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Yang S, Lin Y, Zhong W, Xu W, Huang Z, Cai S, Chen W, Zhang B. Effect of laparoscopic versus open surgery on postoperative wound complications in patients with low rectal cancer: A meta-analysis. Int Wound J 2024; 21:e14471. [PMID: 37935425 PMCID: PMC10898391 DOI: 10.1111/iwj.14471] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 10/16/2023] [Accepted: 10/16/2023] [Indexed: 11/09/2023] Open
Abstract
This meta-analysis was conducted to evaluate the effect of microinvasive and open operations on postoperative wound complications in low rectal carcinoma patients. Research on limited English has been conducted systematically in PubMed, Embase, Cochrane Library and Web of Science. The date up to the search was in August 2023. Following review of the classification and exclusion criteria for this research and the evaluation of its quality in the literature, there were a total of 266 related papers, which were reviewed for inclusion in the period from 2004 to 2017. A total of 1774 cases of low rectal cancer were enrolled. Of these 913 cases, the laparoscopic operation was performed on 913 cases, while 861 cases were operated on low rectal carcinoma. The overall sample was between 10 and 482. Five trials described the efficacy of laparoscopy have lower risk than open on postoperative wound infection in patients with low rectal cancer (OR, 0.72;95 % CI, 0.48,1.09 p = 0.12). Three studies results showed that the anastomotic leak was not significantly different between open and laparoscopy (OR, 0.86; 95% CI, 0.58,1.26 p = 0.44). Six surgical trials in low rectal cancer patients reported haemorrhage, and five cases of surgical time were reported, with laparoscopy having fewer bleeding compared with open surgery (MD, -188.89; 95% CI, -341.27, -36.51 p = 0.02). Compared with laparoscopy, the operation time was shorter for the open operation (MD, 33.06; 95% CI, 30.56, 35.57 p < 0.0001). Overall, there is no significant difference between laparoscopy and open surgery in terms of incidence of infection and anastomosis leak. However, the rate of haemorrhage in laparoscopy is lower，and operation time in open surgery is lower.
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Affiliation(s)
- Shu Yang
- Department of Traditional Chinese MedicineThe second affiliated hospital of Fujian Medical UniversityQuanzhouChina
| | - Yuting Lin
- Department of Traditional Chinese MedicineThe second affiliated hospital of Fujian Medical UniversityQuanzhouChina
| | - Wenjin Zhong
- Department of Clinical LaboratoryThe second affiliated hospital of Fujian Medical UniversityQuanzhouChina
| | - Wenji Xu
- Department of gastroenterologyThe second affiliated hospital of Fujian Medical UniversityQuanzhouChina
| | - Zhongxin Huang
- Department of PathologyThe second affiliated hospital of Fujian Medical UniversityQuanzhouChina
| | - Suqin Cai
- Department of PathologyThe second affiliated hospital of Fujian Medical UniversityQuanzhouChina
| | - Wen Chen
- Department of Traditional Chinese MedicineThe second affiliated hospital of Fujian Medical UniversityQuanzhouChina
| | - Baogen Zhang
- Department of Traditional Chinese MedicineThe second affiliated hospital of Fujian Medical UniversityQuanzhouChina
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2
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Rektumkarzinom. COLOPROCTOLOGY 2021. [DOI: 10.1007/s00053-021-00541-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Toiyama Y, Kusunoki M. Changes in surgical therapies for rectal cancer over the past 100 years: A review. Ann Gastroenterol Surg 2020; 4:331-342. [PMID: 32724876 PMCID: PMC7382427 DOI: 10.1002/ags3.12342] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 02/26/2020] [Accepted: 04/02/2020] [Indexed: 12/15/2022] Open
Abstract
Advances in surgical and adjuvant therapies have resulted in a dramatic improvement in outcomes of rectal cancer in terms of both oncology and functional preservation. Surgery plays a central role in therapy as it is the only means of achieving a complete cure. These surgical advancements result from extensive pioneering research in the fields of anatomy and physiology. Much history lies behind the recent surgical breakthroughs of total mesorectal excision (TME) and intersphincteric resection (ISR). This article outlines the changes that have taken place in surgical therapies for rectal cancer over more than a century based on clinical trials performed to provide scientific evidence for these therapies.
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Affiliation(s)
- Yuji Toiyama
- Department of Gastrointestinal and Pediatric Surgery, Division of Reparative MedicineInstitute of Life Sciences, Mie University Graduate School of MedicineTsuJapan
| | - Masato Kusunoki
- Department of Gastrointestinal and Pediatric Surgery, Division of Reparative MedicineInstitute of Life Sciences, Mie University Graduate School of MedicineTsuJapan
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Knol J, Keller DS. Total Mesorectal Excision Technique-Past, Present, and Future. Clin Colon Rectal Surg 2020; 33:134-143. [PMID: 32351336 DOI: 10.1055/s-0039-3402776] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
While the treatment of rectal cancer is multimodal, above all, a proper oncological resection is critical. The surgical management of rectal cancer has substantially evolved over the past 100 years, and continues to progress as we seek the best treatment. Rectal cancer was historically an unsurvivable disease, with poor understanding of the embryological planes, lymphatic drainage, and lack of standardized technique. Major improvements in recurrence, survival, and quality of life have resulted from advances in preoperative staging, pathologic assessment, the development and timing of multimodal therapies, and surgical technique. The most significant contribution in advancing rectal cancer care may be the standardization and widespread implementation of total mesorectal excision (TME). The TME, popularized by Professor Heald in the early 1980s as a sharp, meticulous dissection of the tumor and mesorectum with all associated lymph nodes through the avascular embryologic plane, has shown universal reproducible reductions in local recurrence and improvement in disease-free and overall survival. Widespread education and training of surgeons worldwide in the TME have significantly impact outcomes for rectal cancer surgery, and the procedure has become the gold standard for curative resection of rectal cancer. In this article, we discuss the evolution of the standard abdominal approach to the TME, with emphasis on the history, relevant anatomy, standard procedure steps, oncologic outcomes, and technical evolution.
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Affiliation(s)
- Joep Knol
- Department of Abdominal Surgery, Jessa Hospital, Hasselt, Belgium
| | - Deborah S Keller
- Division of Colorectal Surgery, NewYork-Presbyterian/Columbia University Medical Center, New York, New York
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Peltrini R, Luglio G, Cassese G, Amendola A, Caruso E, Sacco M, Pagano G, Sollazzo V, Tufano A, Giglio MC, Bucci L, Palma GDD. Oncological Outcomes and Quality of Life After Rectal Cancer Surgery. Open Med (Wars) 2019; 14:653-662. [PMID: 31565674 PMCID: PMC6744610 DOI: 10.1515/med-2019-0075] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/16/2019] [Indexed: 12/16/2022] Open
Abstract
Surgery for rectal cancer has been completely revolutionized thanks to the adoption of new technologies and up-to-date surgical procedures that have been applied to the traditional milestone represented by Total Mesorectal Excision (TME). The multimodal and multidisciplinary approach, with new technologies increased the patients’ life expectancies; nevertheless, they have placed the surgeon in front of newer issues, represented by both oncological outcomes and the patients’ need of a less destructive surgery and improved quality of life. In this review we will go through laparoscopic, robotic and transanal TME surgery, to show how the correct choice of the most appropriate technique, together with a deep knowledge of oncological principles and pelvic anatomy, is crucial to pursue an optimal cancer treatment. Novel technologies might also help to decrease the patients’ fear of surgery and address important issues such as cosmesis and improved preservation of postoperative functionality.
