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Piqeur F, Creemers DMJ, Banken E, Coolen L, Tanis PJ, Maas M, Roef M, Marijnen CAM, van Hellemond IEG, Nederend J, Rutten HJT, Peulen HMU, Burger JWA. Dutch national guidelines for locally recurrent rectal cancer. Cancer Treat Rev 2024; 127:102736. [PMID: 38696903 DOI: 10.1016/j.ctrv.2024.102736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 04/15/2024] [Accepted: 04/18/2024] [Indexed: 05/04/2024]
Abstract
Due to improvements in treatment for primary rectal cancer, the incidence of LRRC has decreased. However, 6-12% of patients will still develop a local recurrence. Treatment of patients with LRRC can be challenging, because of complex and heterogeneous disease presentation and scarce - often low-grade - data steering clinical decisions. Previous consensus guidelines have provided some direction regarding diagnosis and treatment, but no comprehensive guidelines encompassing all aspects of the clinical management of patients with LRRC are available to date. The treatment of LRRC requires a multidisciplinary approach and overarching expertise in all domains. This broad expertise is often limited to specific expert centres, with dedicated multidisciplinary teams treating LRRC. A comprehensive, narrative literature review was performed and used to develop the Dutch National Guideline for management of LRRC, in an attempt to guide decision making for clinicians, regarding the complete clinical pathway from diagnosis to surgery.
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Affiliation(s)
- Floor Piqeur
- Department of Radiation Oncology, Catharina Hospital, Michelangelolaan 2 5623EJ, Eindhoven, the Netherlands; Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121 1066 CX, Amsterdam, the Netherlands; Department of Radiation Oncology, Leiden University Medical Centre, Albinusdreef 2 2333ZA, Leiden, the Netherlands
| | - Davy M J Creemers
- GROW School of Oncology and Developmental Biology, University of Maastricht, Universiteitssingel 40 6229ER, Maastricht, the Netherlands; Department of Surgery, Catharina Hospital, Michelangelolaan 2 5623EJ, Eindhoven, the Netherlands
| | - Evi Banken
- GROW School of Oncology and Developmental Biology, University of Maastricht, Universiteitssingel 40 6229ER, Maastricht, the Netherlands; Department of Medical Oncology, Catharina Hospital, Michelangelolaan 2 5623 EJ, Eindhoven, the Netherlands
| | - Liën Coolen
- Department of Radiology, Catharina Hospital, Michelangelolaan 2 5623 EJ, Eindhoven, the Netherlands
| | - Pieter J Tanis
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus Medical Centre, Dr. Molewaterplein 40 3015 GD, Rotterdam, the Netherlands
| | - Monique Maas
- GROW School of Oncology and Developmental Biology, University of Maastricht, Universiteitssingel 40 6229ER, Maastricht, the Netherlands; Department of Radiology, The Netherlands Cancer Institute, Plesmanlaan 121 1066 CX, Amsterdam, the Netherlands
| | - Mark Roef
- Department of Nuclear Medicine, Catharina Hospital, Michelangelolaan 2 5623EJ, Eindhoven, the Netherlands
| | - Corrie A M Marijnen
- Department of Radiation Oncology, Leiden University Medical Centre, Albinusdreef 2 2333ZA, Leiden, the Netherlands
| | - Irene E G van Hellemond
- Department of Medical Oncology, Catharina Hospital, Michelangelolaan 2 5623 EJ, Eindhoven, the Netherlands
| | - Joost Nederend
- Department of Radiology, Catharina Hospital, Michelangelolaan 2 5623 EJ, Eindhoven, the Netherlands
| | - Harm J T Rutten
- GROW School of Oncology and Developmental Biology, University of Maastricht, Universiteitssingel 40 6229ER, Maastricht, the Netherlands; Department of Surgery, Catharina Hospital, Michelangelolaan 2 5623EJ, Eindhoven, the Netherlands
| | - Heike M U Peulen
- Department of Radiation Oncology, Catharina Hospital, Michelangelolaan 2 5623EJ, Eindhoven, the Netherlands
| | - Jacobus W A Burger
- Department of Surgery, Catharina Hospital, Michelangelolaan 2 5623EJ, Eindhoven, the Netherlands.
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Waller JH, van Kessel CS, Solomon MJ, Lee PJ, Austin KKS, Steffens D. Outcomes Following Pelvic Exenteration for Locally Recurrent Rectal Cancer With and Without En Bloc Sacrectomy. Dis Colon Rectum 2024; 67:796-804. [PMID: 38408876 DOI: 10.1097/dcr.0000000000003154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
BACKGROUND Extended radical resection is often the only chance of cure for locally recurrent rectal cancer. Recurrence in the posterior compartment often necessitates en bloc sacrectomy as part of pelvic exenteration to obtain clear resection margins and provide survival benefit. OBJECTIVE To compare oncological outcomes, morbidity, and quality-of-life outcomes following pelvic exenteration with and without en bloc sacrectomy for recurrent rectal cancer. DESIGN Comparative cohort study with retrospective analysis of prospectively collected data. SETTING This study was conducted at a high-volume pelvic exenteration center. PATIENTS Patients who underwent pelvic exenteration for locally recurrent rectal cancer between 1994 and 2022. MAIN OUTCOME MEASURES Overall survival, postoperative morbidity, R0 resection margin, and quality-of-life outcomes. RESULTS Of 965 patients, 305 (31.6%) underwent pelvic exenteration for locally recurrent rectal cancer. Among these patients, 64.3% were men and the median age was 62 years (range, 29-86). One hundred eighty-five patients (60.7%) underwent en bloc sacrectomy, 65 (35.1%) underwent high transection, and 119 (64.3%) had sacrectomy below S2. R0 resection was achieved in 80% of patients with sacrectomy and 72.5% of patients without sacrectomy. Sacrectomy patients experienced more postoperative complications without increased mortality. The median overall survival was 52 months; median survival was 47 months with sacrectomy and 73 months without ( p = 0.059). Quality-of-life scores were not significantly different across physical component ( p = 0.346), mental component ( p = 0.787), or Functional Assessment of Cancer Therapy-Colorectal ( p = 0.679) scores at 24-month follow-up. LIMITATIONS The generalizability of these findings may be limited outside of subspecialist exenteration units. Selection bias exists in a retrospective analysis. CONCLUSIONS Patients undergoing pelvic exenteration with and without en bloc sacrectomy for locally recurrent rectal cancer experience similar rates of R0 resection, survival, and quality-of-life outcomes. As R0 remains the most important predictor of survival, the requirement of sacral resection should prompt referral to a subspecialist center that performs sacrectomy routinely. See Video Abstract . RESULTADOS DESPUS DE LA EXENTERACIN PLVICA PARA EL CNCER DE RECTO CON RECURRENCIA LOCAL, CON Y SIN SACRECTOMA EN BLOQUE ANTECEDENTES:La resección radical ampliada es generalmente la única posibilidad de curación para el cáncer de recto con recurrencia local. La recurrencia en el compartimento posterior generalmente requiere sacrectomía en bloque como parte de la exenteración pélvica para obtener márgenes de resección claros y proporcionar un beneficio de supervivencia.OBJETIVO:Comparar los resultados oncológicos, de morbilidad y de calidad de vida después de la exenteración pélvica con y sin sacrectomía en bloque para el cáncer de recto recurrente.DISEÑO:Estudio de cohorte comparativo con análisis retrospectivo de datos recopilados prospectivamente.AMBIENTE AJUSTE:Estudio realizado en un centro de exenteración pélvica de alto volumen.PACIENTES:Aquellos sometidos a exenteración pélvica por cáncer de recto con recurrencia local entre 1994 y 2022.PRINCIPALES MEDIDAS DE RESULTADO:Supervivencia general, morbilidad posoperatoria, margen de resección R0 y resultados de calidad de vida.RESULTADOS:305 (31,6%) de 965 pacientes se sometieron a exenteración pélvica por cáncer de recto con recurrencia local. El 64,3% de los pacientes eran hombres con una mediana de edad de 62 años (rango 29-86). 185 pacientes (60,7%) fueron sometidos a sacrectomía en bloque, 65 (35,1%) fueron sometidos a transección alta, 119 (64,3%) tuvieron sacrectomía por debajo de S2. La resección R0 se logró en el 80% de los pacientes con sacrectomía y en el 72,5% sin ella. Los pacientes de sacrectomía experimentaron más complicaciones postoperatorias sin aumento de la mortalidad. La mediana de supervivencia global fue de 52 meses, 47 meses con sacrectomía y 73 meses sin sacrectomía ( p = 0,059). Las puntuaciones de calidad de vida no fueron significativamente diferentes entre las puntuaciones del componente físico ( p = 0,346), componente mental ( p = 0,787) o la evaluación funcional de la terapia contra el cáncer - colorrectal ( p = 0,679) a los 24 meses de seguimiento.LIMITACIONES:La generalización de estos hallazgos puede estar limitada fuera de las unidades de exenteración de subespecialistas. Existe un sesgo de selección en un análisis retrospectivo.CONCLUSIONES:Los pacientes sometidos a exenteración pélvica con y sin sacrectomía en bloque por cáncer de recto con recurrencia local experimentan tasas similares de resección R0, supervivencia y resultados de calidad de vida. Como R0 sigue siendo el predictor más importante de supervivencia, la necesidad de resección sacra debe provocar la derivación a un centro subespecialista que realice sacrectomía de forma rutinaria. (Traducción-Dr. Fidel Ruiz Healy ).
