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Thompson HM, Omer DM, Lin S, Kim JK, Yuval JB, Veheij FS, Qin LX, Gollub MJ, Wu AJC, Lee M, Patil S, Hezel AF, Marcet JE, Cataldo PA, Polite BN, Herzig DO, Liska D, Oommen S, Friel CM, Ternent CA, Coveler AL, Hunt SR, Garcia-Aguilar J. Organ Preservation and Survival by Clinical Response Grade in Patients With Rectal Cancer Treated With Total Neoadjuvant Therapy: A Secondary Analysis of the OPRA Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2350903. [PMID: 38194231 PMCID: PMC10777257 DOI: 10.1001/jamanetworkopen.2023.50903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/20/2023] [Indexed: 01/10/2024] Open
Abstract
Importance Assessing clinical tumor response following completion of total neoadjuvant therapy (TNT) in patients with locally advanced rectal cancer is paramount to select patients for watch-and-wait treatment. Objective To assess organ preservation (OP) and oncologic outcomes according to clinical tumor response grade. Design, Setting, and Participants This was secondary analysis of the Organ Preservation in Patients with Rectal Adenocarcinoma trial, a phase 2, nonblinded, multicenter, randomized clinical trial. Randomization occurred between April 2014 and March 2020. Eligible participants included patients with stage II or III rectal adenocarcinoma. Data analysis occurred from March 2022 to July 2023. Intervention Patients were randomized to induction chemotherapy followed by chemoradiation or chemoradiation followed by consolidation chemotherapy. Tumor response was assessed 8 (±4) weeks after TNT by digital rectal examination and endoscopy and categorized by clinical tumor response grade. A 3-tier grading schema that stratifies clinical tumor response into clinical complete response (CCR), near complete response (NCR), and incomplete clinical response (ICR) was devised to maximize patient eligibility for OP. Main Outcomes and Measures OP and survival rates by clinical tumor response grade were analyzed using the Kaplan-Meier method and log-rank test. Results There were 304 eligible patients, including 125 patients with a CCR (median [IQR] age, 60.6 [50.4-68.0] years; 76 male [60.8%]), 114 with an NCR (median [IQR] age, 57.6 [49.1-67.9] years; 80 male [70.2%]), and 65 with an ICR (median [IQR] age, 55.5 [47.7-64.2] years; 41 male [63.1%]) based on endoscopic imaging. Age, sex, tumor distance from the anal verge, pathological tumor classification, and clinical nodal classification were similar among the clinical tumor response grades. Median (IQR) follow-up for patients with OP was 4.09 (2.99-4.93) years. The 3-year probability of OP was 77% (95% CI, 70%-85%) for patients with a CCR and 40% (95% CI, 32%-51%) for patients with an NCR (P < .001). Clinical tumor response grade was associated with disease-free survival, local recurrence-free survival, distant metastasis-free survival, and overall survival. Conclusions and Relevance In this secondary analysis of a randomized clinical trial, most patients with a CCR after TNT achieved OP, with few developing tumor regrowth. Although the probability of tumor regrowth was higher for patients with an NCR compared with patients with a CCR, a significant proportion of patients achieved OP. These findings suggest the 3-tier grading schema can be used to estimate recurrence and survival outcomes in patients with locally advanced rectal cancer who receive TNT. Trial Registration ClinicalTrials.gov Identifier: NCT02008656.
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Affiliation(s)
- Hannah M. Thompson
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Dana M. Omer
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sabrina Lin
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jin K. Kim
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan B. Yuval
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Floris S. Veheij
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Li-Xuan Qin
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marc J. Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Abraham Jing-Ching Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Meghan Lee
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sujata Patil
- Department of Quantitative Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Aram F. Hezel
- James P. Wilmot Cancer Center, University of Rochester, Rochester, New York
| | | | | | - Blase N. Polite
- Department of Surgery, University of Chicago, Chicago, Illinois
| | - Daniel O. Herzig
- Department of Surgery, Oregon Health & Science University, Portland
| | - David Liska
- Department of Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Samuel Oommen
- Department of Surgery, John Muir Health, Walnut Creek, California
| | - Charles M. Friel
- Department of Surgery, University Hospital, University of Virginia Health System, Charlottesville
| | - Charles A. Ternent
- Department of Surgery, Creighton University Medical Center, Omaha, Nebraska
| | | | - Steven R. Hunt
- Department of Surgery, Washington University, St Louis, Missouri
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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Williams B, Gupta A, Koller SD, Starr TJ, Star MJH, Shaw DD, Hakim AH, Leinicke J, Visenio M, Perrone KH, Torgerson ZH, Person AD, Ternent CA, Chen KA, Kapadia MR, Keller DS, Elnagar J, Okonkwo A, Gagliano RA, Clark CE, Arcomano N, Abcarian AM, Beaty JS. Emergency Colon and Rectal Surgery, What Every Surgeon Needs to Know. Curr Probl Surg 2024; 61:101427. [PMID: 38161059 DOI: 10.1016/j.cpsurg.2023.101427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 10/17/2023] [Indexed: 01/03/2024]
Affiliation(s)
- Brian Williams
- Division of Colon and Rectal Surgery, University Southern California, Los Angelos, CA
| | - Abhinav Gupta
- Division of Colon and Rectal Surgery, University Southern California, Los Angelos, CA
| | - Sarah D Koller
- Division of Colon and Rectal Surgery, University Southern California, Los Angelos, CA
| | - Tanya Jt Starr
- Health Corporation of America, Midwest Division, Kansas City, KS
| | | | - Darcy D Shaw
- Health Corporation of America, Midwest Division, Kansas City, KS
| | - Ali H Hakim
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Jennifer Leinicke
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Michael Visenio
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Kenneth H Perrone
- Department of Colon and Rectal Surgery, Creighton University, Omaha, NE
| | | | - Austin D Person
- Department of Colon and Rectal Surgery, Creighton University, Omaha, NE
| | - Charles A Ternent
- Department of Colon and Rectal Surgery, Creighton University, Omaha, NE
| | - Kevin A Chen
- Division of Gastrointestinal Surgery, University of North Carolina, Chapel Hill, NC
| | - Muneera R Kapadia
- Division of Gastrointestinal Surgery, University of North Carolina, Chapel Hill, NC
| | - Deborah S Keller
- Department of Surgery, Lankenau Medical Center, Wynnewood, PA; Marks Colorectal Surgical Associates, Wynnewood, PA
| | - Jaafar Elnagar
- Department of Surgery, Lankenau Medical Center, Wynnewood, PA
| | | | | | | | - Nicolas Arcomano
- Department of Surgery, University of Illinois College of Medicine at Chicago, Chicago, IL
| | - Ariane M Abcarian
- Department of Surgery, University of Illinois College of Medicine at Chicago, Chicago, IL; Cook County Health, Chicago, IL
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Mueller AN, Torgersen Z, Shashidharan M, Ternent CA. Cost-Effectiveness Analysis: Selective Use of Neoadjuvant Chemoradiation in Locally Advanced Rectal Cancer. Dis Colon Rectum 2023; 66:946-956. [PMID: 37311698 DOI: 10.1097/dcr.0000000000002673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Indexed: 06/15/2023]
Abstract
BACKGROUND Locally advanced rectal cancer has high cure rates with trimodal therapy. Studies sparing neoadjuvant chemoradiation in selected patients show comparable outcomes. OBJECTIVE This study aimed to determine the cost-effectiveness of selective use of neoadjuvant chemoradiation in this population. DESIGN A cost-effectiveness analysis model compared selective and blanket use chemoradiation for locally advanced rectal cancer. SETTINGS Literature review, expert consensus, and a prospective database populated the model. Health care utilization costs were based on information from the Centers for Medicare and Medicaid Services. PATIENTS Adult patients with stage II and III rectal cancer were selected. MAIN OUTCOMES MEASURES Primary outcomes were cost, effectiveness in quality-adjusted disease-free life years, net monetary benefit, and incremental cost-effectiveness ratios in dollars per quality-adjusted disease-free life years. Base-case 5-year disease-free survival for both strategies was 65%. One-way sensitivity analysis found the probability of 5-year disease-free survival for selective ranged between 40% and 65%. Probabilistic sensitivity analysis assessed second-order variability. RESULTS Base-case 5-year disease-free survival demonstrated selective use is dominant with lower cost and higher quality-adjusted disease-free life years. For selective use, cost is $153,176, effectiveness is 2.71 quality-adjusted life years, and net monetary benefit is -$17,564 