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Gouvas N, Manatakis D, Agalianos C, Dimitriou N, Baloyiannis I, Tzovaras G, Xynos E. Defunctioning Ileostomy After Low Anterior Resection of Rectum: Morbidity Related to Fashioning and Closure. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1864. [PMID: 39597049 PMCID: PMC11596492 DOI: 10.3390/medicina60111864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2024] [Revised: 09/21/2024] [Accepted: 11/06/2024] [Indexed: 11/29/2024]
Abstract
Background and Objectives: The aim of this study was to assess any predisposing factors to the morbidity of fashioning and reversal of diverting ileostomy in a prospective cohort of patients who have undergone TME and low colo-rectal or colo-anal anastomosis for rectal cancer. Materials and Methods: Consecutive patients with rectal cancer undergoing low anterior resection and a defunctioning loop ileostomy in three surgical units from 2016 to 2020 were included in the study and retrospectively analyzed. Results: One hundred eighty-two patients from three centres were included. Ileostomy-related mortality was 0.5%, attributed to renal failure.. Ileostomy-related morbidity was 46%. Postoperative ileus was seen in 37.4%, and dehydration in 18.8% of the patients. The readmission rate for ileostomy-related reasons was 15.4%. Stoma care was problematic in 15.7% or poor in 7% of the cases. Advanced age, male gender and obesity were independent risk factors for ileostomy-related morbidity. Ileostomy was reversed in 165 patients. The morbidity in 165 patients was 16%. Ileus was seen in 10.3%, anastomotic leak in 4.8% and wound infection in 12.7% of the cases. One patient died because of an anastomotic leak. No predisposing factors that affect the outcomes of ileostomy closure were identified. Conclusions: Diverting ileostomy-related morbidity is high. Life threatening dehydration and renal failure from ileus is more commonly seen in elderly, male and obese patients and should be anticipated. Ileostomy closure-related morbidity is low.
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Affiliation(s)
- Nikolaos Gouvas
- Department of General Surgery, Medical School, University of Cyprus, Nicosia 2404, Cyprus;
| | - Dimitrios Manatakis
- Department of General Surgery, Naval & Veterans Hospital, 11521 Athens, Greece;
| | - Christos Agalianos
- Department of General Surgery, Naval & Veterans Hospital, 73200 Chania, Greece;
| | - Nikoletta Dimitriou
- Department of General Surgery, Medical School, University of Cyprus, Nicosia 2404, Cyprus;
| | - Ioannis Baloyiannis
- Department of General Surgery, University Hospital of Larissa, 41334 Larisa, Greece; (I.B.); (G.T.)
| | - George Tzovaras
- Department of General Surgery, University Hospital of Larissa, 41334 Larisa, Greece; (I.B.); (G.T.)
| | - Evangelos Xynos
- Department of General Surgery, Creta Interclinic Hospital, 71304 Heraklion, Greece;
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Takao M, Kawai K, Nakano D, Dejima A, Nakamori S, Natsume S, Ise I, Kato H, Yamaguchi T. Recurrence of rectal cancer on the pelvic sidewall after lateral lymph node dissection. Int J Colorectal Dis 2024; 39:80. [PMID: 38806953 PMCID: PMC11133041 DOI: 10.1007/s00384-024-04650-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/17/2024] [Indexed: 05/30/2024]
Abstract
PURPOSE Although lateral lymph node dissection has been performed to prevent lateral pelvic recurrence in locally advanced lower rectal cancer, the incidence of lateral pelvic recurrence after this procedure has not been investigated. Therefore, this study aimed to investigate the long-term outcomes of patients who underwent lateral pelvic lymph node dissection, with a particular focus on recurrence patterns. METHODS This was a retrospective study conducted at a single high-volume cancer center in Japan. A total of 493 consecutive patients with stage II-III rectal cancer who underwent lateral lymph node dissection between January 2005 and August 2022 were included. The primary outcome measures included patterns of recurrence, overall survival, and relapse-free survival. Patterns of recurrence were categorized as lateral or central pelvic. RESULTS Among patients who underwent lateral lymph node dissection, 18.1% had pathologically positive lateral lymph node metastasis. Lateral pelvic recurrence occurred in 5.5% of patients after surgery. Multivariate analysis identified age > 75 years, lateral lymph node metastasis, and adjuvant chemotherapy as independent risk factors for lateral pelvic recurrence. Evaluation of the recurrence rate by dissection area revealed approximately 1% of recurrences in each area after dissection. CONCLUSION We demonstrated the prognostic outcome and limitations of lateral lymph node dissection for patients with advanced lower rectal cancer, focusing on the incidence of recurrence in the lateral area after the dissection. Our study emphasizes the clinical importance of lateral lymph node dissection, which is an essential technique that surgeons should acquire.
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Affiliation(s)
- Misato Takao
- Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, 3-18-22, Honkomagome, Bunkyo-ku, Tokyo, 113-0021, Japan.
| | - Kazushige Kawai
- Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, 3-18-22, Honkomagome, Bunkyo-ku, Tokyo, 113-0021, Japan
| | - Daisuke Nakano
- Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, 3-18-22, Honkomagome, Bunkyo-ku, Tokyo, 113-0021, Japan
| | - Akira Dejima
- Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, 3-18-22, Honkomagome, Bunkyo-ku, Tokyo, 113-0021, Japan
| | - Sakiko Nakamori
- Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, 3-18-22, Honkomagome, Bunkyo-ku, Tokyo, 113-0021, Japan
| | - Soichiro Natsume
- Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, 3-18-22, Honkomagome, Bunkyo-ku, Tokyo, 113-0021, Japan
| | - Ichiro Ise
- Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, 3-18-22, Honkomagome, Bunkyo-ku, Tokyo, 113-0021, Japan
| | - Hiroki Kato
- Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, 3-18-22, Honkomagome, Bunkyo-ku, Tokyo, 113-0021, Japan
| | - Tatsuro Yamaguchi
- Department of Clinical Genetics, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
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Temmink SJD, Peeters KCMJ, Nilsson PJ, Martling A, van de Velde CJH. Surgical Outcomes after Radiotherapy in Rectal Cancer. Cancers (Basel) 2024; 16:1539. [PMID: 38672621 PMCID: PMC11048284 DOI: 10.3390/cancers16081539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 04/12/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
Over the past decade, the treatment of rectal cancer has changed considerably. The implementation of TME surgery has, in addition to decreasing the number of local recurrences, improved surgical morbidity and mortality. At the same time, the optimisation of radiotherapy in the preoperative setting has improved oncological outcomes even further, although higher perineal infection rates have been reported. Radiotherapy regimens have evolved through the adjustment of radiotherapy techniques and fields, increased waiting intervals, and, for more advanced tumours, adding chemotherapy. Concurrently, imaging techniques have significantly improved staging accuracy, facilitating more precise selection of advanced tumours. Although chemoradiotherapy does lead to the downsizing and -staging of these tumours, a very clear effect on sphincter-preserving surgery and the negative resection margin has not been proven. Aiming to decrease distant metastasis and improve overall survival for locally advanced rectal cancer, systemic chemotherapy can be added to radiotherapy, known as total neoadjuvant treatment (TNT). High complete response rates, both pathological (pCR) and clinical (cCR), are reported after TNT. Patients who follow a Watch & Wait program after a cCR can potentially avoid surgical morbidity and colostomy. For both early and more advanced tumours, trials are now investigating optimal regimens in an attempt to offer organ preservation as much as possible. Multidisciplinary deliberation should include patient preference, treatment toxicity, and likelihood of end colostomy, but also the burden of intensive surveillance in a W&W program.
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Affiliation(s)
- Sofieke J. D. Temmink
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76 Stockholm, Sweden
| | - Koen C. M. J. Peeters
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Per J. Nilsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76 Stockholm, Sweden
| | - Anna Martling
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76 Stockholm, Sweden
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Yu Z, Hao Y, Huang Y, Ling L, Hu X, Qiao S. Radiotherapy in the preoperative neoadjuvant treatment of locally advanced rectal cancer. Front Oncol 2023; 13:1300535. [PMID: 38074690 PMCID: PMC10704030 DOI: 10.3389/fonc.2023.1300535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 10/30/2023] [Indexed: 04/04/2024] Open
Abstract
Radiotherapy and chemotherapy are effective treatments for patients with locally advanced rectal cancer (LARC) and can significantly improve the likelihood of R0 resection. Radiotherapy can be used as a local treatment to reduce the size of the tumor, improve the success rate of surgery and reduce the residual cancer cells after surgery. Early chemotherapy can also downgrade the tumor and eliminate micrometastases throughout the body, reducing the risk of recurrence and metastasis. The advent of neoadjuvant concurrent radiotherapy (nCRT) and total neoadjuvant treatment (TNT) has brought substantial clinical benefits to patients with LARC. Even so, given increasing demand for organ preservation and quality of life and the disease becoming increasingly younger in its incidence profile, there is a need to further explore new neoadjuvant treatment options to further improve tumor remission rates and provide other opportunities for patients to choose watch-and-wait (W&W) strategies that avoid surgery. Targeted drugs and immunologic agents (ICIs) have shown good efficacy in patients with advanced rectal cancer but have not been commonly used in neoadjuvant therapy for patients with LARC. In this paper, we review several aspects of neoadjuvant therapy, including radiation therapy and chemotherapy drugs, immune drugs and targeted drugs used in combination with neoadjuvant therapy, with the aim of providing direction and thoughtful perspectives for LARC clinical treatment and research trials.
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Affiliation(s)
| | | | | | | | - Xigang Hu
- Department of Radiation Oncology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
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Vankina SP, Goyal S, Narayanan GS. Upper limit of radiation treatment portals in rectal cancer: is it wise to keep using bony landmarks in the present era of 3D conformal treatment? Rep Pract Oncol Radiother 2023; 28:565-569. [PMID: 37795231 PMCID: PMC10547415 DOI: 10.5603/rpor.a2023.0045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 07/27/2023] [Indexed: 10/06/2023] Open
Abstract
Background This study aimed to compare the levels of L5-S1 interspace and the bifurcation of common iliac vessels on simulation images of rectal cancer patients to evaluate the adequacy of superior borders in conventional 2D planning for covering internal iliac vessels. Materials and methods Simulation images of 236 rectal cancer patients who received neoadjuvant chemoradiation and surgery were analyzed. The images were retrieved from the radiation treatment database and included delineations of L5-S1 interspace and common iliac vessel bifurcation. Distances between these landmarks were measured. Results Among the 236 patients, the majority had the common iliac artery bifurcation positioned above the L5-S1 interspace. Specifically, 78.3% of patients had the right common iliac bifurcation above L5-S1 interspace, with an average distance of 2.02 cm. For the left common iliac artery, 77.11% of patients had the bifurcation above L5-S1 interspace, with an average distance of 1.99 cm. Notably, there were cases where the bifurcations were not at the same level. Conclusion Using the L5-S1 junction as the upper border of the treatment portal may result in missing proximal nodes at risk of metastases. However, further research is needed to determine the significance of failures above the L5-S1 interspace for justifying the inclusion of the common iliac artery bifurcation in the treatment portal.
