Erectile Dysfunction Is Common after Rectal Cancer Surgery: A Cohort Study

Erectile dysfunction is a known late complication following surgery for rectal cancer. We aimed to determine the prevalence of erectile dysfunction after rectal cancer surgery and characterize it. This was a prospective observational cohort study. Data from men after surgery for rectal cancer were collected between October 2019 and April 2023. The primary outcome was the prevalence of erectile dysfunction following surgery based on the International Index of Erectile Function questionnaires, IIEF-5 and 15. Secondary outcomes were prevalence in subgroups and self-perceived erectile function. In total, 101 patients agreed to participate, while 67 patients (67%) responded after a median six-month follow-up after surgery. Based on IIEF-15, 84% of the patients had erectile dysfunction. For subgroups, 74% of patients who underwent robot-assisted surgery had erectile dysfunction, whereas all patients who underwent either laparoscopic or open surgery had erectile dysfunction (p = 0.031). Furthermore, half of the patients rated their self-perceived ability to obtain and keep an erection as very low. In conclusion, in our cohort, erectile dysfunction was common after rectal cancer surgery, and half of the patients were unconfident that they could obtain and keep an erection. Information regarding this finding should be given so that patients feel comfortable discussing therapeutic solutions if needed.

Assessing the role of anastomotic level in low anterior resection (LAR) surgery among rectal cancer patients in the development of LAR syndrome: a systematic review study

BACKGROUND

The etiology of LARS has not been elaborated on clearly. Studies have reported neoadjuvant therapy, low-lying rectal cancers, adjuvant therapy and anastomotic leakage as risk factors for the development of LARS. Anastomotic level has also been proposed as a possible risk factor; However, there have been conflicting results. This study aims to evaluate the role of the level of anastomosis as a potential risk factor for the development of LARS.

METHOD

A systematic literature search was conducted on Pubmed, Scopus, Embase, and Web of Science databases using Mesh terms and non-Mesh terms from 2012 to 2023. Original English studies conducted on rectal cancer patients reporting of anastomotic level and LARS status were included in this study. Eligible studies were assessed regarding quality control with Joanna-Briggs Institute (JBI) questionnaires.

RESULTS

A total of 396 articles were found using the research queries, and after applying selection criteria 4 articles were selected. A sample population of 808 patients were included in this study with a mean age of 61.51 years with male patients consisting 59.28% of the cases. The Mean assessment time was 15.6 months which revealed a mean prevalence of 48.89% for LAR syndrome. Regression analysis revealed significantly increased risk of LAR syndrome development due to low anastomosis level in all 4 studies with odds ratios of 5.336 (95% CI:3.197-8.907), 3.76 (95% CI: 1.34-10.61), 1.145 (95% CI: 1.141-2.149) and 2.11 (95% CI: 1.05-4.27) for low anastomoses and 4.34 (95% CI: 1.05-18.04) for ultralow anastomoses.

CONCLUSIONS

LARS is a long-term complication following surgery, leading to reduced quality of life. Low anastomosis level has been reported as a possible risk factor. All of the studies in this systematic review were associated with an increased risk of LARS development among patients with low anastomosis.

Treatment stratification and prognosis assessment using circulating tumor DNA in locally advanced rectal cancer: A systematic review and meta-analysis

BACKGROUND

Circulating tumor DNA (ctDNA) is an emerging biomarker for locally advanced rectal cancer (LARC), giving hope for stratified treatment. As the completed studies have small sample sizes and different experimental methods, systematic review and meta-analysis were performed to explore their role in predicting pathological complete response (pCR), tumor recurrence, and prognosis.

METHODS

PubMed, Embase, and the Web of Science were searched for potentially eligible studies published up to September 6, 2022. Pooled relative risk (RR) was calculated to predict pCR and tumor recurrence, and pooled hazard ratio (HR) was calculated to evaluate the prognosis of overall survival (OS), recurrence-free survival (RFS), and metastasis-free survival (MRS).

RESULTS

Twelve studies published between 2018 and 2022 included 931 patients, and 2544 serum samples were eventually included in the meta-analysis. The pooled revealed that ctDNA-negative patients were more likely to have a pCR (RR = 1.64, 95% confidence interval [CI]: 1.26-2.12). The pooled revealed that ctDNA-positive patients were at high risk of recurrence (RR = 3.37, 95% CI: 2.34-4.85) and had a poorer prognosis for OS (HR = 3.03, 95% CI: 1.86-4.95), RFS (HR = 7.08, 95% CI: 4.12-12.14), and MRS (HR = 2.77, 95% CI: 2.01-3.83).

CONCLUSION

ctDNA may be useful for stratifying treatment and assessing prognosis in patients with LARC, but its clinical application still needs to be confirmed in a prospective multicenter study with large samples.

Pelvic Intraoperative Neuromonitoring Prevents Dysfunction in Patients With Rectal Cancer: Results From a Multicenter, Randomized, Controlled Clinical Trial of a NEUROmonitoring System (NEUROS)

OBJECTIVE

This NEUROmonitoring System (NEUROS) trial assessed whether pelvic intraoperative neuromonitoring (pIONM) could improve urogenital and ano-(neo-)rectal functional outcomes in patients who underwent total mesorectal excisions (TMEs) for rectal cancer.

BACKGROUND

High-level evidence from clinical trials is required to clarify the benefits of pIONM.

METHODS

NEUROS was a 2-arm, randomized, controlled, multicenter clinical trial that included 189 patients with rectal cancer who underwent TMEs at 8 centers, from February 2013 to January 2017. TMEs were performed with pIONM (n=90) or without it (control, n=99). The groups were stratified according to neoadjuvant chemoradiotherapy and sex, with blocks of variable length. Data were analyzed according to a modified intention-to-treat protocol. The primary endpoint was a urinary function at 12 months after surgery, assessed with the International Prostate Symptom Score, a patient-reported outcome measure. Deterioration was defined as an increase of at least 5 points from the preoperative score. Secondary endpoints were sexual and anorectal functional outcomes, safety, and TME quality.

RESULTS

The intention-to-treat analysis included 171 patients. Marked urinary deterioration occurred in 22/171 (13%) patients, with significantly different incidence between groups (pIONM: n=6/82, 8%; control: n=16/89, 19%; 95% confidence interval, 12.4-94.4; P =0.0382). pIONM was associated with better sexual and ano-(neo)rectal function. At least 1 serious adverse event occurred in 36/88 (41%) in the pIONM group and 53/99 (54%) in the control group, none associated with the study treatment. The groups had similar TME quality, surgery times, intraoperative complication incidence, and postoperative mortality.

CONCLUSION

pIONM is safe and has the potential to improve functional outcomes in rectal cancer patients undergoing TME.

ctDNA on liquid biopsy for predicting response and prognosis in locally advanced rectal cancer: A systematic review

BACKGROUND

The management of locally advanced rectal cancer (LARC) requires a multidisciplinary approach, with an increasing interest for non-operative strategies. Liquid biopsy for obtaining circulating tumor DNA (ctDNA) can provide information on neoadjuvant chemoradiotherapy (nCRT) pathological response and cancer-specific prognosis, and therefore might be a promising guide for these treatments.

METHODS

A systematic review of the studies available in literature has been performed to assess the role of ctDNA as a predictive and prognostic biomarker in LARC patients.

RESULTS

We retrieved 21 publications, of which 17 full-text articles and 4 abstracts. Results have been labelled into two groups: predictive and prognostic. Data about the usefulness of liquid biopsy in this setting is still inconclusive. However, baseline higher levels of longer fragments of cell-free DNA and integrity index, tumor-specific mutations and certain methylated genes could predict non-responders. Also, undetectable baseline ctDNA and decrease of common rectal cancer mutations throughout treatment (dynamic monitoring) were predictive factors of pathological complete response. The continuous detection of ctDNA in different timepoints of treatment (minimal residual disease) was consistently associated with worse prognosis.

CONCLUSIONS

ctDNA is a promising biomarker that could assist predicting treatment response to nCRT and prognosis in patients with LARC. The ideal methods and timings for the liquid biopsy still have to be defined.

