open group and 80 in the minimally invasive group, with a median follow-up time of 74 months. There were significant differences between the groups in terms of neoadjuvant radiation treatment (67.5% of the open versus 81.3% of the minimally invasive group, p = 0.01), operative time (mean of 200 minutes versus 287 minutes, p < 0.0001), and mean length of stay (9.5 days versus 6.6 days, p < 0.0001). Overall complication rates were similar between the groups (34.5% versus 27.5%, p = 0.177). There were no significant differences in the mean number of lymph nodes harvested (21.7 versus 22.2 nodes, p = 0.7), circumferential radial margins (1.48 cm versus 1.37 cm, p = 0.4), or in the rate of involved radial margins (10.8% versus 6.3%, p = 0.37). Five-year overall survival was 70% in the open group versus 80% in the minimally invasive group (p = 0.344), whereas the 5-year disease-free survival rate in the open group was 63.2% versus 77.6% in the minimally invasive group (p = 0.09).

LIMITATIONS

This study was limited because it describes a single referral institution experience.

CONCLUSIONS

Although both approaches have similar perioperative outcomes, the minimally invasive approach benefits the patients with a shorter length of stay and a lower risk for surgical wound infections. Both approaches yield similar oncological technical quality in terms of the lymph nodes harvested and margins status, and they have comparable long-term oncological outcomes. See Video Abstract at http://links.lww.com/DCR/B754.RESULTADOS A LARGO PLAZO DE LA RESECCIÓN ABDOMINOPERINEAL MÍNIMAMENTE INVASIVA VERSUS ABIERTA PARA EL CÁNCER DE RECTO: EXPERIENCIA DE UN SOLO CENTRO ESPECIALIZADOANTECEDENTES:Estudios aleatorizados han validado la proctectomía laparoscópica para el tratamiento del cáncer de recto igual a la proctectomía abierta, pero la mayoría de esos estudios han incluido resecciones con preservación del esfínter junto con resección abdominoperineal.OBJETIVO:Comparar los resultados oncológicos perioperatorios y a largo plazo entre la resección abdominoperineal abierta y mínimamente invasiva.DISEÑO:Análisis retrospectivo de una base de datos mantenida de forma prospectiva.ENTORNO CLINICO:Servicio único especializado en cirugía colorrectal.PACIENTES:Todos los pacientes que se sometieron a resección abdominoperineal por cáncer de recto primario entre 2000 y 2016.PRINCIPALES MEDIDAS DE VALORACION:Resultados oncológicos perioperatorios y a largo plazo.RESULTADOS:Se incluyeron 452 pacientes, 372 en el grupo abierto y 80 en el grupo mínimamente invasivo, con una mediana de seguimiento de 74 meses. Hubo diferencias significativas entre los grupos en términos de tratamiento con radiación neoadyuvante (67,5% del grupo abierto versus 81,3% del grupo mínimamente invasivo, p = 0,01), tiempo operatorio (media de 200 minutos versus 287 minutos, p < 0,0001) y la duración media de la estancia (9,5 días frente a 6,6 días, p < 0,0001). Las tasas generales de complicaciones fueron similares entre los grupos (34,5% versus 27,5%, p = 0,177). No hubo diferencias significativas en el número medio de ganglios linfáticos extraídos (21,7 versus 22,2 ganglios, p = 0,7), márgenes radiales circunferenciales (1,48 cm y 1,37 cm, p = 0,4), ni en la tasa de márgenes radiales afectados (10,8 cm). % versus 6,3%, p = 0,37). La supervivencia general a 5 años fue del 70% en el grupo abierto frente al 80% en el grupo mínimamente invasivo (p = 0,344), mientras que la tasa de supervivencia libre de enfermedad a 5 años en el grupo abierto fue del 63,2% frente al 77,6% en el grupo mínimamente invasivo (p = 0,09).LIMITACIONES:Experiencia en una institución de referencia única.CONCLUSIONES:Si bien ambos tienen resultados perioperatorios similares, el enfoque mínimamente invasivo, beneficia a los pacientes con estadía más corta y menor riesgo de infecciones de la herida quirúrgica. Ambos enfoques, producen una calidad técnica oncológica similar en términos de ganglios linfáticos extraídos y estado de los márgenes, y tienen resultados oncológicos comparables a largo plazo. Consulte Video Resumen en http://links.lww.com/DCR/B754. (Traducción - Dr. Fidel Ruiz Healy).

Prognostic importance of circumferential resection margin in the era of evolving surgical and multidisciplinary treatment of rectal cancer: A systematic review and meta-analysis

BACKGROUND

Circumferential resection margin is considered an important prognostic parameter after rectal cancer surgery, but its impact might have changed because of improved surgical quality and tailored multimodality treatment. The aim of this systematic review was to determine the prognostic importance of circumferential resection margin involvement based on the most recent literature.

METHODS

A systematic literature search of MEDLINE, Embase, and the Cochrane Library was performed for studies published between January 2006 and May 2019. Studies were included if 3- or 5-year oncological outcomes were reported depending on circumferential resection margin status. Outcome parameters were local recurrence, overall survival, disease-free survival, and distant metastasis rate. The Newcastle Ottawa Scale and Jadad score were used for quality assessment of the studies. Meta-analysis was performed using a random effects model and reported as a pooled odds ratio or hazard ratio with 95% confidence interval.

RESULTS

Seventy-five studies were included, comprising a total of 85,048 rectal cancer patients. Significant associations between circumferential resection margin involvement and all long-term outcome parameters were uniformly found, with varying odds ratios and hazard ratios depending on circumferential resection margin definition (<1 mm, ≤1 mm, otherwise), neoadjuvant treatment, study period, and geographical origin of the studies.