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Affiliation(s)
- Surya Prakash Vankina
- Department of Radiation Oncology, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, India
| | - Surekha Goyal
- Department of Radiation Oncology, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, India
| | - Geeta S Narayanan
- Department of Radiation Oncology, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, India
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Effects of Neoadjuvant Radiotherapy on Postoperative Complications in Rectal Cancer: A Meta-Analysis. JOURNAL OF ONCOLOGY 2022; 2022:8197701. [PMID: 35035483 PMCID: PMC8754670 DOI: 10.1155/2022/8197701] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 11/29/2021] [Accepted: 12/18/2021] [Indexed: 02/06/2023]
Abstract
Objective Neoadjuvant radiotherapy (nRT) is an important treatment approach for rectal cancer. The relationship, however, between nRT and postoperative complications is still controversial. Here, we conducted a meta-analysis to evaluate such concerns. Methods The electronic literature from 1983 to 2021 was searched in PubMed, Embase, and Web of Science. Postoperative complications after nRT were included in the meta-analysis. The pooled odds ratio (OR) was calculated by the random-effects model. Statistical analysis was conducted by Review Manager 5.3 and STATA 14. Results A total of 23,723 patients from 49 studies were included in the meta-analysis. The pooled results showed that nRT increased the risk of anastomotic leakage (AL) compared to upfront surgery (OR = 1.23; 95% CI, 1.07-1.41; p=0.004). Subgroup analysis suggested that both long-course (OR = 1.20, 95% CI 1.03-1.40; p=0.02) and short-course radiotherapy (OR = 1.25, 95% CI, 1.02-1.53; p=0.04) increased the incidence of AL. In addition, nRT was the main risk factor for wound infection and pelvic abscess. The pooled data in randomized controlled trials, however, indicated that nRT was not associated with AL (OR = 1.01; 95% CI 0.82-1.26; p=0.91). Conclusions nRT may increase the risk of AL, wound infection, and pelvic abscess compared to upfront surgery among patients with rectal cancer.
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Pach R, Sierzega M, Szczepanik A, Popiela T, Richter P. Preoperative radiotherapy 5 × 5 Gy and short versus long interval between surgery for resectable rectal cancer: 10-Year follow-up of the randomised controlled trial. Radiother Oncol 2021; 164:268-274. [PMID: 34653526 DOI: 10.1016/j.radonc.2021.10.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 10/06/2021] [Accepted: 10/07/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Studies on short-course preoperative radiotherapy in combination with total mesorectal excision for rectal cancer reported improved local control without clear survival benefits. The optimal fractionation and interval between radiotherapy and surgery are still under debate. We, therefore, aimed to report 10-year results of a randomized clinical trial (RCT, NCT01444495) comparing different time intervals between irradiation and surgery for rectal cancer. MATERIAL AND METHODS Data from the RCT conducted at a single academic centre were reviewed based on regular control visits with the median follow-up of 12 years. Patients with rectal cancer were randomly assigned to short-course preoperative radiotherapy (5 × 5 Gy) followed by surgery 7-10 days (short interval) or 4-5 weeks (long interval) after the end of irradiation. The primary endpoint was the local recurrence rate at 5 years. The secondary endpoints included overall survival, disease-free survival, systemic recurrence rate, and downstaging. RESULTS A total of 154 patients were randomly assigned to short (n = 77) or long interval (n = 77) surgery. The cumulative incidence of local recurrence at 10 years was 1.3% and 11.7% in the short and long-interval groups, respectively (p = 0.031). Accordingly, the incidence of systemic relapse was 14.3% versus 9.1% (p = 0.0319). There were no differences in the overall 10-year survival between patients subject to short and long-interval surgery (58% vs 61%, p = 0.754). However, patients with downstaging after radiotherapy had significantly better 10-year survival rates than non-responders. CONCLUSIONS Short-course preoperative radiotherapy with delayed surgery demonstrated an increased risk of local relapse over a 10-year follow-up.
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Affiliation(s)
- Radoslaw Pach
- First Department of Surgery, Jagiellonian University Medical College, Krakow, Poland.
| | - Marek Sierzega
- First Department of Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Antoni Szczepanik
- First Department of Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Tadeusz Popiela
- First Department of Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Piotr Richter
- First Department of Surgery, Jagiellonian University Medical College, Krakow, Poland
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Thakur N, Seam RK, Gupta MK, Gupta M, Fotedar V, Vats S, Rana S, Vias P, Ahuja R. A Prospective Observational Study Comparing Long-Course Conventional Neoadjuvant Chemoradiotherapy with Short-Course Radiotherapy Followed by Consolidation Chemotherapy with Delayed Surgery in Locally Advanced Rectal Cancer. South Asian J Cancer 2020; 9:80-85. [PMID: 33354549 PMCID: PMC7745749 DOI: 10.1055/s-0040-1721220] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background Polish and Australian randomized studies compared short-course radiotherapy (RT) with immediate surgery and long-course chemoradiotherapy (CRT) with delayed surgery. In these studies, similar long-term survival and local control have been reported for both these approaches, but pathological complete response (pCR) is not better with short-course RT. Moreover, studies have shown better tumor downstaging with delayed surgery. In this context, the use of short-course RT with delayed surgery may have some advantages and needs to be tested in clinical trials. Patients and Methods This was a two-arm, prospective, observational study, in which preoperative short-course RT followed by two cycles of chemotherapy was compared with the conventional neoadjuvant CRT in locally advanced rectal cancer. The primary end points were the rate of complete response and toxicity profile. The secondary end points were the rate of R0 resection, overall survival, and progression-free survival. The data obtained from the two arms were analyzed using Pearson's chi-square test to determine the statistical significance between the two treatment arms. Results The pCR rate was 6.7% in the study arm and 0 in the control arm ( p = 0.343). The RO resection rates were 92.8 and 92.3% in the study and control arms, respectively. The rates of grade 3and 4 acute toxicity in the study and control arms were 14.2 and 61.5%, respectively ( p = 0.011). The rates of grade 3 and 4 late toxicity in the study and control arms were 21.4 and 15.3%, respectively ( p = 0.686). Conclusions The pCR rates and the late toxicities in both arms are comparable. The major advantages of the 5 × 5 Gy regimen with chemotherapy in a neoadjuvant setting are a significant reduction in acute toxicities and better patient compliance along with similar efficacy as that of the standard regimen.
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Affiliation(s)
- Niketa Thakur
- Department of Radiation Oncology, Regional Cancer Centre, Indira Gandhi Medical College & Hospital, Shimla, Himachal Pradesh, India
| | - Rajeev K Seam
- Department of Radiation Oncology, Regional Cancer Centre, Indira Gandhi Medical College & Hospital, Shimla, Himachal Pradesh, India
| | - Manoj K Gupta
- Department of Radiation Oncology, Regional Cancer Centre, Indira Gandhi Medical College & Hospital, Shimla, Himachal Pradesh, India
| | - Manish Gupta
- Department of Radiation Oncology, Regional Cancer Centre, Indira Gandhi Medical College & Hospital, Shimla, Himachal Pradesh, India
| | - Vikas Fotedar
- Department of Radiation Oncology, Regional Cancer Centre, Indira Gandhi Medical College & Hospital, Shimla, Himachal Pradesh, India
| | - Siddharth Vats
- Department of Radiation Oncology, Regional Cancer Centre, Indira Gandhi Medical College & Hospital, Shimla, Himachal Pradesh, India
| | - Sakshi Rana
- Department of Radiation Oncology, Regional Cancer Centre, Indira Gandhi Medical College & Hospital, Shimla, Himachal Pradesh, India
| | - Poorva Vias
- Department of Radiation Oncology, Regional Cancer Centre, Indira Gandhi Medical College & Hospital, Shimla, Himachal Pradesh, India
| | - Rachit Ahuja
- Department of Radiation Oncology, Regional Cancer Centre, Indira Gandhi Medical College & Hospital, Shimla, Himachal Pradesh, India
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AlQudah M, Salmo E, Haboubi N. The effect of radiotherapy on rectal cancer: a histopathological appraisal and prognostic indicators. Radiat Oncol J 2020; 38:77-83. [PMID: 33012150 PMCID: PMC7533410 DOI: 10.3857/roj.2020.00010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 04/13/2020] [Indexed: 12/13/2022] Open
Abstract
The management of rectal cancer is a major undertaking. There are currently multiple treatment modalities with variable degrees of complications. Radiotherapy (RT) is one of the more frequently used modalities either on its own or more frequently with chemotherapy mostly before the definitive surgery. The outcome of RT is unpredictable. RT has its serious side effects and there are no guarantees of its usefulness in all patients. This article outlines the effect of RT on the tumor, reviews the various staging systems of responses to RT and present recent evidence of which case is less responsive to such treatments to avoid unnecessary complications.
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Affiliation(s)
- Mohammad AlQudah
- Department of Pathology and Microbiology, School of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Emil Salmo
- Department of Histopathology, The Pennine Acute Hospitals NHS Trust, The Royal Oldham Hospital, Oldham, UK
| | - Najib Haboubi
- Department of Histopathology, Spire Manchester Hospital, Manchester, UK
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Jankowski M, Bała D, Las-Jankowska M, Wysocki WM, Nowikiewicz T, Zegarski W. Overall treatment outcome - analysis of long-term results of rectal cancer treatment on the basis of a new parameter. Arch Med Sci 2020; 16:825-833. [PMID: 32542084 PMCID: PMC7286345 DOI: 10.5114/aoms.2020.94330] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 11/12/2017] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Outcomes of rectal cancer treatment depend on preoperative staging and the effectiveness of treatments. According to disease staging, different variants of combined therapy (surgery, chemo- and radiotherapy) are used. Available parameters such as overall survival rates and disease- free survival rates as well as the presence of recurrence are inaccurate and should be jointly considered. MATERIAL AND METHODS Data from 138 patients with rectal cancer (I-III WHO), who were radically operated on in the period 2001-2004 in Bydgoszcz Oncology Centre were analysed. Among this group 84 patients were radically operated on one week after preoperative radiotherapy 5 × 5 Gy (sRT). We established a new parameter, the overall treatment outcome (OTO), based on the finding that there was no recurrence (local recurrence, distant metastases) of the disease within 5 years, which is generally considered a good result for the treatment of rectal cancer. RESULTS Among all patients (n = 138) and patients following sRT (n = 84) 7.4%...5.9% local recurrence and 24%...29% distant metastases were observed in 5-year follow-up. Recurrence was found in 30% and 31% of patients, respectively. Analysis of results on the basis of the OTO parameter demonstrated that among all groups of patients a worse treatment outcome is related to the number of lymph nodes involved, pN, pT, cancer stage (WHO) and to pN and patient age in the sRT group (p < 0.005). CONCLUSIONS In using a combined therapy, it is possible to optimise rectal cancer treatment outcomes. The OTO parameter is a useful tool for defining these results of cancer combination treatment.