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Affiliation(s)
- Roberto Peltrini
- Department of Clinical Medicine and Surgery. University of Naples "Federico II", 80131 Naples, Via Pansini 5, Italy
| | - Gaetano Luglio
- Department of Public Health. University of Naples "Federico II", Naples, Italy
| | - Gianluca Cassese
- Department of Clinical Medicine and Surgery. University of Naples "Federico II", 80131 Naples, Via Pansini 5, Italy
| | - Alfonso Amendola
- Department of Clinical Medicine and Surgery. University of Naples "Federico II", 80131 Naples, Via Pansini 5, Italy
| | - Emanuele Caruso
- Department of Clinical Medicine and Surgery. University of Naples "Federico II", 80131 Naples, Via Pansini 5, Italy
| | - Michele Sacco
- Department of Clinical Medicine and Surgery. University of Naples "Federico II", 80131 Naples, Via Pansini 5, Italy
| | - Gianluca Pagano
- Department of Clinical Medicine and Surgery. University of Naples "Federico II", 80131 Naples, Via Pansini 5, Italy
| | - Viviana Sollazzo
- Department of Clinical Medicine and Surgery. University of Naples "Federico II", 80131 Naples, Via Pansini 5, Italy
| | - Antonio Tufano
- Department of Urology, University of Rome "La Sapienza", 00161 Roma RM Italy
| | - Mariano Cesare Giglio
- Department of Clinical Medicine and Surgery. University of Naples "Federico II", 80131 Naples, Via Pansini 5, Italy
| | - Luigi Bucci
- Department of Public Health. University of Naples "Federico II", Naples, Italy
| | - Giovanni Domenico De Palma
- Department of Clinical Medicine and Surgery. University of Naples "Federico II", 80131 Naples, Via Pansini 5, Italy.,Center of Excellence for Technical Innovation in Surgery (CEITC). University of Naples Federico II, 80131 Naples, Italy
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6
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Zhang X, Wu Q, Hu T, Gu C, Bi L, Wang Z. Laparoscopic Versus Conventional Open Surgery in Intersphincteric Resection for Low Rectal Cancer: A Systematic Review and Meta-Analysis. J Laparoendosc Adv Surg Tech A 2018; 28:189-200. [PMID: 29232537 DOI: 10.1089/lap.2017.0495] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Xubing Zhang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Qingbin Wu
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Tao Hu
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Chaoyang Gu
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Liang Bi
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Ziqiang Wang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
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7
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Bokey L, Chapuis PH, Chan C, Stewart P, Rickard MJFX, Keshava A, Dent OF. Long-term results following an anatomically based surgical technique for resection of colon cancer: a comparison with results from complete mesocolic excision. Colorectal Dis 2016; 18:676-83. [PMID: 26476136 DOI: 10.1111/codi.13159] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 09/05/2015] [Indexed: 02/08/2023]
Abstract
AIM Complete mesocolic excision (CME) has been advocated as likely to improve the long-term oncological outcome of colon cancer resection, although there is a paucity of long-term results in the literature. The aim of this study was to supplement our previously published results on colon cancer resection based on a standardized technique of precise dissection along anatomical planes with high vascular ligation and to compare our long-term results with those of recent European studies of CME. METHOD Data were drawn from a prospective hospital registry of consecutive resections for colon cancer between 1996 and 2007, including follow-up to the end of 2012. The principal outcomes from potentially curative resections were 5-year Kaplan-Meier rates of local recurrence, systemic recurrence, overall survival and cancer-specific survival. Secondary outcomes for all resections were postoperative complications, number of lymph nodes retrieved and R0 status. RESULTS For 779 potentially curative resections the local recurrence rate was 2.1% (95% CI 1.3-3.4), the systemic recurrence rate was 10.2% (95% CI 8.1-12.7), the 5-year overall survival rate was 76.2% (95% CI 73.0-79.0) and the cancer-specific survival rate was 89.8% (95% CI 87.3-91.9). For all 905 resections, rates of 14 surgical complications were low and not dissimilar to those in a comparable study. The median lymph node count was 15 (range 0-113). R0 status was confirmed in 883/905 patients (97.6%; 95% CI 96.4-98.5). CONCLUSION For colon cancer, meticulous dissection along anatomical planes together with high vascular ligation results in few complications, a high R0 rate, low recurrence and high survival.
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Affiliation(s)
- L Bokey
- Department of Surgery, Liverpool Hospital, Sydney, New South Wales, Australia.,School of Medicine, University of Western Sydney, Sydney, New South Wales, Australia
| | - P H Chapuis
- Department of Colorectal Surgery, Concord Hospital, Sydney, New South Wales, Australia.,Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - C Chan
- Division of Anatomical Pathology, Concord Hospital, Sydney, New South Wales, Australia.,Discipline of Pathology, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - P Stewart
- Department of Colorectal Surgery, Concord Hospital, Sydney, New South Wales, Australia
| | - M J F X Rickard
- Department of Colorectal Surgery, Concord Hospital, Sydney, New South Wales, Australia
| | - A Keshava
- Department of Colorectal Surgery, Concord Hospital, Sydney, New South Wales, Australia.,Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - O F Dent
- Department of Surgery, Liverpool Hospital, Sydney, New South Wales, Australia.,School of Medicine, University of Western Sydney, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Concord Hospital, Sydney, New South Wales, Australia.,Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
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Kulaylat MN. Mesorectal excision: Surgical anatomy of the rectum, mesorectum, and pelvic fascia and nerves and clinical relevance. World J Surg Proced 2015; 5:27-40. [DOI: 10.5412/wjsp.v5.i1.27] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 12/10/2014] [Accepted: 12/31/2014] [Indexed: 02/06/2023] Open
Abstract
Biologic behavior and management of rectal cancer differ significantly from that of colon cancer. The surgical treatment is challenging since the rectum has dual arterial blood supply and venous drainage, extensive lymphatic drainage and is located in a bony pelvic in close proximity to urogenital and neurovascular structures that are invested with intricate fascial covering. The rectum is encased by fatty lymphovascular tissue (mesorectum) that is surrounded by perirectal fascia that act as barrier to the spread of the cancer and constitute the surgical circumferential margin. Locoregional recurrence after rectal cancer surgery is influenced by tumor-related factors and adequacy of the resection. Local recurrence is associated with incomplete excision of circumferential margin, violation of perirectal fascia, transmesorectal dissection, presence of isolated deposits in the mesorectum and tumor in regional lymph nodes and incomplete lymph node clearance. Hence to eradicate the primary rectal tumor and control regional disease, the rectum, first area of lymph node drainage and surrounding tissue must be completely excised while maintaining an intact fascial envelope around the rectum and preserving surrounding structures. This is achieved with extrafascial dissection and removal of the entire mesorectum including the portion distal to the tumor (total mesorectal excision) within its enveloping fascia as an intact unit. Total mesorectal excision is the standard of care surgical treatment of mid and low rectal cancer and can be performed in conjunction with low anterior resection, abdominoperineal resection, extralevator abdominoperineal resection, and extraregional dissection. To accomplish such a resection, thorough knowledge of the surgical anatomy of the rectum and pelvic structures and fascial planes is paramount.