and for blanket use cost is $176,362, effectiveness is 2.64 quality-adjusted life years, and net monetary benefit is -$44,217. One-way sensitivity analysis shows selective use is dominant for disease-free survival above 61.25% and is preferred for disease-free survival above 53.7%. Probabilistic sensitivity analysis shows selective use is optimal in 88% of the iterations for a population of 10,000 patients. LIMITATIONS Model was based on data from the literature, prospective database, and expert consensus. CONCLUSION In a population of patients with locally advanced rectal cancer with base-case disease-free survival of 65%, selective use of neoadjuvant chemoradiation is the superior strategy as long as disease-free survival in this group remains above 53%. See Video Abstract at http://links.lww.com/DCR/C199. ANLISIS DE COSTOEFECTIVIDAD USO SELECTIVO DE QUIMIORRADIACIN NEOADYUVANTE EN CNCER DE RECTO LOCALMENTE AVANZADO ANTECEDENTES:El cáncer de recto localmente avanzado tiene altas tasas de curación con la terapia trimodal. Los estudios que evitan la quimiorradiación neoadyuvante en pacientes seleccionados muestran resultados comparables.OBJETIVO:Determinar la relación costo-efectividad del uso selectivo de quimiorradiación neoadyuvante en esta población.DISEÑO:Un modelo de análisis de costo-efectividad comparó la quimiorradiación selectiva y de uso general para el cáncer de recto localmente avanzado.AJUSTES:Revisión de literatura, consenso de expertos y una base de datos prospectiva poblaron el modelo. Los costos de utilización de la atención médica se basaron en los Centros de Servicios de Medicare y Medicaid.PACIENTES:Se seleccionaron pacientes adultos con cáncer de recto en estadio II y III.PRINCIPALES MEDIDAS DE RESULTADOS:Los resultados primarios fueron el costo, efectividad en años de vida sin enfermedad ajustados por calidad, el beneficio monetario neto y la relación costo-efectividad incremental en $/años de vida sin enfermedad ajustados por calidad. La supervivencia libre de enfermedad a 5 años del caso base para ambas estrategias fue del 65%. El análisis de sensibilidad unidireccional varió la probabilidad de supervivencia libre de enfermedad a 5 años para uso selectivo entre 40%-65%. El análisis de sensibilidad probabilístico evaluó la variabilidad de segundo orden.RESULTADOS:El caso base de 5 años de supervivencia libre de enfermedad demostró que el uso selectivo es dominante con menor costo y años de vida libre de enfermedad ajustados de mayor calidad. El costo, la efectividad y el beneficio monetario neto para el uso selectivo y general fueron ($153 176; 2,71 QALY; -$17 564) y ($176 362; 2,64 QALY; -$44 217). El análisis de sensibilidad unidireccional demostró que el uso selectivo es dominante para la supervivencia sin enfermedad por encima del 61,25% y se prefiere para la supervivencia sin enfermedad por encima del 53,7%. El análisis de sensibilidad probabilístico demostró que el uso selectivo es óptimo en el 88% de las iteraciones para una población de 10 000 pacientes.LIMITACIONES:Modelo basado en datos de literatura, base de datos prospectiva y consenso de expertos.CONCLUSIÓN:En una población de pacientes con cáncer de recto localmente avanzado con caso base de supervivencia libre de enfermedad del 65%, el uso selectivo de quimiorradiación neoadyuvante para el cáncer de recto localmente avanzado es la estrategia superior, siempre y cuando la supervivencia libre de enfermedad en este grupo se mantenga por encima del 53%. Consulte Video Resumen en http://links.lww.com/DCR/C199. (Traducción-Dr. Fidel Ruiz Healy).
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Affiliation(s)
- Andrew N Mueller
- Department of Surgery, Creighton University School of Medicine, Omaha, Nebraska
| | - Zachary Torgersen
- Department of Surgery, Creighton University School of Medicine, Omaha, Nebraska
| | | | - Charles A Ternent
- Department of Surgery, Creighton University School of Medicine, Omaha, Nebraska
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Thompson H, Kim JK, Yuval JB, Verheij F, Patil S, Gollub MJ, Wu AJC, Lee M, Hezel AF, Marcet J, Cataldo P, Polite BN, Herzig D, Liska D, Oommen S, Friel C, Ternent CA, Coveler AL, Hunt SR, Garcia-Aguilar J. Survival and organ preservation according to clinical response after total neoadjuvant therapy in locally advanced rectal cancer patients: A secondary analysis from the organ preservation in rectal adenocarcinoma (OPRA) trial. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.3509] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
3509 Background: Clinical response following neoadjuvant therapy is paramount to identifying locally advanced rectal cancer (LARC) patients suitable for Watch and Wait (WW). A 3-tier schema was devised to stratify clinical response. Patients with a complete clinical response (cCR) are considered for WW, while those with an incomplete clinical response (iCR) are recommended for total mesorectal excision (TME). A near complete response (nCR) tier captures patients with significant, but not complete, response to be considered for WW. This schema’s efficacy has yet to be validated. We investigated survival and organ preservation (OP) rates based on this 3-tier clinical response assessment in patients with LARC who underwent total neoadjuvant therapy (TNT) in a prospective, multi-center clinical trial. Methods: Patients with MRI stage II and III rectal adenocarcinoma were randomized to either induction chemotherapy (FOLFOX or CAPEOX) followed by chemoradiation or chemoradiation followed by consolidation chemotherapy (FOLFOX or CAPEOX). At 8+/-4 weeks following TNT, response on digital rectal and endoscopic examinations was evaluated by the 3-tier schema. The date of this restaging clinical response assessment was used as time zero. The endpoints of rate of OP, disease-free survival (DFS), TME-free DFS, and overall survival (OS) were evaluated using the Kaplan-Meier method with differences analyzed by the log-rank test. Results: Clinical response assessments were available for 294 patients. The median time to assessment after neoadjuvant therapy was 7.9 weeks. Based on the 3-tier schema, 124 patients were categorized as cCR, 113 as nCR, and 57 as iCR. Baseline age, sex, average distance from the anal verge, clinical T classification, and clinical N classification were similar between the response groups. The table shows the 3-year rates of OP, DFS, TME-free DFS, and OS. The median follow-up was 2.36 years. Of the patients with a nCR, the 3-year TME rate was 48% compared with 21% in the cCR group. Conclusions: The 3-tier clinical response assessment has prognostic implications for OP and DFS in patients with LARC who underwent TNT. In patients with a nCR, more than half achieved OP at 3 years. This information should be utilized to counsel patients regarding their expected outcomes. Clinical trial information: NCT02008656. [Table: see text]
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Affiliation(s)
- Hannah Thompson
- Colorectal Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Jin Ki Kim
- Colorectal Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Jonathan B. Yuval
- Colorectal Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Floris Verheij
- Colorectal Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Sujata Patil
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Marc J Gollub
- NRG Oncology and Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Meghan Lee
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Aram F Hezel
- James P. Wilmot Cancer Institute, University of Rochester, Rochester, NY
| | | | | | | | | | | | | | | | | | | | - Steven R. Hunt
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
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Wright M, Menon V, Taylor L, Shashidharan M, Westercamp T, Ternent CA. Factors predicting reclassification of variants of unknown significance. Am J Surg 2018; 216:1148-1154. [PMID: 30217367 DOI: 10.1016/j.amjsurg.2018.08.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [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: 02/17/2018] [Revised: 08/16/2018] [Accepted: 08/23/2018] [Indexed: 10/28/2022]
Abstract
Genetic variants of unknown significance (VUS) are an increasingly common result of genetic testing. VUS present dilemmas for treatment and surveillance. Family history may play a role in VUS reclassification over time. METHODS All genetic tests performed at a tertiary referral center 2006-2015 were evaluated for the presence of VUS. Patients with VUS were evaluated for demographics, clinical characteristics, family history, and gene characteristics. RESULTS In total, 2291 individuals were tested from 1639 families; 150 VUS were identified. Twenty-eight VUS reclassified, 21 to benign and 7 to pathogenic. Logistic regression demonstrated the number of family members with associated phenotypic disease was a significant predictor of reclassification. CONCLUSION The likelihood of VUS reclassification can be predicted by increased positive family history of disease. Most VUS reclassify to benign, but one-fourth reclassify to pathogenic. The actual risk of a VUS should be assessed based on family history and routinely checked for reclassification.
