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Moran BJ. Appendicitis to multivisceral transplantation: a career experience with appendiceal malignancy. Ann R Coll Surg Engl 2024; 106:219-225. [PMID: 37367485 PMCID: PMC10904263 DOI: 10.1308/rcsann.2023.0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2023] [Indexed: 06/28/2023] Open
Abstract
John Hunter is regarded as the father of scientific surgery. His principles involved reasoning, observation and experimentation. His most powerful saying was: "Why not try the experiment?" This manuscript charts a career in abdominal surgery ranging from the treatment of appendicitis to the development of the largest appendiceal tumour centre in the world. The journey has led to the first report of a successful multivisceral and abdominal wall transplant for patients with recurrent non-resectable pseudomyxoma peritonei. We all stand on the shoulders of giants and surgery progresses by learning from the past while being prepared to experiment into the future.
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Affiliation(s)
- BJ Moran
- Hampshire Hospitals NHS Foundation Trust, UK
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2
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Bhagwanani A, El-Sheikha J, Shah N, Thrower A, Carr NJ, Moran BJ. The appendix "mucocoele" misnomer: radiological terminology of "likely appendix mucinous neoplasm" better reflects pathology findings. Clin Radiol 2023; 78:234-238. [PMID: 36411089 DOI: 10.1016/j.crad.2022.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 10/05/2022] [Accepted: 10/17/2022] [Indexed: 11/19/2022]
Abstract
AIM To review the radiological terminology used to describe dilated mucin-containing appendiceal lesions with correlation to the histopathological diagnosis. MATERIALS AND METHODS Radiology and histopathology reports for all patients with an abnormally dilated appendix referred to a tertiary peritoneal malignancy centre, between January 2021 and December 2021, were reviewed. RESULTS Overall, 213 patients were included with a median appendiceal diameter of 25.5 mm (range 10-125 mm). Peritoneal disease was present in 109 patients, with the remaining 104 cases demonstrating a dilated appendix only. Local radiology reports were available for 201 cases with the appendix described in 168 cases as appendiceal mucocoele (n=104), appendiceal neoplasm (n=40), appendicitis (n=18), and dilated appendix (n=6). The appendix was not mentioned in 33/201 (15%), either misinterpreted as other pathology (n=15) or not reported (n=18). Peritoneal malignancy histopathology reports were available in 188 cases and reported as low-grade appendix mucinous neoplasm (LAMN, n=144), high-grade appendix mucinous neoplasm (HAMN, n=13), LAMN with foci of HAMN (n=2), LAMN with neuroendocrine tumour (n=2), LAMN with goblet cell adenocarcinoma (n=1), goblet cell adenocarcinoma (n=8), mucinous adenocarcinoma (n=14), non-mucinous adenocarcinoma (n=1), and benign histology (n=3). Only one case of a true inflammatory "mucocoele"/retention cyst was reported. CONCLUSION In this cohort of patients, the overwhelming majority of dilated, mucin-filled appendices contained malignant cells and benign mucin-filled appendices were rare. The present authors advocate that the term "likely appendix mucinous neoplasm" should replace "appendix mucocoele" to represent the most likely pathology and facilitate less ambiguous interpretation in management decisions.
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Affiliation(s)
- A Bhagwanani
- Peritoneal Malignancy Institute, Hampshire Hospitals NHS Foundation Trust, Basingstoke and North Hampshire Hospital, Basingstoke, UK.
| | - J El-Sheikha
- Peritoneal Malignancy Institute, Hampshire Hospitals NHS Foundation Trust, Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - N Shah
- Peritoneal Malignancy Institute, Hampshire Hospitals NHS Foundation Trust, Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - A Thrower
- Peritoneal Malignancy Institute, Hampshire Hospitals NHS Foundation Trust, Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - N J Carr
- Peritoneal Malignancy Institute, Hampshire Hospitals NHS Foundation Trust, Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - B J Moran
- Peritoneal Malignancy Institute, Hampshire Hospitals NHS Foundation Trust, Basingstoke and North Hampshire Hospital, Basingstoke, UK
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3
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Rokan Z, Simillis C, Kontovounisios C, Moran BJ, Tekkis P, Brown G. Systematic review of classification systems for locally recurrent rectal cancer. BJS Open 2021; 5:6272170. [PMID: 33963369 PMCID: PMC8105621 DOI: 10.1093/bjsopen/zrab024] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 02/13/2021] [Indexed: 01/08/2023] Open
Abstract
Background Classification of pelvic local recurrence (LR) after surgery for primary rectal cancer is not currently standardized and optimal imaging is required to categorize anatomical site and plan treatment in patients with LR. The aim of this review was to evaluate the systems used to classify locally recurrent rectal cancer (LRRC) and the relevant published outcomes. Methods A systematic review of the literature prior to April 2020 was performed through electronic searches of the Science Citation Index Expanded, EMBASE, MEDLINE and CENTRAL databases. The primary outcome was to review the classifications currently in use; the secondary outcome was the extraction of relevant information provided by these classification systems including prognosis, anatomy and prediction of R0 after surgery. Results A total of 21 out of 58 eligible studies, classifying LR in 2086 patients, were reviewed. Studies used at least one of the following eight classification systems proposed by institutions or institutional groups (Mayo Clinic, Memorial Sloan-Kettering – original and modified, Royal Marsden and Leeds) or authors (Yamada, Hruby and Kusters). Negative survival outcomes were associated with increased pelvic fixity, associated symptoms of LR, lateral compared with central LR and involvement of three or more pelvic compartments. A total of seven studies used MRI with specifically defined anatomical compartments to classify LR. Conclusion This review highlights the various imaging systems in use to classify LRRC and some of the prognostic indicators for survival and oncological clearance based on these systems. Implementation of an agreed classification system to document pelvic LR consistently should provide more detailed information on anatomical site of recurrence, burden of disease and standards for comparative outcome assessment.
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Affiliation(s)
- Z Rokan
- Department of Radiology, Royal Marsden Hospital, London, UK.,Pelican Cancer Foundation, Basingstoke, UK.,Cambridge Colorectal Unit, Addenbrookes Hospital, Cambridge, UK
| | - C Simillis
- Cambridge Colorectal Unit, Addenbrookes Hospital, Cambridge, UK.,Department of Surgery & Cancer, Imperial College, London, UK
| | - C Kontovounisios
- Department of Surgery & Cancer, Imperial College, London, UK.,Department of Colorectal Surgery, Royal Marsden Hospital, London, UK.,Department of Colorectal Surgery, Chelsea & Westminster Hospital, London, UK
| | - B J Moran
- Pelican Cancer Foundation, Basingstoke, UK.,Department of Peritoneal Malignancy, Basingstoke & North Hampshire Hospital, Basingstoke, UK
| | - P Tekkis
- Department of Surgery & Cancer, Imperial College, London, UK.,Department of Colorectal Surgery, Royal Marsden Hospital, London, UK.,Department of Colorectal Surgery, Chelsea & Westminster Hospital, London, UK
| | - G Brown
- Department of Radiology, Royal Marsden Hospital, London, UK.,Department of Surgery & Cancer, Imperial College, London, UK
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Zahid A, Clarke L, Carr N, Chandrakumaran K, Tzivanakis A, Dayal S, Mohamed F, Cecil T, Moran BJ. Outcomes of multicystic peritoneal mesothelioma treatment with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. BJS Open 2020; 5:6043736. [PMID: 33688945 PMCID: PMC7944491 DOI: 10.1093/bjsopen/zraa001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 09/03/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Multicystic peritoneal mesothelioma (MCPM) is a rare neoplasm, generally considered a borderline malignancy, best treated by cytoreductive surgery (CRS) to remove macroscopic disease, combined with hyperthermic intraperitoneal chemotherapy (HIPEC). Owing to its rarity, little has been published on clinical presentation, clinical behaviour over time, or an optimal treatment approach. METHODS A prospectively developed peritoneal malignancy database was interrogated for the years 2001-2018. Details on all patients with MCPM as a definitive diagnosis after CRS and HIPEC were analysed, including previous interventions, mode of presentation, surgical treatment, postoperative outcomes, and late follow-up information from abdominal CT and tumour markers. RESULTS Some 40 patients with MCPM underwent CRS and HIPEC between 2001 and 2018. Of these, 32 presented with abdominal pain, distension or bloating, six patients presented with recurrence following previous surgery at the referring hospitals, and two had coincidental diagnoses during a surgical procedure. CRS involved peritonectomy in all 40 patients. Bowel resection was required in 18 patients, and seven had a temporary stoma. Thirty-eight patients were considered to have undergone a complete macroscopic tumour removal (completeness of cytoreduction CC0), and two had residual tumour nodules less than 2.5 mm in size, classified as CC1. Median duration of follow-up was 65 (range 48-79) months. There were no deaths during follow-up. The Kaplan-Meier-predicted recurrence-free interval was 115.4 months. CONCLUSION MCPM is a rare peritoneal neoplasm with a heterogeneous pattern of presentation. CRS and HIPEC is an effective management option for this group of patients, with favourable long-term survival.