CONCLUSION

Circumferential resection margin involvement has remained an independent, poor prognostic factor for local recurrence and survival in most recent literature, indicating that circumferential resection margin status can still be used as a short-term surrogate endpoint.

Total neoadjuvant therapy vs standard therapy of locally advanced rectal cancer with high-risk factors for failure

BACKGROUND

For locally advanced rectal cancer (LARC), standard therapy [consisting of neoadjuvant chemoradiotherapy (CRT), surgery, and adjuvant chemotherapy (ChT)] achieves excellent local control. Unfortunately, survival is still poor due to distant metastases, which remains the leading cause of death among these patients. In recent years, the concept of total neoadjuvant treatment (TNT) has been developed, whereby all systemic ChT-mainly affecting micrometastases-is applied prior to surgery.

AIM

To compare standard therapy and total neoadjuvant therapy for LARC patients with high-risk factors for failure.

METHODS

In a retrospective study, we compared LARC patients with high-risk factors for failure who were treated with standard therapy or with TNT. High-risk for failure was defined according to the presence of at least one of the following factors: T4 stage; N2 stage; positive mesorectal fascia; extramural vascular invasion; positive lateral lymph node. TNT consisted of 12 wk of induction ChT with capecitabine and oxaliplatin or folinic acid, fluorouracil and oxaliplatin, CRT with capecitabine, and 6-8 wk of consolidation ChT with capecitabine and oxaliplatin or folinic acid, fluorouracil and oxaliplatin prior to surgery. The primary endpoint was pathological complete response (pCR). In total, 72 patients treated with standard therapy and 89 patients treated with TNT were included in the analysis.

RESULTS

Compared to standard therapy, TNT showed a higher proportion of pCR (23% vs 7%; P = 0.01), a lower neoadjuvant rectal score (median: 8.43 vs 14.98; P < 0.05), higher T-and N-downstaging (70% and 94% vs 51% and 86%), equivalent R0 resection (95% vs 93%), shorter time to stoma closure (mean: 20 vs 33 wk; P < 0.05), higher compliance during systemic ChT (completed all cycles 87% vs 76%; P < 0.05), lower proportion of acute toxicity grade ≥ 3 during ChT (3% vs 14%, P < 0.05), and equivalent acute toxicity and compliance during CRT and in the postoperative period. The pCR rate in patients treated with TNT was significantly higher in patients irradiated with intensity-modulated radiotherapy/volumetric-modulated arc radiotherapy than with 3D conformal radiotherapy (32% vs 9%; P < 0.05).

CONCLUSION

Compared to standard therapy, TNT provides better outcome for LARC patients with high-risk factors for failure, in terms of pCR and neoadjuvant rectal score.

Rapid transit in the left-sided colon is related to poor defecatory function at early period after stoma closure

Sphincter-saving surgery (SSS) is the gold standard for rectal cancer surgery but results in a wide spectrum of bowel dysfunction. This study investigated the impact of colonic dysmotility on the incontinent form of bowel dysfunction. Bowel function of patients who received SSS with loop ileostomy for treating rectal cancer was reviewed retrospectively from June 2013 two August 2015 at a single hospital. Immediately after closure of a diverting stoma, patients were tested for the colonic transit time (CTT) using radiopaque markers. Bowel dysfunction at 6 and 12 months after SSS was measured as the severity of fecal incontinence according to the Cleveland Clinic Incontinence Score (CCIS) and the use of an anti-diarrheal drug. A short CTT for the left colonic segment was significantly associated with the high CCIS and use of an antidiarrheal agent at 6 months after sphincter preservation. However, the CTT didn't correlate with the CCIS at 12 months after SSS. Rather, age and surgical method demonstrated a significant association. Colonic dysmotility after SSS appears to intensify fecal incontinence for a relatively short period. Its impact abates within a year.

Prognostic Impact of Ventral Versus Dorsal Tumor Location After Total Mesorectal Excision of Rectal Cancer

BACKGROUND

Multidisciplinary treatment of rectal cancer, including neoadjuvant treatment, total mesorectal excision, and adjuvant chemotherapy, have improved oncological outcome. Preoperative radiation therapy is advocated by national and international guidelines in all patients with AJCC stage II and III rectal cancer. Although this treatment reduces local recurrence rates with no effect on overall survival, there are possible short- and long-term side effects of radiation exposure, so patients should be carefully selected for neoadjuvant radiation therapy.

METHODS

We analyzed whether ventral or dorsal tumor location affects local recurrence rates following radical rectal resection. Patients who underwent radical rectal resection for mid or low rectal cancer in our department between October 2001 and December 2013 were included. Prognostic indicators for local recurrence were analyzed using univariate and multivariate analyses.

RESULTS

Overall, 480 patients met the inclusion criteria. Univariate analysis identified surgical procedure (hazard ratio [HR] 1.9, p = 0.006), ventral tumor location (HR 3.8, p < 0.001), and a pathologic circumferential resection margin (pCRM) (HR 9.3, p < 0.001) as prognostic factors of local recurrence. Multivariate analysis revealed tumor location (HR 3.5, p < 0.001) and pCRM (HR 6.0, p = 0.002) as independent factors for local recurrence. Neoadjuvant treatment of AJCC stage II and III tumors reduced the local recurrence rate at ventral but not at dorsal tumor locations (p < 0.001).

CONCLUSIONS

Ventral versus dorsal tumor location is an independent prognostic factor for local recurrence. Tumor location may aid in patient selection for neoadjuvant treatment.

Excluding the ischiorectal fossa irradiation during neoadjuvant chemoradiotherapy with intensity-modulated radiotherapy followed by abdominoperineal resection decreases perineal complications in patients with lower rectal cancer

BACKGROUND

The aim of this study was to explore the impact of including or excluding the ischiorectal fossa (IRF) within the clinical target volume during neoadjuvant chemoradiotherapy (NCRT) using intensity modulated radiotherapy, in locally advanced lower rectal cancer (LALRC).

