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1
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Karahan SN, Gorgun E. Modern rectal cancer management: A review of total neoadjuvant therapy and current practices. Am J Surg 2025; 241:116145. [PMID: 39706107 DOI: 10.1016/j.amjsurg.2024.116145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2024] [Revised: 12/05/2024] [Accepted: 12/10/2024] [Indexed: 12/23/2024]
Abstract
Total Neoadjuvant Therapy (TNT) is a promising strategy for treating locally advanced rectal cancer (LARC) and has started to replace the traditional neoadjuvant chemoradiotherapy (CRT). This review combines findings from pivotal studies that helped TNT to integrate into clinical practice. It emphasizes the efficacy of TNT in improving the disease-free and metastasis-free survival, pathologic complete response and, according to recent studies, a potential improvement in overall survival when compared to standard CRT. In addition, the review analyzes increased organ preservation by TNT and explores the trend towards personalized medicine with the use of TNT. Additionally, it investigates the possibility of excluding radiotherapy in some subgroups. Future directions include integration of immunotherapy, use of TNT in early-stage disease and determining optimal components of TNT, such as type of chemotherapy and type of radiotherapy.
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Affiliation(s)
- Salih N Karahan
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Emre Gorgun
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.
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Wang DC, Peng XF, Yu M. Prediction model construction for the occurrence of LARS after neoadjuvant therapy combined with laparoscopic total mesorectal excision in male patients with mid-low rectal cancer. Front Oncol 2024; 14:1492245. [PMID: 39735602 PMCID: PMC11671363 DOI: 10.3389/fonc.2024.1492245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2024] [Accepted: 11/26/2024] [Indexed: 12/31/2024] Open
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy for rectal cancer improves surgical outcomes and reduces recurrence but can cause low anterior resection syndrome (LARS), affecting quality of life. This study aims to predict the risk of LARS in male patients with mid-low rectal cancer after laparoscopic total mesorectal excision (TME). METHODS Clinical data from 203 male patients with mid-low rectal cancer who underwent neoadjuvant therapy and laparoscopic resection were collected. Patients were divided into training (n=143) and validation (n=60) cohorts. LARS risk factors were identified using logistic regression, and a predictive model was constructed and validated using ROC curve, Hosmer-Lemeshow test, calibration curve, and decision curve analysis (DCA). RESULTS LARS occurred in 53.6% of the patients in this study. Multivariate logistic regression analysis revealed that BMI ≥ 25 kg/m², tumor distance from the anal margin < 5 cm, radiotherapy, and anastomotic leakage were independent risk factors for postoperative LARS in patients (P < 0.05). The areas under the ROC curves for the training cohort and validation cohort were 0.866 (95% CI: 0.807-0.925) and 0.724 (95% CI: 0.595-0.853), respectively, with both groups showing good goodness-of-fit test results (P > 0.05). The DCA curve indicated that the model had a high clinical utility. CONCLUSIONS BMI ≥ 25 kg/m², tumor distance from the anal margin < 5 cm, radiotherapy, and anastomotic leakage are independent risk factors for the occurrence of LARS after neoadjuvant therapy combined with laparoscopic TME in male patients with mid-low rectal cancer. These factors should be emphasized in clinical practice, and corresponding preventive measures should be promptly implemented.