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Affiliation(s)
| | | | | | | | | | | | | | | | - B J Moran
- Correspondence to: Peritoneal Malignancy Institute, Basingstoke and North Hampshire Hospital, Aldermaston Road, Basingstoke RG24 9NA, UK (e-mail: )
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Kusamura S, Kepenekian V, Villeneuve L, Lurvink RJ, Govaerts K, De Hingh IHJT, Moran BJ, Van der Speeten K, Deraco M, Glehen O. Peritoneal mesothelioma: PSOGI/EURACAN clinical practice guidelines for diagnosis, treatment and follow-up. Eur J Surg Oncol 2020; 47:36-59. [PMID: 32209311 DOI: 10.1016/j.ejso.2020.02.011] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 02/12/2020] [Indexed: 12/20/2022] Open
Affiliation(s)
- S Kusamura
- Department of Surgery, Peritoneal Surface Malignancy Unit, Fondazione IRCCS Instituto Nazionale Dei Tumori di Milano, Via Giacomo Venezian 1, Milano, Milan, Cap 20133, Italy
| | - V Kepenekian
- Service de Chirurgie Digestive et Endocrinienne, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France; EMR 3738, Lyon 1 University, Lyon, France
| | - L Villeneuve
- Service de Recherche et Epidémiologie Cliniques, Pôle de Santé Publique, Hospices Civils de Lyon, Lyon, France
| | - R J Lurvink
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - K Govaerts
- Department of Surgical Oncology, Hospital Oost-Limburg, Genk, Belgium
| | - I H J T De Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - B J Moran
- Peritoneal Malignancy Institute, North-Hampshire Hospital, Basingstoke, United Kingdom
| | - K Van der Speeten
- Department of Surgical Oncology, Hospital Oost-Limburg, Genk, Belgium
| | - M Deraco
- Department of Surgery, Peritoneal Surface Malignancy Unit, Fondazione IRCCS Instituto Nazionale Dei Tumori di Milano, Via Giacomo Venezian 1, Milano, Milan, Cap 20133, Italy.
| | - O Glehen
- Department of Digestive Surgery, Centre Hospitalier Lyon Sud, Lyon, France
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Govaerts K, Lurvink RJ, De Hingh IHJT, Van der Speeten K, Villeneuve L, Kusamura S, Kepenekian V, Deraco M, Glehen O, Moran BJ. Appendiceal tumours and pseudomyxoma peritonei: Literature review with PSOGI/EURACAN clinical practice guidelines for diagnosis and treatment. Eur J Surg Oncol 2020; 47:11-35. [PMID: 32199769 DOI: 10.1016/j.ejso.2020.02.012] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 02/12/2020] [Indexed: 12/20/2022] Open
Abstract
Pseudomyxoma Peritonei (PMP) is a rare peritoneal malignancy, most commonly originating from a perforated epithelial tumour of the appendix. Given its rarity, randomized controlled trials on treatment strategies are lacking, nor likely to be performed in the foreseeable future. However, many questions regarding the management of appendiceal tumours, especially when accompanied by PMP, remain unanswered. This consensus statement was initiated by members of the Peritoneal Surface Oncology Group International (PSOGI) Executive Committee as part of a global advisory role in the management of uncommon peritoneal malignancies. The manuscript concerns an overview and analysis of the literature on mucinous appendiceal tumours with, or without, PMP. Recommendations are provided based on three Delphi voting rounds with GRADE-based questions amongst a panel of 80 worldwide PMP experts.
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Affiliation(s)
- K Govaerts
- Department of Surgical Oncology, Hospital Oost-Limburg, Genk, Belgium.
| | - R J Lurvink
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - I H J T De Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - K Van der Speeten
- Department of Surgical Oncology, Hospital Oost-Limburg, Genk, Belgium
| | - L Villeneuve
- Service de Recherche et Epidémiologie Cliniques, Pôle de Santé Publique, Hospices Civils de Lyon, Lyon, France, EMR 3738, Lyon 1 University, Lyon, France
| | - S Kusamura
- Department of Surgery, Peritoneal Surface Malignancy Unit, Fondazione IRCCS Instituto Nazionale Dei Tumori di Milano, Via Giacomo Venezian 1, Milano, Milan Cap, 20133, Italy
| | - V Kepenekian
- Service de Chirurgie Digestive et Endocrinienne, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France, EMR 3738, Lyon 1 University, Lyon, France
| | - M Deraco
- Department of Surgery, Peritoneal Surface Malignancy Unit, Fondazione IRCCS Instituto Nazionale Dei Tumori di Milano, Via Giacomo Venezian 1, Milano, Milan Cap, 20133, Italy
| | - O Glehen
- Department of Digestive Surgery, Centre Hospitalier Lyon Sud, Lyon, France
| | - B J Moran
- Peritoneal Malignancy Institute, North-Hampshire Hospital, Basingstoke, UK
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Brandl A, Westbrook S, Nunn S, Arbuthnot-Smith E, Mulsow J, Youssef H, Carr N, Tzivanakis A, Dayal S, Mohamed F, Moran BJ, Cecil T. Clinical and surgical outcomes of patients with peritoneal mesothelioma discussed at a monthly national multidisciplinary team video-conference meeting. BJS Open 2020; 4:260-267. [PMID: 32003132 PMCID: PMC7093780 DOI: 10.1002/bjs5.50256] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 11/29/2019] [Indexed: 12/21/2022] Open
Abstract
Background Peritoneal mesothelioma (PM) is a rare primary neoplasm of the peritoneum with an increasing incidence worldwide. Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has shown promise as a treatment strategy. A national PM multidisciplinary team (national PM MDT) video‐conference meeting was established in the UK and Ireland in March 2016, aiming to plan optimal treatment, record outcomes and provide evidence for the benefits of centralization. This article reports on the activities and outcomes of the first 2·5 years. Methods Between March 2016 and December 2018, patients with PM, referred to peritoneal malignancy centres in Basingstoke, Birmingham, Manchester and Dublin, were discussed by the national PM MDT via video‐conference. The MDT was composed of surgeons, radiologists, specialist nurses and pathologists. Patients were considered for CRS and HIPEC if considered fit for surgery and if radiological imaging suggested that complete surgical cytoreduction could be achieved. Morbidity and mortality following surgery were analysed. Survival analysis following MDT discussion was conducted. Results A total of 155 patients (M : F ratio 0·96) with a mean(s.d.) age of 57(17) years were discussed. To date, 22 (14·2 per cent) have had CRS and HIPEC; the median Peritoneal Cancer Index for the surgical group was 17·0. Complete cytoreduction was achieved in 19 patients. Clavien–Dindo grade I–II complications occurred in 16 patients; there was no grade III–IV morbidity or 30‐day in‐hospital mortality. The median follow‐up for the whole cohort was 18·7 months, and the 2‐year survival rate from time of first review at the national PM MDT was 68·3 per cent. Conclusion The centralized national PM MDT was effective at selecting patients suitable for CRS and HIPEC, reporting a good outcome from patient selection.
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Affiliation(s)
- A Brandl
- Peritoneal Malignancy Institute, Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - S Westbrook
- Peritoneal Malignancy Institute, Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - S Nunn
- Peritoneal Malignancy Institute, Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - E Arbuthnot-Smith
- Peritoneal Malignancy Institute, Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - J Mulsow
- National Centre for Peritoneal Malignancy, Mater Misericordiae University Hospital, Dublin, Ireland
| | - H Youssef
- Good Hope Hospital, Heart of England NHS Foundation Trust, Birmingham, UK
| | - N Carr
- Peritoneal Malignancy Institute, Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - A Tzivanakis
- Peritoneal Malignancy Institute, Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - S Dayal
- Peritoneal Malignancy Institute, Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - F Mohamed
- Peritoneal Malignancy Institute, Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - B J Moran
- Peritoneal Malignancy Institute, Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - T Cecil
- Peritoneal Malignancy Institute, Basingstoke and North Hampshire Hospital, Basingstoke, UK
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Sakata S, Moran BJ. What is a 'mucocele' of the appendix and how are these lesions best managed? Beware the wolf in sheep's clothing. Colorectal Dis 2019; 21:1237-1239. [PMID: 31495047 DOI: 10.1111/codi.14847] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 08/23/2019] [Indexed: 02/06/2023]
Affiliation(s)
- S Sakata
- Peritoneal Malignancy Institute, Hampshire Hospitals National Health Service Foundation Trust, Basingstoke and North Hampshire Hospital, Basingstoke, Hampshire, UK
| | - B J Moran
- Peritoneal Malignancy Institute, Hampshire Hospitals National Health Service Foundation Trust, Basingstoke and North Hampshire Hospital, Basingstoke, Hampshire, UK
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Affiliation(s)
- S A M Crane
- The Pelican Cancer Foundation, Colorectal Research, Basingstoke, UK
| | - A Sun Myint
- The Pelican Cancer Foundation, Colorectal Research, Basingstoke, UK
| | - B J Moran
- The Pelican Cancer Foundation, Colorectal Research, Basingstoke, UK
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Affiliation(s)
- F Di Fabio
- Colorectal Surgery and Peritoneal Malignancy, Basingstoke North Hampshire Hospital, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
| | - B J Moran
- Colorectal Surgery and Peritoneal Malignancy, Basingstoke North Hampshire Hospital, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
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11
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Affiliation(s)
- B J Moran
- Basingstoke Hospital at Hampshire Hospitals Foundation Trust, Aldermaston Road, Basingstoke, RG24 9NA, Basingstoke, UK
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12
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Dattani M, Moran BJ. Understanding variations in the treatment of significant polyps and early colorectal cancer. Colorectal Dis 2019; 21 Suppl 1:57-59. [PMID: 30809918 DOI: 10.1111/codi.14508] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 10/08/2018] [Indexed: 02/08/2023]
Affiliation(s)
- M Dattani
- Pelican Cancer Foundation, Basingstoke, UK
| | - B J Moran
- Basingstoke and North Hampshire Hospital, Basingstoke, UK
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Tzivanakis A, Dayal SP, Arnold SJ, Mohamed F, Cecil TD, Venkatasubramaniam AK, Moran BJ. Biological mesh is a safe and effective method of abdominal wall reconstruction in cytoreductive surgery for peritoneal malignancy. BJS Open 2018; 2:464-469. [PMID: 30511047 PMCID: PMC6254008 DOI: 10.1002/bjs5.93] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 06/26/2018] [Indexed: 11/11/2022] Open
Abstract
Background Patients with peritoneal malignancy often have multiple laparotomies before referral for cytoreductive surgery (CRS). Some have substantial abdominal wall herniation and tumour infiltration of abdominal incisions. CRS involves complete macroscopic tumour removal and hyperthermic intraperitoneal chemotherapy (HIPEC). Abdominal wall reconstruction is problematic in these patients. The aim of this study was to establish immediate and long-term outcomes of abdominal wall reconstruction with biological mesh in a single centre. Methods A dedicated peritoneal malignancy database was searched for all patients who had biological mesh abdominal wall reconstruction between 2004 and 2015. Short- and long-term outcomes were reviewed. All patients had annual abdominal CT as routine peritoneal malignancy follow-up. Results Some 33 patients (22 women) with a mean age of 53·4 (range 19-82) years underwent abdominal wall reconstruction with biological mesh. The majority (23) had CRS for pseudomyxoma (19 low grade), six for colorectal peritoneal metastasis and four for appendiceal adenocarcinoma; 18 had undergone CRS and HIPEC previously. Twenty-five of the 33 patients had abdominal wall tumour involvement and eight had concurrent hernias. The mean duration of surgery was 486 (range 120-795) min and the mean mesh size used was 345 (50-654) cm2. Ten patients developed wound infections and four had a seroma. Two developed early enterocutaneous fistulas. Mean follow-up was 48 months. Five patients developed an incisional hernia. Four died from progressive malignancy. A further 15 patients had disease recurrence, but only one had isolated abdominal wall recurrence. Conclusion Biological mesh was safe and effective for abdominal wall reconstruction in peritoneal malignancy. Postoperative wound infections were frequent but nevertheless incisional hernia rates were low with no instances of mesh-related bowel erosion or fistulation.
