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Chen N, Li CL, Wang L, Yao YF, Peng YF, Zhan TC, Zhao J, Wu AW. Local excision for middle-low rectal cancer after neoadjuvant chemoradiation: A retrospective study from a single tertiary center. World J Gastrointest Oncol 2024; 16:4614-4624. [PMID: 39678786 PMCID: PMC11577377 DOI: 10.4251/wjgo.v16.i12.4614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Revised: 08/13/2024] [Accepted: 09/05/2024] [Indexed: 11/12/2024] Open
Abstract
BACKGROUND Rectal cancer has become one of the leading malignancies threatening people's health. For locally advanced rectal cancer (LARC), the comprehensive strategy combining neoadjuvant chemoradiotherapy (NCRT), total mesorectal excision (TME), and adjuvant chemotherapy has emerged as a standard treatment regimen, leading to favorable local control and long-term survival. However, in recent years, an increasing attention has been paid on the exploration of organ preservation strategies, aiming to enhance quality of life while maintaining optimal oncological treatment outcomes. Local excision (LE), compared with low anterior resection (LAR) or abdominal-perineal resection (APR) was introduced dating back to 1970's. LE has historically been linked to a heightened risk of recurrence compared to TME, potentially due to occult lymph node metastasis and intraluminal recurrence. Recent evidence has demonstrated that LE might be an alternative approach, instead of LAR or APR, in cases with favorable tumor regression after NCRT with potentially better quality of life. Therefore, a retrospective analysis of clinicopathological data from mid-low LARC patients who underwent LE after NCRT was conducted, aiming to evaluate the treatment's efficacy, safety, and oncologic prognosis. AIM To explore the safety, efficacy, and long-term prognosis of LE in patients with mid-low rectal cancer who had a good response to NCRT. METHODS Patients with LE between 2012 to 2021 were retrospectively collected from the rectal cancer database from Gastro-intestinal Ward III in Peking University Cancer Hospital. The clinicopathological features, postoperative complications, and long-term prognosis of these patients were analyzed. The Kaplan-Meier method was used to create cancer-specific survival curve, and the log-rank test was used to compare the differences regarding outcomes. RESULTS A total of 33 patients were included in this study. The median interval between NCRT and surgery was 25.4 (range: 8.7-164.4) weeks. The median operation time was 57 (20.0-137.0) minutes. The initial clinical T staging (cT): 9 (27.3%) patients were cT2, 19 (57.6%) patients were cT3, and 5 (15.2%) patients were cT4; The initial N staging (cN): 8 patients (24.2%) were cN negative, 25 patients (75.8%) were cN positive; The initial M stage (cM): 2 patients (6.1%) had distant metastasis (ycM1), 31 (93.9%) patients had no distant metastasis (cM0). The pathological results: 18 (54.5%) patients were pathological T0 stage (ypT0), 6 (18.2%) patients were ypT1, 7 (21.2%) patients were ypT2, and 2 (6.1%) patients were ypT3. For 9 cT2 patients, 5 (5/9, 55.6%) had a postoperative pathological result of ypT0. For 19 cT3 patients, 11 (57.9%) patients were ypT0, and 2 (40%) were ypT0 in 5 cT4 patients. The most common complication was chronic perineal pain (71.4%, 5/7), followed by bleeding (43%, 3/7), stenosis (14.3%, 1/7), and fecal incontinence (14.3%, 1/7). The median follow-up time was 42.0 (4.0-93.5) months. For 31 patients with cM0, the 5-year disease-free survival (DFS) rate, 5-year local recurrence-free survival (LRFS) rate, and 5-year overall survival (OS) rate were 88.4%, 96.7%, and 92.9%, respectively. There were significant differences between the ycT groups concerning either DFS (P = 0.042) or OS (P = 0.002) in the Kaplan-Meier analysis. The LRFS curve of ycT ≤ T1 patients was better than that of ycT ≥ T2 patients, and the P value was very close to 0.05 (P = 0.070). The DFS curve of patients with ypT ≤ T1 was better than that of patients with ypT ≥ T2, but the P value was not statistically significant (P = 0.560). There was a significant difference between the ypT groups concerning OS (P = 0.014) in the Kaplan-Meier analysis. The LRFS curve of ypT ≤ T1 patients was better than that of ypT ≥ T2 patients, and the P value was very close to 0.05 (P = 0.070). Two patients with initial cM1 were alive at the last follow-up. CONCLUSION LE for rectal cancer with significant tumor regression after NCRT can obtain better safety, efficiency, and oncological outcome. Minimally invasive or nonsurgical treatment with patient participation in decision-making can be performed for highly selected patients. Further investigation from multiple centers will bring better understanding of potential advantages regarding local resection.
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Affiliation(s)
- Nan Chen
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Gastrointestinal Center, Unit III, Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Chang-Long Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Gastrointestinal Center, Unit III, Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Lin Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Gastrointestinal Center, Unit III, Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Yun-Feng Yao
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Gastrointestinal Center, Unit III, Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Yi-Fan Peng
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Gastrointestinal Center, Unit III, Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Tian-Cheng Zhan
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Gastrointestinal Center, Unit III, Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Jun Zhao
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Gastrointestinal Center, Unit III, Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Ai-Wen Wu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Gastrointestinal Center, Unit III, Peking University Cancer Hospital and Institute, Beijing 100142, China
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Lavingia V, Sardana S, Khanderia M, Bisht N, Patel A, Koyyala VPB, Sheth H, Ramaswamy A, Singh A, deSouza A, Jain SB, Mahajan M, Gohel S, Parikh A, Brown G, Sirohi B. Localized Rectal Cancer: Indian Consensus and Guidelines. Indian J Med Paediatr Oncol 2024; 45:461-480. [DOI: 10.1055/s-0043-1777865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2025] Open
Abstract
AbstractThe rising incidence of colorectal cancer (CRC) in India, particularly the prevalence of rectal cancer over colon cancer (0.7:1), has been a growing concern in recent decades; especially notable is the trend of increasing cases among young CRC patients. Given the diverse treatment approaches for rectal cancer globally and the varying economic capacities of patients in low to middle-income countries (LMICs) like India, it is essential to establish consensus guidelines that are specifically tailored to meet the needs of these patients. To achieve this, a panel comprising 30 eminent rectal cancer experts convened to conduct a comprehensive and impartial evaluation of existing practices and recent advancements in the field. Through meticulous scrutiny of published literature and a consensus-building process that involved voting on pertinent questions, the panel formulated management strategies. These recommendations are the result of a rigorous, evidence-based process and encapsulate the collective wisdom and judgment of leading authorities in the field.
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Affiliation(s)
- Viraj Lavingia
- Department of Medical Oncology, HCG Cancer Center, Ahmedabad, Gujarat, India
| | - Shefali Sardana
- Department of Medical Oncology, Max Institute of Cancer Care, Max Superspeciality Hospital, New Delhi, India
| | - Mansi Khanderia
- Department of Medical Oncology, SPARSH Hospitals, Bangalore, Karnataka, India
| | - Niharika Bisht
- Department of Radiation Oncology, Army Hospital Research and Referral, New Delhi, India
| | - Amol Patel
- Department of Medical Oncology, Indian Naval Hospital Ship Asvini, Mumbai, Maharashtra, India
| | | | - Harsh Sheth
- Department of Advanced Genomic Technologies Division, FRIGE Institute of Human Genetics, Ahmedabad, Gujarat, India
| | - Anant Ramaswamy
- Department of Medical Oncology, Tata Memorial Centre (HBNI), Mumbai, Maharashtra, India
| | - Ashish Singh
- Department of Medical Oncology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ashwin deSouza
- Department of Surgical Oncology, Tata Memorial Centre and Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Sneha Bothra Jain
- Department of Medical Oncology, Mittal Institute of Medical Sciences, Bhilai, Chhattisgarh, India
| | - Mukta Mahajan
- Department of Radiodiagnosis, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - Shruti Gohel
- Department of Medical Oncology, HCG Cancer Centre, Ahmedabad, Gujarat, India
| | - Aparna Parikh
- Department of Medical Oncology, Mass General Cancer Centre, Boston, United States
| | - Gina Brown
- Department of Gastrointestinal Cancer Imaging, Imperial College, London, United Kingdom
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Fadel MG, Ahmed M, Shaw A, Fehervari M, Kontovounisios C, Brown G. Oncological outcomes of local excision versus radical surgery for early rectal cancer in the context of staging and surveillance: A systematic review and meta-analysis. Cancer Treat Rev 2024; 128:102753. [PMID: 38761791 DOI: 10.1016/j.ctrv.2024.102753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 05/09/2024] [Accepted: 05/11/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Local resection (LR) methods for rectal cancer are generally considered in the palliative setting or for patients deemed a high anaesthetic risk. This systematic review and meta-analysis aimed to compare oncological outcomes of LR and radical resection (RR) for early rectal cancer in the context of staging and surveillance assessment. METHODS A literature search of MEDLINE, Embase and Emcare databases was performed for studies that reported data on clinical outcomes for both LR and RR for early rectal cancer from January 1995 to April 2023. Meta-analysis was performed using random-effect models and between-study heterogeneity was assessed. The quality of assessment was assessed using the Newcastle-Ottawa Scale for observational studies and the Cochrane Risk of Bias 2.0 tool for randomised controlled trials. RESULTS Twenty studies with 12,022 patients were included: 6,476 patients had LR and 5,546 patients underwent RR. RR led to an improvement in 5-year overall survival (OR 1.84; 95 % CI 1.54-2.20; p < 0.0001; I2 20 %) and local recurrence (OR 3.06; 95 % CI 2.02-4.64; p < 0.0001; I2 39 %) when compared to LR. However, when staging and surveillance methods were clearly adopted in LR cases, there was an improvement in R0 rates (96.7 % vs 85.6 %), 5-year disease-free survival (93.0 % vs 77.9 %) and overall survival (81.6 % vs 79.0 %) compared to when staging and surveillance was not reported/performed. CONCLUSIONS LR may be appropriate for selected patients without poor prognostic factors in early rectal cancer. This study also highlights that there is currently no single standardised staging or surveillance approach being adopted in the management of early rectal cancer. A more specified and standardised preoperative staging for patient selection as well as clinical and image-based surveillance protocols is needed.
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Affiliation(s)
- Michael G Fadel
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom; Department of Colorectal and General Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Mosab Ahmed
- Department of Colorectal and General Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Annabel Shaw
- Department of Colorectal and General Surgery, Epsom and St. Helier University Hospitals NHS Trust, London, United Kingdom
| | - Matyas Fehervari
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom; Department of Gastrointestinal Surgery, Maidstone and Tunbridge Wells NHS Trust, Kent, United Kingdom
| | - Christos Kontovounisios
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom; Department of Colorectal and General Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom; Department of Colorectal Surgery, Royal Marsden NHS Foundation Trust, London, United Kingdom; 2nd Surgical Department Evaggelismos Athens General Hospital, Athens, Greece.
| | - Gina Brown
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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Meng Y, Ai Q, Hu Y, Han H, Song C, Yuan G, Hou X, Weng W. Clinical development of MRI-based multi-sequence multi-regional radiomics model to predict lymph node metastasis in rectal cancer. Abdom Radiol (NY) 2024; 49:1805-1815. [PMID: 38462557 DOI: 10.1007/s00261-024-04204-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 12/30/2023] [Accepted: 01/12/2024] [Indexed: 03/12/2024]
Abstract
OBJECTIVE We aim to construct a magnetic resonance imaging (MRI)-based multi-sequence multi-regional radiomics model that will improve the preoperative prediction ability of lymph node metastasis (LNM) in T3 rectal cancer. METHODS Multi-sequence MRI data from 190 patients with T3 rectal cancer were retrospectively analyzed, with 94 patients in the LNM group and 96 patients in the non-LNM group. The clinical factors, subjective imaging features, and the radiomic features of tumor and peritumoral mesorectum region of patients were extracted from T2WI and ADC images. Spearman's rank correlation coefficient, Mann-Whitney's U test, and the least absolute shrinkage and selection operator were used for feature selection and dimensionality reduction. Logistic regression was used to construct six models. The predictive performance of each model was evaluated by the receiver operating characteristic curve (ROC). The differences of each model were characterized by area under the curve (AUC) via the DeLong test. RESULTS The AUCs of T2WI, ADC single-sequence radiomics model and multi-sequence radiomics model were 0.73, 0.75, and 0.78, respectively. The multi-sequence multi-regional radiomics model with improved performance was created by combining the radiomics characteristics of the peritumoral mesorectum region with the multi-sequence radiomics model (AUC, 0.87; p < 0.01). The AUC of the clinical model was 0.68, and the MRI-clinical composite evaluation model was obtained by incorporating the clinical data with the multi-sequence multi-regional radiomics features, with an AUC of 0.89. CONCLUSION The MRI-based multi-sequence multi-regional radiomics model significantly improved the prediction ability of LNM for T3 rectal cancer and could be applied to guide surgical decision-making in patients with T3 rectal cancer.
