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Takagawa Y, Suzuki M, Seto I, Azami Y, Machida M, Takayama K, Sulaiman NS, Nakasato T, Kikuchi Y, Murakami M, Honda M, Teranishi Y, Kono K. Proton beam reirradiation for locally recurrent rectal cancer patients with prior pelvic irradiation. JOURNAL OF RADIATION RESEARCH 2024; 65:379-386. [PMID: 38604182 PMCID: PMC11115468 DOI: 10.1093/jrr/rrae019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 01/17/2024] [Indexed: 04/13/2024]
Abstract
The aim of the present study was to report the feasibility of proton beam reirradiation for patients with locally recurrent rectal cancer (LRRC) with prior pelvic irradiation. The study population included patients who were treated with proton beam therapy (PBT) for LRRC between 2008 and December 2019 in our institution. Those who had a history of distant metastases of LRRC, with or without treatment, before reirradiation, were excluded. Overall survival (OS), progression-free survival (PFS) and local control (LC) were estimated using the Kaplan-Meier method. Ten patients were included in the present study. The median follow-up period was 28.7 months, and the median total dose of prior radiotherapy (RT) was 50 Gy (range, 30 Gy-74.8 Gy). The median time from prior RT to reirradiation was 31.5 months (range, 8.1-96.6 months), and the median reirradiation dose was 72 Gy (relative biological effectiveness) (range, 56-77 Gy). The 1-year/2-year OS, PFS and LC rates were 100%/60.0%, 20.0%/10.0% and 70.0%/58.3%, respectively, with a median survival time of 26.0 months. Seven patients developed a Grade 1 acute radiation dermatitis, and no Grade ≥ 2 acute toxicity was recorded. Grade ≥ 3 late toxicity was recorded in only one patient, who had developed a colostomy due to radiation-related intestinal bleeding. Reirradiation using PBT for LRRC patients who had previously undergone pelvic irradiation was feasible. However, the indications for PBT reirradiation for LRRC patients need to be considered carefully due to the risk of severe late GI toxicity.
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Affiliation(s)
- Yoshiaki Takagawa
- Department of Minimally Invasive Surgical and Medical Oncology, Fukushima Medical University, Fukushima, Japan
- Department of Radiation Oncology, Southern TOHOKU Proton Therapy Center, Fukushima, Japan
| | - Motohisa Suzuki
- Department of Radiation Oncology, Southern TOHOKU Proton Therapy Center, Fukushima, Japan
| | - Ichiro Seto
- Department of Radiation Oncology, Southern TOHOKU Proton Therapy Center, Fukushima, Japan
| | - Yusuke Azami
- Department of Radiation Oncology, Southern TOHOKU Proton Therapy Center, Fukushima, Japan
| | - Masanori Machida
- Department of Radiation Oncology, Southern TOHOKU Proton Therapy Center, Fukushima, Japan
| | - Kanako Takayama
- Department of Radiation Oncology, Southern TOHOKU Proton Therapy Center, Fukushima, Japan
| | - Nor Shazrina Sulaiman
- Department of Radiation Oncology, Southern TOHOKU Proton Therapy Center, Fukushima, Japan
| | - Tatsuhiko Nakasato
- Department of Radiation Oncology, Southern TOHOKU Proton Therapy Center, Fukushima, Japan
| | - Yasuhiro Kikuchi
- Department of Radiation Oncology, Southern TOHOKU Proton Therapy Center, Fukushima, Japan
| | - Masao Murakami
- Department of Radiation Oncology, Southern TOHOKU Proton Therapy Center, Fukushima, Japan
| | - Michitaka Honda
- Department of Minimally Invasive Surgical and Medical Oncology, Fukushima Medical University, Fukushima, Japan
- Department of Surgery, Southern TOHOKU General Hospital, Fukushima, Japan
| | - Yasushi Teranishi
- Department of Surgery, Southern TOHOKU General Hospital, Fukushima, Japan
| | - Koji Kono
- Department of Gastrointestinal Tract Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
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van Geffen EGM, Langhout JMA, Hazen SJA, Sluckin TC, van Dieren S, Beets GL, Beets-Tan RGH, Borstlap WAA, Burger JWA, Horsthuis K, Intven MPW, Aalbers AGJ, Havenga K, Marinelli AWKS, Melenhorst J, Nederend J, Peulen HMU, Rutten HJT, Schreurs WH, Tuynman JB, Verhoef C, de Wilt JHW, Marijnen CAM, Tanis PJ, Kusters M, On Behalf Of The Dutch Snapshot Research Group. Evolution of clinical nature, treatment and survival of locally recurrent rectal cancer: Comparative analysis of two national cross-sectional cohorts. Eur J Cancer 2024; 202:114021. [PMID: 38520925 DOI: 10.1016/j.ejca.2024.114021] [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: 01/02/2024] [Revised: 03/04/2024] [Accepted: 03/10/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND In the Netherlands, use of neoadjuvant radiotherapy for rectal cancer declined after guideline revision in 2014. This decline is thought to affect the clinical nature and treatability of locally recurrent rectal cancer (LRRC). Therefore, this study compared two national cross-sectional cohorts before and after the guideline revision with the aim to determine the changes in treatment and survival of LRRC patients over time. METHODS Patients who underwent resection of primary rectal cancer in 2011 (n = 2094) and 2016 (n = 2855) from two nationwide cohorts with a 4-year follow up were included. Main outcomes included time to LRRC, synchronous metastases at time of LRRC diagnosis, intention of treatment and 2-year overall survival after LRRC. RESULTS Use of neoadjuvant (chemo)radiotherapy for the primary tumour decreased from 88.5% to 60.0% from 2011 to 2016. The 3-year LRRC rate was not significantly different with 5.1% in 2011 (n = 114, median time to LRRC 16 months) and 6.3% in 2016 (n = 202, median time to LRRC 16 months). Synchronous metastasis rate did not significantly differ (27.2% vs 33.7%, p = 0.257). Treatment intent of the LRRC shifted towards more curative treatment (30.4% vs. 47.0%, p = 0.009). In the curatively treated group, two-year overall survival after LRRC diagnoses increased from 47.5% to 78.7% (p = 0.013). CONCLUSION Primary rectal cancer patients in 2016 were treated less often with neoadjuvant (chemo)radiotherapy, while LRRC rates remained similar. Those who developed LRRC were more often candidate for curative intent treatment compared to the 2011 cohort, and survival after curative intent treatment also improved substantially.
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Affiliation(s)
- E G M van Geffen
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Treatment and Quality of Life and Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - J M A Langhout
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - S J A Hazen
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Treatment and Quality of Life and Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - T C Sluckin
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Treatment and Quality of Life and Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - S van Dieren
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - G L Beets
- GROW School of Oncology and Developmental Biology, University of Maastricht, Maastricht, the Netherlands; Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - R G H Beets-Tan
- GROW School of Oncology and Developmental Biology, University of Maastricht, Maastricht, the Netherlands; Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands; Department of Radiology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - W A A Borstlap
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Treatment and Quality of Life and Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - J W A Burger
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - K Horsthuis
- Department of Radiology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - M P W Intven
- Department of Radiotherapy, Division Imaging and Oncology, University Medical Centre Utrecht, the Netherlands
| | - A G J Aalbers
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - K Havenga
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - A W K S Marinelli
- Department of Surgery, Haaglanden Medisch Centrum, Den Haag, the Netherlands
| | - J Melenhorst
- GROW School of Oncology and Developmental Biology, University of Maastricht, Maastricht, the Netherlands; Department of Surgery and Colorectal Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - J Nederend
- Department of Radiology, Catharina Hospital, Eindhoven, the Netherlands
| | - H M U Peulen
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - H J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - W H Schreurs
- Department of Surgery, Nothwest Clinics, Alkmaar, the Netherlands
| | - J B Tuynman
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Treatment and Quality of Life and Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - C Verhoef
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - J H W de Wilt
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - C A M Marijnen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands; Department of Radiation Oncology, Leiden University Medical Centre, Leiden, the Netherlands
| | - P J Tanis
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands; Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
| | - M Kusters
- Treatment and Quality of Life and Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, the Netherlands; Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands.
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Keogh C, O’Sullivan NJ, Temperley HC, Flood MP, Ting P, Walsh C, Waters P, Ryan ÉJ, Conneely JB, Edmundson A, Larkin JO, McCormick JJ, Mehigan BJ, Taylor D, Warrier S, McCormick PH, Soucisse ML, Harris CA, Heriot AG, Kelly ME. Redo Pelvic Surgery and Combined Metastectomy for Locally Recurrent Rectal Cancer with Known Oligometastatic Disease: A Multicentre Review. Cancers (Basel) 2023; 15:4469. [PMID: 37760439 PMCID: PMC10527388 DOI: 10.3390/cancers15184469] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/29/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023] Open
Abstract
INTRODUCTION Historically, surgical resection for patients with locally recurrent rectal cancer (LRRC) had been reserved for those without metastatic disease. 'Selective' patients with limited oligometastatic disease (OMD) (involving the liver and/or lung) are now increasingly being considered for resection, with favourable five-year survival rates. METHODS A retrospective analysis of consecutive patients undergoing multi-visceral pelvic resection of LRRC with their oligometastatic disease between 1 January 2015 and 31 August 2021 across four centres worldwide was performed. The data collected included disease characteristics, neoadjuvant therapy details, perioperative and oncological outcomes. RESULTS Fourteen participants with a mean age of 59 years were included. There was a female preponderance (n = 9). Nine patients had liver metastases, four had lung metastases and one had both lung and liver disease. The mean number of metastatic tumours was 1.5 +/- 0.85. R0 margins were obtained in 71.4% (n = 10) and 100% (n = 14) of pelvic exenteration and oligometastatic disease surgeries, respectively. Mean lymph node yield was 11.6 +/- 6.9 nodes, with positive nodes being found in 28.6% (n = 4) of cases. A single major morbidity was reported, with no perioperative deaths. At follow-up, the median disease-free survival and overall survival were 12.3 months (IQR 4.5-17.5 months) and 25.9 months (IQR 6.2-39.7 months), respectively. CONCLUSIONS Performing radical multi-visceral surgery for LRRC and distant oligometastatic disease appears to be feasible in appropriately selected patients that underwent good perioperative counselling.