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Affiliation(s)
- Deng-Chao Wang
- Department of General Surgery, Zigong Fourth People’s Hospital, Zigong, Sichuan, China
| | - Xue-Feng Peng
- Department of General Surgery, Zigong Fourth People’s Hospital, Zigong, Sichuan, China
| | - Miao Yu
- Department of Basic Medicine, Sichuan Vocational College of Health and Rehabilitation, Zigong, Sichuan, China
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Milito P, Piozzi GN, Hussain MI, Dragani TA, Sorrentino L, Cosimelli M, Guaglio M, Battaglia L. Effect of neoadjuvant chemoradiation on anorectal function assessed with anorectal manometry: A systematic review and meta-analysis. TUMORI JOURNAL 2024; 110:284-294. [PMID: 38819198 PMCID: PMC11295399 DOI: 10.1177/03008916241256544] [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: 12/04/2023] [Revised: 04/19/2024] [Accepted: 05/06/2024] [Indexed: 06/01/2024]
Abstract
AIM Improvement in oncological survival for rectal cancer increases attention to anorectal dysfunction. Diagnostic questionnaires can evaluate quality of life but are subjective and dependent on patients' compliance. Anorectal manometry can objectively assess the continence mechanism and identify functional sphincter weakness and rectal compliance. Neoadjuvant chemoradiotherapy is presumed to affect anorectal function. We aim to assess anorectal function in rectal cancer patients who undergo total mesorectal excision, with or without neoadjuvant chemoradiation, using anorectal manometry measurements. METHOD MEDLINE, Embase, and Cochrane databases were searched for studies comparing perioperative anorectal manometry between neoadjuvant chemoradiation and upfront surgery for rectal cancers. Primary outcomes were resting pressure, squeeze pressure, sensory threshold volume and maximal tolerable volume. RESULTS Eight studies were included in the systematic review, of which seven were included for metanalysis. 155 patients (45.3%) had neoadjuvant chemoradiation before definitive surgery, and 187 (54.6%) underwent upfront surgery. Most patients were male (238 vs. 118). The standardized mean difference of mean resting pressure, mean and maximum squeeze pressure, maximum resting pressure, sensory threshold volume, and maximal tolerable volume favored the upfront surgery group but without statistical significance. CONCLUSION Currently available evidence on anorectal manometry protocols failed to show any statistically significant differences in functional outcomes between neoadjuvant chemoradiation and upfront surgery. Further large-scale prospective studies with standardized neoadjuvant chemoradiation and anorectal manometry protocols are needed to validate these findings.
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Affiliation(s)
- Pamela Milito
- Department of Emergency and General Surgery, IRCCS Policlinico San Donato, Milan, Italy
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Guglielmo Niccolò Piozzi
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
- Department of Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | | | - Tommaso A. Dragani
- Department of Research, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Luca Sorrentino
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Maurizio Cosimelli
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Marcello Guaglio
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Luigi Battaglia
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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Conces ML, Mahipal A. Adoption of Total Neoadjuvant Therapy in the Treatment of Locally Advanced Rectal Cancer. Curr Oncol 2024; 31:366-382. [PMID: 38248109 PMCID: PMC10813931 DOI: 10.3390/curroncol31010024] [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: 10/20/2023] [Revised: 12/11/2023] [Accepted: 01/01/2024] [Indexed: 01/23/2024] Open
Abstract
Local and metastatic recurrence are primary concerns following the treatment of locally advanced rectal cancer (LARC). Chemoradiation (CRT) can reduce the local recurrence rates and has subsequently moved to the neoadjuvant setting from the adjuvant setting. Pathological complete response (pCR) rates have also been noted to be greater in patients treated with neoadjuvant CRT prior to surgery. The standard approach to treating LARC would often involve CRT followed by surgery and optional adjuvant chemotherapy and remained the treatment paradigm for almost two decades. However, patients were often unable to complete adjuvant chemotherapy due to a decreased tolerance of chemotherapy following surgery, which led to upfront treatment with both CRT and chemotherapy, and total neoadjuvant therapy, or TNT, was created. The efficacy outcomes of local recurrence, disease-free survival, and pCR have improved in patients receiving TNT compared to the standard approach. Additionally, more recent data suggest a possible improvement in overall survival as well. Patients with a complete clinical response following TNT have the opportunity for watch-and-wait surveillance, allowing some patients to undergo organ preservation. Here, we discuss the clinical trials and studies that led to the adoption of TNT as the standard of care for LARC, with the possibility of watch-and-wait surveillance for patients achieving complete responses. We also review the possibility of overtreating some patients with LARC.