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Affiliation(s)
- Yao Meng
- Department of Radiology, Xinhua Hospital Affiliated to Dalian University, No. 156 Wansui Street, Shahekou District, Dalian, 116021, Liaoning, China
| | - Qi Ai
- Department of Radiology, Xinhua Hospital Affiliated to Dalian University, No. 156 Wansui Street, Shahekou District, Dalian, 116021, Liaoning, China
| | - Yue Hu
- Department of Radiology, Xinhua Hospital Affiliated to Dalian University, No. 156 Wansui Street, Shahekou District, Dalian, 116021, Liaoning, China
| | - Haojie Han
- Department of Radiology, Xinhua Hospital Affiliated to Dalian University, No. 156 Wansui Street, Shahekou District, Dalian, 116021, Liaoning, China
| | - Chunming Song
- Department of Radiology, Xinhua Hospital Affiliated to Dalian University, No. 156 Wansui Street, Shahekou District, Dalian, 116021, Liaoning, China
| | - Guangou Yuan
- Department of Radiology, Xinhua Hospital Affiliated to Dalian University, No. 156 Wansui Street, Shahekou District, Dalian, 116021, Liaoning, China
| | - Xueyan Hou
- Department of Radiology, Xinhua Hospital Affiliated to Dalian University, No. 156 Wansui Street, Shahekou District, Dalian, 116021, Liaoning, China
| | - Wencai Weng
- Department of Radiology, Xinhua Hospital Affiliated to Dalian University, No. 156 Wansui Street, Shahekou District, Dalian, 116021, Liaoning, China.
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Viktil E, Hanekamp BA, Nesbakken A, Løberg EM, Sjo OH, Negård A, Dormagen JB, Schulz A. Early rectal cancer: The diagnostic performance of MRI supplemented with a rectal micro-enema and a modified staging system to identify tumors eligible for local excision. Acta Radiol Open 2024; 13:20584601241241523. [PMID: 38645439 PMCID: PMC11027598 DOI: 10.1177/20584601241241523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2024] [Accepted: 03/08/2024] [Indexed: 04/23/2024] Open
Abstract
Background In staging early rectal cancers (ERC), submucosal tumor depth is one of the most important features determining the possibility of local excision (LE). The micro-enema (Bisacodyl) induces submucosal edema and may hypothetically improve the visualization of tumor depth. Purpose To test the diagnostic performance of MRI to identify ERC suitable for LE when adding a pre-procedural micro-enema and concurrent use of a modified classification system. Material and Methods In this prospective study, we consecutively included 73 patients with newly diagnosed rectal tumors. Two experienced radiologists independently interpreted the MRI examinations, and diagnostic performance was calculated for local tumors eligible for LE (Tis-T1sm2, n = 43) and non-local tumors too advanced for LE (T1sm3-T3b, n = 30). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were registered for each reader. Inter- and intra-reader agreements were assessed by kappa statistics. Lymph node status was derived from the clinical MRI reports. Results Reader1/reader2 achieved sensitivities of 93%/86%, specificities of 90%/83%, PPV of 93%/88%, and NPV of 90%/81%, respectively, for identifying tumors eligible for LE. Rates of overstaging of local tumors were 7% and 14% for the two readers, and kappa values for the inter- and intra-reader agreement were 0.69 and 0.80, respectively. For tumors ≤T2, all metastatic lymph nodes were smaller than 3 mm on histopathology. Conclusion MRI after a rectal micro-enema and concurrent use of a modified staging system achieved good diagnostic performance to identify tumors suitable for LE. The rate of overstaging of local tumors was comparable to results reported in previous endorectal ultrasound (ERUS) studies.
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Affiliation(s)
- Ellen Viktil
- Department of Radiology and Nuclear Medicine, Oslo University Hospital – Ullevål Hospital, Oslo, Norway
- Institution of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Bettina Andrea Hanekamp
- Department of Radiology and Nuclear Medicine, Oslo University Hospital – Ullevål Hospital, Oslo, Norway
- Institution of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Arild Nesbakken
- Institution of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Gastrointestinal Surgery, Oslo University Hospital – Ullevål Hospital, Oslo, Norway
| | - Else Marit Løberg
- Institution of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Pathology, Oslo University Hospital – Ullevål Hospital, Oslo, Norway
| | - Ole Helmer Sjo
- Department of Gastrointestinal Surgery, Oslo University Hospital – Ullevål Hospital, Oslo, Norway
| | - Anne Negård
- Institution of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Radiology, Akershus University Hospital, Lørenskog, Norway
| | - Johann Baptist Dormagen
- Department of Radiology and Nuclear Medicine, Oslo University Hospital – Ullevål Hospital, Oslo, Norway
| | - Anselm Schulz
- Department of Radiology and Nuclear Medicine, Oslo University Hospital – Ullevål Hospital, Oslo, Norway
- Institution of Clinical Medicine, University of Oslo, Oslo, Norway
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Cui Y, Song M, Tie J, Li S, Wang H, Zhang Y, Geng J, Liu Z, Teng H, Sui X, Zhu X, Cai Y, Li Y, Wang W. Clinicopathological factors predict residual lymph node metastasis in locally advanced rectal cancer with ypT0-2 after neoadjuvant chemoradiotherapy. J Cancer Res Clin Oncol 2024; 150:176. [PMID: 38575793 PMCID: PMC10995092 DOI: 10.1007/s00432-024-05662-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 02/21/2024] [Indexed: 04/06/2024]
Abstract
PURPOSE Residual lymph node metastases (RLNM) remained a great concern in the implementation of organ-preserving strategies and led to poor prognosis in locally advanced rectal cancer (LARC). In this study, we aimed to identify the clinicopathological factors correlated with RLNM in LARC patients with ypT0-2 after neoadjuvant chemoradiotherapy (NCRT). METHODS We retrospectively analyzed 417 patients histologically diagnosed middle-low LARC after NCRT and total mesorectal excision (TME), whose pathological staging was ypT0-2. All patients received pelvic magnetic resonance imaging (MRI) before NCRT. The radiation doses were 50-50.6 Gy for the planning gross tumor volume and 41.8-45 Gy for the planning target volume, respectively. A nomogram for predicting RLNM was constructed using a binary logistic regression. Nomogram performance was assessed by receiver operating characteristic (ROC) curve, calibration curve, decision curve analysis (DCA) and clinical impact curve (CIC). RESULTS After surgery, 191 patients (45.8%) were ypT0, 43 patients (10.3%) were ypT1 and 183 patients (43.9%) were ypT2, and a total of 49 patients (11.8%) were found the presence of RLNM. Multivariable analyses identified MRI-defined mesorectal fascia (MRF)-positive, high-grade histopathology at biopsy, advanced ypT-category, and the presence of perineural invasion (PNI) as the predictive factors. The nomogram, incorporating all these predictors, showed good discrimination and calibration efficacy, with the areas under the ROC curve of 0.690 (95% CI: 0.610-0.771). Both DCA and CIC demonstrated that this nomogram has good clinical usefulness. CONCLUSION The nomogram model can predict RLNM in patients with ypT0-2 tumors. It can help select suitable patients for performing organ-preserving strategies after NCRT.
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Affiliation(s)
- Yujun Cui
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Maxiaowei Song
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Jian Tie
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Shuai Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Hongzhi Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Yangzi Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Jianhao Geng
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Zhiyan Liu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Huajing Teng
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Xin Sui
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Xianggao Zhu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Yong Cai
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Yongheng Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China.
| | - Weihu Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China.
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Shilo Yaacobi D, Berger Y, Shaltiel T, Bekhor EY, Khalifa M, Issa N. Excision of malignant and pre-malignant rectal lesions by transanal endoscopic microsurgery in patients under 50 years of age. World J Gastrointest Surg 2023; 15:1892-1900. [PMID: 37901725 PMCID: PMC10600772 DOI: 10.4240/wjgs.v15.i9.1892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/24/2023] [Accepted: 07/29/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND The most common technique for treating benign and early malignant rectal lesions is transanal endoscopic microsurgery (TEM). Local excision is an acceptable technique for high-risk and elderly patients, but there are hardly any data regarding young patients. AIM To describe TEM outcomes in patients under 50 years of age. METHODS We collected demographic, clinical, and pathological data from all patients under the age of 50 years who underwent the TEM procedure at Hasharon Rabin Medical Center from January 2005 to December 2018. RESULTS During the study period, a total of 26 patients under the age of 50 years underwent TEM procedures. Their mean age was 43.3 years. Eleven (42.0%) were male. The mean operative time was 67 min, and the mean tumor size was 2.39 cm, with a mean anal verge distance of 8.50 cm. No major intraoperative or postoperative complications were recorded. The median length of stay was 2 d. Seven (26.9%) lesions were adenomas with low-grade dysplasia, four (15.4%) were high-grade dysplasia adenomas, two were T1 carcinomas (7.8%), and three were T2 carcinomas (11.5%). No residual disease was found following endoscopic polypectomy in two patients (7.8%), but four (15.4%) had other pathologies. Surgical margins were negative in all cases. Local recurrence was detected in one patient 33 mo following surgery. CONCLUSION Among young adult patients, TEM for benign rectal lesions has excellent outcomes. It may also offer a balance between the efficacy of complete oncologic resection and postoperative quality of life in the treatment of rectal cancer. In some cases, it may be considered an alternative to radical surgery.
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Affiliation(s)
- Dafna Shilo Yaacobi
- Department of Plastic Surgery & Burns, Rabin Medical Center, Petah Tikva 4941492, Israel
| | - Yael Berger
- Department of Surgery, Rabin Medical Center-Hasharon Hospital, Petah Tikva 4941492, Israel
| | - Tali Shaltiel
- Department of Surgery, Rabin Medical Center-Hasharon Hospital, Petah Tikva 4941492, Israel
| | - Eliahu Y Bekhor
- Department of Surgery, Rabin Medical Center-Hasharon Hospital, Petah Tikva 4941492, Israel
| | - Muhammad Khalifa
- Department of Surgery, Rabin Medical Center-Hasharon Hospital, Petah Tikva 4941492, Israel
| | - Nidal Issa
- Department of Surgery, Rabin Medical Center-Hasharon Hospital, Petah Tikva 4941492, Israel
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Freund MR, Horesh N, Emile SH, Garoufalia Z, Gefen R, Wexner SD. Predictors and outcomes of positive surgical margins after local excision of clinical T1 rectal cancer: A National Cancer Database analysis. Surgery 2023; 173:1359-1366. [PMID: 36959073 DOI: 10.1016/j.surg.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 02/09/2023] [Accepted: 02/11/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Transanal local excision and the use of specialized platforms has become increasingly popular for early-stage rectal cancer. Predictors and outcomes of positive resection margins following transanal local excision for early-stage rectal cancer have yet to be explored. METHODS This was a retrospective analysis of the National Cancer Database of all patients with clinical nonmetastatic node negative T1 rectal adenocarcinoma who underwent transanal local excision from 2004 to 2017. Patients with positive surgical margins were compared to those with negative resection margins to determine factors associated with predictors and outcomes of positive surgical margins after transanal local excision. The main outcome measure was overall survival. RESULTS Of 318,548 patients with rectal adenocarcinoma in the National Cancer Database, 9,078 (2.8%) met the inclusion criteria. The positive surgical margins rate was 7.4%. Predictors of positive surgical margins were older age (odds ratio, 1.03; P < .001), higher Charlson comorbidity index (odds ratio, 1.24; P = .004), poorly differentiated carcinomas (odds ratio, 1.89; P < .001), mucinous (odds ratio, 2.36; P = .003) and signet-ring cell carcinomas (odds ratio, 4.7; P = .048). Independent predictors of reduced survival were older age (hazard ratio, 1.062; P < .001), male sex (hazard ratio, 1.214; P = .011), Charlson comorbidity index 3 (hazard ratio, 1.94; P < .001), pathologic T2 (hazard ratio, 1.27; P = .036) and T3 stages (hazard ratio, 1.77; P = .006), poorly differentiated carcinomas (hazard ratio, 1.47; P = .008), and positive surgical margins (hazard ratio, 1.374; P = .018). The positive surgical margins group's median overall survival was significantly shorter (88 vs 159.3 months, P < .001). CONCLUSION Positive surgical margins after transanal local excision for early-stage node-negative rectal cancer adversely affects prognosis. Older male patients with higher Charlson comorbidity index scores and poorly differentiated mucinous or signet cell histology tumors are at risk for positive surgical margins. Patient selection according to these suggested criteria may help avoid positive surgical margins.
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Affiliation(s)
- Michael R Freund
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Department of General Surgery, Shaare Zedek Medical Center, the Hebrew University Faculty of Medicine, Jerusalem, Israel. https://twitter.com/mikifreund
| | - Nir Horesh
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Department of Surgery and Transplantations, Sheba Medical Center, Ramat Gan, Israel. https://twitter.com/Nirhoresh1
| | - Sameh Hany Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Colorectal Surgery Unit, Mansoura University, Faculty of Medicine, Egypt. https://twitter.com/dr_samehhany81
| | - Zoe Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL. https://twitter.com/ZGaroufalia
| | - Rachel Gefen
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Department of General Surgery, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Israel. https://twitter.com/RachellGefen
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL.