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Affiliation(s)
- Cian Keogh
- Department of Surgery, St. James’s Hospital, School of Medicine, Trinity College Dublin, D02 R590 Dublin, Ireland
- Department of Surgery, Royal Brisbane and Women’s Hospital, Brisbane 4029, Australia
- School of Medicine, University of Queensland, Brisbane 4072, Australia
| | - Niall J. O’Sullivan
- Department of Surgery, St. James’s Hospital, School of Medicine, Trinity College Dublin, D02 R590 Dublin, Ireland
| | - Hugo C. Temperley
- Department of Surgery, St. James’s Hospital, School of Medicine, Trinity College Dublin, D02 R590 Dublin, Ireland
| | - Michael P. Flood
- Department of Surgery, Peter MacCallum Cancer Centre, Melbourne 3000, Australia
| | - Pascallina Ting
- Department of Surgery, Royal Brisbane and Women’s Hospital, Brisbane 4029, Australia
| | - Camille Walsh
- Department of Surgery, Hôpital Maisonneuve-Rosemont, Montreal, QC H1T 2M4, Canada
| | - Peadar Waters
- Department of Surgery, Peter MacCallum Cancer Centre, Melbourne 3000, Australia
| | - Éanna J. Ryan
- Department of Surgery, St. James’s Hospital, School of Medicine, Trinity College Dublin, D02 R590 Dublin, Ireland
| | - John B. Conneely
- Department of Surgery, Mater Misericordiae University Hospital, D07 R2WY Dublin, Ireland
| | - Aleksandra Edmundson
- Department of Surgery, Royal Brisbane and Women’s Hospital, Brisbane 4029, Australia
| | - John O. Larkin
- Department of Surgery, St. James’s Hospital, School of Medicine, Trinity College Dublin, D02 R590 Dublin, Ireland
| | - Jacob J. McCormick
- Department of Surgery, Peter MacCallum Cancer Centre, Melbourne 3000, Australia
| | - Brian J. Mehigan
- Department of Surgery, St. James’s Hospital, School of Medicine, Trinity College Dublin, D02 R590 Dublin, Ireland
| | - David Taylor
- Department of Surgery, Royal Brisbane and Women’s Hospital, Brisbane 4029, Australia
| | - Satish Warrier
- Department of Surgery, Peter MacCallum Cancer Centre, Melbourne 3000, Australia
| | - Paul H. McCormick
- Department of Surgery, St. James’s Hospital, School of Medicine, Trinity College Dublin, D02 R590 Dublin, Ireland
| | - Mikael L. Soucisse
- Department of Surgery, Hôpital Maisonneuve-Rosemont, Montreal, QC H1T 2M4, Canada
| | - Craig A. Harris
- Department of Surgery, Royal Brisbane and Women’s Hospital, Brisbane 4029, Australia
| | - Alexander G. Heriot
- Department of Surgery, Peter MacCallum Cancer Centre, Melbourne 3000, Australia
| | - Michael E. Kelly
- Department of Surgery, St. James’s Hospital, School of Medicine, Trinity College Dublin, D02 R590 Dublin, Ireland
- Trinity St. James Cancer Institute, D08 W9RT Dublin, Ireland
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van Rees JM, Nordkamp S, Harmsen PW, Rutten H, Burger JWA, Verhoef C. Locally recurrent rectal cancer and distant metastases: is there still a chance ofcure? EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106865. [PMID: 37002176 DOI: 10.1016/j.ejso.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 01/23/2023] [Accepted: 03/03/2023] [Indexed: 03/13/2023]
Abstract
INTRODUCTION Patients with locally recurrent rectal cancer (LRRC) generally have poor prognosis, especially those who have (a history of) distant metastases. The aim of this study was to investigate the impact of distant metastases on oncological outcomes in LRRC patients undergoing curative treatment. METHODS Consecutive patients with surgically treated LRRC between 2005 and 2019 in two tertiary referral hospitals were retrospectively analysed. Oncological survival of patients without distant metastases were compared with outcomes of patients with synchronous distant metastases with the primary tumour, patients with distant metastases in the primary-recurrence interval, and patients with synchronous LRRC distant metastases. RESULTS A total of 535 LRRC patients were analysed, of whom 398 (74%) had no (history of) metastases, 22 (4%) had synchronous metastases with the primary tumour, 44 (8%) had metachronous metastases, and 71 (13%) had synchronous LRRC metastases. Patients with synchronous LRRC metastases had worse survival compared to patients without metastases (adjusted hazard ratio: 1.56 [1.15-2.12]), whilst survival of patients with synchronous primary metastases and metachronous metastases of the primary tumour was similar as those patients who had no metastases. In LRRC patients who had metastases in primary-recurrence interval, patients with early metachronous metastases had better disease-free survival as patients with late metachronous metastases (3-year disease-free survival: 48% vs 22%, p = 0.039). CONCLUSION LRRC patients with synchronous distant metastases undergoing curative surgery have relatively poor prognosis. However, LRRC patients with a history of distant metastases diagnosed nearby the primary tumour have comparable (oncological) survival as LRRC patients without distant metastases.
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Affiliation(s)
- J M van Rees
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands.
| | - S Nordkamp
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - P W Harmsen
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - H Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands; GROW: School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
| | - J W A Burger
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - C Verhoef
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
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Swartjes H, van Rees JM, van Erning FN, Verheij M, Verhoef C, de Wilt JHW, Vissers PAJ, Koëter T. Locally Recurrent Rectal Cancer: Toward a Second Chance at Cure? A Population-Based, Retrospective Cohort Study. Ann Surg Oncol 2023:10.1245/s10434-023-13141-y. [PMID: 36790731 DOI: 10.1245/s10434-023-13141-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 01/09/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND In current practice, rates of locally recurrent rectal cancer (LRRC) are low due to the use of the total mesorectal excision (TME) in combination with various neoadjuvant treatment strategies. However, the literature on LRRC mainly consists of single- and multicenter retrospective cohort studies, which are prone to selection bias. The aim of this study is to provide a nationwide, population-based overview of LRRC after TME in the Netherlands. PATIENTS AND METHODS In total, 1431 patients with nonmetastasized primary rectal cancer diagnosed in the first six months of 2015 and treated with TME were included from the nationwide, population-based Netherlands Cancer Registry. Data on disease recurrence were collected for patients diagnosed in these 6 months only. Competing risk cumulative incidence, competing risk regression, and Kaplan-Meier analyses were performed to assess incidence, risk factors, treatment, and overall survival (OS) of LRRC. RESULTS Three-year cumulative incidence of LRRC was 6.4%; synchronous distant metastases (LRRC-M1) were present in 44.9% of patients with LRRC. Distal localization, R1-2 margin, (y)pT3-4, and (y)pN1-2 were associated with an increased LRRC rate. No differences in LRRC treatment and OS were found between patients who had been treated with or without prior n(C)RT. Curative-intent treatment was given to 42.9% of patients with LRRC, and 3-year OS thereafter was 70%. CONCLUSIONS Nationwide LRRC incidence was low. A high proportion of patients with LRRC underwent curative-intent treatment, and OS of this group was high in comparison with previous studies. Additionally, n(C)RT for primary rectal cancer was not associated with differences in treatment and OS of LRRC.
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Affiliation(s)
- Hidde Swartjes
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Jan M van Rees
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Felice N van Erning
- Department of Research and Development, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands.,Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Marcel Verheij
- Department of Radiation Oncology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Cornelis Verhoef
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Pauline A J Vissers
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Research and Development, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands
| | - Tijmen Koëter
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
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Yang Y, Gu X, Li Z, Zheng C, Wang Z, Zhou M, Chen Z, Li M, Li D, Xiang J. Whole-exome sequencing of rectal cancer identifies locally recurrent mutations in the Wnt pathway. Aging (Albany NY) 2021; 13:23262-23283. [PMID: 34642262 PMCID: PMC8544332 DOI: 10.18632/aging.203618] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 09/29/2021] [Indexed: 12/29/2022]
Abstract
Locally recurrent rectal cancer (LRRC) leads to a poor prognosis and appears as a clinically predominant pattern of failure. In this research, whole-exome sequencing (WES) was performed on 21 samples from 8 patients to search for the molecular mechanisms of LRRC. The data was analyzed by bioinformatics. Gene Expression Profiling Interactive Analysis (GEPIA) and Human Protein Atlas (HPA) were performed to validate the candidate genes. Immunohistochemistry was used to detect the protein expression of LEF1 and CyclinD1 in LRRC, primary rectal cancer (PRC), and non-recurrent rectal cancer (NRRC) specimens. The results showed that LRRC, PRC, and NRRC had 668, 794, and 190 specific genes, respectively. FGFR1 and MYC have copy number variants (CNVs) in PRC and LRRC, respectively. LRRC specific genes were mainly enriched in positive regulation of transcription from RNA polymerase II promoter, plasma membrane, and ATP binding. The specific signaling pathways of LRRC were Wnt signaling pathway, gap junction, and glucagon signaling pathway, etc. The transcriptional and translational expression levels of genes including NFATC1, PRICKLE1, SOX17, and WNT6 related to Wnt signaling pathway were higher in rectal cancer (READ) tissues than normal rectal tissues. The PRICKLE1 mutation (c.C875T) and WNT6 mutation (c.G629A) were predicted as “D (deleterious)”. Expression levels of LEF1 and cytokinin D1 proteins: LRRC > PRC > NRRC > normal rectal tissue. Gene variants in the Wnt signaling pathway may be critical for the development of LRRC. The present study may provide a basis for the prediction of LRRC and the development of new therapeutic drugs.
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Affiliation(s)
- Yi Yang
- Department of General Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Xiaodong Gu
- Department of General Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Zhenyang Li
- Department of General Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Chuang Zheng
- Department of General Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Zihao Wang
- Department of General Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Minwei Zhou
- Department of General Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Zongyou Chen
- Department of General Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Mengzhen Li
- MyGene Diagnostics Co., Ltd, Guangzhou 510000, China
| | - Dongbing Li
- MyGene Diagnostics Co., Ltd, Guangzhou 510000, China
| | - Jianbin Xiang
- Department of General Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
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7
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Pérez Lara FJ, Hebrero Jimenez ML, Moya Donoso FJ, Hernández Gonzalez JM, Pitarch Martinez M, Prieto-Puga Arjona T. Review of incomplete macroscopic resections (R2) in rectal cancer: Treatment, prognosis and future perspectives. World J Gastrointest Oncol 2021; 13:1062-1072. [PMID: 34616512 PMCID: PMC8465452 DOI: 10.4251/wjgo.v13.i9.1062] [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: 02/09/2021] [Revised: 04/28/2021] [Accepted: 07/23/2021] [Indexed: 02/06/2023] Open
Abstract
Colorectal cancer is one of the most prevalent tumours, but with improved treatment and early detection, its prognosis has greatly improved in recent years. However, when the tumour is locally advanced at diagnosis or if there is local recurrence, it is more difficult to perform a complete tumour resection, and there may be a residual macroscopic tumour. In this paper, we review the literature on residual macroscopic tumour resections, concerning both locally advanced primary tumours and recurrences, evaluating the main problems encountered, the treatments applied, the prognosis and future perspectives in this field.
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8
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Coker DJ, Koh CE, Steffens D, Young JM, Vuong K, Alchin L, Solomon MJ. The affect of personality traits and decision-making style on postoperative quality of life and distress in patients undergoing pelvic exenteration. Colorectal Dis 2020; 22:1139-1146. [PMID: 32180326 DOI: 10.1111/codi.15036] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 03/05/2020] [Indexed: 12/11/2022]
Abstract
AIM Our aim was to identify whether personality traits and decision-making styles affect quality of life (QoL) outcomes and levels of psychological distress following pelvic exenteration (PE). METHOD Patients undergoing PE between 2008 and 2015 were identified from a prospectively maintained database at a single quaternary referral centre. Patients were invited to complete two validated questionnaires, with the Big Five inventory being used to assess personality traits and the Melbourne Decision Making Questionnaire to determine decision-making style. Data on QoL outcomes and distress from the prospectively established database were utilized. QoL with respect to both physical and mental health components was measured using Short Form 36 version 2 (SF-36v2) and the Functional Assessment of Cancer Therapy - Colorectal (FACT-C). Distress was measured using the Distress Thermometer. Postoperative pain scores were also measured using SF-36v2. RESULTS Of the 93 patients eligible for participation, 42 returned the study questionnaire. On multivariate analysis, neuroticism was the most significant predictor of poorer QoL and increased levels of distress, consistent across all of the measures utilized and at the different time points used. Other personality traits showed an isolated statistically significant impact upon QoL. There were no significant findings with respect to decision-making style. Apart from neuroticism, the most significant predictor of QoL was the number of major complications for the patient. CONCLUSION Patients demonstrating neurotic personality traits show poorer QoL outcomes and higher levels of distress following PE. Identification of these patients would allow targeted pre- and postoperative intervention to improve outcomes following PE.