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Richardson DP, Porter GA, Johnson PM. Self-reported practice patterns and knowledge of rectal cancer care among Canadian general surgeons. Can J Surg 2015; 57:385-90. [PMID: 25421080 DOI: 10.1503/cjs.001814] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Our objective was to examine the knowledge and treatment decision practice patterns of Canadian surgeons who treat patients with rectal cancer. METHODS A mail survey with 6 questions on staging investigations, management of low rectal cancer, lymph node harvest, surgical margins and use of adjuvant therapies was sent to all general surgeons in Canada. Appropriate responses to survey questions were defined a priori. We compared survey responses according to surgeon training (colorectal/surgical oncology v. others) and geographic region (Atlantic, Central, West). RESULTS The survey was sent to 2143 general surgeons; of the 1312 respondents, 703 treat patients with rectal cancer. Most surgeons responded appropriately to the questions regarding staging investigations (88%) and management of low rectal cancer (88%). Only 55% of surgeons correctly identified the recommended lymph node harvest as 12 or more nodes, 45% identified 5 cm as the recommended distal margin for upper rectal cancer, and 70% appropriately identified which patients should be referred for adjuvant therapy. Surgeons with subspecialty training were significantly more likely to provide correct responses to all of the survey questions than other surgeons. There was limited variation in responses according to geographic region. Subspecialty-trained surgeons and recent graduates were more likely to answer all of the survey questions correctly than other surgeons. CONCLUSION Initiatives are needed to ensure that all surgeons who treat patients with rectal cancer, regardless of training, maintain a thorough and accurate knowledge of rectal cancer treatment issues.
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Affiliation(s)
| | - Geoff A Porter
- The Division of General Surgery and Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS
| | - Paul M Johnson
- The Division of General Surgery and Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS
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10
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Wiegering A, Isbert C, Dietz UA, Kunzmann V, Ackermann S, Kerscher A, Maeder U, Flentje M, Schlegel N, Reibetanz J, Germer CT, Klein I. Multimodal therapy in treatment of rectal cancer is associated with improved survival and reduced local recurrence - a retrospective analysis over two decades. BMC Cancer 2014; 14:816. [PMID: 25376382 PMCID: PMC4236459 DOI: 10.1186/1471-2407-14-816] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 10/27/2014] [Indexed: 12/31/2022] Open
Abstract
Background The management of rectal cancer (RC) has substantially changed over the last decades with the implementation of neoadjuvant chemoradiotherapy, adjuvant therapy and improved surgery such as total mesorectal excision (TME). It remains unclear in which way these approaches overall influenced the rate of local recurrence and overall survival. Methods Clinical, histological and survival data of 658 out of 662 consecutive patients with RC were analyzed for treatment and prognostic factors from a prospectively expanded single-institutional database. Findings were then stratified according to time of diagnosis in patient groups treated between 1993 and 2001 and 2002 and 2010. Results The study population included 658 consecutive patients with rectal cancer between 1993 and 2010. Follow up data was available for 99.6% of all 662 treated patients. During the time period between 2002 and 2010 significantly more patients underwent neoadjuvant chemoradiotherapy (17.6% vs. 60%) and adjuvant chemotherapy (37.9% vs. 58.4%). Also, the rate of reported TME during surgery increased. The rate of local or distant metastasis decreased over time, and tumor related 5-year survival increased significantly with from 60% to 79%. Conclusion In our study population, the implementation of treatment changes over the last decade improved the patient’s outcome significantly. Improvements were most evident for UICC stage III rectal cancer.
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Affiliation(s)
- Armin Wiegering
- Department of General, Visceral, Vascular and Pediatric Surgery, University Hospital, University of Wuerzburg, Oberduerrbacherstr, 2, 97080 Wuerzburg, Germany.
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11
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Therapie des Rektumkarzinoms. COLOPROCTOLOGY 2014. [DOI: 10.1007/s00053-014-0472-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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12
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Surgeon knowledge contributes to the relationship between surgeon volume and patient outcomes in rectal cancer. Ann Surg 2013; 257:295-301. [PMID: 22968065 DOI: 10.1097/sla.0b013e31825ffdca] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine whether surgeon knowledge contributes to the relationship between surgeon procedure volume and patient outcomes in rectal cancer. BACKGROUND Although previous research has shown that treatment by high-volume surgeons is associated with improved outcomes among patients with rectal cancer, the mechanisms for such an association are not well understood. METHODS In 2009, a mail survey with 8 questions pertaining to rectal cancer care was created, modified for content validity, and sent to all general surgeons in Nova Scotia, Canada. Patients with rectal cancer, who were treated by the survey respondents between July 1, 2002, and June 30, 2006, were identified retrospectively, and a comprehensive standardized review of medical records was used to collect outcome data for this population-based cohort. The association between surgeon survey score (dichotomized into high- and low-score groups on the basis of the median score), surgeon procedure volume, and patient outcomes was examined. RESULTS Of 521 patients who underwent treatment with curative intent from July 1, 2002, to June 30, 2006, 377 patients (72%) were treated by 25 surgeons who responded to the survey. After controlling for patient and tumor factors, patients treated by high-volume surgeons were more likely to receive a total mesorectal excision (TME) [odds ratio (OR) = 3.89; 95% confidence interval (CI), 2.20-5.83], more likely to undergo an adequate lymph node harvest (OR = 3.67; 95%CI, 2.36-5.70), less likely to have a permanent colostomy (OR = 0.53; 95%CI, 0.30-0.93), and less likely to develop local recurrence (HR = 0.54; 95%CI, 0.29-0.99). When surgeon survey score was included in the multivariate regression models, the relationship between surgeon procedure volume and permanent colostomy was diminished. There was a significant interaction between surgeon survey score and surgeon volume for the outcomes of use of TME (P < 0.01) and local recurrence (P = 0.01). CONCLUSIONS These data suggest that surgeon knowledge may, at least in part, explain surgeon volume-associated differences in rectal cancer outcomes.
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Oh SY, Kim YB, Paek OJ, Suh KW. Does total mesorectal excision require a learning curve? Analysis from the database of a single surgeon's experience. World J Surg 2011; 35:1130-6. [PMID: 21416172 DOI: 10.1007/s00268-011-1014-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND The procedure of total mesorectal excision (TME) is the gold standard in the treatment of rectal cancer. However, quality control of TME is still under debate. The present study was conducted to determine whether TME requires a learning curve to allow the surgeon to grasp the necessary technical expertise. METHODS We performed a retrospective review of patients with rectal cancer who underwent TME with curative intention between August 1998 and December 2003; 195 consecutive patients were enrolled. From the first patient of the cohort, the first 50 patients were categorized into group 1, the next 50 into group 2, the next 50 into group 3, and the final 45 patients into group 4. Local recurrence rates were compared between the four groups. RESULTS No significant difference in clinicopathological features was observed between the four groups, except for age, operative time, and grade of mesorectum. The local recurrence (LR) rate decreased from 22.3% in the inadequate TME group (G1) to 9.1% in the adequate TME group (G2-4) (p=0.035). In multivariate analysis, regional lymph node metastasis, mesorectal grade (incomplete or nearly complete), and early period of learning curve were independent predictors of local recurrence. CONCLUSIONS Our results suggest that a learning curve is necessary for the development of technical expertise in the performance of TME for treatment of rectal cancer.