Efficacy of Neoadjuvant Therapy in Improving Long-Term Survival of Patients with Resectable Rectal Cancer: A Meta-Analysis

BACKGROUND

The impact of neoadjuvant therapy on long-term prognosis of patients with resectable rectal cancer is currently unknown.

OBJECTIVE

This study aimed to explore the long-term prognosis of patients with resectable rectal cancer following treatment with neoadjuvant therapy.

METHODS

Four major databases (PubMed, Web of Science, Embase, Cochrane library) were searched to identify relevant articles published between January 2000 and July 2020. The main outcome indicators were the 5-year overall survival (OS) and disease-free survival (DFS).

RESULTS

The meta-analysis revealed that 5-year OS (HR: 0.88, 95% Cl: 0.83-0.93) and DFS (HR: 0.95, 95% Cl: 0.91-0.98) were higher in patients with resectable rectal cancer after receiving neoadjuvant therapy than those treated with upfront surgery. Subgroup analysis demonstrated that the long-term survival of patients in Asia and Europe could benefit from neoadjuvant therapy. The neoadjuvant short-course radiotherapy (SCRT) and neoadjuvant chemo-radiotherapy (CRT) improved the 5-year OS and DFS of patients with stage Ⅱ-Ⅲ rectal cancer and mid/low rectal cancer. Further research found that patients with stage Ⅱ only had an increase in OS, while patients with stage Ⅲ have improved 5-year OS and DFS.

CONCLUSION

Neoadjuvant therapy improved the long-term survival of patients with mid/low rectal cancer in stage Ⅱ-Ⅲ (especially stage Ⅲ). Additionally, patients in Asia and Europe seemed to be more likely to benefit from neoadjuvant therapy. For the treatment, we recommend neoadjuvant SCRT and neoadjuvant CRT for resectable rectal cancer.

The association of bowel function, participation in life activities, and quality of life in rectal cancer survivors

PURPOSE

To evaluate whether limited participation in life activities is associated with quality of life (QOL) in rectal cancer survivors, and if so, whether this association is independent of bowel function difficulties.

METHODS

We surveyed rectal cancer survivors from four healthcare systems about their QOL, bowel function, and participation in life activities. Additional demographic and clinical variables were extracted from the electronic health record. We examined independent associations between bowel function, participation in life activities, and QOL, controlling for potential confounders. We also identified factors, including ostomy status, that correlate with participation in life activities.

RESULTS

Of the 527 respondents, 52% were male, 80% were non-Hispanic white, and the mean age was 63. In fully adjusted models for all rectal cancer survivors, participation in life activities was positively associated with QOL, while bowel function was not. Bowel function retained an independent association with QOL for those who previously had an ostomy and were therefore more likely to have a low rectal anastomosis. Lower participation in life activities was correlated with lower self-reported physical and cognitive function, younger age, financial difficulty, and being non-Hispanic white.

CONCLUSIONS

Rectal cancer survivors' participation in life activities was strongly associated with QOL, even when controlling for numerous confounders, including bowel function. Identifying ways to improve participation in life activities may be critical to developing rehabilitative and other supportive interventions that optimize QOL among rectal cancer survivors.

Prospective study of sexual function and analysis of risk factors after rectal cancer surgery

AIM

The aim of this study was to assess the evolution of sexual function over time after rectal cancer surgery and to identify risk factors that may have an impact on the deterioration of postoperative function.

METHOD

This was a prospective cohort study of sexual function after rectal cancer surgery using the International Index of Erectile Function (IIEF) and Female Sexual Function Index (FSFI) preoperatively and at 6 and 12 months after surgery. Predictive factors of worsening were identified by univariate and multivariate analysis.

RESULTS

One hundred and one patients were included (56 men and 45 women). In men, the average IIEF showed decreased erectile function and intercourse satisfaction at 6 months (respectively 21.58 ± 7.18 to 16.60 ± 7.96, p = 0.002 and 10.87 ± 2.94, to 8.09 ± 4.45, p = 0.002) with recovery at 1 year. As a percentage, erectile dysfunction increased from the preoperative value to 6 months (64.5% vs 87.1%, p = 0.022) and was observed in 72% at 1 year. Patients with moderate to severe dysfunction increased from 22% preoperatively to 58% (p = 0.009) at 6 months and 44% at 1 year (p < 0.0001). Neoadjuvant chemoradiotherapy (OR 5.4, 95% CI 0.9-29.6; p = 0.041) and erectile worsening at 6 months (OR 20, 95% CI 1.6-238; p = 0.004) were independent factors for worse function at 6 or 12 months, respectively. No significant worsening of the FSFI was found, although there was an improvement in lubrication and orgasm.

CONCLUSION

Temporary deterioration of erectile function in men is common at 6 months after surgery and chemoradiotherapy is the only predictive factor. Furthermore, patients who remain dysfunctional show an increase in the severity of symptoms in relation to the preoperative period.

Prospective study of urinary function and analysis of risk factors after rectal cancer surgery

BACKGROUND

Alterations in urinary function are complications of rectal cancer surgery. The aim of this study was to prospectively analyze the changes in urinary function in patients operated on for rectal cancer, and to identify risk factors that may have an impact on the deterioration of postoperative urinary function.

METHODS

A prospective study of urinary function in rectal cancer patients who had elective oncological resection with curative intention at the Arnau de Vilanova Hospital in Valencia, Spain, from January 2017 to March 2019. The evaluation of urinary function was performed using the International Prostate Symptom Score (IPSS) preoperatively, at 6 and 12 months after surgery. Predictive factors of urinary dysfunction were identified by univariate and multivariate analysis.

RESULTS

Ninety-four patients were enrolled in the study. Eighty-seven of them completed all the follow-up assessments (48 men and 39 women, mean age 65.74 ± 10.95 years,). The mean IPSS was 7.96 ± 7.59 preoperatively, 9.01 ± 6.81 at 6 months, and 8.63 ± 5.59 at 12 months, without statistically significant differences. There were no differences in IPSS between males and females. Preoperative urinary dysfunction was 39% and at 12 months, a deterioration occurred in 23 patients (26.4%). IPSS analysis of symptoms showed a statistically significant worsening of nocturia at 6 months (p = 0.002) and 1 year after surgery (p = 0.037) in women. American Society of Anesthesiologists (ASA) class (OR: 11, [95% CI2.4-53]; p = 0.010), surgical difficulty (OR: 4.5, [95% CI 1-19]; p = 0.027) and anastomotic leakage (OR: 14, [95% CI 1.6-117]; p = 0.010), were identified as independent risk factors for deterioration of urinary function after surgery.

CONCLUSIONS

Our study showed worsening urinary dysfunction after rectal cancer surgery in 26.4% of the patients. However, there were no statistically significant differences in mean IPSS scores at the three assessment times (preoperatively, 6 months, 12 months). ASA class, surgical difficulty, and anastomotic leakage may predict postoperative deterioration.

Persistent High Rate of Positive Margins and Postoperative Complications After Surgery for cT4 Rectal Cancer at a National Level

BACKGROUND

A more extensive resection is often required in locally advanced rectal cancer, depending on preoperative neoadjuvant treatment response.

OBJECTIVE

Circumferential margin involvement and postoperative outcomes after total mesorectal excision and multivisceral resection were assessed in patients with clinical locally advanced (cT4) rectal cancer at a national level.

DESIGN

This is a population-based study.

SETTINGS

Data were retrieved from the Dutch Colorectal Audit.

PATIENTS

A total of 2242 of 2881 patients with cT4 rectal cancer between January 2009 and December 2017 were selected.

MAIN OUTCOME MEASURES

Main outcomes were resection margins, postoperative complications, and mortality.