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Affiliation(s)
- D J Coker
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Discipline of Surgery, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
| | - C E Koh
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Discipline of Surgery, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia.,The Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, University of Sydney, Camperdown, New South Wales, Australia
| | - D Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Discipline of Surgery, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
| | - J M Young
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Discipline of Surgery, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
| | - K Vuong
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - L Alchin
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - M J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Discipline of Surgery, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia.,The Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, University of Sydney, Camperdown, New South Wales, Australia
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9
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Cyr DP, Zih FS, Wells BJ, Swett-Cosentino J, Burkes RL, Brierley JD, Cummings B, Smith AJ, Swallow CJ. Long-term outcomes following salvage surgery for locally recurrent rectal cancer: A 15-year follow-up study. Eur J Surg Oncol 2020; 46:1131-1137. [PMID: 32224071 DOI: 10.1016/j.ejso.2020.02.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 02/20/2020] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Locally recurrent rectal cancer (LRRC) is a complex problem requiring multidisciplinary consultation and specialized surgical care. Given the paucity of published longer-term survival data, skepticism persists regarding the benefit of major extirpative surgery. We investigated ultra-long-term (~15 years) outcomes following radical resection of LRRC and sought relevant clinicopathologic prognostic variables. METHODS A cohort of 52 consecutive patients who underwent resection of LRRC at our institution between 1997 and 2005 were followed with serial exams and imaging up to the point of death, or 30/06/2019. RESULTS Median follow-up time was 16.5 years (9.9-18.3) for patients who were alive at last follow-up; only one patient was lost to follow-up, at 9.9 years. For the entire cohort of 52 patients, disease-specific survival (DSS) at 5, 10, and 15 years following salvage surgery was 41%, 33%, and 31%, respectively. All patients who had distant metastatic disease at the time of LRRC resection (n = 6) subsequently died of cancer, at a median of 21 months (4-46). In those without distant metastases at time of salvage surgery (n = 46), DSS at 5, 10, and 15 years was 47%, 38%, and 35%, respectively, median 60 months. Negative resection margin (R0) was independently predictive of superior outcomes. In patients with M0 disease who had R0 resection (n = 37), DSS at 5, 10 and 15 years was 58%, 47%, and 44%, respectively, median 73 months. No patient developed re-recurrence after 5.5 years. CONCLUSIONS This study demonstrates exceptionally durable long-term cancer-free survival following salvage surgery for LRRC, indicating that cure is possible.
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Affiliation(s)
- David P Cyr
- Department of Surgical Oncology, Princess Margaret Cancer Centre and Mount Sinai Hospital, Toronto, Canada; Division of General Surgery, Department of Surgery, University of Toronto, Canada; Institute of Medical Science, University of Toronto, Toronto, Canada; Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Canada
| | - Francis Sw Zih
- Department of Surgery, Surrey Memorial Hospital, Surrey, Canada; Division of General Surgery, Department of Surgery, University of British Columbia, Canada
| | - Bryan J Wells
- Division of General Surgery, Nanaimo Regional General Hospital, Nanaimo, Canada
| | | | - Ronald L Burkes
- Department of Medical Oncology, Mount Sinai Hospital and Princess Margaret Cancer Centre, Department of Medicine, University of Toronto, Canada
| | - James D Brierley
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Canada
| | - Bernard Cummings
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Canada
| | - Andrew J Smith
- Sunnybrook Health Sciences Centre and Odette Cancer Centre, Toronto, Canada
| | - Carol J Swallow
- Department of Surgical Oncology, Princess Margaret Cancer Centre and Mount Sinai Hospital, Toronto, Canada; Division of General Surgery, Department of Surgery, University of Toronto, Canada; Institute of Medical Science, University of Toronto, Toronto, Canada; Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Canada.
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10
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Safety and Feasibility of Laparoscopic Pelvic Exenteration for Locally Advanced or Recurrent Colorectal Cancer. Surg Laparosc Endosc Percutan Tech 2020; 29:389-392. [PMID: 31335481 DOI: 10.1097/sle.0000000000000699] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE Pelvic exenteration (PE) for locally advanced or recurrent colorectal cancer is often used to secure negative resection margins. The aim of this study was to evaluate the feasibility of laparoscopic PE. MATERIALS AND METHODS The clinical records of 24 patients (9, open; 15, laparoscopic) who underwent total or posterior PE for locally advanced or recurrent colorectal cancer between July 2012 and April 2016 at Osaka National Hospital were retrospectively reviewed. Operative factors were compared between the 2 groups. RESULTS The R0 resection rate was 100% in the laparoscopic group and 89% in the open group. The operative time and the incidence of postoperative complications were not significantly different between the 2 groups. The laparoscopic group showed less intraoperative blood loss (P=0.019), a lower C-reactive protein elevation on postoperative day 7 (P=0.025), and a shorter postoperative hospital stay (P=0.0009). CONCLUSIONS Laparoscopic PE is a safe and feasible procedure to reduce postoperative stress.
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11
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Hagemans J, van Rees J, Alberda W, Rothbarth J, Nuyttens J, van Meerten E, Verhoef C, Burger J. Locally recurrent rectal cancer; long-term outcome of curative surgical and non-surgical treatment of 447 consecutive patients in a tertiary referral centre. Eur J Surg Oncol 2020; 46:448-454. [DOI: 10.1016/j.ejso.2019.10.037] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 10/08/2019] [Accepted: 10/29/2019] [Indexed: 12/21/2022] Open
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12
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Local Therapy Options for Recurrent Rectal and Anal Cancer: Current Strategies and New Directions. CURRENT COLORECTAL CANCER REPORTS 2019. [DOI: 10.1007/s11888-019-00445-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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13
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Image-guided high-dose-rate interstitial brachytherapy for recurrent rectal cancer after salvage surgery: a case report. J Contemp Brachytherapy 2019; 11:343-348. [PMID: 31523235 PMCID: PMC6737566 DOI: 10.5114/jcb.2019.87000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 06/11/2019] [Indexed: 11/26/2022] Open
Abstract
Treatment options for patients with recurrent rectal cancer in pelvis represent a significant challenge because the balance of efficiency and toxicity needs to be pursued. This case report illustrates a treatment effect of image-guided high-dose-rate interstitial brachytherapy (HDR-ISBT) for locally relapsed rectal cancer after salvage surgery. A 61-year-old male who underwent laparoscopic high anterior resection (LAP-HAR) with D3 lymph node dissection as a primary treatment for rectal cancer (pT3N0M0, well-differentiated adenocarcinoma) had relapsed locally 8 months after initial surgery, for which he underwent salvage abdominal perineal resection (APR), followed by adjuvant 8 cycles of XELOX (capecitabine and oxaliplatin) chemotherapy. He developed pelvic recurrence 1 year after the second surgery. Image-guided HDR-ISBT was performed (30 Gy/5 fractions/3 days) followed by external beam radiation therapy with 39.6 Gy in 22 fractions. There were no severe complications related to salvage radiotherapy. CEA was decreased from 24.5 ng/ml to 0.7 ng/ml, 4 months after the salvage radiotherapy. Complete response was noted on follow-up MRIs done on 2, 5, 8, and 14 months after the treatment. Hence, HDR-ISBT appears to be effective for locally recurrent rectal cancer even after salvage surgery.
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14
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Detering R, Karthaus EG, Borstlap WAA, Marijnen CAM, van de Velde CJH, Bemelman WA, Beets GL, Tanis PJ, Aalbers AGJ. Treatment and survival of locally recurrent rectal cancer: A cross-sectional population study 15 years after the Dutch TME trial. Eur J Surg Oncol 2019; 45:2059-2069. [PMID: 31230980 DOI: 10.1016/j.ejso.2019.06.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 06/12/2019] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION Optimized treatment of primary rectal cancer might have influenced treatment characteristics and outcome of locally recurrent rectal cancer (LRRC). Subgroup analysis of the Dutch TME trial showed that preoperative radiotherapy (PRT) for the primary tumour was an independent poor prognostic factor after diagnosis of LRRC. This cross-sectional population study aimed to evaluate treatment and overall survival (OS) of LRRC patients, stratified for prior preoperative radiotherapy (PRT) and intention of treatment of LRRC. METHODS All patients developing LRRC were selected from a collaborative Snapshot study on 2095 surgically treated rectal cancer patients from 71 Dutch hospitals in the year 2011. Cox proportional hazard analysis was performed to determine predictors for OS. RESULTS A total of 107 LRRC patients (5.1%) were included, of whom 88 (82%) underwent PRT for their primary tumour. LRRC was treated with initial curative intent in 31 patients (29%), with eventual resection in 20 patients (19%). Median OS was 22 and 8 months after curative and palliative intent treatment, respectively (p < 0.001). Initial CRM positivity and palliative intent treatment were associated with worse OS after LRRC, while prior PRT was not. CONCLUSIONS This cross-sectional study revealed that rectal cancer patients, who underwent curative resection in the Netherlands in 2011 and subsequently developed local recurrence, were amenable for again curative intent treatment in 29%, with a corresponding median survival of 22 months. Prior PRT was not significantly associated with survival after diagnosis of LRRC.
