Patient management after primary rectal cancer diagnosis. Special focus on surgical treatment for non-metastatic disease

Background: Rectal cancer is a public health priority. Primary objectives of this study were to evaluate the quality of care for non-metastatic rectal cancer using process and outcome indicators. Delay of management, length of stay and readmission rate, sphincter preservation, morbidity, number of examined lymph nodes, mortality, overall and disease-free survivals were evaluated. Secondary objectives were to estimate the relationship between possible predictive parameters for (1) anastomotic leakage (logistic regression), (2) overall or disease-free survivals (cox regression).Methods: We performed a retrospective study on 312 consecutive patients diagnosed with primary rectal cancer between 2016 and 2019. We focused on the 163 patients treated by surgery for non-metastatic cancer.Results: The treatment began within 33 days (range 0-264) after incidence, resection rate was 67%. Digestive continuity rate in lower, middle and upper rectum was 30%, 87% and 96%. Median of 14 lymph nodes (range 1-46) was analyzed. Length of stay and readmission rate were 11 days (range 3-56) and 4%, respectively. Within 90 postoperative days, clinical anastomotic leakage occurred in 9.2% of cases, major morbidity rate was 17%, mortality 1.2%. Multivariate analysis revealed that stoma decreased the risk of anastomotic leakage [hazard ratio: 0.16; 95% confidence intervals: 0.04-0.63; p = 0.008]. The 5-year overall survival after surgery was 85 ± 4%, disease-free survival 83 ± 4%. Patients with major complications, male gender and R1/R2 resection margin had a poorer prognosis.Conclusion: This work showed encouraging results in rectal cancer treatment in our institution, our results were in line with recommendations at the time.

Trends of sphincter-preserving surgeries for low lying rectal cancer: A 20-year experience in China

Background

Over the last 2 decades, patients with low rectal cancer have had better outcomes from improvements in surgical techniques in sphincter preservation. We aimed to quantify the trends in sphincter-preserving surgeries for low rectal cancer over 20 years in a top tertiary hospital in China.

Methods

Between 1999 and 2021, a cohort of patients with primary malignant rectal tumor ≤5cm from the anal verge and who received elective surgeries at Changhai Hospital, Shanghai, China, was identified. Data were extracted from electronic medical records. A Joinpoint Regression Model was used to analyze trends in surgical procedures by average annual percentage change (AAPC). Adjusted Cox proportional hazards regression model was used to assess overall survival.

Results

Among a total of 4,172 patients during the study period, 3,111 (74.6%) underwent a sphincter-preserving surgery and 1,061 (25.4%) received APR. Sphincter-preserving surgery increased 3.6% per year (95%CI, 2.3-4.9). Low anterior resection was the most performed procedure (86.3%) and maintained a steady trend, while intersphincteric resection increased 49.4% annually (95%CI, 19.5-86.7) after initiation. Laparoscopic techniques increased 15.1% per year (95%CI, 8.4-43.4) after initiation. Sphincter-preserving surgery increased annually for tumors ≤2cm, 2-≤3cm and 3-≤4cm from the anal verge (AAPC 7.1, 4.5-9.8; 4.7, 3.1-6.3; 2.7, 1.7-3.6, respectively). Furthermore, patients with sphincter-preserving surgery had a better overall survival than abdominoperineal resection (APR) patients (adjusted HR 0.78, 95% CI, 0.65-0.93, p=.01).

Conclusions

Utilization of sphincter-preserving surgeries increased significantly over the last 20 years. Patients with low rectal cancer who underwent sphincter preservation had better survival than similar patients who underwent APR.

The Evolving Strategy of Californium-252 Neutron Intracavitary Brachytherapy in Treating Patients With Low-Lying T2 or T3 Rectal Adenocarcinoma: From Fixed to Individualized Regime With Intrarectal Peritumoral Injection of Amifostine

Purpose

To retrospectively and comparatively evaluate the improvement of the efficacy and safety on the addition of ²⁵²Cf neutron intracavitary brachytherapy (ICBT), individualized or individualized with intrarectal peritumoral injection of amifostine (IPIA) to external-beam radiotherapy (EBRT) or concurrent chemo-EBRT in 314 patients with T2N0-1 or T3N0-1 low-lying rectal adenocarcinoma.

Methods

Phase I: from 2009 to 2011, 157 patients were treated with additional ²⁵²Cf neutron ICBT for four fixed fractions with a total dose of 40–45 Gy-eq during the EBRT. Phase II: from 2011 to 2013, 75 patients were treated with individualized neutron ICBT delivered for two to five fractions with a total dose of 26–45 Gy-eq according to the response of tumor after concurrent chemo-EBRT. Phase III: from 2013 to 2014, 82 patients were treated with individualized ICBT protected by pretreatment IPIA.