METHODS

We retrospectively analysed the data of 220 LALRC patients who received NCRT followed by abdominoperineal resection between January 2009 and January 2015. Six patients were excluded because of loss to follow-up, 90 patients received IRF irradiation (IRF group) while 124 patients did not (NIRF group). Survival, patterns of recurrence, and treatment toxicities were compared between the two groups.

RESULTS

Overall, patient/treatment variables were well balanced except for surgical technique. Perineal wound complications in the IRF and NIRF groups, were 40.0 and 24.2%, respectively (p = 0.010); corresponding 3-year perineal recurrence rates, local recurrence free survival, overall survival, and distant relapse free survival were 4.4% vs. 2.4% (p = 0.670), 88.1% vs. 95.0% (p = 0.079), 82.6% vs. 88.4% (p = 0.087), and 61.9% vs. 81.0% (p = 0.026), respectively. Multivariate analyses demonstrated the following factors to be significantly related to perineal wound complications: irradiation of the IRF (odds ratio [OR] 2.892, p = 0.002), anaemia (OR 3.776, p = 0.010), operation duration > 180 min (OR 2.486, p = 0.007), and interval between radiotherapy and surgery > 8 weeks (OR 2.400, p = 0.010).

CONCLUSIONS

Exclusion of the IRF from the clinical target volume during NCRT using intensity-modulated radiotherapy in LALRC could lower the incidence of perineal wound complications after abdominoperineal resection, without compromising oncological outcomes.

Preoperative chemoradiotherapy creates an opportunity to perform sphincter preserving resection for low-lying locally advanced rectal cancer based on an oncologic outcome study

Low-lying locally advanced rectal cancer (LARC) after preoperative chemoradiotherapy (CRT) can be surgically removed by either abdominperineal resection (APR) or sphincter preserving resection (SPR). This retrospective cohort study of 251 consecutive patients with low lying LARC who underwent CRT followed by radical surgery in a single institute, between March 2003 and November 2012, aimed to compare the oncological benefits between the two groups. 3-year disease free survival (DFS), overall survival (OS), cumulative incidence of recurrence and postoperative complications were compared between the two approaches. With median follow-up of 48.6 months, SPR group had higher 3-year DFS rate (86.4% vs 73.6%, P=0.023) and lower incidence of distant recurrence (12.0% vs 23.7%, P=0.026). The postoperative complications, incidence of local recurrence and the 3-year OS were comparable between the two groups. Pathologic T and N stage were the independent predictors for 3-year DFS (P=0.020 and P<0.001). In conclusion, our study suggest that low-lying LARC patients with a significant response to preoperative CRT can benefit from the advantage of SPR in preserving the anal sphincter function without compromising their oncologic outcome.

Short-term Outcomes of an Extralevator Abdominoperineal Resection in the Prone Position Compared With a Conventional Abdominoperineal Resection for Advanced Low Rectal Cancer: The Early Experience at a Single Institution

Purpose

This study compared the perioperative and pathologic outcomes between an extralevator abdominoperineal resection (APR) in the prone position and a conventional APR.

Methods

Between September 2011 and March 2014, an extralevator APR in the prone position was performed on 13 patients with rectal cancer and a conventional APR on 26 such patients. Patients' demographics and perioperative and pathologic outcomes were obtained from the colorectal cancer database and electronic medical charts.

Results

Age and preoperative carcinoembryonic antigen (CEA) level were significantly different between the conventional and the extralevator APR in the prone position (median age, 65 years vs. 55 years [P = 0.001]; median preoperative CEA level, 4.94 ng/mL vs. 1.81 ng/mL [P = 0.011]). For perioperative outcomes, 1 (3.8%) intraoperative bowel perforation occurred in the conventional APR group and 2 (15.3%) in the extralevator APR group. In the conventional and extralevator APR groups, 12 (46.2%) and 6 patients (46.2%) had postoperative complications, and 8 (66.7%) and 2 patients (33.4%) had major complications (Clavien-Dindo III/IV), respectively. The circumferential resection margin involvement rate was higher in the extralevator APR group compared with the conventional APR group (3 of 13 [23.1%] vs. 3 of 26 [11.5%]).

Conclusion

The extralevator APR in the prone position for patients with advanced low rectal cancer has no advantages in perioperative and pathologic outcomes over a conventional APR for such patients. However, through early experience with a new surgical technique, we identified various reasons for the lack of favorable outcomes and expect sufficient experience to produce better peri- or postoperative outcomes.

Circumferential resection margin positivity after preoperative chemoradiotherapy based on magnetic resonance imaging for locally advanced rectal cancer: implication of boost radiotherapy to the involved mesorectal fascia

OBJECTIVE

To identify patients who are at a higher risk of pathologic circumferential resection margin involvement using preoperative magnetic resonance imaging.

METHODS

Between October 2008 and November 2012, 165 patients with locally advanced rectal cancer (cT4 or cT3 with <2 mm distance from tumour to mesorectal fascia) who received preoperative chemoradiotherapy were analysed. The morphologic patterns on post-chemoradiotherapy magnetic resonance imaging were categorized into five patterns from Pattern A (most-likely negative pathologic circumferential resection margin) to Pattern E (most-likely positive pathologic circumferential resection margin). In addition, the location of mesorectal fascia involvement was classified as lateral, posterior and anterior. The diagnostic accuracy of the morphologic criteria was calculated using receiver operating characteristic curve analysis.