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Affiliation(s)
- Michal Jankowski
- Chair of Surgical Oncology, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
- Department of Surgical Oncology, Oncology Center – Prof. Franciszek Lukaszczyk Memorial Hospital, Bydgoszcz, Poland
- Corresponding author: Michal Jankowski MD, PhD, Department of Surgical Oncology, Oncology Center – Prof. Franciszek Lukaszczyk Memorial Hospital, 8 Gminna St, 86-005 Trzciniec, Poland, E-mail:
| | - Dariusz Bała
- Chair of Surgical Oncology, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
- Department of Surgical Oncology, Oncology Center – Prof. Franciszek Lukaszczyk Memorial Hospital, Bydgoszcz, Poland
| | - Manuela Las-Jankowska
- Chair of Surgical Oncology, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
- Department of Clinical Oncology, Oncology Center – Prof. Franciszek Lukaszczyk Memorial Hospital, Bydgoszcz, Poland
| | - Wojciech Maria Wysocki
- Department of General, Oncological and Vascular Surgery, 5th Military Clinical Hospital, Krakow, Poland
- Chair of Surgery, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, Krakow, Poland
- National Institute of Oncology, Maria Skłodowska-Curie Memorial, Scientific Editorial Office, Krakow, Poland
| | - Tomasz Nowikiewicz
- Chair of Surgical Oncology, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
- Department of Breast Cancer and Reconstruction Surgery, Oncology Center – Prof. Franciszek Lukaszczyk Memorial Hospital, Bydgoszcz, Poland
| | - Wojciech Zegarski
- Chair of Surgical Oncology, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
- Department of Surgical Oncology, Oncology Center – Prof. Franciszek Lukaszczyk Memorial Hospital, Bydgoszcz, Poland
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Abraha I, Aristei C, Palumbo I, Lupattelli M, Trastulli S, Cirocchi R, De Florio R, Valentini V, Cochrane Colorectal Cancer Group. Preoperative radiotherapy and curative surgery for the management of localised rectal carcinoma. Cochrane Database Syst Rev 2018; 10:CD002102. [PMID: 30284239 PMCID: PMC6517113 DOI: 10.1002/14651858.cd002102.pub3] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND This is an update of the original review published in 2007.Carcinoma of the rectum is a common malignancy, especially in high income countries. Local recurrence may occur after surgery alone. Preoperative radiotherapy (PRT) has the potential to reduce the risk of local recurrence and improve outcomes in rectal cancer. OBJECTIVES To determine the effect of preoperative radiotherapy for people with localised resectable rectal cancer compared to surgery alone. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; Issue 5, 2018) (4 June 2018), MEDLINE (Ovid) (1950 to 4 June 2018), and Embase (Ovid) (1974 to 4 June 2018). We also searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) for relevant ongoing trials (4 June 2018). SELECTION CRITERIA We included randomised controlled trials comparing PRT and surgery with surgery alone for people with localised advanced rectal cancer planned for radical surgery. We excluded trials that did not use contemporary radiotherapy techniques (with more than two fields to the pelvis). DATA COLLECTION AND ANALYSIS Two review authors independently assessed the 'Risk of bias' domains for each included trial, and extracted data. For time-to-event data, we calculated the Peto odds ratio (Peto OR) and variances, and for dichotomous data we calculated risk ratios (RR) using the random-effects method. Potential sources of heterogeneity hypothesised a priori included study quality, staging, and the use of total mesorectal excision (TME) surgery. MAIN RESULTS We included four trials with a total of 4663 participants. All four trials reported short PRT courses, with three trials using 25 Gy in five fractions, and one trial using 20 Gy in four fractions. Only one study specifically required TME surgery for inclusion, whereas in another study 90% of participants received TME surgery.Preoperative radiotherapy probably reduces overall mortality at 4 to 12 years' follow-up (4 trials, 4663 participants; Peto OR 0.90, 95% CI 0.83 to 0.98; moderate-quality evidence). For every 1000 people who undergo surgery alone, 454 would die compared with 45 fewer (the true effect may lie between 77 fewer to 9 fewer) in the PRT group. There was some evidence from subgroup analyses that in trials using TME no or little effect of PRT on survival (P = 0.03 for the difference between subgroups).Preoperative radiotherapy may have little or no effect in reducing cause-specific mortality for rectal cancer (2 trials, 2145 participants; Peto OR 0.89, 95% CI 0.77 to 1.03; low-quality evidence).We found moderate-quality evidence that PRT reduces local recurrence (4 trials, 4663 participants; Peto OR 0.48, 95% CI 0.40 to 0.57). In absolute terms, 161 out of 1000 patients receiving surgery alone would experience local recurrence compared with 83 fewer with PRT. The results were consistent in TME and non-TME studies.There may be little or no difference in curative resection (4 trials, 4673 participants; RR 1.00, 95% CI 0.97 to 1.02; low-quality evidence) or in the need for sphincter-sparing surgery (3 trials, 4379 participants; RR 0.99, 95% CI 0.94 to 1.04; I2 = 0%; low-quality evidence) between PRT and surgery alone.Low-quality evidence suggests that PRT may increase the risk of sepsis from 13% to 16% (2 trials, 2698 participants; RR 1.25, 95% CI 1.04 to 1.52) and surgical complications from 25% to 30% (2 trials, 2698 participants; RR 1.20, 95% CI 1.01 to 1.42) compared to surgery alone.Two trials evaluated quality of life using different scales. Both studies concluded that sexual dysfunction occurred more in the PRT group. Mixed results were found for faecal incontinence, and irradiated participants tended to resume work later than non-irradiated participants between 6 and 12 months, but this effect had attenuated after 18 months (low-quality evidence). AUTHORS' CONCLUSIONS We found moderate-quality evidence that PRT reduces overall mortality. Subgroup analysis did not confirm this effect in people undergoing TME surgery. We found consistent evidence that PRT reduces local recurrence. Risk of sepsis and postsurgical complications may be higher with PRT.The main limitation of the findings of the present review concerns their applicability. The included trials only assessed short-course radiotherapy and did not use chemotherapy, which is widely used in the contemporary management of rectal cancer disease. The differences between the trials regarding the criteria used to define rectal cancer, staging, radiotherapy delivered, the time between radiotherapy and surgery, and the use of adjuvant or postoperative therapy did not appear to influence the size of effect across the studies.Future trials should focus on identifying participants that are most likely to benefit from PRT especially in terms of improving local control, sphincter preservation, and overall survival while reducing acute and late toxicities (especially rectal and sexual function), as well as determining the effect of radiotherapy when chemotherapy is used and the optimal timing of surgery following radiotherapy.
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Affiliation(s)
- Iosief Abraha
- Regional Health Authority of UmbriaHealth Planning ServicePerugiaItaly06124
| | - Cynthia Aristei
- University of Perugia and Perugia General HospitalRadiation Oncology Section, Department of Surgical and Biomedical SciencePerugiaItaly
| | - Isabella Palumbo
- University of Perugia and Perugia General HospitalRadiation Oncology Section, Department of Surgical and Biomedical SciencePerugiaItaly
| | | | | | | | - Rita De Florio
- Local Health Unit of PerugiaGeneral MedicineAzienda SanitariaLocale USL 1, Medicina GeneralePerugiaItaly
| | - Vincenzo Valentini
- Fondazione Policlinico Universitario A.Gemelli IRCCSRadiation Oncology DepartmentRomeItaly
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12
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Servagi Vernat S, Guilbert P, Bouché G, Ramiandrisoa F, Bellefqih S. [Hypofractionated radiotherapy in rectal cancer for elderly patients]. Cancer Radiother 2018; 22:644-646. [PMID: 30166091 DOI: 10.1016/j.canrad.2018.07.130] [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: 06/07/2018] [Revised: 06/26/2018] [Accepted: 07/04/2018] [Indexed: 11/19/2022]
Abstract
Rectal cancer is a common pathology in the elderly. The standard for advanced rectal tumors is a chemoradiotherapy regimen combined 50Gy with concomitant chemotherapy followed by a surgery. This treatment induces interruptions of chemoradiotherapy and toxicities G3-4 more important in people over 70 years of age. Hypofractionated radiotherapy 5×5Gy with surgery following week is an alternative. All retrospective studies on this fractionation report an excellent immediate and chronic tolerance. The randomized phase III NACRE trial, comparing these 2 radiotherapy, followed by surgery at 6-8 week, established a standard in the management of the elderly patients.
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Affiliation(s)
- S Servagi Vernat
- Département d'oncologie radiothérapie, institut de cancérologie Jean-Godinot, 1, rue du Général Koenig, 51726 Reims cedex, France.
| | - P Guilbert
- Département d'oncologie radiothérapie, institut de cancérologie Jean-Godinot, 1, rue du Général Koenig, 51726 Reims cedex, France
| | - G Bouché
- Département d'oncologie radiothérapie, institut de cancérologie Jean-Godinot, 1, rue du Général Koenig, 51726 Reims cedex, France
| | - F Ramiandrisoa
- Département d'oncologie radiothérapie, institut de cancérologie Jean-Godinot, 1, rue du Général Koenig, 51726 Reims cedex, France
| | - S Bellefqih
- Département d'oncologie radiothérapie, institut de cancérologie Jean-Godinot, 1, rue du Général Koenig, 51726 Reims cedex, France
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13
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Wang Y, Timotin E, Zia W, Farrell T, Reiter H, Chan B, Wong R. Pain Palliation Using Hypofractionated Radiotherapy for Unresectable Pancreatic Cancer. J Med Imaging Radiat Sci 2018; 49:293-300. [PMID: 32074056 DOI: 10.1016/j.jmir.2018.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Revised: 04/22/2018] [Accepted: 04/24/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pain is a common symptom for patients with pancreatic cancer and is often treated using palliative radiation therapy. Standard palliative dose regimes typically consist of 2000 cGy to 3000 cGy in 5 to 10 fractions (fx). With the recent advancements in radiation dosimetric planning and delivery, the Juravinski Cancer Centre in Hamilton, Ontario, offers a hypofractionated dose of 2500 cGy in 5 fx for the improvement of pain and tumour control in selected pancreatic cancer patients. This project reviews the safety and efficacy of this prescription. METHODS A retrospective analysis of 24 patients diagnosed with unresectable pancreatic cancer was conducted. Patient data were collected using in-house medical record systems including MOSAIQ, Meditech, and Centricity. Nonparametric data analysis tests were conducted using Minitab17. RESULTS Nineteen of 24 patients (79%) reported a decrease in pain levels following radiation and 13 of 18 (72%) showed good local control of the tumour on a follow-up CT scan. Around 30% of patients reported nausea and vomiting and fatigue. Only 13% reported diarrhea and 8% reported constipation. Twenty-one percent reported pain flares. All patients were able to finish the entire treatment without pauses or delays. CONCLUSION A palliative radiotherapy dose regime of 2500 cGy/5 fx demonstrates a potential for the effective control of pain with limited acute toxicities in patients with unresectable pancreatic cancer. This study aims to indicate the need for further prospective research comparing this regime to other standard treatments in order to determine which is most beneficial for the patient.
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Affiliation(s)
- Ya Wang
- McMaster University, Medical Radiation Sciences, Hamilton, Ontario, Canada.
| | - Emilia Timotin
- Juravinski Cancer Centre, Radiation Therapy, Hamilton, Ontario, Canada
| | - Waqaas Zia
- Juravinski Cancer Centre, Radiation Therapy, Hamilton, Ontario, Canada
| | - Tom Farrell
- Juravinski Cancer Centre, Medical Physics, Hamilton, Ontario, Canada
| | - Harold Reiter
- Juravinski Cancer Centre, Radiation Therapy, Hamilton, Ontario, Canada; Juravinski Cancer Centre, Radiation Oncology, Hamilton, Ontario, Canada
| | - Bonnie Chan
- McMaster University, Medical Radiation Sciences, Hamilton, Ontario, Canada
| | - Raimond Wong
- Juravinski Cancer Centre, Radiation Oncology, Hamilton, Ontario, Canada
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14
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Narang AK, Meyer J. Neoadjuvant Short-Course Radiation Therapy for Rectal Cancer: Trends and Controversies. Curr Oncol Rep 2018; 20:68. [DOI: 10.1007/s11912-018-0714-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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15
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Kawai K, Ishihara S, Nozawa H, Hata K, Kiyomatsu T, Tanaka T, Nishikawa T, Otani K, Yasuda K, Murono K, Sasaki K, Watanabe T. Recent advances in neoadjuvant chemoradiotherapy in locally advanced rectal cancer. JOURNAL OF THE ANUS RECTUM AND COLON 2018; 1:39-44. [PMID: 31583299 PMCID: PMC6768670 DOI: 10.23922/jarc.2017-005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 02/15/2017] [Indexed: 12/19/2022]
Abstract
Preoperative chemoradiotherapy (CRT) has been actively used in Europe and the United States to treat advanced low rectal cancer, and provides excellent local control. In Japan, however, the standard treatment is lateral lymph node dissection, and to date CRT has not been actively used. In recent years, an increasing number of Japanese institutions have been using preoperative CRT to treat locally advanced rectal cancer. In this review, we describe the latest trends in CRT under five headings: short-course or long-course radiation, efforts to improve combined chemotherapy, the addition of preoperative adjuvant chemotherapy, the watch and wait strategy, and the significance of lateral lymph node dissection in patients receiving CRT.