RESULTS

Multivisceral resection was performed in 936 of 2242 patients, of whom 629 underwent extended multivisceral resection. Positive circumferential margin rate was higher after multivisceral resection than after total mesorectal excision: 21.2% vs 13.9% (p < 0.001). More postoperative complications occurred after limited and extended multivisceral resections than after total mesorectal excision (44.1% and 53.8% vs 37.6%, p < 0.001). Incidence of 30-day mortality was similarly low in both groups (1.5% vs 2.2%, p = 0.20). Independent predictors of postoperative complications were age ≥70 years (OR, 1.28 [95% CI, 1.04-1.56]; p = 0.02), male sex (OR, 1.68 [95% CI, 1.38-2.04]; p< 0.001), mucinous tumors (OR, 1.55 [95% CI, 1.06-2.27]; p = 0.02), extended multivisceral resection (OR, 1.98 [95% CI, 1.56-2.52]; p< 0.001), Hartmann procedure (OR, 1.42 [95% CI, 1.07-1.90]; p = 0.02), and abdominoperineal resection (OR, 1.56 [95% CI, 1.25-1.96]; p < 0.001).

LIMITATIONS

Data specifying the extent of multivisceral resections and Clavien Dindo I to II complications were not available.

CONCLUSIONS

This population-based study revealed relatively high circumferential margin positivity and postoperative complication rates in patients with cT4 rectal cancer, especially after multivisceral resections, but low mortality rates. See Video Abstract at http://links.lww.com/DCR/B457.

ALTA TASA PERSISTENTE DE MRGENES POSITIVOS Y COMPLICACIONES POSTOPERATORIAS DESPUS DE LA CIRUGA DE CNCER RECTAL CTA NIVEL NACIONAL

ANTECEDENTES:A menudo se requiere una resección más extensa en el cáncer de recto localmente avanzado, según la respuesta al tratamiento neoadyuvante preoperatorio.OBJETIVO:Se evaluó la afectación del margen circunferencial y los resultados postoperatorios después de la escisión mesorrectal total y la resección multivisceral en pacientes con cáncer rectal clínico localmente avanzado (cT4) a nivel nacional.DISEÑO:Este es un estudio poblacional.ENTORNO CLINICO:Los datos se recuperaron de la Auditoría colorrectal holandesa.PACIENTES:Se seleccionaron un total de 2242 de 2881 pacientes con cáncer de recto cT4 entre enero de 2009 y diciembre de 2017.PRINCIPALES MEDIDAS DE VALORACION:Los principales resultados fueron los márgenes de resección, las complicaciones postoperatorias y la mortalidad.RESULTADOS:Se realizó resección multivisceral en 936 de 2242 pacientes, de los cuales 629 fueron sometidos a resección multivisceral extendida. La tasa de margen circunferencial positivo fue mayor después de la resección multivisceral que después de la escisión mesorrectal total: 21,2% versus a 13,9% (p <0,001). Se produjeron más complicaciones postoperatorias después de resecciones multiviscerales limitadas y extendidas en comparación con la escisión mesorrectal total (44,1% y 53,8% versus a 37,6%, p <0,001). La incidencia de mortalidad a 30 días fue igualmente baja en ambos grupos (1,5% versus a 2,2%, p = 0,20). Los predictores independientes de complicaciones posoperatorias fueron la edad ≥70 años (OR = 1,28, IC del 95% [1,04 a 1,56], p = 0,02), hombres (OR = 1,68, IC del 95% [1,38 a 2,04], p <0,001), tumores mucinosos (OR = 1,55, IC del 95% [1,06 a 2,27], p = 0,02), resección multivisceral extendida (OR = 1,98, IC del 95% [1,56 a 2,52], p <0,001), Hartmann (OR = 1,42, 95% Cl [1,07 a 1,90], p = 0,02) y resección abdominoperineal (OR 1,56, Cl 95% [1,25 a 1,96], p <0,001).LIMITACIONES:No se disponía de datos que especificaran el alcance de las resecciones multiviscerales y las complicaciones de Clavien Dindo I-II.CONCLUSIONES:Este estudio poblacional reveló tasas de complicaciones postoperatorias y positividad del margen circunferencial relativamente altas en pacientes con cáncer de recto cT4, especialmente después de resecciones multiviscerales, pero tasas de mortalidad bajas. Consulte Video Resumen en http://links.lww.com/DCR/B457.

Nonoperative Management Versus Radical Surgery of Rectal Cancer After Neoadjuvant Therapy-Induced Clinical Complete Response: A Markov Decision Analysis

BACKGROUND

Nonoperative management of rectal cancer was introduced for patients with clinical complete response after neoadjuvant chemoradiotherapy to avoid short- and long-term surgical morbidity related to radical resection.

OBJECTIVE

The purpose of this study was to determine the expected life-years and quality-adjusted life-years for nonoperative management and radical resection of locally advanced rectal cancer after clinical complete response following neoadjuvant chemoradiotherapy.

DESIGN

Markov modeling was used to simulate nonoperative management and radical surgery for a base case scenario over a 10-year time horizon. Estimates for various clinical variables were obtained after extensive literature search. Outcome was expressed in both life-years and quality-adjusted life-years. Deterministic sensitivity analyses were completed to assess the impact of variation in key parameters.

SETTING

A decision model using a Markov model was designed.

PATIENTS

The base case was a 65-year-old man with a distal rectal tumor who had achieved clinical complete response after neoadjuvant chemoradiotherapy.

MAIN OUTCOME MEASURES

Life-years and quality-adjusted life-years were measured.

RESULTS

Quality-adjusted life-years (5.79 for nonoperative management vs 5.62 for radical surgery) and life-years (6.92 for nonoperative management vs 6.96 for radical surgery) were similar between nonoperative management and radical surgery. The preferred treatment strategy changed with variations in the probability of local regrowth in nonoperative management, the probability of salvage surgery for regrowth in nonoperative management, utilities associated with nonoperative management and low anterior resection, and the utility of low anterior resection syndrome. The model was not sensitive to (dis)utilities associated with stoma, chemotherapy, or postoperative morbidity and mortality.

LIMITATIONS

The study was limited by assumptions inherent to modeling studies.

CONCLUSIONS

Nonoperative management and radical surgery resulted in similar (quality-adjusted) life-years. Nonoperative management should therefore be considered as a reasonable treatment option. See Video Abstract at http://links.lww.com/DCR/B246. MANEJO NO-QUIRÚRGICO VERSUS CIRUGÍA RADICAL DEL CÁNCER RECTAL DESPUÉS DE LA RESPUESTA CLÍNICA COMPLETA INDUCIDA POR TERAPIA NEOADYUVANTE: UN ANÁLISIS DE DECISIÓN DE MARKOV: Se introdujo el tratamiento no quirúrgico del cáncer rectal para pacientes con respuesta clínica completa después de la quimiorradioterapia neoadyuvante para evitar la morbilidad quirúrgica a corto y largo plazo relacionada con la resección radical.Determinar los años de vida esperados y los años de vida ajustados por calidad para el tratamiento no-quirúrgico y la resección radical del cáncer rectal localmente avanzado, después de la respuesta clínica completa siguiente de la quimiorradioterapia neoadyuvante.El modelo de Markov se usó para simular el manejo no-quirúrgico y la cirugía radical para un escenario de caso base en un horizonte temporal de 10 años. Se obtuvieron estimaciones para diversas variables clínicas después de una extensa búsqueda bibliográfica. El resultado se expresó tanto en años de vida como en años de vida ajustados por calidad. Se completaron análisis determinísticos de sensibilidad para evaluar el impacto de la variación en los parámetros clave.Se diseñó un modelo de decisión utilizando un modelo de Markov.El caso base fue un hombre de 65 años con un tumor rectal distal que había logrado una respuesta clínica completa después de la quimiorradioterapia neoadyuvante.Años de vida y años de vida ajustados por calidad.Los años de vida ajustados por calidad (5.79 para el tratamiento no-quirúrgico frente a 5.62 para la cirugía radical) y los años de vida (6.92 para el tratamiento no-quirúrgico frente a 6.96 para la cirugía radical) fueron similares entre el tratamiento no-quirúrgico y la cirugía radical. La estrategia de tratamiento preferida cambió con las variaciones en la probabilidad de nuevo crecimiento local en el manejo no-operatorio, la probabilidad de cirugía de rescate para el rebrote en el manejo no-operatorio, las utilidades asociadas con el manejo no-operatorio, y la resección anterior baja y la utilidad de el syndrome de resección anterior baja. El modelo no era sensible a las (des) utilidades asociadas con el estoma, la quimioterapia o la morbilidad y mortalidad postoperatorias.El estudio estuvo limitado por suposiciones inherentes a los estudios de modelado.El manejo no-quirúrgico y la cirugía radical resultaron en años de vida similares (ajustados por calidad). Por lo tanto, el tratamiento no-quirúrgico debe considerarse como una opción de tratamiento razonable. Consulte Video Resumen en http://links.lww.com/DCR/B246.