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Affiliation(s)
| | - Amit Mahipal
- University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH 44106, USA
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Arndt K, Ore AS, Quinn J, Fabrizio A, Crowell K, Messaris E, Cataldo T. Outcomes Following Recent and Distant Neoadjuvant Radiation in Rectal Cancer: An Institutional Retrospective Review and Analysis of NSQIP. Clin Colorectal Cancer 2023; 22:474-484. [PMID: 37863792 DOI: 10.1016/j.clcc.2023.07.006] [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: 05/15/2023] [Revised: 07/06/2023] [Accepted: 07/08/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy (nCRT) is the standard of care in locally advanced rectal cancer (LARC). However, radiation therapy is thought to increase operative difficulty due to induction of fibrosis. Total neoadjuvant therapy (TNT) protocols increase the time between completion of radiation and surgical resection which may lead to increased operative difficulty and complications. METHODS A single institution retrospective review of patients ≥18 years with LARC undergoing nCRT from 2015 to 2022. Patients were dichotomized in 2 cohorts: <90 days from radiation to surgery (recent radiation), and ≥90 days from radiation to surgery (distant radiation). Institutional data was compared to National Surgical Quality Improvement Program (NSQIP) rectal cancer data from 2016 to 2020. Outcomes included intraoperative complications, 30-day morbidity, and oncologic outcomes. RESULTS One hundred forty-six institutional patients included, 120 had recent radiation, 26 had distant radiation. Thirty-day morbidity and intraoperative complications did not differ. There was greater radial margin positivity (7% vs. 24%), fewer lymph nodes harvested (17 ± 5 vs. 15 ± 6), and a lower rate of complete mesorectal dissection (88% vs. 65%,) in distant radiation patients 3059 patients were included in NSQIP analysis, 2029 completed radiation <90 days before surgery and 1030 without radiation 90 days before surgery. Patients without radiation 90 days preoperatively had more radial margin positivity (9.2% vs. 4.6%), organ space infection (8.6% vs. 6.4%), and pneumonia (2.2% vs. 0.9%). CONCLUSION The present study suggests that increased time between radiation and surgery results in more challenging dissection with less complete mesorectal dissection and increased radial margin positivity without increasing technical complications.
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Affiliation(s)
- Kevin Arndt
- Division of Colorectal Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| | - Ana Sofia Ore
- Division of Colorectal Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jeanne Quinn
- Division of Colorectal Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Anne Fabrizio
- Division of Colorectal Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Kristen Crowell
- Division of Colorectal Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Evangelos Messaris
- Division of Colorectal Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Thomas Cataldo
- Division of Colorectal Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Wu J, Huang M, Wu Y, Hong Y, Cai L, He R, Luo Y, Wang P, Huang M, Lin J. Neoadjuvant chemoradiotherapy versus neoadjuvant chemotherapy alone for patients with locally advanced rectal cancer: a propensity-score-matched analysis combined with SEER validation. J Cancer Res Clin Oncol 2023; 149:8897-8912. [PMID: 37154929 PMCID: PMC10374480 DOI: 10.1007/s00432-023-04779-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 04/14/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND Neoadjuvant therapy followed by radical surgery is recommended for locally advanced rectal cancer (LARC). But radiotherapy can cause potential adverse effects. The therapeutic outcomes, postoperative survival and relapse rates between neoadjuvant chemotherapy (N-CT) and neoadjuvant chemoradiotherapy (N-CRT) patients have rarely been studied. METHODS From February 2012 to April 2015, patients with LARC who underwent N-CT or N-CRT followed by radical surgery at our center were included. Pathologic response, surgical outcomes, postoperative complications and survival outcomes (including overall survival [OS], disease-free survival [DFS], cancer-specific survival [CSS] and locoregional recurrence-free survival [LRFS]) were analyzed and compared. Concurrently, the Surveillance, Epidemiology, and End Results Program (SEER) database was used to compare OS in an external source. RESULTS A total of 256 patients were input into the propensity score-matching (PSM) analysis, and 104 pairs remained after PSM. After PSM, the baseline data were well matched and there was a significantly lower tumor regression grade (TRG) (P < 0.001), more postoperative complications (P = 0.009) (especially anastomotic fistula, P = 0.003) and a longer median hospital stay (P = 0.049) in the N-CRT group than in the N-CT group. No significant difference was observed in OS (P = 0.737), DFS (P = 0.580), CSS (P = 0.920) or LRFS (P = 0.086) between the N-CRT group and the N-CT group. In the SEER database, patients who received N-CT had similar OS in both TNM II (P = 0.315) and TNM III stages (P = 0.090) as those who received N-CRT. CONCLUSION N-CT conferred similar survival benefits but caused fewer complications than N-CRT. Thus, it could be an alternative treatment of LARC.
