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Chen Z, Li X, Zheng Z, Liu J, Fang J, Huang J, Chen T, Wei H. DeepGuide: a novel wavelength-specific navigation system for membrane visualization in surgery. Int J Surg 2025; 111:4039-4042. [PMID: 40171568 PMCID: PMC12165551 DOI: 10.1097/js9.0000000000002370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2025] [Accepted: 03/21/2025] [Indexed: 04/03/2025]
Abstract
BACKGROUND Membrane anatomy (MA) has become pivotal in modern surgery, enabling surgeons to operate within avascular natural planes to minimize concomitant injury. However, intraoperative identification of membranous structures remains challenging. Poor membrane visualization compromises both radical resection and functional preservation, underscoring the need for innovative solutions. METHODS In this study, we develop a innovative tool, DeepGuide, to help surgeon make membrane visualization during surgery. Moreover, we design a single-arm prospective study to validated its effectiveness. A total of 60 patients undergoing laparoscopic radical resection for gastrointestinal tumors at The Third Affiliated Hospital of Sun Yat-sen University were enrolled. Primary outcomes included signal-to-background ratio (SBR), mesenteric integrity, absorbance of membrane specimens, and immunofluorescence staining of collagen components. RESULTS DeepGuide significantly improved mesenteric integrity rates from 75% (conventional laparoscopy) to 98%. SBR under DeepGuide (2.30 ± 0.15) surpassed conventional lighting (1.32 ± 0.16). Absorbance analysis revealed reduced light absorption at 385 nm. Immunofluorescence confirmed collagen I/III enrichment in mesenteric submucosa, aligning with 385 nm-excited autofluorescence properties. CONCLUSION DeepGuide revolutionizes intraoperative membrane visualization without requiring contrast agents. It enhances surgical precision and supports MA principles. These findings highlight DeepGuide's potential to redefine standards in oncologic surgery.
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Affiliation(s)
- Zehong Chen
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xuejie Li
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zongheng Zheng
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jianpei Liu
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jiafeng Fang
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jianglong Huang
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Tufeng Chen
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Hongbo Wei
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Bastian S, Joerger M, Holer L, Bärtschi D, Guckenberger M, Jochum W, Koeberle D, Siebenhüner AR, Wicki A, Berger MD, Winterhalder RC, Largiadèr CR, Löffler M, Mosna-Firlejczyk K, Maranta AF, Pestalozzi BC, Csajka C, von Moos R. Neoadjuvant Treatment With Regorafenib and Capecitabine Combined With Radiotherapy in Locally Advanced Rectal Cancer: A Multicenter Phase Ib Trial (RECAP)-SAKK 41/16. Clin Colorectal Cancer 2025; 24:82-88.e1. [PMID: 39537446 DOI: 10.1016/j.clcc.2024.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 01/19/2024] [Accepted: 10/17/2024] [Indexed: 11/16/2024]
Abstract
BACKGROUND The multi tyrosine kinase inhibitor regorafenib is active in metastatic colorectal cancer. Improvement in clinical outcome by adding regorafenib to long-course chemoradiotherapy (LcCRT) was investigated in molecularly undefined LARC. METHODS Patients with T3-4 and/or N+ but M0 rectal cancer were included. Neoadjuvant LcRCT consisted in capecitabine (C) 825mg/m2 d1-d38 and 28 fractions of 1.8Gy (50.4Gy). Regorafenib was added d1-14 and d22-35 in 3 dose escalation (DE) cohorts (40mg/80mg/120mg). The recommended dose (RD) was used for the expansion (EXP) cohort. Primary endpoints were dose-limiting toxicity (DLT) for DE and pathological response (near-complete regression [npCR] or complete regression [pCR]) for EXP. RESULTS Overall, 25 patients were included. Two DLTs occurred at the regorafenib dose level of 120 mg, thereby establishing the RD at 80mg daily. Among the 19 patients who were treated at the RD, 8 (42.1%; 1-sided 80% confidence interval [CI] (lower bound): 30.7%; 95% CI, 20.3%-66.5%) reached the primary endpoint (5 [26.3%] had npCR and 3 [15.8%] pCR). One additional patient received no surgery due to clinical complete response. All patients had R0 resections and clear circumferential margins. Postoperative complications occurred in 6 patients (35.3%). The most common grade ≥ 3 treatment-related adverse event in the EXP cohort was diarrhea (2 patients). CONCLUSION Adding regorafenib 80 mg to LcCRT in LARC resulted in both primary endpoints being met and yielded an expected pathological response rate. Toxicity was manageable, and postoperative complications were as expected.
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Affiliation(s)
- Sara Bastian
- Department of Oncology/Hematology, Kantonsspital Graubuenden, Chur, Switzerland.
| | - Markus Joerger
- Department of Medical Oncology/Hematology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Lisa Holer
- Swiss Group for Clinical Cancer Research (SAKK), Competence Center, Bern, Switzerland
| | - Daniela Bärtschi
- Swiss Group for Clinical Cancer Research (SAKK), Competence Center, Bern, Switzerland
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital of Zurich, Zurich, Switzerland
| | - Wolfram Jochum
- Institute of Pathology, Kantonsspital St.Gallen, St. Gallen, Switzerland
| | - Dieter Koeberle
- Department of Oncology, Claraspital Basel, Basel; Medical Faculty, University of Bern, Bern, Switzerland
| | - Alexander R Siebenhüner
- Department of Medical Oncology and Hematology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Andreas Wicki
- Department of Oncology, University Hospital Basel, Basel, Switzerland
| | - Martin D Berger
- Department of Medical Oncology, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Carlo R Largiadèr
- Department of Clinical Chemistry, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Melanie Löffler
- Department of Oncology, Claraspital Basel, Basel; Medical Faculty, University of Bern, Bern, Switzerland
| | - Katarzyna Mosna-Firlejczyk
- Department of Radiation Oncology, Claraspital Basel, Basel; Medical Faculty, University of Bern, Switzerland
| | | | - Bernhard C Pestalozzi
- Department of Medical Oncology and Hematology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Chantal Csajka
- Institute of Pharmacy, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Roger von Moos
- Department of Oncology/Hematology, Kantonsspital Graubuenden, Chur, Switzerland
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3
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Engels B, De Paoli A, Delmastro E, Munoz F, Vagge S, Norkus D, Everaert H, Tabaro G, Gariboldi E, Ricardi U, Borsatti E, Gabriele P, Innocente R, Palazzari E, Dubaere E, Mahé MA, Van Laere S, Gevaert T, De Ridder M. Preoperative Radiotherapy with a Simultaneous Integrated Boost Compared to Chemoradiotherapy for cT3-4 Rectal Cancer: Long-Term Results of a Multicenter Randomized Study. Cancers (Basel) 2023; 15:3869. [PMID: 37568685 PMCID: PMC10416952 DOI: 10.3390/cancers15153869] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/14/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Preoperative chemoradiotherapy (CRT) is the standard treatment for T3-4 rectal cancer. Here, we compared image-guided and intensity-modulated RT (IG-IMRT) with a simultaneous integrated boost (SIB) (instead of concomitant chemotherapy) versus CRT in a multi-centric randomized trial. METHODS cT3-4 rectal cancer patients were randomly assigned to receive preoperative IG-IMRT 46 Gy/23 fractions plus capecitabine 825 mg/m² twice daily (CRT arm) or IG-IMRT 46 Gy/23 fractions with an SIB to the rectal tumor up to a total dose of 55.2 Gy (RTSIB arm). RESULTS A total of 174 patients were randomly assigned between April 2010 and May 2014. Grade 3 acute toxicities were 6% and 4% in the CRT and RTSIB arms, respectively. The mean fractional change in SUVmax at 5 weeks after completion of preoperative RT were -55.8% (±24.0%) and -52.9% (±21.6%) for patients in the CRT arm and RTSIB arm, respectively (p = 0.43). The pathologic complete response rate was 24% with CRT compared to 14% with RTSIB. There were no differences in 5-year overall survival (OS), progression-free survival (PFS) or local control (LC). CONCLUSIONS The preoperative RTSIB approach was not inferior to CRT in terms of metabolic response, toxicity, OS, PFS and LC, and could be considered an available option for patients unfit for fluorouracil-based CRT.
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Affiliation(s)
- Benedikt Engels
- Department of Radiotherapy, UZ Brussel, Vrije Universiteit Brussel, 1090 Brussels, Belgium
| | - Antonino De Paoli
- Department of Radiation Oncology, Centro di Riferimento Oncologico (CRO)-IRCCS, 33081 Aviano, Italy
| | - Elena Delmastro
- Department of Radiation Oncology, IRCC Candiolo, 10060 Candiolo, Italy
| | - Fernando Munoz
- Department of Oncology, University of Torino, 10126 Torino, Italy
| | - Stefano Vagge
- Department of Radiation Oncology, IRCCS San Martino-IST Genoa, 16132 Genoa, Italy
| | - Darius Norkus
- Department of Radiotherapy, National Cancer Institute, 08406 Vilnius, Lithuania
| | - Hendrik Everaert
- Department of Nuclear Medicine, UZ Brussel, Vrije Universiteit Brussel, 1090 Brussels, Belgium
| | - Gianna Tabaro
- Department of Radiation Oncology, Centro di Riferimento Oncologico (CRO)-IRCCS, 33081 Aviano, Italy
| | | | - Umberto Ricardi
- Department of Oncology, University of Torino, 10126 Torino, Italy
| | - Eugenio Borsatti
- Department of Radiation Oncology, Centro di Riferimento Oncologico (CRO)-IRCCS, 33081 Aviano, Italy
| | - Pietro Gabriele
- Department of Radiation Oncology, IRCC Candiolo, 10060 Candiolo, Italy
| | - Roberto Innocente
- Department of Radiation Oncology, Centro di Riferimento Oncologico (CRO)-IRCCS, 33081 Aviano, Italy
| | - Elisa Palazzari
- Department of Radiation Oncology, Centro di Riferimento Oncologico (CRO)-IRCCS, 33081 Aviano, Italy
| | - Emilie Dubaere
- Department of Radiotherapy, UZ Brussel, Vrije Universiteit Brussel, 1090 Brussels, Belgium
| | - Marc-André Mahé
- Department of Radiotherapy, Institut de Cancérologie de l’Ouest, Nantes, 44800 Saint-Herblain, France
| | - Sven Van Laere
- Department of Radiotherapy, UZ Brussel, Vrije Universiteit Brussel, 1090 Brussels, Belgium
| | - Thierry Gevaert
- Department of Radiotherapy, UZ Brussel, Vrije Universiteit Brussel, 1090 Brussels, Belgium
| | - Mark De Ridder
- Department of Radiotherapy, UZ Brussel, Vrije Universiteit Brussel, 1090 Brussels, Belgium
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4
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Mège D, de Chaisemartin C, Régis-Marigny L, Poizat F, Meillat H, Zemmour C, Moureau L, Lelong B. Supine bottom-up extralevator abdominoperineal excision for anorectal adenocarcinoma is not inferior to standard approach and may be thus safely performed. Surg Endosc 2023:10.1007/s00464-021-08982-1. [PMID: 36952048 DOI: 10.1007/s00464-021-08982-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 12/31/2021] [Indexed: 03/24/2023]
Abstract
BACKGROUND Extralevator abdominoperineal excision (APE) for rectal carcinoma has been described in order to improve pathological and oncological results compared to standard APE. To obtain the same oncological advantages as extralevator APE, we have previously described a new procedure starting by a perineal approach: the supine bottom-up APE. Our objective is to compare oncological and surgical outcomes between the supine bottom-up APE and the standard APE. METHODS All patients with low rectal adenocarcinoma requiring APE were retrospectively included and divided into 2 groups: supine bottom-up APE (Group A) and standard APE (Group B). RESULTS From 2008 to 2016, 61 patients were divided into Groups A (n = 30) and B (n = 31). Postoperative outcomes and median length of stay were similar between groups. Patients from Group A had a significantly longer distal margin (30 [8-120] vs. 20 [1.5-60] mm, p = 0.04) and higher number of harvested lymph nodes (14.5 [0-33] vs. 11 [5-25], p = 0.03) than those from Group B. Circumferential resection margin involvement was similar between groups (28 vs. 22%, p = 0.6), whereas tumors from Group A were significantly larger and more frequently classified as T4 than those from Group B. Operative time was significantly shorter in Group A (437.5 [285-655] minutes) than in Group B (537.5 [361-721] minutes, p = 0.0009). At the end of follow-up, local recurrence occurred in 7 and 16% of patients from Groups A and B (p = 0.68). Three-year overall and disease-free survival rates were similar between groups (87 vs. 90%, p = 0.62 and 61 vs. 63%, p = 0.88, respectively). CONCLUSION Our findings suggest that supine bottom-up APE doesn't impair surgical outcomes, pathological results, overall and disease-free survivals in comparison with standard APE. This new procedure may be thus safely performed and decrease the operative time. Further randomized multicentric studies are required to confirm these results.