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Affiliation(s)
- A Tzivanakis
- Peritoneal Malignancy Institute Basingstoke and North Hampshire Hospital Basingstoke RG24 9NN UK
| | - S P Dayal
- Peritoneal Malignancy Institute Basingstoke and North Hampshire Hospital Basingstoke RG24 9NN UK
| | - S J Arnold
- Peritoneal Malignancy Institute Basingstoke and North Hampshire Hospital Basingstoke RG24 9NN UK
| | - F Mohamed
- Peritoneal Malignancy Institute Basingstoke and North Hampshire Hospital Basingstoke RG24 9NN UK
| | - T D Cecil
- Peritoneal Malignancy Institute Basingstoke and North Hampshire Hospital Basingstoke RG24 9NN UK
| | - A K Venkatasubramaniam
- Peritoneal Malignancy Institute Basingstoke and North Hampshire Hospital Basingstoke RG24 9NN UK
| | - B J Moran
- Peritoneal Malignancy Institute Basingstoke and North Hampshire Hospital Basingstoke RG24 9NN UK
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14
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Dattani M, Crane S, Battersby NJ, Di Fabio F, Saunders BP, Dolwani S, Rutter MD, Moran BJ. Variations in the management of significant polyps and early colorectal cancer: results from a multicentre observational study of 383 patients. Colorectal Dis 2018; 20:1088-1096. [PMID: 29999580 DOI: 10.1111/codi.14342] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 07/11/2018] [Indexed: 02/08/2023]
Abstract
AIM The concept of significant polyps and early colorectal cancer (SPECC) encompasses complex polyps not amenable to routine snare polypectomy or where malignancy cannot be excluded. Surgical resection (SR) offers definitive treatment, but is overtreatment for the majority which are benign and amenable to less invasive endoscopic resection (ER). The aim of this study was to investigate variations in the management and outcomes of significant colorectal polyps. METHOD This was a retrospective observational study of significant colorectal polyps, defined as nonpedunculated lesions of ≥ 20 mm size, diagnosed across nine UK hospitals in 2014. Inclusion criteria were endoscopically or histologically benign polyps at biopsy. RESULTS A total of 383 patients were treated by primary ER (87.2%) or SR (12.8%). Overall, 108/383 (28%) polyps were detected in the Bowel Cancer Screening Programme (BCSP). Primary SR was associated with a significantly longer length of stay and major complications (P < 0.01). Of the ER polyps, 290/334 (86.8%) patients were treated without undergoing surgery. The commonest indication for secondary surgery was unexpected polyp cancer, and of these cases 60% had no residual cancer in the specimen. Incidence of unexpected cancer was 10.7% (n = 41) and was similar between ER and SR groups (P = 0.11). On multivariate analysis, a polyp size of > 30 mm and non-BCSP status were independent risk factors for primary SR [OR 2.51 (95% CI 1.08-5.82), P = 0.03]. CONCLUSION ER is safe and feasible for treating significant colorectal polyps. Robust accreditation within the BCSP has led to improvements in management, with lower rates of SR compared with non-BCSP patients. Standardization, training in polyp assessment and treatment within a multidisciplinary team may help to select appropriate treatment strategies and improve outcomes.
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Affiliation(s)
- M Dattani
- Pelican Cancer Foundation, Basingstoke, UK
| | - S Crane
- Pelican Cancer Foundation, Basingstoke, UK
| | - N J Battersby
- Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - F Di Fabio
- Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - B P Saunders
- St Mark's Hospital and Academic Institute, London, UK
| | - S Dolwani
- School of Medicine, Cardiff University, Cardiff, UK
| | - M D Rutter
- Department of Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, UK
| | - B J Moran
- Basingstoke and North Hampshire Hospital, Basingstoke, UK
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Bignell MB, Mehta AM, Alves S, Chandrakumaran K, Dayal SP, Mohamed F, Cecil TD, Moran BJ. Impact of ovarian metastases on survival in patients treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal malignancy originating from appendiceal and colorectal cancer. Colorectal Dis 2018; 20:704-710. [PMID: 29502336 DOI: 10.1111/codi.14057] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Accepted: 02/20/2018] [Indexed: 12/24/2022]
Abstract
AIM Ovarian metastases from gastrointestinal tract malignancies have been considered an ominous finding with poor prognosis. The aim of this project was to determine the impact on survival, and potential cure, when cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are combined to treat peritoneal malignancy in women with Krukenberg tumours. METHOD A retrospective analysis of prospectively collected data between January 2010 and July 2015. Female patients undergoing complete CRS (macroscopic tumour removal) and HIPEC for pseudomyxoma peritonei (PMP) of appendiceal origin, or colorectal peritoneal metastases (CPM) were included. Survival was estimated using the Kaplan-Meier method and survival rates compared using the log-rank test. RESULTS In total, 889 patients underwent surgery for peritoneal malignancy, of whom 551 were female. Of these, 504/551 (91%) underwent complete CRS and HIPEC. Overall, 405/504 (80%) had at least one involved ovary removed either during CRS and HIPEC or at their index prereferral operation. Three hundred and fifty-two patients (87%) had an appendiceal tumour and 53 (13%) had CPM. At a median follow up of 40 months, overall survival (OS) did not differ significantly between patients with or without ovarian involvement in women with a primary low-grade appendiceal tumour or CPM. In women with high-grade primary appendiceal pathology, OS was significantly lower in patients with ovarian metastases compared with those without ovarian involvement. CONCLUSION Women with ovarian metastases from low-grade appendiceal tumours or colorectal cancer treated with CRS and HIPEC have similar survival rates to patients without ovarian metastases. Long-term survival and cure is feasible in patients amenable to complete tumour removal.
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Affiliation(s)
- M B Bignell
- Peritoneal Malignancy Institute, Basingstoke amd North Hampshire Hospital, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
| | - A M Mehta
- Peritoneal Malignancy Institute, Basingstoke amd North Hampshire Hospital, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
| | - S Alves
- Peritoneal Malignancy Institute, Basingstoke amd North Hampshire Hospital, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
| | - K Chandrakumaran
- Peritoneal Malignancy Institute, Basingstoke amd North Hampshire Hospital, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
| | - S P Dayal
- Peritoneal Malignancy Institute, Basingstoke amd North Hampshire Hospital, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
| | - F Mohamed
- Peritoneal Malignancy Institute, Basingstoke amd North Hampshire Hospital, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
| | - T D Cecil
- Peritoneal Malignancy Institute, Basingstoke amd North Hampshire Hospital, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
| | - B J Moran
- Peritoneal Malignancy Institute, Basingstoke amd North Hampshire Hospital, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
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16
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Moran BJ. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for colorectal peritoneal metastases: from novelty to routine in selected cases. Tech Coloproctol 2017; 21:767-769. [PMID: 28936563 DOI: 10.1007/s10151-017-1679-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Accepted: 06/18/2017] [Indexed: 10/18/2022]
Affiliation(s)
- B J Moran
- Peritoneal Malignancy Institute Basingstoke, Hampshire Hospitals Foundation Trust, Aldermaston Road, Basingstoke, RG24 9NA, UK.
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17
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Dattani M, Moran BJ. Reply to Haboubi and Salmo. Colorectal Dis 2016; 18:1187. [PMID: 27748003 DOI: 10.1111/codi.13543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 09/27/2016] [Indexed: 02/08/2023]
Affiliation(s)
- M Dattani
- Pelican Cancer Foundation, Basingstoke, UK
| | - B J Moran
- Department of Surgery, Basingstoke and North Hampshire Hospital, Basingstoke, UK
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Ansari N, Chandrakumaran K, Dayal S, Mohamed F, Cecil TD, Moran BJ. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in 1000 patients with perforated appendiceal epithelial tumours. Eur J Surg Oncol 2016; 42:1035-41. [PMID: 27132072 DOI: 10.1016/j.ejso.2016.03.017] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Accepted: 03/16/2016] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To report early and long term outcomes following cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in 1000 patients with perforated appendiceal epithelial tumours, predominantly with pseudomyxoma peritonei (PMP). METHODS Retrospective analysis of a prospective database of 1000 consecutive patients undergoing CRS and HIPEC for perforated appendiceal tumours between 1994 and 2014 in a UK National Peritoneal Malignancy unit. RESULTS Overall 1000/1444 (69.2%) patients treated for peritoneal malignancy had appendiceal primary tumours. Of these 738/1000 (73.8%) underwent complete cytoreductive surgery (CCRS), 242 (24.2%) had maximal tumour debulking (MTD) and 20 (2%) had laparotomy and biopsies only. Treatment related 30-day mortality was 0.8% in CCRS and 1.7% in MTD group with major postoperative morbidity rates of 15.2% (CCRS) and 14.5% (MTD). Five- and 10-year overall survival was 87.4% and 70.3% in the 738 patients who had CCRS compared with 39.2% and 8.1% respectively in the MTD group. On multivariate analysis, significant predictors of reduced overall survival were male gender (p = 0.022), elevated CEA (p = 0.001), elevated CA125 (p = 0.001) and high tumour grade or adenocarcinoma (p = 0.001). CONCLUSIONS Perforated epithelial appendiceal tumours are rare, though may be increasing in incidence and can present unexpectedly at elective or emergency abdominal surgery, often with PMP. CRS and HIPEC results in good long term outcomes in most patients.
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Affiliation(s)
- N Ansari
- Peritoneal Malignancy Institute, North Hampshire Hospital, Hampshire Hospital Foundation Trust, Aldermaston Road, Basingstoke, RG24 9NA, United Kingdom.
| | - K Chandrakumaran
- Peritoneal Malignancy Institute, North Hampshire Hospital, Hampshire Hospital Foundation Trust, Aldermaston Road, Basingstoke, RG24 9NA, United Kingdom.
| | - S Dayal
- Peritoneal Malignancy Institute, North Hampshire Hospital, Hampshire Hospital Foundation Trust, Aldermaston Road, Basingstoke, RG24 9NA, United Kingdom.
| | - F Mohamed
- Peritoneal Malignancy Institute, North Hampshire Hospital, Hampshire Hospital Foundation Trust, Aldermaston Road, Basingstoke, RG24 9NA, United Kingdom.
| | - T D Cecil
- Peritoneal Malignancy Institute, North Hampshire Hospital, Hampshire Hospital Foundation Trust, Aldermaston Road, Basingstoke, RG24 9NA, United Kingdom.
| | - B J Moran
- Peritoneal Malignancy Institute, North Hampshire Hospital, Hampshire Hospital Foundation Trust, Aldermaston Road, Basingstoke, RG24 9NA, United Kingdom.