Results

The 4-year local control rates for the entire T2 and T3 patients were 69.4, 72.0, and 79.3%, while the 4-year overall survival rates were 63.1, 54.7, and 72.0% (P=0.08), and the 4-year disease-free survival rates were 55.4, 52.0, and 69.5% (P=0.053) in Phases I, II, and III, respectively. The late complication (LAC, ≥G2) rates were 33.8, 26.7, and 15.9%, respectively (P=0.012), and the serious LAC (≥G3) rates were 4.5, 4.2, and 0%, respectively, in Phases I, II, and III.

Conclusion

Concurrent chemo-EBRT combined with individualized ²⁵²Cf neutron ICBT protected by IPIA shows promising efficacy and safety in treating low-lying T2 and T3 rectal adenocarcinoma patients without surgery opportunity or willing.

Current status of total neoadjuvant therapy for locally advanced rectal cancer

Neoadjuvant chemoradiotherapy (nCRT) plus total mesorectal excision (TME) has been the standard regimen for treatment of patients with locally advanced rectal cancer (LARC), because it significantly reduces the rate of local recurrence and enables sphincter preservation. However, distant metastasis remains the major reason for treatment failure, and the value of postoperative chemotherapy is still controversial. Recent studies have examined the use of total neoadjuvant therapy (TNT), defined as induction and/or consolidation chemotherapy (CONCT) with radiotherapy (RT) or nCRT prior to surgery. The results indicated that TNT may increase the rates of chemotherapy compliance and pathological complete response (pCR), and probably improve the success rate of sphincter preservation surgery. TNT may also improve disease-free survival and overall survival, and even reduce the rate of relapse. Here, we critically appraise the existing literature on three different TNT schemes used for LARC patients.

Para-sacral approach followed by laparoscopic low anterior resection of a gastrointestinal stromal tumour at the anterior wall of the lower rectum

AIM

We present a para-sacral approach followed by a laparoscopic low anterior resection of gastrointestinal stromal tumours located between the urethra and the low rectum.

METHOD

Case 1 is a 56-year-old male patient whose tumour (37 × 28 mm) was located 3.0 cm above the anal verge between the anterior wall of the rectum and the urethra; he underwent surgery after 14 months' administration of imatinib mesylate (400 mg/day). Case 2 is a 68-year-old male patient who presented with dysuria; a tumour (89 × 84 mm) was detected between the urethra and the anterior wall of the low rectum by MRI. He underwent surgery after 5 months' administration of imatinib mesylate (400 mg/day). In order to perform sphincter-preserving surgery and avoid injury not only to the tumour capsule but also to the urethra, a para-sacral approach followed by laparoscopic low anterior resection was adopted in these patients. Restoration of bowel continuity was done by coloanal anastomosis in case 1 and the double stapling technique in case 2. The postoperative course of the patients was uneventful. In case 2, tumour dissection from the urethra caused injury to the posterior wall of the urethra, which could be repaired easily under direct vision. The urethral catheter was removed after 117 postoperative days, and the diverting stoma was closed after 143 postoperative days.

CONCLUSION

The para-sacral approach followed by a laparoscopic low anterior resection of an extraluminal gastrointestinal stromal tumour located between the urethra and anterior wall of the low rectum enables R0 resection of the tumour and an appropriate reconstruction of the rectum.

Intersphincteric resection for low rectal cancer: the risk is functional rather than oncological. A 25-year experience from Bordeaux

AIM

There are few data evaluating the long-term outcomes of intersphincteric resection (ISR), especially the impact of inclusion of more juxtapositioned and intra-anal tumours on oncological and functional outcomes. We compared the oncological and functional results of patients treated by total mesorectal excision and ISR for low rectal cancer over a 25-year period.

METHOD

This is a retrospective study from a single institution evaluating results of ISR over three periods: 1990-1998, 1999-2006 and 2007-2014. Patients treated by partial or total ISR, with or without neoadjuvant chemoradiotherapy, for low rectal cancer (≤ 6 cm from the anal verge) were included. We compared postoperative morbidity, quality of surgery and oncological and functional outcomes in the time periods studied.

