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Somashekhar SP, Saklani A, Dixit J, Kothari J, Nayak S, Sudheer OV, Dabas S, Goud J, Munikrishnan V, Sugoor P, Penumadu P, Ramachandra C, Mehendale S, Dahiya A. Clinical Robotic Surgery Association (India Chapter) and Indian rectal cancer expert group’s practical consensus statements for surgical management of localized and locally advanced rectal cancer. Front Oncol 2022; 12:1002530. [PMID: 36267970 PMCID: PMC9577482 DOI: 10.3389/fonc.2022.1002530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 09/16/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction There are standard treatment guidelines for the surgical management of rectal cancer, that are advocated by recognized physician societies. But, owing to disparities in access and affordability of various treatment options, there remains an unmet need for personalizing these international guidelines to Indian settings. Methods Clinical Robotic Surgery Association (CRSA) set up the Indian rectal cancer expert group, with a pre-defined selection criterion and comprised of the leading surgical oncologists and gastrointestinal surgeons managing rectal cancer in India. Following the constitution of the expert Group, members identified three areas of focus and 12 clinical questions. A thorough review of the literature was performed, and the evidence was graded as per the levels of evidence by Oxford Centre for Evidence-Based Medicine. The consensus was built using the modified Delphi methodology of consensus development. A consensus statement was accepted only if ≥75% of the experts were in agreement. Results Using the results of the review of the literature and experts’ opinions; the expert group members drafted and agreed on the final consensus statements, and these were classified as “strong or weak”, based on the GRADE framework. Conclusion The expert group adapted international guidelines for the surgical management of localized and locally advanced rectal cancer to Indian settings. It will be vital to disseminate these to the wider surgical oncologists and gastrointestinal surgeons’ community in India.
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Affiliation(s)
- S. P. Somashekhar
- Department of Surgical Oncology, Manipal Hospital, Bengaluru, Karnataka, India
- *Correspondence: S. P. Somashekhar,
| | - Avanish Saklani
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Jagannath Dixit
- Department of GI Surgery, HCG Hospital, Bengaluru, Karnataka, India
| | - Jagdish Kothari
- Department of Surgical Oncology HCG Hospital, Ahmedabad, Gujarat, India
| | - Sandeep Nayak
- Department of Surgical Oncology, Fortis Hospital, Bengaluru, Karnataka, India
| | - O. V. Sudheer
- Department of GI Surgery and Surgical Oncology, Amrita Institute of Medical Science, Kochi, Kerala, India
| | - Surender Dabas
- Department of Surgical Oncology, BL Kapur-Max Superspeciality Hospital, Delhi, India
| | - Jagadishwar Goud
- Department of Surgical Oncology, AOI Hospital, Hyderabad, Telangana, India
| | | | - Pavan Sugoor
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
| | | | - C. Ramachandra
- Director and Head, Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
| | - Shilpa Mehendale
- Director and Head, Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
| | - Akhil Dahiya
- Department of Clinical and Medical Affairs, Intuitive Surgical, California, CA, United States
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Hendrick LE, Buckner JD, Guerrero WM, Shibata D, Hinkle NM, Monroe JJ, Glazer ES, Deneve JL, Dickson PV. What Is the Utility of Restaging Imaging for Patients With Clinical Stage II/III Rectal Cancer After Completion of Neoadjuvant Chemoradiation and Prior to Proctectomy? Am Surg 2020; 87:242-247. [PMID: 32927959 DOI: 10.1177/0003134820950298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND In the United States, patients with clinical stage II or III rectal cancer typically receive neoadjuvant chemoradiation therapy (chemo/XRT) over a 5-6 week period followed by a 6-10 week break prior to proctectomy. In the current study, we evaluate the utilization of restaging studies performed and detection of disease progression during this window. METHODS A retrospective review of patients with clinical stage II/III rectal cancer was performed. Medical records were analyzed to collect clinicopathologic data and the performance and results of preoperative, early postoperative, and first surveillance CT and/or PET/CT in patients completing long course neoadjuvant chemo/XRT and undergoing proctectomy. RESULTS Between 2005 and 2017, 176 patients with clinical stage II or III rectal adenocarcinoma completed neoadjuvant chemo/XRT and underwent proctectomy. Preoperative restaging with CT CAP and/or CT/PET was performed in 72 (40.9%) patients with no detection of disease progression. Of the 104 patients without preoperative restaging, 1 had intraoperative detection of liver metastases and 31 had early postoperative reimaging (within 30 days of proctectomy) of which 2 had detection of new pulmonary metastases. Among 72 patients with no preoperative or early postoperative reimaging, first surveillance imaging was available in 47 and detected new metastases in 8 (17%). DISCUSSION In patients with clinical stage II/III rectal cancer who undergo long course neoadjuvant chemo/XRT, perioperative reimaging with CT CAP and/or PET/CT detects new metastases in a small percentage of patients. A multi-institutional, prospective analysis using standardized staging protocols is warranted to better determine the value of preoperative restaging in these patients.