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Affiliation(s)
- Jingjing Wu
- Department of Colorectal Surgery, Department of General Surgery, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, People's Republic of China
| | - Mingzhe Huang
- Department of Colorectal Surgery, Department of General Surgery, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, People's Republic of China
| | - Yuanhui Wu
- Department of Colorectal Surgery, Department of General Surgery, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, People's Republic of China
| | - Yisong Hong
- Department of Colorectal Surgery, Department of General Surgery, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, People's Republic of China
| | - Linbin Cai
- Department of Colorectal Surgery, Department of General Surgery, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, People's Republic of China
| | - Rongzhao He
- Department of Colorectal Surgery, Department of General Surgery, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, People's Republic of China
| | - Yanxin Luo
- Department of Colorectal Surgery, Department of General Surgery, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, People's Republic of China
- Guangdong Institute of Gastroenterology, Guangzhou, Guangdong, People's Republic of China
| | - Puning Wang
- Department of Colorectal Surgery, Department of General Surgery, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, People's Republic of China
| | - Meijin Huang
- Department of Colorectal Surgery, Department of General Surgery, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, People's Republic of China.
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, People's Republic of China.
| | - Jinxin Lin
- Department of Colorectal Surgery, Department of General Surgery, The Sixth Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, People's Republic of China.
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Okamura R, Itatani Y, Fujita Y, Hoshino N, Okumura S, Nishiyama K, Hida K, Obama K. Postoperative recurrence in locally advanced rectal cancer: how does neoadjuvant treatment affect recurrence pattern? World J Surg Oncol 2023; 21:247. [PMID: 37587422 PMCID: PMC10428603 DOI: 10.1186/s12957-023-03136-0] [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: 05/11/2023] [Accepted: 08/06/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND The treatment strategy for locally advanced rectal cancer (LARC) has recently expanded from total mesorectal excision to additional neoadjuvant chemoradiotherapy (nCRT) and/or systemic chemotherapy (NAC). Data on disease recurrence after each treatment strategy are limited. METHODS Clinical stage II to III rectal cancer patients who underwent curative surgery between July 2005 and February 2021 were analyzed. The cumulative incidence and site of first recurrence were assessed. The median follow-up duration was 4.6 years. RESULTS Among the 332 patients, we performed nCRT and NAC in 15.4% (N=51) and 14.8% (N=49), respectively. The overall recurrence rate was 23.5% (N=78). Although several differences in tumor stage or location were observed, there was no significant difference in the rate among the surgery alone (N=54, 23.3%), nCRT (N=11, 21.6%), and NAC (N=13, 26.5%) groups. In this cohort, the local recurrence rate (18.4%) was higher than the rate of distant metastasis in the NAC group (14.3%). All patients with recurrence in the nCRT group had distant metastases (N=11: one patient had distant and local recurrences simultaneously). For pathological stage 0-I, the recurrence rate was higher in the nCRT and NAC groups than in the surgery-alone group (nCRT, 10.0%; NAC, 15.4%; and surgery-alone, 2.0%). Curative-intent resection of distant-only recurrences significantly improved patients' overall survival (hazard ratio [95% confidence interval], 0.34 [0.14-0.84]), which was consistent even when stratified according to neoadjuvant treatment. Regardless of neoadjuvant treatment, >80% of recurrences occurred in the first 2.2 years, and 98.7% within 5 years after surgery. CONCLUSION Regardless of neoadjuvant treatment, detecting distant metastases with intensive surveillance, particularly in the first 2 years after surgery, is important. Also, even if neoadjuvant treatment can downstage LARC to pathological stage 0-I, careful follow-up is needed.