RESULTS

Of 813 patients operated on for low rectal cancer, 303 had ISR. Tumour stage did not differ; however, the distance of the tumour from the anorectal junction decreased from 1 to 0 cm (P < 0.001) and the distal resection margin shortened from 25 to 10 mm (P < 0.001) from 1990 to 2014. The postoperative morbidity and quality of surgery did not change significantly over time. The 5-year local recurrence (4.3% vs 5.9% vs 3.5%; P = 0.741) and disease-free survival (72% vs 71% vs 75%; P = 0.918) did not differ between the three time periods. Functional results improved during the last period; however, overall 42% of patients experienced major bowel dysfunction.

CONCLUSION

Pushing the envelope of sphincter-saving resection in ultra-low rectal cancer reaching or invading the anal sphincter did not compromise oncological and functional outcomes. The main limitation of the ISR procedure appears to be functional rather than oncological, suggesting that bowel rehabilitation programmes should be developed.

Neoadjuvant FOLFIRINOX followed by Chemoradiotherapy for Middle and Lower Rectal Cancer

Objective:

Neoadjuvant concomitant chemoradiotherapy followed by surgical resection is the standard of care in the treatment of rectal cancer. We are investigating the value of adding combination chemotherapy oxaliplatin, irinotecan, leucovorin and fluorouracil (FOLFIRINOX) before neoadjuvant chemoradiotherapy.

Methods:

Forty-one patients with middle and lower rectal cancer were included. FOLFORINOX were given every 2 weeks over 2 months (4 cycles) followed by concomitant chemoradiotherapy (CRT). Surgery was done 6-8 weeks after CRT and then adjuvant 4 months of FOLFOX or XELOX were given. The primary end point was sphincter preservation rate.

Results:

All patients received the four cycles of neoadjuvant chemotherapy FOLFORINOX, 38 patients completed CRT and only 29 patients underwent surgery. 32 patients were available for assessment (29 patients who underwent surgery and three patients who refuse surgery because of no evidence of disease by endoscopy, imaging and biopsy). Sphincter preservation was achieved in twenty-one patients (51.2%). Pathological complete response rate was 24.1%. After a median follow up of 24 months. Median PFS was 20 months and 2-years PFS was 62.3%. The median overall survival of all patients was not reached, while 2-years OS was 76.5%.

Conclusion:

Neoadjuvant FOLFIRINOX followed by CRT for middle and lower rectal cancer is feasible, tolerable with satisfactory sphincter preservation rate.

Robotic versus laparoscopic sphincter-preserving total mesorectal excision: A propensity case-matched analysis

BACKGROUND

Robotic total mesorectal excision (R-TME) is expected to have advantages over laparoscopic total mesorectal excision (L-TME). The aim is to compare the short-term outcomes between initial cases of L-TME and RTME.

MATERIALS AND METHODS

Among a total of 168 patients assigned to receive either R-TME (n = 84) or L-TME (n = 84), short term outcomes were compared between the groups by 1:1 propensity score matching of eight variables.

RESULTS

The inter-sphincteric resection rate (42.9% vs. 25%; P = 0.006) and operative time (372.4 ± 102.8 vs. 301 ± 53.6, P = 0.000) were significantly greater in R-TME. The conversion rate, blood loss, and length of hospital stay were similar. The anastomotic leak rate and major surgical complications rates were significantly higher in L-TME (9.5% vs. 1.2%; P = 0.016) and (13.1% vs. 4.8%; P = 0.034) respectively.

CONCLUSION

The oncologic quality and short-term outcomes in the two groups were comparable; however, anastomotic leak rates and major complications were significantly lower in R-TME. For experienced laparoscopic surgeons, robotic sphincter-saving TME is associated with lower morbidity when compared with laparoscopic approach.

Anterior Sagittal Anorectoplasty with External Sphincter Preservation for the Treatment of Recto-vestibular Fistula: A New Approach

Context

To our knowledge, there is no description of anterior sagittal anorectoplasty (ASARP) with external anal sphincter preservation and passing neorectum in the middle of muscle complex under direct vision for the treatment of recto-vestibular fistula (VF).

Aim

This study evaluates a new modification combining ASARP with under vision sphincter preservation.

Subjects and Methods

This prospective study was conducted on thirty female infants with VF. Procedure starts with a vertical midline incision extending from ectopic opening to posterior limit of external sphincter. Sharp dissection of the fistula is carried out. Artery forceps is passed at the center of muscle complex under vision, then neorectum is placed in the middle of the muscle complex. We introduced a new scoring system based on parental interview assessing functional outcome. Each patient was given a score between 0 and 20; good: 14-20, fair: 7-13, and poor: 0-6.