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Affiliation(s)
- Leah E Hendrick
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jacob D Buckner
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Whitney M Guerrero
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - David Shibata
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Nathan M Hinkle
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Justin J Monroe
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Evan S Glazer
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jeremiah L Deneve
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Paxton V Dickson
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, TN, USA
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Raghavan S, Singh DK, Rohila J, DeSouza A, Engineer R, Ramaswamy A, Ostwal V, Saklani A. Outcomes of Definitive Treatment of Signet Ring Cell Carcinoma of the Rectum: Is Minimal Invasive Surgery Detrimental in Signet Ring Rectal Cancers? Indian J Surg Oncol 2020; 11:597-603. [PMID: 33299278 PMCID: PMC7714872 DOI: 10.1007/s13193-020-01142-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 06/17/2020] [Indexed: 01/18/2023] Open
Abstract
The outcome of surgery for signet ring adenocarcinoma of rectum is suboptimal with high predilection for locoregional and peritoneal metastases. Lack of intercellular adhesion due to focal loss of epithelial cell adhesion molecule (EpCAM) may account for this. In such patients, whether minimal invasive surgery carries a high risk of dissemination by pneumoperitoneum and tumor implantation remains uncertain. The aim of this study was to compare the outcomes of patients undergoing minimally invasive surgery (MIS) versus open surgery in patients with signet ring cell adenocarcinoma of rectum. A retrospective study was conducted at a tertiary care center over 3 years on 39 patients undergoing open surgery and 40 patients undergoing MIS diagnosed with signet ring cell carcinoma (SRCC) identified from our surgical database. Patient characteristics in terms of demographics, clinicoradiological staging, neoadjuvant therapy, and type of surgery with morbidity were compared in the two groups. Data on patients undergoing adjuvant therapy and 3 years disease-free survival (DFS) and overall survival (OS) were analyzed. Recurrence patterns in both groups were separately identified as locoregional, peritoneal, or systemic. The number of patients undergoing surgery in the two arms was 40 (MIS) and 39 (open). In the MIS arm, mean DFS was 29 months whereas in the open arm, it was 25.8 months. The mean OS was 33.65 months for the MIS arm and that for the open arm was 36.34 months. This retrospective study reveals no significant difference in outcomes of surgery for signet ring cell rectal cancers with either MIS or open approach.
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Affiliation(s)
- S Raghavan
- Colorectal Disease Management Group, Department Of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Deepak Kumar Singh
- Colorectal Disease Management Group, Department Of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - J Rohila
- Colorectal Disease Management Group, Department Of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - A DeSouza
- Colorectal Disease Management Group, Department Of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - R Engineer
- Colorectal Disease Management Group, Department Of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - A Ramaswamy
- Colorectal Disease Management Group, Department Of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - V Ostwal
- Colorectal Disease Management Group, Department Of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - A Saklani
- Colorectal Disease Management Group, Department Of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
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Restaging Patients with Rectal Cancer Following Neoadjuvant Chemoradiation: A Systematic Review. World J Surg 2019; 44:973-979. [PMID: 31788724 DOI: 10.1007/s00268-019-05309-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND In the USA, most patients with clinical stage II/III rectal cancer receive neoadjuvant chemoradiation (chemo/XRT) over 5-6 weeks followed by a 6-10-week break before proctectomy. As chemotherapy is delivered at radio-sensitizing doses, there is essentially a 3-month window during which potential systemic disease is untreated. Evidence regarding the utility of restaging patients prior to proctectomy is limited. METHODS PubMed, Scopus, Web of Science, and the Cochrane Library were searched for studies evaluating the utility of restaging patients with rectal cancer after completion of long-course chemo/XRT, and reporting associated changes in management. Studies that were non-English, included <50 patients, or examining the diagnostic accuracy of imaging modalities were excluded. Study quality was evaluated using the modified Newcastle Ottawa Scale. RESULTS Eight studies were identified including a total of 1251 patients restaged between completion of chemo/XRT and proctectomy. All studies were retrospective. Restaging identified new metastatic disease in 72 (6.0%) patients, with 4 studies reporting specific sites: liver (n = 28), lung (n = 8), adrenal (n = 1), bone (n = 1), and multiple sites (n = 7). Overall progression (distant or local) was detected in 88 (7.0%) patients and resulted in a change in management in 77 (87.5%) of these patients. Tumor-related prognostic characteristics were inconsistently reported among studies, precluding meta-analysis. CONCLUSIONS Although restaging between completion of neoadjuvant chemo/XRT and proctectomy detects disease progression in only a small percentage of patients, findings alter the treatment plan in the vast majority of these patients. Multi-institutional collaboration with analysis of well-defined prognostic variables may better identify patients most likely to benefit from restaging.
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Manenti A, Roncati L, Salati M, Simonini E, Zizzo M, Farinetti A. Rectal cancer restaging after neoadjuvant chemoradiation: towards a down-staging score system. J Gastrointest Oncol 2017; 8:187-188. [PMID: 28280623 DOI: 10.21037/jgo.2016.10.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Antonio Manenti
- Department of Surgery, Policlinico Hospital, University of Modena, Modena, Italy
| | - Luca Roncati
- Department of Pathology, Policlinico Hospital, University of Modena, Modena, Italy
| | - Massimiliano Salati
- Department of Oncology, Policlinico Hospital, University of Modena, Modena, Italy
| | - Emilio Simonini
- Department of Radiology, Policlinico Hospital, University of Modena, Modena, Italy
| | - Maurizio Zizzo
- Department of Surgery, Policlinico Hospital, University of Modena, Modena, Italy
| | - Alberto Farinetti
- Department of Surgery, Policlinico Hospital, University of Modena, Modena, Italy
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