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Affiliation(s)
| | | | - Hiroaki Nozawa
- Department of Surgical Oncology, The University of Tokyo
| | - Keisuke Hata
- Department of Surgical Oncology, The University of Tokyo
| | | | | | | | - Kensuke Otani
- Department of Surgical Oncology, The University of Tokyo
| | - Koji Yasuda
- Department of Surgical Oncology, The University of Tokyo
| | - Koji Murono
- Department of Surgical Oncology, The University of Tokyo
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16
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Abstract
Since the first reports in the late 1950's, a large amount of data have been collected. The analysis of the main evidence from the major randomized trials will be analyzed in this paper according to preoperative, postoperative and chemoradiation approaches. Fifteen randomized preoperative trials were reported; they have been grouped according to the fractionation schedule. In the hypofractionation group (5 Gy for fraction), all five studies that delivered 3-5 doses in one week had a significant improvement in local control and one of them also showed improvement in survival. Operative mortality was higher in the radiotherapy arm if inadequate techniques had been applied. In 3 out of 8 studies with conventional fractionation there was a significant improvement in local control, but no impact in survival was detected. No studies with total dose lower than 34 Gy had an improvement in local control. None of the six randomized postoperative studies showed an improvement in local control or survival. In all trials the local control rate was uniform; ranging from 76% to 84%. Toxicity was higher in the radiotherapy arm. One preoperative and five postoperative randomized studies that used chemoradiation were analyzed. One postoperative chemoradiation study showed a significant improvement in survival in comparison to the surgery arm, and another showed the same advantage compared to the postoperative arm. Protracted infusional administration of 5FU concomitant to radiotherapy showed better survival than bolus administration. No advantages were shown in using MeCCNU or Levamisole in two studies. Toxicity was high and related to the dose and the modality of administration of the drugs in order to adequately treat the different stages of rectal cancer, patients must be carefully selected in order to prescribe the most effective and the least toxic treatment for the individual stage; organ preservation should be an essential goal for its impact on quality of life, and the cost estimates should be taken into account.
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Affiliation(s)
- V Valentini
- Cattedra di Radioterapia, Università Cattolica S. Cuore, Rome, Italy.
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17
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Emile SH, de Lacy FB, Keller DS, Martin-Perez B, Alrawi S, Lacy AM, Chand M. Evolution of transanal total mesorectal excision for rectal cancer: From top to bottom. World J Gastrointest Surg 2018; 10:28-39. [PMID: 29588809 PMCID: PMC5867456 DOI: 10.4240/wjgs.v10.i3.28] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 01/30/2018] [Accepted: 02/09/2018] [Indexed: 02/06/2023] Open
Abstract
The gold standard for curative treatment of locally advanced rectal cancer involves radical resection with a total mesorectal excision (TME). TME is the most effective treatment strategy to reduce local recurrence and improve survival outcomes regardless of the surgical platform used. However, there are associated morbidities, functional consequences, and quality of life (QoL) issues associated with TME; these risks must be considered during the modern-day multidisciplinary treatment for rectal cancer. This has led to the development of new surgical techniques to improve patient, oncologic, and QoL outcomes. In this work, we review the evolution of TME to the transanal total mesorectal excision (TaTME) through more traditional minimally invasive platforms. The review the development, safety and feasibility, proposed benefits and risks of the procedure, implementation and education models, and future direction for research and implementation of the TaTME in colorectal surgery. While satisfactory short-term results have been reported, the procedure is in its infancy, and long term outcomes and definitive results from controlled trials are pending. As evidence for safety and feasibility accumulates, structured training programs to standardize teaching, training, and safe expansion will aid the safe spread of the TaTME.
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Affiliation(s)
- Sameh Hany Emile
- Department of General Surgery, Mansoura Faculty of Medicine, Mansoura City 35516, Egypt
| | - F Borja de Lacy
- Department of Surgery, Hospital Clinic, University of Barcelona, Barcelona 08036, Spain
| | - Deborah Susan Keller
- GENIE Centre, University College London, London NW1 2BU, United Kingdom
- Department of Surgery and Interventional Sciences, University College London Hospitals, NHS Trusts, London NW1 2BU, United Kingdom
| | - Beatriz Martin-Perez
- Department of Surgery, Hospital Clinic, University of Barcelona, Barcelona 08036, Spain
| | - Sadir Alrawi
- Department of Surgical Oncology, Alzahra Cancer Center, Al Zahra Hospital, Dubai 3499, United Arab Emirates
| | - Antonio M Lacy
- Department of Surgery, Hospital Clinic, University of Barcelona, Barcelona 08036, Spain
| | - Manish Chand
- GENIE Centre, University College London, London NW1 2BU, United Kingdom
- Department of Surgery and Interventional Sciences, University College London Hospitals, NHS Trusts, London NW1 2BU, United Kingdom
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18
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Abdel-Rahman O, Kumar A, Kennecke HF, Speers CH, Cheung WY. Impact of Duration of Neoadjuvant Radiation on Rectal Cancer Survival: A Real World Multi-center Retrospective Cohort Study. Clin Colorectal Cancer 2017; 17:e21-e28. [PMID: 28709877 DOI: 10.1016/j.clcc.2017.06.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 06/16/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND The utility of neoadjuvant radiotherapy (nRT) for the treatment of stage II and III rectal cancer is well-established. However, the optimal duration of nRT in this setting remains controversial. Using a population-based cohort of patients with stage II and III rectal cancer (RC) treated with curative intent, our aims were to (1) examine the patterns of nRT use and (2) explore the relationship between different nRT schedules and survival in the real-world setting. METHODS This is a multi-center retrospective cohort study based on population-based data from 5 regional comprehensive cancer centers in British Columbia, Canada. We analyzed patients diagnosed with clinical stage II or III RC from 2006 to 2010 and treated with either short-course (SC) or long-course (LC) nRT prior to curative intent surgery. Logistic regression models were constructed to determine the factors associated with the course of nRT delivered to patients. Kaplan-Meier methods and Cox regression that accounted for known prognostic factors were used to evaluate the relationship between nRT schedule and overall (OS), disease-free (DFS), local recurrence-free (LRFS), and distant recurrence-free survival (DRFS). RESULTS We identified 427 patients: the median age was 65 years (range, 31 to 94 years), 67% were men, 87% had T3 or T4 tumors, and 74% had N1 or N2 disease. Among them, 241 (56%) received SC and 186 (44%) received LC. Adjusting for confounders, patients with N1 or N2 disease were more likely to undergo LC (odds ratio [OR], 5.08; 95% confidence interval [CI], 2.51-11.22; P < .0001 and OR, 8.35; 95% CI, 3.35-22.39; P < .0001, respectively), whereas older age patients were less likely to receive LC (OR, 0.95; 95% CI, 0.94-0.98; P < .0001). In Kaplan-Meier analysis, there were no significant differences observed in OS, DFS, LRFS, and DRFS between SC and LC. Likewise, multivariate analyses demonstrated that OS (hazard ratio [HR], 0.91; 95% CI, 0.61-1.37; P = .66), DFS (HR, 1.06; 95% CI, 0.68-1.64; P = .80), LRFS (HR, 0.79; 95% CI, 0.39-1.57; P = .50) and DRFS (HR, 0.99; 95% CI, 0.60-1.61; P = .95) were similar regardless of nRT schedules. Additional baseline clinical and tumor characteristics did not influence outcomes (all P > .05). CONCLUSION Appropriate preoperative selection of SC versus LC nRT for locally advanced RC based on patient and tumor characteristics was not associated with differences in survival outcomes in the real-world setting.
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Affiliation(s)
- Omar Abdel-Rahman
- Clinical Oncology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Aalok Kumar
- Medical Oncology, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Hagen F Kennecke
- Medical Oncology, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Caroline H Speers
- Medical Oncology, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Winson Y Cheung
- Department of Oncology, University of Calgary, Tom Baker Cancer Centre, Calgary, Alberta, Canada.
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19
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Hu MH, Huang RK, Zhao RS, Yang KL, Wang H. Does neoadjuvant therapy increase the incidence of anastomotic leakage after anterior resection for mid and low rectal cancer? A systematic review and meta-analysis. Colorectal Dis 2017; 19:16-26. [PMID: 27321374 DOI: 10.1111/codi.13424] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 04/28/2016] [Indexed: 12/13/2022]
Abstract
AIM The aim was to evaluate the association of neoadjuvant therapy with increases in the incidence of anastomotic leakage (AL) after middle and low rectal anterior resection. METHOD The electronic databases of PubMed, Web of Science, Scopus and Ovid were searched between 1980 and 2015. The random effects model was used to model the pooled data to determine the odds ratio with 95% confidence interval. Heterogeneity was evaluated using the Q test and I2 statistics. Subgroup, sensitivity and meta-regression analysis was conducted to explore heterogeneity. RESULTS Neoadjuvant therapy was not shown to increase the incidence of postoperative AL as demonstrated by an OR of 1.16 [95% CI 0.99-1.36; P = 0.07 (random effects model)]. The subgroup analysis of neoadjuvant radiotherapy using the random effects model suggested that it did not increase the rate of postoperative AL (OR = 1.24, 95% CI 0.97-1.58; P = 0.08). The subgroup analysis of neoadjuvant chemoradiotherapy indicated that the rate of postoperative AL again did not increase with an OR = 1.06 [95% CI 0.86-1.30; P = 0.59 (random effects model)]. The interval to surgery after neoadjuvant therapy and preoperative radiotherapy (short or long course) was not associated with an increased incidence of postoperative AL. CONCLUSION Neoadjuvant therapy does not appear to increase the incidence of postoperative AL after anterior resection for mid and low rectal cancer. In addition, neither the interval to surgery after neoadjuvant therapy nor the radiotherapy regimen increases the rate of postoperative AL.
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Affiliation(s)
- M-H Hu
- Department of Colorectal Surgery, Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - R-K Huang
- Department of Colorectal Surgery, Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - R-S Zhao
- Department of Colorectal Surgery, Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - K-L Yang
- Department of Colorectal Surgery, Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - H Wang
- Department of Colorectal Surgery, Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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20
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Gaertner WB, Kwaan MR, Madoff RD, Melton GB. Rectal cancer: An evidence-based update for primary care providers. World J Gastroenterol 2015; 21:7659-7671. [PMID: 26167068 PMCID: PMC4491955 DOI: 10.3748/wjg.v21.i25.7659] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 04/04/2015] [Accepted: 05/21/2015] [Indexed: 02/07/2023] Open
Abstract
Rectal adenocarcinoma is an important cause of cancer-related deaths worldwide, and key anatomic differences between the rectum and the colon have significant implications for management of rectal cancer. Many advances have been made in the diagnosis and management of rectal cancer. These include clinical staging with imaging studies such as endorectal ultrasound and pelvic magnetic resonance imaging, operative approaches such as transanal endoscopic microsurgery and laparoscopic and robotic assisted proctectomy, as well as refined neoadjuvant and adjuvant therapies. For stage II and III rectal cancers, combined chemoradiotherapy offers the lowest rates of local and distant relapse, and is delivered neoadjuvantly to improve tolerability and optimize surgical outcomes, particularly when sphincter-sparing surgery is an endpoint. The goal in rectal cancer treatment is to optimize disease-free and overall survival while minimizing the risk of local recurrence and toxicity from both radiation and systemic therapy. Optimal patient outcomes depend on multidisciplinary involvement for tailored therapy. The successful management of rectal cancer requires a multidisciplinary approach, with the involvement of enterostomal nurses, gastroenterologists, medical and radiation oncologists, radiologists, pathologists and surgeons. The identification of patients who are candidates for combined modality treatment is particularly useful to optimize outcomes. This article provides an overview of the diagnosis, staging and multimodal therapy of patients with rectal cancer for primary care providers.