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Affiliation(s)
- Moriah Wright
- Section of Colon and Rectal Surgery, Creighton University School of Medicine/CHI Medical Center, Omaha, NE, United States.
| | - Vijay Menon
- Section of Colon and Rectal Surgery, Creighton University School of Medicine/CHI Medical Center, Omaha, NE, United States
| | - Lindsay Taylor
- Section of Colon and Rectal Surgery, Creighton University School of Medicine/CHI Medical Center, Omaha, NE, United States
| | - Maniamparampil Shashidharan
- Section of Colon and Rectal Surgery, Creighton University School of Medicine/CHI Medical Center, Omaha, NE, United States
| | - Twilla Westercamp
- Henry Lynch Cancer Center, Creighton University School of Medicine/CHI Medical Center, Omaha, NE, United States
| | - Charles A Ternent
- Section of Colon and Rectal Surgery, Creighton University School of Medicine/CHI Medical Center, Omaha, NE, United States
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Fleming F, Gaertner W, Ternent CA, Finlayson E, Herzig D, Paquette IM, Feingold DL, Steele SR. The American Society of Colon and Rectal Surgeons Clinical Practice Guideline for the Prevention of Venous Thromboembolic Disease in Colorectal Surgery. Dis Colon Rectum 2018; 61:14-20. [PMID: 29219916 DOI: 10.1097/dcr.0000000000000982] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Fergal Fleming
- Prepared by the Clinical Practice Guidelines Committee of The American Society of Colon and Rectal Surgeons
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Wright M, Thorson A, Blatchford G, Shashidharan M, Beaty J, Bertelson N, Aggrawal P, Taylor L, Ternent CA. Discussion of: "What happens after a failed LIFT for anal fistula?". Am J Surg 2017; 214:1214. [PMID: 29146002 DOI: 10.1016/j.amjsurg.2017.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Moriah Wright
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA
| | - Alan Thorson
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA
| | - Garnet Blatchford
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA
| | - Maniamparampil Shashidharan
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA
| | - Jennifer Beaty
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA
| | - Noelle Bertelson
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA
| | - Piyush Aggrawal
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA
| | - Lindsay Taylor
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA
| | - Charles A Ternent
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA.
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Wright M, Thorson A, Blatchford G, Shashidharan M, Beaty J, Bertelson N, Aggrawal P, Taylor L, Ternent CA. What happens after a failed LIFT for anal fistula? Am J Surg 2017; 214:1210-1213. [PMID: 29146001 DOI: 10.1016/j.amjsurg.2017.08.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Revised: 07/27/2017] [Accepted: 08/05/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Ligation of the intersphincteric fistula tract (LIFT) was developed to treat transsphincteric anal fistulas. The aftermath of a failed LIFT has not been well documented. METHODS Retrospective chart review of LIFT procedure for transsphincteric anal fistula between March 2012 and September 2016. RESULTS 53 patients with LIFT procedure were identified, 20 (37.7%) had persistent fistula with median followup of 4 months. Following LIFT, recurrence of fistula was transsphincteric (75%) or intersphincteric (25%) (p = NS). Persistent transsphincteric fistulas after LIFT were treated with seton (71.4%) followed by advancement flap (20%) or fistulotomy (50%). Of the recurrent intersphincteric fistulas, 50% underwent seton placement followed by fistulotomy, or advancement flap. Of the patients who underwent surgery after failed LIFT, 50% have had resolution of the fistula; 31.7% are still undergoing treatment. CONCLUSION Patients who underwent surgery after failed LIFT had 50% healing with placement of seton followed by fistulotomy or rectal advancement flap.
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Affiliation(s)
- Moriah Wright
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA
| | - Alan Thorson
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA
| | - Garnet Blatchford
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA
| | - Maniamparampil Shashidharan
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA
| | - Jennifer Beaty
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA
| | - Noelle Bertelson
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA
| | - Piyush Aggrawal
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA
| | - Lindsay Taylor
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA
| | - Charles A Ternent
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, CHI Medical Center, Omaha, NE, USA.
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Abstract
Ambulatory surgery is appropriate for most anorectal pathology. Ambulatory anorectal surgery can be performed at reduced cost compared with inpatient procedures with excellent safety, improved efficiency, and high levels of patient satisfaction. Several perioperative strategies are employed to control pain and avoid urinary retention, including the use of a multimodal pain regimen and restriction of intravenous fluids. Ambulatory anorectal surgery often utilizes standardized order sets and discharge instructions.
