R2* mapping and reduced field-of-view diffusion-weighted imaging for preoperative assessment of nonenlarged lymph node metastasis in rectal cancer

The aim of the current study is to investigate the diagnostic value of R2* mapping versus reduced field-of-view diffusion-weighted imaging (rDWI) of the primary lesion of rectal cancer for preoperative prediction of nonenlarged lymph node metastasis (NLNM). Eighty-one patients with pathologically confirmed rectal cancer underwent preoperative R2* mapping and rDWI sequences before total mesorectal excisions and accompanying regional lymph node dissections. Two radiologists independently performed whole-tumor measurements of R2* and apparent diffusion coefficient (ADC) parameters on primary lesions of rectal cancer. Patients were divided into positive (NLNM+) and negative (NLNM-) groups based on their pathological analysis. The tumor location, maximum diameter of the tumor, and maximum short diameter of the lymph node were assessed. R2* and ADC, pT stage, tumor grade, status of mesorectal fascia, and extramural vascular invasion were also studied for their potential relationships with NLNM using multivariate logistic regression analysis. The NLNM+ group had significantly higher R2* (43.56 ± 8.43 vs. 33.87 ± 9.57, p < 0.001) and lower ADC (1.00 ± 0.13 vs. 1.06 ± 0.22, p = 0.036) than the NLNM- group. R2* and ADC were correlated to lymph node metastasis (r = 0.510, p < 0.001 for R2*; r = -0.235, p = 0.035 for ADC). R2* and ADC showed good and moderate diagnostic abilities in the assessment of NLNM status with corresponding area-under-the-curve values of 0.795 and 0.636. R2* provided a significantly better diagnostic performance compared with ADC for the prediction of NLNM status (z = 1.962, p = 0.0498). The multivariate logistic regression analysis demonstrated that R2* was a compelling factor of lymph node metastasis (odds ratio = 56.485, 95% confidence interval: 5.759-554.013; p = 0.001). R2* mapping had significantly higher diagnostic performance than rDWI from the primary tumor of rectal cancer in the prediction of NLNM status.

Technique, sedation, and clinical outcome of endoscopic submucosal dissection for rectal tumor with involvement of dentate line: A retrospective cohort study

Background

Endoscopic submucosal dissection (ESD) of rectal tumors involving the dentate line (RT-DL) is challenging because of the anatomical features of the anal canal. This study aimed to identify optimal techniques and sedation and to determine the clinical outcomes of ESD for RT-DL.

Methods

We retrospectively collected medical records and endoscopic results of patients who underwent ESD for rectal tumors between January 2012 and April 2021. Patients were divided into RT-DL and rectal tumors not involving the dentate line (RT-NDL) groups, as per involvement of the dentate line. The treatment results and clinical outcomes of the two groups were evaluated and analyzed. Additionally, subgroup analysis was performed in the RT-DL group for the sedation method involved.

Results

In total, 225 patients were enrolled and 22 were assigned to the RT-DL group. The complete resection rate (90.9% vs. 95.6%, P =0.336), delayed bleeding (13.6% vs. 5.9%, P =0.084), perforation (0% vs. 3.9%, P = 0.343), hospital stays (4.55 vs. 4.48 days, P = 0.869), and recurrence (0% vs. 0.5%) showed no significant group differences. However, in RT-DL group, the procedure time (78.32 vs. 51.10 min, P = 0.002) was longer and there was more perianal pain (22.7% vs. 0%, P = 0.001). The subgroup analysis revealed that deep sedation using propofol reduced perianal pain during the procedure (0/14 vs. 5/8, P = 0.002).

Conclusions

ESD of RT-DL is a safe and effective treatment despite the challenges of requiring a high level of technique and longer procedure time. In particular, ESD under deep sedation should be considered in patients with RT-DL to control perianal pain.

Influence of proton pump inhibitors on the pathological response of rectal cancer: a multicentre study

Background

The standard neoadjuvant therapy for rectal cancer involves fluoropyrimidines and radiotherapy and, most recently, total neoadjuvant therapy (TNT). A drug-drug interaction between fluoropyrimidines and proton-pump inhibitors (PPI) was suggested, with a negative impact on oncological outcomes in breast, colon and gastric cancers. Little is known about such an effect on rectal tumours. We aimed to evaluate the impact of PPI utilisation on the pathological response after chemoradiation for rectal cancer.

Materials and methods

Retrospective multicentre study of rectal cancer patients treated with neoadjuvant chemoradiotherapy with capecitabine (cohort 1) or 5-fluororuracil (5-FU) (cohort 2); TNT with oxaliplatin-based regimens was allowed. The pathological response was considered a complete (ypCR) or complete + partial (ypCR + ypPR) according to American Joint Committee on Cancer. PPI use was considered at any time during the neoadjuvant period if concomitant to fluoropyrimidines.

Results

From January 2007 to November 2020, 251 patients received capecitabine and 196 5-FU. The rates of PPI use in cohorts 1 and 2 were 20.3% and 26.5%, respectively. TNT was offered to 18.3% in cohort 1. PPI use did not influence ypCR in cohort 1 (yes versus no: 29.4% versus 19.5%; p = 0.13) or 2 (yes versus no: 25.0% versus 26.4%; p = 1.0). Similar ypCR + ypPR were observed in both cohorts 1 (76.5% versus 72.0%; p = 0.60) and 2 (86.5% versus 76.4%; p = 0.16). PPI use was not associated with pathological response in multivariable analysis. PPI users experienced more grade 3 or higher diarrhoea and infections.

Conclusion

PPI concomitant to capecitabine/5-FU chemoradiation did not influence the pathological response in rectal cancer but was associated with more treatment-related adverse events.

Chemical Shift-Encoded Sequence (IDEAL-IQ) and Amide Proton Transfer (APT) MRI for Prediction of Histopathological Factors of Rectal Cancer

To investigate whether parameters from IDEAL-IQ/amide proton transfer MRI (APTWI) could help predict histopathological factors of rectal cancer. Preoperative IDEAL-IQ and APTWI sequences of 67 patients with rectal cancer were retrospectively analyzed. The intra-tumoral proton density fat fraction (PDFF), R2* and magnetization transfer ratio asymmetry (MTRasym (3.5 ppm)) were measured according to the histopathological factors of rectal cancer. The relationship between MR parameters and histopathological factors were analyzed, along with diagnostic performance of MR parameters. PDFF, R2* and MTRasym (3.5 ppm) were statistically different between T1+T2/T3+T4 stages, non-metastatic/metastatic lymph nodes, lower/higher tumor grade and negative/positive status of MRF and EMVI (p < 0.001 for PDFF, p = 0.000-0.015 for R2* and p = 0.000-0.006 for MTRasym (3.5 ppm)). There were positive correlations between the above parameters and the histopathological features of rectal cancer (r = 0.464-0.723 for PDFF (p < 0.001), 0.299-0.651 for R2* (p = 0.000-0.014), and 0.337-0.667 for MTRasym (3.5 ppm) (p = 0.000-0.005)). MTRasym (3.5 ppm) correlated moderately and mildly with PDFF (r = 0.563, p < 0.001) and R2* (r = 0.335, p = 0.006), respectively. PDFF provided a significantly higher diagnostic ability than MTRasym (3.5 ppm) for distinguishing metastatic from non-metastatic lymph nodes (z = 2.407, p = 0.0161). No significant differences were found in MR parameters for distinguishing other histopathological features (p > 0.05). IDEAL-IQ and APTWI were associated with histopathological factors of rectal cancer, and might serve as non-invasive biomarkers for characterizing rectal cancer.

Assessing the histopathological features of rectal adenocarcinoma with chemical shift-encoded sequence (CSE)-MRI and diffusion-weighted imaging (DWI)

Background

It is of clinical importance to assess the histopathological features of rectal cancer. The adipose tissue microenvironment is closely associated with tumor formation and progression. The chemical shift-encoded magnetic resonance imaging (CSE-MRI) sequence can noninvasively quantify adipose tissue. In this study, we aimed to investigate the feasibility of using CSE-MRI and diffusion-weighted imaging (DWI) to predict the histopathological features of rectal adenocarcinoma.

Methods

In this retrospective study, 84 patients with rectal adenocarcinoma and 30 healthy controls were consecutively enrolled at the Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology. CSE-MRI and DWI sequences were performed. The intratumoral proton density fat fraction (PDFF) and R2* of rectal tumors and normal rectal walls were measured. The histopathological features, including pathological T/N stage, tumor grade, mesorectum fascia (MRF) involvement, and extramural venous invasion (EMVI) status were analyzed. The Mann-Whitney test, Spearman correlation, and receiver operating characteristic (ROC) curves were used for statistical analyses.