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9
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Korngold EK, Moreno C, Kim DH, Fowler KJ, Cash BD, Chang KJ, Gage KL, Gajjar AH, Garcia EM, Kambadakone AR, Liu PS, Macomber M, Marin D, Pietryga JA, Santillan CS, Weinstein S, Zreloff J, Carucci LR. ACR Appropriateness Criteria® Staging of Colorectal Cancer: 2021 Update. J Am Coll Radiol 2022; 19:S208-S222. [PMID: 35550803 DOI: 10.1016/j.jacr.2022.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 02/22/2022] [Indexed: 12/19/2022]
Abstract
Preoperative imaging of rectal carcinoma involves accurate assessment of the primary tumor as well as distant metastatic disease. Preoperative imaging of nonrectal colon cancer is most beneficial in identifying distant metastases, regardless of primary T or N stage. Surgical treatment remains the definitive treatment for colon cancer, while organ-sparing approach may be considered in some rectal cancer patients based on imaging obtained before and after neoadjuvant treatment. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Elena K Korngold
- Oregon Health and Science University, Portland, Oregon; Section Chief, Body Imaging; Chair, P&T Committee; Modality Chief, CT.
| | - Courtney Moreno
- Emory University, Atlanta, Georgia; Chair America College of Radiology CT Colonography Registry Committee
| | - David H Kim
- Panel Chair, University of Wisconsin Hospital & Clinics, Madison, Wisconsin; Vice Chair of Education (University of Wisconsin Dept of Radiology)
| | - Kathryn J Fowler
- Panel Vice-Chair, University of California San Diego, San Diego, California; ACR LI-RADS Working Group Chair
| | - Brooks D Cash
- University of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas; American Gastroenterological Association; Chief of GI, UTHealth
| | - Kevin J Chang
- Boston University Medical Center, Boston, Massachusetts; Director of MRI, Associate Chief of Abdominal Imaging; ACR Chair of Committee on C-RADS
| | - Kenneth L Gage
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Aakash H Gajjar
- PRiSMA Proctology Surgical Medicine & Associates, Houston, Texas; American College of Surgeons
| | - Evelyn M Garcia
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Avinash R Kambadakone
- Massachusetts General Hospital, Boston, Massachusetts; Division Chief, Abdominal Imaging, Massachusetts General Hospital; Medical Director, Martha's Vineyard Hospital Imaging
| | - Peter S Liu
- Cleveland Clinic, Cleveland, Ohio; Section Head, Abdominal Imaging, Cleveland Clinic, Cleveland OH
| | | | - Daniele Marin
- Duke University Medical Center, Durham, North Carolina
| | | | - Cynthia S Santillan
- University of California San Diego, San Diego, California; Vice Chair of Clinical Operations for Department of Radiology
| | - Stefanie Weinstein
- University of California San Francisco, San Francisco, California; Associate Chief of Radiology, San Francisco VA Health Systems
| | | | - Laura R Carucci
- Specialty Chair, Virginia Commonwealth University Medical Center, Richmond, Virginia; Director MR and CT at VCUHS; Section Chief Abdominal Imaging VCUHS
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10
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Perez RO, Julião GPS, Vailati BB. Transanal Local Excision of Rectal Cancer after Neoadjuvant Chemoradiation: Is There a Place for It or Should Be Avoided at All Costs? Clin Colon Rectal Surg 2022; 35:122-128. [PMID: 35237107 PMCID: PMC8885162 DOI: 10.1055/s-0041-1742112] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Tumor response to neoadjuvant chemoradiation (nCRT) with tumor downsizing and downstaging has significantly impacted the number of patients considered to be appropriate candidates for transanal local excision (TLE). Some patients may harbor small residual lesions, restricted to the bowel wall. These patients, who exhibit major response ("near-complete") by digital rectal examination, endoscopic assessment, and radiological assessment may be considered for this approach. Although TLE is associated with minimal postoperative morbidity, a few clinical consequences and oncological outcomes must be evaluated in advance and with caution. In the setting of nCRT, a higher risk for clinically relevant wound dehiscences leading to a considerable risk for readmission for pain management has been observed. Worse anorectal function (still better than after total mesorectal excision [TME]), worsening in the quality of TME specimen, and higher rates of abdominal resections (in cases requiring completion TME) have been reported. The exuberant scar observed in the area of TLE also represents a challenging finding during follow-up of these patients. Local excision should be probably restricted for patients with primary tumors located at or below the level of the anorectal ring (magnetic resonance defined). These patients are otherwise candidates for abdominal perineal resections or ultra-low anterior resections with coloanal anastomosis frequently requiring definitive stomas or considerably poor anorectal function.
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Affiliation(s)
- Rodrigo Oliva Perez
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil,Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil,Address for correspondence Rodrigo Oliva Perez, MD, PhD Department of Surgical Oncology, Hospital Beneficencia PortuguesaSão Paulo 01323-001Brazil
| | - Guilherme Pagin São Julião
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil,Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Bruna Borba Vailati
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil,Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
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11
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Zhou Y, Yang R, Wang Y, Zhou M, Zhou X, Xing J, Wang X, Zhang C. Histogram analysis of diffusion-weighted magnetic resonance imaging as a biomarker to predict LNM in T3 stage rectal carcinoma. BMC Med Imaging 2021; 21:176. [PMID: 34809615 PMCID: PMC8609786 DOI: 10.1186/s12880-021-00706-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 11/08/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Preoperative identification of rectal cancer lymph node status is crucial for patient prognosis and treatment decisions. Rectal magnetic resonance imaging (MRI) plays an essential role in the preoperative staging of rectal cancer, but its ability to predict lymph node metastasis (LNM) is insufficient. This study explored the value of histogram features of primary lesions on multi-parametric MRI for predicting LNM of stage T3 rectal carcinoma. METHODS We retrospectively analyzed 175 patients with stage T3 rectal cancer who underwent preoperative MRI, including diffusion-weighted imaging (DWI) before surgery. 62 patients were included in the LNM group, and 113 patients were included in the non-LNM group. Texture features were calculated from histograms derived from T2 weighted imaging (T2WI), DWI, ADC, and T2 maps. Stepwise logistic regression analysis was used to screen independent predictors of LNM from clinical features, imaging features, and histogram features. Predictive performance was evaluated by receiver operating characteristic (ROC) curve analysis. Finally, a nomogram was established for predicting the risk of LNM. RESULTS The clinical, imaging and histogram features were analyzed by stepwise logistic regression. Preoperative carbohydrate antigen 199 level (p = 0.009), MRN stage (p < 0.001), T2WIKurtosis (p = 0.010), DWIMode (p = 0.038), DWICV (p = 0.038), and T2-mapP5 (p = 0.007) were independent predictors of LNM. These factors were combined to form the best predictive model. The model reached an area under the ROC curve (AUC) of 0.860, with a sensitivity of 72.8% and a specificity of 85.5%. CONCLUSION The histogram features on multi-parametric MRI of the primary tumor in rectal cancer were related to LN status, which is helpful for improving the ability to predict LNM of stage T3 rectal cancer.
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Affiliation(s)
- Yang Zhou
- Department of Radiology, Harbin Medical University Cancer Hospital, No. 150, Haping Road, Nangang District, Harbin, 150001, Heilongjiang Province, China
| | - Rui Yang
- Department of Gastrointestinal Medical Oncology, Harbin Medical University Cancer Hospital, No.150 Haping Road, Nangang District, Harbin, 150081, Heilongjiang Province, China
| | - Yuan Wang
- Department of Gastrointestinal Medical Oncology, Harbin Medical University Cancer Hospital, No.150 Haping Road, Nangang District, Harbin, 150081, Heilongjiang Province, China
| | - Meng Zhou
- Department of Gastrointestinal Medical Oncology, Harbin Medical University Cancer Hospital, No.150 Haping Road, Nangang District, Harbin, 150081, Heilongjiang Province, China
| | - Xueyan Zhou
- School of Technology, Harbin University, Harbin, Heilongjiang Province, China
| | - JiQing Xing
- Department of Physical Education, Harbin Engineering University, Harbin, 150001, Heilongjiang Province, China
| | - Xinxin Wang
- Department of Radiology, Harbin Medical University Cancer Hospital, No. 150, Haping Road, Nangang District, Harbin, 150001, Heilongjiang Province, China.
| | - Chunhui Zhang
- Department of Gastrointestinal Medical Oncology, Harbin Medical University Cancer Hospital, No.150 Haping Road, Nangang District, Harbin, 150081, Heilongjiang Province, China.
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12
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Abstract
A 59-year-old man underwent screening colonoscopy that identified a 2-cm rectal polyp in the posterior midline, 7 cm from the anal verge. Biopsy revealed a tubular adenoma with high-grade dysplasia. The patient underwent a robotic-assisted transanal minimally invasive surgery with full-thickness excision (Fig. 1). Final pathology confirmed a well-differentiated adenocarcinoma extending into the submucosa (sm2). There was no lymphovascular or perineural invasion, and the radial margin was 5 mm.
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13
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Oh SY, Park IJ, Kim YIL, Lee JL, Kim CW, Yoon YS, Lim SB, Yu CS, Kim JC. Comparison between Local Excision and Radical Resection for the Treatment of Rectal Cancer in ypT0-1 Patients: An Analysis of the Clinicopathological Factors and Survival Rates. Cancers (Basel) 2021; 13:4823. [PMID: 34638307 PMCID: PMC8507625 DOI: 10.3390/cancers13194823] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 09/23/2021] [Accepted: 09/23/2021] [Indexed: 02/06/2023] Open
Abstract
Tumors with good response to preoperative chemoradiotherapy have a favorable prognosis, and these findings raise interest in rectum-sparing strategies. This study aimed to compare the oncologic outcome between local excision and radical resection in ypT0-1 patients and to analyze prognostic factors. Patients with primary rectal cancer diagnosed with ypT0-1 after PCRT followed by either radical resection (RR) or local excision (LE) between 2005 and 2014 were included in this study (LE = 78, RR = 442). Clinicopathologic features, recurrence-free survival (RFS), and OS were analyzed. There was no statistically significant difference in the RFS and OS between the LE and RR groups. Clinical T stage (cT3-4) before PCRT was related to RFS and in the LE group (p = 0.022). Lymph node metastasis (HR: 4.884, 95% confidence interval: 2.451-9.732, p < 0.001) in the final pathology was the only factor associated with RFS, showing a statistically significant difference in the RR group. Lymph node metastasis and age were associated with OS in the RR group. This study confirms the oncologic feasibility of LE in ypT0-1 rectal cancer after PCRT. Additionally, careful patient selection with higher accuracy modalities should be updated to improve treatment outcomes of LE.
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Affiliation(s)
| | - In Ja Park
- Asan Medical Center, Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Seoul 05505, Korea; (S.Y.O.); (Y.I.K.); (J.-L.L.); (C.W.K.); (Y.S.Y.); (S.-B.L.); (C.S.Y.); (J.C.K.)
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14
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Rectal MRI: the importance of high resolution T2 technique. Abdom Radiol (NY) 2021; 46:4090-4095. [PMID: 33881553 DOI: 10.1007/s00261-021-03047-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/03/2021] [Accepted: 03/09/2021] [Indexed: 01/25/2023]
Abstract
The cornerstone of the MRI rectal examination is the high resolution (HR) T2 sequence. There is varied definition of this term in national guidelines with a resultant wide variation in the spatial resolution of sequences termed 'high resolution'. This article comments on the importance of the original three dimensional HR T2 definition of 0.6 × 0.6 in plane resolution × 3 mm slice thickness with 4 NEX and demonstrates the effect reduced spatial resolution can have on image appearance and interpretation.
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15
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MRI Staging in an Evolving Management Paradigm for Rectal Cancer, From the AJR Special Series on Cancer Staging. AJR Am J Roentgenol 2021; 217:1282-1293. [PMID: 33949877 DOI: 10.2214/ajr.21.25556] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The treatment of rectal cancer centers around the distinct but related goals of management of distant metastases and management of local disease. Optimal local management requires attention to the primary tumor and its anatomic relationship to surrounding pelvic structures, with the goal of minimizing local recurrence (LR). High-resolution MRI is ideally suited for this purpose; application of MRI-based criteria in conjunction with optimized surgical and pathologic techniques have successfully reduced LR rates. This success has led to a shift away from using the TNM-based National Comprehensive Cancer Network (NCCN) guidelines as the sole determinant of whether a patient receives neoadjuvant chemoradiation. The new model uses a hybrid approach for assigning risk categories that combines elements of the TNM staging system with MRI-based anatomic features. These risk categories incorporate tumor proximity to the circumferential resection margin, T category, distance to the anal verge and presence of extramural venous invasion, to classify rectal tumors as low, intermediate, or high-risk. This approach has been validated by accumulated data from numerous multi-institutional studies. This review illustrates key anatomic concepts, depicts common interpretive errors and pitfalls, and discusses ongoing limitations; these insights should guide radiologists in optimal rectal MRI interpretation.