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Affiliation(s)
- Darcy Shaw
- Colon and Rectal Surgery Inc., Omaha, Nebraska
| | - Charles A Ternent
- Department of Surgery, Section of Colon and Rectal Surgery, Creighton University School of Medicine, Omaha, Nebraska; Department of Surgery, Department of Surgery, University of Nebraska College of Medicine, Omaha, Nebraska
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Garcia-Aguilar J, Chow OS, Smith DD, Marcet JE, Cataldo PA, Varma MG, Kumar AS, Oommen S, Coutsoftides T, Hunt SR, Stamos MJ, Ternent CA, Herzig DO, Fichera A, Polite BN, Dietz DW, Patil S, Avila K. Effect of adding mFOLFOX6 after neoadjuvant chemoradiation in locally advanced rectal cancer: a multicentre, phase 2 trial. Lancet Oncol 2015; 16:957-66. [PMID: 26187751 DOI: 10.1016/s1470-2045(15)00004-2] [Citation(s) in RCA: 434] [Impact Index Per Article: 48.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Revised: 05/20/2015] [Accepted: 05/22/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Patients with locally advanced rectal cancer who achieve a pathological complete response to neoadjuvant chemoradiation have an improved prognosis. The need for surgery in these patients has been questioned, but the proportion of patients achieving a pathological complete response is small. We aimed to assess whether adding cycles of mFOLFOX6 between chemoradiation and surgery increased the proportion of patients achieving a pathological complete response. METHODS We did a phase 2, non-randomised trial consisting of four sequential study groups of patients with stage II-III locally advanced rectal cancer at 17 institutions in the USA and Canada. All patients received chemoradiation (fluorouracil 225 mg/m(2) per day by continuous infusion throughout radiotherapy, and 45·0 Gy in 25 fractions, 5 days per week for 5 weeks, followed by a minimum boost of 5·4 Gy). Patients in group 1 had total mesorectal excision 6-8 weeks after chemoradiation. Patients in groups 2-4 received two, four, or six cycles of mFOLFOX6, respectively, between chemoradiation and total mesorectal excision. Each cycle of mFOLFOX6 consisted of racemic leucovorin 200 mg/m(2) or 400 mg/m(2), according to the discretion of the treating investigator, oxaliplatin 85 mg/m(2) in a 2-h infusion, bolus fluorouracil 400 mg/m(2) on day 1, and a 46-h infusion of fluorouracil 2400 mg/m(2). The primary endpoint was the proportion of patients who achieved a pathological complete response, analysed by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00335816. FINDINGS Between March 24, 2004, and Nov 16, 2012, 292 patients were registered, 259 of whom (60 in group 1, 67 in group 2, 67 in group 3, and 65 in group 4) met criteria for analysis. 11 (18%, 95% CI 10-30) of 60 patients in group 1, 17 (25%, 16-37) of 67 in group 2, 20 (30%, 19-42) of 67 in group 3, and 25 (38%, 27-51) of 65 in group 4 achieved a pathological complete response (p=0·0036). Study group was independently associated with pathological complete response (group 4 compared with group 1 odds ratio 3·49, 95% CI 1·39-8·75; p=0·011). In group 2, two (3%) of 67 patients had grade 3 adverse events associated with the neoadjuvant administration of mFOLFOX6 and one (1%) had a grade 4 adverse event; in group 3, 12 (18%) of 67 patients had grade 3 adverse events; in group 4, 18 (28%) of 65 patients had grade 3 adverse events and five (8%) had grade 4 adverse events. The most common grade 3 or higher adverse events associated with the neoadjuvant administration of mFOLFOX6 across groups 2-4 were neutropenia (five in group 3 and six in group 4) and lymphopenia (three in group 3 and four in group 4). Across all study groups, 25 grade 3 or worse surgery-related complications occurred (ten in group 1, five in group 2, three in group 3, and seven in group 4); the most common were pelvic abscesses (seven patients) and anastomotic leaks (seven patients). INTERPRETATION Delivery of mFOLFOX6 after chemoradiation and before total mesorectal excision has the potential to increase the proportion of patients eligible for less invasive treatment strategies; this strategy is being tested in phase 3 clinical trials. FUNDING National Institutes of Health National Cancer Institute.
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Affiliation(s)
- Julio Garcia-Aguilar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Oliver S Chow
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David D Smith
- Division of Biostatistics, City of Hope, Duarte, CA, USA
| | - Jorge E Marcet
- Department of Surgery, University of South Florida, Tampa, FL, USA
| | - Peter A Cataldo
- Department of Surgery, University of Vermont, Burlington, VT, USA
| | - Madhulika G Varma
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Anjali S Kumar
- Department of Surgery, MedStar Health Research Institute, Washington Hospital Center, Washington, DC, USA
| | - Samuel Oommen
- Department of Surgery, John Muir Health, Concord, CA, USA
| | | | - Steven R Hunt
- Department of Surgery, Washington University, St Louis, MO, USA
| | - Michael J Stamos
- Department of Surgery, University of California, Irvine, Irvine, CA, USA
| | - Charles A Ternent
- Department of Surgery, Creighton University Medical Center, University of Nebraska College of Medicine, Omaha, NE, USA
| | - Daniel O Herzig
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | | | - Blase N Polite
- Department of Surgery, University of Chicago, Chicago, IL, USA
| | - David W Dietz
- Department of Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Sujata Patil
- Division of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Karin Avila
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Melstrom LG, Bentrem DJ, Salabat MR, Kennedy TJ, Ding XZ, Strouch M, Rao SM, Witt RC, Ternent CA, Talamonti MS, Bell RH, Adrian TA. Overexpression of 5-lipoxygenase in colon polyps and cancer and the effect of 5-LOX inhibitors in vitro and in a murine model. Clin Cancer Res 2008; 14:6525-30. [PMID: 18927292 DOI: 10.1158/1078-0432.ccr-07-4631] [Citation(s) in RCA: 116] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE Arachidonic acid metabolism via the cyclooxygenase (COX) and 5-lipoxygenase (5-LOX) pathways modulates cell growth and apoptosis. Many studies have examined the effects of COX inhibitors on human colorectal cancer, but the role of 5-LOX in colonic cancer development has not been well studied. The purpose of this study was to evaluate the expression of 5-LOX in colonic polyps and cancer and the effect of 5-LOX inhibition on colon cancer cell proliferation. EXPERIMENTAL DESIGN Colonic polyps, cancer, and normal mucosa were evaluated for 5-LOX expression by immunohistochemistry. Reverse transcription-PCR was used to establish 5-LOX expression in colon cancer cells. Thymidine incorporation and cell counts were used to determine the effect of the nonspecific LOX inhibitor Nordihydroguaiaretic Acid and the 5-LOX inhibitor Rev5901 on DNA synthesis. A heterotopic xenograft model in athymic mice using HT29 and LoVo human colon cancer cells was used to evaluate the effect of the 5-LOX inhibitor zileuton on tumor growth. RESULTS 5-LOX is overexpressed in adenomatous polyps and cancer compared with that of normal colonic mucosa. LOX inhibition and 5-LOX inhibition decreased DNA synthesis in a concentration- and time-dependent manner in the Lovo cell line (P < 0.05). Inhibition of 5-LOX in an in vivo colon cancer xenograft model inhibited tumor growth compared with that of controls (P < 0.05). CONCLUSIONS This study showed that 5-LOX is up-regulated in adenomatous colon polyps and cancer compared with normal colonic mucosa. The blockade of 5-LOX inhibits colon cancer cell proliferation both in vitro and in vivo and may prove a beneficial chemopreventive therapy in colon cancer.
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Affiliation(s)
- Laleh G Melstrom
- Department of Surgery and Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Affiliation(s)
- Charles A Ternent
- Fletcher Allen Health Care, 111 Colchester Avenue, Fletcher 301, Burlington, Vermont 05401, USA
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13
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Cohen JL, Strong SA, Hyman NH, Buie WD, Dunn GD, Ko CY, Fleshner PR, Stahl TJ, Kim DG, Bastawrous AL, Perry WB, Cataldo PA, Rafferty JF, Ellis CN, Rakinic J, Gregorcyk S, Shellito PC, Kilkenny JW, Ternent CA, Koltun W, Tjandra JJ, Orsay CP, Whiteford MH, Penzer JR. Practice parameters for the surgical treatment of ulcerative colitis. Dis Colon Rectum 2005; 48:1997-2009. [PMID: 16258712 DOI: 10.1007/s10350-005-0180-z] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.8] [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] [Indexed: 02/08/2023]
Abstract
The American Society of Colon and Rectal Surgeons is dedicated to assuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Standards Committee is composed of Society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. This is accompanied by developing Clinical Practice Guidelines based on the best available evidence. These guidelines are inclusive, and not prescriptive. Their purpose is to provide information on which decisions can be made, rather than dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.