15-hydroxy-6α,12-epoxy-7β,10αH,11βH-spiroax-4-ene-12-one sensitizes rectal tumor cells to anti-PD1 treatment through agonism of CD11b

PURPOSE

Although immunotherapies have resulted in durable clinical responses, not all tumor types have seen substantial benefit. Extensive recruitment and accumulation of immunosuppressive myeloid cells into the tumor tissues has been postulated as a major mechanism of resistance to immunotherapies. Strategies targeting on single immunosuppressive cell type, in combination with checkpoint inhibitors, have resulted in promising outcomes in animal studies. However, compensatory actions by untargeted cells may limit the therapeutic efficacy. CD11b is highly expressed on the myeloid cell surface with an important role in their trafficking and cellular functions.In this study, we demonstrated that activation of CD11b with 15-hydroxy-6α,12-epoxy-7β,10αH,11βH-spiroax-4-ene-12-one (HESEO) enhanced the therapeutic efficacy of anti-PD1 treatment in the tumor model.

MATERIALS AND METHODS

A syngeneic rectal tumor model was established. Different types of cells from the peripheral blood and tumor tissues were analyzed by flow cytometry. Real-time PCR was used to detect the gene expression. Therapeutic effects of HESEO combining with anti-PD1 antibody were assessed by the tumor model.

RESULTS

Our data demonstrated that HESEO repolarized tumor-associated macrophages and reduced the number of tumor-infiltrating immunosuppressive myeloid cells. We further demonstrated that HESEO and immunotherapy combination promoted tumor growth control in a syngeneic tumor model.

CONCLUSIONS

Our results showed that HESEO improved anti-tumor T cell immunity and rendered anti-PD1 treatment effective in unresponsive tumor models, providing proof of concept for a new combination strategy involving molecular agonism of CD11b to bypass the limitations of current clinical strategies to overcome resistance to immunotherapies.

Comparison of Systematic Video Documentation With Narrative Operative Report in Colorectal Cancer Surgery

Importance

Despite ongoing advances in the field of colorectal surgery, the quality of surgical treatment is still variable. As an intrinsic part of surgical quality, the technical information regarding the surgical procedure is reflected only by the narrative operative report (NR), which has been found to be subjective and regularly omits important information.

Objective

To investigate systematic video recording (SVR) as a potential improvement in quality and safety with regard to important information in colorectal cancer surgery.

Design, Setting, and Participants

The Imaging for Quality Control Trial was a prospective, observational cohort study conducted between January 12, 2016, and October 30, 2017, at 3 centers in the Netherlands. The study group consisted of 113 patients 18 years or older undergoing elective laparoscopic surgery for colorectal cancer. These patients were case matched and compared with cases from a historical cohort that received only an NR.

Interventions

Among study cases, participating surgeons were requested to systematically capture predefined key steps of the surgical procedure intraoperatively on video in short clips.

Main Outcomes and Measures

The SVRs and NRs were analyzed for adequacy with respect to the availability of important information regarding the predefined key steps. Adequacy of the reported information was defined as the proportion of key steps with available and sufficient information in the report. Adequacy of the SVR and NR was compared between the study and control groups, with the SVR alone and as an adjunct to the NR in the study group vs NR alone in the control group.

Results

Of the 113 study patients, 69 women (61.1%) were included; mean (SD) age was 66.3 (9.8) years. In the control group, a mean (SD) of 52.5% (18.3%) of 631 steps were adequately described in the NR. In the study group, the adequacy of both the SVR (78.5% [16.5%], P < .001) and a combination of the SVR with NR (85.1% [14.6%], P < .001) was significantly superior to NR alone. The only significant difference between the study and historical control groups regarding postoperative and pathologic outcomes was a shorter postoperative mean (SD) length of stay in favor of the study group (8.0 [7.7] vs 8.6 [6.8] days; P = .03).

Conclusions and Relevance

Use of SVR in laparoscopic colorectal cancer surgery as an adjunct to the NR might be superior in documenting important steps of the operation compared with NR alone, adding to the overall availability of necessary intraoperative information and contributing to quality control and objectivity.

Does one size fit all? Risks and benefits of neoadjuvant chemoradiation in patients with clinical stage IIA rectal cancer requiring abdominoperineal resection

BACKGROUND

Neoadjuvant chemoradiotherapy (nCRT) has become the standard of care for locally advanced rectal cancer, decreasing locoregional recurrence, yet with an unclear survival advantage. We aimed to assess the benefit of nCRT on oncologic and perioperative outcomes of patients with clinical stage IIA rectal adenocarcinoma treated with abdominoperineal resection (APR).

METHODS

Patients with clinical T3N0 rectal adenocarcinoma that underwent APR between 1995 and 2014 were included. Patients who received nCRT were compared with patients who did not. Multivariate analysis was conducted to compare oncological and perioperative outcomes between the groups.

RESULTS

127 patients were included, of which 94 received nCRT. Median follow-up was 11.9 years. There was no difference in circumferential margins, postoperative morbidity, and complication rates between the groups. There was no difference in 5-year oncological outcomes between the groups.

CONCLUSIONS

No difference was found in 5-year oncological outcomes between patients with clinical T3N0 rectal adenocarcinoma necessitating an APR who received nCRT and those not receiving nCRT, with similar overall complication rates.

Cancer treatment and survivorship statistics, 2019

The number of cancer survivors continues to increase in the United States because of the growth and aging of the population as well as advances in early detection and treatment. To assist the public health community in better serving these individuals, the American Cancer Society and the National Cancer Institute collaborate every 3 years to estimate cancer prevalence in the United States using incidence and survival data from the Surveillance, Epidemiology, and End Results cancer registries; vital statistics from the Centers for Disease Control and Prevention's National Center for Health Statistics; and population projections from the US Census Bureau. Current treatment patterns based on information in the National Cancer Data Base are presented for the most prevalent cancer types. Cancer-related and treatment-related short-term, long-term, and late health effects are also briefly described. More than 16.9 million Americans (8.1 million males and 8.8 million females) with a history of cancer were alive on January 1, 2019; this number is projected to reach more than 22.1 million by January 1, 2030 based on the growth and aging of the population alone. The 3 most prevalent cancers in 2019 are prostate (3,650,030), colon and rectum (776,120), and melanoma of the skin (684,470) among males, and breast (3,861,520), uterine corpus (807,860), and colon and rectum (768,650) among females. More than one-half (56%) of survivors were diagnosed within the past 10 years, and almost two-thirds (64%) are aged 65 years or older. People with a history of cancer have unique medical and psychosocial needs that require proactive assessment and management by follow-up care providers. Although there are growing numbers of tools that can assist patients, caregivers, and clinicians in navigating the various phases of cancer survivorship, further evidence-based resources are needed to optimize care.

Liquid biopsy for rectal cancer: A systematic review

BACKGROUND

The management of locally advanced rectal cancer (RC) is an evolving clinical field where the multidisciplinary approach can reach its best, and liquid biopsy for obtaining tumor-derived component such as circulating tumor DNA (ctDNA) might provide complementary informations.

METHODS

A systematic review of studies available in literature of liquid biopsy in non-metastatic RC has been performed according to PRISMA criteria to assess the role of ctDNA as a diagnostic, predictive and prognostic biomarker in this setting.