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Affiliation(s)
- Diane Mège
- Department of Surgical Oncology, Institut Paoli-Calmettes, 232 Bd Sainte Marguerite, 13009, Marseille, France
| | - Cécile de Chaisemartin
- Department of Surgical Oncology, Institut Paoli-Calmettes, 232 Bd Sainte Marguerite, 13009, Marseille, France.
| | - Laure Régis-Marigny
- Department of Surgical Oncology, Institut Paoli-Calmettes, 232 Bd Sainte Marguerite, 13009, Marseille, France
| | - Flora Poizat
- Department of Biopathology, Institut Paoli-Calmettes, Marseille, France
| | - Hélène Meillat
- Department of Surgical Oncology, Institut Paoli-Calmettes, 232 Bd Sainte Marguerite, 13009, Marseille, France
| | - Christophe Zemmour
- Department of Clinical Research and Innovation, Biostatistics and Methodology Unit, Aix Marseille University, INSERM, IRD, SESSTIM, Marseille, France
| | - Laurence Moureau
- Radiation Oncology Department, Institut Paoli Calmettes, Marseille, France
| | - Bernard Lelong
- Department of Surgical Oncology, Institut Paoli-Calmettes, 232 Bd Sainte Marguerite, 13009, Marseille, France
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5
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Scabini S, Romairone E, Pertile D, Massobrio A, Aprile A, Tagliafico L, Soriero D, Mastracci L, Grillo F, Bacigalupo A, Marrone C, Parodi MC, Sartini M, Cristina ML, Murialdo R, Zoppoli G, Ballestrero A. The Multidisciplinary Approach of Rectal Cancer: The Experience of "COMRE Group" Model. Diagnostics (Basel) 2022; 12:1571. [PMID: 35885477 PMCID: PMC9319737 DOI: 10.3390/diagnostics12071571] [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: 04/14/2022] [Revised: 06/14/2022] [Accepted: 06/27/2022] [Indexed: 11/23/2022] Open
Abstract
Background: Total mesorectal excision (TME) is the gold standard to treat locally advanced rectal cancer. This monocentric retrospective study evaluates the results of laparotomic, laparoscopic and robotic surgery in “COMRE GROUP” (REctalCOMmittee). Methods: 327 selected stage I-II-III patients (pts) underwent TME between November 2005 and April 2020 for low or middle rectal cancer; 91 pts underwent open, 200 laparoscopic and 36 robotic TME. Of these, we analyzed the anthropomorphic, intraoperative, anatomopathological parameters and outcome during the follow up. Results: The length of hospital stay was significantly different between robotic TME and the other two groups (8.47 ± 3.54 days robotic vs. 11.93 ± 5.71 laparotomic, p < 0.001; 8.47 ± 3.54 robotic vs. 11.10 ± 7.99 laparoscopic, p < 0.05). The mean number of harvested nodes was higher in the laparotomic group compared to the other two groups (19 ± 9 laparotomic vs. 15 ± 8 laparoscopic, p < 0.001; 19 ± 9 laparotomic vs. 15 ± 7 robotic, p < 0.05). Median follow-up was 52 months (range: 1−169). Overall survival was significantly shorter in the open TME group compared with the laparoscopic one (Chi2 = 13.36, p < 0.001). Conclusions: In the experience of the “COMRE” group, laparoscopic TME for rectal cancer is a better choice than laparotomy in a multidisciplinary context. Robotic TME has a significant difference in terms of hospital stay compared to the other two groups.
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Affiliation(s)
- Stefano Scabini
- General and Oncologic Surgery, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy; (D.P.); (A.M.); (A.A.); (D.S.)
| | | | - Davide Pertile
- General and Oncologic Surgery, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy; (D.P.); (A.M.); (A.A.); (D.S.)
| | - Andrea Massobrio
- General and Oncologic Surgery, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy; (D.P.); (A.M.); (A.A.); (D.S.)
| | - Alessandra Aprile
- General and Oncologic Surgery, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy; (D.P.); (A.M.); (A.A.); (D.S.)
| | - Luca Tagliafico
- Department of Internal Medicine and Medical Specialties (DiMI), University of Genoa, 16132 Genoa, Italy; (L.T.); (A.B.); (C.M.); (M.C.P.); (R.M.); (G.Z.); (A.B.)
| | - Domenico Soriero
- General and Oncologic Surgery, IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy; (D.P.); (A.M.); (A.A.); (D.S.)
| | - Luca Mastracci
- Pathology Unit, Department of Surgical and Diagnostic Sciences (DISC), University of Genova, 16132 Genova, Italy; (L.M.); (F.G.)
| | - Federica Grillo
- Pathology Unit, Department of Surgical and Diagnostic Sciences (DISC), University of Genova, 16132 Genova, Italy; (L.M.); (F.G.)
| | - Almalina Bacigalupo
- Department of Internal Medicine and Medical Specialties (DiMI), University of Genoa, 16132 Genoa, Italy; (L.T.); (A.B.); (C.M.); (M.C.P.); (R.M.); (G.Z.); (A.B.)
| | - Ciro Marrone
- Department of Internal Medicine and Medical Specialties (DiMI), University of Genoa, 16132 Genoa, Italy; (L.T.); (A.B.); (C.M.); (M.C.P.); (R.M.); (G.Z.); (A.B.)
| | - Maria Caterina Parodi
- Department of Internal Medicine and Medical Specialties (DiMI), University of Genoa, 16132 Genoa, Italy; (L.T.); (A.B.); (C.M.); (M.C.P.); (R.M.); (G.Z.); (A.B.)
| | - Marina Sartini
- Department of Health Sciences, University of Genova, Via Pastore 1, 16132 Genova, Italy
- Operating Unit Hospital Hygiene, Galliera Hospital, Mura delle Cappuccine 14, 16128 Genoa, Italy
| | - Maria Luisa Cristina
- Department of Health Sciences, University of Genova, Via Pastore 1, 16132 Genova, Italy
- Operating Unit Hospital Hygiene, Galliera Hospital, Mura delle Cappuccine 14, 16128 Genoa, Italy
| | - Roberto Murialdo
- Department of Internal Medicine and Medical Specialties (DiMI), University of Genoa, 16132 Genoa, Italy; (L.T.); (A.B.); (C.M.); (M.C.P.); (R.M.); (G.Z.); (A.B.)
| | - Gabriele Zoppoli
- Department of Internal Medicine and Medical Specialties (DiMI), University of Genoa, 16132 Genoa, Italy; (L.T.); (A.B.); (C.M.); (M.C.P.); (R.M.); (G.Z.); (A.B.)
| | - Alberto Ballestrero
- Department of Internal Medicine and Medical Specialties (DiMI), University of Genoa, 16132 Genoa, Italy; (L.T.); (A.B.); (C.M.); (M.C.P.); (R.M.); (G.Z.); (A.B.)
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Adams AM, Vreeland TJ, Teshome M, Francescatti AB, Zheng L, Hunt KK, Katz MHG, Messick CA. American College of Surgeons Commission on Cancer Standard 5.7 for Total Mesorectal Excision for Mid-to-Low Rectal Cancer. J Am Coll Surg 2022; 234:1249-1253. [PMID: 35703824 DOI: 10.1097/xcs.0000000000000175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Alexandra M Adams
- From the Department of Surgery, San Antonio Military Medical Center, Fort Sam Houston, TX (Adams, Vreeland)
| | - Timothy J Vreeland
- From the Department of Surgery, San Antonio Military Medical Center, Fort Sam Houston, TX (Adams, Vreeland)
| | - Mediget Teshome
- the Department of Breast Surgical Oncology (Teshome, Hunt), University of Texas MD Anderson Cancer Center, Houston, TX
| | - Amanda B Francescatti
- the Cancer Surgery Standards Program, American College of Surgeons, Chicago, IL (Francescatti, Zheng)
| | - Linda Zheng
- the Cancer Surgery Standards Program, American College of Surgeons, Chicago, IL (Francescatti, Zheng)
| | - Kelly K Hunt
- the Department of Breast Surgical Oncology (Teshome, Hunt), University of Texas MD Anderson Cancer Center, Houston, TX.,Department of Surgical Oncology (Hunt, Katz), University of Texas MD Anderson Cancer Center, Houston, TX
| | - Matthew H G Katz
- Department of Surgical Oncology (Hunt, Katz), University of Texas MD Anderson Cancer Center, Houston, TX
| | - Craig A Messick
- Department of Colon and Rectal Surgery (Messick), University of Texas MD Anderson Cancer Center, Houston, TX
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7
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Update on Robotic Total Mesorectal Excision for Rectal Cancer. J Pers Med 2021; 11:jpm11090900. [PMID: 34575677 PMCID: PMC8472541 DOI: 10.3390/jpm11090900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 09/04/2021] [Accepted: 09/06/2021] [Indexed: 12/16/2022] Open
Abstract
The minimally invasive treatment of rectal cancer with Total Mesorectal Excision is a complex and challenging procedure due to technical and anatomical issues which could impair postoperative, oncological and functional outcomes, especially in a defined subgroup of patients. The results from recent randomized controlled trials comparing laparoscopic versus open surgery are still conflicting and trans-anal bottom-up approaches have recently been developed. Robotic surgery represents the latest consistent innovation in the field of minimally invasive surgery that may potentially overcome the technical limitations of conventional laparoscopy thanks to an enhanced dexterity, especially in deep narrow operative fields such as the pelvis. Results from population-based multicenter studies have shown the potential advantages of robotic surgery when compared to its laparoscopic counterpart in terms of reduced conversions, complication rates and length of stay. Costs, often advocated as one of the main drawbacks of robotic surgery, should be thoroughly evaluated including both the direct and indirect costs, with the latter having the potential of counterbalancing the excess of expenditure directly related to the purchase and maintenance of robotic equipment. Further prospectively maintained or randomized data are still required to better delineate the advantages of the robotic platform, especially in the subset of most complex and technically challenging patients from both an anatomical and oncological standpoint.
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8
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Martin-Gonzalez P, de Mariscal EG, Martino ME, Gordaliza PM, Peligros I, Carreras JL, Calvo FA, Pascau J, Desco M, Muñoz-Barrutia A. Association of visual and quantitative heterogeneity of 18F-FDG PET images with treatment response in locally advanced rectal cancer: A feasibility study. PLoS One 2020; 15:e0242597. [PMID: 33253194 PMCID: PMC7704000 DOI: 10.1371/journal.pone.0242597] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 11/05/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND PURPOSE Few tools are available to predict tumor response to treatment. This retrospective study assesses visual and automatic heterogeneity from 18F-FDG PET images as predictors of response in locally advanced rectal cancer. METHODS This study included 37 LARC patients who underwent an 18F-FDG PET before their neoadjuvant therapy. One expert segmented the tumor from the PET images. Blinded to the patient´s outcome, two experts established by consensus a visual score for tumor heterogeneity. Metabolic and texture parameters were extracted from the tumor area. Multivariate binary logistic regression with cross-validation was used to estimate the clinical relevance of these features. Area under the ROC Curve (AUC) of each model was evaluated. Histopathological tumor regression grade was the ground-truth. RESULTS Standard metabolic parameters could discriminate 50.1% of responders (AUC = 0.685). Visual heterogeneity classification showed correct assessment of the response in 75.4% of the sample (AUC = 0.759). Automatic quantitative evaluation of heterogeneity achieved a similar predictive capacity (73.1%, AUC = 0.815). CONCLUSION A response prediction model in LARC based on tumor heterogeneity (assessed either visually or with automatic texture measurement) shows that texture features may complement the information provided by the metabolic parameters and increase prediction accuracy.