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Affiliation(s)
- Jeffrey L Cohen
- Fletcher Allen Health Care, 111 Colchester Avenue, Fletcher 301, Burlington, Vermont 05401, USA
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14
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Kennedy TJ, Talamonti M, Ujiki M, Ding XZ, Ternent CA, Bell RH, Adrian TE. Lipoxygenase expression in colon polyps and inhibition of colon cancer growth by lipoxygenase blockade. J Am Coll Surg 2004. [DOI: 10.1016/j.jamcollsurg.2004.05.169] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Brown CL, Ternent CA, Thorson AG, Christensen MA, Blatchford GJ, Shashidharan M, Haynatzki GR. Response to preoperative chemoradiation in stage II and III rectal cancer. Dis Colon Rectum 2003; 46:1189-93. [PMID: 12972962 DOI: 10.1007/s10350-004-6714-y] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.4] [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] [Indexed: 12/13/2022]
Abstract
PURPOSE The purpose of this study was to determine whether a complete pathologic response after neoadjuvant therapy in rectal cancer patients improves disease control and survival. METHODS The study reviewed Stage II and III rectal cancer patients treated with preoperative chemoradiation and resected for cure. Complete pathologic response was defined as no cancer in the resected specimen. The main outcome measures were cancer-specific and disease-free survival in patients achieving a complete pathologic response and a noncomplete pathologic response. Kaplan-Meier curves were evaluated using log-rank analysis. RESULTS Eighty-nine rectal cancer patients received neoadjuvant chemoradiation followed by radical resection for cure. Twenty-one patients (24 percent) achieved a complete pathologic response. Median follow-up for the complete pathologic response group was 23.5 months and 31 months for the noncomplete pathologic response group. There were more Stage III patients in the noncomplete pathologic response group than the complete pathologic response group (P = 0.005). Complete pathologic response patients were less likely to receive postoperative adjuvant chemotherapy than noncomplete pathologic response patients (P = 0.004). Cancer-specific and disease-free survival were not statistically different between the two groups. However, a trend was noted toward improved survival and decreased recurrence in association with a complete pathologic response. CONCLUSION Stage III patients were less likely to be in the complete pathologic response group than Stage II patients. Complete pathologic response patients were less likely to receive postoperative adjuvant chemotherapy than noncomplete pathologic response patients. Complete pathologic response after neoadjuvant chemoradiation for rectal cancer patients demonstrated a trend toward improved survival and decreased recurrence compared with noncomplete pathologic response patients.
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Affiliation(s)
- Craig L Brown
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, Omaha, Nebraska, USA
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Liberman H, Faria J, Ternent CA, Blatchford GJ, Christensen MA, Thorson AG. A prospective evaluation of the value of anorectal physiology in the management of fecal incontinence. Dis Colon Rectum 2001; 44:1567-74. [PMID: 11711725 DOI: 10.1007/bf02234373] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.0] [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] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was designed to determine whether anorectal physiology testing significantly altered patient management in the setting of fecal incontinence. METHODS Patients referred to the anorectal physiology laboratory for evaluation of fecal incontinence were prospectively interviewed and examined by a colon and rectal surgeon. A decision to treat either medically or surgically was reached. The patients underwent physiologic testing with transanal ultrasound, pudendal nerve terminal motor latency, and anorectal manometry. A panel of board-certified colon and rectal surgeons then reviewed the history and physical examination, as well as the anorectal physiology tests, of each patient and reached a consensus on management. Management plans before and after physiologic evaluation were compared. RESULTS Ninety patients (6 males) were entered into the study. The patients were divided in two groups: those with pretest medical management plans (n = 45) and those with pretest surgical management plans (n = 45). A change in management was noted in nine patients (10 percent). In the medical management group, the management changed from medical to surgical therapy in five patients. Transanal ultrasound detected anal sphincter defects in all patients who changed from medical to surgical management but in only 10 percent of those who remained under medical management (P = 0.0001). In the surgical management group, three patients (7 percent) changed from surgical to medical therapy and one patient (2 percent) changed from sphincteroplasty to neosphincter. Transanal ultrasound detected a limited anal sphincter defect in one patient (33 percent) who changed from surgical to medical management and a significant defect in all 41 patients (100 percent) who remained under surgical management (P = 0.003). CONCLUSIONS Anorectal physiology testing is useful in the evaluation of patients with fecal incontinence. Without the information obtained from physiologic testing, 11 percent of patients who may have benefited from surgery would not have been given this option, and 7 percent of patients could have potentially undergone unnecessary surgery. Transanal ultrasound is the study most likely to change a patient's management plan.
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Affiliation(s)
- H Liberman
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, Omaha, Nebraska, USA
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Ternent CA, Thorson AG, Blatchford GJ, Christensen MA, Thompson JS, Lanspa SJ, Adrian TE. Mouth to pouch transit after restorative proctocolectomy: hydrogen breath analysis correlates with scintigraphy. Am J Gastroenterol 2001; 96:1460-3. [PMID: 11374683 DOI: 10.1111/j.1572-0241.2001.03799.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [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] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Fast intestinal transit may be responsible for slow adaptation and unacceptable steady-state function after restorative proctocolectomy. Investigation of GI transit time may be valuable in such a setting. We hypothesized that postprandial hydrogen breath tests may yield transit data that correlate with technetium-labeled meal scintigrams. METHODS This study compared intestinal transit after a lactulose and bean meal via the breath hydrogen and scintigraphy methods in 21 ileoanal pouch subjects. The meal consisted of baked beans (425 g), 30 ml (20 g) lactulose syrup, 1 mCi 99mtechnetium sulfur colloid in finely chopped liver and 170 ml tap water. The meal contained 120 Kcal (70% carbohydrate, 18% protein and 12% fat). RESULTS Of 21 pouch subjects, 11 (53%) had breath tests and scintigraphy transit studies that differed by 5-21 min. Three of 21 (14%) scintigraphy mouth to pouch transit times were faster than breath test transits by 43-107 min. Seven of 21 (33%) subjects did not have breath test peaks >10 ppm. Mouth to pouch transit for breath hydrogen (104+/-16 min) and scintigraphy (98+/-7 min) tests had significant correlation (r = 0.96, p < 0.0001) among subjects with alveolar hydrogen peaks and accurate scintigrams (n = 11). Scintigrams were five times more expensive than breath tests. CONCLUSIONS A peaking hydrogen breath test provides an alternative to scintigraphy for estimating intestinal transit after ileoanal pouch.