Results

Patients with rectal adenocarcinoma demonstrated significantly lower PDFF and R2* values than did the control participants (5.35%±1.70% vs. 11.55%±3.41%, P<0.001; 35.60 s-1±7.30 s-1 vs. 40.15 s-1±5.72 s-1, P=0.003). PDFF and R2* were significantly different in the discrimination of T/N stage, tumor grade, and MRF/EMVI status (P=0.000-0.005). A significant difference was only noted in the differentiation of the T stage for the apparent diffusion coefficient (ADC) (1.09±0.26×10-3 mm2/s vs. 1.00±0.11×10-3 mm2/s; P=0.001). PDFF and R2* exhibited positive correlations with all the histopathological features (r=0.306-0.734; P=0.000-0.005), while ADC was negatively correlated with the T stage (r=-0.380; P<0.001). PDFF demonstrated diagnostic ability, with a sensitivity of 95.00% and a specificity of 87.50%, while R2* had a sensitivity of 95.00% and a specificity of 79.20% in differentiating T stage; both demonstrated a better diagnostic performance than did ADC.

Conclusions

Quantitative CSE-MRI imaging might serve as a noninvasive biomarker for assessing the histopathological features of rectal adenocarcinoma.

Specific Septic Complications after Rectal Cancer Surgery: A Critical Multicentre Study

The postoperative septic complications in gastrointestinal surgery impact immediate as well as long-term outcomes, which lead to reinterventions and additional costs. The authors presented the experience of three surgery clinics in Romania regarding the specific septic complications occurring in patients operated on for rectal cancer. The study group comprised 2674 patients who underwent surgery over a 5-year period (2017-2021). Neoplasms of the middle and lower rectum (76%) were the majority. There were 85% rectal resections and 15% abdominoperineal excisions of the rectum. In total, 68.54% of patients were operated on laparoscopically, and 31.46% received open surgery. Without taking wound infections into account, 97 (3.67%) patients had abdominal-pelvic septic complications. The aim was to evaluate the causes of the complications. The percentage of suppurations after surgery of the rectum treated by radiochemotherapy was considerably higher than after surgery of the non-radiated upper rectum. The fatality rate was 5.15%. The risk of fistulas was significantly associated with the preoperative treatment, tumour position and type of intervention. Sex, age, TNM stage or grade were not significant at 0.05 the threshold. The risk of fistulas is reduced with low anterior resection, but the gravity of these complications is higher in the lower rectum compared with the superior rectum. Preoperative radiochemotherapy is a contributing factor to septic complications.

Rectal bleeding as a symptom of solitary rectal ulcer syndrome mimicking rectal neoplasm on colonoscopy: A case report

Patients complaining of rectal bleeding, constipation, and a suspicious mass in colonoscopy should undergo biopsy. Histological features such as fibromuscular obliteration in the lamina propria favor SRUS, a benign disorder.

Operative and oncological outcomes after robotic rectal resection compared with laparoscopy: a systematic review and meta-analysis

BACKGROUND

Most studies comparing robotic and laparoscopic surgery, show little difference in clinical outcomes to justify the expense. We systematically reviewed and pooled evidence from studies comparing robotic and laparoscopic rectal resection.

METHOD

Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica (EMBASE), and Cochrane databases were searched for studies between 1996 and 2021 comparing clinical outcomes between laparoscopic and robotic rectal surgeries involving total mesorectal excision. Outcome measures included operative times, conversions to open, complications, recurrence and survival rates.

RESULTS

Fifty eligible studies compared outcomes between robotic and laparoscopic rectal resections; three were randomized trials. Pooled results showed significantly longer operating times for robotic surgery but lower conversion and complications rates, shorter lengths of stay in hospital, better rates of complete mesorectal resection and better three-year overall survival. However, the low number of randomized studies makes most data subject to bias.

CONCLUSION

Available evidence supports the safety and ongoing use of robotic rectal cancer surgery, while further high-quality evidence is sought to justify the expense.

Risk and survival in colorectal cancer with increasing body mass index: A nationwide population-based cohort study

AIM

The aim was to explore potential associations between the body mass index (BMI) and the risk of colorectal cancer (CRC), including subsites of the colon, and cancer-specific death.

METHODS

A registry-based cohort study was conducted with baseline data gathered from the Norwegian Tuberculosis Screening Programme, collected between 1963 and 1975, and linked to follow-up data from the Cancer Registry of Norway and the Norwegian Cause of Death Registry. Cox regression models were used to explore associations between BMI and CRC risk and cancer-specific death.

RESULTS

Of 1 723 692 included individuals, 76 616 developed CRC during 55 370 707 person-years of follow-up. In men, a 5 kg/m² increase in BMI was associated with an increased risk of colon cancer, including both right and left subsites, and rectal cancer. Allowing for nonlinearities, we found a U-shaped association for the right colon and an inverse U-shape for the left colon and rectum cancer. In women, a 5 kg/m² increase in BMI in early adulthood was associated with increased risk of colon cancer, including both subsites. In women, an increased risk of CRC death with increasing BMI was found for colon cancer.

CONCLUSIONS

Men of all ages have an increased risk of CRC with increasing BMI, with the highest risk for right-sided colon cancer. An increased risk for colon cancer was also found in women with high BMI in early adulthood. Furthermore, women of all age groups appeared to have an increased risk of CRC death with higher BMI.

Rectal Tropism: An Extremely Rare Case of Prostate Cancer Recurrence With Metastasis to the Rectum Postradical Prostatectomy

Prostate cancer is the most common noncutaneous cancer affecting men in the United States. It is a slow-growing tumor that can be missed during the nascent phase. Prostate cancer commonly metastasizes to the bones and nearby lymph nodes. However, cases of metastatic prostate cancer to the rectum are exceptionally rare. Such metastases may cause obstructive or malabsorption symptoms similar to those observed in primary rectal carcinoma. We present a very rare case of prostate cancer recurrence with rectal metastasis in an elderly male with a history of castration-resistant prostate carcinoma status postradical prostatectomy.

Clinical implication and management of rectal cancer with clinically suspicious lateral pelvic lymph node metastasis: A radiation oncologist's perspective

Rectal cancer is the eighth most common malignancy worldwide. With the introduction of total mesorectal excision (TME) and neoadjuvant chemoradiation (NCRT), intrapelvic local control has been remarkably improved. However, lateral pelvic recurrence remains problematic, especially in patients with clinically suspicious lateral pelvic lymph node (LPLN). LPLN dissection has been applied for the management of LPLN metastasis, mainly in Japan and other Eastern countries, while the role of NCRT is more emphasized and LPLN dissection is performed in very limited cases in Western countries. However, the optimal management strategy for patients with rectal cancer with suspicious LPLN metastasis has not been determined. Herein, we review the latest studies on the optimal management of LPLN metastasis to suggest the most appropriate treatment policies according to current evidence and discuss future research directions.

A Deep Learning Model Based on MRI and Clinical Factors Facilitates Noninvasive Evaluation of KRAS Mutation in Rectal Cancer

BACKGROUND

Recent studies showed the potential of MRI-based deep learning (DL) for assessing treatment response in rectal cancer, but the role of MRI-based DL in evaluating Kirsten rat sarcoma viral oncogene homologue (KRAS) mutation remains unclear.

PURPOSE

To develop a DL method based on T2-weighted imaging (T2WI) and clinical factors for noninvasively evaluating KRAS mutation in rectal cancer.

STUDY TYPE

Retrospective.

SUBJECTS

A total of 376 patients (108 women [28.7%]) with histopathology-confirmed rectal adenocarcinoma and KRAS mutation status.

FIELD STRENGTH/SEQUENCE

A 3 T, turbo spin echo T2WI and single-shot echo-planar diffusion-weighted imaging (b = 0, 1000 sec/mm² ).

ASSESSMENT

A clinical model was constructed with clinical factors (age, gender, carcinoembryonic antigen level, and carbohydrate antigen 199 level) and MRI features (tumor length, tumor location, tumor stage, lymph node stage, and extramural vascular invasion), and two DL models based on modified MobileNetV2 architecture were evaluated for diagnosing KRAS mutation based on T2WI alone (image model) or both T2WI and clinical factors (combined model). The clinical usefulness of these models was evaluated through calibration analysis and decision curve analysis (DCA).

STATISTICAL TESTS

Mann-Whitney U test, Chi-squared test, Fisher's exact test, logistic regression analysis, receiver operating characteristic curve (ROC), Delong's test, Hosmer-Lemeshow test, interclass correlation coefficients, and Fleiss kappa coefficients (P < 0.05 was considered statistically significant).

RESULTS

All the nine clinical-MRI characteristics were included for clinical model development. The clinical model, image model, and combined model in the testing cohort demonstrated good calibration and achieved areas under the curve (AUCs) of 0.668, 0.765, and 0.841, respectively. The combined model showed improved performance compared to the clinical model and image model in two cohorts. DCA confirmed the higher net benefit of the combined model than the other two models when the threshold probability is between 0.05 and 0.85.