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Affiliation(s)
- Paula Martin-Gonzalez
- Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Madrid, Spain
| | - Estibaliz Gomez de Mariscal
- Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Madrid, Spain
- Instituto de Investigación, Sanitaria Gregorio Marañón, Madrid, Spain
| | - M. Elena Martino
- Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Madrid, Spain
- Instituto de Investigación, Sanitaria Gregorio Marañón, Madrid, Spain
| | - Pedro M. Gordaliza
- Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Madrid, Spain
- Instituto de Investigación, Sanitaria Gregorio Marañón, Madrid, Spain
| | - Isabel Peligros
- Instituto de Investigación, Sanitaria Gregorio Marañón, Madrid, Spain
- Department of Pathology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- School of Medicine, Universidad Complutense, Madrid, Spain
| | - Jose Luis Carreras
- Instituto de Investigación, Sanitaria Gregorio Marañón, Madrid, Spain
- Department of Pathology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Department of Radiology and Medical Physics, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Felipe A. Calvo
- Instituto de Investigación, Sanitaria Gregorio Marañón, Madrid, Spain
- School of Medicine, Universidad Complutense, Madrid, Spain
- Department of Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Javier Pascau
- Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Madrid, Spain
- Instituto de Investigación, Sanitaria Gregorio Marañón, Madrid, Spain
| | - Manuel Desco
- Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Madrid, Spain
- Instituto de Investigación, Sanitaria Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
- Centro de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain
| | - Arrate Muñoz-Barrutia
- Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Madrid, Spain
- Instituto de Investigación, Sanitaria Gregorio Marañón, Madrid, Spain
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9
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Detering R, Saraste D, de Neree tot Babberich MPM, Dekker JWT, Wouters MWJM, van Geloven AAW, Bemelman WA, Tanis PJ, Martling A, Westerterp M, the Swedish ColoRectal Cancer Registry and the Dutch ColoRectal Audit AalbersArendBeets‐TanReginaden BoerFrankBreukinkStephanieCoenePeter PaulDoorneboschPascalGelderblomHansKarstenTomLedeboerMichelManusamaEricMarijnenCorrieNagtegaalIrisPeetersKoenTollenaarRobvan de VeldeCockWagnerAnjavan WestreenenErik. International evaluation of circumferential resection margins after rectal cancer resection: insights from the Swedish and Dutch audits. Colorectal Dis 2020; 22:416-429. [PMID: 31696599 PMCID: PMC7187294 DOI: 10.1111/codi.14903] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 10/18/2019] [Indexed: 12/14/2022]
Abstract
AIM This study aimed to determine predictive factors for the circumferential resection margin (CRM) within two northern European countries with supposed similarity in providing rectal cancer care. METHOD Data for all patients undergoing rectal resection for clinical tumour node metastasis (TNM) stage I-III rectal cancer were extracted from the Swedish ColoRectal Cancer Registry and the Dutch ColoRectal Audit (2011-2015). Separate analyses were performed for cT1-3 and cT4 stage. Predictive factors for the CRM were determined using univariable and multivariable logistic regression analyses. RESULTS A total of 6444 Swedish and 12 089 Dutch patients were analysed. Over time the number of hospitals treating rectal cancer decreased from 52 to 42 in Sweden, and 82 to 79 in the Netherlands. In the Swedish population, proportions of cT4 stage (17% vs 8%), multivisceral resection (14% vs 7%) and abdominoperineal excision (APR) (37% vs 31%) were higher. The overall proportion of patients with a positive CRM (CRM+) was 7.8% in Sweden and 5.4% in the Netherlands. In both populations with cT1-3 stage disease, common independent risk factors for CRM+ were cT3, APR and multivisceral resection. No common risk factors for CRM+ in cT4 stage disease were found. An independent impact of hospital volume on CRM+ could be demonstrated for the cT1-3 Dutch population. CONCLUSION Within two northern European countries with implemented clinical auditing, rectal cancer care might potentially be improved by further optimizing the treatment of distal and locally advanced rectal cancer.
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Affiliation(s)
- R. Detering
- Department of SurgeryAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands,Scientific bureau of the Dutch Institute of Clinical AuditingLeidenThe Netherlands
| | - D. Saraste
- Department of Molecular Medicine and SurgeryKarolinska Institutet,StockholmSweden
| | - M. P. M. de Neree tot Babberich
- Scientific bureau of the Dutch Institute of Clinical AuditingLeidenThe Netherlands,Department of Gastroenterology and HepatologyAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - J. W. T. Dekker
- Department of SurgeryReinier de Graaf Hospital,DelftThe Netherlands
| | - M. W. J. M. Wouters
- Scientific bureau of the Dutch Institute of Clinical AuditingLeidenThe Netherlands,Department of Surgical OncologyNetherlands Cancer Institute–Antoni van Leeuwenhoek HospitalAmsterdamThe Netherlands
| | | | - W. A. Bemelman
- Department of SurgeryAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - P. J. Tanis
- Department of SurgeryAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - A. Martling
- Department of Molecular Medicine and SurgeryKarolinska Institutet,StockholmSweden
| | - M. Westerterp
- Department of Colorectal SurgeryHaaglanden Medical CenterThe HagueThe Netherlands
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10
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Chevallay M, Meyer J, Wassmer CH, Ris F, Toso C, Buchs NC. Current Trends in the Management of Low Rectal Tumors: Transanal Total Mesorectal Excision. CURRENT COLORECTAL CANCER REPORTS 2019; 15:90-97. [DOI: 10.1007/s11888-019-00434-2] [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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11
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Chang KP, Chu YW, Wang J. Analysis of Hormone Receptor Status in Primary and Recurrent Breast Cancer Via Data Mining Pathology Reports. Open Med (Wars) 2019; 14:91-98. [PMID: 30847396 PMCID: PMC6401490 DOI: 10.1515/med-2019-0013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 12/05/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Hormone receptors of breast cancer, such as estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (Her-2), are important prognostic factors for breast cancer. OBJECTIVE The current study aimed to develop a method to retrieve the statistics of hormone receptor expression status, documented in pathology reports, given their importance in research for primary and recurrent breast cancer, and quality management of pathology laboratories. METHOD A two-stage text mining approach via regular expression-based word/phrase matching, was developed to retrieve the data. RESULTS The method achieved a sensitivity of 98.8%, 98.7% and 98.4% for extraction of ER, PR, and Her-2 results. The hormone expression status from 3679 primary and 44 recurrent breast cancer cases was successfully retrieved with the method. Statistical analysis of these data showed that the recurrent disease had a significantly lower positivity rate for ER (54.5% vs 76.5%, p=0.001278) than primary breast cancer and a higher positivity rate for Her-2 (48.8% vs 16.2%, p=9.79e-8). These results corroborated the previous literature. CONCLUSION Text mining on pathology reports using the developed method may benefit research of primary and recurrent breast cancer.
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Affiliation(s)
- Kai-Po Chang
- Department of Pathology, China Medical University Hospital, Taichung404, Taiwan
- Ph.D. Program in Medical Biotechnology, National Chung Hsing University, Taichung402, Taiwan
| | - Yen-Wei Chu
- Biotechnology Center, Agricultural Biotechnology Center, Institute of Molecular Biology, National Chung Hsing University, Taichung402, Taiwan
- Institute of Genomics and Bioinformatics, National Chung Hsing University, Taichung402, Taiwan
| | - John Wang
- Department of Pathology, China Medical University Hospital, Taichung404, Taiwan
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12
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Okuyama T, Sameshima S, Takeshita E, Yoshioka R, Yamagata Y, Ono Y, Tagaya N, Noie T, Oya M. Therapeutic effects of oxaliplatin-based neoadjuvant chemotherapy and chemoradiotherapy in patients with locally advanced rectal cancer: a single-center, retrospective cohort study. World J Surg Oncol 2018; 16:105. [PMID: 29871650 PMCID: PMC5989356 DOI: 10.1186/s12957-018-1403-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 05/22/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy (NACRT) has now become the standard treatment for locally advanced rectal cancer (LARC). NACRT has decreased local relapse (LR) rate in patients with LARC; however, distant relapse has recently attracted much attention. This study aimed to assess the feasibility and efficiency of neoadjuvant chemotherapy (NAC) for LARC. METHODS Data on patients with cT3/4 and N+ rectal cancer who were treated in our institution from April 2010 to February 2016 were reviewed retrospectively. Twenty-seven patients who received 2-9 cycles of oxaliplatin-based NAC and 28 patients who received NACRT (45 Gy delivered in 25 fractions and 5-fluorouracil-based oral chemotherapy) were analyzed. The primary and secondary endpoints of the present study were the 3-year relapse-free survival (RFS) and the local and distant relapse rates, respectively. RESULTS Regardless of the kind of neoadjuvant therapy, no patient experienced any grade 3-4 therapy-related adverse events. The frequent toxic events were grade 1 diarrhea in patients with NACRT and neutropenia in patients with NAC. A significantly higher proportion of patients with NAC underwent laparoscopic surgery and anterior resection (p = 0.037 and p = 0.003, respectively). The percentages of patients with lymph node yield less than 12 in the NAC group, and those in the NACRT group were 26 and 68%, respectively (p = 0.002). Comparing the NAC with the NACRT groups, the local relapse and distant relapse rates were 7.4 and 7.1% and 7.4 and 18%, respectively. There were no significant differences in 3-year RFS and 4-year overall survival (OS) between NAC and NACRT (3-year RFS 85.2 vs. 70.4%, p = 0.279; 4-year OS 96.3 vs. 89.1%, p = 0.145, respectively). With an analysis excluding patients who received postoperative adjuvant chemotherapy, no patients who received NAC had a distant relapse, and there was a significant difference in 3-year RFS compared with the NACRT groups (94.4 vs. 63.2%, p = 0.043). CONCLUSION These outcomes suggest that the therapeutic effect of oxaliplatin-based NAC is at least equal to that of NACRT and that NAC is a feasible and promising option for LARC.