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Affiliation(s)
- Jacob H Waller
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Charlotte S van Kessel
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Peter J Lee
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Kirk K S Austin
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
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Milanko NA, Kelly ME, Turner G, Kong J, Behrenbruch C, Mohan H, Guerra G, Warrier S, McCormick J, Heriot A. Evaluating postoperative hernia incidence and risk factors following pelvic exenteration. Int J Colorectal Dis 2024; 39:70. [PMID: 38717479 PMCID: PMC11078832 DOI: 10.1007/s00384-024-04638-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2024] [Indexed: 05/12/2024]
Abstract
Pelvic exenteration (PE) is a technically challenging surgical procedure. More recently, quality of life and survivorship following PEs are being increasingly acknowledged as important patient outcomes. This includes evaluating major long-term complications such as hernias, defined as the protrusion of internal organs through a facial defect (The PelvEx Collaborative in Br J Surg 109:1251-1263, 2022), for which there is currently limited literature. The aim of this paper is to ascertain the incidence and risk factors for postoperative hernia formation among our PE cohort managed at a quaternary centre. METHOD A retrospective cohort study examining hernia formation following PE for locally advanced rectal carcinoma and locally recurrent rectal carcinoma between June 2010 and August 2022 at a quaternary cancer centre was performed. Baseline data evaluating patient characteristics, surgical techniques and outcomes was collated among a PE cohort of 243 patients. Postoperative hernia incidence was evaluated via independent radiological screening and clinical examination. RESULTS A total of 79 patients (32.5%) were identified as having developed a hernia. Expectantly, those undergoing flap reconstruction had a lower incidence of postoperative hernias. Of the 79 patients who developed postoperative hernias, 16.5% reported symptoms with the most common symptom reported being pain. Reintervention was required in 18 patients (23%), all of which were operative. CONCLUSION This study found over one-third of PE patients developed a hernia postoperatively. This paper highlights the importance of careful perioperative planning and optimization of patients to minimize morbidity.
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Affiliation(s)
- Nicole Anais Milanko
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia.
| | - Michael Eamon Kelly
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
- Trinity St James Cancer Institute, Dublin, Ireland
| | - Greg Turner
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
- Auckland District Health Board, Auckland, New Zealand
| | - Joeseph Kong
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
| | - Cori Behrenbruch
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
| | - Helen Mohan
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
| | - Glen Guerra
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
| | - Satish Warrier
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
| | - Jacob McCormick
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
- Department of General Surgery, Royal Melbourne Hospital, Melbourne, Australia
| | - Alexander Heriot
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia.
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Fiore M, Sarre-Lazcano C, Smith M, Khan M, Raut CP, Honoré C, Sargos P, Cananzi F, Grignani G, Iwata S, Gronchi A. Primary pelvic soft tissue sarcomas (PELVISARC): outcomes from the TransAtlantic Australasian Retroperitoneal Sarcoma Working Group (TARPSWG). Br J Surg 2024; 111:znae128. [PMID: 38805374 PMCID: PMC11132121 DOI: 10.1093/bjs/znae128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 02/20/2024] [Accepted: 04/30/2024] [Indexed: 05/30/2024]
Affiliation(s)
- Marco Fiore
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Catherine Sarre-Lazcano
- Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán General Surgery, Mexico City, Mexico
| | - Myles Smith
- Sarcoma Unit, Royal Marsden Hospital, London, UK
| | - Misbah Khan
- Sarcoma Unit, Royal Marsden Hospital, London, UK
| | - Chandrajit P Raut
- Dana-Farber Cancer Institute, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Charles Honoré
- Department of Surgical Oncology, Institut Gustave Roussy, Paris, France
| | - Paul Sargos
- Department of Radiotherapy, Institut Bergonié, Bordeaux, France
| | - Ferdinando Cananzi
- Sarcoma, Melanoma and Rare Tumors Surgery Unit, IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Giovanni Grignani
- Division of Medical Oncology, Candiolo Cancer Institute, Candiolo, Italy
| | - Shintaro Iwata
- Department of Musculoskeletal Oncology and Rehabilitation, National Cancer Center Hospital, Tokyo, Japan
| | - Alessandro Gronchi
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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Denys A, Thielemans S, Salihi R, Tummers P, van Ramshorst GH. Quality of Life After Extended Pelvic Surgery with Neurovascular or Bony Resections in Gynecological Oncology: A Systematic Review. Ann Surg Oncol 2024; 31:3280-3299. [PMID: 38459419 DOI: 10.1245/s10434-023-14649-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 11/09/2023] [Indexed: 03/10/2024]
Abstract
BACKGROUND Extended pelvic surgery with neurovascular or bony resections in gynecological oncology has significant impact on quality of life (QoL) and high morbidity. The objective of this systematic review was to provide an overview of QoL, morbidity and mortality following these procedures. METHODS The registered PROSPERO protocol included database-specific search strategies. Studies from 1966 onwards reporting on QoL after extended pelvic surgery with neurovascular or bony resections for gynecological cancer were considered eligible. All others were excluded. Study selection (Rayyan), data extraction, rating of evidence (GRADE) and risk of bias (ROBINS-I) were performed independently by two reviewers. RESULTS Of 349 identified records, 121 patients from 11 studies were included-one prospective study, seven retrospective studies, and three case reports. All studies were of very low quality and with an overall serious risk of bias. Primary tumor location was the cervix (n = 78, 48.9%), vulva (n = 30, 18.4%), uterus (n = 21, 12.9%), endometrium (n = 15, 9.2%), ovary (n = 8, 4.9%), (neo)vagina (n = 3, 1.8%), Gartner duct/paracolpium (n = 1, 0.6%), or synchronous tumors (n = 3, 1.8%), or were not reported (n = 4, 2.5%). Bony resections included the pelvic bone (n = 36), sacrum (n = 2), and transverse process of L5 (n = 1). Margins were negative in 70 patients and positive in 13 patients. Thirty-day mortality was 1.7% (2/121). Three studies used validated QoL questionnaires and seven used non-validated measurements; all reported acceptable QoL postoperatively. CONCLUSIONS In this highly selected patient group, mortality and QoL seem to be acceptable, with a high morbidity rate. This comprehensive study will help to inform eligible patients about the outcomes of extended pelvic surgery with neurovascular or bony resections. Future collaborative studies can enable the collection of QoL data in a validated, uniform manner.