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Abstract
Meticulous follow-up needed
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Affiliation(s)
- M Dattani
- Pelican Cancer Foundation, The Ark, Basingstoke, UK
| | - B J Moran
- Department of Colorectal Surgery, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
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Kusamura S, Moran BJ, Sugarbaker PH, Levine EA, Elias D, Baratti D, Morris DL, Sardi A, Glehen O, Deraco M, Gilly FN, Barrios P, Quenet F, Loggie BW, Gómez Portilla A, de Hingh IHJT, Ceelen WP, Pelz JOW, Piso P, González-Moreno S, Van Der Speeten K, Chua TC, Yan TD, Liauw W. Multicentre study of the learning curve and surgical performance of cytoreductive surgery with intraperitoneal chemotherapy for pseudomyxoma peritonei. Br J Surg 2014; 101:1758-65. [DOI: 10.1002/bjs.9674] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Revised: 08/19/2014] [Accepted: 09/17/2014] [Indexed: 12/18/2022]
Abstract
Abstract
Background
The learning curves for cytoreductive surgery with intraperitoneal chemotherapy for treatment of pseudomyxoma peritonei (PMP) were explored between international centres/surgeons to identify institutional or other factors that might affect performance.
Methods
Data from patients with PMP treated with the combined procedure across 33 international centres between 1993 and 2012 were analysed retrospectively. A risk-adjusted sequential probability ratio test was conducted after defining the target outcome as early oncological failure (disease progression within 2 years of treatment), an acceptable risk for the target outcome (odds ratio) of 2, and type I/II error rates of 5 per cent. The risk prediction model was elaborated and patients were evaluated sequentially for each centre/surgeon. The learning curve was considered to be overcome and proficiency achieved when the odds ratio for early oncological failure became smaller than 2.
Results
Rates of optimal cytoreduction, severe postoperative morbidity and early oncological failure were 84·4, 25·7 and 29·0 per cent respectively. The median annual centre volume was 17 (range 6–66) peritoneal malignancies. Only eight of the 33 centres and six of 47 surgeons achieved proficiency after a median of 100 (range 78–284) and 96 (86–284) procedures respectively. The most important institutional factor affecting surgical performance was centre volume.
Conclusion
The learning curve is extremely long, so centralization and/or networking of centres is necessary to assure quality of services. One centre for every 10–15 million inhabitants would be ideal.
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Affiliation(s)
- S Kusamura
- Peritoneal Surface Malignancy Programme, Colorectal Cancer Unit, IRCCS Fondazione Istituto Nazionale Tumori di Milano, Milan, Italy
| | - B J Moran
- Basingstoke and North Hampshire NHS Foundation Trust, Basingstoke, UK
| | - P H Sugarbaker
- Washington Cancer Institute, Washington Hospital Center, Washington, DC
| | - E A Levine
- Surgical Oncology Service, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina
| | - D Elias
- Department of Surgical Oncology, Institut Gustave Roussy, Cancer Centre, Villejuif
- RENAPE: Centre Expert National de Référence des Cancers Rares du Péritoine, Unité de Recherche Clinique, Centre Hospitalier Universitaire (CHU) de Lyon Sud, Pierre Bénite, France
| | - D Baratti
- Peritoneal Surface Malignancy Programme, Colorectal Cancer Unit, IRCCS Fondazione Istituto Nazionale Tumori di Milano, Milan, Italy
| | - D L Morris
- Hepatobiliary and Surgical Oncology Unit, University of New South Wales Department of Surgery, St George Hospital, New South Wales, Sydney, Australia
| | - A Sardi
- Division of Surgery, Department of Surgical Oncology, Institute for Cancer Care, Mercy Medical Center, Baltimore, Maryland, USA
| | - O Glehen
- RENAPE: Centre Expert National de Référence des Cancers Rares du Péritoine, Unité de Recherche Clinique, Centre Hospitalier Universitaire (CHU) de Lyon Sud, Pierre Bénite, France
- Department of Digestive Surgery, CHU de Lyon Sud, Hospices Civils de Lyon, Pierre Bénite, France
| | - M Deraco
- Peritoneal Surface Malignancy Programme, Colorectal Cancer Unit, IRCCS Fondazione Istituto Nazionale Tumori di Milano, Milan, Italy
| | - F N Gilly
- Department of Digestive Surgery, Centre Hospitalier Universitaire (CHU) de Lyon Sud, Hospices Civils de Lyon, and RENAPE, Unité de Recherche Clinique, CHU de Lyon Sud, Pierre-Benite, France
| | - P Barrios
- Department of Oncological Surgery, Hospital Sant Joan Despí, Moises Broggi, Peritoneal Surface Malignancy Catalonian's Programme, Sant Joan Despí, Barcelona, Spain
| | - F Quenet
- Centre Régional de Lutte du Cancer Val d'Aurell, Montpellier, and RENAPE, CHU de Lyon Sud, Pierre-Benite, France
| | - B W Loggie
- Division of Surgical Oncology, Creighton University Medical Center, Omaha, New England, USA
| | - A Gómez Portilla
- Department of General Surgery and Digestive Diseases, Hospital Santiago Apostol, Vitoria, Spain
| | - I H J T de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - W P Ceelen
- Department of Gastrointestinal Surgery, University Hospital, Ghent, Belgium
| | - J O W Pelz
- Department of General, Visceral and Paediatric Surgery, University of Wuerzburg, Wuerzburg, Germany
| | - P Piso
- Department of Surgery, University Medical Centre Regensburg, Regensburg, Germany
| | - S González-Moreno
- Peritoneal Surface Oncology Programme, Department of Surgical Oncology, M. D. Anderson Cancer Center Madrid, Madrid, Spain
| | - K Van Der Speeten
- Department of Surgical Oncology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - T C Chua
- Hepatobiliary and Surgical Oncology Unit, University of New South Wales Department of Surgery, St George Hospital, Sydney, New South Wales, Australia
| | - T D Yan
- Department of Cardiothoracic Surgery, University of Sydney, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - W Liauw
- Hepatobiliary and Surgical Oncology Unit, University of New South Wales Department of Surgery, St George Hospital, Sydney, New South Wales, Australia
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Lord AC, Shihab O, Chandrakumaran K, Mohamed F, Cecil TD, Moran BJ. Recurrence and outcome after complete tumour removal and hyperthermic intraperitoneal chemotherapy in 512 patients with pseudomyxoma peritonei from perforated appendiceal mucinous tumours. Eur J Surg Oncol 2014; 41:396-9. [PMID: 25216980 DOI: 10.1016/j.ejso.2014.08.476] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 08/07/2014] [Accepted: 08/13/2014] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Pseudomyxoma peritonei (PMP) usually originates from perforated mucinous appendiceal tumours and may present unexpectedly at surgery, or be suspected at cross sectional imaging. The optimal treatment involves macroscopic tumour removal by cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC). The 10-year Kaplan-Meier predicted disease-free survival is 61%. Some patients with recurrence are amenable to further CRS and HIPEC. AIM To evaluate the outcomes of re-do surgery in a large single centre series of reoperation for recurrence of peritoneal surface malignancy. METHOD Retrospective analysis of prospective database of 752 patients undergoing CRS for perforated appendiceal tumours analysed. Routine follow up involved annual CT scans and serum tumour marker measurement. The survival and recurrence in the 512/752 (68.1%) who had complete cytoreduction between March 1994 and January 2012 was calculated by Kaplan-Meier univariate analysis. RESULTS Overall 137/512 (26.4%) developed recurrence and of those 35/137 (25.5%) underwent repeat surgery. Complete tumour removal was again achieved in 20/35 (57.1%). There were no postoperative deaths and no significant difference in early postoperative complications and length of stay compared to primary CRS surgery. The 5-year survival in the 375 without recurrence, the 35 who had re-do surgery and the 102 who had recurrence with no surgery was 90.9%, 79.0% and 64.5% respectively. CONCLUSION Approximately one in four patients develops recurrence after complete CRS and HIPEC for PMP of appendiceal origin. Selected patients can undergo salvage surgery with good outcomes.
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Affiliation(s)
- A C Lord
- Peritoneal Malignancy Unit, Basingstoke and North Hampshire Hospital Aldermaston Road, Basingstoke, Hampshire RG24 9NA, UK.
| | - O Shihab
- Peritoneal Malignancy Unit, Basingstoke and North Hampshire Hospital Aldermaston Road, Basingstoke, Hampshire RG24 9NA, UK
| | - K Chandrakumaran
- Peritoneal Malignancy Unit, Basingstoke and North Hampshire Hospital Aldermaston Road, Basingstoke, Hampshire RG24 9NA, UK
| | - F Mohamed
- Peritoneal Malignancy Unit, Basingstoke and North Hampshire Hospital Aldermaston Road, Basingstoke, Hampshire RG24 9NA, UK
| | - T D Cecil
- Peritoneal Malignancy Unit, Basingstoke and North Hampshire Hospital Aldermaston Road, Basingstoke, Hampshire RG24 9NA, UK
| | - B J Moran
- Peritoneal Malignancy Unit, Basingstoke and North Hampshire Hospital Aldermaston Road, Basingstoke, Hampshire RG24 9NA, UK
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Foster JD, Gash KJ, Carter FJ, West NP, Acheson AG, Horgan AF, Longman RJ, Coleman MG, Moran BJ, Francis NK. Development and evaluation of a cadaveric training curriculum for low rectal cancer surgery in the English LOREC National Development Programme. Colorectal Dis 2014; 16:O308-19. [PMID: 24460775 DOI: 10.1111/codi.12576] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Accepted: 12/07/2013] [Indexed: 12/27/2022]
Abstract
AIM The National Development Programme for Low Rectal Cancer in England (LOREC) was commissioned in response to wide variation in the outcome of patients with low rectal cancer. One of the aims of LOREC was to enhance surgical techniques in managing low rectal cancer. This study reports on the development and evaluation of a novel national technical skills cadaveric training curriculum in extralevator abdominoperineal excision. METHOD Three sites were commissioned for the cadaveric workshops, each delivering the same training curriculum. Training was undertaken in pairs using a fresh-frozen cadaveric model under the supervision of expert mentors. Global assessment score (GAS) forms were developed to promote reflective learning. Feedback on the impact of the workshop was obtained from a sample of delegates at the end of the course, and also after 3-23 months via an online questionnaire. RESULTS Overall 112 consultant colorectal surgeons attended one of 15 cadaveric technical skills training workshops. Seventy-six per cent of delegates reported easy identification of anatomy in the cadaveric model; 67% found tissue planes easy to interpret. Ninety-six per cent of delegates felt the workshop would influence their future practice; 96% reported increased awareness of important anatomy. Only 2% of delegates wished to pursue supplementary formal training from LOREC. CONCLUSION Fresh-frozen cadavers could provide an effective training model for low rectal surgery. A structured 1-day cadaveric workshop has facilitated the dissemination of technical skills for management of low rectal cancer. Attending the cadaveric workshop enhanced delegates' confidence in performing this procedure.