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Affiliation(s)
- Takashi Okuyama
- Department of Surgery, Dokkyo Medical University, Koshigaya Hospital, 2-1-50, Minami Koshigaya, Koshigaya, Saitama 343-8555 Japan
| | - Shinichi Sameshima
- Department of Surgery, Dokkyo Medical University, Koshigaya Hospital, 2-1-50, Minami Koshigaya, Koshigaya, Saitama 343-8555 Japan
| | - Emiko Takeshita
- Department of Surgery, Dokkyo Medical University, Koshigaya Hospital, 2-1-50, Minami Koshigaya, Koshigaya, Saitama 343-8555 Japan
| | - Ryuji Yoshioka
- Department of Surgery, Dokkyo Medical University, Koshigaya Hospital, 2-1-50, Minami Koshigaya, Koshigaya, Saitama 343-8555 Japan
| | - Yukinori Yamagata
- Department of Surgery, Dokkyo Medical University, Koshigaya Hospital, 2-1-50, Minami Koshigaya, Koshigaya, Saitama 343-8555 Japan
| | - Yuko Ono
- Department of Pathology, Dokkyo Medical University, Koshigaya Hospital, 2-1-50, Minami Koshigaya, Koshigaya, Saitama 343-8555 Japan
| | - Nobumi Tagaya
- Department of Surgery, Dokkyo Medical University, Koshigaya Hospital, 2-1-50, Minami Koshigaya, Koshigaya, Saitama 343-8555 Japan
| | - Tamaki Noie
- Department of Surgery, Dokkyo Medical University, Koshigaya Hospital, 2-1-50, Minami Koshigaya, Koshigaya, Saitama 343-8555 Japan
| | - Masatoshi Oya
- Department of Surgery, Dokkyo Medical University, Koshigaya Hospital, 2-1-50, Minami Koshigaya, Koshigaya, Saitama 343-8555 Japan
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13
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Abstract
BACKGROUND Total mesorectal excision is the standard of care for patients with rectal cancer. Pathological evaluation of the quality of the total mesorectal excision specimen is an important prognostic factor that correlates with local recurrence, but is potentially subjective. OBJECTIVE This study aimed to determine the degree of variation in grading, both between assessors and between fresh and formalin-fixed specimens. DESIGN Raters included surgeons, pathologists, pathology residents, pathologists' assistants, and pathologists' assistant trainees. Specimens were assessed by up to 6 raters in the fresh state and by 2 raters postfixation. Four parameters were evaluated: mesorectal bulk, surface regularity, defects, and coning. Interrater agreement was measured using ordinal α-values. SETTING The study was conducted at a single academic center. MAIN OUTCOME MEASURES The primary outcome was agreement between individuals when grading total mesorectal excision specimens. RESULTS A total of 37 total mesorectal excision specimens were assessed. Reliability between all raters for fresh specimens for mesorectal bulk, surface regularity, defects, coning, and overall grade were 0.85, 0.85, 0.92, 0.84, and 0.91. When compared with all raters, pathologists and residents had higher agreement and pathologists and surgeons had lower agreement. Ordinal α-values comparing pathologist and pathologist's assistant agreement for overall grade were similar pre- and postfixation (0.78 vs 0.80), but agreement for assessing defects decreased postfixation. Among pathologists' assistants, agreement was higher when grading specimens postfixation than when grading fresh specimens. LIMITATIONS Assessment bias may have occurred because of the greater number of pathologists' assistants participating than the number of residents and pathologists. CONCLUSIONS The results indicate good interrater agreement for the assessment of overall grade, with defects showing the best interrater agreement in fresh specimens. Although total mesorectal excision specimens may be consistently graded postfixation, the assessment of defects postfixation may be less reliable. This study highlights the need for additional knowledge-transfer activities to ensure consistency and accurate grading of total mesorectal excision specimens. See Video Abstract at http://links.lww.com/DCR/A497.
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14
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Role of "Second Look" Lymph Node Search in Harvesting Optimal Number of Lymph Nodes for Staging of Colorectal Carcinoma. Gastroenterol Res Pract 2018; 2018:1985031. [PMID: 29805441 PMCID: PMC5902050 DOI: 10.1155/2018/1985031] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 01/15/2018] [Indexed: 01/01/2023] Open
Abstract
As with other malignancies, lymph node metastasis is an important staging element and prognostic factor in colorectal carcinomas. The number of involved lymph nodes is directly related to decreased 5-year overall survival for all pT stages according to United States Surveillance, Epidemiology, and End Results (SEER) cancer registry database. The National Quality Forum specifies that the presence of at least 12 lymph nodes in a surgical resection is one of the key quality measures for the evaluation of colorectal cancer. Therefore, the harvesting of a minimum of twelve lymph nodes is the most widely accepted standard for evaluating colorectal cancer. Since this is an accepted quality standard, a second attempt at lymph node dissection in the gross specimen is often performed when the initial lymph node count is less than 12, incurring a delay in reporting and additional expense. However, this is an arbitrary number and not based on any hard scientific evidence. We decided to investigate whether the additional effort and expense of submitting additional lymph nodes had any effect on pathologic lymph node staging (pN). We identified a total of 99 colectomies for colorectal cancer in which the prosector subsequently submitted additional lymph nodes following initial review. The mean lymph node count increased from 8.3 ± 7.5 on initial search to 14.6 ± 8.0 following submission of additional sections. The number of cases meeting the target of 12 lymph nodes increased from 14 to 69. Examination of the additional lymph nodes resulted in pathologic upstaging (pN) of five cases. Gross reexamination and submission of additional lymph nodes may provide more accurate staging in a limited number of cases. Whether exhaustive submission of mesenteric fat or fat-clearing methods is justified will need to be further investigated.
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15
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Keane C, Lin AY, Kramer N, Bissett I. Can pathological reports of rectal cancer provide national quality indicators? ANZ J Surg 2018; 88:E639-E643. [DOI: 10.1111/ans.14440] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 01/21/2018] [Accepted: 01/23/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Celia Keane
- Department of Surgery; The University of Auckland; Auckland New Zealand
| | - Anthony Y. Lin
- Department of Surgery; The University of Auckland; Auckland New Zealand
- Department of Surgery; Auckland City Hospital; Auckland New Zealand
| | - Nicole Kramer
- Department of Pathology; Auckland City Hospital; Auckland New Zealand
| | - Ian Bissett
- Department of Surgery; The University of Auckland; Auckland New Zealand
- Department of Surgery; Auckland City Hospital; Auckland New Zealand
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16
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Song SB, Wu GJ, Pan HD, Yang H, Hu ML, Li Q, Yan QX, Xiao G. The quality of total mesorectal excision specimen: A review of its macroscopic assessment and prognostic significance. Chronic Dis Transl Med 2018; 4:51-58. [PMID: 29756123 PMCID: PMC5938287 DOI: 10.1016/j.cdtm.2018.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Indexed: 12/28/2022] Open
Abstract
As a surgical procedure which could significantly lower the recurrence rate of cancers, total mesorectal excision (TME) has been the gold standard for middle and lower rectal cancer treatment. However, previous studies have shown that the procedure did not achieve the ideal theoretical local recurrence rates of rectal cancers. Some researchers pointed out it was very likely that not all so-called TME treatments completely removed the mesorectum, implying that some of these TME surgical treatments failed to meet oncological quality standards. Therefore, a suitable assessment tool for the surgical quality of TME is necessary. The notion of “macroscopic assessment of mesorectal excision (MAME)” was put forward by some researchers as a better assessment tool for the surgical quality of TME and has been confirmed by a series of studies. Besides providing rapid and accurate surgical quality feedbacks for surgeons, MAME also effectively assesses the prognosis of patients with rectal cancer. However, as a new assessment tool used for TME surgical quality, MAME has an only limited influence on the current guidelines and is yet to be widely applied in most countries. The aims of this review are to provide a detailed introduction to MAME for clinical practice and to summarize the current prognostic significance of MAME.
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Affiliation(s)
- Shi-Bo Song
- Department of Gastrointestinal Surgery, Beijing Hospital, National Center of Gerontology, Beijing 100730, China.,Peking University Fifth School of Clinical Medicine, Beijing 100730, China
| | - Guo-Ju Wu
- Department of Gastrointestinal Surgery, Beijing Hospital, National Center of Gerontology, Beijing 100730, China
| | - Hong-Da Pan
- Department of Gastrointestinal Surgery, Beijing Hospital, National Center of Gerontology, Beijing 100730, China
| | - Hua Yang
- Department of Gastrointestinal Surgery, Beijing Hospital, National Center of Gerontology, Beijing 100730, China
| | - Mao-Lin Hu
- Department of Gastrointestinal Surgery, Beijing Hospital, National Center of Gerontology, Beijing 100730, China.,Peking University Fifth School of Clinical Medicine, Beijing 100730, China
| | - Qiang Li
- Department of Gastrointestinal Surgery, Beijing Hospital, National Center of Gerontology, Beijing 100730, China.,Peking University Fifth School of Clinical Medicine, Beijing 100730, China
| | - Qiu-Xia Yan
- Department of Gastrointestinal Surgery, Beijing Hospital, National Center of Gerontology, Beijing 100730, China.,Peking University Fifth School of Clinical Medicine, Beijing 100730, China
| | - Gang Xiao
- Department of Gastrointestinal Surgery, Beijing Hospital, National Center of Gerontology, Beijing 100730, China
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17
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Pai RK, Pai RK. Pathologic assessment of gastrointestinal tract and pancreatic carcinoma after neoadjuvant therapy. Mod Pathol 2018; 31:4-23. [PMID: 28776577 DOI: 10.1038/modpathol.2017.87] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 05/31/2017] [Accepted: 06/18/2017] [Indexed: 12/17/2022]
Abstract
Neoadjuvant therapy is increasingly used to treat patients with a wide variety of malignancies. Histologic evaluation of treated specimens provides important prognostic information and may guide subsequent chemotherapy. Neoadjuvant therapy is commonly employed in the treatment of locally advanced rectal adenocarcinoma, hepatic colorectal metastases, esophageal/esophagogastric junction carcinoma, and pancreatic ductal adenocarcinoma. Numerous tumor regression schemes have been used in these tumors and standardized approaches to evaluate these specimens are needed. In this review, the various tumor regression scoring systems that have been used in these organs are described and their associations with clinical outcomes are discussed. Recommendations regarding how to handle and report the histologic findings in these resections specimens are provided.
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Affiliation(s)
- Reetesh K Pai
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Rish K Pai
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Scottsdale, AZ, USA
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18
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Cheong C, Kim NK. Minimally Invasive Surgery for Rectal Cancer: Current Status and Future Perspectives. Indian J Surg Oncol 2017; 8:591-599. [PMID: 29203993 PMCID: PMC5705499 DOI: 10.1007/s13193-017-0624-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 01/31/2017] [Indexed: 02/07/2023] Open
Abstract
Although laparoscopic resection for colon cancer has been proven safe and feasible when compared with open resection, currently no clear evidence is available regarding minimally invasive surgery for rectal cancer. This type of surgery may benefit patients by allowing fast recovery of normal dietary intake and bowel function, reduced postoperative pain, and shorter hospitalization. Therefore, minimally invasive surgeries such as laparoscopic or robot surgery have become the predominant treatment option for colon cancer. Specifically, the proportion of laparoscopic colorectal cancer surgery in Korea increased from 42.6 to 64.7% until 2013. However, laparoscopic surgery for rectal cancer is more difficult and technically demanding. In addition, the procedure requires a prolonged learning curve to achieve equivalent outcomes relative to open surgery. It is very challenging to approach the deep and narrow pelvis using laparoscopic instruments. However, robotic surgery provides better vision with a high definition three-dimensional view, exceptional ergonomics, Endowrist technology, enhanced dexterity of movement, and a lack of physiologic tremor, facilitated by the use of an assistant in the narrow and deep pelvis. Recently, an increasing number of reports have compared the outcomes of laparoscopic and open surgery for colon cancer. Such reports have prompted a discussion of the outcomes of minimally invasive surgery, including robotic surgery, for rectal cancer. The aim of this review is to summarize current data regarding the clinical outcomes, including oncologic outcomes, of minimally invasive surgery for rectal cancer.
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Affiliation(s)
- Chinock Cheong
- Department of Surgery, Yonsei University College of Medicine, 50 Yonsei-ro Seodaemun-gu, Seoul, 120-752 South Korea
| | - Nam Kyu Kim
- Department of Surgery, Yonsei University College of Medicine, 50 Yonsei-ro Seodaemun-gu, Seoul, 120-752 South Korea
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19
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The feasibility of laparoscopic rectal resection in patients undergoing reoperation after transanal endoscopic microsurgery (TEM). Surg Endosc 2017; 32:2020-2025. [PMID: 29052070 DOI: 10.1007/s00464-017-5898-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 09/17/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND The success of transanal endoscopic microsurgery (TEM) for early rectal cancer depends on proper indications and strict patient selection. When unfavorable pathologic features are identified after TEM operation, total mesorectal excision is recommended to minimize the risk of recurrence. In this study, data were collected in a retrospective series of patients to determine the results of laparoscopic reoperation after TEM. METHODS All patients underwent an accurate rectal-digital examination and clinical tumor staging by transanal endosonography, CT, and/or MRI. The histologic examination included an evaluation of the free margins, depth of tumor infiltration according to International Union Against Cancer guidelines, degree of tumor differentiation, and the presence of lymphovascular and perineural invasion. When a high-risk tumor was identified, reoperation was performed within 6 weeks from TEM. The patients were divided into two groups according to the procedure performed: laparoscopic anterior resection (LAR) or laparoscopic abdominal perineal amputation (LAPR). RESULTS Sixty-eight patients (5.3%) underwent reoperation: 38 underwent LAR and 30 underwent LAPR. The mean operative time was 148.24 min (± 35.8, p = 0.62). Meanwhile, the mean distance of the TEM scar from the anal verge differed statistically between the two groups (p = 0.003) and was statistically correlated with abdominal perineal amputation (p = 0.0001) in multivariate analysis. Conversion to open surgery was required in 6 patients (15.7%) in the LAR group and 3 patients (10%) in the LAPR group (p = 0.38). The histologic examination revealed residual cancer cells in 3 cases (3 pT2N0) and 1 case (1 pT3N0), respectively, and lymph node metastases in 4 cases. No residual neoplasms were detected in the remaining 60 cases (88.3%). After a mean follow-up of 108 months, the overall disease-free survival was 98% (95% CI 88-99%). CONCLUSIONS In our experience, reoperation after TEM using a laparoscopic approach is feasible and safe, with low conversion rates and optimal postoperative results.