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16
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Surveillance Intensity Comparison by Risk for T1NX Locally Excised Rectal Adenocarcinoma: a Cost-Effective Analysis. J Gastrointest Surg 2020; 24:198-208. [PMID: 31724115 DOI: 10.1007/s11605-019-04369-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 08/12/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Controversy exists regarding the optimal surveillance strategy following local excision of T1NX rectal adenocarcinoma. This study aims to determine the cost-effectiveness of surveillance strategies for locally excised T1NX rectal adenocarcinoma based on histopathologic and local staging risk factors. METHODS A Markov model with 10-year follow-up was developed for cost-effectiveness analysis of high-, medium-, and low-intensity surveillance strategies after local excision of T1NX rectal adenocarcinoma. Literature review and expert consensus were utilized to populate state/transition probabilities and rewards. Based on this data, 87% of T1NX patients undergoing local excision were low risk. Healthcare utilization costs were based on Centers for Medicare and Medicaid Services data. The primary outcomes were costs in 2018 US dollars and effectiveness in life-years presented as net monetary benefit and incremental cost-effectiveness ratios. One-way sensitivity and probabilistic sensitivity analyses were performed. RESULTS Net monetary benefit for low-, medium-, and high-intensity surveillance strategies ($393,117.00, $397,978.80, and $397,290.00) shows medium-intensity surveillance to be optimal. One-way sensitivity analysis shows medium-intensity surveillance to be optimal when the cohort is 73-94% low risk. High-intensity surveillance is preferred when less than 73% of the cohort is low risk. Low-intensity surveillance is preferred when greater than 94% is low risk. Probabilistic sensitivity analysis of the base-case shows medium-intensity surveillance is the optimal strategy for 51.5% of the iterations performed. CONCLUSIONS Medium-intensity surveillance is the most cost-effective surveillance strategy for locally excised T1NX rectal adenocarcinoma in a clinically representative population model.
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17
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Russo S, Anker CJ, Abdel-Wahab M, Azad N, Das P, Dragovic J, Goodman KA, Herman JM, Jones W, Kennedy T, Konski A, Kumar R, Lee P, Patel NM, Sharma N, Small W, Suh WW, Jabbour SK. Executive Summary of the American Radium Society Appropriate Use Criteria for Local Excision in Rectal Cancer. Int J Radiat Oncol Biol Phys 2019; 105:977-993. [PMID: 31445109 PMCID: PMC11101014 DOI: 10.1016/j.ijrobp.2019.08.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 08/02/2019] [Accepted: 08/11/2019] [Indexed: 02/07/2023]
Abstract
The goal of treatment for early stage rectal cancer is to optimize oncologic outcome while minimizing effect of treatment on quality of life. The standard of care treatment for most early rectal cancers is radical surgery alone. Given the morbidity associated with radical surgery, local excision for early rectal cancers has been explored as an alternative approach associated with lower rates of morbidity. The American Radium Society Appropriate Use Criteria presented in this manuscript are evidence-based guidelines for the use of local excision in early stage rectal cancer that include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) used by a multidisciplinary expert panel to rate the appropriateness of imaging and treatment procedures. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. These guidelines are intended for the use of all practitioners and patients who desire information regarding the use of local excision in rectal cancer.
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Affiliation(s)
- Suzanne Russo
- Case Western Reserve University School of Medicine and University Hospitals, Cleveland, Ohio.
| | | | - May Abdel-Wahab
- International Atomic Energy Agency, Division of Human Health, New York, New York
| | - Nilofer Azad
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Prajnan Das
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | | | - Joseph M Herman
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - William Jones
- UT Health Cancer Center, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | | | - Andre Konski
- University of Pennsylvania Perelman School of Medicine, Chester County Hospital, West Chester, Pennsylvania
| | - Rachit Kumar
- Banner MD Anderson Cancer Center, Gilbert, Arizona
| | - Percy Lee
- University of California, Los Angeles, Jonsson Comprehensive Cancer Center, Los Angeles, California
| | | | - Navesh Sharma
- Milton S. Hershey Cancer Institute, Hershey, Pennsylvania
| | | | - W Warren Suh
- Ridley-Tree Cancer Center Santa Barbara @ Sansum Clinic, Santa Barbara California
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18
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Stijns RCH, de Graaf EJR, Punt CJA, Nagtegaal ID, Nuyttens JJME, van Meerten E, Tanis PJ, de Hingh IHJT, van der Schelling GP, Acherman Y, Leijtens JWA, Bremers AJA, Beets GL, Hoff C, Verhoef C, Marijnen CAM, de Wilt JHW. Long-term Oncological and Functional Outcomes of Chemoradiotherapy Followed by Organ-Sparing Transanal Endoscopic Microsurgery for Distal Rectal Cancer: The CARTS Study. JAMA Surg 2019; 154:47-54. [PMID: 30304338 DOI: 10.1001/jamasurg.2018.3752] [Citation(s) in RCA: 168] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance Treatment of rectal cancer is shifting toward organ preservation aiming to reduce surgery-related morbidity. Short-term outcomes of organ-preserving strategies are promising, but long-term outcomes are scarce in the literature. Objective To explore long-term oncological outcomes and health-related quality of life (HRQL) in patients with cT1-3N0M0 rectal cancer who underwent neoadjuvant chemoradiotherapy (CRT) followed by transanal endoscopic microsurgery (TEM). Design, Setting, and Participants In this multicenter phase II feasibility study, patients with cT1-3N0M0 rectal cancer admitted to referral centers for rectal cancer throughout the Netherlands between February 2011 and September 2012 were prospectively included. These patients were to be treated with neoadjuvant CRT followed by TEM in case of good response. An intensive follow-up scheme was used to detect local recurrences and/or distant metastases. Data from validated HRQL questionnaires and low anterior resection syndrome questionnaires were collected. Data were analyzed from February 2011 to April 2017. Main Outcomes and Measures The primary study outcome of the study was the number of ypT0-1 specimens by performing TEM. Secondary outcome parameters were locoregional recurrences and HRQL. Results Of the 55 included patients, 30 (55%) were male, and the mean (SD) age was 64 (39-82) years. Patients were followed up for a median (interquartile range) period of 53 (39-57) months. Two patients (4%) died during CRT, 1 (2%) stopped CRT, and 1 (2%) was lost to follow-up. Following CRT, 47 patients (85%) underwent TEM, of whom 35 (74%) were successfully treated with local excision alone. Total mesorectal excision was performed in 16 patients (4 with inadequate responses, 8 with completion after TEM, and 4 with salvage for local recurrence). The actuarial 5-year local recurrence rate was 7.7%, with 5-year disease-free and overall survival rates of 81.6% and 82.8%, respectively. Health-related quality of life during follow-up was equal to baseline, with improved emotional well-being in patients treated with local excision (mean score at baseline, 72.0; 95% CI, 67.1-80.1; mean score at follow-up, 86.9; 95% CI, 79.2-94.7; P = .001). Major, minor, and no low anterior resection syndrome was experienced in 50%, 28%, and 22%, respectively, of patients with successful organ preservation. Conclusions and Relevance In early-stage rectal cancer (cT1-3N0M0), CRT enables organ preservation with additional TEM surgery in approximately two-thirds of patients with good long-term oncological outcome and HRQL. This multimodality treatment triggers a certain degree of bowel dysfunction, and one-third of patients still undergo radical surgery and are overtreated by CRT.
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Affiliation(s)
- Rutger C H Stijns
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Eelco J R de Graaf
- Department of Surgery, IJsselland Hospital, Capelle aan de Ijssel, the Netherlands
| | - Cornelis J A Punt
- Department of Medical Oncology, Academic Medical Centre, Amsterdam, the Netherlands
| | - Iris D Nagtegaal
- Department of Pathology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Joost J M E Nuyttens
- Department of Radiation Oncology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Esther van Meerten
- Department of Oncology, Erasmus Medical Centre Cancer Institute, Rotterdam, the Netherlands
| | - Pieter J Tanis
- Department of Surgery, Academic Medical Centre, Amsterdam, the Netherlands
| | | | | | - Yair Acherman
- Department of Surgery, Medical Centre Slotervaart, Amsterdam, the Netherlands
| | | | - Andreas J A Bremers
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Geerard L Beets
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Christiaan Hoff
- Department of Surgery, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
| | - Cornelis Verhoef
- Department of Surgical Oncology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Corrie A M Marijnen
- Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
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Gamboa AC, Liu Y, Lee RM, Zaidi MY, Staley CA, Russell MC, Cardona K, Sullivan PS, Maithel SK. A novel preoperative risk score to predict lymph node positivity for rectal neuroendocrine tumors: An NCDB analysis to guide operative technique. J Surg Oncol 2019; 120:932-939. [PMID: 31448820 PMCID: PMC6791747 DOI: 10.1002/jso.25679] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 08/10/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND/OBJECTIVE Staging and type of resection for rectal neuroendocrine tumors (R-NETS) relies on preoperative identification of lymph node (LN) involvement. Study objective was to develop a Preoperative Rectal Stratification Score (PReSS) for LN-positivity and to assess the association of PReSS with overall survival (OS). METHODS All patients in the National Cancer Database (2004-2014) with non-metastatic/nonfunctional R-NETS were included. Tumor size was divided into three categories (<1, 1-2, and ≥2 cm). RESULTS Among 383 patients, median age was 57 years, 52% were male (n = 200), median tumor size was 1.4 cm, 43% had positive LNs (n = 163). On univariate analysis, age > 60, poorly differentiated grade, depth of invasion past submucosa, and size >1 cm were associated with LN positivity. On multivariable analysis, depth of invasion past submucosa, and increasing tumor size >1 cm remained associated with LN positivity. As these can be determined preoperatively, incidence of LN positivity was determined for each combination of tumor size and depth of invasion. Each variable was assigned a score to create a PReSS of four groups (0-3) associated with an increasing rate of LN-positivity (PReSS group 0: 11%, 1: 38%, 2: 50%, 3: 78%, P < .01). PReSS correlated with 10-year OS (PReSS 0: 90%; 1: 81%; 2: 59%; 3: 41%). CONCLUSION For R-NETS, depth of invasion and tumor size predict LN positivity and both can be obtained preoperatively. PReSS incorporates both variables and stratifies tumors into four risk groups of progressively increasing LN positivity and should be used to guide surgical approach.
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Affiliation(s)
- Adriana C. Gamboa
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Yuan Liu
- Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Rachel M. Lee
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Mohammad Y. Zaidi
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Charles A. Staley
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Maria C. Russell
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Kenneth Cardona
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Patrick S. Sullivan
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Shishir K. Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
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20
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Enker WE. Reprint of: The natural history of rectal cancer 1908-2008: the evolving treatment of rectal cancer into the twenty-first century. SEMINARS IN COLON AND RECTAL SURGERY 2018. [DOI: 10.1053/j.scrs.2018.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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21
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Fowler KJ, Kaur H, Cash BD, Feig BW, Gage KL, Garcia EM, Hara AK, Herman JM, Kim DH, Lambert DL, Levy AD, Peterson CM, Scheirey CD, Small W, Smith MP, Lalani T, Carucci LR. ACR Appropriateness Criteria ® Pretreatment Staging of Colorectal Cancer. J Am Coll Radiol 2018; 14:S234-S244. [PMID: 28473079 DOI: 10.1016/j.jacr.2017.02.012] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 01/27/2017] [Accepted: 02/02/2017] [Indexed: 12/17/2022]
Abstract
Colorectal cancers are common tumors in the United States and appropriate imaging is essential to direct appropriate care. Staging and treatment differs between tumors arising in the colon versus the rectum. Local staging for colon cancer is less integral to directing therapy given radical resection is often standard. Surgical options for rectal carcinoma are more varied and rely on accurate assessment of the sphincter, circumferential resection margins, and peritoneal reflection. These important anatomic landmarks are best appreciated on high-resolution imaging with transrectal ultrasound or MRI. When metastatic disease is suspected, imaging modalities that provide a global view of the body, such as CT with contrast or PET/CT may be indicated. Rectal cancer often metastasizes to the liver and so MRI of the liver with and without contrast provides accurate staging for liver metastases. This article focuses on local and distant staging and reviews the appropriateness of different imaging for both variants. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Kathryn J Fowler
- Principal Author, Mallinckrodt Institute of Radiology, Saint Louis, Missouri.
| | - Harmeet Kaur
- Co-author, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Brooks D Cash
- University of South Alabama, Mobile, Alabama; American Gastroenterological Association
| | - Barry W Feig
- University of Texas MD Anderson Cancer Center, Houston, Texas; American College of Surgeons
| | | | - Evelyn M Garcia
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | | | - Joseph M Herman
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, Maryland
| | - David H Kim
- University of Wisconsin Hospital and Clinic, Madison, Wisconsin
| | - Drew L Lambert
- University of Virginia Health System, Charlottesville, Virginia
| | - Angela D Levy
- Georgetown University Hospital, Washington, District of Columbia
| | | | | | - William Small
- Stritch School of Medicine Loyola University Chicago, Maywood, Illinois
| | - Martin P Smith
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Tasneem Lalani
- Speciality Chair, Inland Imaging Associates and University of Washington, Seattle, Washington
| | - Laura R Carucci
- Panel Chair, Virginia Commonwealth University Medical Center, Richmond, Virginia
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22
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Wang SJ, Hathout L, Malhotra U, Maloney-Patel N, Kilic S, Poplin E, Jabbour SK. Decision-Making Strategy for Rectal Cancer Management Using Radiation Therapy for Elderly or Comorbid Patients. Int J Radiat Oncol Biol Phys 2018; 100:926-944. [PMID: 29485072 PMCID: PMC11131033 DOI: 10.1016/j.ijrobp.2017.12.261] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 11/14/2017] [Accepted: 12/11/2017] [Indexed: 02/07/2023]
Abstract
Rectal cancer predominantly affects patients older than 70 years, with peak incidence at age 80 to 85 years. However, the standard treatment paradigm for rectal cancer oftentimes cannot be feasibly applied to these patients owing to frailty or comorbid conditions. There are currently little information and no treatment guidelines to help direct therapy for patients who are elderly and/or have significant comorbidities, because most are not included or specifically studied in clinical trials. More recently various alternative treatment options have been brought to light that may potentially be utilized in this group of patients. This critical review examines the available literature on alternative therapies for rectal cancer and proposes a treatment algorithm to help guide clinicians in treatment decision making for elderly and comorbid patients.