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Affiliation(s)
- J D Foster
- Yeovil District Hospital, NHS Foundation Trust, Yeovil, UK
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Moran BJ, Holm T, Brannagan G, Chave H, Quirke P, West N, Brown G, Glynne-Jones R, Sebag-Montefiore D, Cunningham C, Janjua AZ, Battersby NJ, Crane S, McMeeking A. The English national low rectal cancer development programme: key messages and future perspectives. Colorectal Dis 2014; 16:173-8. [PMID: 24267315 DOI: 10.1111/codi.12501] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 09/15/2013] [Indexed: 02/08/2023]
Abstract
AIM Adenocarcinoma of the lower rectum is clinically challenging because of the need to choose between a wide excision to achieve oncological clearance, on the one hand, and sphincter conservation to maintain anal function, on the other. The English National Low Rectal Cancer Development Programme (LOREC) was developed under the auspices of the Association of Coloproctology of Great Britain and Ireland and the English National Cancer Action Team to improve the outcome of low rectal cancer in England. METHOD LOREC was initiated focusing on preoperative imaging, selective neoadjuvant therapy, optimal surgical treatment and detailed pathological assessment of the excised specimen. Its key elements were 1-day multidisciplinary team (MDT) workshops, cadaveric surgical training, surgical mentoring, pathological audit and radiological workshops. RESULTS Overall, 147 (89.6%) of 164 MDTs from 151 National Health Service (NHS) Trusts (some with two MDTs) in England participated in 15 workshops in Basingstoke or Leeds. In addition, 112 surgeons attended a 1-day cadaveric training programme in Bristol, Newcastle or Nottingham, with the main focus on extralevator abdominoperineal excision and pelvic reconstruction, with input from anatomists and from colorectal and plastic surgeons. CONCLUSION Optimal staging, selective preoperative chemoradiotherapy and precise surgery were considered as crucial to improve the outcome for patients with low rectal cancer.
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Affiliation(s)
- B J Moran
- Colorectal Surgery, Hampshire Hospitals Foundation Trust, Basingstoke, UK
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Taflampas P, Dayal S, Chandrakumaran K, Mohamed F, Cecil TD, Moran BJ. Pre-operative tumour marker status predicts recurrence and survival after complete cytoreduction and hyperthermic intraperitoneal chemotherapy for appendiceal Pseudomyxoma Peritonei: Analysis of 519 patients. Eur J Surg Oncol 2014; 40:515-520. [PMID: 24462284 DOI: 10.1016/j.ejso.2013.12.021] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Revised: 12/16/2013] [Accepted: 12/20/2013] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Cytoreductive surgery (CRS) combined with Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is the optimal treatment for Pseudomyxoma Peritonei (PMP). Despite treatment, disease often recurs and may not be amenable to further CRS. Clinical experience suggests a spectrum of disease which may correlate with tumour marker levels. The aim of this study was to analyse the influence of markers on recurrence and survival. METHODS The details of all patients undergoing surgery for PMP of appendiceal origin at a national centre for peritoneal malignancy were recorded in a dedicated prospective database. The data on all patients who had CRS and HIPEC between March 1994 and January 2012 was analysed and recurrence and survival correlated with pre-operative levels of CEA, CA-125 and CA19-9. RESULTS Overall, 519 (69%) of 752 consecutive patients, underwent complete CRS and HIPEC. The median (range) age was 56 (20-82) years with 342/519 (66%) females. The mean overall (OS) and disease free survival (DFS) in the 131/519 patients who had normal preoperative tumour markers was 168 (128-207) and 125 (114-136) months respectively, significantly higher when compared with the 109/519 (21%) who had all three tumour markers elevated (OS of 65 (42-88) and DFS of 55 (41-70) months respectively) (P = 0.002). CONCLUSIONS Elevated tumour markers predict an increased risk of recurrence and reduced survival after complete CRS. This may reflect cell biology in low grade tumours and is an independent prognostic feature. Further analysis may help to select patients for post-operative chemotherapy, second look procedures or stratification of follow up.
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Affiliation(s)
- P Taflampas
- Peritoneal Malignancy Department, Basingstoke and North Hampshire Hospitals, UK.
| | - S Dayal
- Peritoneal Malignancy Department, Basingstoke and North Hampshire Hospitals, UK
| | - K Chandrakumaran
- Peritoneal Malignancy Department, Basingstoke and North Hampshire Hospitals, UK
| | - F Mohamed
- Peritoneal Malignancy Department, Basingstoke and North Hampshire Hospitals, UK
| | - T D Cecil
- Peritoneal Malignancy Department, Basingstoke and North Hampshire Hospitals, UK
| | - B J Moran
- Peritoneal Malignancy Department, Basingstoke and North Hampshire Hospitals, UK
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Thanigaimani K, Mohamed F, Cecil T, Moran BJ, Bell J. The use of cardiac output monitoring to guide the administration of intravenous fluid during hyperthermic intraperitoneal chemotherapy. Colorectal Dis 2013; 15:1537-42. [PMID: 24119169 DOI: 10.1111/codi.12444] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Accepted: 07/16/2013] [Indexed: 02/08/2023]
Abstract
AIM The optimal strategy for intravenous (IV) fluid management during administration of hyperthermic intraperitoneal chemotherapy (HIPEC) is unclear. In this prospective study we describe the use of a LiDCOrapid™ (LiDCO, Cambridge, UK) cardiac output monitor to guide IV fluid management during cytoreductive surgery (CRS) with HIPEC. The aim of this study was to determine whether cardiac output monitoring will allow close maintenance of physiological parameters during the HIPEC phase. METHOD Twenty-five patients who underwent CRS combined with HIPEC were included in the study. Intra-operative IV fluid boluses were titrated using parameters measured by the LiDCOrapid™ monitor. Stroke volume variation was maintained below 10% with fluid boluses and mean arterial pressure was maintained within 20% of the baseline figure with vasopressors. RESULTS There was no significant change in heart rate and cardiac output. The systemic vascular resistance dropped from an average of 966 dyn.s/cm-5 to 797 dyn s/cm(5) at 60 min during the HIPEC phase (P = 0.62) despite an increase in the dose of phenylepherine. The average total volume of fluid given was 748 ml in the first 30 min and 630 ml in the second 30 min with an average urine output of 307 and 445 ml, respectively. The change in lactate levels was not statistically or clinically significant. CONCLUSION LiDCOrapid™ is an effective noninvasive tool for guiding fluid management in this population. It allows the anaesthesiologist to maintain tight control of essential physiological parameters during a phase of the procedure in which there is a risk of renal injury.
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Affiliation(s)
- K Thanigaimani
- Department of Anaesthetics, Basingstoke and North Hampshire Hospital, Basingstoke, UK
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Abstract
Need for centres and training standards
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Affiliation(s)
- B J Moran
- Peritoneal Malignancy Institute Basingstoke, Hampshire Hospitals Foundation Trust, Aldermaston Road, Basingstoke, RG24 9NA, UK
| | - T D Cecil
- Peritoneal Malignancy Institute Basingstoke, Hampshire Hospitals Foundation Trust, Aldermaston Road, Basingstoke, RG24 9NA, UK
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Abstract
AIM Optimal colon cancer surgery correlates with a reduction in recurrence rate and improved overall prognosis. This technical note describes the extraperitoneal approach for locally advanced right colon cancer. METHOD The retroperitoneal technique, mainly used in pseudomyxoma peritonei resectional surgery, is described in three surgical steps and it is compared with existing surgical approaches for right colon cancer. RESULTS This approach has the advantages of early entry in the retroperitoneal plane well away from the tumour, early recognition and protection of the ureter and minimal manipulation of the tumour-bearing right colon. CONCLUSION Extraperitoneal resection of the right colon for locally advanced colon cancer is technically feasible, safe and achieves tumour-free retroperitoneal margins.
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Affiliation(s)
- P Taflampas
- Colorectal Unit, Basingstoke and North Hampshire Hospital Trust, Basingstoke, UK
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Nash GF, Turner KJ, Hickish T, Smith J, Chand M, Moran BJ. Interactions in the aetiology, presentation and management of synchronous and metachronous adenocarcinoma of the prostate and rectum. Ann R Coll Surg Engl 2012; 94:456-62. [PMID: 23031761 PMCID: PMC3954237 DOI: 10.1308/003588412x13373405384611] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Adenocarcinoma of the prostate and rectum are common male pelvic cancers and may present synchronously or metachronously and, due to their anatomic proximity. The treatment of rectal or prostate cancer (in particular surgery and/or radiotherapy) may alter the presentation, incidence and management should a metachronous tumour develop. This review focuses on the interaction between prostatic and rectal cancer diagnosis and management. We have restricted the scope of this large topic to general considerations, management of rectal cancer after prostate cancer treatment and vice versa, management of synchronous disease and cancer follow-up issues.
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Affiliation(s)
- G F Nash
- Poole Hospital NHS Foundation Trust, Dorset, UK.
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Affiliation(s)
- E J Cook
- Poole General Hospital NHS Foundation Trust, UK
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Affiliation(s)
- T J Moore
- Hampshire Hospitals NHS Foundation Trust, Basingstoke and North Hampshire Hospital, Hampshire, UK
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Abstract
AIM Extralevator abdominoperineal excision in the prone position has been reported as a method to improve the poor outcome sometimes observed after abdominoperineal excision (APE) for low rectal cancer. In this paper a pictorial guide is presented describing the key anatomical steps and landmarks of the operation. METHOD Intraoperative footage of five APE operations filmed in high definition was reviewed and key stages of the operation were identified. Still frames were captured from these sequences to illustrate this guide. An edited video sequence was produced from one of these operations to accompany this paper. CONCLUSION The prone APE allows improved visualization of the perineal portion of the operation by the surgeon, assistants and observers. It permits clear demonstration for teaching. Prospective evaluation is still required to identify patients who would benefit from extralevator APE.