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Affiliation(s)
- Seung Yeop Oh
- Department of Surgery, Ajou University School of Medicine, San 5, Wonchon-dong, Yeongtong-gu, Suwon, 443-721, Korea
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Zhu J, Xu Y, Gu W, Peng J, Cai G, Cai G, Sun W, Shen W, Cai S, Zhang Z. Adjuvant therapy for T3N0 rectal cancer in the total mesorectal excision era- identification of the high risk patients. Radiat Oncol 2010; 5:118. [PMID: 21156077 PMCID: PMC3009675 DOI: 10.1186/1748-717x-5-118] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2010] [Accepted: 12/15/2010] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Adjuvant therapy for T3N0 rectal cancer was controversial with respect to both radiation and the use of a combined regimen of chemotherapy. We evaluated both clinical features and biomarkers and sought to determine risk factors for those patients retrospectively. METHODS A total of 122 patients with T3N0 rectal cancer were analyzed in this study from January 2000 to December 2005. Clinicopathologic and biomarkers were used to predict local recurrence (LR), disease-free survival (DFS), and overall survival (OS). RESULTS The median follow-up interval was 45.4 months. Five-year LR, DFS, and OS rates were 10.4%, 68.3%, and 88.7%. Having a lower tumor location and showing low P21 and high CD44v6 expression were identified as risk factors for LR: patients with two or three of these risk factors had a higher 5-year LR rate (19.3%) than did patients with none or one of these risk factors (6.8%) (p = 0.05). A poorer DFS was related to low P21 nor high CD44v6 expression but not to tumor location: the 5-year DFS rates were 79.3% for those with neither, 65.9% for those with either one or the other, and 16.9% for those with both (p = 0.00). CONCLUSIONS The prognostic model including tumor location, P21 and CD44v6 expressions could help to distinguish these patients with high risk T3N0 patients and determine whether adjuvant therapy was beneficial.
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Affiliation(s)
- Ji Zhu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, PR China
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15
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Abstract
The introduction of total mesorectal excision (TME) for rectal cancer has reduced local recurrence rates and improved oncologic outcomes, although complication rates such as anastomotic leak have also been a consequence. With the advent of neoadjuvant therapy for rectal cancer, many are questioning how this development may change the role of TME. This review presents a history of how TME evolved and a description of this technique. Complication rates, the impact of neoadjuvant therapy on local recurrence, variations of TME such as nerve-sparing proctectomy and cancer-specific mesorectal excision, and a review of functional outcomes for various methods of reconstruction are presented.
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Affiliation(s)
- David B Stewart
- Division of Surgery, Washington University School of Medicine, Barnes-Jewish-Christian Hospital, St. Louis, MO 63110, USA
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16
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Rosenberg R, Maak M, Schuster T, Becker K, Friess H, Gertler R. Does a rectal cancer of the upper third behave more like a colon or a rectal cancer? Dis Colon Rectum 2010; 53:761-70. [PMID: 20389210 DOI: 10.1007/dcr.0b013e3181cdb25a] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE This study aimed to evaluate whether cancers in the upper third of the rectum should be treated according to colon or rectal cancer guidelines. METHODS We evaluated 499 patients with tumors located in the sigmoid colon (299 patients, 60%), the upper third of the rectum (95 patients, 19%), or the middle third of the rectum (105 patients, 21%), International Union against Cancer tumor stage II or III, no preoperative radiochemotherapy, and primary curative tumor resection between 1990 and 2006. Patients' surgical, histopathological, and prognostic parameters were compared. The median follow-up time was 80 months. RESULTS Patients with sigmoid cancer showed a trend of significantly better estimated cause-specific survival (5-y value +/- 95% CI: 83.6 +/- 4.7%) compared with patients with rectal cancers of the upper third of the rectum (5-y value +/- 95% CI: 74.3 +/- 9.6%) or the middle third of the rectum (5-y value +/- 95% CI: 73.4 +/- 9.2%) (P = .063). Tumor location was an independent prognostic parameter (P = .036), with an increased risk of cause-specific death for rectal cancers of the upper third (hazard ratio, 1.87; P = .007) and of the middle third (hazard ratio, 1.43; P = .022) compared with sigmoid cancers. Stratification of upper third rectal cancers according to tumor grade, tumor infiltration depth (pT), and lymph node status (pN) identified a high-risk group. CONCLUSIONS Cancers of the upper third of the rectum have more similarities with rectal cancers of the middle third of the rectum than with sigmoid cancers. A subgroup of patients with upper third rectal cancer can be identified who may require a more aggressive therapy than only primary resection followed by adjuvant therapy.
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Pigazzi A, Luca F, Patriti A, Valvo M, Ceccarelli G, Casciola L, Biffi R, Garcia-Aguilar J, Baek JH. Multicentric study on robotic tumor-specific mesorectal excision for the treatment of rectal cancer. Ann Surg Oncol 2010; 17:1614-20. [PMID: 20087780 DOI: 10.1245/s10434-010-0909-3] [Citation(s) in RCA: 211] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2009] [Indexed: 12/17/2022]
Abstract
BACKGROUND Recently, traditional laparoscopic anterior resection has been used for rectal cancer, offering good functional results compared with open resection and resulting in better early postoperative outcomes. Few studies investigating the role of robot-assisted tumor-specific rectal surgery (RTSRS) have been carried out to show its feasibility. The aim of the study was to verify on a multicentric basis the perioperative and oncologic outcome of RTSRS. METHODS One hundred forty-three consecutive patients undergoing RTSR in three centers were reviewed. Pathologic data, and postoperative and oncologic outcome measures were prospectively collected and analyzed by an independent researcher. RESULTS A total of 112 restorative surgeries and 31 abdominoperineal resections were carried out. Conversion rate was 4.9%, mean blood loss was 283 ml, and mean operative time was 297 min. The number of harvested nodes (14.1 +/- 6.5) and margin status compared favorably with those of open series (mean distal margin 2.9 +/- 1.8 cm; negative radial margin in 142 cases). The 3-year overall survival rate was 97%, and no isolated local recurrences were found at mean follow-up of 17.4 months. CONCLUSION RTSRS is a safe and feasible procedure that may facilitate mesorectal excision. Randomized clinical trials and longer follow-up are needed to evaluate a possible influence of RTSRS on patient survival.
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Affiliation(s)
- Alessio Pigazzi
- Division of General and Oncologic Surgery, City of Hope National Medical Center, Duarte, CA, USA.
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18
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Ratto C, Ricci R, Valentini V, Castri F, Parello A, Gambacorta MA, Cellini N, Vecchio FM, Doglietto GB. Neoplastic mesorectal microfoci (MMF) following neoadjuvant chemoradiotherapy: clinical and prognostic implications. Ann Surg Oncol 2007; 14:853-61. [PMID: 17103068 DOI: 10.1245/s10434-006-9163-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Neoplastic microfoci have frequently been found in the mesorectum, with poor outcome. In this study, incidence and clinical significance of mesorectal microfoci (MMF) were analyzed in patients operated on for rectal cancer following neoadjuvant chemoradiation. METHODS A case series of 68 patients with extraperitoneal rectal cancer treated with neoadjuvant chemoradiation and surgery (including total mesorectal excision) were investigated for presence of neoplastic MMF. RESULTS MMF were found in 26 cases (38.2%). Increasing incidence of microfoci was statistically related to pathologic involvement of the bowel wall (P = 0.0006), Mandard's tumor regression grading (P = 0.0006), and pathologic neoplastic mesorectal involvement (P < 0.00001). None of the nine patients with complete tumor disappearance displayed both microfoci and lymph node metastasis. Only one local recurrence developed in a patient with multiple MMF. One out of nine pT0 or TRG1 patients (11.1%) had distant metastases compared with 15 out of 59 pT1-4 or TRG2-5 (25.4%, P = 0.70). CONCLUSIONS A remarkable incidence of MMF was found following chemoradiation. However, when this therapy induced complete regression of primary tumor (pT0-TRG1), we found that node metastases and neoplastic MMF also disappeared. These features should be confirmed to assess the impact of these microfoci in treatment decision making in rectal cancers.