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Affiliation(s)
- Ryosuke Okamura
- Department of Surgery, Kyoto University Hospital, 54 Shogoin-Kawahara-Cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yoshiro Itatani
- Department of Surgery, Kyoto University Hospital, 54 Shogoin-Kawahara-Cho, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Yusuke Fujita
- Department of Surgery, Kyoto University Hospital, 54 Shogoin-Kawahara-Cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Nobuaki Hoshino
- Department of Surgery, Kyoto University Hospital, 54 Shogoin-Kawahara-Cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Shintaro Okumura
- Department of Surgery, Kyoto University Hospital, 54 Shogoin-Kawahara-Cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kazuhiro Nishiyama
- Department of Surgery, Kyoto University Hospital, 54 Shogoin-Kawahara-Cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Koya Hida
- Department of Surgery, Kyoto University Hospital, 54 Shogoin-Kawahara-Cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kazutaka Obama
- Department of Surgery, Kyoto University Hospital, 54 Shogoin-Kawahara-Cho, Sakyo-ku, Kyoto, 606-8507, Japan
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Couwenberg AM, Varvoglis DN, Grieb BC, Marijnen CA, Ciombor KK, Guillem JG. New Opportunities for Minimizing Toxicity in Rectal Cancer Management. Am Soc Clin Oncol Educ Book 2023; 43:e389558. [PMID: 37307515 PMCID: PMC10450577 DOI: 10.1200/edbk_389558] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Advances in multimodal management of locally advanced rectal cancer (LARC), consisting of preoperative chemotherapy and/or radiotherapy followed by surgery with or without adjuvant chemotherapy, have improved local disease control and patient survival but are associated with significant risk for acute and long-term morbidity. Recently published trials, evaluating treatment dose intensification via the addition of preoperative induction or consolidation chemotherapy (total neoadjuvant therapy [TNT]), have demonstrated improved tumor response rates while maintaining acceptable toxicity. In addition, TNT has led to an increased number of patients achieving a clinical complete response and thus eligible to pursue a nonoperative, organ-preserving, watch and wait approach, thereby avoiding toxicities associated with surgery, such as bowel dysfunction and stoma-related complications. Ongoing trials using immune checkpoint inhibitors in patients with mismatch repair-deficient tumors suggest that this subgroup of patients with LARC could potentially be treated with immunotherapy alone, sparing them the toxicity associated with preoperative treatment and surgery. However, the majority of rectal cancers are mismatch repair-proficient and less responsive to immune checkpoint inhibitors and require multimodal management. The synergy noted in preclinical studies between immunotherapy and radiotherapy on immunogenic tumor cell death has led to the design of ongoing clinical trials that explore the benefit of combining radiotherapy, chemotherapy, and immunotherapy (mainly of immune checkpoint inhibitors) and aim to increase the number of patients eligible for organ preservation.
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Affiliation(s)
- Alice M. Couwenberg
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Brian C. Grieb
- Vanderbilt University Medical Center/Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Corrie A.M. Marijnen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Kristen K. Ciombor
- Vanderbilt University Medical Center/Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Jose G. Guillem
- Department of Surgery, Lineberger Comprehensive Cancer Center, University of North Carolina-Chapel Hill, Chapel Hill, NC
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Bascoul-Mollevi C, Gourgou S, Borg C, Etienne PL, Rio E, Rullier E, Juzyna B, Castan F, Conroy T. Neoadjuvant chemotherapy with FOLFIRINOX and preoperative chemoradiotherapy for patients with locally advanced rectal cancer (UNICANCER PRODIGE 23): Health-related quality of life longitudinal analysis. Eur J Cancer 2023; 186:151-165. [PMID: 37068407 DOI: 10.1016/j.ejca.2023.03.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/15/2023] [Accepted: 03/17/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND Results from the phase 3 PRODIGE 23 study showed that neoadjuvant chemotherapy (NAC) with mFOLFIRINOX and preoperative chemoradiotherapy improved disease-free survival compared with preoperative chemoradiotherapy in patients with locally advanced rectal cancer. We aimed to assess the health-related quality of life (HRQOL) outcomes from this study. PATIENTS AND METHODS A total of 461 patients (231 versus 230 patients) from 35 French hospitals were randomly assigned to either NAC with FOLFIRINOX (oxaliplatin 85 mg/m2, irinotecan 180 mg/m2, leucovorin 400 mg/m2, fluorouracil 2400 mg/m2 over 46 h intravenously every 2 weeks for 6 cycles) followed by preoperative chemoradiotherapy or chemoradiotherapy only. HRQOL was assessed at baseline, during treatments and at 2-year follow-up using the European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-CR29 questionnaires. RESULTS Compared to baseline, HRQOL scores during NAC were better for tumour symptoms but worse for global health status, functional domains, fatigue, nausea/vomiting and appetite loss. During follow-up, improved emotional functioning was observed, but deterioration of body image, increased urinary incontinence, and lower male sexual function were observed. Linear mixed model exhibited a treatment-by-time interaction effect for nausea/vomiting and insomnia symptoms showing a greater deterioration in the standard-of-care group. Only treatment arm and baseline physical functioning were independent significant favourable prognostic factors. CONCLUSION NAC improved tumour-related symptoms and transitorily reduced most functional scores. Adding NAC before chemoradiotherapy and increased physical functioning at baseline were independent significant prognostic factors for longer disease-free survival.