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Affiliation(s)
- O C Shihab
- Colorectal Research, Pelican Cancer Foundation, Basingstoke, Hampshire, UK
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Affiliation(s)
- EJ Cook
- Department of General Surgery,Poole General Hospital, Poole,UK
| | - BJ Moran
- Department of General Surgery,North Hampshire Hospital, Basingstoke,UK
| | - RJ Heald
- Department of General Surgery,North Hampshire Hospital, Basingstoke,UK
| | - GF Nash
- Department of General Surgery,Poole General Hospital, Poole,UK
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Janjua AZ, Moran BJ. Outcomes following surgery without radiotherapy for rectal cancer (Br J Surg 2012 99 137-143). Br J Surg 2012; 99:878-9; author reply 879. [PMID: 22539124 DOI: 10.1002/bjs.8800] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
The Editors welcome topical correspondence from readers relating to articles published in the Journal. Responses should be sent electronically via the BJS website (http://www.bjs.co.uk). All letters will be reviewed and, if approved, appear on the website. A selection of these will be edited and published in the Journal. Letters must be no more than 250 words in length.
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Newman CM, Arnold SJ, Coull DB, Linn TY, Moran BJ, Gudgeon AM, Cecil TD. The majority of colorectal resections require an open approach, even in units with a special interest in laparoscopic surgery. Colorectal Dis 2012; 14:29-34; discussion 42-3. [PMID: 21070568 DOI: 10.1111/j.1463-1318.2010.02504.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Proponents suggest that laparoscopic colorectal resection might be achievable in up to 90% of cases, while keeping conversion rates below 10%. This unselected prospective case series reports on the proportion of patients having a completed laparoscopic colorectal resection in two units where laparoscopic colorectal practice is well established and readily available. METHOD All patients undergoing elective and emergency colorectal resection during a 6-month period were identified. The underlying pathology and the surgical approach (laparoscopic or open) were recorded. The contraindications to laparoscopic resection were also documented. The need and rationale for conversion to an open approach were recorded. RESULTS In total, 205 consecutive patients (160 elective and 45 emergency procedures) underwent colorectal resection for malignancy [117 (57%) patients] and benign pathology [88 (43%) patients]. Laparoscopic resection was attempted in 127/205 (62%) patients and 31/127 (24%) of these were converted to open surgery. The main reasons for not attempting laparoscopic resection were locally advanced disease and emergency surgery. The commonest reasons for conversion were advanced disease and to allow completion of rectal dissection and/or cross-stapling of the rectum. CONCLUSION Despite a special interest in laparoscopic colorectal surgery of the two colorectal units who provided the data for this study, fewer than half (96/205; 47%) of the patients in this consecutive unselected series who were undergoing major colorectal resection had the procedure completed laparoscopically.
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Affiliation(s)
- C M Newman
- Department of Colorectal Surgery, North Hampshire Hospital, Basingstoke, Hampshire, UK.
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Cao C, Yan TD, Deraco M, Elias D, Glehen O, Levine EA, Moran BJ, Morris DL, Chua TC, Piso P, Sugarbaker PH. Importance of gender in diffuse malignant peritoneal mesothelioma. Ann Oncol 2011; 23:1494-8. [PMID: 22056853 DOI: 10.1093/annonc/mdr477] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Combined therapy involving cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy has been shown to improve survival outcomes for patients with diffuse malignant peritoneal mesothelioma (DMPM). The present study aims to investigate gender as a potential prognostic factor on overall survival. PATIENTS AND METHODS Over a period of two decades, 294 patients who underwent CRS and perioperative intraperitoneal chemotherapy were selected from a large multi-institutional registry to assess the prognostic significance of gender on overall survival. RESULTS Female patients were shown to have a significantly improved survival outcome than male patients (P < 0.001). Staging according to a recently proposed tumor-node-metastasis categorization system was significant in both genders. Older female patients had significantly worse survival than younger female patients (P = 0.019), a finding that was absent in male patients. Female patients with low-stage disease were found to have a very favorable long-term outcome after combined treatment. CONCLUSIONS Gender has demonstrated a significant impact on overall survival for patients with DMPM after CRS and perioperative intraperitoneal chemotherapy. An improved understanding of the role of estrogen in the pathogenesis of DMPM may improve the prognostication of patients and determine the role of adjuvant hormonal treatment in the future.
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Affiliation(s)
- C Cao
- The Baird Institute for Applied Heart and Lung Surgical Research, Sydney
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Shihab OC, Taylor F, Bees N, Blake H, Jeyadevan N, Bleehen R, Blomqvist L, Creagh M, George C, Guthrie A, Massouh H, Peppercorn D, Moran BJ, Heald RJ, Quirke P, Tekkis P, Brown G. Relevance of magnetic resonance imaging-detected pelvic sidewall lymph node involvement in rectal cancer. Br J Surg 2011; 98:1798-804. [PMID: 21928408 DOI: 10.1002/bjs.7662] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2011] [Indexed: 12/19/2022]
Abstract
BACKGROUND The significance of magnetic resonance imaging (MRI)-suspected pelvic sidewall (PSW) lymph node involvement in rectal cancer is uncertain. METHODS Magnetic resonance images were reviewed retrospectively by specialist gastrointestinal radiologists for the presence of suspicious PSW nodes. Scans and outcome data were from patients with biopsy-proven rectal cancer and a minimum of 5 years' follow-up in the Magnetic Resonance Imaging and Rectal Cancer European Equivalence Study. Overall disease-free survival (DFS) was analysed using the Kaplan-Meier product-limit method and stratified according to preoperative therapy. Binary logistic regression was used to match patients for propensity of clinical and staging characteristics, and further survival analysis was carried out to determine associations between suspicious PSW nodes on MRI and survival outcomes. RESULTS Of 325 patients, 38 (11·7 per cent) had MRI-identified suspicious PSW nodes on baseline scans. Such nodes were associated with poor outcomes. Five-year DFS was 42 and 70·7 per cent respectively for patients with, and without suspicious PSW nodes (P < 0·001). Among patients undergoing primary surgery, MRI-suspected PSW node involvement was associated with worse 5-year DFS (31 versus 76·3 per cent; P = 0·001), but the presence of suspicious nodes had no impact on survival among patients who received preoperative therapy. After propensity matching for clinical and tumour characteristics, the presence of suspicious PSW nodes on MRI was not an independent prognostic variable. CONCLUSION Patients with suspicious PSW nodes on MRI had significantly worse DFS that appeared improved with the use of preoperative therapy. These nodes were associated with adverse features of the primary tumour and were not an independent prognostic factor.
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Simunovic M, Jacob S, Coates AJ, Vogt K, Moran BJ, Heald RJ. Outcomes following a limited approach to radiotherapy in rectal cancer. Br J Surg 2011; 98:1483-8. [PMID: 21633949 DOI: 10.1002/bjs.7560] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2011] [Indexed: 12/19/2022]
Abstract
BACKGROUND Variation in the use of neoadjuvant and adjuvant radiotherapy for rectal cancer suggests an opportunity to avoid it in all but patients at highest risk of local recurrence. METHODS Between 1 July 1999 and 1 February 2006, patients with primary rectal cancer were treated by a single surgeon operating at McMaster University, Hamilton, Ontario, Canada. Digital rectal examination and pelvic computed tomography were used to determine whether the mesorectal margin was threatened by tumour and thus whether preoperative radiotherapy would be needed. The study outcome was local tumour recurrence. RESULTS Forty-six (48 per cent) of 96 patients received preoperative radiation therapy. The median follow-up was 4·2 years. Tumours were fixed or tethered in 31 (67 per cent) of the 46 irradiated patients. In contrast, no tumour was fixed in unirradiated patients and only ten (20 per cent) of the 50 tumours were tethered. The proportion of patients with stage I or II tumours based on final pathology was similar: 61 per cent (28 of 46) and 56 per cent (28 of 50) in irradiated and unirradiated groups respectively (P = 0·287). There were four (9 per cent) and two (4 per cent) local recurrences among irradiated and unirradiated patients respectively (P = 0·422). CONCLUSION Limiting preoperative radiotherapy in rectal cancer to patients with a threatened circumferential margin does not compromise patient outcome.
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Affiliation(s)
- M Simunovic
- Department of Surgery, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada.
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Abstract
AIM Adequate colonic imaging is generally an invasive procedure with attendant risks, particularly perforation. Endoscopy, barium enema and computed tomographic colonography (CTC) are the main techniques for investigating patients with symptoms of, or screening for, colorectal cancer. The potential complications of these investigations have to be weighed against the benefits. This article reviews the literature on the incidence, presentation and management of iatrogenic colonic perforation at colonic imaging. METHOD A literature review of relevant studies was undertaken using PubMed, Cochrane library and personal archives of references. Manual cross-referencing was performed, and relevant references from selected articles were reviewed. Studies reporting complications of endoscopy, barium enema and CT colonography were included in this review. RESULTS Twenty-four studies were identified comprising 640,433 colonoscopies, with iatrogenic perforation recorded in 585 patients (0.06%). The reported perforation rate with double-contrast barium enema was between 0.02 and 0.24%. Serious complications with CTC were infrequent, though nine perforations were reported in a case series of 24,365 patients (0.036%) undergoing CTC. CONCLUSION Perforation remains an infrequent and almost certainly under-reported, complication of all colonic imaging modalities. Risk awareness, early diagnosis and active management of iatrogenic perforation minimizes an adverse outcome.
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Affiliation(s)
- J S Khan
- Queen Alexandra Hospital, Portsmouth, UK.
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40
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Arvold ND, Chen M, Moul JW, Moran BJ, Dosoretz DE, Banez LL, Katin MJ, Braccioforte MH, D'Amico AV. Risk of death from prostate cancer after radical prostatectomy or brachytherapy in men with low- or intermediate-risk disease. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.7_suppl.198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
198 Background: Radical prostatectomy (RP) and brachytherapy (BT) are widely utilized treatments for favorable-risk prostate cancer (PC). We estimated the risk of PC-specific mortality (PCSM) following RP or BT in men with low- or intermediate-risk PC using prospectively collected data. Methods: The study cohort comprised 5,760 men with low-risk PC (prostate-specific antigen [PSA] level ≤ 10 ng/mL, clinical category T1c or 2a, and Gleason score ≤ 6), and 3,079 men with intermediate-risk PC (PSA level 10-20 ng/mL, clinical T2b or T2c, or Gleason score 7). Competing risks multivariable regression was performed to assess risk of PCSM after RP or BT, adjusting for age, treatment year, cardiovascular comorbidity, and known PC prognostic factors. Results: There was no significant difference in the risk of PCSM among men with low-risk PC (11 vs. 6 deaths: adjusted hazard ratio [AHR], 1.62; 95% CI, 0.59–4.45; P = 0.35) who received BT compared to RP. However among men with intermediate-risk PC, despite significantly shorter median follow-up for men undergoing BT as compared to RP (4.1 vs. 7.2 years, P < 0.001), there was a trend toward an increased risk of PCSM (18 vs. 9 deaths: AHR, 2.30; 95% CI, 0.95–5.58; P = 0.07) for men treated with BT. Conclusions: The risk of PCSM among men with low-risk PC was not significantly different following RP or BT, however there may be a reduced risk of PCSM after RP as compared to BT in men with intermediate-risk PC. [Table: see text] No significant financial relationships to disclose.