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Affiliation(s)
- Robin Detering
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands.
| | - Eleonora G Karthaus
- Leiden University Medical Center, Department of Surgery, Leiden, the Netherlands
| | - Wernard A A Borstlap
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
| | - Corrie A M Marijnen
- Netherlands Cancer Institute-Antoni van Leeuwenhoek, Department of Radiotherapy, Amsterdam, the Netherlands
| | | | - Willem A Bemelman
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
| | - Geerard L Beets
- Netherlands Cancer Institute-Antoni van Leeuwenhoek, Department of Surgery, Amsterdam, the Netherlands
| | - Pieter J Tanis
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
| | - Arend G J Aalbers
- Netherlands Cancer Institute-Antoni van Leeuwenhoek, Department of Surgery, Amsterdam, the Netherlands
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15
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Westberg K, Palmer G, Hjern F, Holm T, Martling A. Population-based study of surgical treatment with and without tumour resection in patients with locally recurrent rectal cancer. Br J Surg 2019; 106:790-798. [PMID: 30776087 DOI: 10.1002/bjs.11098] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 10/26/2018] [Accepted: 11/23/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND Population-based studies of treatment of locally recurrent rectal cancer (LRRC) are lacking. The aim was to investigate the surgical treatment of patients with LRRC at a national population-based level. METHODS All patients undergoing abdominal resection for primary rectal cancer between 1995 and 2002 in Sweden with LRRC as a first event were included. Detailed information about treatment, complications and outcomes was collected from the medical records. The patients were analysed in three groups: patients who had resection of the LRRC, those treated without tumour resection and patients who received best supportive care only. RESULTS In all, 426 patients were included in the study. Of these, 149 (35·0 per cent) underwent tumour resection, 193 (45·3 per cent) had treatment without tumour resection and 84 (19·7 per cent) received best supportive care. Abdominoperineal resection was the most frequent surgical procedure, performed in 65 patients (43·6 per cent of those who had tumour resection). Thirteen patients had total pelvic exenteration. In total, 63·8 per cent of those whose tumour was resected had potentially curative surgery. After tumour resection, 62 patients (41·6 per cent) had a complication within 30 days. Patients who received surgical treatment without tumour resection had a lower complication rate but a significantly higher 30-day mortality rate than those who underwent tumour resection (10 versus 1·3 per cent respectively; P = 0·002). Of all patients included in the study, 22·3 per cent had potentially curative treatment and the 3-year survival rate for these patients was 56 per cent. CONCLUSION LRRC is a serious condition with overall poor outcome. Patients undergoing curative surgery have an acceptable survival rate but substantial morbidity. There is room for improvement in the management of patients with LRRC.
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Affiliation(s)
- K Westberg
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Division of Surgery, Danderyd Hospital, Stockholm, Sweden
| | - G Palmer
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Center of Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - F Hjern
- Department of Clinical Sciences, Karolinska Institutet and Center of Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - T Holm
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Center of Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - A Martling
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Center of Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
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S1 Sacrectomy for Re-recurrent Rectal Cancer: Our Experience with Reconstruction Using an Expandable Vertebral Body Replacement Device. Dis Colon Rectum 2018; 61:261-265. [PMID: 29337783 DOI: 10.1097/dcr.0000000000000935] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION R0 resection is achieved by high sacrectomy for local recurrence of colorectal cancer, but significant rates of perioperative complications and long-term patient morbidity are associated with this procedure. In this report, we outline our unique experience of using an expandable cage for vertebral body reconstruction following S1 sacrectomy in a 66-year-old patient with re-recurrent rectal cancer. We aim to highlight several key steps, with a view to improving postoperative outcomes. TECHNIQUE A midline laparotomy was performed with the patient in supine Lloyd-Davies position, demonstrating recurrence of tumor at the S1 vertebral body. Subtotal vertebral body excision of S1 with sparing of the posterior wall and ventral foramina was completed by using an ultrasonic bone aspirator. Reconstruction was performed using an expandable corpectomy spacer system. The system was assembled and expanded in situ to optimally bridge the corpectomy. The device was secured into the L5 and S2 vertebrae by means of angled end plate screws superiorly and inferiorly. Bone grafts were positioned adjacent to the implant after this. RESULTS Total operating time was 266 minutes with 350 mL of intraoperative blood loss. There were no immediate postoperative complications. The patient did not report any back pain at the time of discharge, and no neurological deficit was reported or identified. Postoperative CT scan showed excellent vertebral alignment and preservation of S1 height. CONCLUSION We conclude that high sacrectomy with an expandable metal cage is feasible in the context of re-recurrent rectal cancer when consideration is given to the method of osteotomy and vertebral body replacement.
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17
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Management and prognosis of locally recurrent rectal cancer - A national population-based study. Eur J Surg Oncol 2017; 44:100-107. [PMID: 29224985 DOI: 10.1016/j.ejso.2017.11.013] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 10/27/2017] [Accepted: 11/16/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The rate of local recurrence of rectal cancer (LRRC) has decreased but the condition remains a therapeutic challenge. This study aimed to examine treatment and prognosis in patients with LRRC in Sweden. Special focus was directed towards potential differences between geographical regions and time periods. METHOD All patients with LRRC as first event, following primary surgery for rectal cancer performed during the period 1995-2002, were included in this national population-based cohort-study. Data were collected from the Swedish Colorectal Cancer Registry and from medical records. The cohort was divided into three time periods, based on the date of diagnosis of the LRRC. RESULTS In total, 426 patients fulfilled the inclusion criteria. Treatment with curative intent was performed in 149 patients (35%), including 121 patients who had a surgical resection of the LRRC. R0-resection was achieved in 64 patients (53%). Patients with a non-centrally located tumour were more likely to have positive resection margins (R1/R2) (OR 5.02, 95% CI:2.25-11.21). Five-year survival for patients resected with curative intent was 43% after R0-resection and 14% after R1-resection. There were no significant differences in treatment intention or R0-resection rate between time periods or regions. The risk of any failure was significantly higher in R1-resected patients compared with R0-resected patients (HR 2.04, 95% CI:1.22-3.40). CONCLUSION A complete resection of the LRRC is essential for potentially curative treatment. Time period and region had no influence on either margin status or prognosis.
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Kishan AU, Voog JC, Wiseman J, Cook RR, Ancukiewicz M, Lee P, Ryan DP, Clark JW, Berger DL, Cusack JC, Wo JY, Hong TS. Standard fractionation external beam radiotherapy with and without intraoperative radiotherapy for locally recurrent rectal cancer: the role of local therapy in patients with a high competing risk of death from distant disease. Br J Radiol 2017; 90:20170134. [PMID: 28613934 DOI: 10.1259/bjr.20170134] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE We sought to evaluate the effectiveness and safety of utilizing radiotherapy (RT) with standard fractionation, with or without intraoperative RT (IORT), to treat locally recurrent rectal cancer (LRRC). METHODS Retrospective review of 25 patients with LRRC treated with standard fractionation RT from 2005 to 2011. 15 patients (60%) had prior pelvic RT and 10 (40%) had synchronous metastases. The median equivalent dose in 2-Gy fractions was 30 and 49.6 Gy in patients with and without prior RT, respectively. 23 patients (92%) received concurrent chemotherapy and 16 (64%) underwent surgical resection. Eight patients (33.3%, four with and four without prior RT) received IORT. A competing risks model was developed to estimate the cumulative incidence of local failure with death treated as a competing event. RESULTS Median follow-up was 36.9 months after the date of local recurrence. 3-year rates of overall survival (OS), local control (LC) and death with LC were 51.6%, 73.3% and 69.2%, respectively. On multivariable analysis, surgical resection was significantly predictive of improved OS (p < 0.05). If surgical resection were removed from the multivariable model, given the collinearity between IORT delivery and surgical resection, then IORT also became a significant predictor of OS (p < 0.05). Systemic disease at the time of local recurrence was not associated with either LC or OS. No patient had grade ≥3 acute or late toxicity. CONCLUSION RT with standard fractionation is safe and effective in the treatment of patients with LRRC, even in patients with significant risk of systemic disease and/or history of prior RT. Advances in knowledge: The utility of RT with standard fractionation, generally with chemotherapy, in the treatment of LRRC is demonstrated. In this high-risk cohort of patients with a 40% incidence of synchronous metastatic disease, surgical resection of the recurrence was the major predictor of OS, though a benefit to IORT was also suggested. No patients had grade ≥3 acute or late toxicity, though 40% had undergone prior RT, underscoring the tolerability of standard fractionation RT in this setting.
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Affiliation(s)
- Amar U Kishan
- 1 Department of Radiation Oncology, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Justin C Voog
- 2 Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | | | - Ryan R Cook
- 1 Department of Radiation Oncology, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Marek Ancukiewicz
- 2 Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Percy Lee
- 1 Department of Radiation Oncology, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - David P Ryan
- 4 Department of Medical Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Jeffrey W Clark
- 5 Division of General and Gastrointestinal Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - David L Berger
- 5 Division of General and Gastrointestinal Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - James C Cusack
- 6 Division of Surgical Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Jennifer Y Wo
- 2 Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Theodore S Hong
- 2 Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
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Musaev ER, Polynovsky AV, Rasulov AO, Tsaryuk VF, Kuz'michev DV, Sushentsov EA, Balyasnikova SS, Safronov DI. [The possibilities of treatment of recurrent colorectal cancer with sacral invasion]. Khirurgiia (Mosk) 2017:24-35. [PMID: 28374710 DOI: 10.17116/hirurgia2017324-35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
AIM To describe current methods of surgical treatment of rare form of recurrent rectal cancer with sacral invasion. MATERIAL AND METHODS The article presents the methodology for the treatment of patients with recurrent colorectal cancer and sacral invasion using preoperative chemoradiotherapy followed by high-tech surgery of recurrent tumor removal with sacral resection at various levels (including high intersection at S1 level). CONCLUSION It was concluded that chemoradiotherapy is indicated in patients with recurrent colorectal cancer if it was not made at the first stage of treatment. Additional radiotherapy up to optimum overall focal dose prior to surgery is advisable in those patients who previously underwent radiotherapy with partial dose. This type of operations has high risk of complications and requires a personalized approach to the selection of patients. However, R0-resection is associated with favorable long-term prognosis, significantly increased survival and overall quality of life. Combined surgery for recurrent tumors with sacral invasion should be performed by multidisciplinary surgical team in specialized centers using current possibilities of anesthesiology and intensive care.
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Affiliation(s)
- E R Musaev
- Blokhin Russian Cancer Research Center, Ministry of Health of the Russian Federation, Moscow
| | - A V Polynovsky
- Blokhin Russian Cancer Research Center, Ministry of Health of the Russian Federation, Moscow
| | - A O Rasulov
- Blokhin Russian Cancer Research Center, Ministry of Health of the Russian Federation, Moscow
| | - V F Tsaryuk
- Blokhin Russian Cancer Research Center, Ministry of Health of the Russian Federation, Moscow
| | - D V Kuz'michev
- Blokhin Russian Cancer Research Center, Ministry of Health of the Russian Federation, Moscow
| | - E A Sushentsov
- Blokhin Russian Cancer Research Center, Ministry of Health of the Russian Federation, Moscow
| | - S S Balyasnikova
- Blokhin Russian Cancer Research Center, Ministry of Health of the Russian Federation, Moscow
| | - D I Safronov
- Blokhin Russian Cancer Research Center, Ministry of Health of the Russian Federation, Moscow
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González-Castillo A, Biondo S, García-Granero Á, Cambray M, Martínez-Villacampa M, Kreisler E. Resultados de la cirugía de la recidiva pélvica de cáncer de recto. Experiencia en un centro de referencia. Cir Esp 2016; 94:518-524. [DOI: 10.1016/j.ciresp.2016.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 08/02/2016] [Accepted: 08/02/2016] [Indexed: 01/14/2023]
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Holman FA, Bosman SJ, Haddock MG, Gunderson LL, Kusters M, Nieuwenhuijzen GAP, van den Berg H, Nelson H, Rutten HJ. Results of a pooled analysis of IOERT containing multimodality treatment for locally recurrent rectal cancer: Results of 565 patients of two major treatment centres. Eur J Surg Oncol 2016; 43:107-117. [PMID: 27659000 DOI: 10.1016/j.ejso.2016.08.015] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 07/13/2016] [Accepted: 08/09/2016] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Aim of this study is analysing the pooled results of Intra-Operative Electron beam Radiotherapy (IOERT) containing multimodality treatment of locally recurrent rectal cancer (LRRC) of two major treatment centres. METHODS AND MATERIALS Five hundred sixty five patients with LRRC who underwent multimodality-treatment up to 2010 were studied. The preferred treatment was preoperative chemo-radiotherapy, surgery and IOERT. In uni- and multivariate analyses risk factors for local re-recurrence, distant metastasis free survival, relapse free survival, cancer-specific survival and overall survival were studied. RESULTS Two hundred fifty one patients (44%) underwent a radical (R0) resection. In patients who had no preoperative treatment the R0 resection rate was 26%, and this was 43% and 50% for patients who respectively received preoperative re-(chemo)-irradiation or full-course radiotherapy (p < 0.0001). After uni- and multivariate analysis it was found that all oncologic parameters were influenced by preoperative treatment and radicality of the resection. Patients who were re-irradiated had a similar outcome compared to patients, who were radiotherapy naive and could undergo full-course treatment, except the chance of local re-recurrence was higher for re-irradiated patients. Waiting-time between preoperative radiotherapy and IOERT was inversely correlated with the chance of local re-recurrence, and positively correlated with the chance of a R0 resection. CONCLUSIONS R0 resection is the most important factor influencing oncologic parameters in treatment of LRRC. Preoperative (chemo)-radiotherapy increases the chance of achieving radical resections and improves oncologic outcomes. Short waiting-times between preoperative treatment and IOERT improves the effectiveness of IOERT to reduce the chance of a local re-recurrence.