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Affiliation(s)
- Caroline Bascoul-Mollevi
- Biometrics Unit, Institut du Cancer Montpellier, Montpellier, France; Institut Desbrest d'Epidémiologie et de Santé Publique, Université de Montpellier, Inserm, Montpellier, France; French National Platform Quality of Life and Cancer, France.
| | - Sophie Gourgou
- Biometrics Unit, Institut du Cancer Montpellier, Montpellier, France; French National Platform Quality of Life and Cancer, France
| | - Christophe Borg
- University Hospital of Besançon, CIC-BT1431, Besançon, France
| | | | - Emmanuel Rio
- Institut de Cancérologie de l'Ouest - Site René Gauducheau, Saint-Herblain, France
| | - Eric Rullier
- Centre Hospitalier et Universitaire de Bordeaux, Hôpital Haut-Lévêque, Pessac, France
| | | | - Florence Castan
- Biometrics Unit, Institut du Cancer Montpellier, Montpellier, France; French National Platform Quality of Life and Cancer, France
| | - Thierry Conroy
- Medical Oncology Department, Institut de Cancérologie de Lorraine, Vandœuvre-lès-Nancy, France; Université de Lorraine, APEMAC, Equipe MICS, Nancy, France
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10
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Aoyama R, Hida K, Hasegawa S, Yamaguchi T, Manaka D, Kato S, Yamada M, Yamanokuchi S, Kyogoku T, Kanazawa A, Kawada K, Sakamoto T, Goto S, Sakai Y, Obama K. Long-term results of a phase 2 study of neoadjuvant chemotherapy with molecularly targeted agents for locally advanced rectal cancer. Int J Clin Oncol 2023; 28:392-399. [PMID: 36622469 DOI: 10.1007/s10147-023-02291-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 01/03/2023] [Indexed: 01/10/2023]
Abstract
BACKGROUND We previously reported the feasibility and efficacy of neoadjuvant chemotherapy without radiotherapy for locally advanced rectal cancer. Here, we report the results of a long-term follow-up study. METHODS This was a multi-institutional, prospective phase 2 study of patients with locally advanced rectal cancer. Patients received neoadjuvant chemotherapy with molecularly targeted agents before undergoing total mesorectal excision. Six cycles of modified FOLFOX (mFOLFOX6) with bevacizumab were administered to KRAS-mutant patients, and mFOLFOX6 with cetuximab was administered to KRAS-wild-type patients. Here, we report the secondary end points of overall survival, relapse-free survival, and local recurrence rate. RESULTS Sixty patients were enrolled in this study. R0 resection was achieved in 98.3% (59/60) patients, and pathological complete response was achieved in 16.7% (10/60) patients. After a median follow-up of 5.4 years, the 5 year overall survival was 81.6%, the 5 year relapse-free survival was 71.7%, and the 5 year local recurrence rate was 12.6%. None of the patients who achieved pathological complete response developed recurrence within 5 years. CONCLUSIONS The use of molecularly targeted agents in the neoadjuvant setting for locally advanced rectal cancer has an acceptable prognosis.