RESULTS

Twenty-five publications have been retrieved, of which 8 full-text articles, 7 abstracts and 10 clinical trials. Results have been categorized into three groups: diagnostic, predictive and prognostic. Few but promising data are available about the use of liquid biopsy for early diagnosis of RC, with the main limitation of sensitivity due to low concentrations of ctDNA in this setting. In terms of prediction of response to chemoradiation, still inconclusive data are available about the utility of a pre-treatment liquid biopsy, whereas some studies report a positive correlation with a dynamic (pre/post-treatment) monitoring. The presence of minimal residual disease by ctDNA was consistently associated with worse prognosis across studies.

CONCLUSIONS

The use of liquid biopsy for monitoring response to chemoradiation and assess the risk of disease recurrence are the most advanced potential applications for liquid biopsy in RC, with implications also in the context of non-operative management strategies.

Recommendations for follow-up of colorectal cancer survivors

Colorectal cancer (CRC) is one of the tumours with the highest incidence and mortality in the Spanish population. Nevertheless, the advances in prevention and treatment have contributed to an increased number of patients who survive for prolonged periods of time. In addition, despite recurrences, improved survival following metastasis resection is likewise on the rise. This underscores the importance of carrying out follow-up programmes even in low-risk patients for the early detection of recurrence. The main objective of this article is to provide a set of recommendations for optimising the follow-up of CRC survivors as well as for managing the sequelae that result from either pharmacological or surgical treatment.

Rate of Anastomotic Leakage After Rectal Anastomosis Depends on the Definition: Pelvic Abscesses are Significant

BACKGROUND AND AIMS

The International Study Group of Rectal Cancer has proposed that a pelvic abscess in the proximity of the anastomosis is considered an anastomotic leak, whether or not its point of origin is detectable. This study describes how the inclusion of pelvic abscesses alters the leakage rate.

MATERIAL AND METHODS

Risk factors and postoperative complications in patients with visible anastomotic leakage ("direct leakage"), pelvic abscesses alone in the vicinity of a visibly intact anastomosis ("abscess leakage"), and no leakage were retrospectively evaluated.

RESULTS

In total, 341 patients operated with anterior resections and who received an anastomosis within 15 cm as measured from the anal verge were included. A total of 37 patients (10.9%) had direct leakage, 13 (3.8%) had abscess leakage, and 291 (85.3%) had no leakage. The overall anastomotic leakage rate was 14.7% (50 patients). In accordance with the grading system outlined by International Study Group of Rectal Cancer, 7 patients (2.1%) experienced Grade A leakage, 19 (5.6%) Grade B, and 24 (7.0%) Grade C. Direct leak patients had more often a reoperation due to anastomotic complications (odds ratio = 19.7, p = 0.001), a permanent stoma (odds ratio = 28.5, p = 0.001), and a longer hospital stay than abscess leak patients (29.0 vs 15.5 days, p = 0.030).

CONCLUSION

Abscess leakage accounted for over one-fourth of the overall leakage rate, raising the leakage rate. Direct leak patients were at a higher risk of requiring a reoperation, permanent stoma, and longer hospital stay than abscess leak patients. Abscess leak patients were at a greater risk for a urinary tract infection, wound infection, and postoperative intestinal obstruction than non-leak patients.

Potential of memory T cells in bridging preoperative chemoradiation and immunotherapy in rectal cancer

The management of locally advanced rectal cancer has passed a long way of developments, where total mesorectal excision and preoperative radiotherapy are crucial to secure clinical outcome. These and other aspects of multidisciplinary strategies are in-depth summarized in the literature, while our mini-review pursues a different goal. From an ethical and medical standpoint, we witness a delayed implementation of novel therapies given the cost/time consuming process of organizing randomized trials that would bridge an already excellent local control in cT3-4 node-positive disease with long-term survival. This unfortunate separation of clinical research and medical care provides a strong motivation to repurpose known pharmaceuticals that suit for treatment intensification with a focus on distant control. In the framework of on-going phase II-III IG/IMRT-SIB trials, we came across an intriguing translational observation that the ratio of circulating (protumor) myeloid-derived suppressor cells to (antitumor) central memory CD8+ T cells is drastically increased, a possible mechanism of tumor immuno-escape and spread. This finding prompts that restoring the CD45RO memory T-cell pool could be a part of integrated adjuvant interventions. Therefore, the immunocorrective potentials of modified IL-2 and the anti-diabetic drug metformin are thoroughly discussed in the context of tumor immunobiology, mTOR pathways and revised Warburg effect.

Long-Term and Latent Side Effects of Specific Cancer Types

Although many cancer survivors diagnosed with early-stage disease will outlive their cancer, they may continue to experience long-term and/or latent side effects due to cancer treatment. Many of these side effects are common and contribute to worse quality of life, morbidity, and mortality for cancer survivors. This article summarizes the treatment side effects for several of the most prevalent cancers in the United States.

Magnetic resonance based texture parameters as potential imaging biomarkers for predicting long-term survival in locally advanced rectal cancer treated by chemoradiotherapy

AIM

The study aimed to investigate whether textural features of rectal cancer on MRI can predict long-term survival in patients treated with long-course chemoradiotherapy.

METHOD

Textural analysis (TA) using a filtration-histogram technique of T2-weighted pre- and 6-week post-chemoradiotherapy MRI was undertaken using TexRAD, a proprietary software algorithm. Regions of interest enclosing the largest cross-sectional area of the tumour were manually delineated on the axial images and the filtration step extracted features at different anatomical scales (fine, medium and coarse) followed by quantification of statistical features [mean intensity, standard deviation, entropy, skewness, kurtosis and mean of positive pixels (MPP)] using histogram analysis. Cox multiple regression analysis determined which univariate features including textural, radiological and histological independently predicted overall survival (OS), disease-free survival (DFS) and recurrence-free survival (RFS).

RESULTS

MPP [fine texture, hazard ratio (HR) 6.9, 95% CI: 2.43-19.55, P < 0.001], mean (medium texture, HR 5.6, 95% CI: 1.4-21.7, P = 0.007) and extramural venous invasion (EMVI) on MRI (HR 2.96, 95% CI: 1.04-8.37, P = 0.041) independently predicted OS while mean (medium texture, HR 4.53, 95% CI: 1.58-12.94, P = 0.003), MPP (fine texture, HR 3.36, 95% CI: 1.36-8.31, P = 0.008) and threatened circumferential resection margin (CRM) on MRI (HR 3.1, 95% CI: 1.01-9.46, P = 0.046) predicted DFS. For OS, EMVI on MRI (HR 4.23, 95% CI: 1.41-12.69, P = 0.01) and for DFS kurtosis (medium texture, HR 3.97, 95% CI: 1.44-10.94, P = 0.007) and CRM involvement on MRI (HR 3.36, 95% CI: 1.21-9.32, P = 0.02) were the independent post-treatment factors. Only TA independently predicted RFS on pre- or post-treatment analyses.

CONCLUSION

MR based TA of rectal cancers can predict outcome before undergoing surgery and could potentially select patients for individualized therapy.

Rectal cancer treatment in a teaching hospital

BACKGROUND

Rectal adenocarcinomas surgery morbidity and mortality might be impaired by neoadjuvant therapy. We performed this retropsective study to be compared with the PROCARE study running afterwards.

METHODS

We performed a retrospective study of 95 patients operated on for rectal adenocarcinoma in a single institution during the period of 2007-2009. We used logistic regression to estimate the relationship between possible predictive parameters of anastomotic leakage (AL).