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Affiliation(s)
- F A Holman
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - S J Bosman
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - M G Haddock
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - L L Gunderson
- Department of Radiation Oncology, Mayo Clinic, Scottsdale, AZ, USA
| | - M Kusters
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands; Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | | | - H van den Berg
- Department of Radiotherapy, Catharina Hospital, Eindhoven, The Netherlands
| | - H Nelson
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - H J Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands; GROW: School of Oncology and Developmental Biology, University of Maastricht, Maastricht, The Netherlands.
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Outcomes of Pelvic Exenteration with en Bloc Partial or Complete Pubic Bone Excision for Locally Advanced Primary or Recurrent Pelvic Cancer. Dis Colon Rectum 2016; 59:831-5. [PMID: 27505111 DOI: 10.1097/dcr.0000000000000656] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Neoplasms infiltrating the pubic bone have until recently been considered a contraindication to surgery. Paucity of existing published data in regard to surgical techniques and outcomes exist. OBJECTIVE This study aims to address outcomes of our recently published technique for en bloc composite pubic bone excision during pelvic exenteration. DESIGN A prospective database was reviewed to identify patients who underwent a partial or complete pubic bone composite excision over a 12-year period. SETTINGS This study was conducted at a tertiary level exenteration unit. MAIN OUTCOME MEASURES Primary outcomes measured were resection margin and survival. Secondary outcomes included patient and operative demographics, type of cancer, extent of pubic bone excision, morbidity, and 30-day mortality. RESULTS Twenty-nine of over 500 patients undergoing exenterations (mean age, 57.9; 20 males) underwent en bloc complete (11 patients) or partial (18 patients) composite pubic bone excision. Twenty-two patients (76%) underwent resection for recurrent as opposed to advanced primary malignant disease of which rectal adenocarcinoma was the most common followed by squamous-cell carcinoma. The median operating time was 10.5 (range, 6-15) hours, and median blood loss was 2971 (range, 300-8600) mL. Seventeen (59%) patients had a concurrent sacrectomy performed mainly S3 and below. A total cystectomy was performed in 26 patients (90%). Fifteen of 20 male patients (75%) had a perineal urethrectomy. A clear (R0) resection margin was achieved in 22 patients (76%) with a 5-year overall survival of 53% after a median follow-up of 3.2 years (r = 1.4-12.3 years). There was no 30-day mortality. Seventy percent of patients experienced morbidity with a pelvic collection the most common. LIMITATIONS This study was limited because it was a retrospective review, it occurred at a single site, and it used a small heterogeneous sample. CONCLUSION Within the realm of evolving exenteration surgery, en bloc composite pubic bone excision offers results comparable to central, lateral, and posterior compartment excisions, and, as such, is a reasonable strategy in the management of neoplasms infiltrating the pubic bone.
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Belli A, Bianco F, De Franciscis S, Romano GM. Indications for Surgery and Surgical Techniques. Updates Surg 2016. [DOI: 10.1007/978-88-470-5767-8_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Cai G, Zhu J, Palmer JD, Xu Y, Hu W, Gu W, Cai S, Zhang Z. CAPIRI-IMRT: a phase II study of concurrent capecitabine and irinotecan with intensity-modulated radiation therapy for the treatment of recurrent rectal cancer. Radiat Oncol 2015; 10:57. [PMID: 25889149 PMCID: PMC4353448 DOI: 10.1186/s13014-015-0360-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 02/16/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND This study investigated the local effect and acute toxicity of irinotecan and capecitabine with concurrent intensity-modulated radiation therapy (IMRT) for the treatment of recurrent rectal cancer without prior pelvic irradiation. METHODS Seventy-one patients diagnosed with recurrent rectal cancer who did not previously receive pelvic irradiation were treated in our hospital from October 2009 to July 2012. Radiotherapy was delivered to the pelvis, and IMRT of 45 Gy (1.8 Gy per fraction), followed by a boost of 10 Gy to 16 Gy (2 Gy per fraction), was delivered to the recurrent sites. The concurrent chemotherapy regimen was 50 mg/m(2) irinotecan weekly and 625 mg/m(2) capecitabine twice daily (Mon-Fri). Radical surgery was recommended for medically fit patients without extra-pelvic metastases. The patients were followed up every 3 months. Tumor response was evaluated using CT/MRIs according to the RECIST criteria or postoperative pathological findings. NCI-CTC 3.0 was used to score the toxicities. RESULTS Forty-eight patients (67.6%) had confirmed recurrent rectal cancer without extra pelvic metastases, and 23 patients (32.4%) had extra pelvic metastases. Fourteen patients (19.7%) underwent radical resections (R0) post-chemoradiation. A pathologic complete response was observed in 7 of 14 patients. A clinical complete response was observed in 4 patients (5.6%), and a partial response was observed in 22 patients (31.0%). Only 5 patients (7.0%) showed progressive disease during or shortly after treatment. Of 53 symptomatic patients, clinical complete and partial symptom relief with chemoradiation was achieved in 56.6% and 32.1% of patients, respectively. Only 2 patients (2.8%) experienced grade 4 leukopenia. The most common grade 3 toxicity was diarrhea (16 [22.5%] patients). The median follow-up was 31 months. The cumulative local progression-free survival rate was 74.2% and 33.9% at 1 and 3 years after chemoradiation, respectively. The cumulative total survival rate was 80.1% and 36.5% at 1 and 3 years after chemoradiation, respectively. CONCLUSIONS This study revealed that concurrent irinotecan and capecitabine with IMRT significantly relieves local symptoms and exhibits promising efficacy with manageable toxicities in recurrent rectal cancer without prior pelvic irradiation. Improving the rate of R0 resections will be investigated in a future study.
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Affiliation(s)
- Gang Cai
- Department of Radiation Oncology, Shanghai Cancer Center, Shanghai Medical College, Fudan University, 270 Dong An Road, Shanghai, China.
| | - Ji Zhu
- Department of Radiation Oncology, Shanghai Cancer Center, Shanghai Medical College, Fudan University, 270 Dong An Road, Shanghai, China.
| | - Joshua D Palmer
- Department of Radiation Oncology, Kimmel Cancer Center, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Ye Xu
- Department of Radiation Oncology, Shanghai Cancer Center, Shanghai Medical College, Fudan University, 270 Dong An Road, Shanghai, China.
| | - Weigang Hu
- Department of Radiation Oncology, Shanghai Cancer Center, Shanghai Medical College, Fudan University, 270 Dong An Road, Shanghai, China.
| | - Weilie Gu
- Department of Radiation Oncology, Shanghai Cancer Center, Shanghai Medical College, Fudan University, 270 Dong An Road, Shanghai, China.
| | - Sanjun Cai
- Department of Radiation Oncology, Shanghai Cancer Center, Shanghai Medical College, Fudan University, 270 Dong An Road, Shanghai, China.
| | - Zhen Zhang
- Department of Radiation Oncology, Shanghai Cancer Center, Shanghai Medical College, Fudan University, 270 Dong An Road, Shanghai, China.
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Westberg K, Palmer G, Johansson H, Holm T, Martling A. Time to local recurrence as a prognostic factor in patients with rectal cancer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2015; 41:659-66. [PMID: 25749391 DOI: 10.1016/j.ejso.2015.01.035] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 12/18/2014] [Accepted: 01/29/2015] [Indexed: 02/07/2023]
Abstract
AIMS Survival after the local recurrence of rectal cancer is influenced by several factors. The aim of this study was to ascertain whether the time interval from primary surgery for rectal cancer to local recurrence diagnosis has any impact on survival. METHODS Population-based data was collected from the Swedish Colorectal Cancer Registry. 7410 patients were operated with radical abdominal surgery for rectal cancer during the period 1995-2002. Of these, 386 (5%) developed a local recurrence as a first event. The patients were divided into two groups: early local recurrence (ELR), diagnosed <12 months after primary surgery, and late local recurrence (LLR), diagnosed ≥12 months after primary surgery. Kaplan-Meier curves and hazard ratios were calculated for survival analyses. Survival was calculated from the date of the local recurrence diagnosis to death or end of follow-up. RESULTS Ninety-five patients had ELR and 291 patients LLR. Median time to local recurrence was 1.7 (0.1-7.9) years. Patients with a stage III primary tumour and non-irradiated patients were more common in the ELR compared with the LLR group. Factors that influenced survival were age at diagnosis of local recurrence (p < 0.001), stage of primary tumour (p = 0.027), and surgical resection of local recurrence (p < 0.001). Time to diagnosis of local recurrence had no influence on survival. CONCLUSIONS No difference in survival from date of diagnosis of local recurrence was seen between patients with ELR and patients with LLR. All patients with local recurrence should therefore be assessed for potential curative surgery, disregarding time to local recurrence.