RESULTS

Pathologic circumferential resection margin involvement was identified in 17 patients (10.3%). The diagnostic accuracy of predicting pathologic circumferential resection margin involvement was 0.73 using the five-scale magnetic resonance imaging pattern. The sensitivity, specificity, positive predictive value and negative predictive value for predicting pathologic circumferential resection margin involvement were 76.5, 65.5, 20.3 and 96.0%, respectively, when cut-off was set between Patterns C and D. On multivariate logistic regression, the magnetic resonance imaging patterns D and E (P= 0.005) and posterior or lateral mesorectal fascia involvement (P= 0.017) were independently associated with increased probability of pathologic circumferential resection margin involvement. The rate of pathologic circumferential resection margin involvement was 30.0% when the patient had Pattern D or E with posterior or lateral mesorectal fascia involvement.

CONCLUSIONS

Patients who are at a higher risk of pathologic circumferential resection margin involvement can be identified using preoperative magnetic resonance imaging although the predictability is moderate.

Laparoscopic vs open abdominoperineal resection in the multimodality management of low rectal cancers

AIM

To evaluate the safety and feasibility of laparoscopic abdominoperineal resection compared with the open procedure in multimodality management of rectal cancer.

METHODS

A total of 106 rectal cancer patients who underwent open abdominoperineal resection (OAPR) were matched with 106 patients who underwent laparoscopic abdominoperineal resection (LAPR) in a 1 to 1 fashion, between 2009 and 2013 at Fudan University Shanghai Cancer Center. Propensity score matching was carried out based on age, gender, pathological staging of the disease and administration of neoadjuvant chemoradiation. Data regarding preoperative staging, surgical technique, pathological results, postoperative recovery and complications were reviewed and compared between the LAPR and OAPR groups. Perineal closure around the stoma and pelvic floor reconstruction were performed only in OAPR, not in LAPR. Therefore, abdominoperineal resection procedure-specific surgical complications including parastomal hernia and perineal wound complications were compared between the open and laparoscopic procedure. Regular surveillance of the two cohorts was carried out to gather prognostic data. Disease-free survival was analyzed using Kaplan-Meier estimate and log-rank test. Subgroup analysis was performed in patients with locally advanced disease treated with preoperative chemoradiation followed by surgical resection.

RESULTS

No significant difference was found between the LAPR group and the OAPR group in terms of clinicopathological features. The operation time (180.8 ± 47.8 min vs 172.1 ± 49.2 min, P = 0.190), operative blood loss (93.9 ± 60.0 mL vs 88.4 ± 55.2 mL, P = 0.494), total number of retrieved lymph nodes (12.9 ± 6.9 vs 12.9 ± 5.4, P = 0.974), surgical complications (12.3% vs 15.1%, P = 0.549) and pathological characteristics were comparable between the LAPR and OAPR group, respectively. Compared with OAPR patients, LAPR patients showed significantly shorter postoperative analgesia (2.4 ± 0.7 d vs 2.7 ± 0.6 d, P < 0.001), earlier first flatus (57.3 ± 7.9 h vs 63.5 ± 9.2 h, P < 0.001), shorter urinary drainage time (6.5 ± 3.4 d vs 7.8 ± 1.3 d, P < 0.001), and shorter postoperative admission (11.2 ± 4.7 d vs 12.6 ± 4.0 d, P = 0.014). With regard to APR-specific complications (perineal wound complications and parastomal hernia), there were no significant differences between the two groups. Similar results were found in the 26 pairs of patients administered neoadjuvant chemoradiation in subgroup analysis. During the follow-up period, no port site recurrences were observed.

CONCLUSION

Laparoscopic abdominoperineal resection for multidisciplinary management of rectal cancer is safe, and is associated with earlier recovery and shorter admission time in combination with neoadjuvant chemoradiation.

Systematic review and meta-analysis of the accuracy of MRI and endorectal ultrasound in the restaging and response assessment of rectal cancer following neoadjuvant therapy

AIM

Restaging imaging by MRI or endorectal ultrasound (ERUS) following neoadjuvant chemoradiotherapy is not routinely performed, but the assessment of response is becoming increasingly important to facilitate individualization of management.

METHOD

A search of the MEDLINE and Scopus databases was performed for studies that evaluated the accuracy of restaging of rectal cancer following neoadjuvant chemoradiotherapy with MRI or ERUS against the histopathological outcome. A systematic review of selected studies was performed. The methodological quality of studies that qualified for meta-analysis was critically assessed to identify studies suitable for inclusion in the meta-analysis.

RESULTS

Sixty-three articles were included in the systematic review. Twelve restaging MRI studies and 18 restaging ERUS studies were eligible for meta-analysis of T-stage restaging accuracy. Overall, ERUS T-stage restaging accuracy (mean [95% CI]: 65% [56-72%]) was nonsignificantly higher than MRI T-stage accuracy (52% [44-59%]). Restaging MRI is accurate at excluding circumferential resection margin involvement. Restaging MRI and ERUS were equivalent for prediction of nodal status: the accuracy of both investigations was 72% with over-staging and under-staging occurring in 10-15%.

CONCLUSION

The heterogeneity amongst restaging studies is high, limiting conclusive findings regarding their accuracies. The accuracy of restaging imaging is different for different pathological T stages and highest for T3 tumours. Morphological assessment of T- or N-stage by MRI or ERUS is currently not accurate or consistent enough for clinical application. Restaging MRI appears to have a role in excluding circumferential resection margin involvement.

Therapeutic results of abdominoperineal resection in the prone jackknife position for T3-4 low rectal cancers

OBJECTIVE

To evaluate the therapeutic results of abdominoperineal resections in the prone jackknife position for T3-4 low rectal cancers.

METHODS

From January 2002 to January 2011, 536 patients with T3-T4 low rectal cancer underwent abdominoperineal resection. Two hundred forty-three were treated in the Lloyd-Davies position and 293 in the prone jackknife position. Clinicopathological data and survival of the two groups were analyzed retrospectively.