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20
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Li X, Wang T, Yao L, Hu L, Jin P, Guo T, Yang K. The safety and effectiveness of robot-assisted versus laparoscopic TME in patients with rectal cancer: A meta-analysis and systematic review. Medicine (Baltimore) 2017; 96:e7585. [PMID: 28723798 PMCID: PMC5521938 DOI: 10.1097/md.0000000000007585] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The aim of this study was to assess the safety and effectiveness of robotic-assisted versus laparoscopic total mesorectal excision (TME) in patients with rectal cancer. METHODS We systematically searched PubMed, EMBASE, Cochrane library, Web of science, and Chinese Biomedical Literature Database up to July 2016 to identify case-controlled studies that compared robotic TME (RTME) with laparoscopic TME (LTME) for rectal cancer. GRADE was used to interpret the primary outcomes of this meta-analysis. RESULTS We included 17 case-control studies (3601 participants: 1726 underwent RTME and 1875 LTME for rectal cancer) that compared RTME with LTME for rectal cancer. We found no statistically significant differences between techniques for local recurrence [odds ratio (OR) = 0.68, P = .216] and overall survival at 3 years (OR = 0.71, P = 1.140), complications (OR = 1.02, P = .883), positive circumferential resection margin (PCRM) (OR = 0.80, P = .256), the first passing flatus [weighted mean difference (WMD) = -0.11, P = .130], reoperation (OR = 0.66, P = .080), estimated blood loss (EBL) (WMD = -12.45, P = .500), and length of stay in hospital (LOS) (WMD = -0.69, P = .089). Compared with LTME, RTME was associated with lower rate of conversion (OR = 0.35, P < .001), urinary retention (OR = 0.41, P = .025), and longer operative time (WMD = 57.43, P < .001). The overall quality of evidence was poor in all outcomes. CONCLUSION RTME in patients with rectal cancer was associated with a lower rate of conversion and less incidence of urinary retention. Generally, operative time in RTME was significantly longer than in LTME. The long-term oncological and function outcomes of RTME seem to be equivalent with LTME. Therefore, analysis of current studies to date did not indicate a major benefit of RTME over LTME.
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Affiliation(s)
- Xiaofei Li
- Department of General Surgery, Gansu Province People's HospitalGansu
- School of Clinical Medical Sciences, Ningxia Medical UniversityYinchuan
| | | | - Liang Yao
- Institution of Clinical Research and Evidence Based Medicine, Gansu Province People's Hospital
| | - Lidong Hu
- Department of General Surgery, Gansu Province People's HospitalGansu
- Institution of Clinical Research and Evidence Based Medicine, Gansu Province People's Hospital
| | - Penghui Jin
- School of Clinical Medical Sciences, Gansu University of Traditional Chinese Medicine
| | - Tiankang Guo
- Department of General Surgery, Gansu Province People's HospitalGansu
- School of Clinical Medical Sciences, Ningxia Medical UniversityYinchuan
| | - Kehu Yang
- Institution of Clinical Research and Evidence Based Medicine, Gansu Province People's Hospital
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
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21
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Pollheimer MJ, Langner C. [Pathology of the R1 classification in visceral cancer surgery]. Chirurg 2017; 88:731-739. [PMID: 28593347 DOI: 10.1007/s00104-017-0448-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The completeness of tumor removal is described in the residual tumor classification (R classification). The R category of a surgical specimen reflects the effects of treatment, influences further treatment decisions and is associated with patient survival. Thorough pathological examination of all resection planes, including the circumferential margin, is necessary for accurate classification.
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Affiliation(s)
- M J Pollheimer
- Institut für Pathologie, Medizinische Universität Graz, Auenbruggerplatz 25, 8036, Graz, Österreich
| | - C Langner
- Institut für Pathologie, Medizinische Universität Graz, Auenbruggerplatz 25, 8036, Graz, Österreich.
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22
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Nitta T, Nakamura T, Mitsuhashi T, Asano T, Okamura K, Tsuchikawa T, Tamoto E, Murakami S, Noji T, Kurashima Y, Ebihara Y, Nakanishi Y, Shichinohe T, Hirano S. The impact of margin status determined by the one-millimeter rule on tumor recurrence and survival following pancreaticoduodenectomy for pancreatic ductal adenocarcinoma. Surg Today 2016; 47:490-497. [PMID: 27677294 DOI: 10.1007/s00595-016-1420-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 07/15/2016] [Indexed: 12/31/2022]
Abstract
PURPOSE The tumor-node-metastasis (TNM) classification defines R1 as the presence of tumor cells at the resection margin, while the current Royal College of Pathologists guidelines for pancreaticoduodenectomy specimens regard the presence of tumor cells within 1 mm from the resection margin as R1 (the "1-mm rule"). The aims of this study were to investigate the resection margin status of pancreatic head cancer retrospectively according to both the TNM and 1-mm rule classifications, and to evaluate the postoperative survival and tumor recurrence patterns. METHODS A total of 117 patients with pancreatic head cancer were the subjects of this study. RESULTS R11-mm rule resection was associated with a significantly worse disease-free survival (DFS) than R01-mm rule resection (p = 0.0259), while R1TNM had no impact on DFS. R11-mm rule resection margin status correlated with the incidence of tumor recurrence in the liver (p = 0.0483). In a multivariate analysis, R11-mm rule resection was the independent variable for predicting poor DFS (hazard ratio 1.71; p = 0.0289). CONCLUSIONS R1 resection margin status determined by the 1-mm rule may be an independent indicator for predicting disease recurrence, especially liver metastasis. These results may be useful for selecting the appropriate adjuvant therapy protocol and conducting strict surveillance in PDAC patients.
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Affiliation(s)
- Takeo Nitta
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N14, W5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Toru Nakamura
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N14, W5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan.
| | - Tomoko Mitsuhashi
- Department of Surgical Pathology, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Toshimichi Asano
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N14, W5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Keisuke Okamura
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N14, W5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Takahiro Tsuchikawa
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N14, W5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Eiji Tamoto
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N14, W5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Soichi Murakami
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N14, W5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Takehiro Noji
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N14, W5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Yo Kurashima
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N14, W5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Yuma Ebihara
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N14, W5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Yoshitsugu Nakanishi
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N14, W5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Toshiaki Shichinohe
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N14, W5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N14, W5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
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Robotic versus Laparoscopic Intersphincteric Resection for Low Rectal Cancer: A Comparative Study of Short-term Outcomes. ACTA ACUST UNITED AC 2015. [DOI: 10.7602/jmis.2015.18.4.98] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Wilder FG, Burnett A, Oliver J, Demyen MF, Chokshi RJ. A Review of the Long-Term Oncologic Outcomes of Robotic Surgery Versus Laparoscopic Surgery for Colorectal Cancer. Indian J Surg 2015; 78:214-9. [PMID: 27358517 DOI: 10.1007/s12262-015-1375-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 10/12/2015] [Indexed: 12/23/2022] Open
Abstract
The goal of this review was to compare long-term oncologic outcomes of robotic versus laparoscopic resection of colorectal cancer. A literature search was performed using PubMed, EMBASE, Cochrane, and Medline (2002-2014). Search terms: laparoscopic, robotic, rectal, colon, surgery, oncologic, and outcomes. Studies comparing overall and disease free survival of robotic versus laparoscopic surgery for colorectal cancer were included. Meta-analysis was performed using OpenMeta[Analyst] for Windows 8. Five studies were identified reporting on overall survival, disease free survival, lymph node extraction, and distal and circumferential resection margin. Three hundred and seventeen patients underwent robotic resection and 368 underwent laparoscopic resection, with similar demographics. Operative times were longer with robotic resections, with no difference in estimated blood loss (EBL) or length of stay. The disease stage was distributed similarly in both groups. Similar numbers underwent neo-adjuvant therapy. Laparoscopic resection was associated with 3.2 mm larger distal resection margins (p = 0.04) and 2.2 more lymph nodes removed (p = 0.001), but with equivalent circumferential resection margin status. Disease-free and overall survival was equivalent. Robotic and laparoscopic surgery for colorectal cancer offer comparable overall and disease free survival. Laparoscopic surgery offered a slight advantage in operative time, distal margin, and lymph node yield. Larger, prospective trials are needed to confirm the equivalence of these approaches.
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Affiliation(s)
- Fatima G Wilder
- Department of Surgery, Rutgers-New Jersey Medical School, 185 South Orange Avenue, Newark, NJ 07101 USA
| | - Atuhani Burnett
- Department of Surgery, Rutgers-New Jersey Medical School, 185 South Orange Avenue, Newark, NJ 07101 USA
| | - Joseph Oliver
- Department of Surgery, Rutgers-New Jersey Medical School, 185 South Orange Avenue, Newark, NJ 07101 USA
| | - Michael F Demyen
- Department of Medicine, Rutgers-New Jersey Medical School, 90 Bergen St, DOC 2100, Newark, NJ 07103 USA
| | - Ravi J Chokshi
- Rutgers-New Jersey Medical School, University Hospital Cancer Center, 205 South Orange Avenue, G-1228, Newark, NJ 07103 USA
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Lino-Silva LS, Salcedo-Hernández RA, Luna-Ortiz K, Padilla-Rosciano A, Meneses-García A, Herrera-Gómez Á, Maldonado-Martínez HA, Ruiz-García EB. Un adecuado número de ganglios linfáticos puede ser obtenido en la mayoría de los especímenes quirúrgicos de resección radical de recto después de tratamiento neoadyuvante. REVISTA ESPAÑOLA DE PATOLOGÍA 2015; 48:197-202. [DOI: 10.1016/j.patol.2015.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2025]
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26
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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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Xiong B, Ma L, Huang W, Zhao Q, Cheng Y, Liu J. Robotic versus laparoscopic total mesorectal excision for rectal cancer: a meta-analysis of eight studies. J Gastrointest Surg 2015; 19:516-26. [PMID: 25394387 DOI: 10.1007/s11605-014-2697-8] [Citation(s) in RCA: 110] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 11/02/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Robotic surgery has been used successfully in many branches of surgery, but there is little evidence in the literature on its use in rectal cancer (RC). We conducted this meta-analysis of randomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs) to evaluate whether the safety and efficacy of robotic total mesorectal excision (RTME) in patients with RC are equivalent to those of laparoscopic TME (LTME). METHODS Pubmed, Embase, Cochrane Library, Ovid, and Web of Science databases were searched. Studies clearly documenting a comparison of RTME with LTME for RC were selected. Operative and recovery outcomes, early postoperative morbidity, and oncological parameters were evaluated. RESULTS Eight studies were identified that included 1229 patients in total, 554 (45.08 %) in the RTME group and 675 (54.92 %) in the LTME group. Compared with LTME, RTME was associated with lower conversion rate (OR 0.23, 95 % CI [0.10, 0.52]; P = 0.0004), lower positive rate of circumferential resection margins (CRM) (2.74 % vs 5.78 %, OR 0.44, 95 % CI [0.20, 0.96], P = 0.04), and lesser incidence of erectile dysfunction (ED) (OR 0.09, 95 % CI [0.02, 0.41]; P = 0.002). Operation time, estimated blood loss, recovery outcome, postoperative morbidity and mortality, length of hospital stay, number of lymph nodes harvested, distal resection margin (DRM), proximal resection margin (PRM), and local recurrence had no significant differences between the two groups. CONCLUSIONS RTME is safe and feasible and may be an alternative treatment for RC. More international multicenter prospective large sample RCTs investigating the long-term oncological and functional outcomes are needed to determine the advantages of RTME over LTME in RC.