DATA CONCLUSION

The proposed combined DL model incorporating T2WI and clinical factors may show good diagnostic performance. Thus, it could potentially serve as a supplementary approach for noninvasively evaluating KRAS mutation in rectal cancer.

EVIDENCE LEVEL

3 TECHNICAL EFFICACY: Stage 2.

Large Bowel Obstruction Caused by Metastatic Prostate Cancer: A Case Report

Bowel obstruction is a frequently encountered condition worldwide that causes numerous admissions to hospitals. Metastatic carcinoma has been identified as one of the infrequently encountered causes of bowel obstruction. Prostate cancer typically metastasizes to lymph nodes, bone, lungs, liver, and brain. In this article, we reported the case of a 75-year-old man who presented with bowel obstruction due to narrowing and stricture of the rectum. Primary rectal mass was initially diagnosed, but upon further investigation, it was found that the mass resembled prostate tissue. The bowel obstruction was managed surgically with a colostomy. The patient was later referred to oncology for chemotherapy and hormonal therapy.

Total neoadjuvant therapy in patients with locally advanced rectal cancer: A tertiary medical center experience

The current standard of care for locally advanced rectal cancer (LARC) includes preoperative chemoradiation, followed by total mesorectal excision and adjuvant chemotherapy. This multimodality treatment improves local control but is associated with low compliance rates without clear beneficial effects on overall survival (OS) and distant metastasis. In this retrospective study, the charts of patients diagnosed with cT3/4 or cT2-node-positive rectal cancer between January 2011 and June 2019 were reviewed. The chemoradiation therapy (CRT) group received a long course of CRT with capecitabine followed by surgery and adjuvant chemotherapy. The total neoadjuvant therapy (TNT) group received 6 cycles mFOLFOX and a short course of radiation therapy followed by surgery. A total of 81 patients were included, among which 55 (67.9%) received CRT and 26 (32.1%) received TNT. In the CRT group, 15 (27.3%) patients achieved pathologic complete response (pCR) compared with 10 (38.5%) in the TNT group (P=0.22). A total of 19 (35.8%) cases in the CRT group downstaged to pT0N0 or pT1N0 compared with 11 (42.3%) in the TNT group (P=0.33). The 2-year disease-free survival (DFS) rate was 81.0% in the TNT group and 84.0% in the CRT group (P=0.15). Out of 55 patients in the CRT group, 30 patients received adjuvant chemotherapy, 22 (40.0% of CRT cases) of which completed a full course. All 26 patients in the TNT group received neoadjuvant chemotherapy, where 22 (84.6%) patients took a full course (P<0.001). In conclusion, the present study revealed that patients treated with TNT were more compliant to chemotherapy than those treated with CRT. A numerically higher pCR rate, and nodal and tumor downstaging were noted in the TNT group without significance. No difference was noted in the 2-year DFS. Longer follow-up is required.

Early and late clinico-pathologic outcomes of minimally invasive total mesorectal excision for rectal cancer: A propensity score-matched comparison of robotic and laparoscopic approaches

BACKGROUND

This study aimed to compare the early and late clinical outcomes of laparoscopic and robotic total mesorectal excision (TME) using propensity score matching.

METHODS

The retrospective study included 489 patients who underwent laparoscopic or robotic TME for rectal cancer between June 2011 and December 2018. Overall, 131 matched pairs were generated via propensity scoring matching according to several factors.

RESULTS

The matched groups had generally similar demographic characteristics. The robotic TME group had significantly longer mean times for the total operation and the TME procedure. There were no significant differences in terms of the other procedure-specific parameters, although the robotic TME group had significantly shorter duration of hospitalisation and shorter duration of need for postoperative indwelling urinary catheter. Moreover, the robotic TME group had non-significantly lower rates of late postoperative complications and reoperation.

CONCLUSIONS

Early and late clinico-pathologic outcomes of robotic TME were comparable to that of laparoscopic TME.

Ostomy prevalence and survival in elderly patients with stage III and IV rectal cancer

AIM

Oncological strategies in the elderly population are often debated. The objective of this study was to investigate the survival rates and prevalence of ostomy in elderly patients operated on for stage III and IV rectal cancers.

METHODS

This retrospective multicentric population-based study included 151 patients aged ≥75 years with stage III and IV rectal adenocarcinoma who underwent surgery between 2007 and 2014. Multivariable logistic regression was used to assess the impact of different prognostic factors.

RESULTS

The median age of the patients was 81 years (range: 75-97 years) with 40 patients >85 years of age. Age was significantly correlated with overall survival (OS) in both stage III and IV cancers (P < 0.001). For patients ≥80 years the presence of comorbid conditions was associated with a lower chance of survival (P = 0.02). A digestive stoma was created in 67 (76.1%) patients with stage III cancer and 26 (29.54%) had a stoma reversal. A palliative derivative stoma was performed in half of patients with stage IV cancer. Adjuvant chemotherapy was independently associated with improved 5-year OS (P < 0.001).

CONCLUSIONS

Age, comorbidities and adjuvant chemotherapy were independent predictors for OS. Resection of rectal tumors in fit elderly patients should be promoted; however, patients should be aware of the high risk of stoma. Geriatr Gerontol Int 2021; 21: 670-675.

Transanal Endoscopic Microsurgery for Rectal Neoplasms

Despite the increasing application of transanal endoscopic microsurgery (TEM) for rectal lesions, the cost of the equipment may play a role in a hospital's hesitancy to invest in the platform. This study compares the cost of TEM to laparoscopic low anterior resection (LAR). Patients who underwent laparoscopic LAR (n = 24) for rectal neoplasm between 2006 and 2014 were case-matched based on sex, age, comorbidities, lesion size and location to patients who underwent TEM at a busy secondary care urban hospital. Procedure-related costs and costs associated with readmissions for complications and related subsequent surgeries in the first 3 years were calculated. There were 42 hospital admissions for 24 LAR patients, totalling 326 hospital days. For 24 TEM patients, there were 25 hospital admissions, totalling 56 hospital days. Subsequent operations for LAR patients included 2 washout and diverting ileostomies (8%), 2 adhesionolysis (8%), 4 ventral hernia repairs (16%) and 11 ileostomy reversals (46%). In the TEM group, there was one operation for recurrence (4%). The mean cost of LAR, including all related hospital costs in the subsequent 3 years, was CAD 14,851 (95% CI: CAD 10,124-19,579). The mean cost of TEM was CAD 2449 (95% CI: CAD 2133-2767; p < 0.0001), with a savings of CAD 12,402 per patient. TEM for rectal neoplasm is associated with significantly lower hospital costs, which far outweigh the costs of acquiring and maintaining the technology.

Establishment and clinical application value of an automatic diagnosis platform for rectal cancer T-staging based on a deep neural network

BACKGROUND

Colorectal cancer is harmful to the patient's life. The treatment of patients is determined by accurate preoperative staging. Magnetic resonance imaging (MRI) played an important role in the preoperative examination of patients with rectal cancer, and artificial intelligence (AI) in the learning of images made significant achievements in recent years. Introducing AI into MRI recognition, a stable platform for image recognition and judgment can be established in a short period. This study aimed to establish an automatic diagnostic platform for predicting preoperative T staging of rectal cancer through a deep neural network.

METHODS

A total of 183 rectal cancer patients' data were collected retrospectively as research objects. Faster region-based convolutional neural networks (Faster R-CNN) were used to build the platform. And the platform was evaluated according to the receiver operating characteristic (ROC) curve.

RESULTS

An automatic diagnosis platform for T staging of rectal cancer was established through the study of MRI. The areas under the ROC curve (AUC) were 0.99 in the horizontal plane, 0.97 in the sagittal plane, and 0.98 in the coronal plane. In the horizontal plane, the AUC of T1 stage was 1, AUC of T2 stage was 1, AUC of T3 stage was 1, AUC of T4 stage was 1. In the coronal plane, AUC of T1 stage was 0.96, AUC of T2 stage was 0.97, AUC of T3 stage was 0.97, AUC of T4 stage was 0.97. In the sagittal plane, AUC of T1 stage was 0.95, AUC of T2 stage was 0.99, AUC of T3 stage was 0.96, and AUC of T4 stage was 1.00.

CONCLUSION

Faster R-CNN AI might be an effective and objective method to build the platform for predicting rectal cancer T-staging.

TRIAL REGISTRATION

chictr.org.cn: ChiCTR1900023575; http://www.chictr.org.cn/showproj.aspx?proj=39665.