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Affiliation(s)
- C A Ternent
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, Omaha, Nebraska, USA
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Liberman H, Adams DR, Blatchford GJ, Ternent CA, Christensen MA, Thorson AG. Clinical use of the self-expanding metallic stent in the management of colorectal cancer. Am J Surg 2000; 180:407-11; discussion 412. [PMID: 11182388 DOI: 10.1016/s0002-9610(00)00492-x] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE This report describes our experience with the use of self-expanding metallic stents (SEMS) in the management of obstructing colorectal cancer. METHODS A retrospective chart review of all patients undergoing placement of SEMS between May 1997 and January 2000 was performed. RESULTS Insertion of SEMS was attempted in 12 patients. Successful stent placement was achieved in 10 of the 12 patients. The locations of lesions were hepatic flexure (2), splenic flexure (1), left colon (1), sigmoid colon (4) and rectum (4). The intended uses of SEMS were for palliation in 3 patients and as a bridge to elective surgery in 9. In the latter group, SEMS placement allowed for preoperative bowel preparation in 4 patients and administration of neoadjuvant therapy prior to elective surgery in 2 patients. One patient died prior to definitive surgery. Stent placement was unsuccessful in 2 patients. Three SEMS-related complications occurred; 1 stent migrated and 1 stent obstructed secondary to tumor ingrowth. One patient died 13 days after stent placement and colonic decompression. CONCLUSION SEMS represent a useful tool in the management of obstructing colorectal neoplasms. As a bridge to surgery, SEMS provide time for a complete preoperative evaluation and a mechanical bowel preparation and may obviate the need for fecal diversion or on-table lavage. It may also allow for time to administer neoadjuvant therapy when indicated. As a palliative measure, SEMS can eliminate the need for an operation.
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Affiliation(s)
- H Liberman
- Department of Surgery, Section of Colon and Rectal Surgery, Creighton University School of Medicine, Omaha, Nebraska 68114, USA
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19
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Shashidharan M, Lin KM, Ternent CA, Smyrk TC, Thorson AG, Blatchford GJ, Christensen MA. Influence of arginine dietary supplementation on healing colonic anastomosis in the rat. Dis Colon Rectum 1999; 42:1613-7. [PMID: 10613483 DOI: 10.1007/bf02236217] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [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] [Indexed: 02/08/2023]
Abstract
INTRODUCTION This study sought to determine whether dietary arginine influences colonic anastomotic healing in the rat model. METHODS Three groups of 42 Sprague-Dawley rats were fed 0, 1, and 3 percent arginine diets for three preoperative and three postoperative days. Animals underwent transection of the transverse colon with hand-sewn anastomosis. Subgroups of 14 animals in each dietary group were killed on postoperative Days 6, 10, or 14, and bursting pressures, histologic inflammation, and collagen content were compared. RESULTS Mean anastomotic bursting pressures on postoperative Day 6 were lower for the 0 percent arginine group than the 1 and 3 percent arginine groups (mean +/- standard error of the mean = 134+/-6 mm Hg, 164+/-7 mm Hg, and 166+/-7 mm Hg, respectively; P<0.0005). On Days 10 and 14, no significant differences in bursting pressures were noted between arginine diets. Mean bursting pressures on postoperative Day 6 (155+/-4 mm Hg) were significantly lower than on Days 10 (204+/-5 mm Hg) and 14 (217+/-6 mm Hg; P<0.001) for all arginine diets. Microscopic evaluation of the anastomoses did not show significant differences in inflammation or collagen content between arginine diets. Collagen content in all dietary groups peaked at Day 10. CONCLUSIONS Perioperative arginine deficiency in the rat model is associated with impaired anastomotic healing during the first week, as reflected by lower bursting pressures. Arginine supplementation to 3 percent does not improve bursting pressures above those found in the usual 1 percent arginine diet at 6, 10, or 14 days. Bursting pressures plateau by Day 10 regardless of perioperative dietary arginine, whereas collagen content peaks at Day 10 after six-day perioperative arginine diet manipulation.
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Affiliation(s)
- M Shashidharan
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, Omaha, Nebraska, USA
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Abstract
PURPOSE This study compared characteristics of colorectal cancer between families with dominant breast cancer inheritance and the general population. The cumulative incidence of colorectal cancer was also studied in genetically determined breast cancer syndrome subjects with BRCA1 and BRCA2 mutations and compared with the general population. METHODS Subjects included 42 patients with colorectal cancer from 32 clinically determined hereditary breast cancer kindreds based on the autosomal dominant inheritance of breast cancers and early age of onset. The general population colorectal cancer cohort was composed of 755 patients from a tumor registry. Lifetime risk of colorectal cancer was determined in 164 BRCA1 and 88 BRCA2 gene mutation carriers and compared with the general population. Mean age of colorectal cancer onset, anatomic site distribution, histologic stage at presentation, and five year stage-stratified survival rates were compared between clinically determined hereditary breast cancer family members and the general population. RESULTS The lifetime risk of colorectal cancer in male BRCA1 and BRCA2 mutation carriers was 5.6 percent, which was not different from 6 percent in males from the general population. Likewise, the lifetime colorectal cancer risk in female BRCA1 and BRCA2 mutation carriers was 3.2 percent, which was not different from 5.9 percent in females from the general population. Mean age of onset +/- standard error for patients with colorectal cancer was 60 +/- 2 years for hereditary breast cancer kindreds compared with 67 +/- 0.4 years for the general population (P = 0.0004). Colorectal cancer site distribution did not vary between hereditary breast cancer and the general population. Overall colorectal cancer stage distribution was significantly different, with more Stage I and fewer Stage IV cancers in subjects with hereditary breast cancer compared with the general population (P = 0.01). Overall five year stage-stratified colorectal cancer survival rate +/- standard error was 66 +/- 8 percent for hereditary breast cancer kindreds and 46 +/- 2 percent for the general population (P = 0.023). CONCLUSION Lifetime cumulative colorectal cancer incidence in subjects with BRCA1 and BRCA2 gene mutations was not different from the general population. However, significant differences in colorectal cancer were noted between hereditary breast cancer family members and the general population. Hereditary breast cancer-associated colorectal cancer had an earlier age of onset, lower tumor stage, and better survival rate than the general population. Except for age of onset, colorectal cancer in hereditary breast cancer kindreds exhibited more favorable characteristics than colorectal cancer in the general population.
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Affiliation(s)
- K M Lin
- Department of Surgery, Creighton University School of Medicine, Omaha, Nebraska, USA
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Shashidharan M, Smyrk T, Lin KM, Ternent CA, Thorson AG, Blatchford GJ, Christensen MA, Lynch HT. Histologic comparison of hereditary nonpolyposis colorectal cancer associated with MSH2 and MLH1 and colorectal cancer from the general population. Dis Colon Rectum 1999; 42:722-6. [PMID: 10378595 DOI: 10.1007/bf02236925] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [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] [Indexed: 02/08/2023]
Abstract
PURPOSE Hereditary nonpolyposis colorectal cancer is reported to have special histologic features. This study compares the histologic features of hereditary nonpolyposis colorectal cancer to colorectal cancers from the general population when hereditary nonpolyposis colorectal cancer cases are restricted to families with known MSH2 and MLH1 mutations. METHODS Thirty-seven cancers from kindreds carrying MSH2 mutations, 27 cancers from kindreds carrying MLH1 mutations, and 37 colorectal cancers from the general population were reviewed by a pathologist blinded to hereditary nonpolyposis colorectal cancer gene status. Tumor grade, growth pattern, Crohn's-like lymphoid reaction, mucin production, extent of disease in the bowel wall, and lymph node status were evaluated. RESULTS Poor differentiation and Crohn's-like reaction were a feature of 44 and 49 percent of hereditary nonpolyposis colorectal cancer compared with 14 percent (P = 0.002) and 27 percent (P = 0.049) of colorectal cancers from the general population, respectively. There was no difference in growth pattern, mucin production, lymph node involvement, or local extent of disease between hereditary nonpolyposis colorectal cancer and colorectal cancers from the general population. Poor differentiation and lymph node metastases were found in 57 and 49 percent of MSH2 compared with 26 percent (P = 0.002) and 10 percent (P = 0.03) of MLH1-associated cancers, respectively. There was no difference in growth pattern, mucin production, Crohn's-like lymphoid reaction, or local extent of disease between subgroups of hereditary nonpolyposis colorectal cancer. CONCLUSIONS Poor differentiation and Crohn's-like reaction are more common in hereditary nonpolyposis colorectal cancer than colorectal cancers from general population. Poor differentiation and lymph node metastases are more commonly seen in MSH2-associated cancers than MLH1. Evaluation of the natural history, pathogenesis, and prognosis of colorectal cancer in hereditary nonpolyposis colorectal cancer should include consideration of which mismatch repair genes are mutated and what the specific mutations are.