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Affiliation(s)
- Andreas Denys
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Sofie Thielemans
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Rawand Salihi
- Department of Gynecology and Obstetrics, Ghent University Hospital, Ghent, Belgium
- Department of Gynecology and Obstetrics, AZ St. Lucas Hospital, Ghent, Belgium
| | - Philippe Tummers
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
- Department of Gynecology and Obstetrics, Ghent University Hospital, Ghent, Belgium
| | - Gabrielle H van Ramshorst
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium.
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium.
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Piqeur F, Peulen HM, Cnossen JS, Bimmel-Nagel CCH, Rutten HJ, Burger JW, Verrijssen ASE. Post-operative complications following dose adaptation of intra-operative electron beam radiation therapy in locally advanced or recurrent rectal cancer. J Contemp Brachytherapy 2024; 16:85-94. [PMID: 38808205 PMCID: PMC11129652 DOI: 10.5114/jcb.2024.139276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 03/11/2024] [Indexed: 05/30/2024] Open
Abstract
Purpose The benefit of intra-operative radiotherapy (IORT) in the treatment of locally advanced rectal cancer (LARC) or locally recurrent rectal cancer (LRRC) lie in its ability to provide high-dose of radiation to limited at-risk volume, thereby eliminating microscopic disease and decreasing toxicity. A comparative study between high-dose-rate (HDR) brachytherapy, named intra-operative brachytherapy (IOBT), and intra-operative electron radiotherapy (IOERT) was performed showing favorable LRFS after IOBT, possibly due to a higher surface dose that is inherent in IOBT technique. The IOERT technique in Catharina Hospital Eindhoven was adapted to increase the surface dose, aiming to improve local control. Post-operative complications due to an increased radiation dose remain the matter of concern. This retrospective study was performed to compare complication rates before and after adapted IOERT dose. Material and methods All patients undergoing surgery with IOERT for LARC or LRRC from September 2019 until July 2023, were considered. Patients selected until August 31, 2021 were included in control cohort (n = 108), and those chosen from September 1, 2021 onwards were included in intervention cohort (n = 92). Perioperative and (major) post-operative complications were classified retrospectively, during admission, at 30 days, and at 90 days. Results In LARC patients, a decrease in post-operative complications was observed (p = 0.009). 19% of LARC patients experienced major post-operative surgical complications, i.e., Clavien-Dindo grade 3b-5, regardless of treatment group. No difference in major 90-day complications was noted (p = 0.142). In LRRC patients, the use of induction chemotherapy decreased from 78% to 29% (p < 0.001), which complicated comparison. However, no difference in major post-operative complications was observed at 30 days (p = 0.222) or 90 days (p = 0.977) after surgery. Conclusions Increased surface dose of IOERT does not seem to lead to an increase in post-operative complications. Further research is needed to evaluate the efficacy of dose adaptation in IOERT to improve local oncological control rates. Routine evaluation of CTCAE scores in follow-up will help uncover possible long-term radiation-induced toxicity.
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Affiliation(s)
- Floor Piqeur
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, The Netherlands
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Heike M.U. Peulen
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, The Netherlands
| | - Jeltsje S. Cnossen
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, The Netherlands
| | | | - Harm J.T. Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
- GROW School of Oncology and Reproduction, University of Maastricht, Maastricht, The Netherlands
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Mirnezami AH, Drami I, Glyn T, Sutton PA, Tiernan J, Behrenbruch C, Guerra G, Waters PS, Woodward N, Applin S, Charles SJ, Rose SA, Denys A, Pape E, van Ramshorst GH, Baker D, Bignall E, Blair I, Davis P, Edwards T, Jackson K, Leendertse PG, Love-Mott E, MacKenzie L, Martens F, Meredith D, Nettleton SE, Trotman MP, van Hecke JJM, Weemaes AMJ, Abecasis N, Angenete E, Aziz O, Bacalbasa N, Barton D, Baseckas G, Beggs A, Brown K, Buchwald P, Burling D, Burns E, Caycedo-Marulanda A, Chang GJ, Coyne PE, Croner RS, Daniels IR, Denost QD, Drozdov E, Eglinton T, Espín-Basany E, Evans MD, Flatmark K, Folkesson J, Frizelle FA, Gallego MA, Gil-Moreno A, Goffredo P, Griffiths B, Gwenaël F, Harris DA, Iversen LH, Kandaswamy GV, Kazi M, Kelly ME, Kokelaar R, Kusters M, Langheinrich MC, Larach T, Lydrup ML, Lyons A, Mann C, McDermott FD, Monson JRT, Neeff H, Negoi I, Ng JL, Nicolaou M, Palmer G, Parnaby C, Pellino G, Peterson AC, Quyn A, Rogers A, Rothbarth J, Abu Saadeh F, Saklani A, Sammour T, Sayyed R, Smart NJ, Smith T, Sorrentino L, Steele SR, Stitzenberg K, Taylor C, Teras J, Thanapal MR, Thorgersen E, Vasquez-Jimenez W, Waller J, Weber K, Wolthuis A, Winter DC, Brangan G, Vimalachandran D, Aalbers AGJ, Abdul Aziz N, Abraham-Nordling M, Akiyoshi T, Alahmadi R, Alberda W, Albert M, Andric M, Angeles M, Antoniou A, Armitage J, Auer R, Austin KK, Aytac E, Baker RP, Bali M, Baransi S, Bebington B, Bedford M, Bednarski BK, Beets GL, Berg PL, Bergzoll C, Biondo S, Boyle K, Bordeianou L, Brecelj E, Bremers AB, Brunner M, Bui A, Burgess A, Burger JWA, Campain N, Carvalhal S, Castro L, Ceelen W, Chan KKL, Chew MH, Chok AK, Chong P, Christensen HK, Clouston H, Collins D, Colquhoun AJ, Constantinides J, Corr A, Coscia M, Cosimelli M, Cotsoglou C, Damjanovic L, Davies M, Davies RJ, Delaney CP, de Wilt JHW, Deutsch C, Dietz D, Domingo S, Dozois EJ, Duff M, Egger E, Enrique-Navascues JM, Espín-Basany E, Eyjólfsdóttir B, Fahy M, Fearnhead NS, Fichtner-Feigl S, Fleming F, Flor B, Foskett K, Funder J, García-Granero E, García-Sabrido JL, Gargiulo M, Gava VG, Gentilini L, George ML, George V, Georgiou P, Ghosh A, Ghouti L, Giner F, Ginther N, Glover T, Golda T, Gomez CM, Harris C, Hagemans JAW, Hanchanale V, Harji DP, Helbren C, Helewa RM, Hellawell G, Heriot AG, Hochman D, Hohenberger W, Holm T, Holmström A, Hompes R, Hornung B, Hurton S, Hyun E, Ito M, Jenkins JT, Jourand K, Kaffenberger S, Kapur S, Kanemitsu Y, Kaufman