Factors contributing to time to diagnosis in symptomatic colorectal cancer: A scoping review

INTRODUCTION

Colorectal cancer (CRC) is the third most common cancer worldwide (Ferlay et al., 2015, International Journal of Cancer, 136, E359), and delayed diagnosis is associated with mortality (Tørring et al., 2011, British Journal of Cancer, 104, 934; Tørring et al., 2012, Journal of Clinical Epidemiology, 65, 669). The purpose of this review was to determine the factors associated with time to diagnosis in symptomatic CRC using scoping review methods.

METHODS

We performed database and citation searches to identify studies which examine the length of any interval from symptom presentation to diagnosis. Study selection was conducted by two independent reviewers. Factors contributing to time to diagnosis were extracted from selected articles and mapped onto a conceptual framework consisting of four levels: patient and disease factors, provider factors, organisation/setting factors and sectors of influence.

RESULTS

From the 31 studies included in this review, we identified 138 unique factors, 17 of which were investigated by at least three studies and 11 of which had consistent results. Patient and disease factors were most commonly studied. Patient perception that their symptoms were benign, a non-urgent referral, female sex and rectal tumour location were each associated with a longer time to diagnosis.

CONCLUSION

Thus far, the literature has focused on patient or disease-related factors, while other levels of influence have been relatively understudied.

Robotic rectal surgery: Outcomes of the first 102 totally robotic cases handled using the single-docking technique in a reference institution

BACKGROUND AND OBJECTIVE

Rectal cancer is often surgically treated, but it is still associated with morbidity rates. Minimally invasive techniques are increasingly being used to reduce complications, and the use of such techniques can be found in the literature. This study aims to report our experience in a reference oncology center.

METHODS

A retrospective cohort study was performed on a prospective database of patients who underwent robotic surgery for rectal cancer using the single-docking technique from September 2014 to April 2018. Clinical and surgical variables, as well as morbidity and mortality rates, were analyzed.

RESULTS

One hundred and two patients underwent robotic surgery. Intraoperative complications occurred in six patients (4.9%), and postoperative complications in 24 patients (23.5%), of which anastomotic fistula represented 3.9%. The conversion rate was 1.96%. Two cases (1.9%) faced death within 30 days. The median length of hospitalization was 3 days. The median number of lymph nodes dissected was 15. Clinical and surgical data were correlated with postoperative complications, and no statistically significant differences were found.

CONCLUSION

Robotic surgery is a safe and feasible approach to manage rectal cancer. The method presents satisfactory results with regard to the rate of operative complications, conversion rate, oncologic outcomes, and length of hospitalization.

A Prospective Observational Study Comparing Long-Course Conventional Neoadjuvant Chemoradiotherapy with Short-Course Radiotherapy Followed by Consolidation Chemotherapy with Delayed Surgery in Locally Advanced Rectal Cancer

Background  Polish and Australian randomized studies compared short-course radiotherapy (RT) with immediate surgery and long-course chemoradiotherapy (CRT) with delayed surgery. In these studies, similar long-term survival and local control have been reported for both these approaches, but pathological complete response (pCR) is not better with short-course RT. Moreover, studies have shown better tumor downstaging with delayed surgery. In this context, the use of short-course RT with delayed surgery may have some advantages and needs to be tested in clinical trials. Patients and Methods  This was a two-arm, prospective, observational study, in which preoperative short-course RT followed by two cycles of chemotherapy was compared with the conventional neoadjuvant CRT in locally advanced rectal cancer. The primary end points were the rate of complete response and toxicity profile. The secondary end points were the rate of R0 resection, overall survival, and progression-free survival. The data obtained from the two arms were analyzed using Pearson's chi-square test to determine the statistical significance between the two treatment arms. Results  The pCR rate was 6.7% in the study arm and 0 in the control arm ( p = 0.343). The RO resection rates were 92.8 and 92.3% in the study and control arms, respectively. The rates of grade 3and 4 acute toxicity in the study and control arms were 14.2 and 61.5%, respectively ( p = 0.011). The rates of grade 3 and 4 late toxicity in the study and control arms were 21.4 and 15.3%, respectively ( p = 0.686). Conclusions  The pCR rates and the late toxicities in both arms are comparable. The major advantages of the 5 × 5 Gy regimen with chemotherapy in a neoadjuvant setting are a significant reduction in acute toxicities and better patient compliance along with similar efficacy as that of the standard regimen.

Retrospective survival analysis of stage II-III rectal cancer: tumour regression grade, grading and lymphovascular invasion are the only predictors

BACKGROUND

Tumour regression grade is gaining interest as a prognostic factor of patients undergoing neoadjuvant chemoradiotherapy and surgery for locally advanced rectal cancer.

METHODS

A series of 68 consecutive patients with locally advanced rectal cancer treated by neoadjuvant chemoradiotherapy and surgery between 2010 and 2016 was retrospectively studied. The impact on disease-free survival (DFS) and overall survival (OS) of several criteria was analysed. Univariate analysis was performed through Kaplan-Meier statistics. Multivariate analysis was performed through Cox regression model. Using criteria found to be related to long-term outcomes, a predictive model of patient's OS was calculated.

RESULTS

Poor tumour regression grade - TRG3 (P = 0.010), poor grading - G3 (P = 0.001) and lymphovascular invasion (LVI; P = 0.030) were associated with short OS at univariate analysis. OS was associated with TRG3 and G3 at multivariate analysis (P = 0.016 and P = 0.027, respectively). DFS was associated with LVI (P = 0.001), G3 tumours (P = 0.046) and TRG3 (P = 0.045) at univariate analysis. At multivariate analysis, only LVI was associated with DFS (P = 0.041). A score, pondering the impact of three parameters (2 points for TRG3, 2 for G3 and 1 for LVI), was created and resulted to predict patient OS (P = 0.008), ranging from 94.5 months (score = 0-1) to 32 months (score = 3-5).

CONCLUSION

TRG3 and G3 were associated with poor OS, and LVI was the most significant predictor of DFS. An easy-to-use score may allow for a more accurate prediction of OS.

Quality of life in patients with resectable rectal cancer during the first 24 months following diagnosis

AIM

An increasing number of patients survive rectal cancer, resulting in more patients living with the side-effects of the treatment. Exploring quality of life before and after treatment enables follow-up and additional treatment to be adjusted to the patient's needs. The aim of the study was to describe the quality of life during the 24 months following diagnosis and to identify risk factors for poor quality of life.

METHOD

This is a prospective cohort study of patients with rectal cancer followed up by extensive questionnaires. Patients from 16 surgical departments in Denmark and Sweden from 2012 to 2015 were included. The self-assessed quality of life was measured with a seven-point Likert scale.

RESULTS

A total of 1110 patients treated with curative intent were included, and the response rate at the 24-month follow-up was 71%. Patients with rectal cancer assessed their quality of life before start of treatment as poorer than that of a reference population. At the 12- and 24-month follow-up, the quality of life on group level had recovered to the same level as for the reference population. Risk factors for poor quality of life included bother with urinary, bowel and stoma function. A reference population was used for comparison.

CONCLUSION

The quality of life of patients with resectable rectal cancer recovered to levels comparable to a reference population 12 and 24 months after diagnosis. Our results indicate that the urinary, bowel and stoma function has an impact on quality of life.

Efficacy and prognosis of surgical treatment in ARMM and its effects on immune and inflammatory profiles

The aim of the present study was to investigate the efficacy and prognosis of surgical treatment in anorectal malignant melanoma (ARMM) as well as its effects on immune and inflammatory profiles. A total of 64 patients with ARMM were enrolled and divided into control group (n=32) and observation group (n=32) based on different therapeutic methods. Patients in the observation group underwent wide local excision, while those in the control group were given non-surgical treatment. The immune function was compared between the two groups after treatment. The expression levels of serum IL-17, IL-23 and vascular endothelial growth factor (VEGF) were compared between the groups before and after treatment. Patients were followed up for 5 years to observe the recurrence and survival rates in the two groups. Compared with those in the control group, the levels of cluster of differentiation (CD)3⁺, CD4⁺ and CD4⁺/CD8⁺ were increased, while the level of CD8⁺ was reduced in the observation group (P<0.05). The levels of serum IL-17, IL-23 and VEGF were significantly lower in both groups at 4, 6 and 8 weeks after treatment than those before treatment, and the decrease was more obvious in the observation group (P<0.05). The observation group exhibited a notably elevated 5-year survival rate and a remarkably decreased recurrence rate in comparison with the control group (P<0.05). For ARMM, surgical treatment is more effective than non-surgical treatment, which has less effect on immune function, is able to reduce serum IL-17, IL-23 and VEGF levels, lower recurrence rate, improve patient survival rate, and plays a certain positive role in prolonging the survival time of ARMM patients.

Nonsurgical Management Following Local Resection for Early Rectal Cancer in Patients with High-risk Factors: A Single-institute Experience

Objective

Additional surgery is considered for patients at high risk for lymph node metastasis (LNM) after local resection for early rectal cancer. Several factors are considered as indications for additional surgery, although there are currently no definitive criteria. This study aimed to clarify the need for additional surgery based on the number of risk factors for LNM and to evaluate the significance of submucosal invasion on recurrence.