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21
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Smart PJ, Burbury KL, Lynch AC, Mackay JR, Heriot AG. Thromboembolism During Neoadjuvant Therapy for Gastrointestinal Cancer. Am J Clin Oncol 2014; 37:627-34. [DOI: 10.1097/coc.0b013e318280d78a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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22
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Does Preoperative Radio(chemo)therapy Increase Anastomotic Leakage in Rectal Cancer Surgery? A Meta-Analysis of Randomized Controlled Trials. Gastroenterol Res Pract 2014; 2014:910956. [PMID: 25477955 PMCID: PMC4244918 DOI: 10.1155/2014/910956] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Accepted: 10/22/2014] [Indexed: 12/15/2022] Open
Abstract
Objective. Preoperative radio(chemo)therapy (pR(C)T) appears to increase postoperative complications of rectal cancer resection, but clinical trials have reported conflicting results. The objective of this meta-analysis was performed to assess the effects of pR(C)T on anastomotic leak after rectal cancer resection. Methods. PubMed, Embase, and the Cochrane Library were searched from January 1980 to January 2014. Randomized controlled trials included all original articles reporting anastomotic leak in patients with rectal cancer, among whom some received preoperative radiotherapy or chemoradiotherapy while others did not. The analysed end-points were the anastomotic leak. Result. Seven randomized controlled trials with 3375 patients were included in the meta-analysis. 1660 forming the group undergoing preoperative radiotherapy or chemoradiotherapy versus 1715 patients undergoing without preoperative radiotherapy or chemoradiotherapy. The meta-analyses found that pR(C)T was not an independent risk factor for anastomotic leakage (OR 1.02, 95% CI 0.80-1.30; P = 0.88). Subgroups analysis was performed and the result was not altered. Conclusions. Current evidence demonstrates that pR(C)T did not increase the risk of postoperative anastomotic leak after rectal cancer resection in patients.
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23
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Kye BH, Cho HM. Overview of radiation therapy for treating rectal cancer. Ann Coloproctol 2014; 30:165-74. [PMID: 25210685 PMCID: PMC4155135 DOI: 10.3393/ac.2014.30.4.165] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Accepted: 07/23/2014] [Indexed: 12/13/2022] Open
Abstract
A major outcome of importance for rectal cancer is local control. Parallel to improvements in surgical technique, adjuvant therapy regimens have been tested in clinical trials in an effort to reduce the local recurrence rate. Nowadays, the local recurrence rate has been reduced because of both good surgical techniques and the addition of radiotherapy. Based on recent reports in the literature, preoperative chemoradiotherapy is now considered the standard of care for patients with stages II and III rectal cancer. Also, short-course radiotherapy appears to provide effective local control and the same overall survival as more long-course chemoradiotherapy schedules and, therefore, may be an appropriate choice in some situations. Capecitabine is an acceptable alternative to infusion fluorouracil in those patients who are able to manage the responsibilities inherent in self-administered, oral chemotherapy. However, concurrent administration of oxaliplatin and radiotherapy is not recommended at this time. Radiation therapy has long been considered an important adjunct in the treatment of rectal cancer. Although no prospective data exist for several issues, we hope that in the near future, patients with rectal cancer can be treated by using the best combination of surgery, radiation therapy, and chemotherapy in near future.
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Affiliation(s)
- Bong-Hyeon Kye
- Department of Surgery, St. Vincent Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
| | - Hyeon-Min Cho
- Department of Surgery, St. Vincent Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea
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24
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Ciria JP, Eguiguren M, Cafiero S, Uranga I, Diaz de Cerio I, Querejeta A, Urraca JM, Minguez J, Guimon E, Puertolas JR. Could preoperative short-course radiotherapy be the treatment of choice for localized advanced rectal carcinoma? Rep Pract Oncol Radiother 2014; 20:1-11. [PMID: 25535578 DOI: 10.1016/j.rpor.2014.06.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Revised: 05/01/2014] [Accepted: 06/29/2014] [Indexed: 12/18/2022] Open
Abstract
Short-course preoperative radiotherapy (RT) is widely used in northern Europe for locally advanced resectable rectal cancer, but its role in the era of advanced imaging techniques is uncertain. Here, we reviewed articles and abstracts on SCRT published from 1974 through 2013 with the goal of identifying patients who might be best suited for short-course RT. We included relevant articles comparing surgery with or without preoperative radiation published before and after the advent of total mesorectal excision. We also analyzed two randomized trials directly comparing short-course RT with conventionally fractionated chemoradiation (the Polish Colorectal Study Group and the Trans-Tasman Radiation Oncology Group) that compared short-course RT with conventional chemoradiotherapy. We conclude from our review that short-course RT can be generally applied for operable rectal cancer and produces high rates of pelvic control with acceptable toxicity; it reduces local recurrence rates but does not increase overall survival. SCRT seems to be best used for tumors considered "low risk," i.e., those that are >5 cm from the anal margin, without circumferential margin involvement, and involvement of fewer than 4 lymph nodes. Whether sequential chemotherapy can further improve outcomes remains to be seen, as does the best time for surgery (immediately or 6-8 weeks after RT). We further recommend that selection of patients for short-course RT should be based on findings from magnetic resonance imaging or transrectal ultrasonography.
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Affiliation(s)
- Juan Pablo Ciria
- Departments of Radiation Oncology and Radiation Physics, IDOH Instituto de Oncohematología Hospital, Universitario Donostia, Donostia, Basque Country, Spain
| | - Mikel Eguiguren
- Departments of Radiation Oncology and Radiation Physics, IDOH Instituto de Oncohematología Hospital, Universitario Donostia, Donostia, Basque Country, Spain
| | - Sergio Cafiero
- Departments of Radiation Oncology and Radiation Physics, IDOH Instituto de Oncohematología Hospital, Universitario Donostia, Donostia, Basque Country, Spain
| | - Intza Uranga
- Departments of Radiation Oncology and Radiation Physics, IDOH Instituto de Oncohematología Hospital, Universitario Donostia, Donostia, Basque Country, Spain
| | - Ivan Diaz de Cerio
- Departments of Radiation Oncology and Radiation Physics, IDOH Instituto de Oncohematología Hospital, Universitario Donostia, Donostia, Basque Country, Spain
| | - Arrate Querejeta
- Departments of Radiation Oncology and Radiation Physics, IDOH Instituto de Oncohematología Hospital, Universitario Donostia, Donostia, Basque Country, Spain
| | - Jose Maria Urraca
- Departments of Radiation Oncology and Radiation Physics, IDOH Instituto de Oncohematología Hospital, Universitario Donostia, Donostia, Basque Country, Spain
| | - Julian Minguez
- Departments of Radiation Oncology and Radiation Physics, IDOH Instituto de Oncohematología Hospital, Universitario Donostia, Donostia, Basque Country, Spain
| | - Elena Guimon
- Departments of Radiation Oncology and Radiation Physics, IDOH Instituto de Oncohematología Hospital, Universitario Donostia, Donostia, Basque Country, Spain
| | - Jose Ramón Puertolas
- Departments of Radiation Oncology and Radiation Physics, IDOH Instituto de Oncohematología Hospital, Universitario Donostia, Donostia, Basque Country, Spain
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Abstract
The treatment of rectal cancer has evolved significantly in recent decades. Both modern radiotherapy treatment concepts and surgical techniques have been able to improve oncological as well as functional outcomes for rectal cancer patients. Large-scale, multicenter, randomized trials have been able to demonstrate the benefits of neoadjuvant treatment over adjuvant radiotherapy. In addition, local tumor control is improved by neoadjuvant irradiation. Conversely, patients receiving a total mesorectal excision showed no survival advantage following irradiation vs. only surgically resected patients. In addition, radiation therapy is associated with a certain morbidity and mortality. This paper summarizes the available evidence regarding postoperative morbidity, mortality, and long-term chronic effects of neoadjuvant radiotherapy.
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van den Broek CB, Vermeer TA, Bastiaannet E, Rutten HJ, van de Velde CJ, Marijnen CA. Impact of the interval between short-course radiotherapy and surgery on outcomes of rectal cancer patients. Eur J Cancer 2013; 49:3131-9. [DOI: 10.1016/j.ejca.2013.05.025] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Revised: 03/04/2013] [Accepted: 05/26/2013] [Indexed: 11/25/2022]
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Colorectal Cancer in the Elderly: How Do We Tailor Treatment with Chemotherapy and Radiotherapy Most Appropriately? CURRENT COLORECTAL CANCER REPORTS 2013. [DOI: 10.1007/s11888-013-0163-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Collin Å, Gustafsson UM, Smedh K, Påhlman L, Graf W, Folkesson J. Effect of local gentamicin-collagen on perineal wound complications and cancer recurrence after abdominoperineal resection: a multicentre randomized controlled trial. Colorectal Dis 2013; 15:341-6. [PMID: 22889358 DOI: 10.1111/j.1463-1318.2012.03196.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
AIM Perineal wound sepsis is a common problem after abdominoperineal resection of the rectum (APR), with a reported incidence of 10-15% in previously non-irradiated patients, 20-30% in patients given preoperative radiation and 50% among patients submitted to preoperative radiation combined with chemotherapy. The local application of gentamicin-collagen was evaluated to determine whether its use in the perineal wound reduced risk complications and had an effect on cancer recurrence. METHOD In this prospective multicentre (seven hospitals) randomized controlled trial, 102 patients undergoing APR due to cancer or benign disease were randomized into two groups including surgery with gentamicin-collagen (GS+, n = 52) or surgery without gentamicin-collagen (GS-, n = 50). Patients were followed at 7, 30 and 90 days and at 1 and 5 years. RESULTS There were no statistically significant differences between the two groups regarding perineal wound complications, infectious or non-infectious, or cancer recurrence. CONCLUSION There was no statistically significant effect on perineal wound complications or cancer recurrence following the local administration of gentamicin-collagen during APR.
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Affiliation(s)
- Å Collin
- Department of Surgical Science, Uppsala University, Uppsala, Sweden.
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Salmenkylä S, Kouri M, Österlund P, Pukkala E, Luukkonen P, Hyöty M, Pääkkönen M, Mäkelä J, Mustonen H, Järvinen HJ. Does Preoperative Radiotherapy with Postoperative Chemotherapy Increase Acute Side-Effects and Postoperative Complications of Total Mesorectal Excision? Report of the Randomized Finnish Rectal Cancer Trial. Scand J Surg 2012; 101:275-82. [DOI: 10.1177/145749691210100410] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background and Aims: In a randomized trial the effect of short-term preoperative radio therapy and postoperative chemotherapy was studied in patients undergoing total mesorectal excision (TME) for clinically resectable rectal cancer. The primary endpoint was overall survival. The secondary endpoints published herein were the incidence of postoperative complications and adverse events with perioperative adjuvant therapy. Material and Methods: In 1995–2002, 278 eligible patients with stage II and stage III rectal cancer were randomly assigned to TME alone (surgery group) or to preoperative 25Gy radiotherapy in 5 fractions and postoperative 5-fluorouracil and leucovorin chemotherapy in addition (RT+CTgroup). Results: Anastomotic leakage rate did not significantly differ between the surgery and the RT + CT group, 20.6% vs. 27.4%. Postoperative infections (15.5 vs. 26.2%, p = 0.037) and perineal wound dehiscence (15.9 vs. 38.5%, p = 0.045) were more common after radiotherapy. Grade 3–5 adverse events were uncommon with preoperative radiotherapy (one, 0.7% with reversible lumbar plexopathy) and postoperative chemotherapy (hematologic in 10.8%, with one septic death, and gastrointestinal in 4.8%). Conclusions: Perioperative adjuvant therapy was generally well tolerated and did not lead to an increase in serious surgical complications. Wound infections and perineal wound dehiscence were more common in irradiated patients.