M, Kelley SR, Keller DS, Kersting S, Ketelaers SHJ, Khan MS, Khaw J, Kim H, Kim HJ, Kiran R, Koh CE, Kok NFM, Kontovounisios C, Kose F, Koutra M, Kraft M, Kristensen HØ, Kumar S, Lago V, Lakkis Z, Lampe B, Larsen SG, Larson DW, Law WL, Laurberg S, Lee PJ, Limbert M, Loria A, Lynch AC, Mackintosh M, Mantyh C, Mathis KL, Margues CFS, Martinez A, Martling A, Meijerink WJHJ, Merchea A, Merkel S, Mehta AM, McArthur DR, McCormick JJ, McGrath JS, McPhee A, Maciel J, Malde S, Manfredelli S, Mikalauskas S, Modest D, Morton JR, Mullaney TG, Navarro AS, Neto JWM, Nguyen B, Nielsen MB, Nieuwenhuijzen GAP, Nilsson PJ, Nordkamp S, O’Dwyer ST, Paarnio K, Pappou E, Park J, Patsouras D, Peacock O, Pfeffer F, Piqeur F, Pinson J, Poggioli G, Proud D, Quinn M, Oliver A, Radwan RW, Rajendran N, Rao C, Rasheed S, Rasmussen PC, Rausa E, Regenbogen SE, Reims HM, Renehan A, Rintala J, Rocha R, Rochester M, Rohila J, Rottoli M, Roxburgh C, Rutten HJT, Safar B, Sagar PM, Sahai A, Schizas AMP, Schwarzkopf E, Scripcariu D, Scripcariu V, Seifert G, Selvasekar C, Shaban M, Shaikh I, Shida D, Simpson A, Skeie-Jensen T, Smart P, Smith JJ, Solbakken AM, Solomon MJ, Sørensen MM, Spasojevic M, Steffens D, Stocchi L, Stylianides NA, Swartling T, Sumrien H, Swartking T, Takala H, Tan EJ, Taylor D, Tejedor P, Tekin A, Tekkis PP, Thaysen HV, Thurairaja R, Toh EL, Tsarkov P, Tolenaar J, Tsukada Y, Tsukamoto S, Tuech JJ, Turner G, Turner WH, Tuynman JB, Valente M, van Rees J, van Zoggel D, Vásquez-Jiménez W, Verhoef C, Vierimaa M, Vizzielli G, Voogt ELK, Uehara K, Wakeman C, Warrier S, Wasmuth HH, Weiser MR, Westney OL, Wheeler JMD, Wild J, Wilson M, Yano H, Yip B, Yip J, Yoo RN, Zappa MA. The empty pelvis syndrome: a core data set from the PelvEx collaborative. Br J Surg 2024; 111:znae042. [PMID: 38456677 PMCID: PMC10921833 DOI: 10.1093/bjs/znae042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 01/15/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored. METHOD Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition. RESULTS One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed. CONCLUSIONS EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.
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Shur JD, Qiu S, Johnston E, Tait D, Fotiadis N, Kontovounisios C, Rasheed S, Tekkis P, Riddell A, Koh DM. Multimodality Imaging to Direct Management of Primary and Recurrent Rectal Adenocarcinoma Beyond the Total Mesorectal Excision Plane. Radiol Imaging Cancer 2024; 6:e230077. [PMID: 38363197 PMCID: PMC10988347 DOI: 10.1148/rycan.230077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 10/11/2023] [Accepted: 01/10/2024] [Indexed: 02/17/2024]
Abstract
Rectal tumors extending beyond the total mesorectal excision (TME) plane (beyond-TME) require particular multidisciplinary expertise and oncologic considerations when planning treatment. Imaging is used at all stages of the pathway, such as local tumor staging/restaging, creating an imaging-based "roadmap" to plan surgery for optimal tumor clearance, identifying treatment-related complications, which may be suitable for radiology-guided intervention, and to detect recurrent or metastatic disease, which may be suitable for radiology-guided ablative therapies. Beyond-TME and exenterative surgery have gained acceptance as potentially curative procedures for advanced tumors. Understanding the role, techniques, and pitfalls of current imaging techniques is important for both radiologists involved in the treatment of these patients and general radiologists who may encounter patients undergoing surveillance or patients presenting with surgical complications or intercurrent abdominal pathology. This review aims to outline the current and emerging roles of imaging in patients with beyond-TME and recurrent rectal malignancy, focusing on practical tips for image interpretation and surgical planning in the beyond-TME setting. Keywords: Abdomen/GI, Rectum, Oncology © RSNA, 2024.
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Affiliation(s)
- Joshua D. Shur
- From the Royal Marsden Hospital NHS Foundation Trust, Downs Road,
Sutton SM2 5PT, England (J.D.S., S.Q., E.J., D.T., N.F., C.K., S.R.,
P.T., A.R., D.M.K.); and Institute of Cancer Research, Sutton, England (E.J.,
N.F., D.M.K.)
| | - Sheng Qiu
- From the Royal Marsden Hospital NHS Foundation Trust, Downs Road,
Sutton SM2 5PT, England (J.D.S., S.Q., E.J., D.T., N.F., C.K., S.R.,
P.T., A.R., D.M.K.); and Institute of Cancer Research, Sutton, England (E.J.,
N.F., D.M.K.)
| | - Edward Johnston
- From the Royal Marsden Hospital NHS Foundation Trust, Downs Road,
Sutton SM2 5PT, England (J.D.S., S.Q., E.J., D.T., N.F., C.K., S.R.,
P.T., A.R., D.M.K.); and Institute of Cancer Research, Sutton, England (E.J.,
N.F., D.M.K.)
| | - Diana Tait
- From the Royal Marsden Hospital NHS Foundation Trust, Downs Road,
Sutton SM2 5PT, England (J.D.S., S.Q., E.J., D.T., N.F., C.K., S.R.,
P.T., A.R., D.M.K.); and Institute of Cancer Research, Sutton, England (E.J.,
N.F., D.M.K.)
| | - Nicos Fotiadis
- From the Royal Marsden Hospital NHS Foundation Trust, Downs Road,
Sutton SM2 5PT, England (J.D.S., S.Q., E.J., D.T., N.F., C.K., S.R.,
P.T., A.R., D.M.K.); and Institute of Cancer Research, Sutton, England (E.J.,
N.F., D.M.K.)
| | - Christos Kontovounisios
- From the Royal Marsden Hospital NHS Foundation Trust, Downs Road,
Sutton SM2 5PT, England (J.D.S., S.Q., E.J., D.T., N.F., C.K., S.R.,
P.T., A.R., D.M.K.); and Institute of Cancer Research, Sutton, England (E.J.,
N.F., D.M.K.)
| | - Shahnawaz Rasheed
- From the Royal Marsden Hospital NHS Foundation Trust, Downs Road,
Sutton SM2 5PT, England (J.D.S., S.Q., E.J., D.T., N.F., C.K., S.R.,
P.T., A.R., D.M.K.); and Institute of Cancer Research, Sutton, England (E.J.,
N.F., D.M.K.)
| | - Paris Tekkis
- From the Royal Marsden Hospital NHS Foundation Trust, Downs Road,
Sutton SM2 5PT, England (J.D.S., S.Q., E.J., D.T., N.F., C.K., S.R.,
P.T., A.R., D.M.K.); and Institute of Cancer Research, Sutton, England (E.J.,
N.F., D.M.K.)
| | - Angela Riddell
- From the Royal Marsden Hospital NHS Foundation Trust, Downs Road,
Sutton SM2 5PT, England (J.D.S., S.Q., E.J., D.T., N.F., C.K., S.R.,
P.T., A.R., D.M.K.); and Institute of Cancer Research, Sutton, England (E.J.,
N.F., D.M.K.)
| | - Dow-Mu Koh
- From the Royal Marsden Hospital NHS Foundation Trust, Downs Road,
Sutton SM2 5PT, England (J.D.S., S.Q., E.J., D.T., N.F., C.K., S.R.,
P.T., A.R., D.M.K.); and Institute of Cancer Research, Sutton, England (E.J.,
N.F., D.M.K.)