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Affiliation(s)
- Binghong Xiong
- Department of General Surgery, Peking University Shougang Hospital, No 9 Jinyuanzhuang Road, Shijingshan District, 100144, Beijing, People's Republic of China,
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Rectal Cancer. Surg Oncol 2015. [DOI: 10.1007/978-1-4939-1423-4_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Borowski DW, Banky B, Banerjee AK, Agarwal AK, Tabaqchali MA, Garg DK, Hobday C, Hegab M, Gill TS. Intra-arterial methylene blue injection into ex vivo colorectal cancer specimens improves lymph node staging accuracy: a randomized controlled trial. Colorectal Dis 2014; 16:681-9. [PMID: 24911342 DOI: 10.1111/codi.12681] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 04/15/2014] [Indexed: 02/06/2023]
Abstract
AIM A randomized controlled trial was carried out to study the effect of a recently proposed technique of ex vivo intra-arterial methylene blue injection of the surgical specimen removed for colorectal cancer on lymph node harvest and staging. METHOD Between May 2012 and February 2013, 100 consecutive colorectal cancer resection specimens in a single institution were randomly assigned to intervention (methylene blue injection) and control (standard manual palpation technique) groups before formalin fixation. The specimen was then examined by the histopathologist for lymph nodes. RESULTS Both groups were similar for age, sex, site of tumour, operation and tumour stage. In the intervention group, a higher number of nodes was found [median 23 (5-92) vs. 15 (5-37), P < 0.001], with only one specimen not achieving the recommended minimum standard of 12 nodes [1/50 (2%) vs. 8/50 (16%), P = 0.014]. However, there was no upstaging effect in the intervention group [23/50 (46.0%) vs. 20/50 (40.0%); P = 0.686]. With a significantly lower number of nodes harvested in rectal cancer, the positive effect of the intervention was particularly observed in the patients who underwent preoperative neoadjuvant radiotherapy [median 30 nodes (12-57) vs. 11 (7-15); P = 0.011; proportion of cases with < 12 nodes 0/5 vs. 5/8 (62.5%), P = 0.024]. CONCLUSION Ex vivo intra-arterial methylene blue injection increases lymph node yield and can help to reduce the number of cases with a lower-than-recommended number of nodes, particularly in patients with rectal cancer having neoadjuvant treatment. The technique is easy to perform, cheap and saves time.
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Affiliation(s)
- D W Borowski
- Department of Colorectal Surgery, North Tees and Hartlepool NHS Foundation Trust, University Hospital of North Tees, Stockton-on-Tees, UK
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Munkedal DLE, West NP, Iversen LH, Hagemann-Madsen R, Quirke P, Laurberg S. Implementation of complete mesocolic excision at a university hospital in Denmark: An audit of consecutive, prospectively collected colon cancer specimens. Eur J Surg Oncol 2014; 40:1494-501. [PMID: 24947074 DOI: 10.1016/j.ejso.2014.04.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 03/21/2014] [Accepted: 04/08/2014] [Indexed: 02/07/2023] Open
Abstract
AIM Over recent years there has been a new focus on the quality of colon cancer surgery following the description and introduction of complete mesocolic excision (CME). In the same period, laparoscopic surgery has been widely applied to the treatment of colon cancer. We aimed to evaluate the introduction of both CME and laparoscopic-assisted surgery at Aarhus University Hospital, Denmark between 2008 and 2011. Secondly we aimed to evaluate the impact on the quality of surgery of post-operative team meetings where pathologists demonstrated the plane of surgery on the specimens. METHOD A series of 209 consecutive and prospectively collected colon cancer specimens were evaluated by assessing the plane of surgery and measuring the amount of tissue resected. Multivariate analyses were used to control for influencing factors. RESULTS The proportion of specimens resected in the mesocolic plane was high and increased significantly following the introduction of post-operative team meetings (52%-76%, p = 0.02). Laparoscopic surgery enhanced the distance between the tumour and the arterial tie by a mean of 27 mm (p < 0.0001) and the distance between the nearest bowel wall and the arterial tie by 26 mm (p < 0.0001) when compared to an open approach. Factors such as body mass index and age influenced the outcome for surgical quality. CONCLUSION Implementation of CME and laparoscopic-assisted surgery for colon cancer is a challenge and requires continuous training and feedback. Post-operative multidisciplinary team meetings may be a key element in this process.
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Affiliation(s)
- D L E Munkedal
- Department of Surgery P, Aarhus University Hospital, 8000 Aarhus C, Denmark.
| | - N P West
- Pathology, Anatomy & Tumour Biology, Leeds Institute of Cancer and Pathology, University of Leeds, St. James's University Hospital, Leeds LS9 7TF, UK.
| | - L H Iversen
- Department of Surgery P, Aarhus University Hospital, 8000 Aarhus C, Denmark.
| | - R Hagemann-Madsen
- Pathology Department, Aarhus University Hospital, 8000 Aarhus C, Denmark.
| | - P Quirke
- Pathology, Anatomy & Tumour Biology, Leeds Institute of Cancer and Pathology, University of Leeds, St. James's University Hospital, Leeds LS9 7TF, UK.
| | - S Laurberg
- Department of Surgery P, Aarhus University Hospital, 8000 Aarhus C, Denmark.
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Xiong B, Ma L, Zhang C, Cheng Y. Robotic versus laparoscopic total mesorectal excision for rectal cancer: a meta-analysis. J Surg Res 2014; 188:404-14. [PMID: 24565506 DOI: 10.1016/j.jss.2014.01.027] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 01/05/2014] [Accepted: 01/16/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Robotic surgery has been used successfully in many branches of surgery; but there is little evidence in the literature on its use in rectal cancer (RC). We conducted this meta-analysis that included randomized controlled trials and nonrandomized controlled trials of robotic total mesorectal excision (RTME) versus laparoscopic total mesorectal excision (LTME) to evaluate whether the safety and efficacy of RTME in patients with RC are equivalent to those of LTME. MATERIALS AND METHODS Pubmed, Embase, Cochrane Library, Ovid, and Web of Science databases were searched. Studies clearly documenting a comparison of RTME with LTME for RC were selected. Operative and recovery outcomes, early postoperative morbidity, and oncological parameters were evaluated. RESULTS Eight studies were identified that included 1229 patients in total, 554 (45.08%) in the RTME and 675 (54.92%) in the LTME. Meta-analysis suggested that the conversion rate to open surgery in RTME was significantly lower than in LTME (P = 0.0004). There were no significant differences in operation time, estimated blood loss, recovery outcome, postoperative morbidity and mortality, length of hospital stay, and the oncological accuracy of resection and local recurrence between the two groups. The positive rate of circumferential resection margins (P = 0.04) and the incidence of erectile dysfunction (P = 0.002) were lower in RTME compared with LTME. CONCLUSIONS RTME for RC is safe and feasible, and the short- and medium-term oncological and functional outcomes are equivalent or preferable to LTME. It may be an alternative treatment for RC. More multicenter randomized controlled trials investigating the long-term oncological and functional outcomes are required to determine the advantages of RTME over LTME in RC.
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Affiliation(s)
- Binghong Xiong
- Department of General Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China.
| | - Li Ma
- Department of Internal Medicine, Chongqing Huaxi Hospital, Chongqing, People's Republic of China
| | - CaiQuan Zhang
- Department of General Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Yong Cheng
- Department of General Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China.
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Engels B, Platteaux N, Van den Begin R, Gevaert T, Sermeus A, Storme G, Verellen D, De Ridder M. Preoperative intensity-modulated and image-guided radiotherapy with a simultaneous integrated boost in locally advanced rectal cancer: report on late toxicity and outcome. Radiother Oncol 2013; 110:155-9. [PMID: 24239243 DOI: 10.1016/j.radonc.2013.10.026] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 10/11/2013] [Accepted: 10/14/2013] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND PURPOSE The addition of chemotherapy to preoperative radiotherapy has been established as the standard of care for patients with cT3-4 rectal cancer. As an alternative strategy, we explored intensity-modulated and image-guided radiotherapy (IMRT-IGRT) with a simultaneous integrated boost (SIB) in a prospective phase II study. Here, we report outcome and late toxicity after a median follow-up of 54 months. METHODS AND MATERIALS A total of 108 patients were treated preoperatively with IMRT-IGRT, delivering a dose of 46 Gy in fractions of 2 Gy. Patients (n=57) displaying an anticipated circumferential resection margin (CRM) of less than 2mm based on magnetic resonance imaging received a SIB to the tumor up to a total dose of 55.2 Gy. RESULTS The absolute incidence of grade ≥3 late gastrointestinal and urinary toxicity was 9% and 4%, respectively, with a 13% rate of any grade ≥3 late toxicity. The actuarial 5-year local control (LC), progression-free survival (PFS) and overall survival (OS) were 97%, 57%, and 68%. On multivariate analysis, R1 resection and pN2 disease were associated with significantly impaired OS. CONCLUSIONS The use of preoperative IMRT-IGRT with a SIB resulted in a high 5-year LC rate and non-negligible late toxicity.
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Affiliation(s)
- Benedikt Engels
- Department of Radiotherapy, UZ Brussel, Vrije Universiteit Brussel, Belgium.
| | - Nele Platteaux
- Department of Radiotherapy, UZ Brussel, Vrije Universiteit Brussel, Belgium
| | | | - Thierry Gevaert
- Department of Radiotherapy, UZ Brussel, Vrije Universiteit Brussel, Belgium
| | - Alexandra Sermeus
- Department of Gastroenterology, UZ Brussel, Vrije Universiteit Brussel, Belgium
| | - Guy Storme
- Department of Radiotherapy, UZ Brussel, Vrije Universiteit Brussel, Belgium
| | - Dirk Verellen
- Department of Radiotherapy, UZ Brussel, Vrije Universiteit Brussel, Belgium
| | - Mark De Ridder
- Department of Radiotherapy, UZ Brussel, Vrije Universiteit Brussel, Belgium
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Sole CV, Calvo FA, Alvarez E, Peligros I, Garcia-Alfonso P, Ferrer C, Ochoa E, Herranz R, Carreras JL. Clinical significance of VEGFR-2 and ¹⁸F-FDG PET/CT SUVmax pretreatment score in predicting the long-term outcome of patients with locally advanced rectal cancer treated with neoadjuvant therapy. Eur J Nucl Med Mol Imaging 2013; 40:1635-44. [PMID: 23801169 DOI: 10.1007/s00259-013-2479-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 06/03/2013] [Indexed: 02/06/2023]
Abstract
PURPOSE Vascular endothelial growth factor receptor-2 (VEGFR-2), epidermal growth factor receptor-1 (EGFR), and cyclooxygenase-2 (COX-2) stimulate key processes involved in tumor progression and are important targets for cancer drugs. (18)F-FDG maximum standardized uptake value (SUVmax) is a marker of tumor metabolic activity. The purpose of this study was to measure SUVmax combined with VEGFR-2, EGFR and COX-2 proteins in pretreatment tumor biopsies from patients with locally advanced rectal cancer receiving intensive neoadjuvant treatment and to correlate the findings with clinical outcome. METHODS VEGFR-2, EGFR and COX-2 were measured using the immunoreactive score (IRS). SUVmax (median 8.4) was quantified in tumors with molecular overexpression (IRS ≥3 + SUVmax ≥ 8.4 indicating active tumors; SUVmax <8.4 indicating inactive tumors). The Cox proportional hazards model was used to explore associations between tumor markers, disease-free survival (DFS) and overall survival (OS). RESULTS The study group comprised 38 patients with a median follow-up of 69.3 months (range 4.5 - 92 months). Multivariate analysis showed that active tumors (overexpressing VEGFR-2, high SUVmax) were associated with worse DFS (HR 4.73, 95 % CI 1.18 - 22.17; p = 0.04) and OS (HR 4.28, 95 % CI 1.04 - 20.12; p = 0.05). CONCLUSION Active tumors overexpressing VEGFR-2 are associated with a worse overall outcome in patients with rectal cancer treated with induction chemotherapy followed by pelvic chemoradiation and surgery. The optimal diagnostic cut-off level for this novel biomarker association should be investigated. Evaluation in a clinical trial is required to determine whether selected patients could benefit from a VEGFR-targeting drug.