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Affiliation(s)
- Carlo Ratto
- Department of Clinica Chirurgica, Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy.
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Chen W, Shen W, Chen M, Cai G, Liu X. Study on the relationship between lymphatic vessel density and distal intramural spread of rectal cancer. Eur Surg Res 2007; 39:332-9. [PMID: 17622763 DOI: 10.1159/000104837] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2007] [Accepted: 05/02/2007] [Indexed: 02/05/2023]
Abstract
BACKGROUND The smallest safe margin of distal clearance for lower rectal cancer is very important for the operation. In a previous study, a few factors were found to play a role in distal intramural spread (DIS), but there are few data regarding the influence of lymphangiogenesis. We studied the relationship between lymphatic vessel density (LVD) and DIS of rectal cancer, analyzing the probable value of LVD in determining the length of distal resection of lower rectal cancer. METHODS Nine-two patients who had undergone curative resection of lower rectal cancer were included. The length of DIS, LVD and other clinicopathological factors were evaluated. Immunohistochemical lymphatic vessel staining with LYVE-1 (lymphatic vessel endothelial hyaluronan receptor) were performed to detect the LVD. RESULTS 44 cases had DIS (range 0.1-2.44, mean 0.31 cm), and cancer emboli were the most common modalities of DIS. The LVD of a peritumoral lesion was significantly higher than that of an intratumoral lesion; the LVD of the DIS subgroup was significantly higher than that of the no DIS subgroup, and the LVD of the 2 subgroups was significantly higher than that of normal rectal tissue. A significant correlation was shown by a rank correlation test between the length of DIS and the LVD at the periphery of the rectal cancer (n = 44, r = 0.755, p < 0.01). The LVD was also related to the extent of infiltration, lymphatic invasion and lymph node metastases. CONCLUSIONS Lymphangiogenesis plays an important role in rectal cancer cell metastasis and patients with a higher LVD have a better prognosis. The LVD is closely correlated with DIS. These findings may be helpful in determining the distal clearance length of rectal cancer.
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Affiliation(s)
- W Chen
- Department of General Surgery, Second Affiliated Hospital, Shantou University Medical College, Shantou, China.
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21
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Ratto C, Ricci R, Valentini V, Castri F, Parello A, Gambacorta MA, Cellini N, Vecchio FM, Doglietto GB. Neoplastic mesorectal microfoci (MMF) following neoadjuvant chemoradiotherapy: clinical and prognostic implications. Ann Surg Oncol 2006; 13:1393-402. [PMID: 17013687 DOI: 10.1245/s10434-006-9164-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Neoplastic microfoci have frequently been found in the mesorectum, with poor outcome. In this study, incidence and clinical significance of mesorectal microfoci (MMF) were analyzed in patients operated upon for rectal cancer following neoadjuvant chemoradiation. METHODS A case series of 68 patients with extraperitoneal rectal cancer, treated with neoadjuvant chemoradiation and surgery (including total mesorectal excision), was investigated for the presence of neoplastic MMF. RESULTS Mesorectal microfoci were found in 26 cases (38.2%). Increasing incidence of microfoci was statistically related to pathologic involvement of bowel wall (P = 0.0006), Mandard's tumor regression grading (P = 0.0006) and pathologic neoplastic mesorectal involvement (P < 0.00001). None of the nine patients with complete tumor disappearance displayed both microfoci and lymph node metastasis. Only one local recurrence developed in a patient with multiple MMF. Out of 9 pT0 or TRG1 patients, 1 (11.1%) had distant metastases, compared to 15 out of 59 pT1-4 or TRG2-5 (25.4%, P = 0.70). CONCLUSIONS A remarkable incidence of MMF was found following chemoradiation. However, when this therapy induces complete regression of primary tumor (pT0-TRG1), node metastases and neoplastic MMF could also disappear, as shown in our cases. These features should be confirmed because they could significantly impact the treatment decision-making of rectal cancers.
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Affiliation(s)
- Carlo Ratto
- Department of Clinica Chirurgica, Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy.
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Pan ZZ, Wan DS, Zhang CQ, Shao JY, Li LR, Chen G, Zhou ZW, Wang FL. Using p53-immunostained large specimens to determine the distal intramural spread margin of rectal cancer. World J Gastroenterol 2006; 12:1626-9. [PMID: 16570359 PMCID: PMC4124299 DOI: 10.3748/wjg.v12.i10.1626] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the distal intramural spread (DIS) margin of rectal cancer.
METHODS: Sixty-one p53-positive specimens of rectal cancer were used. After conventional hematoxylin and eosin (H&E) staining, the DIS margin of rectal cancer in large specimens was examined by immunohistochemistry. The patients were divided into A, B, C, and D groups. After a long-term follow-up, the survival curves of the four groups were estimated using the life table.
RESULTS: Fifty-one of the sixty-one cases (83.6%) had DIS. The extent of DIS ranged 0.11-3.5 cm; meanwhile the mean of DIS measured by H&E staining was 0.13 cm. The significant difference was found between the means (t=5.622, P<0.0001). Only 1 of 51 patients had DIS greater than 3 cm. The DIS was less than 1.0 cm in most rectal cancer patients. The long-term results indicated that the survival rate of the patients whose DIS was greater than 1.0 cm was lower than that of the patients whose DIS was less than 0.5 cm.
CONCLUSION: Rectal cancer patients with DIS greater than 1.0 cm have poor prognosis.
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Affiliation(s)
- Zhi-Zhong Pan
- Department of Abdominal Surgery, Cancer Center, Sun Yat-Sen University, 651 Dongfeng Road, Guangzhou 510060, Guangdong Province, China.
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Yoo JH, Hasegawa H, Ishii Y, Nishibori H, Watanabe M, Kitajima M. Long-term outcome of per anum intersphincteric rectal dissection with direct coloanal anastomosis for lower rectal cancer. Colorectal Dis 2005; 7:434-40. [PMID: 16108877 DOI: 10.1111/j.1463-1318.2005.00837.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The authors have performed per anum intersphincteric rectal dissection. With direct coloanal anastomosis for cases of lower rectal cancer in which the distal surgical margin is difficult to secure by the double stapling technique. The aim of this study was to evaluate the long-term outcome and to clarify the surgical indications for this operation. PATIENTS AND METHODS Between 1993 and 2002, 31 patients underwent per anum intersphincteric rectal dissection with direct coloanal anastomosis. Of these, two patients (one stage 0 and one stage IV) were excluded from the analysis of oncological outcome. The remaining 29 patients formed the basis of this study. The median follow-up was 57 months (range 6-106 months). RESULTS Local recurrence and distant metastasis developed in 9 and 3 patients, respectively. Local recurrence rate for pT1 was significantly lower than that for pT2/T3 disease. The local recurrence rate cases with tumours less than 3 cm was significantly lower than that for tumours sized 3 cm or more. The distant metastasis rate for cases with lymph node metastasis was significantly higher than that for cases without lymph node metastasis. There was an association between distant metastasis and TNM or pT stage. The overall survival rates for stage I, II and III were 85%, 80% and 89%, respectively. No significant difference was seen in total Cleveland Clinic incontinence score between per anum intersphincteric rectal dissection with direct coloanal anastomosis and the double stapling technique. CONCLUSION The surgical indications of this operation should be limited to patients with T1 rectal cancer or tumours less than 3 cm.