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Giannas E, Kavallieros K, Nanidis T, Giannas J, Tekkis P, Kontovounisios C. Re-Do Plastic Reconstruction for Locally Advanced and Recurrent Colorectal Cancer Following a beyond Total Mesorectal Excision (TME) Operation-Key Considerations. J Clin Med 2024; 13:1228. [PMID: 38592018 PMCID: PMC10932044 DOI: 10.3390/jcm13051228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/12/2024] [Accepted: 02/19/2024] [Indexed: 04/10/2024] Open
Abstract
Innovation in surgery and pelvic oncology have redefined the boundaries of pelvic exenteration for CRC. However, surgical approaches and outcomes following repeat exenteration and reconstruction are not well described. The resulting defect from a second beyond Total Mesorectal Excision (TME) presents a challenge to the reconstructive surgeon. The aim of this study was to explore reconstructive options for patients undergoing repeat beyond TME for recurrent CRC following previous beyond TME and regional reconstruction. MEDLINE and Embase were searched for relevant articles, yielding 2353 studies. However, following full text review and the application of the inclusion criteria, all the studies were excluded. This study demonstrated the lack of reporting on re-do reconstruction techniques following repeat exenteration for recurrent CRC. Based on this finding, we conducted a point-by-point discussion of certain key aspects that should be taken into consideration when approaching this patient cohort.
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Affiliation(s)
- Emmanuel Giannas
- Department of Surgery and Cancer, Imperial College London, London SW7 2BX, UK; (E.G.); (K.K.); (P.T.)
- Department of General Surgery, Chelsea and Westminster Hospital, London SW10 9NH, UK
| | - Konstantinos Kavallieros
- Department of Surgery and Cancer, Imperial College London, London SW7 2BX, UK; (E.G.); (K.K.); (P.T.)
- Department of General Surgery, Chelsea and Westminster Hospital, London SW10 9NH, UK
| | - Theodoros Nanidis
- Department of Plastic Surgery, The Royal Marsden Hospital, London SW3 6JJ, UK;
| | - John Giannas
- Department of Plastic and Reconstructive Surgery, Euroclinic, 115 21 Athens, Greece;
- Department of Plastic and Reconstructive Surgery, The London Welbeck Hospital, London W1G 83N, UK
| | - Paris Tekkis
- Department of Surgery and Cancer, Imperial College London, London SW7 2BX, UK; (E.G.); (K.K.); (P.T.)
- Department of General Surgery, Chelsea and Westminster Hospital, London SW10 9NH, UK
- Department of Surgery, The Royal Marsden Hospital, London SE3 6JJ, UK
| | - Christos Kontovounisios
- Department of Surgery and Cancer, Imperial College London, London SW7 2BX, UK; (E.G.); (K.K.); (P.T.)
- Department of General Surgery, Chelsea and Westminster Hospital, London SW10 9NH, UK
- Department of Surgery, The Royal Marsden Hospital, London SE3 6JJ, UK
- 2nd Surgical Department Evaggelismos, Athens General Hospital, 115 21 Athens, Greece
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10
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Maudsley J, Clifford RE, Aziz O, Sutton PA. A systematic review of oncosurgical and quality of life outcomes following pelvic exenteration for locally advanced and recurrent rectal cancer. Ann R Coll Surg Engl 2024. [PMID: 38362800 DOI: 10.1308/rcsann.2023.0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
INTRODUCTION Pelvic exenteration (PE) is now the standard of care for locally advanced (LARC) and locally recurrent (LRRC) rectal cancer. Reports of the significant short-term morbidity and survival advantage conferred by R0 resection are well established. However, longer-term outcomes are rarely addressed. This systematic review focuses on long-term oncosurgical and quality of life (QoL) outcomes following PE for rectal cancer. METHODS A systematic review of the PubMed®, Cochrane Library, MEDLINE® and Embase® databases was conducted, in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. Studies were included if they reported long-term outcomes following PE for LARC or LRRC. Studies with fewer than 20 patients were excluded. FINDINGS A total of 25 papers reported outcomes for 5,489 patients. Of these, 4,744 underwent PE for LARC (57.5%) or LRRC (42.5%). R0 resection rates ranged from 23.2% to 98.4% and from 14.9% to 77.8% respectively. The overall morbidity rates were 17.8-87.0%. The median survival ranged from 12.5 to 140.0 months. None of these studies reported functional outcomes and only four studies reported QoL outcomes. Numerous different metrics and timepoints were utilised, with QoL scores frequently returning to baseline by 12 months. CONCLUSIONS This review demonstrates that PE is safe, with a good prospect of R0 resection and acceptable mortality rates in selected patients. Morbidity rates remain high, highlighting the importance of shared decision making with patients. Longer-term oncological outcomes as well as QoL and functional outcomes need to be addressed in future studies. Development of a core outcomes set would facilitate better reporting in this complex and challenging patient group.
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Affiliation(s)
- J Maudsley
- Colorectal and Peritoneal Oncology Centre, Christie NHS Foundation Trust, UK
- Division of Cancer Sciences, University of Manchester, UK
| | - R E Clifford
- Institute of Translational Medicine, University of Liverpool, UK
| | - O Aziz
- Colorectal and Peritoneal Oncology Centre, Christie NHS Foundation Trust, UK
- Division of Cancer Sciences, University of Manchester, UK
| | - P A Sutton
- Colorectal and Peritoneal Oncology Centre, Christie NHS Foundation Trust, UK
- Division of Cancer Sciences, University of Manchester, UK
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11
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Beating the empty pelvis syndrome: the PelvEx Collaborative core outcome set study protocol. BMJ Open 2024; 14:e076538. [PMID: 38316595 PMCID: PMC10860036 DOI: 10.1136/bmjopen-2023-076538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 12/20/2023] [Indexed: 02/07/2024] Open
Abstract
INTRODUCTION The empty pelvis syndrome is a significant source of morbidity following pelvic exenteration surgery. It remains poorly defined with research in this field being heterogeneous and of low quality. Furthermore, there has been minimal engagement with patient representatives following pelvic exenteration with respect to the empty pelvic syndrome. 'PelvEx-Beating the empty pelvis syndrome' aims to engage both patient representatives and healthcare professionals to achieve an international consensus on a core outcome set, pathophysiology and mitigation of the empty pelvis syndrome. METHODS AND ANALYSIS A modified-Delphi approach will be followed with a three-stage study design. First, statements will be longlisted using a recent systematic review, healthcare professional event, patient and public engagement, and Delphi piloting. Second, statements will be shortlisted using up to three rounds of online modified Delphi. Third, statements will be confirmed and instruments for measurable statements selected using a virtual patient-representative consensus meeting, and finally a face-to-face healthcare professional consensus meeting. ETHICS AND DISSEMINATION The University of Southampton Faculty of Medicine ethics committee has approved this protocol, which is registered as a study with the Core Outcome Measures in Effectiveness Trials Initiative. Publication of this study will increase the potential for comparative research to further understanding and prevent the empty pelvis syndrome. TRIAL REGISTRATION NUMBER NCT05683795.