Methods

Patients with early rectal cancer harboring risk factors for LNM who underwent local resection between March 2005 and December 2016 were retrospectively analyzed. Associations among the number of risk factors, prognosis, and additional treatment after local resection were investigated.

Results

A total of 29 eligible patients were classified into the surgery (n = 10), chemoradiotherapy (n = 7), and no-additional-treatment (NAT, n = 12) groups. Among the 29 patients, 15 patients (52%) with only one risk factor did not relapse. The NAT group harbored fewer risk factors for LNM, and 8 of the 12 patients (67%) had only deep submucosal invasion. Local recurrence occurred in one patient in the chemoradiotherapy group. The estimated 5-year overall survival rates were 88.9%, 75.0%, and 81.5% in the surgery, chemoradiotherapy, and NAT groups, respectively. There were no disease-specific deaths in the overall cohort.

Conclusions

In the present study, no recurrence occurred in patients who did not receive additional surgery with deep submucosal invasion as the only risk factor. A multicenter investigation is necessary to confirm the safety of nonsurgical options.

Survival outcomes after isolated local recurrence of rectal cancer and risk analysis affecting its resectability

BACKGROUND AND OBJECTIVES

This study aimed to investigate the clinical course and prognostic factors after isolated local recurrence (iLR) and to identify the predictive factors for R0 resection of locally recurrent rectal cancer (LRRC).

METHODS

We retrospectively reviewed the medical records of 76 patients with iLR who had undergone radical surgery for a primary tumor from 2003 to 2015.

RESULTS

The iLR rate was 2.5%. From 76 patients, 39 patients underwent R0 resection for iLR. Multivariate analysis revealed that initial open surgery, neoadjuvant chemoradiation, and p/ypT ≥ 3 were poor prognostic factors after iLR as regard to the variables related to the primary tumor; and symptom presence at the time of iLR diagnosis, higher fixity, and no chemotherapy after iLR were associated with shorter overall survival after iLR, and R0 resection of LRRC was the only favorable prognostic factor for progression-free survival after iLR as regard to the variables related to LRRC. Higher tumor level, negative pathologic circumferential margin of the primary tumor, and low fixity of LRRC were favorable factors in achieving R0 resection of LRRC.

CONCLUSIONS

Early detection of iLR before symptom development, use of chemotherapy after iLR and R0 resection of LRRC should be considered to improve survival outcomes after iLR.

Factors influencing recurrence of stage I-III rectal cancer in regional Australia

BACKGROUND

As treatments for rectal cancer improve with developments in surgical techniques, radiotherapy and chemotherapy, the nature of recurrences are evolving. We used a comprehensive database of a large Australian population with stage I-III rectal adenocarcinoma to identify timing and prognostic significance of recurrences, and factors associated with risk of developing recurrent disease.

METHODS

All patients with locoregional rectal cancer treated with curative intent in our health district from 2006 to 2017 were included. Multivariate analysis using Cox regression models were used to identify factors associated with recurrence.

RESULTS

A total of 483 patients were included. Recurrence occurred in 117 (24.2%) of 483 patients, being locoregional in 15 (3.1%) patients, distant in 85 patients (17.6%) and both locoregional and distant in 17 (3.5%) patients. Compared to those with locoregional recurrence, those with both locoregional and distant recurrence had worse cancer-specific survival. On univariate analysis, factors associated with recurrence included stage, grade, radiotherapy, chemotherapy, surgery type and distal tumour location. Factors which remained significant on multivariate analysis included higher grade and stage.

CONCLUSION

In the era of multimodality therapy for rectal cancer, recurrences are predominantly distant. Traditional predictors including higher stage, grade and distal tumour location remain independently associated with recurrence, despite current treatment paradigms.

Defunctioning Protective Stoma Can Reduce the Rate of Anastomotic Leakage after Low Anterior Resection in Rectal Cancer Patients

PURPOSE

This study aimed to identify risk factors for anastomotic leakage and to evaluate the impact of protective stoma on the rate of anastomotic leakage and subsequent management.

METHODS

This retrospective study analyzed data from 4,282 patients who underwent low anterior resection between 2007 and 2014. Among these, 1,367 (31.9%) underwent surgery to create protective diverting stoma and 232 (5.4%) experienced anastomotic leakage. At 6-month timepoints, data were evaluated to identify any correlation between the presence of diverting stoma and the incidence of anastomotic leakage. In addition, clinicopathological parameters were investigated to identify risk factors for anastomotic leakage.

RESULTS

Diverting stomas significantly reduced the rate of anastomotic leakage [HR 0.334, 95% CI 0.212.

Expression of vascular endothelial growth factor as a predictor of complete response for preoperative chemoradiotherapy in rectal cancer

Biomarkers that predict tumor response before surgical treatment are necessary to help select patients for preoperative chemoradiotherapy for rectal cancer. However, no definite predictive biomarker has been established. This study explored programmed death-ligand 1 (PD-L1), epidermal growth factor receptor (EGFR), vascular endothelial growth factor (VEGF), p-signal transducer and activator of transcription 3 (p-STAT3), and death-domain associated protein as predictive biomarkers with regard to preoperative chemoradiotherapy in rectal cancer.Formalin-fixed paraffin-embedded cancer tissues from pretreatment biopsies from 31 patients who underwent preoperative chemoradiotherapy were studied. The biomarkers were evaluated by immunohistochemistry.PD-L1 positivity was found in 22.6% of 31 patients and complete response (CR) showed 33.3% and non-CR showed 18.2%. EGFR positivity was found in 71.0% of 31 patients and CR showed 88.9% and non-CR showed 73.6%. VEGF positivity was found in 83.9% of 31 patients and CR showed 88.9% and non-CR showed 81.8%. p-STAT3 positivity was found in 80.6% of 31 patients and CR showed 88.9% and non-CR showed 77.3%. On multiple logistic regression analysis, only VEGF expression was found to be a significant predictive factor for CR (P = .001). VEGF expression in pretreatment biopsies might be a predictive marker for CR after preoperative chemoradiation in rectal cancer.Although there is a restriction of small sample size, our finding suggested that this study can be foundation for a larger further study for biomarkers which can predict neoadjuvant therapy response of specimens obtained for diagnosis before surgery.

Clinical and pathological outcomes of induction chemotherapy before neoadjuvant radiotherapy in locally-advanced rectal cancer

Background and Objectives

In North America, preoperative combination chemoradiation is the most commonly recommended and utilized approach to locally advanced rectal cancer. There is increasing interest in the use of induction chemotherapy (IC) before radiation and surgery in locally advanced rectal cancer. How widely IC is being used and whether it improves pathologic and oncologic outcomes is unknown.

Methods

We evaluated clinical stage 2 or 3 rectal cancer patients in the National Cancer Database between 2006 and 2015. We identified predictors of use of IC with multivariable logistic regression and compared survival between groups using Cox proportional hazards regression.

Results

Among 36 268 patients, IC use increased significantly over time from 5.5% in 2006 to 15.9% in 2015 (P < 0.001). Treatment at a hospital with a high IC rate was an independent predictor of receipt of IC. IC and traditional therapy yielded similar pathologic complete response rates (32.2% vs 30.5%, P = 0.2) and similar 5‐year survival (82.4% vs 81.4%, 0.71).

Conclusions

Use of IC for locally advanced rectal cancer has increased significantly. The choice of IC seems to be driven more by institutional and regional practice patterns than clinical characteristics and is not associated with improved pathologic or oncologic outcomes.

Comparative Outcomes of Preoperative Chemoradiotherapy and Selective Postoperative Chemoradiotherapy in Clinical Stage T3N0 Low and Mid Rectal Cancer

Purpose/aim: Preoperative chemoradiotherapy (pre-CRT) and total mesorectal excision (TME) have become the standard of care for patients with locally advanced rectal cancer (LARC). Nevertheless, it is a controversial issue whether pre-CRT in cT3N0M0 patients would result in potential overtreatment. Materials and methods: In total, 183 clinical stage IIA rectal cancer patients treated with and without pre-CRT between 2011 and 2014 were retrospectively analyzed. Capecitabine/FOLFOX/CAPOX chemotherapy was co-administered with preoperative radiotherapy. Surgical resection with laparoscopic or open TME was conducted 8-12 weeks after completion of the pre-CRT. Postoperative radiotherapy was routinely given to patients with pT4 lesion or circumferential margin (CRM) and/or distal resection margin (DRM) involvement. Results: In total, 108 (59%) patients received pre-CRT and 75 (41%) underwent surgery first. The pre-CRT patients presented with less-advanced pathological T stage tumors compared with the surgery-first patients (p < 0.001). However, the pathological N stage was not significantly different between the two groups (p = 0.065). The 3-year overall survival (OS), disease-free survival (DFS), and 2-year local recurrence (LR) rate were similar in the pre-CRT and surgery-first patients (88.4 versus 88.7%, p = 0.552; 79.6 versus 83.3%, p = 0.797; 2.8 versus 2.7%, p = 0.960, respectively). Cox regression analysis showed that pN stage and CRM/DRM involvement were independently correlated with an unfavorable DFS. Conclusions: In this study, the omission of pre-CRT in cT3N0M0 patients did not translate into a worse oncological outcome. Postoperative radiotherapy should remain a standard option for patients with CRM/DRM involvement and pathological T4 tumors. A generalized indication for pre-CRT in cT3N0 patients is likely to result in overtreatment.