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Affiliation(s)
- Claudio V Sole
- Department of Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain,
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Ahn YJ, Kwon HY, Park YA, Sohn SK, Lee KY. Contributing factors on lymph node yield after surgery for mid-low rectal cancer. Yonsei Med J 2013; 54:389-395. [PMID: 23364972 PMCID: PMC3575998 DOI: 10.3349/ymj.2013.54.2.389] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Revised: 04/15/2012] [Accepted: 04/18/2012] [Indexed: 01/27/2023] Open
Abstract
PURPOSE The purpose of the present study was to evaluate the contributing factors to the lymph node status as well as to define the impact of preoperative concurrent chemoradiotherapy (CCRT) on the number of lymph nodes retrieved in mid-low rectal cancer. MATERIALS AND METHODS We retrospectively analyzed 277 patients who underwent curative surgical resection for mid-low rectal cancer between 1998 and 2007. Eighty-two patients received long course preoperative CCRT followed by surgery. RESULTS A mean of 13.12±9.28 lymph nodes was retrieved. In a univariate analysis, distance from the anal verge, pT stage, pN stage, lymphovascular invasion, preoperative CCRT had significant influence on the number of lymph nodes retrieved. In a multivariate model, patients in the CCRT group had fewer retrieved lymph nodes than the non-CCRT group (p<0.001). Both univariate and multivariate analyses showed that the ypN0 group had fewer retrieved lymph nodes than the ypN1-2 group (p=0.027) in the CCRT group. CONCLUSION Preoperative CCRT was an independent risk factor for failure to harvest an appropriate number of lymph nodes, and node-negative patients who received CCRT had fewer lymph nodes harvested.
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Affiliation(s)
- Young Jae Ahn
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Youn Kwon
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Ah Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Kook Sohn
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kang Young Lee
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Calvo FA, Sole CV, de la Mata D, Cabezón L, Gómez-Espí M, Alvarez E, Madariaga P, Carreras JL. 18F-FDG PET/CT-based treatment response evaluation in locally advanced rectal cancer: a prospective validation of long-term outcomes. Eur J Nucl Med Mol Imaging 2013; 40:657-67. [DOI: 10.1007/s00259-013-2341-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Accepted: 01/04/2013] [Indexed: 12/11/2022]
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Total mesorectal excision: a comparison of oncological and functional outcomes between robotic and laparoscopic surgery for rectal cancer. Surg Endosc 2013; 27:1887-95. [PMID: 23292566 DOI: 10.1007/s00464-012-2731-4] [Citation(s) in RCA: 190] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2012] [Accepted: 12/04/2012] [Indexed: 02/01/2023]
Abstract
BACKGROUND Long-term data from the CLASICC study demonstrated the oncologic equivalence of laparoscopic and open rectal cancer surgery despite an increased circumferential resection margin involvement in the laparoscopic group in the initial report. Moreover, laparoscopic total mesorectal excision (TME) may be associated with increased rates of male sexual dysfunction compared to conventional open TME. Robotic surgery could potentially obtain better results than laparoscopy. The aim of this study was to compare the clinical and functional outcomes of robotic and laparoscopic surgery in a single-center experience. METHODS This study was based on 100 patients who underwent minimally invasive anterior rectal resection with TME. Fifty consecutive robotic rectal anterior resections with TME (R-TME) were compared to the first 50 consecutive laparoscopic rectal resections with TME (L-TME). RESULTS Median operative time was 270 min in R-TME and 275 min in L-TME. No conversions occurred in the R-TME group whereas six conversions occurred in the L-TME group. The mean number of harvested lymph nodes was 16.5 ± 7.1 for R-TME and 13.8 ± 6.7 for L-TME. The circumferential margin (CRM) was <2 mm in six L-TME patients, whereas no one in R-TME group had a CRM <2 mm. The International Prostate Symptom Score (IPSS) scores were significantly increased 1 month after surgery in both the L-TME and R-TME groups, but they normalized 1 year after surgery. Erectile function worsened significantly 1 month after surgery in both the groups but it was restored completely 1 year after surgery in the R-TME group and partially in the L-TME group. CONCLUSIONS Robotic TME is oncologically safe and adequate for rectal cancer treatment, showing better results than laparoscopic TME in terms of CRM, conversions, and hospital length of stay. Better recovery in voiding and sexual function is achieved with the robotic technique.
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Predictive factors of positive circumferential resection margin after radiochemotherapy for rectal cancer: The French randomised trial ACCORD12/0405 PRODIGE 2. Eur J Cancer 2013; 49:82-9. [DOI: 10.1016/j.ejca.2012.06.028] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 05/08/2012] [Accepted: 06/23/2012] [Indexed: 02/03/2023]
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Sitarz R, Kocemba K, Maciejewski R, Polkowski WP. Effective cancer treatment by multidisciplinary teams. POLISH JOURNAL OF SURGERY 2012; 84:371-376. [PMID: 22935461 DOI: 10.2478/v10035-012-0063-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Robert Sitarz
- Department of Surgical Oncology, Medical University in Lublin
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Abstract
The treatment of rectal cancer largely depends on disease stage at diagnosis, based on which patients can be classified as low, intermediate, or high risk. Prognostic and predictive markers, specific to each risk category, can be applied for optimal risk classification and subsequent treatment allocation. These markers are either histopathological, determined with imaging, or have a biomolecular background. This review provides an overview of the current status of treatment options and the use of prognostic and predictive markers in each risk category. An effort was made to identify those markers that are currently lacking in, but have the potential to improve, the clinical decision process by discussing the data from recent studies aimed at the development of new prognostic and predictive markers. At this moment, none of the markers studied has been proven to be of significant, independent value, justifying implementation in daily clinical practice. However, recent developments in imaging techniques and biomolecular research do show great potential.
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Elferink M, Pukkala E, Klaase J, Siesling S. Spatial variation in stage distribution in colorectal cancer in the Netherlands. Eur J Cancer 2012; 48:1119-25. [DOI: 10.1016/j.ejca.2011.06.058] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Revised: 06/27/2011] [Accepted: 06/30/2011] [Indexed: 10/17/2022]
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Optimal lymph node harvest in rectal cancer (UICC stages II and III) after preoperative 5-FU-based radiochemotherapy. Acetone compression is a new and highly efficient method. Am J Surg Pathol 2012; 36:202-13. [PMID: 22251939 DOI: 10.1097/pas.0b013e31823fa35b] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Preoperative 5-fluorouracil-based radiochemotherapy (RCT), followed by total mesorectal excision, is accepted as standard therapy in rectal cancers (UICC stages II and III). The accurate evaluation of ypN status after RCT with valuable lymph node (LN) harvest is essential for postoperative risk-adapted treatment decisions. Actual numbers of assessed LNs and validity of ypN status vary extensively depending on the methods used. MATERIAL AND METHODS This prospective study validates the acetone compression (AC), whole mesorectal compartment embedding (WME), and fat clearance (FC) methods for LN retrieval in n=257 rectal cancer specimens obtained from 2 high-volume surgical centers. For optimal LN retrieval, the AC method (n=161 specimens: 52 cases with RCT, 109 cases without RCT) was compared with the WME (n=64 cases, with RCT) and FC methods (n=32 cases: 17 cases with RCT, 15 cases without RCT). The efficacy of LN retrieval, costs involved, and molecular diagnostics were measured. RESULTS Using the AC method, 41 LNs (mean; range 14 to 86 LNs) were detectable in total mesorectal excision specimens after RCT and 44 LNs (mean; range 9 to 78 LNs) in cases without RCT. The LN yield after RCT obtained by using the AC method was equivalent to that of the WME method (mean 32 LNs/specimen; range 12 to 81 LNs) but demonstrated a better time and cost-efficacy. In addition, the AC method facilitated assessment of any tumor deposits, including perineural invasion, and did not hamper molecular analyses. The AC method increased LN retrieval 4- to-6-fold as compared with the literature and 2-fold compared with manual dissection after the FC method. DISCUSSION The AC method is the method of choice for accurate LN staging in locally advanced rectal cancer, especially after preoperative RCT, and is well suited for routine gastrointestinal pathology workup.
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McDonald JR, Renehan AG, O'Dwyer ST, Haboubi NY. Lymph node harvest in colon and rectal cancer: Current considerations. World J Gastrointest Surg 2012; 4:9-19. [PMID: 22347537 PMCID: PMC3277879 DOI: 10.4240/wjgs.v4.i1.9] [Citation(s) in RCA: 108] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2011] [Revised: 04/18/2011] [Accepted: 04/25/2011] [Indexed: 02/06/2023] Open
Abstract
The prognostic significance of identifying lymph node (LN) metastases following surgical resection for colon and rectal cancer is well recognized and is reflected in accurate staging of the disease. An established body of evidence exists, demonstrating an association between a higher total LN count and improved survival, particularly for node negative colon cancer. In node positive disease, however, the lymph node ratios may represent a better prognostic indicator, although the impact of this on clinical treatment has yet to be universally established. By extension, strategies to increase surgical node harvest and/or laboratory methods to increase LN yield seem logical and might improve cancer staging. However, debate prevails as to whether or not these extrapolations are clinically relevant, particularly when very high LN counts are sought. Current guidelines recommend a minimum of 12 nodes harvested as the standard of care, yet the evidence for such is questionable as it is unclear whether an increasing the LN count results in improved survival. Findings from modern treatments, including down-staging in rectal cancer using pre-operative chemoradiotherapy, paradoxically suggest that lower LN count, or indeed complete absence of LNs, are associated with improved survival; implying that using a specific number of LNs harvested as a measure of surgical quality is not always appropriate. The pursuit of a sufficient LN harvest represents good clinical practice; however, recent evidence shows that the exhaustive searching for very high LN yields may be unnecessary and has little influence on modern approaches to treatment.
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Affiliation(s)
- James R McDonald
- James R McDonald, Andrew G Renehan, Sarah T O'Dwyer, Department of Surgery, The Christie NHS Foundation Trust, Manchester M20 4BX, United Kingdom
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Moszkowicz D, Alsaid B, Bessede T, Penna C, Nordlinger B, Benoît G, Peschaud F. Where does pelvic nerve injury occur during rectal surgery for cancer? Colorectal Dis 2011; 13:1326-34. [PMID: 20718836 DOI: 10.1111/j.1463-1318.2010.02384.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AIM Optimal treatment of rectal adenocarcinoma involves total mesorectal excision with nerve-preserving dissection. Urinary and sexual dysfunction is still frequent following these procedures. Improved knowledge of pelvic nerve anatomy may help reduce this and define the key anatomical zones at risk. METHOD The MEDLINE database was searched for available literature on pelvic nerve anatomy and damage after rectal surgery using the key words 'autonomic nerve', 'pelvic nerve', 'colorectal surgery', and 'genitourinary dysfunction'. All relevant French and English publications up to May 2010 were reviewed. Reviewed data were illustrated using 3D reconstruction of the foetal pelvis. RESULTS The ligation of the inferior mesenteric artery and dissection of the retrorectal space can cause damage to the superior hypogastric plexus and/or hypogastric nerve. Anterolateral dissection in the 'lateral ligament' area and division of Denonvilliers' fascia can damage the inferior hypogastric plexus and efferent pathways. Perineal dissection can indirectly damage the pudendal nerve. CONCLUSIONS In most cases, the pelvic nerves can be preserved during rectal surgery. Complete oncological resection may require dissection close to the nerves where the tumour is located anterolaterally where it is fixed and when the pelvis is narrow.