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Affiliation(s)
- Shang-Jui Wang
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Lara Hathout
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Usha Malhotra
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Nell Maloney-Patel
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Sarah Kilic
- Rutgers New Jersey Medical School, Rutgers, the State University of New Jersey, Newark, New Jersey
| | - Elizabeth Poplin
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey.
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Abstract
BACKGROUND The prevalence of obesity is as high as one-third of the adult population in the ultrasound. Obese patients operated for rectal cancer are less likely to undergo sphincter-preserving surgery, and have an increased morbidity and mortality. We aim to report the outcomes of transanal-endoscopic-microsurgery (TEM) in obese patients with benign and malignant neoplasms. MATERIALS AND METHODS An analysis was carried out of all patients undergoing TEM at a single institution between 2004 and 2015. Clinical, demographic, and pathologic data were analyzed in respect to BMI; a dichotomous variable was created categorizing the patients in this retrospective case series as either obese (BMI≥30) or nonobese (BMI<30). RESULTS Of the 158 patients who underwent TEM during the study period, 51 (32%) were obese and 107 (68%) were nonobese. No significant differences were found in terms of patients' demographics and tumor characteristics. There were no significant differences in operative time [105 min (range: 75-170) and 98 (range: 56-170), respectively, P=0.2], hospital length of stay [3 days (range: 2-6) and 4 (range: 2-12), respectively, P=0.48], or complication rates (20 and 23%, respectively, P=0.68). CONCLUSION TEM is a safe procedure for rectal neoplasms in the obese population. We found no difference in surgical time and completeness of specimen resection, and no increase in complications or length of stay in the hospital in obese versus nonobese patients. As for selected high risk patients, the TEM may be of benefit in obese patients with T1/T2N0M0 rectal cancer.
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Stijns RCH, Tromp MSR, Hugen N, de Wilt JHW. Advances in organ preserving strategies in rectal cancer patients. Eur J Surg Oncol 2017; 44:209-219. [PMID: 29275912 DOI: 10.1016/j.ejso.2017.11.024] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 10/23/2017] [Accepted: 11/19/2017] [Indexed: 02/06/2023] Open
Abstract
Treatment of rectal cancer patients has been subjected to change over the past thirty years. Total mesorectal excision is considered the cornerstone of rectal cancer treatment, but is also associated with significant morbidity resulting in an impaired quality of life. The addition of neoadjuvant chemoradiotherapy to surgery has shown to improve survival and local control and may lead to a partial or even complete response (CR). This raises questions regarding the necessity for subsequent radical surgery. After careful patient selection local excision and wait-and-see approaches are explored, aiming to improve quality of life without compromising oncological outcome. A multimodality diagnostic approach for optimal staging is crucial in determining the appropriate neoadjuvant treatment regimen. Adequate endoscopic restaging of rectal tumours after multimodality treatment will aid in selecting patients who are eligible for an organ preserving approach. The role and accuracy of imaging in the detection of the primary tumour, residual rectal cancer or local recurrence seems vital. Alternative neoadjuvant regimens are currently explored to increase the rate of clinical CRs, which may support organ preserving approaches. This review aims to generate insight into the advances in diagnostics and treatment modalities in all stages of rectal cancer and will highlight future studies that may support further implementation of organ preservation treatment in rectal cancer.
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Affiliation(s)
- Rutger C H Stijns
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Mike-Stephen R Tromp
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Niek Hugen
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
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São Julião GP, Celentano JP, Alexandre FA, Vailati BB. Local Excision and Endoscopic Resections for Early Rectal Cancer. Clin Colon Rectal Surg 2017; 30:313-323. [PMID: 29184466 DOI: 10.1055/s-0037-1606108] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Radical surgery is considered as the standard treatment for rectal cancer. Transanal local excision has been considered an interesting alternative for the management of selected patients with rectal cancers for many decades. Different approaches had been considered for local excision, from endoscopic submucosal dissection to resections using platforms, such as transanal endoscopic microsurgery or transanal minimally invasive surgery. Identifying the ideal candidate for this approach is crucial, as a local failure after local excision is associated with poor outcomes, even for an initial early rectal tumor. In this article, the diagnostic tools and criteria to select patients for local excision, the different modalities used, and the outcomes are discussed.
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26
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Abstract
Local excision (LE) of early-stage rectal cancer avoids the morbidity associated with radical surgery but has historically been associated with inferior oncologic outcomes. Newer techniques, including transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS), have been developed to improve the quality of LE and extend the benefits of LE to tumors in the more proximal rectum. This article provides an overview of conventional LE, TEM, and TAMIS techniques, including indications for their use and pertinent literature on their associated outcomes for rectal cancer.
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Affiliation(s)
- Daniel Owen Young
- Colorectal Surgery Program, Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, 1100 9th Avenue Seattle, WA 98101, USA
| | - Anjali S Kumar
- Colorectal Surgery Program, Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, 1100 9th Avenue Seattle, WA 98101, USA.
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Valero M, Robles-Medranda C. Endoscopic ultrasound in oncology: An update of clinical applications in the gastrointestinal tract. World J Gastrointest Endosc 2017; 9:243-254. [PMID: 28690767 PMCID: PMC5483416 DOI: 10.4253/wjge.v9.i6.243] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 04/10/2017] [Accepted: 05/05/2017] [Indexed: 02/06/2023] Open
Abstract
An accurate staging is necessary to select the best treatment and evaluate prognosis in oncology. Staging usually begins with noninvasive imaging such as computed tomography, magnetic resonance imaging or positron emission tomography. In the absence of distant metastases, endoscopic ultrasound plays an important role in the diagnosis and staging of gastrointestinal tumors, being the most accurate modality for local-regional staging. Its use for tumor and nodal involvement in pre-surgical evaluation has proven to reduce unnecessary surgeries. The aim of this article is to review the current role of endoscopic ultrasound in the diagnosis and staging of esophageal, gastric and colorectal cancer.
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28
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Abstract
BACKGROUND There is debate regarding the appropriate use of transanal endoscopic microsurgery for rectal cancer. OBJECTIVE This study analyzed our single-center experience with transanal endoscopic microsurgery for early rectal cancer. DESIGN Medical charts of patients who underwent transanal endoscopic microsurgery were reviewed to determine lesion characteristics, as well as operative and treatment characteristics. Complications and recurrences were recorded. SETTINGS The study was conducted at a single academic medical center. PATIENTS Patients with early stage cancer (T1 or T2, N0, and M0) of the rectum were included. MAIN OUTCOME MEASURES Local and overall recurrence and disease-specific survival were measured. RESULTS A total of 92 patients were analyzed. Median follow-up was 4.6 years. Negative margins were obtained in 98.9%. Length of stay was 1 day for 95.4% of patients. The complication rate was 10.9% (n = 10), including urinary retention at 4.3% (n = 4) and postoperative bleeding at 4.3% (n = 4). Preoperative staging included 54 at T1 (58.7%) and 38 at T2 (41.3%). Adjuvant therapy was recommended for all of the T2 and select T1 lesions with adverse features on histology. The final pathologic stages of tumors were ypT0 at 8.7% (n = 8), pT1 at 58.7% (n = 54), pT2 at 23.9% (n = 22), and ypT2 at 8.7% (n = 8). The 3-year local recurrence risk was 2.4% (SE = 1.7), and overall recurrence was 6.7% (SE = 2.9). There were no recurrences among patients with complete pathologic response to neoadjuvant therapy. Mean time to recurrence was 2.5 years (SD = 1.43). A total of 89.2% of patients with very low tumors underwent curative resection without a permanent stoma (33/37). The 3-year disease-specific survival rate was 98.6% (95% CI, 90.4%-99.8%), and overall survival rate was 89.4% (95% CI, 79.9%-94.6%). LIMITATIONS The study was limited by its single-center retrospective experience. CONCLUSIONS Transanal endoscopic microsurgery provides comparable oncologic outcomes to radical resection in properly selected patients with early rectal cancer. Sphincter preservation rates approach 90% even in patients with very distal rectal cancer.
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29
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Debove C, Svrcek M, Dumont S, Chafai N, Tiret E, Parc Y, Lefèvre JH. Is the assessment of submucosal invasion still useful in the management of early rectal cancer? A study of 91 consecutive patients. Colorectal Dis 2017; 19:27-37. [PMID: 27253882 DOI: 10.1111/codi.13405] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 04/28/2016] [Indexed: 02/06/2023]
Abstract
AIM The only studies on the prognosis of T1 tumours are old and investigate colic and rectal cancers. Very few studies use Kikuchi's classification (of dividing submucosa into three strata) to evaluate the depth of the submucosal invasion. This study aimed to assess the pathological risk factors for lymph node metastasis (LNM), and the pathological and oncological results of patients with early rectal cancer (ERC, pT1 tumour). METHOD Between 2000 and 2014, 91 consecutive patients undergoing surgery [primary total mesorectal excision (TME) or local excision (LE) alone, or LE followed by TME] for ERC were included. RESULTS Eighteen patients underwent LE, 22 underwent LE followed by TME and 51 underwent primary total TME. After TME (n = 73), 16 (23%) patients had LNM. The LNM rate was 15% for Sm1 tumours, 14% for Sm2 tumours and 30% for Sm3 tumours. In multivariate analysis, lymphovascular invasion (P = 0.027) and high tumour budding (P = 0.037) were the only independent factors predictive of LNM. The depth of submucosal invasion was not associated with an increased risk of LNM. After a mean follow up of 56 ± 46 months, 5-year overall survival, specific survival and disease-free survival were, respectively, 82%, 93% and 75%. No significant difference of survival was found according to the depth of submucosal invasion or to the surgical management. CONCLUSION Histological features seem to be stronger risk factors for LNM than depth of submucosal invasion. Considering the LNM rate, TME should be discussed after LE in terms of one of these pathological criteria.
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Affiliation(s)
- C Debove
- Department of Digestive Surgery, St Antoine Hospital (AP-HP), Paris VI University, Paris, France
| | - M Svrcek
- Department of Pathology, St Antoine Hospital (AP-HP), Paris VI University, Paris, France
| | - S Dumont
- Pierre et Marie Curie University, Paris VI University, Paris, France
| | - N Chafai
- Department of Digestive Surgery, St Antoine Hospital (AP-HP), Paris VI University, Paris, France
| | - E Tiret
- Department of Digestive Surgery, St Antoine Hospital (AP-HP), Paris VI University, Paris, France
| | - Y Parc
- Department of Digestive Surgery, St Antoine Hospital (AP-HP), Paris VI University, Paris, France
| | - J H Lefèvre
- Department of Digestive Surgery, St Antoine Hospital (AP-HP), Paris VI University, Paris, France
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30
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Fraum TJ, Owen JW, Fowler KJ. Beyond Histologic Staging: Emerging Imaging Strategies in Colorectal Cancer with Special Focus on Magnetic Resonance Imaging. Clin Colon Rectal Surg 2016; 29:205-15. [PMID: 27582645 DOI: 10.1055/s-0036-1584288] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Imaging plays an increasingly important role in the staging and management of colorectal cancer. In recent years, magnetic resonance imaging (MRI) has supplanted transrectal ultrasound as the preferred modality for the locoregional staging of rectal cancer. Furthermore, the advent of both diffusion-weighted imaging and hepatobiliary contrast agents has significantly enhanced the ability of MRI to detect colorectal liver metastases. In clinical practice, MRI routinely provides prognostic information, helps to guide surgical strategy, and determines the need for neoadjuvant therapies related to both the primary tumor and metastatic disease. Expanding on these roles for MRI, positron emission tomography (PET)/MRI is the newest clinical hybrid imaging modality and combines the metabolic information of PET with the high soft tissue contrast of MRI. The addition of PET/MRI to the clinical staging armamentarium has the potential to provide comprehensive state-of-the-art colorectal cancer staging in a single examination.