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Affiliation(s)
- S. Salmenkylä
- Department of Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - M. Kouri
- Department of Oncology, Helsinki University Central Hospital, Helsinki, Finland
| | - P. Österlund
- Department of Oncology, Helsinki University Central Hospital, Helsinki, Finland
| | - E. Pukkala
- Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, Helsinki, Finland
| | - P. Luukkonen
- Department of Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - M. Hyöty
- Department of Surgery, Tampere University Hospital, Tampere, Finland
| | - M. Pääkkönen
- Department of Surgery, Kuopio University Hospital, Kuopio, Finland
| | - J. Mäkelä
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - H. Mustonen
- Department of Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - H. J. Järvinen
- Department of Surgery, Helsinki University Central Hospital, Helsinki, Finland
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Thariat J, Hannoun-Levi JM, Sun Myint A, Vuong T, Gérard JP. Past, present, and future of radiotherapy for the benefit of patients. Nat Rev Clin Oncol 2012. [PMID: 23183635 DOI: 10.1038/nrclinonc.2012.203] [Citation(s) in RCA: 255] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Radiotherapy has been driven by constant technological advances since the discovery of X-rays in 1895. Radiotherapy aims to sculpt the optimal isodose on the tumour volume while sparing normal tissues. The benefits are threefold: patient cure, organ preservation and cost-efficiency. The efficacy and tolerance of radiotherapy were demonstrated by randomized trials in many different types of cancer (including breast, prostate and rectum) with a high level of scientific evidence. Such achievements, of major importance for the quality of life of patients, have been fostered during the past decade by linear accelerators with computer-assisted technology. More recently, these developments were augmented by proton and particle beam radiotherapy, usually combined with surgery and medical treatment in a multidisciplinary and personalized strategy against cancer. This article reviews the timeline of 100 years of radiotherapy with a focus on breakthroughs in the physics of radiotherapy and technology during the past two decades, and the associated clinical benefits.
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Affiliation(s)
- Juliette Thariat
- Department of Radiation Oncology, Centre Antoine Lacassagne--University Nice Sophia Antipolis, 33 Avenue Valombrose, 06189 Nice, France
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Penninckx F, Beirens K, Fieuws S, Ceelen W, Demetter P, Haustermans K, Van de Stadt J, Vindevoghel K. Risk adjusted benchmarking of clinical anastomotic leakage rate after total mesorectal excision in the context of an improvement project. Colorectal Dis 2012; 14:e413-21. [PMID: 22321047 DOI: 10.1111/j.1463-1318.2012.02977.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Anastomotic leakage (AL) after total mesorectal excision (TME) is a major adverse event. This study evaluates variability in AL between centres participating on a voluntary basis in PROCARE, a Belgian improvement project, and how further improvement of the AL rate might be achieved. METHOD Between January 2006 and March 2011, detailed data on 1815 patients (mean age 65.5 years, 63% male) who underwent elective TME with colo-anal reconstruction for rectal cancer were registered by 48 centres. Variability in early clinical AL rate was analysed before and after adjustment for gender, age > 60 years, American Society of Anesthesiologists score of 3 or more and body mass index > 25 kg/m(2). RESULTS The overall AL rate was 6.7% (95% CI 5.6%-7.9%). Early AL required reoperation in 86.8% of patients. It increased length of hospital stay from 14.7 days to 32.4 days and in-hospital mortality from 1.1% to 4.8%. Statistically significant variability in AL rate between centres was not observed, either before or after risk adjustment. Nonetheless, further improvement may be achievable in some centres by targeting the adjusted performance of better performing centres. These centres used neoadjuvant treatment, rectal irrigation, mobilization of the splenic flexure, resection of the sigmoid colon, side-to-end colo-anastomosis with or without pouch and defunctioning stoma at primary surgery in a significantly higher proportion of patients than less well performing centres. CONCLUSION The overall AL rate was low but needs to be interpreted with caution because of incomplete registration. Further improvement might be achieved by adopting the approach of better performing centres.
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Affiliation(s)
- F Penninckx
- PROCARE p/a Foundation Belgian Cancer Registry, Brussels, Belgium.
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Combs SE, Kieser M, Habermehl D, Weitz J, Jäger D, Fossati P, Orrechia R, Engenhart-Cabillic R, Pötter R, Dosanjh M, Jäkel O, Büchler MW, Debus J. Phase I/II trial evaluating carbon ion radiotherapy for the treatment of recurrent rectal cancer: the PANDORA-01 trial. BMC Cancer 2012; 12:137. [PMID: 22472035 PMCID: PMC3342902 DOI: 10.1186/1471-2407-12-137] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Accepted: 04/03/2012] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Treatment standard for patients with rectal cancer depends on the initial staging and includes surgical resection, radiotherapy as well as chemotherapy. For stage II and III tumors, radiochemotherapy should be performed in addition to surgery, preferentially as preoperative radiochemotherapy or as short-course hypofractionated radiation. Advances in surgical approaches, especially the establishment of the total mesorectal excision (TME) in combination with sophisticated radiation and chemotherapy have reduced local recurrence rates to only few percent. However, due to the high incidence of rectal cancer, still a high absolute number of patients present with recurrent rectal carcinomas, and effective treatment is therefore needed.Carbon ions offer physical and biological advantages. Due to their inverted dose profile and the high local dose deposition within the Bragg peak precise dose application and sparing of normal tissue is possible. Moreover, in comparison to photons, carbon ions offer an increase relative biological effectiveness (RBE), which can be calculated between 2 and 5 depending on the cell line as well as the endpoint analyzed.Japanese data on the treatment of patients with recurrent rectal cancer previously not treated with radiation therapy have shown local control rates of carbon ion treatment superior to those of surgery. Therefore, this treatment concept should also be evaluated for recurrences after radiotherapy, when dose application using conventional photons is limited. Moreover, these patients are likely to benefit from the enhanced biological efficacy of carbon ions. METHODS AND DESIGN In the current Phase I/II-PANDORA-01-Study the recommended dose of carbon ion radiotherapy for recurrent rectal cancer will be determined in the Phase I part, and feasibilty and progression-free survival will be assessed in the Phase II part of the study.Within the Phase I part, increasing doses from 12 × 3 Gy E to 18 × 3 Gy E will be applied.The primary endpoint in the Phase I part is toxicity, the primary endpoint in the Phase II part is progression-free survival. DISCUSSION With conventional photon irradiation treatment of recurrent rectal cancer is limited, and the clinical effect is only moderate. With carbon ions, an improved outcome can be expected due to the physical and biological characteristics of the carbon ion beam. However, the optimal dose applicable in this clincial situation as re-irradiation still has to be determined. This, as well as efficacy, is to be evaluated in the present Phase I/II trial. TRIAL REGISTRATION NCT01528683.
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Affiliation(s)
- Stephanie E Combs
- Deparment of Radiation Oncology, University Hospital of Heidelberg, Heidelberg, Germany.
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Sullivan MC, Roman SA, Sosa JA. Emergency Surgery in Patients Who Have Undergone Recent Radiotherapy is Associated With Increased Complications and Mortality: Review of 536 Patients. World J Surg 2011; 36:31-8. [DOI: 10.1007/s00268-011-1230-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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Use of primary radiotherapy for rectal cancer in the Netherlands between 1997 and 2008: a population-based study. Clin Oncol (R Coll Radiol) 2011; 24:e1-8. [PMID: 21968247 DOI: 10.1016/j.clon.2011.09.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Revised: 06/23/2011] [Accepted: 08/10/2011] [Indexed: 01/27/2023]
Abstract
AIMS To describe variation in the utilisation rates of primary radiotherapy for patients with rectal cancer in the Netherlands, focusing on time trends and age effects. MATERIALS AND METHODS Data on primary non-metastatic rectal cancer were derived from the population-based cancer registries of four comprehensive cancer centres (regions) in the Netherlands (1997-2008, n=13,055). RESULTS An increase in the utilisation rate was noted for the four regions, from 37-46% in 1997 to 66-76% in 2008, for both genders. This increase was found predominately for preoperative radiotherapy (from 13-31% to 58-67%) and (unsurprisingly) was most pronounced for stage T2-3 patients (from 9-27% to 68-80%). The probability of receiving radiotherapy decreased with age: the odds of receiving preoperative radiotherapy was reduced in patients aged 65 years and older, as well as the odds of receiving postoperative radiotherapy in those aged 75 years and older, which remained significant after adjustment for stage, gender and region. Regional differences persisted in multivariable analyses, i.e. the odds of receiving preoperative radiotherapy was reduced in two regions: odds ratio: 0.4 (95% confidence interval: 0.4-0.5) and 0.7 (0.6-0.8). The odds of receiving postoperative radiotherapy was significantly increased in these regions [odds ratio: 2.6 (2.2-3.2) and 1.6 (1.3-1.9), respectively] and reduced in another [odds ratio 0.8 (0.6-0.96)]. CONCLUSIONS The utilisation rate of radiotherapy for rectal cancer increased significantly over time, particularly for preoperative radiotherapy and was most pronounced for T2-3 patients. Due to national multidisciplinary treatment guidelines, regional differences became limited in recent years after adjustment for age and stage of the disease. A low utilisation rate of radiotherapy was seen in women and elderly patients.
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Lin CT, Chen SG, Chen TM, Dai NT, Fu JP, Chang SC. Successful management of osteoradionecrotic precoccygeal defect with the free latissimus dorsi muscle flap: case report and literature review. Microsurgery 2011; 31:490-4. [PMID: 21766328 DOI: 10.1002/micr.20893] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Accepted: 02/01/2011] [Indexed: 01/26/2023]
Abstract
Perineal wound complications following abdominoperineal resection (APR) are still frequent and most troublesome complications. We report the case of a 79-year-old male found to have the huge precoccygeal defect with infection after APR for rectal carcinoma. Before surgery, the patient received a complete course of chemoradiation therapy to treat for downgrade staging of the rectal malignancy. Extensive debridement of the perianal wound was performed for three times, followed by perianal reconstruction and packing and augmentation of the precoccygeal dead space with free latissimus dorsi (LD) muscle flap. Although persisted wound infection was still observed after reconstruction, the patient still led a good result after one time of further debridement and split-thickness skin graft. We selected free LD muscle flap to fill and seal off the large pelvic dead space without the needs to change the jackknife position of the patient after debridement. To the best of our knowledge, this is the first case reported in the literature with the radiation-associated perianal wound infection after APR reconstructed successfully by free LD muscle flap.