Fluorescent-guided surgery for sentinel lymph node detection in gastric cancer and carcinoembryonic antigen targeted fluorescent-guided surgery in colorectal and pancreatic cancer

Sentinel lymph node procedures for gastric cancer resections using indocyanine green (ICG) linked to Nanocoll outperformed normal ICG but did not provide information on possible lymph node metastasis. Carcinoembryonic antigen targeted fluorescent imaging using SGM‐101 was successful in both pancreatic and colorectal cancer. A large phase III multicentre trial will soon be initiated in colorectal cancer patients.

Prevalence of low anterior resection syndrome at a regional Australian centre

BACKGROUND

With decreasing indication for abdominoperineal resection and an increase in sphincter preserving surgery, there is a growing population of patients who suffer from low anterior resection syndrome (LARS). The aim of this study is to use the LARS score to determine the prevalence of LARS at a regional centre in Australia and determine the effect of short- and long-course neoadjuvant therapy, anastomotic technique and interval from surgery will also be assessed.

METHODS

Patients who had undergone an anterior resection (high, low or ultralow) at a regional centre over an 11-year period were identified. Eligible patients were contacted to complete a LARS score questionnaire. Results were analysed to determine the rate of major LARS and possible causative roles of certain patient and treatment-related variables.

RESULTS

A total of 64 of 76 patients (84%) returned completed questionnaires. The prevalence of major LARS was 37.5%. Short-course neoadjuvant therapy appeared to be more likely to be associated with major LARS compared to long course (odds ratio (OR) = 2.4, 95% confidence interval (CI) 0.37-15.3, P = 0.35); however, this did not reach statistical significance. Rates of major LARS appear to decrease slowly over time and J-pouch colonic anastomosis appears to be slightly protective against major LARS (OR = 0.7, 95% CI 0.12-3.9, P = 0.70); however, neither results were statistically significant.

CONCLUSION

The rate of major LARS at this regional centre is 37.5%. Larger prospective multicentre studies are required to determine impact of variables such as type of neoadjuvant therapy, anastomotic techniques and progression of LARS over time.

Baseline neutrophil-lymphocyte ratio and platelet-lymphocyte ratio in rectal cancer patients following neoadjuvant chemoradiotherapy

PURPOSE

There is uncertainty over the effect of systemic inflammatory response on oncologic outcomes in patients who underwent neoadjuvant chemoradiotherapy and surgery for rectal cancer. We investigated the association between neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) as markers of systemic inflammation and tumor response and prognosis after treatment.

METHODS

A total of 176 patients who underwent neoadjuvant chemoradiotherapy and curative surgery for rectal cancer were analyzed retrospectively. Pretreatment hematologic parameters and the main clinical factors for patients and tumors were investigated with respect to their relationship with tumor regression and survival.

RESULTS

In the receiver operating characteristic analysis, NLR 2.0 and PLR 133.4 had the highest sensitivity and specificity in predicting tumor response. NLR <2.0 and PLR <133.4 were significantly correlated with good tumor response (odds ratio [OR] 2.490, 95% confidence interval [CI] 1.264-4.904, p = .008; OR 3.009, 95% CI 1.477-6.127, p < .001). Patients with NLR <2.0 had significantly better 5-year disease-free survival rate and overall survival rate compared to patients with NLR ⩾2.0 in multivariate analysis (86.8% vs 70.7%, p = .014; 92.4% vs 71.9%, p = .027).

CONCLUSIONS

Elevated NLR and PLR levels can be considered as predictors of poor pathologic response, and NLR can be considered a prognosticator in patients who underwent neoadjuvant chemoradiotherapy for locally advanced rectal cancer.

Critical and Challenging Issues in the Surgical Management of Low-Lying Rectal Cancer

Despite innovative advancements, the management of distally located rectal cancer (RC) remains a formidable endeavor. The critical location of the tumor predisposes it to a circumferential resection margin that tends to involve the sphincters and surrounding organs, pelvic lymph node metastasis, and anastomotic complications. In this regard, colorectal surgeons should be aware of issues beyond the performance of total mesorectal excision (TME). For decades, abdominoperineal resection had been the standard of care for low-lying RC; however, its association with high rates of tumor recurrence, tumor perforation, and poorer survival has stimulated the development of novel surgical techniques and modifications, such as extralevator abdominoperineal excision. Similarly, difficult dissections and poor visualization, especially in obese patients with low-lying tumors, have led to the development of transanal TME or the "bottom-to-up" approach. Additionally, while neoadjuvant chemoradiotherapy has allowed for the execution of more sphincter-saving procedures without oncologic compromise, functional outcomes remain an issue. Nevertheless, neoadjuvant treatment can lead to significant tumor regression and complete pathological response, permitting the utilization of organ-preserving strategies. At present, an East and West dualism pervades the management of lateral lymph node metastasis, thereby calling for a more global and united approach. Moreover, with the increasing importance of quality of life, a tailored, individualized treatment approach is of utmost importance when taking into account oncologic and anticipated functional outcomes.

Prognostic value of inferior mesenteric artery lymph node metastasis in cancer of the descending colon, sigmoid colon and rectum

AIM

This study aimed to analyse the potential significance of metastasis to the inferior mesenteric artery lymph node (IMA-LN) in patients with malignancy of the left colon and rectum.

METHOD

A retrospective analysis of a cohort of 890 patients collected prospectively who underwent radical resection of a primary tumour of the descending colon, sigmoid colon and rectum in our department from 1 January 2009 to 31 December 2015 was performed. Patients were divided into an IMA-LN metastasis (IMA-LN (+)) group (n = 51) and a non IMA-LN metastasis (IMA-LN (-)) group (n = 839). A total of 801 patients were followed by a designated member of the study staff. Clinical features, pathological characteristics, recurrence patterns and survival rates were compared between the two groups.

RESULTS

In the IMA-LN (+) group, the risk ratio of overall recurrence and tumour related death was 7.786 (95% CI 4.142-14.637) and 7.756 (95% CI 4.142-14.525) respectively. Significant differences were found in overall survival (log-rank: χ²  = 69.06, P < 0.0001) and disease-free survival (log-rank: χ²  = 69.06, P < 0.0001) between the two groups. Furthermore, there were significant differences in overall survival (log-rank: χ²  = 18.47, P < 0.0001) and disease-free survival (log-rank: χ²  = 16.99, P < 0.0001) between the IMA-LN (-) and IMA-LN (+) subgroups of patients with Stage N2 disease. Multivariate survival analysis indicated that IMA-LN (+) was an independent risk factor of poor prognosis. There was no difference in the prognosis between high tie and low tie with IMA-LN dissection.

CONCLUSION

Inferior mesenteric artery lymph node metastasis was an independent predictive factor for high systemic recurrence. Low ligation of the IMA with IMA-LN dissection was not inferior to high ligation.

Prognostic significance of survivin in rectal cancer patients treated with surgery and postoperative concurrent chemo-radiation therapy

Background & Aims

This study is designed to investigate the expression of survivin and p53 in human rectal cancer tissues and analyze associations between expression and clinical outcomes in terms of disease recurrence and survival duration.

Results

During follow-up (median 119.0, range 6.6 to 161.3 months), tumor recurrence was detected in 50 patients (43.1%), and local recurrence developed as a first failure site in 13 patients (11.2%). Positive immunostaining of nuclear and cytoplasmic survivin was observed in about one quarter of patients, and about half of all patients had positive staining for p53. Both survivin and p53 were significant prognostic factors of disease-free survival in the univariate analyses, but only survivin remained a significant prognostic factor in the multivariate analysis.

Methods

We performed a retrospective study with 116 locally advanced rectal cancer patients who underwent total mesorectal excision (TME) followed by postoperative concurrent chemo-radiation therapy (CCRT). Immunohistochemical staining was conducted using antibodies for survivin or p53, and their expression was analyzed using an individual score that combined the percentage of positive cells and staining intensity.

Conclusions

Overexpression of nuclear and cytoplasmic survivin in locally advanced rectal cancer patients was associated with a higher recurrence rate in rectal cancer patients treated with TME followed by postoperative CCRT.