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Affiliation(s)
- Tyler J Fraum
- Mallinckrodt Institute of Radiology, Washington University, Saint Louis, Missouri
| | - Joseph W Owen
- Mallinckrodt Institute of Radiology, Washington University, Saint Louis, Missouri
| | - Kathryn J Fowler
- Mallinckrodt Institute of Radiology, Washington University, Saint Louis, Missouri
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31
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Lutz MP, Zalcberg JR, Glynne-Jones R, Ruers T, Ducreux M, Arnold D, Aust D, Brown G, Bujko K, Cunningham C, Evrard S, Folprecht G, Gerard JP, Habr-Gama A, Haustermans K, Holm T, Kuhlmann KF, Lordick F, Mentha G, Moehler M, Nagtegaal ID, Pigazzi A, Pucciarelli S, Roth A, Rutten H, Schmoll HJ, Sorbye H, Van Cutsem E, Weitz J, Otto F. Second St. Gallen European Organisation for Research and Treatment of Cancer Gastrointestinal Cancer Conference: consensus recommendations on controversial issues in the primary treatment of rectal cancer. Eur J Cancer 2016; 63:11-24. [PMID: 27254838 DOI: 10.1016/j.ejca.2016.04.010] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 04/10/2016] [Accepted: 04/17/2016] [Indexed: 01/12/2023]
Abstract
Primary treatment of rectal cancer was the focus of the second St. Gallen European Organisation for Research and Treatment of Cancer (EORTC) Gastrointestinal Cancer Conference. In the context of the conference, a multidisciplinary international expert panel discussed and voted on controversial issues which could not be easily answered using published evidence. Main topics included optimal pretherapeutic imaging, indication and type of neoadjuvant treatment, and the treatment strategies in advanced tumours. Here we report the key recommendations and summarise the related evidence. The treatment strategy for localised rectal cancer varies from local excision in early tumours to neoadjuvant radiochemotherapy (RCT) in combination with extended surgery in locally advanced disease. Optimal pretherapeutic staging is a key to any treatment decision. The panel recommended magnetic resonance imaging (MRI) or MRI + endoscopic ultrasonography (EUS) as mandatory staging modalities, except for early T1 cancers with an option for local excision, where EUS in addition to MRI was considered to be most important because of its superior near-field resolution. Primary surgery with total mesorectal excision was recommended by most panellists for some early tumours with limited risk of recurrence (i.e. cT1-2 or cT3a N0 with clear mesorectal fascia on MRI and clearly above the levator muscles), whereas all other stages were considered for multimodal treatment. The consensus panel recommended long-course RCT over short-course radiotherapy for most clinical situations where neoadjuvant treatment is indicated, with the exception of T3a/b N0 tumours where short-course radiotherapy or even no neoadjuvant therapy were regarded to be an option. In patients with potentially resectable tumours and synchronous liver metastases, most panel members did not see an indication to start with classical fluoropyrimidine-based RCT but rather favoured preoperative short-course radiotherapy with systemic combination chemotherapy or alternatively a liver-first resection approach in resectable metastases, which both allow optimal systemic therapy for the metastatic disease. In general, proper patient selection and discussion in an experienced multidisciplinary team was considered as crucial component of care.
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Affiliation(s)
| | - John R Zalcberg
- Department of Epidemiology and Preventive Medicine, School of Public Health, Monash University, The Alfred Centre, Melbourne, Australia
| | - Rob Glynne-Jones
- Department of Medical Oncology, Mount Vernon Cancer Centre, Northwood, UK
| | - Theo Ruers
- The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Michel Ducreux
- Gustave Roussy, Université Paris-Saclay, Département de Médecine, Villejuif, France
| | - Dirk Arnold
- CUF Hospitals, Oncology Center, Lisbon, Portugal
| | - Daniela Aust
- Universitätsklinikum Carl Gustav Carus, Dresden, Germany
| | - Gina Brown
- Department of Diagnostic Imaging, The Royal Marsden NHS Foundation Trust, London, UK
| | - Krzysztof Bujko
- The Maria Sklodowska-Curie Memorial Cancer Centre, Warsaw, Poland
| | | | - Serge Evrard
- Institut Bergonié, Université de Bordeaux, Bordeaux, France
| | | | | | | | - Karin Haustermans
- Department of Radiation Oncology, University Hospitals Leuven, Belgium
| | - Torbjörn Holm
- Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | | | - Florian Lordick
- University Cancer Center Leipzig (UCCL), University Medicine Leipzig, Germany
| | | | - Markus Moehler
- I. Med. Klinik und Poliklinik, Johannes Gutenberg Universität Mainz, Mainz, Germany
| | - Iris D Nagtegaal
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Alessio Pigazzi
- Department of Surgery, University of California, Irvine, CA, USA
| | | | | | - Harm Rutten
- Catharina Hospital Eindhoven, Eindhoven and GROW: School of Oncology and Developmental Biology, University Maastricht, Maastricht, The Netherlands
| | - Hans-Joachim Schmoll
- Department of Oncology/Haematology, Martin-Luther-University Halle, Halle (Saale), Germany
| | - Halfdan Sorbye
- Department of Oncology, Haukeland University Hospital, University of Bergen, Norway; Department of Clinical Science, Haukeland University Hospital, University of Bergen, Norway
| | - Eric Van Cutsem
- Digestive Oncology, University Hospitals Gasthuisberg/Leuven, Leuven, Belgium
| | - Jürgen Weitz
- Universitätsklinikum Carl Gustav Carus, Dresden, Germany
| | - Florian Otto
- Tumor- und Brustzentrum ZeTuP, St. Gallen, Switzerland
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Xynos E, Tekkis P, Gouvas N, Vini L, Chrysou E, Tzardi M, Vassiliou V, Boukovinas I, Agalianos C, Androulakis N, Athanasiadis A, Christodoulou C, Dervenis C, Emmanouilidis C, Georgiou P, Katopodi O, Kountourakis P, Makatsoris T, Papakostas P, Papamichael D, Pechlivanides G, Pentheroudakis G, Pilpilidis I, Sgouros J, Triantopoulou C, Xynogalos S, Karachaliou N, Ziras N, Zoras O, Souglakos J. Clinical practice guidelines for the surgical treatment of rectal cancer: a consensus statement of the Hellenic Society of Medical Oncologists (HeSMO). Ann Gastroenterol 2016; 29:103-26. [PMID: 27064746 PMCID: PMC4805730 DOI: 10.20524/aog.2016.0003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
In rectal cancer management, accurate staging by magnetic resonance imaging, neo-adjuvant treatment with the use of radiotherapy, and total mesorectal excision have resulted in remarkable improvement in the oncological outcomes. However, there is substantial discrepancy in the therapeutic approach and failure to adhere to international guidelines among different Greek-Cypriot hospitals. The present guidelines aim to aid the multidisciplinary management of rectal cancer, considering both the local special characteristics of our healthcare system and the international relevant agreements (ESMO, EURECCA). Following background discussion and online communication sessions for feedback among the members of an executive team, a consensus rectal cancer management was obtained. Statements were subjected to the Delphi methodology voting system on two rounds to achieve further consensus by invited multidisciplinary international experts on colorectal cancer. Statements were considered of high, moderate or low consensus if they were voted by ≥80%, 60-80%, or <60%, respectively; those obtaining a low consensus level after both voting rounds were rejected. One hundred and two statements were developed and voted by 100 experts. The mean rate of abstention per statement was 12.5% (range: 2-45%). In the end of the process, all statements achieved a high consensus. Guidelines and algorithms of diagnosis and treatment were proposed. The importance of centralization, care by a multidisciplinary team, adherence to guidelines, and personalization is emphasized.
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Affiliation(s)
- Evaghelos Xynos
- General Surgery, InterClinic Hospital of Heraklion, Greece (Evangelos Xynos)
| | - Paris Tekkis
- Colorectal Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK (Paris Tekkis, Panagiotis Georgiou)
| | - Nikolaos Gouvas
- General Surgery, Metropolitan Hospital of Piraeus, Greece (Nikolaos Gouvas)
| | - Louiza Vini
- Radiation Oncology, Iatriko Center of Athens, Greece (Louza Vini)
| | - Evangelia Chrysou
- Radiology, University Hospital of Heraklion, Greece (Evangelia Chrysou)
| | - Maria Tzardi
- Pathology, University Hospital of Heraklion, Greece (Maria Tzardi)
| | - Vassilis Vassiliou
- Radiation Oncology, Oncology Center of Bank of Cyprus, Nicosia, Cyprus (Vassilis Vassiliou)
| | - Ioannis Boukovinas
- Medical Oncology, Bioclinic of Thessaloniki, Greece (Ioannis Boukovinas)
| | - Christos Agalianos
- General Surgery, Athens Naval & Veterans Hospital, Greece (Christos Agalianos, George Pechlivanides)
| | - Nikolaos Androulakis
- Medical Oncology, Venizeleion Hospital of Heraklion, Greece (Nikolaos Androulakis)
| | | | | | - Christos Dervenis
- General Surgery, Konstantopouleio Hospital of Athens, Greece (Christos Dervenis)
| | - Christos Emmanouilidis
- Medical Oncology, Interbalkan Medical Center, Thessaloniki, Greece (Christos Emmanouilidis)
| | - Panagiotis Georgiou
- Colorectal Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK (Paris Tekkis, Panagiotis Georgiou)
| | - Ourania Katopodi
- Medical Oncology, Iaso General Hospital, Athens, Greece (Ourania Katopodi)
| | - Panteleimon Kountourakis
- Medical Oncology, Oncology Center of Bank of Cyprus, Nicosia, Cyprus (Panteleimon Kountourakis, Demetris Papamichael)
| | - Thomas Makatsoris
- Medical Oncology, University Hospital of Patras, Greece (Thomas Makatsoris)
| | - Pavlos Papakostas
- Medical Oncology, Ippokrateion Hospital of Athens, Greece (Pavlos Papakostas)
| | - Demetris Papamichael
- Medical Oncology, Oncology Center of Bank of Cyprus, Nicosia, Cyprus (Panteleimon Kountourakis, Demetris Papamichael)
| | - George Pechlivanides
- General Surgery, Athens Naval & Veterans Hospital, Greece (Christos Agalianos, George Pechlivanides)
| | | | - Ioannis Pilpilidis
- Gastroenterology, Theageneion Cancer Hospital, Thessaloniki, Greece (Ioannis Pilpilidis)
| | - Joseph Sgouros
- Medical Oncology, Agioi Anargyroi Hospital of Athens, Greece (Joseph Sgouros)
| | | | - Spyridon Xynogalos
- Medical Oncology, George Gennimatas General Hospital, Athens, Greece (Spyridon Xynogalos)
| | - Niki Karachaliou
- Medical Oncology, Dexeus University Institute, Barcelona, Spain (Niki Karachaliou)
| | - Nikolaos Ziras
- Medical Oncology, Metaxas Cancer Hospital, Piraeus, Greece (Nikolaos Ziras)
| | - Odysseas Zoras
- General Surgery, University Hospital of Heraklion, Greece (Odysseas Zoras)
| | - John Souglakos
- Medical Oncology, University Hospital of Heraklion, Greece (John Souglakos)
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Bartel MJ, Brahmbhatt BS, Wallace MB. Management of colorectal T1 carcinoma treated by endoscopic resection from the Western perspective. Dig Endosc 2016; 28:330-41. [PMID: 26718885 DOI: 10.1111/den.12598] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 12/21/2015] [Accepted: 12/25/2015] [Indexed: 12/13/2022]
Abstract
Detection of early colorectal cancer is expected to rise in light of national colorectal cancer screening programs. This The present review article delineates current endoscopic risk assessments, differentiating invasive from non-invasive neoplasia, for high likelihood of lymph node metastasis in early colorectal cancer, also termed high-risk early colorectal cancer, and endoscopic and surgical resection methods from a Western hemisphere perspective.
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Fábián A, Bor R, Farkas K, Bálint A, Milassin Á, Rutka M, Tiszlavicz L, Wittmann T, Nagy F, Molnár T, Szepes Z. Rectal Tumour Staging with Endorectal Ultrasound: Is There Any Difference between Western and Eastern European Countries? Gastroenterol Res Pract 2015; 2016:8631381. [PMID: 26858754 PMCID: PMC4706948 DOI: 10.1155/2016/8631381] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 06/27/2015] [Accepted: 07/05/2015] [Indexed: 12/17/2022] Open
Abstract
Background. Rectal tumour management depends highly on locoregional extension. Rectal endoscopic ultrasound (ERUS) is a good alternative to computed tomography and magnetic resonance imaging. However, in Hungary only a small amount of rectal tumours is examined with ERUS. Methods. Our retrospective study (2006-2012) evaluates the diagnostic accuracy of ERUS and compares the results, the first data from Central Europe, with those from Western Europe. The effect of neoadjuvant therapy, rectal probe type, and investigator's experience were also assessed. Results. 311 of the 647 ERUS assessed locoregional extension. Histological comparison was available in 177 cases: 67 patients underwent surgery alone; 110 received neoadjuvant chemoradiotherapy (CRT); ERUS preceded CRT in 77 and followed it in 33 patients. T-staging was accurate in 72% of primarily operated patients. N-staging was less accurate (62%). CRT impaired staging accuracy (64% and 59% for T- and N-staging). Rigid probes were more accurate (79%). At least 30 examinations are needed to master the technique. Conclusions. The sensitivity of ERUS complies with the literature. ERUS is easy to learn and more accurate in early stages but unnecessary for restaging after CRT. Staging accuracy is similar in Western and Central Europe, although the number of examinations should be increased.