RESULTS

Abdominoperineal resections in the prone jackknife position group were associated with significantly less blood loss (124 ± 50.68 vs 210.67 ± 83.32 ml, P < 0.001) and shorter operation times (3.10 ± 1.08 vs 3.82 ± 1.43 h, p = 0.010) than those in Lloyd-Davies position group. The total local recurrence rate is 8.4 % (45/536). The local recurrence rate in the prone jackknife position group was significantly lower than in the Lloyd-Davies position group (5.5 vs 11.9 %, P < 0.001). By multivariate regression analysis, depth of tumor invasion (P = 0.032), CRM (P < 0.001), and position (P = 0.015) were found to be independent risk factors for local recurrence. Multivariate Cox regression survival analysis, lymph node metastasis, and CRM (P < 0.001) were proven to be the major independent prognostic factors for T3-T4 low rectal cancer patients.

CONCLUSIONS

Abdominoperineal resection in the prone jackknife position for T3-T4 low rectal cancers is feasible and has a lower local recurrence.

Better operative outcomes achieved with the prone jackknife vs. lithotomy position during abdominoperineal resection in patients with low rectal cancer

Background

Lithotomy (LT) and prone jackknife positions (PJ) are routinely used for abdominoperineal resection (APR). The present study compared the clinical, pathological, and oncological outcomes of PJ-APR vs. LT-APR in low rectal cancer patients in order to confirm which position will provide more benefits to patients undergoing APR.

Methods

This is a retrospective study of consecutive patients with low rectal cancer who underwent curative APR between January 2002 and December 2011. Patients were matched 1:2 (PJ-APR = 74 and LT-APR = 37 patients) based on gender and age. Perioperative data, postoperative outcomes, and survival were compared between the two approaches.

Results

Hospital stay was shorter with PJ-APR compared with LT-APR (P < 0.05). Compared with LT-APR, duration of anesthesia (234 ± 50.8 vs. 291 ± 69 min, P = 0.022) and surgery (183 ± 44.8 vs. 234 ± 60 min, P = 0.016) was shorter with PJ-APR, and estimated blood losses were smaller (549 ± 218 vs. 674 ± 350 mL, P < 0.001). Blood transfusions were required in 37.8% of LT-APR patients and in 8.1% of PJ-APR patients (P < 0.001). There was no difference in the distribution of N stages (P = 0.27). Median follow-up was 47.1 (13.6–129.7) months. Postoperative complications were reported by fewer patients after PJ-APR compared with LT-APR (14.9% vs. 32.4%, P = 0.030). There were no significant differences in overall survival, disease-free survival, local recurrence, and distant metastasis (P > 0.05).

Conclusions

The PJ position provided a better exposure for low rectal cancer and had a lower operative risk and complication rates than LT-APR. However, there was no difference in rectal cancer prognosis between the two approaches. PJ-APR might be a better choice for patients with low rectal cancer.

Surgical strategy for low rectal cancers

The two goals of surgery for lower rectal cancer surgery are to obtain clear "curative" margins and to limit post-surgical functional disorders. The question of whether or not to preserve the anal sphincter lies at the center of the therapeutic choice. Histologically, tumor-free distal and circumferential margins of>1mm allow a favorable oncologic outcome. Whether such margins can be obtained depends of TNM staging, tumor location, response to chemoradiotherapy and type of surgical procedure. The technique of intersphincteric resection relies on these narrow margins to spare the sphincter. This procedure provides satisfactory oncologic outcome with a rate of circumferential margin involvement ranging from 5% to 11%, while good continence is maintained in half of the patients. The extralevator abdominoperineal resection provides good oncologic results, however this procedure requires a permanent colostomy. A permanent colostomy alters several domains of quality of life when located at the classical abdominal site but not when brought out at the perineal site as a perineal colostomy.

Robotic interface for transabdominal division of the levators and pelvic floor reconstruction in abdominoperineal resection: a case report and technical description

BACKGROUND

Extralevator abdominoperineal resection (APR) in a prone jackknife position was developed to avoid a positive circumferential resection margin, and its application led to lower rates of local recurrence. The paper describes a technique of robotic extralevator APR with transabdominal levator division followed by pelvic floor reconstruction with bilayered composite mesh.

METHODS

A 42-year-old man with low rectal cancer required APR that was performed in a lithotomy position with transabdominal division of the levators. After the perineal phase, the robot was redocked and a bilayered composite mesh was sutured to the pelvic inlet using robotic needle drivers.

RESULTS

The specimen had a cylindrical shape, and there was no surgical waist or perforation. Histology revealed a ypT2N0 tumor without circumferential margin involvement.

CONCLUSIONS

The robotic interface can aid in APR by accurately transecting the levators from the top. Additionally, it allows suturing of mesh around the pelvic inlet to prevent perineal hernias. Copyright © 2014 John Wiley & Sons, Ltd.

A study of laparoscopic extraperitoneal sigmoid colostomy after abdomino-perineal resection for rectal cancer

OBJECTIVE

To established a procedure for laparoscopic extraperitoneal ostomy after abdomino-perineal resection (APR) and study safety aspects and complications.

METHOD

From July 2011 to July 2012, 36 patients with low rectal cancer undergoing APR were included in the study and divided into extraperitoneal ostomy group (n = 18) and intraperitoneal ostomy group (n = 18). Short- and long-term complications were compared between the two groups. All patients were followed up and the median duration was 17 months (range: 12-24).

RESULTS

The rates of short-term complication related to colostomies were comparable between the two groups, except the rate for stoma edema was higher in the extraperitoneal group (33.3% vs 0%; P = 0.008). In the intraperitoneal ostomy group, two patients developed stoma prolapse, one had stoma stenosis, and two had parastomal hernia. In contrast, no long-term complications related to colostomies occurred in the extraperitoneal ostomy group. The rate of long-term complication was lower in the extraperitoneal ostomy group (0% vs 22.2%; P = 0.036).