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12
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O’Sullivan NJ, Temperley HC, Horan MT, Corr A, Mehigan BJ, Larkin JO, McCormick PH, Kavanagh DO, Meaney JFM, Kelly ME. Radiogenomics: Contemporary Applications in the Management of Rectal Cancer. Cancers (Basel) 2023; 15:5816. [PMID: 38136361 PMCID: PMC10741704 DOI: 10.3390/cancers15245816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/05/2023] [Accepted: 12/11/2023] [Indexed: 12/24/2023] Open
Abstract
Radiogenomics, a sub-domain of radiomics, refers to the prediction of underlying tumour biology using non-invasive imaging markers. This novel technology intends to reduce the high costs, workload and invasiveness associated with traditional genetic testing via the development of 'imaging biomarkers' that have the potential to serve as an alternative 'liquid-biopsy' in the determination of tumour biological characteristics. Radiogenomics also harnesses the potential to unlock aspects of tumour biology which are not possible to assess by conventional biopsy-based methods, such as full tumour burden, intra-/inter-lesion heterogeneity and the possibility of providing the information of tumour biology longitudinally. Several studies have shown the feasibility of developing a radiogenomic-based signature to predict treatment outcomes and tumour characteristics; however, many lack prospective, external validation. We performed a systematic review of the current literature surrounding the use of radiogenomics in rectal cancer to predict underlying tumour biology.
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Affiliation(s)
- Niall J. O’Sullivan
- Department of Radiology, St. James’s Hospital, D08 NHY1 Dublin, Ireland; (M.T.H.)
- School of Medicine, Trinity College Dublin, D02 PN40 Dublin, Ireland
- The National Centre for Advanced Medical Imaging (CAMI), St. James’s Hospital, D08 NHY1 Dublin, Ireland
| | - Hugo C. Temperley
- Department of Surgery, St. James’s Hospital, D08 NHY1 Dublin, Ireland;
| | - Michelle T. Horan
- Department of Radiology, St. James’s Hospital, D08 NHY1 Dublin, Ireland; (M.T.H.)
- School of Medicine, Trinity College Dublin, D02 PN40 Dublin, Ireland
- The National Centre for Advanced Medical Imaging (CAMI), St. James’s Hospital, D08 NHY1 Dublin, Ireland
| | - Alison Corr
- Department of Radiology, St. James’s Hospital, D08 NHY1 Dublin, Ireland; (M.T.H.)
| | - Brian J. Mehigan
- School of Medicine, Trinity College Dublin, D02 PN40 Dublin, Ireland
- Department of Surgery, St. James’s Hospital, D08 NHY1 Dublin, Ireland;
| | - John O. Larkin
- School of Medicine, Trinity College Dublin, D02 PN40 Dublin, Ireland
- Department of Surgery, St. James’s Hospital, D08 NHY1 Dublin, Ireland;
| | - Paul H. McCormick
- School of Medicine, Trinity College Dublin, D02 PN40 Dublin, Ireland
- Department of Surgery, St. James’s Hospital, D08 NHY1 Dublin, Ireland;
| | - Dara O. Kavanagh
- Department of Surgery, Tallaght University Hospital, D24 NR0A Dublin, Ireland
- Department of Surgery, Royal College of Surgeons, D02 YN77 Dublin, Ireland
| | - James F. M. Meaney
- Department of Radiology, St. James’s Hospital, D08 NHY1 Dublin, Ireland; (M.T.H.)
- The National Centre for Advanced Medical Imaging (CAMI), St. James’s Hospital, D08 NHY1 Dublin, Ireland
| | - Michael E. Kelly
- School of Medicine, Trinity College Dublin, D02 PN40 Dublin, Ireland
- Department of Surgery, St. James’s Hospital, D08 NHY1 Dublin, Ireland;
- Trinity St. James’s Cancer Institute (TSJCI), D08 NHY1 Dublin, Ireland
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Stelzner S, Kittner T, Schneider M, Schuster F, Grebe M, Puffer E, Sims A, Mees ST. Beyond Total Mesorectal Excision (TME)-Results of MRI-Guided Multivisceral Resections in T4 Rectal Carcinoma and Local Recurrence. Cancers (Basel) 2023; 15:5328. [PMID: 38001587 PMCID: PMC10670363 DOI: 10.3390/cancers15225328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 10/31/2023] [Accepted: 11/02/2023] [Indexed: 11/26/2023] Open
Abstract
Rectal cancer invading adjacent organs (T4) and locally recurrent rectal cancer (LRRC) pose a special challenge for surgical resection. We investigate the diagnostic performance of MRI and the results that can be achieved with MRI-guided surgery. All consecutive patients who underwent MRI-based multivisceral resection for T4 rectal adenocarcinoma or LRRC between 2005 and 2019 were included. Pelvic MRI findings were reviewed according to a seven-compartment staging system and correlated with histopathology. Outcomes were investigated by comparing T4 tumors and LRRC with respect to cause-specific survival in uni- and multivariate analysis. We identified 48 patients with T4 tumors and 28 patients with LRRC. Overall, 529 compartments were assessed with an accuracy of 81.7%, a sensitivity of 88.6%, and a specificity of 79.2%. Understaging was as low as 3.0%, whereas overstaging was 15.3%. The median number of resected compartments was 3 (interquartile range 3-4) for T4 tumors and 4 (interquartile range 3-5) for LRRC (p = 0.017). In 93.8% of patients with T4 tumors, a histopathologically complete (R0(local)-) resection could be achieved compared to 57.1% in LRRC (p < 0.001). Five-year overall survival for patients with T4 tumors was 53.3% vs. 32.1% for LRRC (p = 0.085). R0-resection and M0-category emerged as independent prognostic factors, whereas the number of resected compartments was not associated with prognosis in multivariate analysis. MRI predicts compartment involvement with high accuracy and especially avoids understaging. Surgery based on MRI yields excellent loco-regional results for T4 tumors and good results for LRRC. The number of resected compartments is not independently associated with prognosis, but R0-resection remains the crucial surgical factor.
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Affiliation(s)
- Sigmar Stelzner
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, D-01067 Dresden, Germany; (A.S.); (S.T.M.)
- Department of Visceral, Transplant, Thoracic, and Vascular Surgery, University Hospital of Leipzig, D-04103 Leipzig, Germany
| | - Thomas Kittner
- Department of Radiology, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, D-01067 Dresden, Germany;
| | - Michael Schneider
- Department of Urology, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, D-01067 Dresden, Germany; (M.S.); (F.S.)
| | - Fred Schuster
- Department of Urology, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, D-01067 Dresden, Germany; (M.S.); (F.S.)
| | - Markus Grebe
- Department of Gynaecology, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, D-01067 Dresden, Germany;
| | - Erik Puffer
- Institut of Pathology, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, D-01067 Dresden, Germany;
| | - Anja Sims
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, D-01067 Dresden, Germany; (A.S.); (S.T.M.)
| | - Soeren Torge Mees
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, D-01067 Dresden, Germany; (A.S.); (S.T.M.)