Development of a pelvic exenteration service at a tertiary referral centre

BACKGROUND

Over one-third of primary rectal cancers are locally advanced at diagnosis, and local recurrence of rectal cancer occurs at a rate of 3-10% following primary curative resection. Extended resectional surgery, including pelvic exenteration, is the only proven therapy with curative potential in the treatment of these cancers along with many other pelvic malignancies. A microscopically clear resection margin (R0 resection) is the predominant prognostic factor affecting overall and disease-free survival. The extent and complexity of surgery required to achieve an R0 resection is associated with significant risk of morbidity and mortality. The aim of this paper is to show that pelvic exenterations can be performed with acceptable oncological and safe perioperative results in an appropriately resourced specialist centre.

METHODS

Data was collected retrospectively for 61 consecutive patients treated between June 2012 and February 2017. This included patient demographics, tumour characteristics, operative, clinical and histological data, length of hospital stay, morbidity and mortality data.

RESULTS

A total of 61 patients underwent surgery. Median age was 57 years (range 27-78 years). Median length of stay was 41 days (range 6-288 days). Median operative time was 624 min (range 239-1035 min); 30-day mortality was 3.3% (n = 2). Resection rates were 91.5% - R0, 6.8% - R1 and 1.7% - R2 resections. Histologically, 86.9% - adenocarcinomas, 3.3% - squamous cell carcinomas and 9.8% - represented by leiomyosarcoma, melanoma, myxoid chondrosarcoma, non-neoplastic processes and undifferentiated carcinoma.

CONCLUSION

Our experience confirms that radical resectional pelvic surgery can be safely performed with acceptable results during the establishment phase of a dedicated tertiary service.

A case report of rectal schwannoma treated with laparoscopic proctectomy

RATIONALE

Schwannomas of gastrointestinal tracts are rare and difficult to detect preoperatively because of negative results of endoscopic and imaging examinations. Here, we reported a case of rectal schwannoma, which was diagnosed by immunohistochemical staining after laparoscopic protectomy.

PATIENT CONCERNS

A 61-year-old woman complained of a 1-month history of difficulty in defecation and irregularly abdominal discomfort during her physical checkup in our hospital.

DIAGNOSES

Immunohistochemical staining results after laparoscopic protectomy revealed a strong positive reaction for S-100 protein. Therefore, rectal schwannoma was confirmed.

INTERVENTIONS

Treatment with laparoscopic protectomy was given.

OUTCOMES

Symptoms resolved completely after 12 days of the surgery, and was regular followed-up in outpatient clinic.

LESSONS

Schwannomas are difficult to identify preoperatively, and immunohistochemical staining for S-100 protein is an effective method to diagnose it.

Clinical Values of Preoperative Use of Antibiotics in Transanal Endoscopic Microsurgery

OBJECTIVE

To investigate the clinical values of preoperative use of antibiotics in transanal endoscopic microsurgery (TEM).

METHODS

Thirty patients undergoing TEM surgery to treat rectal neoplasms in our hospital were selected in this study. All patients were randomly divided into two groups: antibiotic group that antibiotics were used before and after surgery, and control group that antibiotics were only used after surgery. Several markers were evaluated before and after surgery in all patients, including erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), changes procalcitonin (PCT), white blood cell count (WBC), neutrophils (NE%) and temperature (T).

RESULTS

The patients in the antibiotic group at the first and third days after surgery showed lower values of ESR, CRP, WBC, NE% and T than the control group (p < 0.05), furthermore, the WBC and NE% were significantly decreased at the third day after surgery compared with the first day after surgery. For the PCT, there was a significant difference in the first day after surgery between the two groups (p < 0.05), but no significant difference was observed between them at the third day after surgery (p > 0.05).

CONCLUSION

The preoperative use of antibiotics in TEM surgery to treat rectal neoplasms may become an effective method to reduce inflammation and prevent infecting after surgery, which will be verified by an amount of studies on large sample.

Overall Survival Associated With Ileostomy Closure in Patients With Rectal Cancer Before and After Adjuvant Therapy

BACKGROUND

A diverting loop ileostomy is commonly constructed to protect a distal anastomosis after proctectomy for rectal cancer. Little data are available on whether closing the ileostomy before or after adjuvant chemotherapy affects survival.

METHODS

We conducted a retrospective review of patients with rectal cancer who underwent a low anterior resection with diverting loop ileostomy followed by adjuvant chemotherapy at Ochsner Medical Center. The primary outcome was the long-term survival in patients who had their loop ileostomies closed before chemotherapy (BC) vs after chemotherapy (AC).

RESULTS

Seventy-two patients were identified (22 in the BC group vs 50 in the AC group). No difference in mean age (BC 59.5 ± 9.8 vs AC 59.2 ± 12.6, P=0.9) or preoperative clinical stage was seen between study groups. The mean interval from ileostomy creation to closure was significantly shorter in the BC group vs AC group (16.9 ± 14.5 weeks vs 33.6 ± 18.1 weeks, P=0.0001). Follow-up data revealed a similar mean duration from surgery to last contact (BC 50.6 ± 23.6 months vs AC 43.5 ± 22.1 months, P=0.23) and similar overall survival (BC 86% vs AC 70%, P=0.23) between groups.

CONCLUSION

Long-term survival was similar in patients who underwent ileostomy closure before and after adjuvant therapy following low anterior resection for rectal cancer. While this study was underpowered, it adds additional insight to an area of surgery lacking significant data. The timing of ileostomy closure should be individualized for each patient.

Complete pathologic response after chemoradiotherapy in a patient with rectal squamous cell carcinoma: a case report

Squamous cell carcinoma (SCC) of the rectum is a rare disease. A 59-year-old man presented with SCC of the middle rectum located 10 cm from the anus. The stage of the tumor was revealed to be T3N+M0. The patient received a combined treatment with cisplatin and fluorouracil in concomitance with external radiation therapy. He then underwent an anterior resection of the rectum. The postoperative histopathological findings classified the tumor as ypT0N0 with cancer-free margins and lymph nodes. Treatment of SCC remains very challenging, and the acquisition of more consistent data is needed.

Adjuvant radiotherapy for the treatment of stage IV rectal cancer after curative resection: A propensity score-matched analysis and meta-analysis

The role of pelvic radiotherapy (RT) in stage IV rectal cancer with total mesorectal excision (TME) has not been defined. We evaluated the impact of RT on oncologic outcomes among patients with stage IV rectal cancer who underwent TME and performed a meta-analysis of published studies.The records of stage IV rectal cancer patients who underwent TME between August 2001 and December 2011 were reviewed. Patients who received pelvic RT (RT group) and those who did not (non-RT group) were matched using a propensity score. Oncologic outcomes were compared between the groups. A systematic literature search and meta-analysis was conducted.One hundred seventy-six patients were matched with propensity score matching, resulting in 39 patients in each group. The local recurrence-free survival (LRFS) of the RT group was significantly higher than that of the non-RT group (2-year LRFS: 100% vs 83.6%, respectively, P = 0.038). The overall survival, disease-free survival, and systemic recurrence were not significantly different between the groups. In the meta-analysis, the RT group had a reduced risk for loco-regional recurrence than the non-RT group (RR: 0.48, 95% confidence interval: 0.29-0.79).Pelvic RT might have benefits for loco-regional control in patients with stage IV rectal cancer who undergo TME.

Evaluating rectal tumor staging with magnetic resonance imaging, computed tomography, and endoluminal ultrasound: A meta-analysis

BACKGROUND

Magnetic resonance imaging (MRI), endoluminal ultrasound (EUS), and computed tomography (CT) are commonly used imaging tools to evaluate rectal tumor staging, but there was no recent meta-analysis to define the present role of the 3 tools. Here, we proposed to systematically compare the accuracy of the 3 imaging tools for rectal tumor staging.

METHODS

We systematically searched diagnostic accuracy studies of MRI, CT, or EUS on rectal cancer staging, written in English or Chinese, published between January 1, 2003 and Dec 31, 2015 from database of PubMed, EMBASE, and Cochrane Library. The reference standards should be pathological findings. Hierarchical regression model was used for producing summary receiver operating characteristic (SROC) curves and calculating diagnostic accuracy data including sensitivity, specificity, and diagnostic odds ratio for the 3 imaging tools. Investigation of sample size, quality items and resolution, and magnetic field strength on heterogeneity was detected by using subgroup analysis and SROC regression.

RESULTS

This analysis included 89 studies. MRI, CT, and EUS yielded similar diagnostic accuracy. Better performance was observed with high-resolution MRI and 3.0-T MRI (P = 0.01 and 0.04, respectively). EUS showed lower diagnostic accuracy after preoperative therapies (P = 0.03).