RESULTS

The laparoscopic approach is favored in 63.1% of the cases with a conversion rate of 11.6%, mainly in man (6 out of 7). For low rectal cancer though, laparotomy was the first choice (92.3%). From a carcinological point of view, laparoscopy allowed a complete tumor resection according to the PME (n = 27) and TME (n = 26) standards. Multivariate analysis revealed that women, lower BMI, lower rectum tumor, laparoscopic surgery, neoadjuvant treatment and anal suture were associated with higher risk of AL. The mean hospital stay was 15.4 days (3-46 days) with an in-hospital mortality rate of 3.1%. Adjuvant chemotherapy was completed in 42.1% of the patients. Despite these treatments, we registered a recurrence rate of 26.6%. Of these, 72% were distally localized and 12% exclusively locally. Among the patients operated on by laparoscopy, there was one local recurrence and one local with distant metastases (3.7%). The one- and three-year survival rates were 91.5% and 80.4%, respectively.

CONCLUSIONS

Our study showed a higher rate of AL than expected (18%). In our series recorded in PROCARE-Home, our leak rate has dropped to 10%. It may be indicating a positive effect of PROCARE.

Long-term oncologic outcomes of neoadjuvant concurrent chemoradiotherapy with capecitabine and radical surgery in locally advanced rectal cancer: 10-year experiences at a single institution

PURPOSE

Oral capecitabine has demonstrated to be safe and efficient as neoadjuvant concurrent chemoradiotherapy (NCRT) for locally advanced rectal cancers. The aim of this study was to evaluate the long-term oncologic outcomes of NCRT with capecitabine and radical surgery.

METHODS

From January 2000 to June 2010, 238 patients were treated at our center for locally advanced rectal cancers using conventional NCRT with capecitabine and radical surgery. Univariate and multivariate analyses were used to evaluate the factors associated with oncologic outcomes with log rank and Cox regression tests.

RESULTS

The incidence of grade >3 capecitabine-related toxicity was found to be 4.6%. A pathologic complete response was observed in 14.7% of patients. The 5-year overall and 5-year disease-free survival rate, local and systemic recurrence rate were 82.8%, 75.1%, 4.8%, and 20.3%. Abdominoperineal resection and node-positive disease were independent prognostic factors of 5-year overall survival, 5-year disease-free survival, and systemic recurrence.

CONCLUSION

NCRT with capecitabine and radical surgery showed favorable long-term oncologic outcomes with benefits of acceptable toxicity and convenience. We suggest that capecitabine can be one of the favorable therapeutic options for NCRT in rectal cancer.

Imaging for Quality Control: Comparison of Systematic Video Recording to the Operative Note in Colorectal Cancer Surgery. A Pilot Study

Background

Oncological and functional results after colorectal cancer surgery vary considerably between hospitals and surgeons. At present, the only source of technical information about the surgical procedure is the operative note, which is subjective and omits critical information. This study aimed to evaluate the feasibility of operative video recording in demonstrating both objective information concerning the surgical procedure and surgical quality, as using a systematic approach might improve surgical performance.

Methods

From July 2015 through November 2015, patients aged ≥18 years undergoing elective colorectal cancer surgery were prospectively included in a single-institution trial. Video recording of key moments was performed peroperatively and analyzed for adequacy. The study cases were compared with a historic cohort. Video was compared with the operative note using the amount of adequate steps and a scoring system.

Results

This study compared 15 cases to 32 cases from the historic control group. Compared to the written operative note alone, significant differences in availability of information were seen in favor of video as well as using a combination of video plus the operative note (N adequate steps p = .024; p = <.001. Adequacy score: p = .039; p = <.001, both respectively).

Conclusions

Systematic video registration is feasible and seems to improve the availability of essential information after colorectal cancer surgery. In this respect, combining video with a traditional operative note would be the best option. A multicenter international study is being organized to further evaluate the effect of operative video capture on surgical outcomes.

Cancer treatment and survivorship statistics, 2016

The number of cancer survivors continues to increase because of both advances in early detection and treatment and the aging and growth of the population. For the public health community to better serve these survivors, the American Cancer Society and the National Cancer Institute collaborate to estimate the number of current and future cancer survivors using data from the Surveillance, Epidemiology, and End Results cancer registries. In addition, current treatment patterns for the most prevalent cancer types are presented based on information in the National Cancer Data Base and treatment-related side effects are briefly described. More than 15.5 million Americans with a history of cancer were alive on January 1, 2016, and this number is projected to reach more than 20 million by January 1, 2026. The 3 most prevalent cancers are prostate (3,306,760), colon and rectum (724,690), and melanoma (614,460) among males and breast (3,560,570), uterine corpus (757,190), and colon and rectum (727,350) among females. More than one-half (56%) of survivors were diagnosed within the past 10 years, and almost one-half (47%) are aged 70 years or older. People with a history of cancer have unique medical and psychosocial needs that require proactive assessment and management by primary care providers. Although there are a growing number of tools that can assist patients, caregivers, and clinicians in navigating the various phases of cancer survivorship, further evidence-based resources are needed to optimize care. CA Cancer J Clin 2016;66:271-289. © 2016 American Cancer Society.

Continuous intraoperative monitoring of pelvic autonomic nerves during TME to prevent urogenital and anorectal dysfunction in rectal cancer patients (NEUROS): a randomized controlled trial

Background

Urinary, sexual and anorectal sequelae are frequent after rectal cancer surgery and were found to be related to intraoperative neurogenic impairment. Neuromonitoring methods have been developed to identify and preserve the complex pelvic autonomic nervous system in order to maintain patients’ quality of life. So far no randomized study has been published dealing with the role of neuromonitoring in rectal cancer surgery.

Methods/design

NEUROS is a prospective two-arm randomized controlled multicenter clinical trial comparing the functional outcome in rectal cancer patients undergoing total mesorectal excision (TME) with and without pelvic intraoperative neuromonitoring (pIONM). A total of 188 patients will be included. Primary endpoint is the urinary function measured by the International Prostate Symptom Score. Secondary endpoints consist of sexual, anorectal functional outcome and safety, especially oncologic safety and quality of TME. Sexual function is assessed in females with the Female Sexual Function Index and in males with the International Index of Erectile Function. For evaluation of anorectal function the Wexner-Vaizey score is used. Functional evaluation is scheduled before radiochemotherapy (if applicable), preoperatively (baseline), before hospital discharge, 3 and 6 months after stoma closure and 12 months after surgery. For assessment of safety adverse events, the rates of positive resection margins and quality of mesorectum are documented.

Discussion

This study will provide high quality evidence on the efficacy of pIONM aiming for improvement of functional outcome in rectal cancer patients undergoing TME.

Trial registration

Clinicaltrials.gov: NCT01585727. Registration date is 04/25/2012

Systematic Video Documentation in Laparoscopic Colon Surgery Using a Checklist: A Feasibility and Compliance Pilot Study

BACKGROUND

High-quality images can be readily captured during laparoscopic colon surgery, but there are no guidelines for documentation of these video data or how to best measure surgical quality from an operative video. This study evaluates the feasibility and compliance in documenting key steps during laparoscopic right hemicolectomy and sigmoid colectomy.

MATERIALS AND METHODS

A retrospective review of previously recorded videos of patients undergoing laparoscopic right hemicolectomy or sigmoid colectomy from September to December 2011 in a single institution was performed. Patients' demographics, intraoperative features, postoperative complications, and variables for video recording and editing were collected. Compliance of key surgical steps was assessed using a checklist by two independent surgeons.

RESULTS

Sixteen laparoscopic operations (seven right hemicolectomies and nine sigmoid colectomies) were recorded. Twelve (75%) were laparoscopic-assisted, and four (25%) were hand-assisted laparoscopic operations. Compliance with key surgical steps in laparoscopic right hemicolectomy and sigmoid colectomy was demonstrated in the majority of patients, with steps ranging in compliance from 42.9% to 100% and from 77.8% to 100%, respectively. The edited video had a median duration of 3 minutes 47 seconds (range, 1 minute 44 seconds-5 minutes 38 seconds) with a production time of nearly 1 hour and a resolution of 1440 × 1080 pixels.

CONCLUSIONS

Key surgical steps during laparoscopic right hemicolectomy and sigmoid colectomy can be documented and edited into a short representative video. Standardization of this process should allow video documentation to improve quality in laparoscopic colon surgery.