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14
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Galbraith NJ, McCollum C, Di Mascio L, Lowrie J, Hinckley M, Lo S, Watson S, Telfer JR, Roxburgh CS, Horgan PG, Chong PS, Quinn M, Steele CW. Effect of differing flap reconstruction strategies in perineal closure following advanced pelvic oncological resection: a retrospective cohort study. Int J Surg 2023; 109:3375-3382. [PMID: 37678294 PMCID: PMC10651229 DOI: 10.1097/js9.0000000000000617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 07/09/2023] [Indexed: 09/09/2023]
Abstract
INTRODUCTION Advancing approaches to locally invasive pelvic malignancy creates a large tissue defect resulting in perineal wound complications, dehiscence, and perineal hernia. Use of reconstructive flaps such as vertical rectus abdominus myocutaneous (VRAM) flap, gracilis, anterolateral thigh and gluteal flaps have been utilised in our institution to address perineal closure. The authors compared outcomes using different flap techniques along with primary perineal closure in advanced pelvic oncological resection. METHODS A prospectively maintained database of patients undergoing advanced pelvic oncological resection in a single tertiary hospital was retrospectively analysed. This study included consecutive patients between 2014 and 2021 according to the Strengthening The Reporting of Cohort Studies in Surgery (STROCSS) criteria. Primary outcome measures were the frequency of postoperative perineal complications between primary closure, VRAM, gluteal and thigh (anterolateral thigh and gracilis) reconstruction. RESULTS One hundred twenty-two patients underwent advanced pelvic resection with perineal closure. Of these, 40 patients underwent extra-levator abdominoperineal resection, and 70 patients underwent pelvic exenteration. Sixty-four patients received reconstructive flap closure, which included VRAM (22), gluteal (21) and thigh flaps (19). Perineal infection and dehiscence rates were low. Infection rates were lower in the flap group despite a higher rate of radiotherapy ( P <0.050). Reoperation rates were infrequent (<10%) but specific for each flap, such as donor-site hernia following VRAM and flap dehiscence after thigh flap reconstruction. CONCLUSIONS In patients who are at high risk of postoperative perineal infections, reconstructive flap closure offers acceptable outcomes. VRAM, gluteal and thigh flaps offer comparable outcomes and can be tailored to the individual patient.
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Affiliation(s)
- Norman J. Galbraith
- Academic Department of Surgery, Glasgow Royal Infirmary, University of Glasgow
| | - Catherine McCollum
- Academic Department of Surgery, Glasgow Royal Infirmary, University of Glasgow
| | - Lucia Di Mascio
- Academic Department of Surgery, Glasgow Royal Infirmary, University of Glasgow
| | - Joanna Lowrie
- Academic Department of Surgery, Glasgow Royal Infirmary, University of Glasgow
| | - Matthew Hinckley
- Academic Department of Surgery, Glasgow Royal Infirmary, University of Glasgow
| | - Steven Lo
- Canniesburn Department of Plastic and Reconstructive Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | - Stuart Watson
- Canniesburn Department of Plastic and Reconstructive Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | - John R.C. Telfer
- Canniesburn Department of Plastic and Reconstructive Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | | | - Paul G. Horgan
- Academic Department of Surgery, Glasgow Royal Infirmary, University of Glasgow
| | - Peter S. Chong
- Academic Department of Surgery, Glasgow Royal Infirmary, University of Glasgow
| | - Martha Quinn
- Academic Department of Surgery, Glasgow Royal Infirmary, University of Glasgow
| | - Colin. W. Steele
- Academic Department of Surgery, Glasgow Royal Infirmary, University of Glasgow
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15
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O'Sullivan NJ, Kelly ME. Radiomics and Radiogenomics in Pelvic Oncology: Current Applications and Future Directions. Curr Oncol 2023; 30:4936-4945. [PMID: 37232830 DOI: 10.3390/curroncol30050372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/19/2023] [Accepted: 05/08/2023] [Indexed: 05/27/2023] Open
Abstract
Radiomics refers to the conversion of medical imaging into high-throughput, quantifiable data in order to analyse disease patterns, guide prognosis and aid decision making. Radiogenomics is an extension of radiomics that combines conventional radiomics techniques with molecular analysis in the form of genomic and transcriptomic data, serving as an alternative to costly, labour-intensive genetic testing. Data on radiomics and radiogenomics in the field of pelvic oncology remain novel concepts in the literature. We aim to perform an up-to-date analysis of current applications of radiomics and radiogenomics in the field of pelvic oncology, particularly focusing on the prediction of survival, recurrence and treatment response. Several studies have applied these concepts to colorectal, urological, gynaecological and sarcomatous diseases, with individual efficacy yet poor reproducibility. This article highlights the current applications of radiomics and radiogenomics in pelvic oncology, as well as the current limitations and future directions. Despite a rapid increase in publications investigating the use of radiomics and radiogenomics in pelvic oncology, the current evidence is limited by poor reproducibility and small datasets. In the era of personalised medicine, this novel field of research has significant potential, particularly for predicting prognosis and guiding therapeutic decisions. Future research may provide fundamental data on how we treat this cohort of patients, with the aim of reducing the exposure of high-risk patients to highly morbid procedures.
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Affiliation(s)
- Niall J O'Sullivan
- The Trinity St. James's Cancer Institute, D08 NHY1 Dublin, Ireland
- School of Medicine, Trinity College Dublin, D02 PN40 Dublin, Ireland
| | - Michael E Kelly
- The Trinity St. James's Cancer Institute, D08 NHY1 Dublin, Ireland
- School of Medicine, Trinity College Dublin, D02 PN40 Dublin, Ireland
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16
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Harji DP, Koh C, McKigney N, Solomon MJ, Griffiths B, Evans M, Heriot A, Sagar PM, Velikova G, Brown JM. Development and validation of a patient reported outcome measure for health-related quality of life for locally recurrent rectal cancer: a multicentre, three-phase, mixed-methods, cohort study. EClinicalMedicine 2023; 59:101945. [PMID: 37256101 PMCID: PMC10225622 DOI: 10.1016/j.eclinm.2023.101945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 03/18/2023] [Accepted: 03/20/2023] [Indexed: 06/01/2023] Open
Abstract
Background Locally recurrent rectal cancer (LRRC) occurs in 5-10% of patients following previous treatment of rectal cancer. It has a significant impact on patients' overall health-related quality of life (HrQoL). Major advances in surgical treatments have led to improved survival outcomes. However, due to the lack of disease-specific, validated patient-reported outcome measure (PROM), HrQoL, is variably assessed. The aim of this study is to develop a disease-specific, psychometrically robust, and validated PROM for use in LRRC. Methods A multicentre, three phase, mixed-methods, observational study was performed across five centres in the UK and Australia. Adult patients (>18 years old) with an existing or previously treated LRRC within the last 2 years were eligible to participate. Patients completed the proposed LRRC-QoL, EORTC QLQ-CR29, and FACT-C questionnaires. Scale structure was analysed using multi-trait scaling analysis and exploratory factor analysis, reliability was assessed using Cronbach's and the intra-class coefficient, convergent validity was assessed using Pearson's correlation, and known-groups comparison was assessed using the student t-test or ANOVA. Findings Between 01/03/2015 and 31/12/2019, 117 patients with a diagnosis of LRRC were recruited. The final scale structure of the LRRC-QoL consisted of nine multi-item scales (healthcare services, psychological impact, pain, urostomy-related symptoms, lower limb symptoms, stoma, sexual function, sexual interest, and urinary symptoms) and three single items. Cronbach's Alpha and Intraclass correlation values of >0.7 across the majority of scales supported overall reliability. Convergent validity was demonstrated between LRRC-QoL Pain Scale and FACT-C Physical Well Being scale (r = 0.528, p < 0.001), LRRC-QoL Psychological Impact scale with EORTC QLQ CR29 Body Image (r = 0.680, p < 0.001) and the FACT-C Emotional Well Being scale (r = 0.326, p < 0.001), and LRRC-QoL Urinary Symptoms scale with EORTC QLQ-CR29 Urinary Frequency scale (r = 0.310, p < 0.001). Known-groups validity was demonstrated for gender, disease location, treatment intent, and re-recurrent disease. Interpretation The LRRC-QoL has demonstrated robust psychometric properties and can be used in clinical and academic practice. Funding None.