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Affiliation(s)
- K Westberg
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Division of Surgery, Danderyd Hospital, S-182 88 Stockholm, Sweden.
| | - G Palmer
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Center of Digestive Diseases, P9:03, Karolinska University Hospital, S-171 76, Stockholm, Sweden
| | - H Johansson
- Department of Oncology-Pathology, Karolinska Institutet, K7, Z4:01, Karolinska University Hospital, S-171 76, Stockholm, Sweden
| | - T Holm
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Center of Digestive Diseases, P9:03, Karolinska University Hospital, S-171 76, Stockholm, Sweden
| | - A Martling
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Center of Digestive Diseases, P9:03, Karolinska University Hospital, S-171 76, Stockholm, Sweden
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Nielsen M, Rasmussen P, Pedersen B, Hagemann-Madsen R, Lindegaard J, Laurberg S. Early and Late Outcomes of Surgery for Locally Recurrent Rectal Cancer: A Prospective 10-Year Study in the Total Mesorectal Excision Era. Ann Surg Oncol 2015; 22:2677-84. [DOI: 10.1245/s10434-014-4317-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Indexed: 12/21/2022]
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Alberda WJ, Haberkorn BC, Morshuis WG, Oudendijk JF, Nuyttens JJ, Burger JWA, Verhoef C, van Meerten E. Response to chemotherapy in patients with recurrent rectal cancer in previously irradiated area. Int J Colorectal Dis 2015; 30:1075-80. [PMID: 26077667 PMCID: PMC4512261 DOI: 10.1007/s00384-015-2270-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/15/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Tumor lesions in previously irradiated area may have a less favorable response to chemotherapy compared to tumor sites outside the radiation field. The aim of the present study was to evaluate the response to chemotherapy of locally recurrent rectal cancer (LRRC) within the previous radiation field compared to the response of distant metastases outside the radiation field. PATIENTS AND METHODS All patients with LRRC referred between 2000 and 2012 to our tertiary university hospital were reviewed. The response to chemotherapy of LRRC within previously irradiated area was compared to the response of synchronous distant metastases outside the radiation field according to the Response Evaluation Criteria in Solid Tumors (RECIST). RESULTS Out of 363 cases with LRRC, 29 previously irradiated patients with distant metastases were treated with chemotherapy and eligible for analysis. Twenty-six patients (89 %) suffered a first recurrence and three patients (11 %) a second recurrence. These patients were followed with a median of 22 months (IQR, 9-40 months) and had a median survival of 33 months (IQR, 14-42). In 23 patients (79 %), the local recurrence showed stable disease, but the overall response rate of the local recurrences in the previously irradiated area was significantly lower than the response rate of distant metastases outside the radiation field (10 vs. 41 %,p = 0.034). CONCLUSIONS Previously irradiated patients with LRRC have a lower response rate to chemotherapy of the local recurrence within the radiation field compared to the response rate of distant metastases outside the radiation field. This suggests that chemotherapy for local palliation may not have the desired effect.
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Affiliation(s)
- W J Alberda
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands,
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Conditional survival for long-term colorectal cancer survivors in the Netherlands: who do best? Eur J Cancer 2014; 50:1731-1739. [PMID: 24814358 DOI: 10.1016/j.ejca.2014.04.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Revised: 02/26/2014] [Accepted: 04/04/2014] [Indexed: 11/21/2022]
Abstract
AIM With the increase in the number of long-term colorectal cancer (CRC) survivors, there is a growing need for subgroup-specific analysis of conditional survival. METHODS All 137,030 stage I-III CRC patients diagnosed in the Netherlands between 1989 and 2008 aged 15-89 years were selected from the Netherlands Cancer Registry. We determined conditional 5-year relative survival rates, according to age, subsite and tumour stage for each additional year survived up to 15 years after diagnosis as well as trends in absolute risks for and distribution of causes of death during follow-up. RESULTS Minimal excess mortality (conditional 5-year relative survival >95%) was observed 1 year after diagnosis for stage I colon cancer patients, while for rectal cancer patients this was seen after 6 years. For stage II and III CRC, minimal excess mortality was seen 7 years after diagnosis for colon cancer, while for rectal cancer this was 12years. The differences in conditional 5-year relative survival between colon and rectal cancer diminished over time for all patients, except for stage III patients aged 60-89 years. The absolute risk to die from CRC diminished sharply over time and was below 5% after 5 years. The proportion of patients dying from CRC decreased over time after diagnosis while the proportions of patients dying from other cancers, cardiovascular disease and other causes increased. CONCLUSION Prognosis for CRC survivors improved with each additional year survived, with the largest improvements in the first years after diagnosis. Quantitative insight into conditional relative survival estimates is useful for caregivers to inform and counsel patients with stage I-III colon and rectal cancer during follow-up.
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Abstract
STUDY DESIGN A review of prospectively collected data on a consecutive series of patients undergoing single-stage anterior high sacrectomy for locally recurrent rectal carcinoma (LRRC). OBJECTIVE To determine the clinical outcome of patients who underwent anterior high sacrectomy for LRRC. SUMMARY OF BACKGROUND DATA High sacrectomy for oncological resection remains technically challenging. Surgery has the potential to achieve cure in carefully selected patients. Complete (R0) tumor excision in LRRC may require sacrectomy. High sacral resections (S3 and above) typically require a combined anterior/supine and posterior/prone procedure. We investigated our experience performing single-stage anterior high sacrectomy for LRRC. METHODS A consecutive series of patients with LRRC without systemic metastases who underwent resection with curative intent requiring high sacrectomy were identified. A review of a prospectively maintained colorectal and spine cancer database data was performed. An oblique dome high sacral osteotomy was performed during a single-stage anterior procedure. Outcome measures included surgical resection margin status, hospital length of stay, postoperative complications, physical functioning status, and overall survival. RESULTS Nineteen consecutive patients were treated between 2002 and 2011. High sacrectomy was performed at sacral level S1-S2 in 4 patients, S2-S3 in 9 patients, and through S3 in 6 patients. An R0 resection margin was achieved histologically in all 19 cases. There was 1 early (<30 d) postoperative death (1/19, 5%). At median follow-up of 38 months, 13 patients had no evidence of residual disease, 1 was alive with disease, and 4 had died of disease. Morbidities occurred in 15 of the 19 patients (79%). CONCLUSION Although high sacrectomy may require a combined anterior and posterior surgical approach, our series demonstrates the feasibility of performing single-stage anterior high sacrectomy in LRRC, with acceptable risks and outcomes compared with the literature. The procedure described by us for LRRC lessens the need for a simultaneous or staged prone posterior resection, with favorable R0 tumor resections, patient survival, and clinical outcomes. LEVEL OF EVIDENCE N/A.
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Seo YS, Kim MS, Yoo HJ, Jang WI. Stereotactic body radiotherapy for oligo-recurrence within the nodal area from colorectal cancer. World J Gastroenterol 2014; 20:2005-2013. [PMID: 24587675 PMCID: PMC3934470 DOI: 10.3748/wjg.v20.i8.2005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 09/25/2013] [Accepted: 01/08/2014] [Indexed: 02/06/2023] Open
Abstract
Recurrence of colorectal cancer (CRC) often presents as solitary metastases, oligometastases or oligo-recurrence. Surgical resection became the preferred treatment for patients with CRC lung and hepatic metastases. However, surgical treatment for oligo-recurrence within nodal area is not a widely accepted treatment due to due to their relative rarity and high postoperative morbidity. Stereotactic body radiotherapy (SBRT) is one of the emerging radiation treatment techniques in which a high radiation dose can be delivered to the tumor. High-dose SBRT can ablate the tumor with an efficacy similar to that achieved with surgery, especially for small tumors. However, there have been very few studies on SBRT for oligo-recurrence within nodal area, although several studies have evaluated the role of SBRT in the treatment of liver and lung metastases from CRC. This article reviews the current clinical status of and treatment methods for oligo-recurrence within nodal area from CRC, with particular emphasis on SBRT.
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Alberda WJ, Verhoef C, Nuyttens JJ, Rothbarth J, van Meerten E, de Wilt JHW, Burger JWA. Outcome in patients with resectable locally recurrent rectal cancer after total mesorectal excision with and without previous neoadjuvant radiotherapy for the primary rectal tumor. Ann Surg Oncol 2013; 21:520-6. [PMID: 24121879 DOI: 10.1245/s10434-013-3306-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND The widespread use of neoadjuvant radiotherapy (nRTx) followed by total mesorectal excision (TME) introduced the problem of treating locally recurrent rectal cancer (LRRC) after nRTx and TME. Few data exist on the outcome of the surgical treatment of this type of LRRC and the influence of nRTx for the primary tumor on the outcome is unclear. METHODS All patients receiving multimodality treatment (including intraoperative radiotherapy) for LRRC in our center between 1996 and 2012 were analyzed retrospectively. The outcome of patients with nonmetastasized resectable LRRC who received nRTx and TME for the primary tumor was compared to the outcome of patients who did not receive nRTx for the primary tumor. RESULTS During this period, 139 patients underwent surgery for LRRC; 93 of these patients underwent curative surgery for LRRC after TME for the primary tumor. Sixty-five patients did not receive nRTx for the primary tumor, whereas 28 patients received nRTx for the primary tumor. There were no significant differences in the number of incomplete resections or perioperative morbidities. There was no significant difference in 5-year overall survival (28 vs. 43%, p = 0.81), recurrence-free survival (55 vs. 48%, p = 0.5), and disease-free survival (27 vs. 40%, p = 0.59). CONCLUSIONS Surgical treatment of carefully selected patients with nonmetastasized resectable LRRC after nRTx and TME for the primary tumor is feasible and can result in sustained local control and overall survival. Patients with resectable LRRC who received nRTx for the primary tumor do not have a poorer outcome than patients who did not.
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Affiliation(s)
- Wijnand J Alberda
- Division of Surgical Oncology, Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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Consensus statement on the multidisciplinary management of patients with recurrent and primary rectal cancer beyond total mesorectal excision planes. Br J Surg 2013; 100:E1-33. [PMID: 23901427 DOI: 10.1002/bjs.9192_1] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The management of primary rectal cancer beyond total mesorectal excision planes (PRC-bTME) and recurrent rectal cancer (RRC) is challenging. There is global variation in standards and no guidelines exist. To achieve cure most patients require extended, multivisceral, exenterative surgery, beyond conventional total mesorectal excision planes. The aim of the Beyond TME Group was to achieve consensus on the definitions and principles of management, and to identify areas of research priority. METHODS Delphi methodology was used to achieve consensus. The Group consisted of invited experts from surgery, radiology, oncology and pathology. The process included two international dedicated discussion conferences, formal feedback, three rounds of editing and two rounds of anonymized web-based voting. Consensus was achieved with more than 80 per cent agreement; less than 80 per cent agreement indicated low consensus. During conferences held in September 2011 and March 2012, open discussion took place on areas in which there is a low level of consensus. RESULTS The final consensus document included 51 voted statements, making recommendations on ten key areas of PRC-bTME and RRC. Consensus agreement was achieved on the recommendations of 49 statements, with 34 achieving consensus in over 95 per cent. The lowest level of consensus obtained was 76 per cent. There was clear identification of the need for referral to a specialist multidisciplinary team for diagnosis, assessment and further management. CONCLUSION The consensus process has provided guidance for the management of patients with PRC-bTME or RRC, taking into account global variations in surgical techniques and technology. It has further identified areas of research priority.