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Affiliation(s)
- J-H Yoo
- Department of Surgery, School of Medicine, Keio University, Tokyo, Japan
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Liersch T, Langer C, Ghadimi BM, Becker H. Aktuelle Behandlungsstrategien beim Rektumkarzinom. Chirurg 2005; 76:309-32; quiz 333-4. [PMID: 15739059 DOI: 10.1007/s00104-005-1005-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
In the last ten years, considerable progress has been achieved in the treatment of rectal cancer. According to improved interdisciplinary staging, rectal carcinomas can be treated based on a stage-dependent concept: "low-risk" pT1 (G1/G2) carcinomas can be cured by local full wall excision, while "high-risk" pT1 (G3/G4) and pT2 carcinomas require transabdominal resection. In contrast, locally advanced rectal cancers in cUICC-II/-III stages (T3/T4 or N(+)) should receive long-term, 5-FU-based, neoadjuvant chemoradiotherapy according to the excellent results of the CAO/AIO/ARO-94 trial of the German Rectal Cancer Study Group. High-quality resection must be based on radical oncologic principles such as "no-touch" technique, radicular dissection of vessels, and total mesorectal excision. Multimodal treatment is completed with adjuvant 5-FU-based chemotherapy. This therapeutic approach led to a reduction in the 5-year local recurrence rate to 6% and disease-free survival of approximately 68% in advanced rectal cancer (overall survival: 76%).
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Affiliation(s)
- T Liersch
- Klinik für Allgemeinchirurgie, Universitätsklinikum Göttingen
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25
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Law WL, Ho JWC, Chan R, Au G, Chu KW. Outcome of anterior resection for stage II rectal cancer without radiation: the role of adjuvant chemotherapy. Dis Colon Rectum 2005; 48:218-26. [PMID: 15711860 DOI: 10.1007/s10350-004-0813-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND This study aimed to evaluate the oncological outcome of patients who had Stage II rectal cancer and underwent curative nonsphincter-ablation surgery without adjuvant radiation. PATIENTS AND METHODS During the study period from August 1993 to December 2002, 224 patients (141 men) with Stage II cancer underwent curative anterior resection or Hartmann's procedure without adjuvant radiation. Data were collected prospectively. The oncologic outcomes of these patients were studied and the risk factors for recurrence and survival were analyzed. RESULTS The median age of the patients was 69 (range, 27-89) years and the median level of the tumor from the anal verge was 8 (range, 3-20) cm. Four patients (1.8 percent) died in the postoperative period and postoperative complications occurred in 74 patients (33 percent). The median follow-up time of the surviving patients was 43.6 months. The actuarial five-year recurrence rate was 25.4 percent, whereas the five-year actuarial local and systemic recurrence rates were 6.1 percent and 20 percent, respectively. On multivariate analysis, independent factors associated with a higher recurrence rate included lymphovascular invasion, perineural invasion, and absence of chemotherapy. The overall and cancer-specific survival rates of the patients were 71.1 percent and 81.1 percent, respectively. On multivariate analysis, only adjuvant chemotherapy (P = 0.024; hazard ratio = 6.04; 95 percent confidence interval, 1.27-28.74) and the absence of lymphovascular invasion (P = 0.002; hazard ratio = 3.77; 95 percent confidence interval, 1.63-8.77) were independent factors associated with significantly better cancer-specific survival. CONCLUSION A low local recurrence rate can be achieved in patients with Stage II rectal cancer treated with nonsphincter-ablation surgery without adjuvant radiation. Postoperative chemotherapy is associated with a lower recurrence rate and higher survival rates. Further study is warranted to define the role of adjuvant chemotherapy in patients with rectal cancer.
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Affiliation(s)
- Wai Lun Law
- Department of Surgery, University of Hong Kong Medical Center, Queen Mary Hospital, Hong Kong.
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Leo E, Belli F, Andreola S, Gallino G, Bonfanti G, Vitellaro M, Bruce C, Vannelli A, Battaglia L. Sphincter-saving surgery for low rectal cancer. The experience of the National Cancer Institute, Milano. Surg Oncol 2004; 13:103-9. [PMID: 15572092 DOI: 10.1016/j.suronc.2004.09.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The treatment of tumors of the distal rectum continues to be a matter of great controversy among oncologic surgeons. There are increasingly promising indications that functionally conservative surgery may be a valid therapeutic alternative to conventional therapy in patients with tumours of the lower rectum, traditionally treated by abdomino-perineal resection and definitive colostomy. Many points are presently under evaluation and we want to discuss some of the most relevant topics that are now permitting to change the guide lines of therapy of this disease. Our view of the problem is based on a personal experience cumulated in fourteen years of activity in a specialized unit and this paper reports the main results of a complex and diversified study carried out during this period at the National Cancer Institute of Milan.
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Affiliation(s)
- Ermanno Leo
- Colo-rectal Cancer Surgery Unit, Department of Surgery, National Cancer Institute, Via G. Venezian 1, 20133 Milan, Italy
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Abstract
At the present time, standard therapy for potentially curable rectal cancer consists of transabdominal surgical resection and adjuvant chemoradiation for American Joint Committee on Cancer stage II/III disease. Controversial issues include the use of local excision as opposed to formal resection and total mesorectal excision (TME) alone without adjuvant therapy. Although early stage tumors are the ideal potential candidates for local excision, clinical staging with endoscopic ultrasound is extremely variable in accurately predicting T and N stage. In addition, even low-grade or T1 tumors are associated with a 7% to 14% chance of nodal metastatic disease. Overall, the risk for local recurrence is higher after local excision but may be reduced by adjuvant therapy. Salvage rates for recurrent disease range from 21% to 91%. In regard to TME, local recurrence rates are an impressive 0% to 12% without adjuvant radiation. However, the addition of radiation therapy may further reduce these already low rates, especially in higher-risk groups. The results of 2 large European studies show acceptable complication rates and the applicability of this technique to a diverse patient population.