CONCLUSION

The laparoscopic extraperitoneal ostomy is a relatively simple and safe procedure, with fewer long-term complications related to colostomy. However the follow-up period was not too long and needs to be extended.

Analysis of bevacizumab-based preoperative radiochemotherapy in patients with locally advanced rectal cancer on surgery-associated spectrum of complications

BACKGROUND

Preoperative radiochemotherapy (RCT) is a standard of care for patients with locally advanced rectal cancer (LARC; stages II and III). Results of our phase II study (BevXelOx-RT) have shown that this regimen is feasible but without a significant improvement of pathological complete response. Whether preoperatively administered bevacizumab, due to its specific toxicity profile, leads to increased rates of surgical complications is currently a subject for debate. This analysis focusses on the surgery-associated spectrum of complications.

METHODS

Data from 62 patients with rectal cancer (uT3-4; N0/1, M0) of the phase II trial were analyzed. Patients received radiotherapy (50.4/1.8 Gy fractions), simultaneous bevacizumab 5 mg/kg (d1, d15, d29), and capecitabine 825 mg/m(2) twice daily (d1-14, d22-35), oxaliplatin 50 mg/m(2) (d1, d8, d22, d29). Four to six weeks after RCT, surgical resection was performed.

RESULTS

Overall, 69/69 patients underwent surgery, and 66 (95.7 %) patients had R0 resection. Surgery was mainly conducted (in 66 %) by highly experienced surgeons (>20 resections of rectal cancer/year) with differences between the institutions due to the operative procedures but without effects on the rate of R0 resection or complications. The average duration of surgery was 239 min (±10). Frequency of multivisceral resections (11 %), intraoperative (8 %) and postoperative (43 %) complications were all in the expected range. In particular, we did not observe an increased rate of postoperative bleedings (3 %). The postoperative mortality rate was 0 %.

CONCLUSIONS

Quantity and the kind of surgery-associated spectrum of complications followed by a preoperative bevacizumab-containing RCT regimen in patients with LARC were in line with comparable trials of bevacizumab-based approaches.

Modern multidisciplinary treatment of rectal cancer based on staging with magnetic resonance imaging leads to excellent local control, but distant control remains a challenge

AIM

The purpose of this multicenter cohort study was to evaluate whether a differentiated treatment of primary rectal cancer based on magnetic resonance imaging (MRI) can reduce the number of incomplete resections and local recurrences and improve recurrence-free and overall survival.

METHODS

From February 2003 until January 2008, 296 patients with rectal cancer underwent preoperative MRI using a lymph node specific contrast agent to predict circumferential resection margin (CRM), T- and N-stage. Based on expert reading of the MRI, patients were stratified in: (a) low risk for local recurrence (CRM>2mm and N0 status), (b) intermediate risk and (c) high risk (close/involved CRM, N2 status or distal tumours). Mainly based on this MRI risk assessment patients were treated with (a) surgery only (TME or local excision), (b) preoperative 5 × 5 Gy+TME and (c) a long course of chemoradiation therapy followed by surgery after a 6-8 week interval.

RESULTS

Overall 228 patients underwent treatment with curative intent: 49 with surgery only, 86 with 5 × 5 Gy and surgery and 93 with chemoradiation and surgery. The number of complete resections (margin>1mm) was 218 (95.6%). At a median follow-up of 41 months the three-year local recurrence rate, disease-free survival rate and overall survival rate is 2.2%, 80% and 84.5%, respectively.

CONCLUSION

With a differentiated multimodality treatment based on dedicated preoperative MR imaging, local recurrence is no longer the main problem in rectal cancer treatment. The new challenges are early diagnosis and treatment, reducing morbidity of treatment and preferably prevention of metastatic disease.

Update and debate issues in surgical treatment of middle and low rectal cancer

Based on a review of the literature, this paper provides an update on surgical treatment of middle and low rectal cancer and discusses issues of debate surrounding that treatment. The main goal of the surgical treatment of rectal cancer is radical resection of the tumor and surrounding lymphatic tissue. Local excision of early rectal cancer can be another treatment option, in which the patient can avoid possible complications related to radical surgery. Neoadjuvant chemoradiation therapy (CRT) has been recommended for patients with cT3-4N0 or any T N+ rectal cancer because CRT shows better local control and less toxicity than adjuvant CRT. However, recent clinical trials showed promising results for local excision after neoadjuvant CRT in selected patients with low rectal cancer. In addition, the "wait and see" concept is another modality that has been reported for the management of tumors that show complete clinical remission after neoadjuvant CRT. Although radical surgery for middle and low rectal cancer is the cornerstone therapy, an ultralow anterior resection with or without intersphincteric resection (ISR) has become an alternative standard surgical method for selected patients. Many studies have reported on the oncological safety of the ISR, but few of them have addressed the issue the functional outcome. Furthermore, an abdominoperineal resection (APR) has problems with high rates of tumor perforations and positive circumferential resection margins, and those factors have contributed to its having a high rate of local recurrence and a poor survival rate for rectal cancer compared with sphincter-saving procedures. Recently, great efforts have been made to reduce these problems, and the total levator excision or the extended APR concept has emerged. Surgical management for low rectal cancer should aim to radically excise the tumor and to preserve as much of the sphincter function as possible by using multidisciplinary approaches. However, further prospective clinical trials are needed for tailored treatment of rectal cancer patients.

Prognostic significance of lymph node ratio in patients undergoing abdominoperineal resection of rectum

BACKGROUND

Lymph node ratio (LNR) has been shown to be an independent prognostic factor in stage III colorectal cancer. Abdominoperineal resection (APR) of rectum is historically associated with poorer oncological outcomes compared to other colorectal resections, and significance of LNR in this group of patients has not been studied.