Results

ASARP was performed at a mean age of 2.6 months, a mean weight of 5.2 kg, a mean operative time of 102 min, and a mean hospital stay of 3.6 days. Wound infection occurred in four cases, seven cases had perianal excoriations, six cases had anal stenosis, and only one case complained of anal displacement. Patients followed for a mean of 18.8 months. Majority of our patients (50%) had good score (mean = 16.8), normal frequency, no or mild soiling, normal anal position with no or mild stenosis. Fourteen patients had fair score (mean = 10.5). Only one had poor outcome with severe soiling and perineal excoriation.

Conclusion

Our modification offers optimal correction, with minimal sphincteric damage, without additional complexity or difficulties. Scoring system is simple, practical, and truly reflects early functional and parent satisfaction after surgery.

Local control of sphincter-preserving procedures and abdominoperineal resection for locally advanced low rectal cancer: Propensity score matched analysis

Sphincter‐preserving procedures (SPPs) for surgical treatment of low‐lying rectal tumors have advanced considerably. However, their oncological safety for locally advanced low rectal cancer compared with abdominoperineal resection (APR) is contentious. We retrospectively analyzed cohort data of 1500 consecutive patients who underwent elective resection for stage II‐III rectal cancer between 2010 and 2011. Patients with tumors 2‐5 cm from the anal verge and clinical stage T3‐4 were eligible. Primary outcome was 3‐year local recurrence rate, and confounding effects were minimized by propensity score matching. The study involved 794 patients (456 SPPs and 338 APR). Before matching, candidates for APR were more likely to have lower and advanced lesions, whereas SPPs were carried out more often following preoperative treatment, by laparoscopic approach, and at institutions with higher case volume. After matching, 398 patients (199 each for SPPs and APR) were included in the analysis sample. Postoperative morbidity was similar between the SPPs and APR groups (38% vs 39%; RR 0.98, 95% CI 0.77‐1.27). Margin involvement was present in eight patients in the SPPs group (one and seven at the distal and radial margins, respectively) and in 12 patients in the APR group. No difference in 3‐year local recurrence rate was noted between the two groups (11% vs 14%; HR 0.77, 95% CI 0.42‐1.41). In this observational study, comparability was ensured by adjusting for possible confounding factors. Our results suggest that SPPs and APR for locally advanced low rectal cancer have demonstrably equivalent oncological local control.

Applications of computed tomography pelvimetry and clinical-pathological parameters in sphincter preservation of mid-low rectal cancer

BACKGROUND

This study aims to evaluate the predictive value of pelvic anatomical and clinical-pathological parameters that influence the success of sphincter preservation procedure (SPP).

METHODS

We studied 42 consecutive patients who underwent low anterior resection (LAR) with double stapling technique (DST) anastomosis or abdominoperineal resection (APR) for mid-low rectal cancer between June 2009 and April 2014. The surgical procedures were performed by the same surgeon and surgical team at the Department of Surgery of Wenzhou Central Hospital. Pelvic dimensions and angles were measured using three-dimensional reconstruction of spiral computed tomography (CT) images. A number of clinical-pathological parameters were also examined. Univariate and multivariate analyses were performed to determine the predictive significance of these variables that might affect a successful SPP for mid-low rectal cancer.

RESULTS

Body mass index (BMI), distance of tumor from anal verge, and diameter of upper pubis to coccyx affected the success of SPP. It was the higher distance of tumor from anal verge, the higher BMI, and the larger diameter of upper pubis to coccyx contributed most to the success of SPP.

CONCLUSIONS

Diameter of upper pubis to coccyx is the only one of the pelvic anatomical parameters that could affect the success of SPP for mid-low rectal cancer patients. Furthermore, within the normal BMI range, higher BMI seemed to be a favorable factor for the success of SPP.

Sphincter-sparing surgery in patients with low-lying rectal cancer: techniques, oncologic outcomes, and functional results

BACKGROUND

Rectal cancer management has evolved into a complex multimodality approach with survival, local recurrence, and quality of life parameters being the relevant endpoints. Surgical treatment for low rectal cancer has changed dramatically over the past 100 years.

DISCUSSION

Abdominoperineal resection, once the standard of care for all rectal cancers, has become much less frequently utilized as surgeons devise and test new techniques for preserving the sphincters, maintaining continuity, and performing oncologically sound ultra-low anterior or local resections. Progress in rectal cancer surgery has been driven by improved understanding of the anatomy and pathophysiology of the disease, innovative surgical technique, improved technology, multimodality approaches, and increased appreciation of the patient's quality of life. The patient with a low rectal cancer, once almost universally destined for impotence and a colostomy, now has the real potential for improved survival, avoidance of a permanent stoma, and preservation of the normal route of defecation.