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Aljebreen AM, Azzam NA, Alzubaidi AM, Alsharqawi MS, Altraiki TA, Alharbi OR, Almadi MA. The accuracy of multi-detector row computerized tomography in staging rectal cancer compared to endoscopic ultrasound. Saudi J Gastroenterol 2013; 19:108-12. [PMID: 23680707 PMCID: PMC3709372 DOI: 10.4103/1319-3767.111950] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND/AIM Our aim was to evaluate the diagnostic accuracy of multi-detector row computerized tomography (MDCT) in staging of rectal cancer by comparing it to rectal endoscopic ultrasound (EUS). MATERIALS AND METHODS We prospectively included all patients with rectal cancer referred to our gastroenterology unit for staging of rectal cancer from December 2007 until February 2011, 53 patients whose biopsy had proven rectal cancer underwent both MDCT scan of the pelvis and rectal EUS. Both imaging modalities were compared and the agreement between T- and N-staging of the disease was assessed. RESULTS We staged 62 patients with rectal cancer during the study period. Of these, 53 patients met the inclusion criteria and were evaluated (25 women and 28 men). The mean age was 57.79 ± 14.99 years (range 21-87). MDCT had poor accuracy compared with EUS in T-staging with a low degree of agreement (kappa = 0.26), while for N-staging MDCT had a better accuracy and a moderate degree of agreement with EUS (kappa = 0.45). CONCLUSIONS MDCT has a poor accuracy for predicting tumor invasion compared to EUS for T-staging while it has moderate accuracy for N-staging.
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Affiliation(s)
- Abdulrahman M. Aljebreen
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Nahla A. Azzam
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Ahmad M. Alzubaidi
- Division of Colorectal Surgery, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Mohamed S. Alsharqawi
- Division of Radiology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Thamer A. Altraiki
- Division of Colorectal Surgery, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Othman R. Alharbi
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Majid A. Almadi
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia,The McGill University Health Center, Montreal General Hospital, McGill University, Montreal, Canada,Address for correspondence: Dr. Majid A. Almadi, Division of Gastroenterology, King Khalid University Hospital, King Saud University, P.O. Box 2925 (59), Riyadh 11461, Saudi Arabia. E-mail:
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Kim J. Pelvic exenteration: surgical approaches. JOURNAL OF THE KOREAN SOCIETY OF COLOPROCTOLOGY 2012; 28:286-93. [PMID: 23346506 PMCID: PMC3548142 DOI: 10.3393/jksc.2012.28.6.286] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Accepted: 12/28/2012] [Indexed: 01/27/2023]
Abstract
Although the incidence of local recurrence after curative resection of rectal cancer has decreased due to the understanding of the anatomy of pelvic structures and the adoption of total mesorectal excision, local recurrence in the pelvis still remains a significant and troublesome complication. While surgery for recurrent rectal cancer may offer a chance for a cure, conservative management, including radiation and chemotherapy, remain widely accepted courses of treatment. Recent improvement in imaging modalities, perioperative care, and surgical techniques, including bone resection and wound coverage, have allowed for reductions in operative mortality, though postoperative morbidity still remains high. In this review, the techniques, including surgical approaches, employed for management of locally recurrent rectal cancer are highlighted.
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Affiliation(s)
- Jin Kim
- Division of Colorectal Surgery, Department of Surgery, Korea University College of Medicine, Seoul, Korea
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Weber GF, Rosenberg R, Murphy JE, Meyer zum Büschenfelde C, Friess H. Multimodal treatment strategies for locally advanced rectal cancer. Expert Rev Anticancer Ther 2012; 12:481-94. [PMID: 22500685 DOI: 10.1586/era.12.3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
This review outlines the important multimodal treatment issues associated with locally advanced rectal cancer. Changes to chemotherapy and radiation schema, as well as modern surgical approaches, have led to a revolution in the management of this disease but the morbidity and mortality remains high. Adequate treatment is dependent on precise preoperative staging modalities. Advances in staging via endorectal ultrasound, computed tomography, MRI and PET have improved pretreatment triage and management. Important prognostic factors and their impact for this disease are under investigation. Here we discuss the different treatment options including modern tumor-related surgical approaches, neoadjuvant as well as adjuvant therapies. Further clinical progress will largely depend on the broader implementation of multidisciplinary treatment strategies following the principles of evidence-based medicine.
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Affiliation(s)
- Georg F Weber
- Massachusetts General Hospital/Harvard Medical School, Boston, MA 02114, USA
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Thaysen HV, Jess P, Laurberg S. Health-related quality of life after surgery for primary advanced rectal cancer and recurrent rectal cancer: a review. Colorectal Dis 2012; 14:797-803. [PMID: 21689340 DOI: 10.1111/j.1463-1318.2011.02668.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Health-related quality of life is an important outcome measure in treatment of cancer. A review of the literature was undertaken to provide an overview of health-related quality of life (HRQoL) after surgery for primary advanced or recurrent rectal cancer and to outline proposals for future HRQoL studies in this area. METHOD A systematic literature search was undertaken. Only studies concerning surgery for primary advanced or recurrent rectal cancer and describing methods used for measuring HRQoL were considered. RESULTS Seven studies were identified, including two prospective longitudinal studies, three cross-sectional studies and two based on qualitative data. Global quality of life, and physical, social, role and sexual function seemed to be impaired for a varying time after surgery. All the studies had methodical problems due to small sample size (12-44 patients) and different points of time for the assessment of HRQoL (12.3-47 months), which made it difficult to determine the period of time of impaired HRQoL and also if this is different after surgery for locally advanced or recurrent disease compared with after total mesorectal excision used for earlier tumours. CONCLUSION Several aspects of HRQoL are impaired for a variable time after treatment for locally advanced or recurrence of rectal cancer. Larger prospective longitudinal studies are needed to provide further information regarding the effects of this extensive surgery on quality of life.
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Affiliation(s)
- H V Thaysen
- Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark.
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Surgical management of locally recurrent rectal cancer. Int J Surg Oncol 2012; 2012:464380. [PMID: 22701789 PMCID: PMC3371749 DOI: 10.1155/2012/464380] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Accepted: 04/08/2012] [Indexed: 02/06/2023] Open
Abstract
Developments in chemotherapeutic strategies and surgical technique have led to improved loco regional control of rectal cancer and a decrease in recurrence rates over time. However, locally recurrent rectal cancer continues to present considerable technical challenges and results in significant morbidity and mortality. Surgery remains the only therapy with curative potential. Despite a hostile intra-operative environment, with meticulous pre-operative planning and judicious patient selection, safe surgery is feasible. The potential benefit of new techniques such as intra-operative radiotherapy and high intensity focussed ultrasonography has yet to be thoroughly investigated. The future lies in identification of predictors of recurrence, development of schematic clinical algorithms to allow standardised surgical technique and further research into genotyping platforms to allow individualisation of therapy. This review highlights important aspects of pre-operative planning, intra-operative tips and future strategies, focussing on a multimodal multidisciplinary approach.
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Kodeda K, Derwinger K, Gustavsson B, Nordgren S. Local recurrence of rectal cancer: a population-based cohort study of diagnosis, treatment and outcome. Colorectal Dis 2012; 14:e230-7. [PMID: 22107152 DOI: 10.1111/j.1463-1318.2011.02895.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Local recurrence is an important endpoint of rectal cancer treatment, but details of this form of treatment failure are less well described. The aim of this study was to acquire deeper knowledge of local recurrence regarding symptoms, diagnostic work-up, clinical management, health-care utilization and outcome. METHOD Of 671 patients with rectal cancer, 57 were diagnosed with local recurrence within 5 years after surgery. Their records were analysed. RESULTS At diagnosis of local recurrence 49 (86%) of 57 patients were symptomatic and 40 (70%) were diagnosed between scheduled follow-up visits. The predominant symptom was pain. Forty-five of the 57 (79%) had a palpable tumour. Most were deemed incurable at presentation and 10 (18%) were operated on with curative intent. Five years after the initial rectal cancer surgery, two patients were alive, with one free of disease. Despite the need for multiple interventions, including surgery, only four out of 40 patients were classified as being well-palliated in the terminal stage. CONCLUSION Follow-up after rectal cancer surgery by annual clinical examination is not sufficient to detect local recurrence when it is asymptomatic. Local recurrence of rectal cancer is often associated with intractable symptoms. These patients require frequent interventions and can rarely be cured if diagnosed at an advanced stage. Strategies for early detection of local recurrence and the management thereof require improvement.
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Affiliation(s)
- K Kodeda
- Sahlgrenska Academy, University of Gothenburg, Department of Surgery, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden.
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Evans MD, Griffiths B, Harji D, Sagar PM. Re: A proposal for the annotation of recurrent colorectal cancer. Colorectal Dis 2012; 14:387. [PMID: 22168534 DOI: 10.1111/j.1463-1318.2011.02911.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Abstract
AIM A review of the literature was undertaken to provide an overview of the surgical management of locally recurrent rectal cancer (LRRC) after the introduction of total mesorectal excision (TME). METHOD A systematic literature search was undertaken using PubMed, Embase, Web of Science and Cochrane databases. Only studies on patients having surgery for their primary tumour after 1995, or if more than half of the patients were operated on after 1995, were considered for analysis. Studies concerning only palliative treatments were excluded. RESULTS A total of 19 studies fulfilled the inclusion criteria. Locally recurrent rectal cancer still occurred in 5-10% of the patients and was a major clinical problem, due to severe symptoms and poor survival. In most studies, 40-50% of all patients with LRRC could be expected to undergo surgery with a curative intent and of those, 30-45% would have R0 resection. Thus, only 20-30% of all patients with LRRC would have a potentially curative operation. The postoperative complication rate varied considerably, from 15 to 68%. The rate of re-recurrence varied from 4 to 54% after curative surgery. The 5-year overall survival varied between 9 and 39% and the median survival between 21 and 55 months. CONCLUSION Compared with previous studies, the proportion of potentially curative resections seems to have increased, probably due to improved staging, neoadjuvant treatment and increased surgical experience in dedicated centres, which has resulted in a tendency to improved survival.
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Affiliation(s)
- M B Nielsen
- Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark.
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Lee JH, Kim DY, Kim SY, Park JW, Choi HS, Oh JH, Chang HJ, Kim TH, Park SW. Clinical outcomes of chemoradiotherapy for locally recurrent rectal cancer. Radiat Oncol 2011; 6:51. [PMID: 21595980 PMCID: PMC3118124 DOI: 10.1186/1748-717x-6-51] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Accepted: 05/20/2011] [Indexed: 11/11/2022] Open
Abstract
Background To assess the clinical outcome of chemoradiotherapy with or without surgery for locally recurrent rectal cancer (LRRC) and to find useful and significant prognostic factors for a clinical situation. Methods Between January 2001 and February 2009, 67 LRRC patients, who entered into concurrent chemoradiotherapy with or without surgery, were reviewed retrospectively. Of the 67 patients, 45 were treated with chemoradiotherapy plus surgery, and the remaining 22 were treated with chemoradiotherapy alone. The mean radiation doses (biologically equivalent dose in 2-Gy fractions) were 54.6 Gy and 66.5 Gy for the chemoradiotherapy with and without surgery groups, respectively. Results The median survival duration of all patients was 59 months. Five-year overall (OS), relapse-free (RFS), locoregional relapse-free (LRFS), and distant metastasis-free survival (DMFS) were 48.9%, 31.6%, 66.4%, and 40.6%, respectively. A multivariate analysis demonstrated that the presence of symptoms was an independent prognostic factor influencing OS, RFS, LRFS, and DMFS. No statistically significant difference was found in OS (p = 0.181), RFS (p = 0.113), LRFS (p = 0.379), or DMFS (p = 0.335) when comparing clinical outcomes between the chemoradiotherapy with and without surgery groups. Conclusions Chemoradiotherapy with or without surgery could be a potential option for an LRRC cure, and the symptoms related to LRRC were a significant prognostic factor predicting poor clinical outcome. The chemoradiotherapy scheme for LRRC patients should be adjusted to the possibility of resectability and risk of local failure to focus on local control.