Driving Surgical Quality Using Operative Video

Recent evidence suggests surgical quality may be demonstrated and evaluated using video capture during surgery. Operative video documentation may also aid in quality improvement initiatives. We discuss how operative video has the potential to help improve patient outcomes and increase professional accountability, patient safety, and surgical quality.

Impact of neoadjuvant therapy in downstaging of lower rectal adenocarcinoma and the role of pelvic magnetic resonance in staging

ABSTRACT Objective: to evaluate the effect of neoadjuvant therapy on the stage (TNM) of patients with rectal adenocarcinoma and validate the use of MRI as a method of determining locoregional stage. Methods: we conducted a retrospective study of 157 patients with lower rectum adenocarcinoma, whom we divided into two groups: Group 1, 81 patients (52%) who had undergone surgical treatment initially, with the purpose to analyze the accuracy of locoregional staging by pelvic magnetic resonance imaging throug the comparison of radiological findings with pathological ones; Group 2, 76 patients (48%), who had been submitted to neoadjuvant therapy (chemotherapy and radiation) prior to definitive surgical treatment, so as to evaluate its effects on the stage by comparing clinical and radiological findings with pathology. Results: In group 1, the accuracy of determining tumor depth (T) and lymph node involvement (N) was 91.4% and 82.7%, respectively. In group 2, neoadjuvant therapy decreased the T stage, N stage and TNM stage in 51.3%, 21% and 48.4% of cases, respectively. Conclusion: neoadjuvant therapy in patients with rectal adenocarcinoma is effective in decreasing disease stage, and pelvic magnetic resonance imaging is effective for locoregional staging.

Electrophysiology-based quality assurance of nerve-sparing in laparoscopic rectal cancer surgery: Is it worth the effort?

BACKGROUND

After low anterior resection for rectal cancer, visual assessment of pelvic autonomic nerve preservation can be difficult due to the complexity of neuroanatomy, as well as surgery- and patient-related factors. The present study aimed to evaluate nerve-sparing quality assurance using the laparoscopic neuromapping (LNM) technique.

METHODS

We prospectively investigated a series of 30 patients undergoing laparoscopic low anterior resection. Nerve-sparing was evaluated both visually and electrophysiologically. LNM was performed using stimulation of pelvic autonomic nerves under simultaneous cystomanometry and processed electromyography of the internal anal sphincter. Urogenital and anorectal functions were evaluated using validated and standardized questionnaires preoperatively, at short-term follow-up, and at mid-term follow-up at a median of 9 months (range 6-12 months) after surgery.

RESULTS

One patient reported new onset of urinary dysfunction, and another patient reported new onset of anorectal dysfunction. Of the 20 sexually active patients, five reported sexual dysfunction. Visual assessment by laparoscopy confirmed complete nerve preservation in 28 of 30 cases. For prediction of urinary and anorectal function, LNM sensitivity, specificity, positive and negative predictive value, and overall accuracy were each 100 %. LNM with combined assessment for prediction of sexual function yielded a sensitivity of 80 %, specificity of 93 %, positive predictive value of 80 %, negative predictive value of 93 %, and overall accuracy of 90 %.

CONCLUSIONS

LNM is an appropriate method for reliable quality assurance of laparoscopic nerve-sparing.

The outcome and the frequency of pathological complete response after neoadjuvant radiotherapy in curative resections for advanced rectal cancer: a population-based study

AIM

Pathological complete response (ypCR) after neoadjuvant treatment for rectal cancer is associated with favourable survival and a low rate of local recurrence. The aim of the study was to assess the incidence of ypCR among patients with advanced rectal cancer treated with neoadjuvant chemoradiotherapy and curative resection and to explore factors associated with survival.

METHOD

From 2000 to 2009, 1384 patients enrolled in the national population- based colorectal cancer registry of Norway with advanced T3 and T4 rectal cancer with N0-2, M0 received neoadjuvant long-course (chemo)radiation. The duration of follow-up was a median of 5 years.

RESULTS

ypCR was achieved in 147 (10.6%) patients. The estimated 5-year overall survival rate was 87% (confidence interval ± 5.4) among ypCR and 67% among non-ypCR (confidence interval ± 2.7) (P < 0.0001). Distant metastasis developed in 12 (8%) of 147 and 328 (26.5%) of 1237 patients respectively (P < 0.001). In a Cox proportional hazards ratio model the effect of ypCR on survival was adjusted for age [hazard ratio (HR) 1.056, P = 0.0001], metachronous metastasis (HR 4.7, P = 0.0001), local recurrence (HR 4.3, P = 0.0001) and surgical procedure (HR 1.48, P = 0.0001). The independent effect of ypCR (HR 0.65, P = 0.041) on survival almost disappeared compared with the univariate analysis.

CONCLUSION

The rate of ypCR in advanced rectal cancer was about 10%. This phenomenon seems to occur in tumours with a low risk of metastasizing. The contribution of neoadjuvant therapy to ypCR on survival was small or absent.

American Cancer Society Colorectal Cancer Survivorship Care Guidelines

Colorectal cancer (CRC) is the third most common cancer and third leading cause of cancer death in both men and women and second leading cause of cancer death when men and women are combined in the United States (US). Almost two-thirds of CRC survivors are living 5 years after diagnosis. Considering the recent decline in both incidence and mortality, the prevalence of CRC survivors is likely to increase dramatically over the coming decades with the increase in rates of CRC screening, further advances in early detection and treatment and the aging and growth of the US population. Survivors are at risk for a CRC recurrence, a new primary CRC, other cancers, as well as both short-term and long-term adverse effects of the CRC and the modalities used to treat it. CRC survivors may also have psychological, reproductive, genetic, social, and employment concerns after treatment. Communication and coordination of care between the treating oncologist and the primary care clinician is critical to effectively and efficiently manage the long-term care of CRC survivors. The guidelines in this article are intended to assist primary care clinicians in delivering risk-based health care for CRC survivors who have completed active therapy.

Nationwide improvement of rectal cancer treatment outcomes in Norway, 1993-2010

BACKGROUND

The Norwegian Rectal Cancer Project was initated in 1993 with the aims of improving surgery, decreasing local recurrence rates, improving survival, and establishing a national rectal cancer registry. Here we present results from the Norwegian Colorectal Cancer Registry (NCCR) from 1993 to 2010.

MATERIAL AND METHODS

A total of 15 193 patients were diagnosed with rectal cancer in Norway 1993-2010, and were registered with clinical data regarding diagnosis, treatment, locoregional recurrences and distant metastases. Of these, 10 796 with non-metastatic disease underwent tumour resection. The results were stratified into five time periods, and the treatment outcomes were compared. Recurrence rates are presented for the 9785 patients who underwent curative major resection (R0/R1).

RESULTS

Among all 15 193 patients, relative five-year survival increased from 54.1% in 1993-1997 to 63.4% in 2007-2010 (p < 0.001). Among the 10 796 patients with stage I-III disease who underwent tumour resection, from 1993-1997 to 2007-2010, relative five-year survival improved from 71.2% to 80.6% (p < 0.001). An increasing proportion of these patients underwent surgery at large-volume hospitals; and 30- and 100-day mortality rates, respectively, decreased from 3.0% to 1.4% (p < 0.001) and from 5.1% to 3.0% (p < 0.011). Use of preoperative chemoradiotherapy increased from 6.5% in 1993 to 39.0% in 2010 (p < 0.001). Estimated local recurrence rate after major resection (R0/R1) decreased from 14.5% in 1993-1997 to 5.0% in 2007-2009 (p < 0.001), and distant recurrence rate decreased from 26.0% to 20.2% (p < 0.001).

CONCLUSION

Long-term outcomes from a national population-based rectal cancer registry are presented. Improvements in rectal cancer treatment have led to decreased recurrence rates of 5% and increased survival on a national level.