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Affiliation(s)
- John M Kane
- Surgical Oncology, Roswell Park Cancer Institute, State University of New York at Buffalo, Buffalo, NY, USA
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28
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Abstract
In North America there are two conventional treatments for clinically resectable rectal cancer. First is surgery and, if the tumour is T3 and/or N1-2, this is followed by postoperative combined modality therapy. The second, for patients with ultrasound T3 or clinical T4 disease, is pre-operative combined modality therapy followed by surgery and postoperative chemotherapy. Pre-operative therapy (most commonly combined modality therapy) has gained acceptance as a standard adjuvant therapy. The potential advantages of this approach compared with postoperative therapy include less acute toxicity and enhanced sphincter preservation. Recently completed randomized trials in the US and Germany will provide a definitive answer to this theory. In contrast to the combined modality approach to pre-operative therapy a number of European centres advocate an intensive short course of radiation (5 Gy x 5 followed one week later by surgery). The only randomized trial which has revealed a significant advantage in survival is the Swedish Rectal Cancer Trial. The Dutch CKVO 95-04 TME trial did not confirm a survival advantage and two metanalyses report conflicting results. Due to selection bias, it is not possible accurately to compare the local recurrence and survival results of intensive short course radiation with conventional pre-operative combined modality therapy. The intensive short course radiation approach is not used in North America due to its higher toxicity and lack of sphincter preservation. In the Dutch trial the 5-year local recurrence was 12% with TME and was significantly decreased to 6% with pre-operative radiation. The 5-year local recurrence rate in the 324 patients with stage III disease who underwent a TME alone with negative margins was 20%. Therefore, despite TME surgery, radiation therapy is still a necessary component in the adjuvant management of rectal cancer.
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Affiliation(s)
- B D Minsky
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA.
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Kachnic LA, Shih HA, Willett CG. Advances in combined radiation therapy for the management of rectal cancer. Expert Rev Anticancer Ther 2003; 3:471-83. [PMID: 12934659 DOI: 10.1586/14737140.3.4.471] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Significant advances have been made in the use of adjuvant radiation for patients with localized rectal cancer. Recent progress in adjuvant postoperative radiation regimens relates to the integration of systemic therapy into radiation, as well as redefining the techniques and sequences for both modalities. The adjuvant radiation management approach in both North America and Europe has been shifting towards preoperative adjuvant therapy to promote sphincter-preserving surgery and to decrease acute and late toxicity. Although 5-fluorouracil-based chemotherapy in combination with radiation remains the standard adjuvant therapy for rectal cancer, the integration of novel chemotherapeutic agents and biologic modulators remains an active area of investigation.
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Affiliation(s)
- Lisa A Kachnic
- Department of Radiation Oncology, Boston Medical Center, Boston University School of Medicine, MA 02118, USA.
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Colquhoun P, Wexner SD, Cohen A. Adjuvant therapy is valuable in the treatment of rectal cancer despite total mesorectal excision. J Surg Oncol 2003; 83:133-9. [PMID: 12827680 DOI: 10.1002/jso.10267] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Cafiero F, Gipponi M, Lionetto R. Randomised clinical trial of adjuvant postoperative RT vs. sequential postoperative RT plus 5-FU and levamisole in patients with stage II-III resectable rectal cancer: a final report. J Surg Oncol 2003; 83:140-6. [PMID: 12827681 DOI: 10.1002/jso.10261] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVES A randomised clinical trial was performed in patients undergoing radical surgery for rectal cancer to compare the efficacy and toxicity of adjuvant postoperative radiation therapy (RT) to sequential RT and chemotherapy (CT) with 5-fluorouracil (5-FU) plus levamisole (LEV). The primary end point was overall survival (OS); secondary end points were disease-free survival (DFS), the rate of loco-regional recurrence, and treatment-related toxicity; the final results of this trial are reported. METHODS Patients in arm I underwent RT (50 Gy) in daily fractions of 2 Gy, 5 days/week for 5 weeks. Patients in arm II began with 5-FU (450 mg/sqm/day intravenous (i.v.) bolus, days 1-5) plus LEV (150 mg/day orally, days 1-3); postoperative RT was delivered during week 2 at the same dosage and schedule as in arm I. The other five cycles of CT (5-FU every 28 days and LEV every 15 days for the length of 5-FU administration) continued after the end of RT if clinical and hemato-biochemical parameters were in the normal range. RESULTS From May 1992 to December 1998, 218 patients were enrolled into the randomised clinical trial (144 men, 74 women; age range: 28-75, median 64 years). The median follow-up time was 58.1 months (range: 1-3,271 days). No significant difference was observed between the two arms of treatment as regards OS and DFS (P = 0.18 and P = 0.66, respectively). Cox regression analysis for OS confirmed what was observed by univariate analysis for all variables except age. Older age (>60 years) and pathologic lymph-node involvement defined the subgroups with the worst prognosis. Cox regression analysis for DFS confirmed what was observed by univariate analysis for all variables: the only independent variable in predicting DFS was pathologic lymph-node involvement. CONCLUSIONS Our findings suggest no difference in OS, loco-regional and distant site progressions of postoperative RT alone compared to sequential postoperative RT and CT; notably, this latter regimen was associated with higher toxicity which seriously impaired the patient's compliance to CT. The low loco-regional recurrence rate (9.2%) observed in our patients undergoing postoperative RT alone compared to similarly treated patients in previously performed clinical trials (20-25%) underline the role of radical surgery (mesorectal excision) coupled with a complete postoperative RT regimen. On the other hand, the similar efficacy of these two adjuvant modalities of treatment might be conditioned by both the low compliance (59%) to the CT regimen as well as the sequential, instead of concurrent, schedule of administration of RT and CT, which may have decreased further the expected efficacy of the combined regimen.
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Affiliation(s)
- Ferdinando Cafiero
- Division of Surgical Oncology, National Cancer Research Institute, Genoa, Italy
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Abstract
BACKGROUND Sphincter preservation is the goal in the treatment of rectal cancer and should be considered in all patients with an intact sphincter. Sphincter preservation for tumors of the upper rectum is easily achieved, but surgical management of cancer of the mid and lower third of the rectum continues to evolve. Several recent advances may influence future treatment strategies. METHODS We reviewed the literature to identify the current methods of sphincter-preserving surgery and their oncologic and functional results. RESULTS Proctectomy with total mesorectal excision reduces the incidence of local recurrence to less than 10% while preserving genitourinary function. The use of preoperative radiotherapy may further diminish the risk of local recurrence. In selected patients, partial resection of the anal sphincter may avoid definitive colostomy without compromising oncologic outcome. In contrast, the role of local resection of rectal cancer remains controversial. Restoration of continuity by means of a colonic reservoir reduces stool frequency and urgency and improves continence when compared to a straight coloanal anastomosis. The transverse colpoplasty pouch may allow pouch construction in patients in whom it is currently impossible, but long-term follow-up is not yet available. CONCLUSIONS Sphincter-preserving surgery is possible for the majority of patients with rectal cancer. Optimal functional results may be obtained by a nerve-sparing operative technique and by use of a colonic reservoir for reconstruction following resection of mid or low rectal cancers.
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Affiliation(s)
- Deborah A McNamara
- Centre de Chirurgie Digestive, Hopital Saint-Antoine, 75012 Paris, France
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33
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Minsky BD. Combined modality therapy for rectal cancer. ACTA ACUST UNITED AC 2003; 21:803-16. [PMID: 15338775 DOI: 10.1016/s0921-4410(03)21038-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Affiliation(s)
- Bruce D Minsky
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA.