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Affiliation(s)
- Chin-Ta Lin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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Abstract
BACKGROUND The optimal type of neoadjuvant therapy regimen in rectal cancer is contentious. OBJECTIVE This study aimed to review the impact of neoadjuvant therapy on oncological outcomes and complications (short and long term) in patients undergoing total mesorectal excision for rectal cancer. DATA SOURCES An electronic search of MEDLINE, PubMed, EMBASE, and the Cochrane Database of Collected Reviews was performed through March 2010. STUDY SELECTION Key-word combinations including rectal cancer, total mesorectal excision, radiotherapy, chemotherapy, endorectal ultrasound, and magnetic resonance imaging were used to identify randomized control trials where chemotherapy and/or radiotherapy were deployed before resectional surgery. INTERVENTION(S) Patients underwent total mesorectal excision for rectal cancer who did and did not receive preoperative chemotherapy and/or radiotherapy. MAIN OUTCOME MEASURES The main outcome measures comprised the impact of the addition of neoadjuvant therapy to total mesorectal excision on the perioperative complication rate, the pathological complete response rate, the rate of local recurrence, and long-term treatment-related complications. RESULTS A total of 12 randomized control trials involving 9410 patients were included. Both short-course radiotherapy and long-course chemoradiation can offer a relative risk reduction of 50% in local recurrence in appropriately selected patients with stage II and III rectal cancer. This oncological benefit comes at the cost of a relative risk increase of 50% in both acute treatment-related toxicity and long-term anorectal dysfunction. LIMITATIONS Preoperative staging provides only an estimate of the "true" tumor stage that can only be determined by histological assessment of the tumor specimen which renders appropriate patient selection challenging. CONCLUSIONS The current treatment trade-off of a relative risk reduction of local recurrence of 50% at the cost of a relative increase of 50% in treatment-related complications underpins the need for more accurate patient staging and more precise delivery of neoadjuvant therapy.
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Affiliation(s)
- Fergal J Fleming
- Division of Colorectal Surgery, University of Rochester Medical Center, Rochester, New York 14642, USA.
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Ishihara S, Watanabe T, Kiyomatsu T, Yasuda K, Nagawa H. Prognostic significance of response to preoperative radiotherapy, lymph node metastasis, and CEA level in patients undergoing total mesorectal excision of rectal cancer. Int J Colorectal Dis 2010; 25:1417-25. [PMID: 20809426 DOI: 10.1007/s00384-010-1051-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/17/2010] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of this study was to investigate the prognostic significance of the response of primary rectal lesions to preoperative radiotherapy, pathological nodal status, and carcinoembryonic antigen (CEA) levels before and after radiotherapy in rectal cancer patients treated with a total mesorectal excision. METHODS We investigated the prognostic significance of the clinical and pathological factors in 97 patients treated with preoperative radiotherapy (50-50.4 Gy over 5-6 weeks) followed by curative resections. RESULTS A high CEA level (>5 ng/mL) after radiotherapy (hazard ratio, 2.849; 95% confidence interval, 1.061-7.651; p = 0.0377) and pathological lymph node metastasis (hazard ratio, 0.350; 95% confidence interval, 0.154-0.797; p = 0.0124) were independently associated with postoperative recurrence. Although the CEA level before radiotherapy was associated with disease-free survival in a univariate analysis, it lost its statistical significance in a multivariate analysis. The response of the primary rectal lesions, evaluated pathologically by T stage and the degree of regression, was not associated with disease-free survival. In patients without lymph node metastasis, the 5-year disease-free survival of those with a high CEA level after radiotherapy was significantly worse than those with low CEA after radiotherapy (61.6% vs. 89.0%, respectively, p = 0.0234). CONCLUSIONS Pathological lymph node metastasis and a high CEA level after radiotherapy were independent predictors of a poor outcome in rectal cancer patients treated with preoperative radiotherapy. The CEA level after radiotherapy was capable of discriminating patients with a high risk of recurrence among pathologically node-negative patients.
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Affiliation(s)
- Soichiro Ishihara
- Department of Surgery, Teikyo University, 2-11-1, Kaga, Itabashi-ku, Tokyo, 173-8605, Japan.
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Gollins S. Radiation, chemotherapy and biological therapy in the curative treatment of locally advanced rectal cancer. Colorectal Dis 2010; 12 Suppl 2:2-24. [PMID: 20618363 DOI: 10.1111/j.1463-1318.2010.02320.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To review the published evidence relating to the use of radiotherapy (RT), chemotherapy and biological therapy as adjuncts to surgery in the curative treatment of rectal cancer. METHODS Searches were carried out of the MEDLINE and CANCERLIT databases together with conference abstracts from key meetings including the American Society of Clinical Oncology Annual Meeting and Gastrointestinal Cancers Symposium and the ECCO/ESMO Multidisciplinary Congress. RESULTS RT reduces local pelvic recurrence when used as an adjunct to surgery, even when this is performed optimally by total mesorectal excision (TME). RT is usually given as short-course preoperative radiotherapy (SCPRT) followed by immediate surgery which produces no or very little downstaging or long-course concurrent chemoradiation (CRT) followed by a 6-8 week gap prior to surgery which produces significant downstaging. The prognostic importance of achieving a clear histological circumferential resection margin is now well recognised and pathological assessment of the quality of surgery can predict long-term outcomes. Internationally there is considerable heterogeneity in the staging modalities and criteria used in deciding which approach might be used, in the reporting of histological results and in RT parameters (time/dose/fractionation/volume). Attempts to increase the potency of CRT have included the addition of concurrent chemotherapeutic and biological agents to the standard fluoropyrimidine although there is little randomised data and none with regard to long-term survival outcomes. Neither SCPRT nor downstaging CRT have been shown to reduce the rate of subsequent distant metastatic relapse which remains a significant clinical problem. The potential additional benefit of neoadjuvant or adjuvant chemotherapy in addition to SCPRT or long-course CRT remains ill-defined. Late morbidity can include bowel and sexual dysfunction, pelvic fractures and second malignancies with considerably more being known in relation to SCPRT than long-course CRT. CONCLUSIONS Improvements in imaging, pathology and surgical technique combined with multimodality treatment using RT and chemotherapy are leading to continuing improvements in the long term outcome for patients with rectal cancer although much remains to be learnt regarding the optimum strategy for use of these in different clinical contexts and their relationship to long-term morbidity.
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Affiliation(s)
- S Gollins
- North Wales Cancer Treatment Centre, Glan Clwyd Hospital, Bodelwyddan, Denbighshire, UK.
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Olsson LI, Granström F, Påhlman L. Sphincter preservation in rectal cancer is associated with patients' socioeconomic status. Br J Surg 2010; 97:1572-81. [DOI: 10.1002/bjs.7157] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Abstract
Background
Decision making regarding the choice of surgical procedure in rectal cancer is complex. It was hypothesized that, in addition to clinical factors, several aspects of patients' socioeconomic background influence this process.
Methods
Individually attained data on civil status, education and income were linked to the Swedish Rectal Cancer Registry 1995–2005 (16 713 patients) and analysed by logistic regression.
Results
Anterior resection (AR) was performed in 7433 patients (44·5 per cent), abdominoperineal resection (APR) in 3808 (22·8 per cent) and Hartmann's procedure in 1704 (10·2 per cent). Unmarried patients were least likely (odds ratio (OR) 0·76, 95 per cent confidence interval (c.i.) 0·64 to 0·88) and university-educated men were most likely (OR 1·30, 1·04 to 1·62) to have an AR. Patients with the highest income were more likely to undergo AR (OR 0·80, 0·85 and 0·86 respectively for first, second and third income quartiles). Socioeconomic differences in the use of AR were smallest among the youngest patients. Unmarried patients were more likely (OR 1·21, 95 per cent c.i. 1·00 to 1·48) and university-educated patients less likely (OR 0·78, 95 per cent c.i. 0·63 to 0·98) to have an APR.
Conclusion
The choice of surgical strategy in rectal cancer is not socioeconomically neutral. Confounding factors, such as co-morbidity or smoking, may explain some of the differences but inequality in treatment is also plausible.
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Affiliation(s)
- L I Olsson
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - F Granström
- Centre for Clinical Research, Sörmland County Council/Uppsala University, Uppsala, Sweden
| | - L Påhlman
- Department of Surgery, Uppsala University, Uppsala, Sweden
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Abstract
Anorectal procedures are associated with significant morbidity and include complications of the perineum, which can cause substantial difficulty for the patient. Prevention of perineal complications is key, but many anorectal procedures are performed in difficult situations such as large bulky tumors or inflammatory bowel diseases. In this review, the authors outline many of the complications encountered following both simple and complex anorectal procedures while highlighting best evidence for treatment.
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Affiliation(s)
- James W Ogilvie
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA
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Kerr SF, Klonizakis M, Glynne-Jones R. Suppression of the postoperative neutrophil leucocytosis following neoadjuvant chemoradiotherapy for rectal cancer and implications for surgical morbidity. Colorectal Dis 2010; 12:549-54. [PMID: 19486105 DOI: 10.1111/j.1463-1318.2009.01858.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The extent to which neoadjuvant chemoradiotherapy for rectal cancer influences postoperative morbidity is controversial. This study investigated whether this treatment suppresses the normal perioperative inflammatory response and explored the clinical implications. METHOD Prospective databases were queried to identify 37 consecutive study patients undergoing definitive surgery following 5-FU/capecitabine-based chemoradiotherapy and 34 consecutive untreated control patients operated upon for rectal or rectosigmoid cancer. Preoperative (< 10 days) and postoperative (< 24 h) neutrophil counts, along with morbidity data, were confirmed retrospectively. Univariate and multivariate analyses assessed the apparent effect of chemoradiotherapy on change in neutrophil count. The latter's association with postoperative morbidity was then examined. RESULTS Sufficient data were available for 34 study and 27 control patients. Repeated-measures ANCOVA revealed significant differences between their perioperative neutrophil counts (P = 0.02). Of the other characteristics which differed between the groups, only age and tumour location were prognostically significant regarding perioperative change in neutrophil count. Accounting for relevant covariates, chemoradiotherapy was significantly associated with a suppressed perioperative neutrophil leucocytosis. Local postoperative complications affected 25 of 61 patients, who had lower perioperative neutrophil increases than their counterparts (P = 0.016). CONCLUSION Chemoradiotherapy appears to suppress the perioperative inflammatory response, thereby increasing susceptibility to local postoperative complications.
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Affiliation(s)
- S F Kerr
- Department of Surgery, Barnet Hospital, Barnet, Hertfordshire, UK
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Abstract
OBJECTIVE This systematic review was designed to determine postoperative complication rates of radical surgery for rectal cancer (abdominal perineal resection and anterior resection). SUMMARY OF BACKGROUND DATA Lack of accepted complication rates for rectal cancer surgery may hinder quality improvement efforts and may impede the conception of future studies because of uncertainty regarding the expected event rates. METHODS All prospective studies of rectal cancer receiving radical surgery published between 1990 and August 2008 were obtained by searching Ovid MEDLINE, EMBASE, as well as ASCO GI, CAGS, and ASCRS meeting abstracts between 2004 and 2008. There was no language restriction. The outcomes extracted were anastomotic leak, pelvic sepsis, postoperative death, wound infection, and fecal incontinence. Summary complication rates were obtained using a random effects model; the Z-test was used to test for study heterogeneity. RESULTS Fifty-three prospective cohort studies and 45 randomized controlled studies with 36,315 patients (24,845 patients had an anastomosis) were eligible for inclusion. Most of the studies found were based in continental Europe (58%), followed by Asia (25%), United Kingdom (10%), North America (5%), and Australia/New Zealand. The anastomotic leak rate, reported in 84 studies, was 11% (95% CI: 10, 12); the pelvic sepsis rate, in 29 studies, was 12% (9, 16); the postoperative death rate, in 75 studies, was 2% (2, 3); and the wound infection rate, in 50 studies, was 7% (5, 8). Fecal incontinence rates were reported in too few studies and so heterogeneously that numerical summarization was inappropriate. Year of publication, use of preoperative radiation, use of laparoscopy, and use of protecting stoma were not significant variables, but average age, median tumor height, and method of detection (clinical vs. radiologic) showed significance to explain heterogeneity in anastomotic leak rates. Year of publication, study origin, average age, and use of laparoscopy were significant, but median tumor height and preoperative radiation use were not significant in explaining heterogeneity among observed postoperative death rates. With multivariable analysis, only average age for anastomotic leak and year of publication for postoperative death remained significant. CONCLUSIONS Benchmark complication rates for radical rectal cancer surgery were obtained for use in sample size calculations in future studies and for quality control purposes. Postoperative death rates showed improvement in recent years.