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Affiliation(s)
- Joo Ho Lee
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
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Increased Local Recurrence and Reduced Survival From Colorectal Cancer Following Anastomotic Leak. Ann Surg 2011; 253:890-9. [DOI: 10.1097/sla.0b013e3182128929] [Citation(s) in RCA: 631] [Impact Index Per Article: 48.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Abstract
Over the last decades the therapy of rectal carcinoma has shown continuous improvement. Due to improvements in operative techniques, such as the establishment of total mesorectal excision (TME) and the combination of surgery and (neo-) adjuvant radiochemotherapy, the incidence of locally recurrent rectal cancer could be improved from nearly 50% to less then 10%. Nevertheless recurrent rectal carcinoma remains a severe problem. Predictive factors relating to locally recurrent rectal cancer are surgical experience, localization of the tumor, circumferential resection margins, stage-oriented multimodal therapy and a suitable oncological procedure for the primary tumor. In addition the tumor-specific biology also seems to be a relevant risk factor for recurrence. Operative treatment of locally recurrent rectal cancer was seen for a long time as a palliative procedure. Newer data show that resection of locally recurrent rectal cancer can be carried out with a curative intention in experienced institutions with a long-term 5 year survival of about 30% and mortality around 5%. The composite sacropelvic resection technique is a reasonable option in the curative treatment of locally recurrent rectal cancer. For the future the focus must be on improvements in the primary therapy of rectal carcinoma to avoid local recurrence. In addition early diagnosis of local recurrence and multimodal therapies will be of decisive importance.
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Maurer CA, Renzulli P, Kull C, Käser SA, Mazzucchelli L, Ulrich A, Büchler MW. The impact of the introduction of total mesorectal excision on local recurrence rate and survival in rectal cancer: long-term results. Ann Surg Oncol 2011; 18:1899-906. [PMID: 21298350 DOI: 10.1245/s10434-011-1571-0] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2010] [Indexed: 12/16/2022]
Abstract
PURPOSE To investigate the influence of the introduction of total mesorectal excision (TME) on local recurrence rate and survival in patients with rectal cancer. METHODS A total of 171 consecutive patients underwent anterior or abdominoperineal resection for primary rectal cancer. When the TME technique was introduced, the clinical setting, including the surgeons, remained the same. Group 1 (1993-95, n =53) underwent conventional surgery and group 2 (1995-2001, n = 118) underwent TME. All patients were followed for 7 years or until death. RESULTS Between the two groups, no statistically significant differences were present with regards to patient-, treatment-, or tumor-related characteristics apart from the time point of radiotherapy. The total local recurrence rates were 11 of 53 (20.8%) in group 1 and 7 of 118 (5.9%) in group 2, and the rates of isolated local recurrences were 6 of 53 (11.3%) in group 1 and 2 of 118 (1.7%) in group 2. Both differences were highly statistically significant. The disease-free survival in groups 1 and 2 was 60.4 and 65.3% at 5 years, and 58.5 and 65.3% at 7 years, respectively. Excluding patients with synchronous or metachronous distant metastasis from the analysis, both the disease-free survival and the cancer-specific survival were statistically significantly better in group 2 than in group 1. No statistically significant difference between the two groups was detected regarding the overall survival. CONCLUSIONS The introduction of TME led to an impressive reduction of the local recurrence rate. Survival is mainly determined by the occurrence of distant metastasis, but TME seems to improve survival in patients without systemic disease.
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Affiliation(s)
- C A Maurer
- Department of Visceral and Transplantation Surgery, University of Berne, Berne, Switzerland.
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Rodriguez-Bigas MA, Chang GJ, Skibber JM. Multidisciplinary approach to recurrent/unresectable rectal cancer: how to prepare for the extent of resection. Surg Oncol Clin N Am 2011; 19:847-59. [PMID: 20883958 DOI: 10.1016/j.soc.2010.07.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Local recurrence from rectal cancer is a complex problem that should be managed by a multidisciplinary team. Pelvic re-irradiation and intraoperative radiation should be considered in the management of these patients. Long-term survival can be achieved in patients who undergo radical surgery with negative margins of resections. The morbidity of these procedures is high and at times may compromise quality of life. Palliative surgical procedures can be considered; however, in some cases, palliative resections may not be better than nonsurgical palliation.
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Affiliation(s)
- Miguel A Rodriguez-Bigas
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe, Houston, TX 77030, USA.
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You YN, Habiba H, Chang GJ, Rodriguez-bigas MA, Skibber JM. Prognostic value of quality of life and pain in patients with locally recurrent rectal cancer. Ann Surg Oncol 2010; 18:989-96. [PMID: 21132391 DOI: 10.1245/s10434-010-1218-6] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2010] [Indexed: 01/23/2023]
Abstract
BACKGROUND Care of patients with locally recurrent rectal cancer (LRRC) requires careful patient selection. While curative resection offers survival benefits, significant trade-offs exist for the patient. Knowledge of patient-reported outcomes will help inform treatment decisions. METHODS Quality of life (QOL) and pain were prospectively assessed in 105 patients treated for LRRC at a single institution, using the validated Functional Assessment of Cancer Therapy-Colorectal (FACT-C) and Brief Pain Inventory (BPI) questionnaires. In 54 patients enrolled and followed from diagnosis of LRRC, relationship between pretreatment pain, QOL, and overall survival (OS) were examined. RESULTS Patients underwent curative surgical resection (C, 59%), noncurative surgery (NC, 12%) or nonsurgical treatment (NS, 28%). Median OS was 7.1, 1.4, and 1.9 years, respectively (C versus NC: p < 0.001; C versus NS: p = 0.006; NC versus NS: p = 0.261). Physical well-being QOL differed over time (p = 0.042), with greatest difference between C and NC surgery patients (p = 0.049). The remaining QOL domain scores and pain scores demonstrated no significant time or treatment effect. For the 54 patients assessed from diagnosis, median OS was independently predicted by treatment group (C, NC, NS: 4.3, 1.7, versus 2.4 years; p < 0.001) and pretreatment pain intensity (score ≤ 4 versus > 4: 3.8 versus 2.0 years; p = 0.001). CONCLUSION Curative surgery offered prolonged survival, but significant pain exists among long-term survivors and should be a focus of survivorship care. Noncurative surgery did not offer apparent advantages over nonsurgical palliation. Patient's pretreatment pain has prognostic value, and should be assessed, treated, and considered in treatment decisions.
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Affiliation(s)
- Y Nancy You
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
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de Maat MFG, van de Velde CJH, Benard A, Putter H, Morreau H, van Krieken JHJM, Meershoek Klein-Kranenbarg E, de Graaf EJ, Tollenaar RAEM, Hoon DSB. Identification of a quantitative MINT locus methylation profile predicting local regional recurrence of rectal cancer. Clin Cancer Res 2010; 16:2811-8. [PMID: 20460484 DOI: 10.1158/1078-0432.ccr-09-2717] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE Risk assessment for locoregional disease recurrence would be highly valuable in preoperative treatment planning for patients undergoing primary rectal tumor resection. Epigenetic aberrations such as DNA methylation have been shown to be significant prognostic biomarkers of disease outcome. In this study, we evaluated the significance of a quantitative epigenetic multimarker panel analysis of primary tumors to predict local recurrence in rectal cancer patients from a retrospective multicenter clinical trial. EXPERIMENTAL DESIGN Primary tumors were studied from patients enrolled in the trial who underwent total mesorectal excision for rectal cancer (n=325). Methylation levels of seven methylated-in-tumor (MINT) loci were assessed by absolute quantitative assessment of methylated alleles. Unsupervised random forest clustering of quantitative MINT methylation data was used to show subclassification into groups with matching methylation profiles. RESULTS Variable importance parameters [Gini-Index (GI)] of the clustering algorithm indicated MINT3 and MINT17 (GI, 20.2 and 20.7, respectively) to be informative for patient grouping compared with the other MINT loci (highest GI, 12.2). When using this two-biomarker panel, four different patient clusters were identified. One cluster containing 73% (184 of 251) of the patients was at significantly increased risk of local recurrence (hazard ratio, 10.23; 95% confidence interval, 1.38-75.91) in multivariate analysis, corrected for standard prognostic factors of rectal cancer. This group showed a significantly higher local recurrence probability than patients receiving preoperative radiation (P<0.0001). CONCLUSION Quantitative epigenetic subclassification of rectal cancers has clinical utility in distinguishing tumors with increased risk for local recurrence and may help tailor treatment regimens for locoregional control.
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Affiliation(s)
- Michiel F G de Maat
- Department of Molecular Oncology, John Wayne Cancer Institute, Santa Monica, California 90404, USA
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Mirnezami AH, Sagar PM. Surgery for recurrent rectal cancer: technical notes and management of complications. Tech Coloproctol 2010; 14:209-16. [PMID: 20461538 DOI: 10.1007/s10151-010-0585-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Accepted: 04/21/2010] [Indexed: 12/12/2022]
Abstract
Local recurrence following surgery for rectal cancer remains a significant clinical problem and poses major therapeutic challenges. Radical surgical salvage is the only option with potential for curative treatment and is indicated in carefully selected patients. Surgery also provides acceptable palliation in certain cases. Nevertheless, such surgery is challenging, not commonly used, and historically associated with considerable morbidity and mortality. In more recent times, improvements in surgical techniques, reconstruction methods and management of perioperative complications have helped expand the options available for patients with recurrent rectal cancer. This review article highlights the techniques employed at our institution for the management of locally recurrent rectal cancer with particular emphasis on the surgical approaches, the methods used for reconstruction and the avoidance of complications.
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Affiliation(s)
- A H Mirnezami
- John Goligher Colorectal Unit, Clarendon Wing, Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, UK
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Peng JY, Wang Y. Tumor stroma: a determinant role in local recurrence of rectal cancer patients receiving total mesorectal excision? Med Hypotheses 2010; 75:442-4. [PMID: 20447772 DOI: 10.1016/j.mehy.2010.04.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Accepted: 04/03/2010] [Indexed: 11/18/2022]
Abstract
Local recurrence (LR) dramatically decreases since the adoption of total mesorectal excision (TME) but still could not be avoided. Current mainstream views try to elucidate LR by focusing on tumor cells invasion, such as tumor stage or regional lymph nodes metastasis. But we hypothesize that not tumor cells but the cancer stroma should be responsible for the LR after TME. We believed current resection range of TME may cause remnant cancer stroma, which might act as the determinant role in LR by motivating carcinogenesis of neighboring normal epithelium. A series of supportive evidences are listed and future experiments to test our hypothesis are suggested. Once this hypothesis proved, current standards of TME should be substantially rewritten concerning the resection margins.
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Affiliation(s)
- Jia-Yuan Peng
- Department of Surgery, The Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, 600 Yishan Road, Shanghai 200233, People's Republic of China
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