Current considerations in colorectal cancer surgery

Colorectal cancer is one of the most common cancers in the world. The last decades improvement in survival in all stages of the disease has been achieved. Many factors contributes to this improvement; earlier diagnosis, better pre-operative staging, neoadjuvant radiochemotherapy, better surgical method and approach, introduction of pre- and post-operative multidisciplinary team conferences and adjuvant chemotherapy. Currently, new modalities are developing; robotics and organ preserving through wait-and-watch will give colorectal surgeons even more treatment options. This article highlights important aspects of colorectal cancer management now and in the future.

Standardization of laparoscopic total mesorectal excision for rectal cancer: a structured international expert consensus

OBJECTIVE

To establish a structured international expert consensus on a detailed technical description of the laparoscopic total mesorectal excision (TME).

BACKGROUND

Laparoscopic TME is a common surgical approach for the treatment of rectal cancer, but there is little agreement on technical details and standards.

METHODS

Sixty leading surgical experts from 5 different world regions with a median overall experience of 250 laparoscopic TME participated in this study. Four stages of mixed quantitative and qualitative consensus-finding methods were applied. (1) Semistructured expert interviews were independently analyzed by 2 assessors. (2) Consensus on the interview data was reached using reiterating questionnaires (Delphi method). (3) This was further refined in an interactive workshop. (4) Based on this meeting, a comprehensive text was drafted and final approval was sought by all experts.

FINDINGS

Three theme categories were identified in 9 detailed interviews (anatomical landmarks, description of tissue retraction, and operating strategies). Following 2 rounds of a 54-item questionnaire, 29 items achieved very high agreement (A* ≥90%), 14 with good agreement (≥80%), 13 with moderate agreement (≥50%), and 18 with little or no agreement (<50%). In the workshop, areas of agreement were consolidated and conclusions were sought for those with less agreement. The final document was approved after 2 further rounds of surveys by all respondents.

CONCLUSIONS

This detailed and agreed technical description of laparoscopic TME may have implications on training, assessment, quality control, and future research.

Efficacy of transanal tube for prevention of anastomotic leakage following laparoscopic low anterior resection for rectal cancers: a retrospective cohort study in a single institution

BACKGROUND

Anastomotic leakage is one of the most serious complications following laparoscopic low anterior resection (LAR) for rectal cancers. The purpose of this study was to investigate whether transanal tube placement can reduce anastomotic leakage following laparoscopic LAR.

METHODS

Retrospective assessment was performed on 205 patients with rectal cancers who underwent laparoscopic LAR. A transanal tube was placed after anastomosis in 96 patients (group A). Another 109 patients were operated on without a transanal tube (group B). Clinicopathological and operative variables, the frequencies of anastomotic leakage and re-operation after leakage were investigated.

RESULTS

Patient age, gender, body mass index, tumor size, Dukes' stage, intra-operative blood loss, and the rate of left colic artery preservation were comparable between the two groups. Tumor location was lower and operative time was significantly longer in group A than group B (p < 0.001). Overall rate of leakage was 9.3 % (19/205). The frequency of leakage was 4.2 % (4/96) in group A and was 13.8 % (15/109) in group B. The rate of leakage was significantly lower in group A (p < 0.05). Furthermore, the re-operation rate for symptomatic anastomotic leakage was 0 % (0/4) in group A, while in contrast it was 73.3 % (10/15) in group B. The rate of re-operation was lower in group A than group B (p < 0.05) and all cases with symptomatic leakage in group A were cured by conservative treatment.

CONCLUSIONS

Transanal tube placement was effective for prevention of anastomotic leakage following laparoscopic LAR and avoiding re-operation after symptomatic leakage.

Multicentre propensity score-matched analysis of conventional versus extended abdominoperineal excision for low rectal cancer

BACKGROUND

Abdominal perineal excision (APE) was originally described with levator ani removal for rectal cancer. An even wider, more aggressive extralevator resection for APE has been proposed. Although some surgeons are performing a very wide 'extralevator APE (ELAPE)', there are few data to recommend it routinely. This multicentre study aimed to compare outcomes of APE and ELAPE.

METHODS

A multicentre propensity case-matched analysis comparing two surgical approaches (APE and ELAPE) was performed. All patients who underwent abdominoperineal resection of a rectal tumour were considered for the analysis. Tumour height was defined by magnetic resonance imaging measurement and patients with stage II-III tumours had neoadjuvant radiochemotherapy. Involvement of the circumferential resection margin (CRM) and intraoperative tumour perforation were the main outcome measures. A logistic regression model was used to study the relationship between the surgical approaches and outcomes.

RESULTS

From January 2008 to March 2013 a total of 1909 consecutive patients underwent APE or ELAPE, of whom 914 matched patients (457 in each group) formed the cohort for analysis. Intraoperative tumour perforation occurred in 7.9 and 7.7 per cent of patients during APE and ELAPE respectively (P = 0.902), and there was CRM involvement in 13.1 and 13.6 per cent (P = 0.846). There were no differences between APE and ELAPE in terms of postoperative complication rates (52.3 versus 48.1 per cent; P = 0.209), need for reoperation (7.7 versus 7.0 per cent; P = 0.703), perineal wound problems (26.0 versus 21.9 per cent; P = 0.141), mortality rate (2.0 versus 2.0 per cent; P = 1.000) and local recurrence rate at 2 years (2.7 versus 5.6 per cent; P = 0.664).

CONCLUSION

ELAPE does not improve rates of CRM involvement, intraoperative tumour perforation, local recurrence or mortality.

Laparoscopic total mesorectal excision for extraperitoneal rectal cancer: long-term results of a 18-year single-centre experience

BACKGROUND AND OBJECTIVES

The oncologic efficacy of laparoscopic total mesorectal excision (TME) for middle-low rectal cancer is still under discussion because of the few long-term data. This study reports the results arising from a single-institution experience during a 18-year period.

METHODS

Data about 132 consecutive laparoscopic TME performed between January 1994 and January 2012 were analysed with Kaplan-Meier method and a uni- and multi-variate analysis was conducted to define independent survival predictors.

RESULTS

A total of 116 sphincter-preserving operations and 16 abdominoperineal resections were performed. Postoperative mortality and morbidity were 0.8 and 18.2%, with a rate of anastomotic leakage of 13.8%. Average follow-up was 85.9 months (range 13-210). Actuarial local recurrence rate was 4.13% at 5 years (any pelvic recurrence developed after 3 years from surgery). Overall and disease-free survival was respectively 83 and 79.8% at 5 years, 71 and 73% at 10 years and then remained constant until 18 years. Survival was correlated only to tumour stage and the type of surgery.

CONCLUSIONS

Laparoscopic TME for extraperitoneal rectal cancer shows long-term oncologic outcomes similar to open rectal resections.

New trends in rectal cancer treatment

SUMMARY 

The treatment philosophy for rectal cancer has changed a lot during the last three decades. In the 1970s it was more or less a pure surgical business and rectal cancer was considered radiation resistant. Owing to the unacceptable high local recurrence rates, surgery was changed (the total mesorectal excision technique) during the 1980s and treatment was, in many countries, concentrated to lager units. Moreover, the addition of adjuvant radiotherapy was tested during the same period in several randomized trials and demonstrated that the local recurrence rate could be reduced by 50%, provided the radiation dose was high enough. Since then, treatment has changed very rapidly with several interesting approaches, such as timing and type of radiotherapy, the place of chemotherapy, surgery with modern technique including laparoscopy; natural orifice transendoscopic surgery or robotics; and the whole idea of ‘wait-and-watch’ program. All of these new aspects are covered and discussed in the view of the standard-of-care in 2014.

Locally advanced rectal cancer: new findings in anticancer therapy

SUMMARY Rectal cancer accounts for nearly a third of colorectal cancer cases, with a mortality of 4–10 cases per 100,000 per year, thus accounting for 9% of cancer deaths both in males and in females in western countries. Management of locally advanced rectal cancer has undergone and continues to undergo significant progress in the last two decades: in particular, new multimodality strategies have contributed to marked improvements in terms of reduction of both local and distant recurrence rates. This review focuses and summarizes the effectiveness of multimodality approaches in the standard treatment programs for locally advanced rectal cancer and also discusses the ongoing research to improve these regimens.