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Affiliation(s)
- Anna Fábián
- First Department of Internal Medicine, University of Szeged, Korányi Fasor 8-10, Szeged 6720, Hungary
| | - Renáta Bor
- First Department of Internal Medicine, University of Szeged, Korányi Fasor 8-10, Szeged 6720, Hungary
| | - Klaudia Farkas
- First Department of Internal Medicine, University of Szeged, Korányi Fasor 8-10, Szeged 6720, Hungary
| | - Anita Bálint
- First Department of Internal Medicine, University of Szeged, Korányi Fasor 8-10, Szeged 6720, Hungary
| | - Ágnes Milassin
- First Department of Internal Medicine, University of Szeged, Korányi Fasor 8-10, Szeged 6720, Hungary
| | - Mariann Rutka
- First Department of Internal Medicine, University of Szeged, Korányi Fasor 8-10, Szeged 6720, Hungary
| | - László Tiszlavicz
- Department of Pathology, University of Szeged, Állomás Utca 2, Szeged 6720, Hungary
| | - Tibor Wittmann
- First Department of Internal Medicine, University of Szeged, Korányi Fasor 8-10, Szeged 6720, Hungary
| | - Ferenc Nagy
- First Department of Internal Medicine, University of Szeged, Korányi Fasor 8-10, Szeged 6720, Hungary
| | - Tamás Molnár
- First Department of Internal Medicine, University of Szeged, Korányi Fasor 8-10, Szeged 6720, Hungary
| | - Zoltán Szepes
- First Department of Internal Medicine, University of Szeged, Korányi Fasor 8-10, Szeged 6720, Hungary
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Perez RO, Habr-Gama A, São Julião GP, Proscurshim I, Fernandez LM, de Azevedo RU, Vailati BB, Fernandes FA, Gama-Rodrigues J. Transanal Endoscopic Microsurgery (TEM) Following Neoadjuvant Chemoradiation for Rectal Cancer: Outcomes of Salvage Resection for Local Recurrence. Ann Surg Oncol 2015; 23:1143-8. [PMID: 26577119 DOI: 10.1245/s10434-015-4977-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Indexed: 12/25/2022]
Abstract
BACKGROUND Transanal endoscopic microsurgery (TEM) has been considered an alternative for selected patients with rectal cancer following neoadjuvant chemoradiation (CRT). Immediate total mesorectal completion for all patients with unfavorable pathological features would result in unnecessary protectomies in a significant proportion of patients. Instead, salvage total mesorectal excision (TME) could be restricted for patients developing local recurrence. The aim of the present study is to determine oncological outcomes of salvage resection for local recurrences following CRT and TEM. METHODS Consecutive patients undergoing TEM following neoadjuvant CRT for rectal cancer were reviewed. Patients with "near" complete response to CRT (≤3 cm; ycT1-2N0) were offered TEM. Salvage surgery was attempted in the event of a local recurrence. RESULTS A total of 53 patients were managed by CRT followed by TEM. Unfavorable pathological features were present in 36 patients (68 %). None of the patients underwent immediate completion TME. There were 12 patients who developed local recurrence resulting in a 2-year local recurrence-free survival of 77 % (95 % CI, 53-100 %). Of these patients, 9 developed exclusively local recurrences, and all had at least 1 unfavorable pathological feature in the specimen after TEM (100 %). Eight patients (8 of 9) underwent salvage resection (abdominoperineal resection [APR] in 87 %) with CRM+ in 7 of 8 patients (87 %). Four patients developed local re-recurrence after a median 36 months of follow-up. The 2-year local re-recurrence free survival was 60 %. CONCLUSIONS Salvage resection for local recurrence following CRT and TEM is associated with high rates of R1 resection (CRM+) and local re-recurrence. Immediate completion of TME should be considered for patients with unfavorable pathological features after TEM.
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Affiliation(s)
- Rodrigo Oliva Perez
- Angelita and Joaquim Gama Institute, São Paulo, Brazil. .,Colorectal Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil. .,São Paulo Branch, Ludwig Institute for Cancer Research, São Paulo, Brazil.
| | - Angelita Habr-Gama
- Angelita and Joaquim Gama Institute, São Paulo, Brazil.,University of São Paulo School of Medicine, São Paulo, Brazil
| | | | | | | | - Rafael Ulysses de Azevedo
- Angelita and Joaquim Gama Institute, São Paulo, Brazil.,University of São Paulo School of Medicine, São Paulo, Brazil
| | | | - Felipe Alexandre Fernandes
- Angelita and Joaquim Gama Institute, São Paulo, Brazil.,University of São Paulo School of Medicine, São Paulo, Brazil
| | - Joaquim Gama-Rodrigues
- Angelita and Joaquim Gama Institute, São Paulo, Brazil.,University of São Paulo School of Medicine, São Paulo, Brazil
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Garcia-Aguilar J, Renfro LA, Chow OS, Shi Q, Carrero XW, Lynn PB, Thomas CR, Chan E, Cataldo PA, Marcet JE, Medich DS, Johnson CS, Oommen SC, Wolff BG, Pigazzi A, McNevin SM, Pons RK, Bleday R. Organ preservation for clinical T2N0 distal rectal cancer using neoadjuvant chemoradiotherapy and local excision (ACOSOG Z6041): results of an open-label, single-arm, multi-institutional, phase 2 trial. Lancet Oncol 2015; 16:1537-1546. [PMID: 26474521 PMCID: PMC4984260 DOI: 10.1016/s1470-2045(15)00215-6] [Citation(s) in RCA: 291] [Impact Index Per Article: 29.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 08/03/2015] [Accepted: 08/04/2015] [Indexed: 02/06/2023]
Abstract
Background Local excision is an organ-preserving treatment alternative for patients with stage I rectal cancer. However, local excision alone is associated with a high risk of local recurrence and inferior survival compared to transabdominal rectal resection. Here we investigate the oncologic and functional outcomes of neoadjuvant chemoradiotherapy and local excision for T2N0 rectal cancer. Methods This was a prospective, multi-institutional, single arm phase 2 trial for patients with clinically-staged T2N0 distal rectal cancer, treated with neoadjuvant chemoradiotherapy consisting of capecitabine (original dose 825mg/m2, twice daily, on days 1-14 and 22-35) , oxaliplatin (50mg/m2 weeks 1, 2, 4, 5), and radiation (5 days/week at 1.8 Gy/day for 5 weeks to a dose of 45 Gy, then a boost, for a total dose of 54 Gy) followed by local excision. Due to adverse events during chemoradiotherapy, the dose of capecitabine was reduced to 725 mg /m2, twice daily, 5 days/week, for 5 weeks, and the total dose of radiation to 50.4 Gy. Patients were followed at scheduled intervals and evaluated for recurrence and survival. Anorectal function (ARF) and quality of life (QOL) were assessed at baseline and one year after surgery, using validated instruments. The primary endpoint was 3-year disease-free survival for all eligible patients and for patients who completed chemotherapy and radiation, and had ypT0, ypT1, or ypT2 tumors, and negative resection margins. This trial is registered with ClinicalTrials.gov, number NCT00114231. Findings Seventy-nine eligible patients were accrued to the trial, and started nCRT. Three patients did not complete nCRT or LE per-protocol. Four additional patients completed protocol treatment, but one had a positive margin and three had ypT3 tumours. Median follow-up was 56 months. Of the 79 patients, five (6%) developed distant recurrence, and three (4%) recurred locally. All but two underwent salvage surgery. Three-year disease-free survival and overall survival for the entire group were 88% (0.88 (95% CI: 0.81, 0.96) and 95% (95% CI: 0.90, 1.00), respectively. Overall 14 (29%) of 79 patients had grade 3-4 gastrointestinal adverse events, 12 (16%) of 79 patients had grade 3-4 pain as an adverse event, 12 (16%) of 79 patients had grade 3-4 hematological adverse events, and 9 (11%) of 79 patients had grade 3 dermatologic adverse events during chemoradiation. Six (8%) of the 77 patients who had surgery had grade 3 pain, 3(4%) of 77 patients had grade 3-4 hemorrhage, 3 (4%) of 77 patients had gastrointestinal adverse events, 2 (3%) of 77 patients had infectious/febrile neutropenia, 2 (3%) of 77 patients had hematological adverse events, and one (1%) had neurological adverse events. The rectum was preserved in 72 of the 79 (91%) patients. ARF and QOL were unchanged one year after surgery compared to baseline. Interpretation Most patients with T2N0 rectal cancer treated with nCRT and LE achieved organ preservation without deterioration of their quality of life. The estimated 3-year DFS rate was within the defined margin of efficacy. Our data suggest that nCRT followed by LE may be considered as an organ-preserving alternative in carefully selected patients with clinically-staged T2N0 tumours who refuse, or are not candidates for, transabdominal resection.
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Affiliation(s)
| | | | - Oliver S Chow
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | | | | | - Emily Chan
- Vanderbilt University Medical Center, Nashville, TN, USA
| | | | | | - David S Medich
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Use of Preoperative MRI to Select Candidates for Local Excision of MRI-Staged T1 and T2 Rectal Cancer: Can MRI Select Patients With N0 Tumors? Dis Colon Rectum 2015; 58:923-30. [PMID: 26347963 DOI: 10.1097/dcr.0000000000000437] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND To minimize the recurrence rate after local excision of rectal cancer, the false-negative rate of nodal staging should be minimized. OBJECTIVE The purpose of this study was to develop a set of criteria using preoperative MRI that would minimize the false-negative rate for the diagnosis of regional lymph node metastasis. DESIGN A prospectively maintained colorectal cancer database and MRI images were retrospectively reviewed. SETTINGS This study was conducted at a multidisciplinary tertiary center. PATIENTS A total of 246 consecutive patients who underwent MRI and curative-intent surgery for MRI-staged T1/T2 rectal cancer from January 2008 to July 2012 were included. MAIN OUTCOME MEASURES MRI features significantly associated with lymph node metastasis were identified using a χ test. Five diagnostic criteria for lymph node metastasis were created based on these predictive MRI features, and their false-negative rates were compared using the generalized estimating equation method. RESULTS Small size/homogeneity of lymph nodes and no visible tumor/partially involved muscular layer were significantly associated with lower risks of lymph node metastasis. When tumor invasion depth was not considered, the false-negative rate did not decrease below 10%, even when the strictest criterion for morphologic evaluation of lymph nodes (not visible or <3 mm) was used. Adding invasion depth to the diagnostic criteria significantly decreased the false-negative rate as low as 1.8%. LIMITATIONS This study is limited by its small sample size and retrospective nature. CONCLUSIONS Assessing both the depth of tumor invasion and lymph node morphology may reduce the false-negative rate and can be helpful to better identify candidates suitable for local excision of early stage rectal cancer. However, strict MRI criteria for oncologic safety might result in considerable false-positive cases and limit the application of local excision.
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Hassan I, Wise PE, Margolin DA, Fleshman JW. The Role of Transanal Surgery in the Management of T1 Rectal Cancers. J Gastrointest Surg 2015; 19:1704-12. [PMID: 26048145 DOI: 10.1007/s11605-015-2866-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 05/25/2015] [Indexed: 02/06/2023]
Abstract
The management of T1 rectal cancers is based on finding the balance between optimal oncologic outcomes and acceptable functional results for the patient. While radical resection involving a proctectomy is considered the most oncologically adequate option, its adverse effects on patient reported outcomes makes this a less than ideal choice in certain circumstances. While local excision can circumvent some of the adverse functional outcomes, its inadequacy in assessing metastatic lymph node disease and the subsequent negative impact of untreated positive lymph nodes on patient prognosis is a cause for concern. As a result, the therapeutic strategy has to be based on patient and disease-related factors in order to identify the best treatment choice that maximizes survival benefit and preserves health-related quality of life. After adequate preoperative staging work up, in selected patients with favorable pathological features, local excision can be considered. These cancers can be removed by transanal local excision or transanal endoscopic microsurgery, depending on the location of the cancer and expertise available. While perioperative morbidity is minimal, close postoperative follow-up is essential.
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Affiliation(s)
- Imran Hassan
- Department of Surgery, University of Iowa, Iowa City, IA, USA,
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Marone P, Bellis MD, D’Angelo V, Delrio P, Passananti V, Girolamo ED, Rossi GB, Rega D, Tracey MC, Tempesta AM. Role of endoscopic ultrasonography in the loco-regional staging of patients with rectal cancer. World J Gastrointest Endosc 2015; 7:688-701. [PMID: 26140096 PMCID: PMC4482828 DOI: 10.4253/wjge.v7.i7.688] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Revised: 11/26/2014] [Accepted: 03/20/2015] [Indexed: 02/05/2023] Open
Abstract
The prognosis of rectal cancer (RC) is strictly related to both T and N stage of the disease at the time of diagnosis. RC staging is crucial for choosing the best multimodal therapy: patients with high risk locally advanced RC (LARC) undergo surgery after neoadjuvant chemotherapy and radiotherapy (NAT); those with low risk LARC are operated on after a preoperative short-course radiation therapy; finally, surgery alone is recommended only for early RC. Several imaging methods are used for staging patients with RC: computerized tomography, magnetic resonance imaging, positron emission tomography, and endoscopic ultrasound (EUS). EUS is highly accurate for the loco-regional staging of RC, since it is capable to evaluate precisely the mural infiltration of the tumor (T), especially in early RC. On the other hand, EUS is less accurate in restaging RC after NAT and before surgery. Finally, EUS is indicated for follow-up of patients operated on for RC, where there is a need for the surveillance of the anastomosis. The aim of this review is to highlight the impact of EUS on the management of patients with RC, evaluating its role in both preoperative staging and follow-up of patients after surgery.