CONCLUSION

MRI, CT, and EUS have comparable accuracy for rectal tumor staging. High-resolution MRI and 3.0-T MRI can produce better staging results and were recommended. EUS is not suitable for rectal tumor staging for its significantly decreased accuracy.

Is diffusion-weighted MRI superior to FDG-PET or FDG-PET/CT in evaluating and predicting pathological response to preoperative neoadjuvant therapy in patients with rectal cancer?

OBJECTIVE

This meta-analysis aimed to compare the diagnostic accuracy of diffusion-weighted magnetic resonance imaging (DW-MRI) and fluorodeoxyglucose-positron emission tomography (FDG-PET) or FDG-PET/computed tomography (CT) in evaluating and predicting pathological response to preoperative neoadjuvant chemoradiotherapy (NCRT) in patients with rectal cancer.

METHODS

A comprehensive literature research was conducted to identify the relevant studies for this meta-analysis. Combined sensitivity, specificity, positive (PPV) and negative predictive values (NPV) were calculated.

RESULTS

A total of 33 studies including 1564 patients met the inclusion criteria. The pooled sensitivity (81% [95% CI 74-86%] vs 85% [95% CI 75-91%]) and NPV (80% [95% CI 68-89%] vs 91% [95% CI 80-95%]) for FDG-PET or FDG-PET/CT were significantly lower than those for DW-MRI (P < 0.05). No differences were observed in pooled specificity and PPV between DW-MRI and FDG-PET or FDG-PET/CT. Further subgroup analyses showed that DW-MRI had higher sensitivity on adenocarcinomas alone than on those including mucinous-type adenocarcinomas (92% [95% CI 83-99%] vs 76% [95% CI 63-90%], P = 0.00).

CONCLUSIONS

DW-MRI is superior to FDG-PET or FDG-PET/CT in predicting and evaluating pathological responses to preoperative NCRT in patients with rectal cancer. However, its relatively low specificity and PPV limit its application in clinic, making it currently inappropriate to monitor such patients, especially those with mucinous-type rectal adenocarcinomas.

Outcomes in the surgical treatment of low rectal cancer: does neoadjuvant treatment equalize results?

BACKGROUND

The choice of operation for potentially curable cancer of the low rectum (≤6 cm from the anal verge) is usually between ultra low anterior resection (ULAR) or abdominal perineal excision (APE). Numerous studies have suggested improved results with ULAR.

METHODS

This study was a retrospective review of prospectively collected data for a series of patients undergoing surgical treatment for low rectal cancer at three Melbourne hospitals. The patient details and outcomes were compared between those undergoing APE and ULAR.

RESULTS

One hundred and ninety-eight of 213 patients with potentially curable low rectal cancer were treated by either ULAR (n = 82) or APE (n = 116). Overall survival and local recurrence rates were similar, although there was a trend towards improved results for ULAR. Preoperative radiation was received by 89 (76.7%) of APE patients and 44 (53.7%) of ULAR patients (P < 0.0005).

CONCLUSION

In this study there was no statistical difference in the oncological results between APE and ULAR. However, there was a trend to improved result for ULAR in spite of a strikingly higher rate of neoadjuvant radiation in the APE group. It is possible that enhanced use of preoperative radiation has a beneficial role in the management of low rectal cancer treated by conventional APE.

Preoperative chemoradiotherapy with oxaliplatin and tegafur-uracil in locally advanced rectal cancer: pathologic complete response rate and preliminary results of overall and disease-free survival in a single institute in Taiwan

BACKGROUND

We conducted a Phase II study of biweekly oxaliplatin plus oral tegafur-uracil in the preoperative chemoradiotherapy (CRT) for locally advanced resectable mid-to-lower rectal cancer in our hospital, to evaluate the feasibility of this drug combination in tumor pathologic response, acute toxicity, local control, disease-free survival (DFS), overall survival (OS), and time to distant metastasis in an Asian cohort.

METHODS

Twenty patients with histopathologically confirmed rectal cancer (Stage II-III) were enrolled in the study. Radiotherapy of 50 Gy was delivered in 25 fractions of 2 Gy, one fraction/day, five fractions/week, for 5 weeks. Oxaliplatin 55 mg/m(2) was administered intravenously for 60 minutes on Day 1 every 2 weeks, and tegafur-uracil 350 mg/m(2) was given orally everyday during the whole radiotherapy course, including holidays. Surgery was scheduled 6 weeks after completion of the preoperative chemoradiotherapy. The primary endpoint was to determine the pathologic complete response (pCR) rate after this neoadjuvant chemoradiotherapy. The secondary endpoint was to determine the treatment-related toxicity profile, local control, DFS, OS, and time to metastasis.

RESULTS

All patients underwent a complete course of preoperative chemoradiotherapy. There was no local recurrence during the study period. The complete resection rate was 20/20 (100%) and the close resection margin rate was 3/20 (15%). The pCR rate was 8/20 (40%). During chemoradiotherapy, the most frequent toxicity was diarrhea 9/20 (45% of patients, grade 2 in 3/20, 15%). There were no grade 3 or higher hematologic or non-hematologic events or treatment-related deaths. The 3-year OS and DFS rates were 94.1% and 78.6%, respectively.

CONCLUSION

Preoperative chemoradiotherapy with oxaliplatin and tegafur-uracil was well-tolerated and achieved an excellent pCR in our patients with locally advanced mid-to-lower rectal cancer.

[Single port laparoscopic colostomy using the glove technique]

The single port surgery with glove technique is a novel process, suitable to the present day economic and technological moment. Colostomies are surgical interventions suitable to its application. We describe the surgical method and outcome of patients who underwent colostomy by single port glove technique within the years 2011 and 2012, in two hospitals in Asturias, Spain. We carried out six sigmoid colostomies. Four patients had tumoral pathology, another a perineal necrotizing fasciitis, and the sixth, a patient with Crohn's disease and complex perianal fistulas. The average age of the patients, four men and two women, was 54 years (range 42-67 years). The average intervention time was 42 minutes (range 30-65 minutes). There were no complications during the surgery or in the postoperative period. In our facilities material expenditure was reduced to half as regards other conventional single port devices. The glove technique represents the most economic and least invasive approach for the surgical procedure of stomas, in our experience considered a simple, safe and easily reproducible technique.

Contributing factors on lymph node yield after surgery for mid-low rectal cancer

PURPOSE

The purpose of the present study was to evaluate the contributing factors to the lymph node status as well as to define the impact of preoperative concurrent chemoradiotherapy (CCRT) on the number of lymph nodes retrieved in mid-low rectal cancer.

MATERIALS AND METHODS

We retrospectively analyzed 277 patients who underwent curative surgical resection for mid-low rectal cancer between 1998 and 2007. Eighty-two patients received long course preoperative CCRT followed by surgery.

RESULTS

A mean of 13.12±9.28 lymph nodes was retrieved. In a univariate analysis, distance from the anal verge, pT stage, pN stage, lymphovascular invasion, preoperative CCRT had significant influence on the number of lymph nodes retrieved. In a multivariate model, patients in the CCRT group had fewer retrieved lymph nodes than the non-CCRT group (p<0.001). Both univariate and multivariate analyses showed that the ypN0 group had fewer retrieved lymph nodes than the ypN1-2 group (p=0.027) in the CCRT group.

CONCLUSION

Preoperative CCRT was an independent risk factor for failure to harvest an appropriate number of lymph nodes, and node-negative patients who received CCRT had fewer lymph nodes harvested.

Circumferential resection margin involvement in stage III rectal cancer patients treated with curative resection followed by chemoradiotherapy: a surrogate marker for local recurrence?

PURPOSE

Circumferential resection margin (CRM) involvement is a well-known predictor for poor prognosis in rectal cancer. However, the significance is controversial in some studies. Accordingly, this study attempted to examine the prognostic impact of CRM involvement in stage III rectal cancer.

MATERIALS AND METHODS

Between January 1990 and December 2007, a total of 449 patients who underwent curative resection followed by complete adjuvant chemoradiotherapy for stage III rectal cancer located within 12 cm from the anal verge were selected. Patients were divided into a CRM-positive group (n=79, 17.6%) and a CRM-negative group (n=370, 82.4%).

RESULTS

With a median follow-up of 56.6 months, recurrent disease was seen in 53.2 and 43.5% of the CRM-positive and CRM-negative group, respectively. CRM involvement was an independent prognostic factor for 5-year systemic recurrence-free survival (HR: 1.5, CI: 1.0-2.2, p=0.017). However, no significant difference was observed for local recurrence rate between the two groups (13.0 and 13.5%, respectively, p=0.677).

CONCLUSION

In this study, local recurrence rate did not differ according to CRM involvement status in stage III rectal cancer patients, although CRM involvement was shown to be an independent poor prognostic factor. Accordingly, validation of the results of this study by further large prospective randomized trials is warranted.