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Affiliation(s)
- M Shashidharan
- Department of Surgery, Creighton University School of Medicine, Omaha, Nebraska 68131-2197, USA
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Abstract
INTRODUCTION Transrectal ultrasound is the standard method for preoperative staging of rectal cancer. This study reviews the accuracy of transrectal ultrasound staging for T3 disease and its use in the selection of patients for neoadjuvant chemoradiation. METHODS One hundred seventeen patients underwent preoperative transrectal ultrasound evaluation for rectal cancer. Accuracy of transrectal ultrasound was evaluated among 70 patients not receiving preoperative chemoradiation. Forty-seven patients received neoadjuvant chemoradiation based on transrectal ultrasound results. Tumor downstaging and early recurrence were evaluated among 45 of 47 patients receiving neoadjuvant chemoradiation. RESULTS Among 70 nonirradiated patients, 19 were pathologic Stage pT3. Transrectal ultrasound correctly identified 18 of 19 patients with Stage pT3 (sensitivity, 94.7 percent). Transrectal ultrasound correctly identified 44 of 51 patients with less than pT3 disease (specificity, 86.3 percent). After preoperative chemoradiation in 45 patients with ultrasound Stage uT3 or uT4 tumors, 56 percent of them experienced a reduction in T stage. Residual nodal disease was found in 31 percent of patients. A complete pathologic response with no residual disease at operation was observed in 22 percent of patients. During a median follow-up period of 21 months after diagnosis, seven patients experienced a recurrence of their disease at a median of 12 months after diagnosis. Five of seven patients with recurrence were among a subgroup of ten patients who both failed to downstage T and had residual nodal disease at operation. CONCLUSION Transrectal ultrasound is an accurate modality for selecting patients for neoadjuvant treatment. Preoperative chemoradiation produced downstaging in 56 percent of patients. Factors related to early recurrence included residual nodal disease and failure to downstage T after neoadjuvant chemoradiation.
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Affiliation(s)
- D R Adams
- Department of Surgery, Creighton University, Omaha, Nebraska 38131, USA
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Ternent CA, Staab P, Thorson AG, Blatchford GJ, Christensen MA, Thompson JS, Lanspa SJ, Meade PG, Cali RA, Falk PM, Sentovich SM, Adrian TE. Ileoanal pouch function and release of peptide YY. Dis Colon Rectum 1998; 41:868-74. [PMID: 9678372 DOI: 10.1007/bf02235368] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [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] [Indexed: 02/08/2023]
Abstract
PURPOSE This study evaluates peptide tyrosine-tyrosine (PYY), intestinal transit, fecal retention time, and anal sphincter manometry in colectomized patients with ileal pouch-anal anastomosis. METHODS Plasma and pouch PYY, mouth-to-pouch transit time, fecal retention time, and anal canal pressures were studied in 27 patients with ileoanal pouches a mean of 50 (range, 3-84) months after loop ileostomy closure. RESULTS Basal and peak postprandial plasma PYY were significantly reduced in patients with pouches compared with controls (P < 0.0001). Pouch PYY was decreased compared with control ileal PYY (P = 0.0003). No significant correlation was noted between intestinal transit and total integrated PYY response in patients with pouches (r=0.36; P=0.06). Fecal retention time was related to postprandial total integrated response of plasma PYY (r=0.43; P=0.02), mouth-to-pouch transit (r=0.87; P < 0.0001), and resting (r=0.44; P=0.02) and squeeze (r=0.62; P=0.0006) anal sphincter pressures. CONCLUSIONS Colectomized ileoanal patients with pouches showed decreased plasma and pouch PYY compared with controls. Intestinal transit was not significantly related to PYY release. However, prolonged pouch fecal retention was associated with greater PYY release, mouth-to-pouch transit, and anal sphincter pressures.
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Affiliation(s)
- C A Ternent
- Section of Colon and Rectal Surgery, Creighton University School of Medicine, Omaha, Nebraska 68131, USA
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Lin KM, Shashidharan M, Ternent CA, Thorson AG, Blatchford GJ, Christensen MA, Lanspa SJ, Lemon SJ, Watson P, Lynch HT. Colorectal and extracolonic cancer variations in MLH1/MSH2 hereditary nonpolyposis colorectal cancer kindreds and the general population. Dis Colon Rectum 1998; 41:428-33. [PMID: 9559626 DOI: 10.1007/bf02235755] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.0] [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] [Indexed: 02/07/2023]
Abstract
PURPOSE This clinical case review aimed to identify phenotypic variations in colorectal and extracolonic cancer expression between hereditary nonpolyposis colorectal cancer (HNPCC) families with MLH1 and MSH2 germline mutations and the general population. METHODS Colorectal cancer onset and site distribution were compared among 67 members of MLH1 kindreds, 45 members of MSH2 kindreds, and 1,189 patients from the general population. Synchronous and metachronous cancer rates, tumor stage, extracolonic cancer incidence, and survival were also compared. RESULTS Mean ages of colorectal cancer onset were 44, 46, and 69 years for MLH1, MSH2, and the general population, respectively (P < 0.001). More proximal and fewer distal colon cancers were noted in HNPCC than the general population (P < 0.001, P = 0.04). Site distribution showed disparity of rectal cancers (8 percent MLH1 vs. 28 percent MSH2; P = 0.01) based on genotypes. Overall, synchronous colorectal cancer rates were 7.4, 6.7, and 2.4 percent for MLH1, MSH2, and the general population, respectively (P = 0.016). Annual metachronous colorectal cancer rates were 2.1, 1.7, and 0.33 percent for MLH1, MSH2, and the general population, respectively (P = 0.041). Colorectal cancer stage presentation was lower in HNPCC than the general population (P = 0.0028). Extracolonic cancers were noted in 33 percent of MSH2 patients, compared with 12 percent of MLH1 patients and 7.3 percent of the general population with colorectal cancers (P < 0.001). Combined MLH1 and MSH2 ten-year survival was 68.7 percent compared with 47.8 percent for the general population (P = 0.009 stage stratified, hazard ratio 0.57). CONCLUSION The presence of rectal cancer should not preclude the diagnosis of HNPCC, because the incidence of rectal cancer in MSH2 was comparable with that in the general population. Phenotypic variations, including the preponderance of extracolonic cancers in MSH2 patients, did not result in survival differences between genotypic subgroups. These phenotypic features of HNPCC genotypes may have clinical significance in the design of specific screening, surveillance, and follow-up for affected individuals.