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Thomson EM, Tolan DJM. RE: The value of TRUS in the staging of rectal carcinoma before and after radiotherapy and comparison with the staging postoperative pathology. Clin Radiol 2015; 70:801-2. [PMID: 25773988 DOI: 10.1016/j.crad.2015.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 01/31/2015] [Accepted: 02/05/2015] [Indexed: 12/01/2022]
Affiliation(s)
- E M Thomson
- St James University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
| | - D J M Tolan
- St James University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Perez RO, Habr-Gama A, São Julião GP, Proscurshim I, Coelho AQ, Figueiredo MN, Fernandez LM, Gama-Rodrigues J. Transanal local excision for distal rectal cancer and incomplete response to neoadjuvant chemoradiation - does baseline staging matter? Dis Colon Rectum 2014; 57:1253-9. [PMID: 25285691 DOI: 10.1097/dcr.0000000000000215] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Local excision may offer the possibility of organ preservation for the management of select patients after neoadjuvant chemoradiation. The oncological outcomes of this strategy have been largely associated with the risk of nodal metastases. Therefore, in addition to final ypT status, baseline staging has been suggested to potentially influence the outcomes of this treatment modality. OBJECTIVE The aim of this study is to compare the pathological and oncological outcomes of patients following neoadjuvant chemoradiation and incomplete clinical response managed by transanal endoscopic microsurgery according to baseline staging. DESIGN This study is a retrospective review of prospectively collected data. SETTINGS The study was conducted at a single center. PATIENTS Forty-six patients with distal rectal cancer cT2-4N0-2M0 underwent 5-fluorouracil-based neoadjuvant chemoradiation. Assessment of response was performed at least 8 weeks from radiotherapy completion. Patients with a complete clinical response were not operated on immediately. Patients with an incomplete clinical response were managed by surgery. Those with small (≤3 cm) residual cancers (ycT1-2N0M0) were managed by transanal endoscopic microsurgery. MAIN OUTCOME MEASURES Patients undergoing local excision following chemoradiation were compared according to baseline staging. RESULTS Fifteen patients (32%) were cT2N0 at baseline. Final ypT status was ypT0 in 3 (20%) patients, ypT1 in 2 (13%) patients, ypT2 in 9 (60%) patients, and ypT3 in 1 (7%) patient. There were no differences in final ypT status in comparison with patients with baseline cT3-4 or cN+ undergoing chemoradiation followed by transanal endoscopic microsurgery (p = 0.38). Local recurrence was observed in 1 patient with baseline cT2N0 (7%) and in 7 patients (23%) with stage II and III (p = 0.18). LIMITATIONS This study was limited by the short follow-up, its limited sample size, and its retrospective and nonrandomized nature. CONCLUSIONS Patients with baseline cT2N0 that do not develop complete response to chemoradiation (ycT0-2N0; ≤3 cm) frequently present unfavorable pathological features for transanal local excision (ypT2 or 3 in >66%). In the presence of incomplete clinical response following chemoradiation, patients with baseline cT2N0 have pathological and oncological outcomes similar to patients with baseline stage II or III and are probably not ideal candidates for local excision (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A159).
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Affiliation(s)
- Rodrigo O Perez
- 1Angelita & Joaquim Gama Institute, São Paulo, Brazil 2University of São Paulo School of Medicine, Colorectal Surgery Division, São Paulo, Brazil 3Ludwig Institute for Cancer Research, São Paulo Branch, São Paulo, Brazil 4University of São Paulo School of Medicine, São Paulo, Brazil
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Kulu Y, Müller-Stich BP, Bruckner T, Gehrig T, Büchler MW, Bergmann F, Ulrich A. Radical Surgery with Total Mesorectal Excision in Patients with T1 Rectal Cancer. Ann Surg Oncol 2014; 22:2051-8. [DOI: 10.1245/s10434-014-4179-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Indexed: 01/03/2023]
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The impact of pathologic nodal status on survival following neoadjuvant chemoradiation for locally advanced rectal cancer. Int J Colorectal Dis 2014; 29:1061-8. [PMID: 24970021 DOI: 10.1007/s00384-014-1917-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/02/2014] [Indexed: 02/07/2023]
Abstract
PURPOSE For patients with locally advanced rectal cancer, the accuracy rates of preneoadjuvant therapy nodal staging and potential nodal downstaging make the prognostic significance of nodal status unclear. We therefore sought to review our experience in order to better understand the impact of clinical and pathologic nodal status upon patient outcomes. METHODS 174 patients were identified as having undergone neoadjuvant chemoradiation and resection for rectal cancer. For analytic purposes, patients were grouped into four nodal categories (uN( 0)· pN( 0), uN( 0)· pN( +), uN (+) · pN( 0), and uN (+) · pN( +)). Univariate and multivariate analyses were performed. RESULTS 104 men and 70 women of median age 60 years (29-85 years) were followed for a median of 31 months (1-121 months). Nodal staging was available for 129 patients, with a median of 8 lymph nodes (range 0-39) evaluated. Disease recurred in 3 of 41 (7%) uN (0) ·pN ( 0), 10 of 52 (20%) uN ( +)·pN ( 0), 7 of 18 (41%) uN ( 0)·pN ( +), and 6 of 17 (35%) uN ( +)·pN ( +) patients. Those patients having nodal downstaging (uN ( +)·pN ( 0)) experienced superior overall survival (p = 0.03). Only pathologic nodal status was a significant predictor of both disease-free and overall survival in multivariate modeling. Adjuvant chemotherapy did not impact disease-free or overall survival for patients with pN0. CONCLUSIONS Pathologic nodal status may represent a superior predictor of survival for patients with local advanced rectal cancers. Our findings may have potential implications for the application of adjuvant therapy.
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Baatrup G, Qvist N. Local resection of early rectal cancer. APMIS 2014; 122:715-722. [PMID: 25046201 DOI: 10.1111/apm.12292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Accepted: 06/14/2014] [Indexed: 12/15/2022]
Abstract
The introduction of the National Danish screening programme for colorectal cancer will result in the detection of more early rectal cancers (ERC), which may be considered for local excision. For the low risk≤T1 cancer, the oncological outcome at local excision in smaller patient series has shown similar results to conventional surgery, but with a significantly lower rate of serious complications, morbidity and mortality. The challenge is correct preoperative staging, and a meticulous systematic histopathological staging of the excised specimen to distinguish the low risk from high-risk cases, where rescue surgery may be considered. The establishment of a regional or national clinical database is necessary to improve the local treatment of ERC.
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Affiliation(s)
- Gunnar Baatrup
- Institute of Regional Health, Medical Faculty, University of Southern Denmark, Svendborg, Denmark; Department of Surgery A, Odense University Hospital, Svendborg, Denmark
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Czakó L, Dubravcsik Z, Gasztonyi B, Hamvas J, Pakodi F, Szepes A, Szepes Z. [The role of endoscopic ultrasound in the diagnosis and therapy of gastrointestinal disorders]. Orv Hetil 2014; 155:526-540. [PMID: 24681675 DOI: 10.1556/oh.2014.29866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Endoscopic ultrasound is one of those diagnostic methods in gastrointestinal endoscopy which has developed rapidly in the last decade and has became exceedingly available to visualize the walls of the internal organs in details corresponding to histological layers, or analyze the adjacent structures. Fine needles and other endoscopic accessories can be introduced into the neighbouring tissues under the guidance of endoscopic ultrasound, and diagnostic and minimally invasive therapeutic interventions can be performed. The endoscopic ultrasound became more widely available in Hungary in recent years. This review focuses on the indications, benefits and complications of diagnostic and therapeutic endoscopic ultrasound. We recommend this article to gastroenterologists, surgeons, internists, pulmonologists, and to specialists in oncology and radiology. This recommendation was based on the consensus of the Board members of the Endoscopic Ultrasound Section of the Hungarian Gastroenterological Society.
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Affiliation(s)
- László Czakó
- Szegedi Tudományegyetem, Általános Orvostudományi Kar I. Belgyógyászati Klinika Szeged Pf. 427 6701
| | | | | | - József Hamvas
- Bajcsy-Zsilinszky Kórház I. Belgyógyászat-Gasztroenterológia Budapest
| | - Ferenc Pakodi
- Pécsi Tudományegyetem, Általános Orvostudományi Kar I. Belgyógyászati Klinika Pécs
| | - Attila Szepes
- Bács-Kiskun Megyei Kórház Gasztroenterológiai Osztály Kecskemét
| | - Zoltán Szepes
- Szegedi Tudományegyetem, Általános Orvostudományi Kar I. Belgyógyászati Klinika Szeged Pf. 427 6701
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Abstract
Early rectal cancer (ERC) is defined as invasive adenocarcinoma spreading into, but not beyond, the submucosa or muscularis propria-that is a Dukes'A: T1N0 or T2N0 tumour in the tumour node metastasis (TNM) classification (Taylor et al. 2008). Among these tumours it is suggested that the most superficial T1 tumours least likely to metastasize to local lymph nodes than adenocarcinoma invading deeper where the rich lymphatic and venous plexuses within the submucosa provide a mechanism for tumour spread beyond the rectum. Currently, only about 10 % of patients presenting symptomatically with rectal cancer are diagnosed with early disease; however, up to 30 % of screen detected cancers are being identified as Dukes'A. Thus, the overall detection of early stage tumours is likely to increase following greater implementation in screening programs. The goal of this invited review is to provide recommendations based on the consensus discussion on the information from preoperative imaging that is of relevance for clinical decision-making for patients with early rectal cancer.
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Affiliation(s)
- Jo Waage
- Haukeland University Hospital, Surgical Clinic, Bergen, Norway
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Weiser MR, Beets-Tan R, Beets G. Management of Complete Response After Chemoradiation in Rectal Cancer. Surg Oncol Clin N Am 2014; 23:113-25. [DOI: 10.1016/j.soc.2013.09.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Maeda K, Koide Y, Katsuno H. When is local excision appropriate for "early" rectal cancer? Surg Today 2013; 44:2000-14. [PMID: 24254058 PMCID: PMC4194025 DOI: 10.1007/s00595-013-0766-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Accepted: 09/30/2013] [Indexed: 12/20/2022]
Abstract
Local excision is increasingly performed for “early stage” rectal cancer in the US; however, local recurrence after local excision has become a controversial issue in Western countries. Local recurrence is considered to originate based on the type of tumor and procedure performed, and in surgical margin-positive cases. This review focuses on the inclusion criteria of “early” rectal cancers for local excision from the Western and Japanese points of view. “Early” rectal cancer is defined as T1 cancer in the rectum. Only the tumor grade and depth of invasion are the “high risk” factors which can be evaluated before treatment. T1 cancers with sm1 or submucosal invasion <1,000 μm are considered to be “low risk” tumors with less than 3.2 % nodal involvement, and are considered to be candidates for local excision as the sole curative surgery. Tumors with a poor tumor grade should be excluded from local excision. Digital examination, endoscopy or proctoscopy with biopsy, a barium enema study and endorectal ultrasonography are useful for identifying “low risk” or excluding “high risk” factors preoperatively for a comprehensive diagnosis. The selection of an initial local treatment modality is also considered to be important according to the analysis of the nodal involvement rate after initial local treatment and after radical surgery.
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Affiliation(s)
- Kotaro Maeda
- Department of Surgery, Fujita Health University School of Medicine, 1-98 Kutsukake, Toyoake, Aichi, 470-1192, Japan,
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Bor R, Fábián A, Farkas K, Bálint A, Tiszlavicz L, Wittmann T, Nagy F, Molnár T, Szepes Z. [The role of endoscopic ultrasonography in the diagnosis of rectal cancers]. Orv Hetil 2013; 154:1337-1344. [PMID: 23955969 DOI: 10.1556/oh.2013.29686] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The exact extent of rectal cancer and regional lymph node involvement are essential for providing the optimal treatment. AIM The aim of the authors was to evaluate the diagnostic accuracy of endoscopic ultrasonography in routine clinical staging of rectal cancer. METHOD Outcomes of endoscopic ultrasonography performed between 2006 and 2012 for rectal cancer staging were retrospectively analyzed. The correlation between the endoscopic and pathological stages was evaluated. RESULTS In patients without neoadjuvant chemotherapy the sensitivity (75% and 73%) and specificity (74% and 80%) of endoscopic ultrasonography for differentiating T1 and T2 stages (respectively) were high, however, it was significantly decreased in differentiation of T3 stage (58%). A weak association was found in different N stages (45-62%). The diagnostic accuracy of endoscopic ultrasound was reduced significantly after the oncological treatment due to the overevaluation (27%) of the findings. After a relatively short learning curve (30 examinations) high correlation was detected between pT and uT stages. CONCLUSIONS Endoscopic ultrasonography provides great help in staging early rectal cancers. Due to the lower sensitivity in patients receiving neoadjuvant therapy, it is not a useful tool after down-staging.
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Affiliation(s)
- Renáta Bor
- Szegedi Tudományegyetem, Általános Orvostudományi Kar I. Belgyógyászati Klinika Szeged Korányi fasor 8-10. 6720
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Williams JG, Pullan RD, Hill J, Horgan PG, Salmo E, Buchanan GN, Rasheed S, McGee SG, Haboubi N. Management of the malignant colorectal polyp: ACPGBI position statement. Colorectal Dis 2013; 15 Suppl 2:1-38. [PMID: 23848492 DOI: 10.1111/codi.12262] [Citation(s) in RCA: 130] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- J G Williams
- Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK.
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