OBJECTIVE

Our aim was to determine impact of LNR on oncological outcomes in a series of patients with rectal cancers undergoing APR.

PATIENTS AND METHODS

A series of patients who had undergone APR and had lymph node metastasis were identified from a prospectively maintained clinical, histopathological and radiological database. LNR was calculated, and Cox regression was used to determine the impact of factors affecting local recurrence, distal metastases and overall survival.

RESULTS

Fifty-eight (42 males) patients were identified to have rectal cancer with lymph node involvement. LNR was an independent predictor of distal metastasis and overall survival at cutoff levels of 0.17, 0.41 and 0.69.

CONCLUSION

Lymph node ratio is an independent predictor of survival outcomes in patients with stage III tumours undergoing APR. LNR may help improve stratification of this group of patients.

Imaging-guided curative surgical resection of pancreatic cancer in a xenograft mouse model

Pancreatic cancer is the fourth leading cause of cancer related deaths in North America. The poor survival statistics are due to the fact that there are no reliable tests for early diagnosis and no effective therapies once metastasis has occurred. Surgical resection is the only curative treatment for pancreatic cancer; however, only less than 15% of the patients are eligible for surgery at diagnosis. New therapies are urgently needed for this malignant disease. And combinational therapy including surgery, chemotherapy and molecular targeted therapy may further improve the efficacy of individual therapies. However, a reliable mouse model which mimics the human disease and can be used for testing the surgical treatment and surgery-based combinational therapy is not available. In this study, we have established a mouse model for curative surgical resection of pancreatic cancer. Human pancreatic cancer cells were used to create orthotopic xenografts in nude mice, distal pancreatectomy was performed using imaging-guided technology to remove the pancreatic tumors, and sham surgery was performed in the control group. All mice survived the operation and no complication was observed. Surgical resection at early stage improved the survival rate and quality of life of the mice compared with the sham surgery and surgical resection at the late stage. If combined with other therapies such as chemotherapy and molecular targeted therapy, it could further improve the outcome of pancreatic cancer. This mouse model is a useful tool to study the surgical therapy and the tumor recurrence of pancreatic cancer, and could potentially impact the therapeutic choices for this deadly disease.

Evaluation of the impact of implementing the prone jackknife position for the perineal phase of abdominoperineal excision of the rectum

BACKGROUND

Abdominoperineal excision of rectum has been associated with poor oncological specimens and high local recurrence rates in comparison with restorative surgery. The role of recent changes in operative position has yet to be evaluated.

OBJECTIVES

This study aimed to determine whether a change in the perineal phase from the Lloyd-Davies position to the prone jackknife position might improve excision margins and oncological outcomes.

METHODS

A single-institution review of a prospectively maintained database comparing the quality of excision and oncological outcomes after abdominoperineal excision in conventional and prone position was performed. Consecutive abdominoperineal excisions performed for adenocarcinoma of the rectum between January 1999 and April 2008 were included.

RESULTS

Abdominoperineal excision cases were assessed including 63 in the Lloyd-Davies position and 58 in the prone jackknife position. The 5-year local recurrence rate was 5% in the prone jackknife group in comparison with 23% in the Lloyd-Davies group (p = 0.03) by life table analysis. For local recurrence, the most significant and independent risk factors were a favorable effect of having the patient in the prone jackknife position for the perineal phase of abdominoperineal excision (HR 0.2; 95% CI 0.04-0.81) and, unfavorably, a positive circumferential resection margin (HR 7.1; 95% CI 2.4-20). Lymph node involvement (N2) was an independent risk factor for overall survival (HR 4.6; 95% CI 2.1-9.5) and relapse of disease (HR 4.0; 95% CI 0.7-9.4).

LIMITATIONS

This study has some limitations because it is a retrospective review of a prospective database.

CONCLUSION

These data suggest that the rate of local recurrence after abdominoperineal excision may be lowered by adaptation of the prone jackknife position.

Extended abdominoperineal excision vs. standard abdominoperineal excision in rectal cancer--a systematic overview

BACKGROUND

After introduction of total mesorectal excision (TME) as the gold standard for rectal cancer surgery, oncologic results appeared to be inferior for abdominoperineal excision (APE) as compared to anterior resection. This has been attributed to the technique of standard APE creating a waist at the level of the tumor-bearing segment. This systematic review investigates outcome of both standard and extended techniques of APE regarding inadvertent bowel perforation, circumferential margin (CRM) involvement, and local recurrence.

METHODS

A literature search was performed to identify all articles reporting on APE after the introduction of TME using Medline, Ovid, and Embase. Extended APE was defined as operations that resected the levator ani muscle close to its origin. All other techniques were taken to be standard. Studies so identified were evaluated using a validated instrument for assessing nonrandomized studies. Rates for perforation, CRM involvement, and local recurrence were compared using chi-square statistics.

RESULTS

In the extended group, 1,097 patients, and in the standard group, 4,147 patients could be pooled for statistical analysis. The rate of inadvertent bowel perforation and the rate of CRM involvement for extended vs. standard APE was 4.1% vs. 10.4% (relative risk reduction 60.6%, p = 0.004) and 9.6% vs. 15.4% (relative risk reduction 37.7%, p = 0.022), respectively. The local recurrence rate was 6.6% vs. 11.9% (relative risk reduction 44.5%, p < 0.001) for the two groups.

CONCLUSION

This systematic review suggests that extended techniques of APE result in superior oncologic outcome as compared to standard techniques.

β-catenin and Her2/neu expression in rectal cancer: association with histomorphological response to neoadjuvant therapy and prognosis

BACKGROUND

Neoadjuvant treatment strategies have been developed to improve survival of patients with advanced rectal cancer. Since mainly patients with major histopathological response benefit from this therapy, predictive and prognostic markers are needed. We examined the association of β-catenin and Her2/neu protein expression with histopathologic response to neoadjuvant radiochemotherapy and prognosis in patients with locally advanced rectal cancer.