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Abstract
Important advances have been made in our understanding of the role of adjuvant therapy for colorectal cancer. Current standard 5FU-based regimens have been convincingly shown to reduce the incidence of recurrences and to prolong overall survival in patients with resected stage III colon cancer. Colon cancer patients with stage II disease have a better-overall prognosis than those with stage III; however, the relative merits of adjuvant treatment in these patients remains controversial. Combined chemotherapy plus radiation therapy is currently the standard adjuvant approach for stage II and III rectal cancer patients. Despite the advances that have been made, far too many patients with resectable colorectal cancer ultimately relapse and die of their disease. There remains a pressing need for continued development of improved adjuvant treatments. Participation of eligible patients in clinical trials must continue to be actively encouraged. Only in this way will we be able to continue to build and expand on the progress that has been made thus far.
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Affiliation(s)
- Leonard B Saltz
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA
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35
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Abstract
The two conventional treatments for clinically resectable rectal cancer are surgery followed by postoperative combined modality therapy and preoperative combined modality therapy followed by surgery and postoperative chemotherapy. Preoperative therapy (most commonly combined modality therapy) has gained acceptance as a standard adjuvant therapy. The potential advantages of the preoperative approach include decreased tumor seeding, less acute toxicity, increased radiosensitivity due to more oxygenated cells, and enhanced sphincter preservation. There are a number of new chemotherapeutic agents that have been developed for the treatment of patients with colorectal cancer. Phase I/II trials examining the use of new chemotherapeutic agents in combination with pelvic radiation therapy are in progress.
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Affiliation(s)
- Bruce D Minsky
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA.
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Law WL, Chu KW. Strategies in the management of mid and distal rectal cancer with total mesorectal excision. Asian J Surg 2002; 25:255-64. [PMID: 12376227 DOI: 10.1016/s1015-9584(09)60187-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
In the last two decades, dramatic improvement in outcome has been made in the management of rectal cancer. This has been brought about mainly by advancements in surgical technique for radical resection. With the recognition of the importance of the circumferential margin and presence of spread in the lymphovascular tissues in the mesorectum, total mesorectal excision is now commonly recognized as the optimal surgical technique for cancer of the mid and distal rectum. Not only have local control and disease-specific survival improved with the practice of total mesorectal excision, but various bodily functions have also been preserved following surgery for rectal cancer. New issues have arisen with the practice of total mesorectal excision and the strategies for management of rectal cancer require re-evaluation. In this article, the rationale and the outcomes of total mesorectal excision are reviewed. Issues such as the high anastomotic leakage rate following sphincter-preserving surgery, the poor results of abdominoperineal resection, the role of adjuvant therapy and bowel function disturbances will be addressed. Lastly, the status of the laparoscopic approach to rectal cancer with the principle of total mesorectal excision are discussed.
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Affiliation(s)
- W L Law
- Department of Surgery, Queen Mary Hospital, University of Hong Kong Medical Centre, Hong Kong.
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37
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Abstract
Lymph node involvement is an important prognostic factor in colorectal cancer. Sentinel node status has a significant impact on the management of breast cancer and melanoma. A 'sentinel lymph node' (SLN) is defined as the first regional lymph node to receive lymph flow from the primary tumour site. An electronic literature search was performed for all articles using key words: sentinel + lymph node + colorectal + cancer. The review indicated that the sentinel node model may help understanding different aspects of tumour biology in colorectal cancer. It will provide important information about variations in lymphatic pathways and skip metastases. It may alter the management if sentinel lymph node can be assessed preoperatively with radioisotope techniques by identifying patients with micrometastases who may benefit from adjuvant therapy. Although the sentinel lymph node concept has only recently been applied to colorectal cancer, it has a great potential for management.
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38
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Abstract
The most common neo-adjuvant therapy for rectal cancer is chemotherapy and concurrent radiation therapy. In general, it is delivered pre-operatively for patients with clinical evidence of T(3-4) disease or post-operatively in patients who have undergone surgery and have T(3) and/or N(1-2) disease. This chapter reviews the rationale and results for neo-adjuvant therapy, the selection process for pre-operative versus post-operative treatment, and new approaches and controversies.
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Affiliation(s)
- Bruce D Minsky
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, Cornell University, USA
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Nesbakken A, Nygaard K, Westerheim O, Mala T, Lunde OC. Local recurrence after mesorectal excision for rectal cancer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2002; 28:126-34. [PMID: 11884047 DOI: 10.1053/ejso.2001.1231] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
AIMS Controversy still exists about the optimal surgical treatment of rectal cancer. The main purpose of the present study was to compare local recurrence (LR) rates after mesorectal excision (ME) and conventional surgery (CS) technique. METHODS All rectal cancer patients from a defined catchment area were included. Outcome after ME in the period 1993-1999 (n=161) was compared with the outcome after CS (n=217) in the period 1983-1992. Partial ME (PME) was the routine in upper, and total ME the routine in mid- and low rectal cancer. The follow-up programmes were identical, and the median observation times very similar (37 and 38 months) in the two periods. Five-year actuarial LR rate and survival were estimated using the Kaplan-Meier method, and adjustment for prognostic factors was performed with Cox regression analysis. RESULTS Total LR rate after R0 resection was 7.7% crude and 9% 5 year actuarial in the ME period, as compared with 16.0% crude and 24% actuarial in the CS period (P=0.02). Cox regression analyses confirmed these differences with a hazard ratio of 0.40 for ME vs CS (P=0.02). Isolated LR rate was 2% after ME and 8% after CS. Five-year actuarial total LR rate after rectal resection with curative intent was 11% after ME and 27% after CS (P<0.01). Actuarial total LR rate after PME was 6%, and none of these patients developed isolated LR. CONCLUSION Standardization of surgical technique and application of ME resulted in a significant reduction of LRs. LR rate was low after PME, indicating that this procedure is adequate in upper rectal cancer.
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Affiliation(s)
- A Nesbakken
- Department of Surgery, Aker Hospital, Oslo, Norway.
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40
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41
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Sasson AR, Sigurdson ER. Surgery of Rectal Cancer. COLORECTAL CANCER 2002. [DOI: 10.1007/978-1-59259-160-2_18] [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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42
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Abstract
Substantial advances have been made in the adjuvant management of patients with resectable rectal cancer. Increasing interest in patient quality of life has promoted the use of radiation therapy to enhance sphincter-preserving surgical approaches as an alternative to the standard abdominoperineal resection. Because of the suggestion of enhanced sphincter preservation with preoperative therapy and the potential advantage of decreased acute morbidity, randomized trials comparing preoperative and postoperative adjuvant combined modality therapy are ongoing. Recent progress in adjuvant postoperative treatment regimens relates to the integration of systemic therapy to radiation, and redefining the techniques for both modalities. The incorporation of improved radiation planning may reduce treatment-related bowel toxicity. The integration of novel chemotherapeutic agents in the adjuvant therapy of rectal cancer remains an active area of investigation.
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Affiliation(s)
- L A Kachnic
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA.
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43
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Abstract
The treatment of rectal cancer typically involves a multidisciplinary approach. A minority of patients will have tumors that are full thickness, involve adjacent structures, or have metastatic disease to regional lymph nodes. The combination of adjuvant therapy and surgical resection is the mainstay of treatment for locally advanced carcinoma of the rectum. This article will review the role of adjuvant chemotherapy and radiotherapy in patients with high risk tumors. The operative considerations in advanced rectal cancers will be reviewed. In particular, the role of mesorectal excision and exenterative surgery will be discussed.
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Affiliation(s)
- A R Sasson
- Department of Surgical Oncology, Fox Chase Cancer Center, 7701 Burholme Avenue, Philadelphia, PA 19111, USA
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