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Affiliation(s)
- Deena P. Harji
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Cherry Koh
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
- RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Niamh McKigney
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Michael J. Solomon
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
- RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Ben Griffiths
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Martyn Evans
- Department of Surgery, Morriston HospitalHeol Maes Eglwys, Morriston, Swansea, Wales, UK
| | - Alexander Heriot
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | - Peter M. Sagar
- The John Goligher Department of Colorectal Surgery, St. James's University Hospital, Leeds, UK
| | - Galina Velikova
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
- St James's Institute of Oncology, St James's University Hospital, Leeds, UK
| | - Julia M. Brown
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
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17
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Fitzsimmons T, Thomas M, Tonkin D, Murphy E, Hollington P, Solomon M, Sammour T, Luck A. Establishing a state-wide pelvic exenteration multidisciplinary team meeting in South Australia. ANZ J Surg 2022; 93:1227-1231. [PMID: 36567641 DOI: 10.1111/ans.18220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/04/2022] [Accepted: 12/13/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Pelvic exenteration surgery is complex, necessitating co-ordinated multidisciplinary input and improved referral pathways. A state-wide pelvic exenteration multidisciplinary team (MDT) meeting was established in SA and the outcomes of this were audited and compared with historical data. METHODS All patients referred for discussion between August 2021 and July 2022 to the SA State-wide Pelvic Exenteration MDT were included in this study. MDT discussion centred around disease resectability, risk versus benefit of surgery, and need for local or interstate referral. Prospective data collection included patient demographics and MDT recommendations of surgery, palliation, or referral. Patients referred for surgery locally or interstate were compared with a retrospective patient cohort treated previously between January and December 2020. RESULTS Over 12 months, 91 patients were discussed (including nine multiple times), by a mean of 18 meeting participants each month. Forty-eight patients (58.5%) had primary malignancy, 25 (30.5%) recurrent malignancy, and 9 (11.0%) had non-malignant disease. Colorectal cancer was the most common presentation (56.1%), followed by gynaecological (30.5%) and urological (6.1%) malignancy. Pelvic exenteration surgery was recommended to be performed locally in 53.7% of patients and the remainder for non-surgical treatment, palliation, or re-discussion. During this time, 44 patients underwent surgery locally (versus 34 in 2020) and only 4 referred interstate (versus 8 in 2020). CONCLUSION The establishment of a dedicated state-wide pelvic exenteration MDT has resulted in better coordination of care for patients with locally advanced pelvic malignancy in SA, and significantly reduced the need for interstate referral.
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Affiliation(s)
- Tracy Fitzsimmons
- Surgical Specialties, Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia.,Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Michelle Thomas
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Darren Tonkin
- Colorectal Unit, Department of Surgery, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Elizabeth Murphy
- Colorectal Unit, Division of Surgery, Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Paul Hollington
- Flinders Medical Centre, Division of Surgery and Perioperative Medicine, Flinders University, Adelaide, South Australia, Australia
| | - Michael Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Tarik Sammour
- Surgical Specialties, Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia.,Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Andrew Luck
- Colorectal Unit, Division of Surgery, Lyell McEwin Hospital, Adelaide, South Australia, Australia
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18
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Fernandez B, Fleming CA, Marichez A, Mauriac P, Denost Q. Advances in pelvic exenteration surgery can support clear margin resection for metastatic non-pelvic primary malignancies. Br J Surg 2022; 109:1023-1024. [DOI: 10.1093/bjs/znac289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 06/30/2022] [Indexed: 11/13/2022]
Affiliation(s)
| | | | - Arthur Marichez
- Department of Colorectal Surgery, CHU Bordeaux , Bordeaux , France
| | - Paul Mauriac
- Department of Colorectal Surgery, CHU Bordeaux , Bordeaux , France
| | - Quentin Denost
- Department of Colorectal Surgery, CHU Bordeaux , Bordeaux , France
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19
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Fadel MG, Ahmed M, Malietzis G, Pellino G, Rasheed S, Brown G, Tekkis P, Kontovounisios C. Oncological outcomes of multimodality treatment for patients undergoing surgery for locally recurrent rectal cancer: A systematic review. Cancer Treat Rev 2022; 109:102419. [PMID: 35714574 DOI: 10.1016/j.ctrv.2022.102419] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/01/2022] [Accepted: 06/05/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND There are several strategies in the management of locally recurrent rectal cancer (LRRC) with the optimum treatment yet to be established. This systematic review aims to compare oncological outcomes in patients undergoing surgery for LRRC who underwent neoadjuvant radiotherapy or chemoradiotherapy (CRT), adjuvant CRT, surgery only or surgery and intraoperative radiotherapy (IORT). METHODS A literature search of MEDLINE, EMBASE and CINAHL was performed for studies that reported data on oncological outcomes for the different treatment modalities in patients with LRRC from January 1990 to January 2022. Weighted means were calculated for the following outcomes: postoperative resection status, local control, and overall survival at 3 and 5 years. RESULTS Fifteen studies of 974 patients were included and they received the following treatment: 346 neoadjuvant radiotherapy, 279 neoadjuvant CRT, 136 adjuvant CRT, 189 surgery only, and 24 surgery and IORT. The highest proportion of R0 resection was found in the neoadjuvant CRT group followed by neoadjuvant radiotherapy and adjuvant CRT groups (64.07% vs 52.46% vs 47.0% respectively). The neoadjuvant CRT group had the highest mean 5-year local control rate (49.50%) followed by neoadjuvant radiotherapy (22.0%). Regarding the 5-year overall survival rate, the neoadjuvant CRT group had the highest mean of 34.92%, followed by surgery only (29.74%), neoadjuvant radiotherapy (28.94%) and adjuvant CRT (20.67%). CONCLUSIONS The findings of this systematic review suggest that neoadjuvant CRT followed by surgery can lead to improved resection status, long-term disease control and survival in the management of LRRC. However, treatment strategies in LRRC are complex and further comparisons, particularly taking into account previous treatments for the primary rectal cancer, are required.
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Affiliation(s)
- Michael G Fadel
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK; Department of Surgery and Cancer, Imperial College, London, UK.
| | - Mosab Ahmed
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK
| | - George Malietzis
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK; Department of Surgery and Cancer, Imperial College, London, UK; Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy; Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Shahnawaz Rasheed
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK; Department of Surgery and Cancer, Imperial College, London, UK; Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
| | - Gina Brown
- Department of Surgery and Cancer, Imperial College, London, UK
| | - Paris Tekkis
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK; Department of Surgery and Cancer, Imperial College, London, UK; Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
| | - Christos Kontovounisios
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK; Department of Surgery and Cancer, Imperial College, London, UK; Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
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