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Affiliation(s)
- D Moszkowicz
- Laboratory of Experimental Surgery, Faculty of Medicine, University Paris-Sud 11, Le Kremlin-Bicêtre, France
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Bibeau F, Rullier A, Jourdan MF, Frugier H, Palasse J, Leaha C, Gudin de Vallerin A, Rivière B, Bodin X, Perrault V, Cantos C, Lavaill R, Boissière-Michot F, Azria D, Colombo PE, Rouanet P, Rullier E, Panis Y, Guedj N. [Locally advanced rectal cancer management: which role for the pathologist in 2011?]. Ann Pathol 2011; 31:433-41. [PMID: 22172116 DOI: 10.1016/j.annpat.2011.10.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Accepted: 10/15/2011] [Indexed: 01/16/2023]
Abstract
Locally advanced rectal cancers mainly correspond to lieberkünhien adenocarcinomas and are defined by T3-T4 lesions with or without regional metastatic lymph nodes. Such tumors benefit from neoadjuvant treatment combining chemotherapy and radiotherapy, followed by surgery with total mesorectum excision. Such a strategy can decrease the rate of local relapse and lead to an easier complementary surgery. The pathologist plays an important role in the management of locally advanced rectal cancer. Indeed, he is involved in the gross examination of the mesorectum excision quality and in the exhaustive sampling of the most informative areas. He also has to perform a precise histopathological analysis, including the determination of the circumferential margin or clearance and the evaluation of tumor regression. All these parameters are major prognostic factors which have to be clearly included in the pathology report. Moreover, the next challenge for the pathologist will be to determine and validate new prognostic and predictive markers, notably by using pre-therapeutic biopsies. The goal of this mini-review is to emphasize the pathologist's role in the different steps of the management of locally advanced rectal cancers and to underline its implication in the determination of potential biomarkers of aggressiveness and response.
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Affiliation(s)
- Frédéric Bibeau
- Service de pathologie, CRLC Val-d'Aurelle, Montpellier, France.
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Engels B, Tournel K, Everaert H, Hoorens A, Sermeus A, Christian N, Storme G, Verellen D, De Ridder M. Phase II study of preoperative helical tomotherapy with a simultaneous integrated boost for rectal cancer. Int J Radiat Oncol Biol Phys 2011; 83:142-8. [PMID: 22014952 DOI: 10.1016/j.ijrobp.2011.05.068] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2011] [Revised: 05/20/2011] [Accepted: 05/26/2011] [Indexed: 12/27/2022]
Abstract
PURPOSE The addition of concomitant chemotherapy to preoperative radiotherapy is considered the standard of care for patients with cT3-4 rectal cancer. The combined treatment modality increases the complete response rate and local control (LC), but has no impact on survival or the incidence of distant metastases. In addition, it is associated with considerable toxicity. As an alternative strategy, we explored prospectively, preoperative helical tomotherapy with a simultaneous integrated boost (SIB). METHODS AND MATERIALS A total of 108 patients were treated with intensity-modulated and image-guided radiotherapy using the Tomotherapy Hi-Art II system. A dose of 46 Gy, in daily fractions of 2 Gy, was delivered to the mesorectum and draining lymph nodes, without concomitant chemotherapy. Patients with an anticipated circumferential resection margin (CRM) of less than 2 mm, based on magnetic resonance imaging, received a SIB to the tumor up to a total dose of 55.2 Gy. Acute and late side effects were scored using the National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0. RESULTS A total of 102 patients presented with cT3-4 tumors; 57 patients entered the boost group and 51 the no-boost group. One patient in the no-boost group developed a radio-hypersensitivity reaction, resulting in a complete tumor remission, a Grade 3 acute and Grade 5 late enteritis. No other Grade ≥3 acute toxicities occurred. With a median follow-up of 32 months, Grade ≥3 late gastrointestinal and urinary toxicity were observed in 6% and 4% of the patients, respectively. The actuarial 2-year LC, progression-free survival and overall survival were 98%, 79%, and 93%. CONCLUSIONS Preoperative helical tomotherapy displays a favorable acute toxicity profile in patients with cT3-4 rectal cancer. A SIB can be safely administered in patients with a narrow CRM and resulted in a promising LC.
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Affiliation(s)
- Benedikt Engels
- Department of Radiotherapy, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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Schmitz KJ, Chmelar C, Berg E, Schmid KW. [Pathological work-up of rectal cancer following partial/total mesorectal excision]. DER PATHOLOGE 2011; 32:321-9. [PMID: 21660476 DOI: 10.1007/s00292-011-1439-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Total mesorectal excision (TME) refers to the anatomically accurate surgical resection of the rectum from its surrounding fascias and has become the gold standard for treating rectal cancer. The pathologist plays a key role in the assessment of these specimens and good pathological reporting of rectal cancer is essential to achieving the optimum possible results for patients with rectal cancer. In experienced hands, these techniques result in a dramatic improvement in cancer-related cure rates from 45% to 75% and a reduction in pelvic recurrences from 40% to 5%-10%. Moreover, preservation of sexual and urinary functions is possible in the majority of cases. This article reviews the pathological assessment of the TME specimen in detail with regards to current international guidelines and describes its anatomical background. In addition, particular issues relating to margins, lymph node dissection and effects of neoadjuvant therapy are discussed.
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Affiliation(s)
- K J Schmitz
- Institut für Pathologie und Neuropathologie, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland.
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The effects of short-course preoperative irradiation on local recurrence rate and survival in rectal cancer: a population-based nationwide study. Dis Colon Rectum 2011; 54:672-80. [PMID: 21552050 DOI: 10.1007/dcr.0b013e318210c067] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Preoperative irradiation with 5 × 5 Gy in randomized trials reduces local recurrence rate and may improve survival in patients with resectable rectal cancer. OBJECTIVE The aim of this study was to determine whether the same favorable effects could be observed in a population-based study. DESIGN This study was conducted via a retrospective analysis of prospectively collected data from the Swedish Rectal Cancer Registry. SETTINGS This study examined population-based data from Sweden. PATIENTS All newly diagnosed rectal cancers in Sweden are reported to the Swedish Rectal Cancer Registry. INTERVENTIONS Between 1995 and 2001, 6878 patients (stages I-III) were operated on with an anterior resection, an abdominoperineal resection, or a Hartmann's procedure. Short-course irradiation was given to 41% of patients preoperatively. To reduce bias, patients operated on with a Hartmann procedure or older than 75 years were excluded when 5-year survival was analyzed (n = 3466). Tumors were analyzed according to height (0-5 cm, 6-10 cm, 11-15 cm). MAIN OUTCOME MEASURES Five-year cumulative local recurrence and survival rates. RESULTS The 5-year cumulative local recurrence rate was 6.3% (95% CI 5.4-7.4) for patients receiving preoperative irradiation and 12.1% (95% CI 10.8-13.5) for patients not receiving preoperative irradiation. Multivariate analyses indicated the risk of local recurrence was 50% lower for patients receiving preoperative irradiation compared with patients not receiving irradiation (hazard ratio = 0.50; 95% CI 0.40-0.62). Among patients younger than 76 years and operated on with an anterior resection or abdominoperineal resection, the 5-year cumulative survival rate was 0.70 (95% CI 0.69-0.72). Disease-free and overall survivals were higher in irradiated patients, and the difference was statistically significant in low tumors. CONCLUSIONS In this population-based analysis, the favorable effect of preoperative short-course irradiation on local recurrence rates, seen in randomized trials, was confirmed for the entire Swedish population irrespective of tumor height and stage. Data also suggested an effect on 5-year survival, especially in patients with low tumors (0-5 cm).
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Tosun AB, Gunduz-Demir C. Graph run-length matrices for histopathological image segmentation. IEEE TRANSACTIONS ON MEDICAL IMAGING 2011; 30:721-732. [PMID: 21097378 DOI: 10.1109/tmi.2010.2094200] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
The histopathological examination of tissue specimens is essential for cancer diagnosis and grading. However, this examination is subject to a considerable amount of observer variability as it mainly relies on visual interpretation of pathologists. To alleviate this problem, it is very important to develop computational quantitative tools, for which image segmentation constitutes the core step. In this paper, we introduce an effective and robust algorithm for the segmentation of histopathological tissue images. This algorithm incorporates the background knowledge of the tissue organization into segmentation. For this purpose, it quantifies spatial relations of cytological tissue components by constructing a graph and uses this graph to define new texture features for image segmentation. This new texture definition makes use of the idea of gray-level run-length matrices. However, it considers the runs of cytological components on a graph to form a matrix, instead of considering the runs of pixel intensities. Working with colon tissue images, our experiments demonstrate that the texture features extracted from "graph run-length matrices" lead to high segmentation accuracies, also providing a reasonable number of segmented regions. Compared with four other segmentation algorithms, the results show that the proposed algorithm is more effective in histopathological image segmentation.
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Affiliation(s)
- Akif Burak Tosun
- Department of Computer Engineering, Bilkent University, Ankara TR-06800, Turkey.
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Merkel S, Hohenberger W, Hermanek P. [Intra-operative local tumor cell dissemination in rectal carcinoma surgery: effect of operation principles and neoadjuvant therapy]. Chirurg 2011; 81:719-27. [PMID: 20694787 DOI: 10.1007/s00104-010-1919-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND The influence of surgical principles and neoadjuvant therapy on the frequency of local tumor cell dissemination (LTCD) in rectal carcinoma surgery and its consequences for local recurrence and survival rates were analyzed. PATIENTS AND METHODS Data from the Erlangen registry for colorectal carcinomas (ERCRC) from 1969-2008 were compared with data from the literature published in 1980-2008. RESULTS LTCD was observed in 6.7% in the ERCRC (n=2764) and a frequency of 6.9% was reported in in the literature (n=13,395). In the course of time and especially since the introduction of total mesorectal excision (TME) surgery, the incidence of LTCD has significantly decreased. Neoadjuvant treatment did not influence the frequency of LTCD. Following LTCD the rate of local recurrence significantly increased and the 5 year survival rate significantly decreased. This also applied to patients with neoadjuvant therapy. CONCLUSIONS Even in the era of TME surgery attention must to be paid to avoidance of LTCD. It is obligatory to document the occurrence of LTCD and it must be taken into consideration in routine quality assurance. In cases of LTCD postoperative chemoradiation is indicated for patients without neoadjuvant irradiation.
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Affiliation(s)
- S Merkel
- Chirurgische Klinik, Universitätsklinikum Erlangen, Deutschland.
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De Hertogh G, Geboes KP. Practical and molecular evaluation of colorectal cancer: new roles for the pathologist in the era of targeted therapy. Arch Pathol Lab Med 2010; 134:853-63. [PMID: 20524863 DOI: 10.5858/134.6.853] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT Colorectal cancer is the third most common cancer and the fourth most common cause of cancer death worldwide. Patient cases are discussed in multidisciplinary meetings to decide on the best management on an individual basis. Until recently, the main task of the pathologist in such teams was to provide clinically useful reports comprising staging of colorectal cancer in surgical specimens. The advent of total mesorectal excision and the application of anti-epidermal growth factor receptor (EGFR)-targeted therapies for selected patients with metastasized colorectal cancer have changed the role of the pathologist. OBJECTIVES To present the traditional role of the pathologist in the multidisciplinary team treating patients with colorectal cancer, to address the technique of total mesorectal excision and its implications for the evaluation of surgical specimens, to offer background information on the various EGFR-targeted therapies, and to review the currently investigated tissue biomarkers assumed to be predictive for efficacy of such therapies, with a focus on the role of the pathologist in determining the status of such biomarkers in individual tumors. DATA SOURCES This article is based on selected articles pertaining to biopsy evaluation of colorectal carcinoma and reviews of EGFR-targeted therapies for this cancer. All references are accessible via the PubMed database (US National Library of Medicine and the National Institutes of Health). CONCLUSIONS Pathologists play an increasingly important role in the diagnosis and management of colorectal cancer because of the advent of new surgical techniques and of targeted therapies. It is expected that this role will increase further in the near future.
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Affiliation(s)
- Gert De Hertogh
- Department of Pathology, University Hospitals KULeuven, Leuven, Belgium.
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