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MESH Headings
- Adaptor Proteins, Signal Transducing
- Adult
- Age of Onset
- Aged
- Carrier Proteins
- Colorectal Neoplasms/epidemiology
- Colorectal Neoplasms/genetics
- Colorectal Neoplasms/pathology
- Colorectal Neoplasms, Hereditary Nonpolyposis/epidemiology
- Colorectal Neoplasms, Hereditary Nonpolyposis/genetics
- Colorectal Neoplasms, Hereditary Nonpolyposis/pathology
- DNA Repair
- DNA-Binding Proteins
- Female
- Genotype
- Germ-Line Mutation
- Humans
- Incidence
- Male
- Middle Aged
- MutL Protein Homolog 1
- MutS Homolog 2 Protein
- Neoplasm Proteins/genetics
- Neoplasm Staging
- Neoplasms/epidemiology
- Neoplasms/genetics
- Neoplasms/pathology
- Neoplasms, Multiple Primary/epidemiology
- Neoplasms, Multiple Primary/genetics
- Neoplasms, Multiple Primary/pathology
- Neoplasms, Second Primary/epidemiology
- Neoplasms, Second Primary/genetics
- Neoplasms, Second Primary/pathology
- Nuclear Proteins
- Proto-Oncogene Proteins/genetics
- Statistics as Topic
- Survival Rate
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Affiliation(s)
- K M Lin
- Department of Surgery, Creighton University School of Medicine, Omaha, Nebraska 68131-2197, USA
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Lin KM, Shashidharan M, Thorson AG, Ternent CA, Blatchford GJ, Christensen MA, Watson P, Lemon SJ, Franklin B, Karr B, Lynch J, Lynch HT. Cumulative incidence of colorectal and extracolonic cancers in MLH1 and MSH2 mutation carriers of hereditary nonpolyposis colorectal cancer. J Gastrointest Surg 1998; 2:67-71. [PMID: 9841970 DOI: 10.1016/s1091-255x(98)80105-4] [Citation(s) in RCA: 99] [Impact Index Per Article: 3.8] [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] [Indexed: 01/31/2023]
Abstract
The extracolonic tumor spectrum of hereditary nonpolyposis colorectal cancer (HNPCC) includes cancer of the endometrium, ovaries, stomach, biliary tract, and urinary tract. This study was designed to determine the penetrance of colorectal and extracolonic tumors in HNPCC mutation carriers. Forty-nine patients (22 females and 27 males) were identified with an MSH2 germline mutation, and 56 patients (28 females and 28 males) were identified with an MLH1 I mutation. Cumulative incidence by age 60 (lifetime risk) and mean age of cancer diagnosis were compared. The lifetime risk of extracolonic cancers in MSH2 and MLH1 carriers was 48% and 11%, respectively (P = 0.016). Extracolonic cancer risk in MSH2 females and males was 69% and 34%, respectively (P = 0.042). Mean age of extracolonic cancer diagnosis was significantly older for MSH2 males than females (55.4 vs. 39.0, P = 0.013). No difference was observed in colorectal cancer risk between MLH1 and MSH2 carriers (84% vs. 71%). Colorectal cancer risk was 96% in MSH2 males compared to 39% in MSH2 females (P = 0.034). No differences in colorectal and extracolonic cancer risks between MLH1 females and males were identified. The risk of extracolonic cancer by age 60 was greater in MSH2 mutation carriers than in MLH1 carriers. Gender differences in colorectal and extracolonic cancer risk were observed for MSH2 carriers only. These phenotypic features of HNPCC genotypes may have clinical significance in the design of genotype-specific screening, surveillance, and follow-up for affected individuals.
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Affiliation(s)
- K M Lin
- Section of Colon and Rectal Surgery, Department of Surgery, Creighton Universiy School of Medicine, Omaha, NE, USA
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Ternent CA, Shashidharan M, Blatchford GJ, Christensen MA, Thorson AG, Sentovich SM. Transanal ultrasound and anorectal physiology findings affecting continence after sphincteroplasty. Dis Colon Rectum 1997; 40:462-7. [PMID: 9106697 DOI: 10.1007/bf02258393] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.7] [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] [Indexed: 02/04/2023]
Abstract
PURPOSE This study was undertaken to evaluate endosonographic and physiologic determinants of fecal continence after sphincteroplasty. METHODS Sixteen female patients with severe fecal incontinence were treated with overlapping sphincteroplasty. Mean postoperative follow-up was 12 (range, 3-48) months. All patients underwent preoperative and postoperative transanal endosonography and anal manometry. Bilateral pudendal nerve terminal motor latency determinations were performed in each patient. A physiologic continence score was used to assess stool control. RESULTS Postoperatively, continence was worse, unchanged, and improved in one, five, and ten patients, respectively. An inverse correlation was noted between endosonographic sphincter discontinuity postoperatively, in degrees, and the change in fecal continence after overlapping sphincteroplasty (r = -0.51; P = 0.04). Postoperative increases in sphincter resting (r = 0.6; P = 0.02) and squeeze (r = 0.54; P = 0.03) pressures correlated with improved fecal continence. Mean pudendal nerve terminal motor latency (r = -0.34; P = 0.20) and changes in anal sphincter length at rest (r = 0.41; P = 0.11) and squeeze (r = 0.33; P = 0.20) after sphincteroplasty did not significantly correlate with the change in continence. Patients with intact endosonographic anatomy postoperatively and bilateral, unilateral, or no evidence of pudendal neuropathy had a mean change in continence score of 0.5, 1.8, and 2.2, respectively (P = 0.48). CONCLUSIONS Endosonography after sphincteroplasty can identify residual sphincter defects that are significant in terms of fecal continence. Restoration of anal canal resting and squeeze pressures was related to improved fecal control after overlapping sphincteroplasty. Mean pudendal nerve terminal motor latency was not significantly related to poor postoperative continence. A trend toward less improvement in fecal continence was noted with bilateral pudendal neuropathy.
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Affiliation(s)
- C A Ternent
- Department of Surgery, Creighton University School of Medicine, Omaha, Nebraska 68131, USA
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Meade PG, Blatchford GJ, Thorson AG, Christensen MA, Ternent CA. Preoperative chemoradiation downstages locally advanced ultrasound-staged rectal cancer. Am J Surg 1995; 170:609-12; discussion 612-3. [PMID: 7492011 DOI: 10.1016/s0002-9610(99)80026-9] [Citation(s) in RCA: 54] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND This prospective study assessed the effect of preoperative radiation and chemotherapy on the pathologic staging of advanced rectal cancer. METHODS Twenty patients with rectal cancer were treated with combined chemoradiation prior to operation, after pretreatment staging of all lesions with transrectal ultrasound (TRUS). Perirectal fat invasion served as minimal criteria for preoperative neoadjuvant therapy. The pretreatment stage of these rectal lesions as defined by TRUS was then compared with the pathological stage of the surgical specimen following resection. Cancers were treated with high-dose radiation (45 to 54 Gy) in 19 of 20 patients. One patient received in excess of 60 Gy because of tumor characteristics. Chemotherapy consisted of 5-fluorouracil delivered as a continuous infusion or bolus therapy. Four to 8 weeks after neoadjuvant therapy, 13 abdominal perineal resections, 5 low anterior resections, and 2 completion proctectomies were performed. RESULTS Following resection, rectal cancer was downstaged in 14 of 20 patients. No tumor was present in the rectal wall in 8 of 20 patients. Complete pathological response was present in 7 of 20 patients. Local recurrence occurred in 2 of 20 patients. Disease-free survival in the remaining 17 of 20 patients ranges from 9 to 51 months (average 26). CONCLUSIONS Preoperative chemoradiation in the surgical management of advanced rectal cancer results in demonstrable tumor downstaging.
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Affiliation(s)
- P G Meade
- Department of Surgery, Creighton University School of Medicine, Omaha, Nebraska 68131, USA
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Affiliation(s)
- L Grimaldi
- Department of Radiology, Millard Fillmore Hospital, Williamsville, New York
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