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Affiliation(s)
- N. D. Arvold
- Harvard Radiation Oncology Program, Boston, MA; University of Connecticut, Storrs, CT; Duke University Medical Center, Durham, NC; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
| | - M. Chen
- Harvard Radiation Oncology Program, Boston, MA; University of Connecticut, Storrs, CT; Duke University Medical Center, Durham, NC; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
| | - J. W. Moul
- Harvard Radiation Oncology Program, Boston, MA; University of Connecticut, Storrs, CT; Duke University Medical Center, Durham, NC; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
| | - B. J. Moran
- Harvard Radiation Oncology Program, Boston, MA; University of Connecticut, Storrs, CT; Duke University Medical Center, Durham, NC; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
| | - D. E. Dosoretz
- Harvard Radiation Oncology Program, Boston, MA; University of Connecticut, Storrs, CT; Duke University Medical Center, Durham, NC; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
| | - L. L. Banez
- Harvard Radiation Oncology Program, Boston, MA; University of Connecticut, Storrs, CT; Duke University Medical Center, Durham, NC; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
| | - M. J. Katin
- Harvard Radiation Oncology Program, Boston, MA; University of Connecticut, Storrs, CT; Duke University Medical Center, Durham, NC; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
| | - M. H. Braccioforte
- Harvard Radiation Oncology Program, Boston, MA; University of Connecticut, Storrs, CT; Duke University Medical Center, Durham, NC; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
| | - A. V. D'Amico
- Harvard Radiation Oncology Program, Boston, MA; University of Connecticut, Storrs, CT; Duke University Medical Center, Durham, NC; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
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Mitin T, Chen M, Moran BJ, Dosoretz DE, Katin MJ, Braccioforte MH, Salenius S, D'Amico AV. Diabetes mellitus, race, and the odds of high-grade prostate cancer in men diagnosed with prostate cancer in the United States. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.7_suppl.180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
180 Background: African American (AA) men present more frequently with high-grade prostate cancer (PCa) and are also more likely to have diabetes mellitus (DM). We evaluated whether there is an independent association between DM and the risk of high-grade PCa in men diagnosed with PCa, adjusting for the known predictors of high-grade PCa including AA race. Methods: Between 1991 and 2009 15,377 men newly diagnosed with PCa and treated at 1 of 26 centers, were analyzed in 2 cohorts. Multivariable logistic regression was performed to evaluate whether a diagnosis of DM was associated with the odds of Gleason 7 or 8 to 10 PCa, adjusting for AA race, advancing age, PSA level, and DRE findings. Results: AA men (AOR, 1.87; 95% CI, 1.04-3.37, P=0.04) and non-AA men (AOR, 1.61; 95% CI, 1.34-1.93; P<0.001) with diabetes were more likely to have GS 8 to 10 versus GS 6 or less PCa, compared to non-diabetic men. AA as compared to non-AA race was not significantly associated with the odds of having GS 8 to 10 as compared to 6 or less PCa, both in men with a diagnosis of DM (AOR, 1.47; 95% CI, 0.87-2.50; P=0.15) and without DM (AOR, 1.27; 95% CI, 0.92-1.74, P=0.14). AA race, however (AOR, 1.37; 95% CI, 1.17-1.60, P<0.001), but not DM (AOR 1.09; 95% CI, 0.97-1.22, P=0.16), was associated with GS 7 versus 6 or less PCa. Conclusions: A diagnosis of DM is a risk factor for presenting with Gleason 8 to 10 PCa independent of race. [Table: see text] No significant financial relationships to disclose.
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Affiliation(s)
- T. Mitin
- Brigham and Women's Hospital, Boston, MA; University of Connecticut, Storrs, CT; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
| | - M. Chen
- Brigham and Women's Hospital, Boston, MA; University of Connecticut, Storrs, CT; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
| | - B. J. Moran
- Brigham and Women's Hospital, Boston, MA; University of Connecticut, Storrs, CT; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
| | - D. E. Dosoretz
- Brigham and Women's Hospital, Boston, MA; University of Connecticut, Storrs, CT; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
| | - M. J. Katin
- Brigham and Women's Hospital, Boston, MA; University of Connecticut, Storrs, CT; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
| | - M. H. Braccioforte
- Brigham and Women's Hospital, Boston, MA; University of Connecticut, Storrs, CT; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
| | - S. Salenius
- Brigham and Women's Hospital, Boston, MA; University of Connecticut, Storrs, CT; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
| | - A. V. D'Amico
- Brigham and Women's Hospital, Boston, MA; University of Connecticut, Storrs, CT; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
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Youssef H, Moran BJ. On or in the liver? Two cases with diffuse pseudomyxoma peritonei and synchronous hepatic pathology. Tech Coloproctol 2011; 15:85-7. [PMID: 21249511 DOI: 10.1007/s10151-010-0671-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Accepted: 12/21/2010] [Indexed: 11/30/2022]
Abstract
Pseudomyxoma peritonei (PMP) is a borderline malignancy, simulating carcinomatosis and generally arising from perforation of an appendiceal mucinous tumour. Some patients have coincidental dual pathology. Liver abnormalities in particular may be overlooked and/or misclassified. We report 2 cases of patients who had diffuse PMP with synchronous hepatic pathology to highlight the need for vigilance and appropriate assessment of coincidental liver lesions. An assessment and management strategy is outlined.
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Affiliation(s)
- H Youssef
- Department of Pseudomyxoma Surgery, Basingstoke and North Hampshire NHS Foundation Trust, Basingstoke, Hampshire, UK.
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Newman CM, Moran BJ. Pseudomyxoma peritonei presenting as recurrent rectal cancer: a preventable condition? Tech Coloproctol 2010; 15:89-90. [PMID: 21120570 DOI: 10.1007/s10151-010-0654-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2010] [Accepted: 10/18/2010] [Indexed: 11/24/2022]
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Mirnezami AH, Mirnezami R, Venkatasubramaniam AK, Chandrakumaran K, Cecil TD, Moran BJ. Robotic colorectal surgery: hype or new hope? A systematic review of robotics in colorectal surgery. Colorectal Dis 2010; 12:1084-93. [PMID: 19594601 DOI: 10.1111/j.1463-1318.2009.01999.x] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Robotic colorectal surgery is an emerging field and may offer a solution to some of the difficulties inherent to conventional laparoscopic surgery. The aim of this review is to provide a comprehensive and critical analysis of the available literature on the use of robotic technology in colorectal surgery. METHOD Studies reporting outcomes of robotic colorectal surgery were identified by systematic searches of electronic databases. Outcomes examined included operating time, length of stay, blood loss, complications, cost, oncological outcome, and conversion rates. RESULTS Seventeen Studies (nine case series, seven comparative studies, one randomized controlled trial) describing 288 procedures were identified and reviewed. Study heterogeneity precluded a meta-analysis of the data. Robotic procedures tend to take longer and cost more, but may reduce the length of stay, blood loss, and conversion rates. Complication profiles and short-term oncological outcomes are similar to laparoscopic surgery. CONCLUSION Robotic colorectal surgery is a promising field and may provide a powerful additional tool for optimal management of more challenging pathology, including rectal cancer. Further studies are required to better define its role.
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Affiliation(s)
- A H Mirnezami
- Department of Colorectal Surgery, Southampton University Hospital NHS Trust, Southampton, UK.
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45
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Chua TC, Yan TD, Deraco M, Glehen O, Moran BJ, Sugarbaker PH. Multi-institutional experience of diffuse intra-abdominal multicystic peritoneal mesothelioma. Br J Surg 2010; 98:60-4. [PMID: 20872843 DOI: 10.1002/bjs.7263] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2010] [Indexed: 12/31/2022]
Abstract
BACKGROUND This study was undertaken to measure survival of patients with multicystic peritoneal mesothelioma treated by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy through a multi-institutional collaboration. METHODS A multi-institutional data registry, established by the Peritoneal Surface Oncology Group, was used to identify patients with peritoneal mesothelioma and the subgroup with multicystic tumours, treated by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Outcomes for this subgroup are reported. The primary endpoint was overall survival. A secondary endpoint was the incidence of treatment-related complications. RESULTS Of 405 patients with peritoneal mesothelioma, 26 (6·4 per cent) had multicystic tumours. There were 20 women and six men with a mean(s.d.) age of 42(12) years. The median peritoneal carcinomatosis index (PCI) was 14 (range 6-39). There was no perioperative mortality. Six patients developed grade III or IV complications. After a median follow-up of 54 (range 5-129) months, all 26 patients were still alive. CONCLUSION Multicystic peritoneal mesothelioma appears to be a distinct subtype of peritoneal mesothelioma, where long-term survival may be achieved through cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.
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Affiliation(s)
- T C Chua
- University of New South Wales Department of Surgery, St George Hospital, Sydney, New South Wales, Australia
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Shihab OC, Quirke P, Heald RJ, Moran BJ, Brown G. Magnetic resonance imaging-detected lymph nodes close to the mesorectal fascia are rarely a cause of margin involvement after total mesorectal excision. Br J Surg 2010; 97:1431-6. [PMID: 20603854 DOI: 10.1002/bjs.7116] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND In rectal cancer the management of suspicious magnetic resonance imaging (MRI)-detected lymph nodes lying close to the mesorectal fascia poses an ongoing dilemma. Key decisions in treatment planning are commonly based on the prediction of margin status. However, it is unclear whether a lymph node that appears to contain tumour close to the mesorectal fascia will result in a positive margin. METHODS Some 396 patients with rectal cancer were included. MRI assessment of mesorectal nodes, the pathologically involved circumferential resection margin (CRM) rate and causes of margin involvement were analysed to establish the clinical significance of MRI-detected suspicious lymph nodes at the resection margin. RESULTS Fifty (12.6 per cent) of 396 patients had a positive CRM on histopathological analysis, five (10 per cent) solely due to an involved lymph node. Four of the five malignant nodes were not predicted on MRI. Thirty-one of the 396 MRI studies had suspicious nodes 1 mm or less from the CRM. None of these patients had a positive CRM owing to nodal involvement. CONCLUSION Involvement of the CRM by lymph node metastases alone is uncommon.