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Konishi T, Watanabe T, Nagawa H, Oya M, Ueno M, Kuroyanagi H, Fujimoto Y, Akiyoshi T, Yamaguchi T, Muto T. Preoperative chemoradiation and extended pelvic lymphadenectomy for rectal cancer: Two distinct principles. World J Gastrointest Surg 2010; 2:95-100. [PMID: 21160857 PMCID: PMC2999227 DOI: 10.4240/wjgs.v2.i4.95] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Revised: 02/14/2010] [Accepted: 02/21/2010] [Indexed: 02/06/2023] Open
Abstract
Extended pelvic lymphadenectomy (EPL) with total mesorectal excision (TME) has been reported to provide oncological benefit in lower rectal cancer in Japan. In Western countries EPL is not widely accepted because of frequent morbidity but instead preoperative chemoradiation (CRT) followed by TME has been established as a standard treatment for decreasing local recurrence. Recently, several studies have focused on the comparison between these two distinct therapeutic approaches in Western countries and Japan. A study comparing Dutch trial data and Japanese data revealed that EPL and RT are almost equivalent in decreasing local recurrence in lower rectal cancer as compared with TME alone. Considering that almost 45% survival can be achieved by EPL even in the presence of metastatic lateral lymph nodes (LLNs), EPL performed by experienced surgeons definitely contributes to decrease local recurrence. On the other hand, a randomized controlled trial in Japan that compared EPL with conventional TME following preoperative RT revealed that EPL is associated with a higher frequency of sexual and urinary dysfunction without oncological benefits in the presence of preoperative RT. On this point, preoperative CRT followed by conventional TME without EPL would be a better therapeutic approach in patients without evident metastatic LLNs. For future treatment, it would be desirable to have a narrower indication for EPL using full advantage of recent improvement in image diagnosis. Although objective comparison of these two principles between Japan and the West is difficult due to differences in patient groups, further studies would lead to the next great step towards future improvement in treating lower rectal cancer.
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Affiliation(s)
- Tsuyoshi Konishi
- Tsuyoshi Konishi, Masatoshi Oya, Masashi Ueno, Hiroya Kuroyanagi, Yoshiya Fujimoto, Takashi Akiyoshi, Toshiharu Yamaguchi, Tetsuichiro Muto, Department of Gastroenterological Surgery, Cancer Institute Hospital, Tokyo, 135-8550, Japan
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Crane CH, Eng C, Feig BW, Das P, Skibber JM, Chang GJ, Wolff RA, Krishnan S, Hamilton S, Janjan NA, Maru DM, Ellis LM, Rodriguez-Bigas MA. Phase II trial of neoadjuvant bevacizumab, capecitabine, and radiotherapy for locally advanced rectal cancer. Int J Radiat Oncol Biol Phys 2010; 76:824-30. [PMID: 19464823 DOI: 10.1016/j.ijrobp.2009.02.037] [Citation(s) in RCA: 137] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2008] [Revised: 01/21/2009] [Accepted: 02/09/2009] [Indexed: 02/03/2023]
Abstract
PURPOSE We designed this Phase II trial to assess the efficacy and safety of the addition of bevacizumab to concurrent neoadjuvant capecitabine-based chemoradiation in locally advanced rectal cancer. METHODS Between April 2004 and December 2007, 25 patients with clinically staged T3N1 (n = 20) or T3N0 (n = 5) rectal cancer received neoadjuvant therapy with radiotherapy (50.4 Gy in 28 fractions over 5.5 weeks), bevacizumab every 2 weeks (3 doses of 5 mg/kg), and capecitabine (900 mg/m(2) orally twice daily only on days of radiation), followed by surgical resection a median of 7.3 weeks later. RESULTS Procedures included abdominoperineal resection (APR; 6 patients), proctectomy with coloanal anastamosis (8 patients), low anterior resection (10 patients), and local excision (1 patient). Eight (32%) of 25 patients had a pathologic complete response, and 6 (24%) of 25 had <10% viable tumor cells in the specimen. No patient had Grade 3 hand-foot syndrome, gastrointestinal toxicity, or significant hematologic toxicity. Three wound complications required surgical intervention (one coloanal anastamostic dehiscence requiring completion APR and two perineal wound dehiscences after initial APR). Five minor complications occurred that resolved without operative intervention. With a median follow-up of 22.7 months (range, 4.5-32.4 months), all patients were alive; one patient has had a recurrence in the pelvis (2-year actuarial rate, 6.2%) and 3 had distant recurrences. CONCLUSIONS The addition of bevacizumab to neoadjuvant chemoradiation resulted in encouraging pathologic complete response without an increase in acute toxicity. The impact of bevacizumab on perineal wound and anastamotic healing due to concurrent bevacizumab requires further study.
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Affiliation(s)
- Christopher H Crane
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
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Guckenberger M, Wulf J, Thalheimer A, Wehner D, Thiede A, Müller G, Sailer M, Flentje M. Prospective phase II study of preoperative short-course radiotherapy for rectal cancer with twice daily fractions of 2.9 Gy to a total dose of 29 Gy--long-term results. Radiat Oncol 2009; 4:67. [PMID: 20025752 PMCID: PMC2806295 DOI: 10.1186/1748-717x-4-67] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2009] [Accepted: 12/21/2009] [Indexed: 12/20/2022] Open
Abstract
Background To evaluate clinical outcome after preoperative short-course radiotherapy for rectal cancer with twice daily fractions of 2.9 Gy to a total dose of 29 Gy and adjuvant chemotherapy for pathological stage UICC ≥ II. Methods 118 patients (median age 64 years; male : female ratio 2.5 : 1) with pathological proven rectal cancer (clinical stage II 50%, III 41.5%, IV 8.5%) were treated preoperatively with twice daily radiotherapy of 2.9 Gy single fraction dose to a total dose of 29 Gy; surgery was performed immediately in the following week with total mesorectal excision (TME). Adjuvant 5-FU based chemotherapy was planned for pathological stage UICC ≥ II. Results After low anterior resection (70%) and abdominoperineal resection (30%), pathology showed stage UICC I (27.1%), II (25.4%), III (37.3%) and IV (9.3%). Perioperative mortality was 3.4% and perioperative complications were observed in 22.8% of the patients. Adjuvant chemotherapy was given in 75.3% of patients with pathological stage UICC ≥ II. After median follow-up of 46 months, five-year overall survival was 67%, cancer-specific survival 76%, local control 92% and freedom from systemic progression 75%. Late toxicity > grade II was observed in 11% of the patients. Conclusions Preoperative short-course radiotherapy, total mesorectal excision and adjuvant chemotherapy for pathological stage UICC ≥ II achieved excellent local control and favorable survival.
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den Dulk M, Marijnen CAM, Collette L, Putter H, Påhlman L, Folkesson J, Bosset JF, Rödel C, Bujko K, van de Velde CJH. Multicentre analysis of oncological and survival outcomes following anastomotic leakage after rectal cancer surgery. Br J Surg 2009; 96:1066-75. [PMID: 19672927 DOI: 10.1002/bjs.6694] [Citation(s) in RCA: 192] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The association between diverting stomas and symptomatic anastomotic leakage after rectal cancer surgery was studied, as well as the impact of leakage on local recurrence, distant metastasis, and disease-free, overall and cancer-specific survival. METHODS Data from the Swedish Rectal Cancer Trial, Dutch TME trial, CAO/ARO/AIO-94 trial, EORTC 22921 trial and Polish Rectal Cancer Trial were pooled (n = 5187). All eligible patients without distant metastases at the time of low anterior resection were selected (n = 2726); overall survival was studied in patients aged 75 years or less (n = 2480). Multivariable models were used to study the association between diverting stomas and anastomotic leakage, and between leakage and recurrence or survival. RESULTS Some 9.7 per cent of patients were diagnosed with a symptomatic anastomotic leak; diverting stomas were negatively associated with leakage (11.6 per cent without and 7.8 per cent with a stoma; P = 0.002). Anastomotic leakage was negatively associated with overall survival in the multivariable analysis (hazard ratio (HR) 1.29 (95 per cent confidence interval 1.02 to 1.63); P = 0.034), but not with cancer-specific survival (HR 1.12 (0.83 to 1.52); P = 0.466). CONCLUSION Diverting stomas were associated with less symptomatic anastomotic leakage. Oncological outcome was not significantly influenced by leakage, but overall survival was reduced.
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Affiliation(s)
- M den Dulk
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
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Short-course versus long-course neoadjuvant radiotherapy for lower rectal cancer: a systematic review. Ir J Med Sci 2009; 179:165-71. [DOI: 10.1007/s11845-009-0382-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2009] [Accepted: 06/09/2009] [Indexed: 10/20/2022]
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Aparicio T, Navazesh A, Boutron I, Bouarioua N, Chosidow D, Mion M, Choudat L, Sobhani I, Mentré F, Soulé JC. Half of elderly patients routinely treated for colorectal cancer receive a sub-standard treatment. Crit Rev Oncol Hematol 2009; 71:249-57. [PMID: 19131256 DOI: 10.1016/j.critrevonc.2008.11.006] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2008] [Revised: 11/03/2008] [Accepted: 11/20/2008] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Several database studies report a lack of care in elderly patients with colorectal cancer. PURPOSE To describe the management of elderly patients admitted for colorectal cancer; to identify factors associated with standard management according to recommendations and to study factors influencing the survival. PATIENTS AND METHODS All consecutive patients over 75 years managed for a colorectal adenocarcinoma in our hospital from 1995 to 2000 and followed until 2006 were retrospectively included. The appropriateness of the management of their disease according to the recommendations available at that time was assessed. Several risk factors in receiving the standard cancer treatment were tested using univariate and then multivariate logistic regression. Risk factors of survival were studied using univariate and then multivariate survival analysis. RESULTS One hundred and ten patients were included. Median age was 82 years (range: 75-96). A surgical treatment was performed in 96 patients. The median overall survival was 32 (1-108) months. A standard cancer treatment according to recommendations was performed in 53 (48%) patients: adjuvant chemotherapy in 6/23 patients with stage III tumour, palliative chemotherapy in 3/18 patients with stage IV tumour and adjuvant radiotherapy in 4/14 patients who had a rectal tumour resection. Multivariate analysis retains tumour stage I or II (OR=7.6, 95% C.I.=[2.9-19.9], p<0.0001) as the only factor associated with standard treatment and presence of metastasis (HR=3.9, 95% C.I. [1.4-10.8], p=0.005), and Charlson's score >3 (HR=28.9, 95% C.I. [2.5-335.6], p=0.001) as independent risk factors of poor survival. CONCLUSIONS Fifty two percent of elderly patients have had a sub-standard cancer treatment. The majority had a surgical treatment, but only a few received chemotherapy or radiotherapy. Metastasis, older age and Charlson's comorbidity score are the main prognosis factors of poor survival.
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Affiliation(s)
- Thomas Aparicio
- Service d'Hépato-Gastroentérologie, AP-HP, Hôpital Bichat, Université Denis Diderot, Paris 7, UFR de Médecine, Paris, France.
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Resectable Rectal Cancer: Preoperative Short-Course Radiation. COLORECTAL CANCER 2009. [DOI: 10.1007/978-1-4020-9545-0_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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