METHODS

Fifty-four patients (33 male; 21 female; median age 60.4 years) with locally advanced rectal cancer were included in this study. All patients received a neoadjuvant radiochemotherapy (50.4 Gy, 5-FU) followed by surgical resection. Histomorphologic regression was evaluated by Dworak and Cologne staging system. Major response was defined by Dworak classification when resected specimens contained less than 50% vital tumor cells (n = 14) and by Cologne grading system when resected specimens contained less than 10% vital tumor cells (n = 15). Intratumoral β-catenin (nuclear/membranous) and Her2/neu (cytoplasmatic/membranous) expression was determined by immunohistochemistry in pre- and post-therapeutic specimens and correlated with clinicopathologic parameters.

RESULTS

A significant association was detected between pre-therapeutic membranous β-catenin levels and response: patients with a lower β-catenin protein expression showed significantly more often a major response compared with patients having high intratumoral protein levels (p = 0.011). In addition, patients with a higher Her2/neu protein expression showed a significant survival benefit compared with patients having low intratumoral protein levels (5-year survival rate: 81% vs. low 41%; p = 0.023).

CONCLUSIONS

The pre-therapeutic β-catenin and Her2/neu protein expression seem to be valuable predictive and prognostic markers in the multimodality treatment of advanced rectal cancer.

The current abdominoperineal resection: oncological problems and surgical modifications for low rectal cancer

Abdominoperineal resection is the one of the oldest surgical procedures for rectal cancer. Outcome after abdominoperineal resection for rectal carcinoma is not as good as anterior resection as the risk of local recurrence is higher and survival is poorer. During abdominoperineal resection, the rate of rectal perforation is high and the circumferential margin is often involved. Recently the concept of cylindrical abdominoperineal resection has been reintroduced. It allows a large excision and the initial results are encouraging. The purpose of this article was to analyse the oncological results of abdominoperineal resection and to develop the potential technical modifications of the procedure.

Randomized trial of postoperative adjuvant therapy in Stage II and III rectal cancer to define the optimal sequence of chemotherapy and radiotherapy: 10-year follow-up

PURPOSE

To determine the optimal sequence of postoperative adjuvant chemotherapy and radiotherapy in patients with Stage II or III rectal cancer.

METHODS AND MATERIALS

A total of 308 patients were randomized to early (n = 155) or late (n = 153) radiotherapy (RT). Treatment included eight cycles of chemotherapy, consisting of fluorouracil 375 mg/m(2)/day and leucovorin 20 mg/m(2)/day, at 4-week intervals, and pelvic radiotherapy of 45 Gy in 25 fractions. Radiotherapy started on Day 1 of the first chemotherapy cycle in the early RT arm and on Day 1 of the third chemotherapy cycle in the late RT arm.

RESULTS

At a median follow-up of 121 months for surviving patients, disease-free survival (DFS) at 10 years was not statistically significantly different between the early and late RT arms (71% vs. 63%; p = 0.162). A total of 36 patients (26.7%) in the early RT arm and 49 (35.3%) in the late RT arm experienced recurrence (p = 0.151). Overall survival did not differ significantly between the two treatment groups. However, in patients who underwent abdominoperineal resection, the DFS rate at 10 years was significantly greater in the early RT arm than in the late RT arm (63% vs. 40%; p = 0.043).

CONCLUSIONS

After the long-term follow-up duration, this study failed to show a statistically significant DFS advantage for early radiotherapy with concurrent chemotherapy after resection of Stage II and III rectal cancer. Our results, however, suggest that if neoadjuvant chemoradiation is not given before surgery, then early postoperative chemoradiation should be considered for patients requiring an abdominoperineal resection.

Patterns of response after preoperative intensity-modulated radiation therapy and capecitabine/oxaliplatin in rectal cancer: is there still a place for ecoendoscopic ultrasound?

PURPOSE

The main goals of preoperative chemoradiotherapy (CHRT) in rectal cancer are to achieve pathological response and to ensure tumor control with functional surgery when possible. Assessment of the concordance between clinical and pathological responses is necessary to make decisions regarding alternative conservative procedures. The present study evaluates the patterns of response after a preoperative CHRT regimen, and the value of endoscopic ultrasound (EUS) in assessing response.

METHODS AND MATERIALS

A total of 51 EUS-staged T3 to T4 and/or N0 to N+ rectal cancer patients received preoperative CHRT (intensity-modulated radiation therapy and capecitabine/oxaliplatin (XELOX) followed by radical resection. Clinical response was assesed by EUS. Rates of pathological tumor regression grade (TRG) and lymph node (LN) involvement were determined in the surgical specimen. Clinical and pathological responses were compared, and the accuracy of EUS in assessing response was calculated.

RESULTS

Twenty-four patients (45%) achieved a major pathological response (complete or >95% pathological response (TRG 3+/4)). Sensitivity, specificity, negative predictive value, and positive predictive value of EUS in predicting pathological T response after preoperative CHRT were 77.8%, 37.5%, 60%, and 58%, respectively. The EUS sensitivity, specificity, negative predictive value, and positive predictive value for nodal staging were 44%, 88%, 88%, and 44%, respectively. Furthermore, EUS after CHRT accurately predicted the absence of LN involvement in 7 of 7 patients (100%) with major pathological response of the primary tumor.

CONCLUSION

Preoperative IMRT with concomitant XELOX induces favorable rates of major pathological response. EUS has a limited ability to predict primary tumor response after preoperative CHRT, but it is useful for accurately determining LN status. EUS may have a potential value in identifying patients with a very low risk of LN involvement in association with a good pathological response as potential candidates for conservative local surgical protocols.