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Affiliation(s)
- O C Shihab
- Colorectal Research, Pelican Cancer Foundation, Basingstoke, UK
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Hayes JH, Chen M, Moran BJ, Braccioforte MH, Dosoretz D, Salenius S, Katin M, Ross R, D’Amico AV. Short-course androgen suppression therapy prior to brachytherapy for favorable-risk prostate cancer and the risk of all-cause mortality in men with or without preexisting cardiovascular disease. J Clin Oncol 2009. [DOI: 10.1200/jco.2009.27.15_suppl.5066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
5066 Background: AST is used to reduce prostate size in men with favorable-risk prostate cancer who have pubic arch interference in order to enable them to undergo prostate brachytherapy. While no disease-specific benefit has been demonstrated to AST in this setting, AST use has been associated with both cardiovascular morbidity and mortality. The Objective is to determine the effect of short-course androgen suppression therapy (AST) prior to brachytherapy on all cause mortality (ACM), stratified by the presence or absence of preexisting cardiovascular disease (CVD). Methods: The study cohort included 12,792 men with previously-untreated low or intermediate risk prostate cancer (PSA < 20 ng/mL; Gleason score 7 or below on initial biopsy; clinical category T2c or below) treated between 1992 and 2005 at one of 21 community-based medical centers in Illinois, Florida, New York, or North Carolina. Men were treated with brachytherapy with or without neoadjuvant AST. Multivariate Cox regression analysis was performed to assess whether significant associations between preexisting CVD and ACM existed adjusting for age, year of treatment and known prostate cancer prognostic factors. Results: After a median follow up of 3.76 years (interquartile range, 2.03 to 5.92 years), 1557 deaths had occurred. The use of neoadjuvant AST was significantly associated with an increased risk of ACM in men with pretreatment CVD (adjusted hazard ratio (AHR) 1.62, 95% CI, 1.40 to 1.87, p < 0.001) but not in men without CVD (AHR 1.06, 95% CI, 0.91 to 1.25, p = 0.5). In men with preexisting CVD, AST use was associated with an increased risk of ACM at 5 years compared to men with CVD who did not use AST (17.5% (95%CI, 15.57% to 19.64%) vs. 14.35% (95%CI, 12.80% to 16.06%), p < 0.0001). Conclusions: Preexisting CVD is associated with an increased risk of death in men with favorable-risk prostate cancer treated with short-course AST prior to brachytherapy. No significant financial relationships to disclose.
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Affiliation(s)
- J. H. Hayes
- Dana-Farber Cancer Institute, Boston, MA; University of Connecticut, Storrs, CT; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Brigham and Women's Hospital, Boston, MA
| | - M. Chen
- Dana-Farber Cancer Institute, Boston, MA; University of Connecticut, Storrs, CT; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Brigham and Women's Hospital, Boston, MA
| | - B. J. Moran
- Dana-Farber Cancer Institute, Boston, MA; University of Connecticut, Storrs, CT; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Brigham and Women's Hospital, Boston, MA
| | - M. H. Braccioforte
- Dana-Farber Cancer Institute, Boston, MA; University of Connecticut, Storrs, CT; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Brigham and Women's Hospital, Boston, MA
| | - D. Dosoretz
- Dana-Farber Cancer Institute, Boston, MA; University of Connecticut, Storrs, CT; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Brigham and Women's Hospital, Boston, MA
| | - S. Salenius
- Dana-Farber Cancer Institute, Boston, MA; University of Connecticut, Storrs, CT; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Brigham and Women's Hospital, Boston, MA
| | - M. Katin
- Dana-Farber Cancer Institute, Boston, MA; University of Connecticut, Storrs, CT; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Brigham and Women's Hospital, Boston, MA
| | - R. Ross
- Dana-Farber Cancer Institute, Boston, MA; University of Connecticut, Storrs, CT; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Brigham and Women's Hospital, Boston, MA
| | - A. V. D’Amico
- Dana-Farber Cancer Institute, Boston, MA; University of Connecticut, Storrs, CT; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Brigham and Women's Hospital, Boston, MA
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D'Amico AV, Braccioforte MH, Moran BJ, Chen M. Diabetes and the risk of death in men with favorable or high-risk prostate cancer following radiation therapy. J Clin Oncol 2009. [DOI: 10.1200/jco.2009.27.15_suppl.5157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
5157 Background: An increased risk of all cause mortality (ACM) has been observed in patients with cancer who have diabetes mellitus (DM) (JAMA 2008:300:2754–2764). Yet, how a diagnosis of DM affects survival across the risk-strata of men with prostate cancer (PC) remains unknown. Methods: The study cohort comprised 7041 men of median age 69.6 years treated with brachytherapy with or without external beam radiation therapy (RT) between 10/97 and 7/07. Short course neoadjuvant hormonal therapy (HT) was used in men with pubic arch interference in order to make them eligible for brachytherapy. Cox regression multivariable analyses were performed in men with Gleason score 8 to 10 disease and also in men with favorable-risk (low or intermediate) disease to assess whether men with DM were at increased risk for ACM compared to men without DM. The hazard ratios (HR) and 95% Confidence intervals (CI) reported were adjusted for age, extent of RT, history of myocardial infarction (MI), use of HT and known PC prognostic factors. Estimates of PC-specific mortality (PCSM) were estimated using a cumulative incidence method. Results: After a median follow-up of 4.1 years, 544 (8%) men had died. In the 466 men with Gleason score 8 to 10 cancers 31% (22/70) of deaths were from PC and a diagnosis of DM was not associated with an increased risk of ACM (Adjusted HR (AHR): 1.1 [95% CI: 0.6 to 2.2]; p = 0.78). However, as shown in the Table , for the 6575 men with favorable-risk disease where only 10% (49/474) of deaths were from PC, there was an increased risk of ACM (AHR: 1.5 [95% CI: 1.2 to 2.0]; p < 0.001) in men with diabetes as compared to those without diabetes. PCSM estimates were significantly higher (p < 0.001) in men with Gleason 8 to 10 as compared to low or intermediate-risk PC reaching 10% and 1% respectively by 7 years. Conclusions: These data highlight the importance of aggressive management of DM in men with favorable-risk PC where death from PC is unlikely. [Table: see text] No significant financial relationships to disclose.
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Affiliation(s)
- A. V. D'Amico
- Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA; Prostate Cancer Foundation of Chicago, Chicago, IL; University of Connecticut, Storrs, CT
| | - M. H. Braccioforte
- Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA; Prostate Cancer Foundation of Chicago, Chicago, IL; University of Connecticut, Storrs, CT
| | - B. J. Moran
- Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA; Prostate Cancer Foundation of Chicago, Chicago, IL; University of Connecticut, Storrs, CT
| | - M. Chen
- Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA; Prostate Cancer Foundation of Chicago, Chicago, IL; University of Connecticut, Storrs, CT
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Nanda A, Chen M, Moran BJ, Braccioforte MH, Dosoretz D, Salenius S, Katin M, Ross R, D'Amico AV. Predictors of prostate cancer-specific mortality in elderly men with intermediate-risk prostate cancer treated with radiation therapy. J Clin Oncol 2009. [DOI: 10.1200/jco.2009.27.15_suppl.9543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
9543 Background: To identify clinical factors associated with prostate cancer-specific mortality (PCSM), adjusting for co-morbidity, in elderly men with intermediate-risk prostate cancer treated with brachytherapy alone or in conjunction with external beam radiation therapy (EBRT). Methods: The study cohort comprised 1,978 men of median age 71 (interquartile range [IQR], 66–75) years with intermediate-risk prostate cancer (Gleason score 7 with PSA 20 ng/mL or less and tumor category T2c or less). Fine and Gray's multivariable competing risks regression was used to assess whether presence of cardiovascular disease (CVD), age, treatment, year of brachytherapy, PSA level, or tumor category were associated with the risk of PCSM. Results: After a median follow up of 3.2 (IQR, 1.7 - 5.4) years, 15 men were observed to experience PCSM. The presence of CVD was significantly associated with a decreased risk of PCSM (AHR 0.20, 95% CI 0.04 - 0.99, P = 0.05), whereas an increasing PSA level was significantly associated with an increased risk of PCSM (AHR 1.14, 95% CI 1.02 - 1.27, P = 0.02). In the absence of CVD, cumulative incidence estimates of PCSM were higher (P = 0.03) in men with PSA levels above as compared to the median PSA level (7.3 ng/mL) or less; however, in the setting of CVD there was no difference (P = 0.27) in these estimates stratified by the median PSA level (6.9 ng/mL). Conclusions: Detection of intermediate-risk prostate cancer in elderly men without CVD at lower PSA levels is associated with a lower risk of PCSM; this risk reduction is not observed in men with known CVD. [Table: see text] No significant financial relationships to disclose.
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Affiliation(s)
- A. Nanda
- Harvard Radiation Oncology Program, Boston, MA; University of Connecticut, Storrs, CT; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Brigham and Women's Hospital, Boston, MA
| | - M. Chen
- Harvard Radiation Oncology Program, Boston, MA; University of Connecticut, Storrs, CT; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Brigham and Women's Hospital, Boston, MA
| | - B. J. Moran
- Harvard Radiation Oncology Program, Boston, MA; University of Connecticut, Storrs, CT; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Brigham and Women's Hospital, Boston, MA
| | - M. H. Braccioforte
- Harvard Radiation Oncology Program, Boston, MA; University of Connecticut, Storrs, CT; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Brigham and Women's Hospital, Boston, MA
| | - D. Dosoretz
- Harvard Radiation Oncology Program, Boston, MA; University of Connecticut, Storrs, CT; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Brigham and Women's Hospital, Boston, MA
| | - S. Salenius
- Harvard Radiation Oncology Program, Boston, MA; University of Connecticut, Storrs, CT; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Brigham and Women's Hospital, Boston, MA
| | - M. Katin
- Harvard Radiation Oncology Program, Boston, MA; University of Connecticut, Storrs, CT; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Brigham and Women's Hospital, Boston, MA
| | - R. Ross
- Harvard Radiation Oncology Program, Boston, MA; University of Connecticut, Storrs, CT; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Brigham and Women's Hospital, Boston, MA
| | - A. V. D'Amico
- Harvard Radiation Oncology Program, Boston, MA; University of Connecticut, Storrs, CT; Prostate Cancer Foundation of Chicago, Westmont, IL; 21st Century Oncology, Fort Myers, FL; Brigham and Women's Hospital, Boston, MA
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