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Affiliation(s)
- Ryuhei Aoyama
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koya Hida
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Suguru Hasegawa
- Department of Gastroenterological Surgery, Fukuoka University, Fukuoka, Japan
| | | | - Dai Manaka
- Department of Surgery, Kyoto Katsura Hospital, Kyoto, Japan
| | - Shigeru Kato
- Department of Gastrointestinal Surgery, Tenri Yorozu Hospital, Nara, Japan
| | | | | | | | - Akiyoshi Kanazawa
- Department of Gastroenterological Surgery and Oncology, Kitano Hospital Medical Research Institute, Osaka, Japan
| | - Kenji Kawada
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takashi Sakamoto
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Saori Goto
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yoshiharu Sakai
- Department of Surgery, Osaka Red Cross Hospital, Osaka, Japan
| | - Kazutaka Obama
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Mathew A, Ramachandra D, Goyal A, Nariampalli Karthyarth M, Joseph P, Raj Rakesh N, Kaushal G, Agrawal A, Bhadoria AS, Dhar P. Reconstructive techniques following low anterior resection for carcinoma of the rectum: meta-analysis. Br J Surg 2023; 110:313-323. [PMID: 36630589 DOI: 10.1093/bjs/znac400] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 10/21/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Multiple trials have compared reconstruction techniques used following the resection of distal rectal cancers, including straight colorectal anastomosis (SCA), colonic J pouch (CJP), side-to-end anastomosis (SEA), and transverse coloplasty (TCP). The latest meta-analysis on the subject concluded that all the reservoir techniques produce equally good surgical and functional outcomes compared with SCA. Numerous trials have been published in this regard subsequently. Hence, a network analysis (NMA) was performed to rank these techniques. METHODS A literature search of MEDLINE, Embase, and the Cochrane Library from their inception until April 2021 was conducted to identify randomized trials. Functional and surgical outcome data were pooled. ORs and standardized mean differences (MDs) were used as pooled effect size measures. A frequentist NMA model was used. RESULTS Thirty-two trials met the eligibility criteria comprising 3072 patients. CJP showed better functional outcomes, such as low stool frequency and better incontinence score, both in the short term (stool frequency, MD -2.06, P < 0.001; incontinence, MD -1.17, P = 0.007) and intermediate term (stool frequency, MD -0.81, P = 0.021; incontinence MD -0.56, P = 0.083). Patients with an SEA (long-term OR 4.37; P = 0.030) or TCP (long-term OR 5.79; P < 0.001) used more antidiarrheal medications constantly. The urgency and sensation of incomplete evacuation favoured CJP in the short term. TCP was associated with a higher risk of anastomotic leakage (OR 12.85; P < 0.001) and stricture (OR 3.21; P = 0.012). CONCLUSION Because of its better functional outcomes, CJP should be the reconstruction technique of choice. TCP showed increased anastomotic leak and stricture rates, warranting judicious use.
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Affiliation(s)
- Anvin Mathew
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh, India
| | - Deepti Ramachandra
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh, India
| | - Anuj Goyal
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh, India
| | | | - Princy Joseph
- National Health Systems Resource Centre, New Delhi, India
| | - Nirjhar Raj Rakesh
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh, India
| | - Gourav Kaushal
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Bathinda, India
| | - Abhishek Agrawal
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh, India
| | - Ajeet Singh Bhadoria
- Department of Community and Family Medicine, All India Institute of Medical Sciences, Rishikesh, India
| | - Puneet Dhar
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh, India
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12
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Pilkington SA, Bhome R, Gilbert S, Harris S, Richardson C, Dudding TC, Knight JS, King AT, Mirnezami AH, Beck NE, Nichols PH, Nugent KP. Sequential assessment of bowel function and anorectal physiology after anterior resection for cancer: a prospective cohort study. Colorectal Dis 2021; 23:2436-2446. [PMID: 34032359 DOI: 10.1111/codi.15754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/16/2021] [Accepted: 05/18/2021] [Indexed: 02/08/2023]
Abstract
AIM The aim of this study was to investigate changes in bowel function and anorectal physiology (ARP) after anterior resection for colorectal cancer. METHOD Patients were recruited from November 2006 to September 2008. Cleveland Clinic Incontinence (CCI) scores and stool frequency were determined by patient questionnaires before surgery (t0 ) and at three (t3 ), six (t6 ), nine (t9 ) and 12 (t12 ) months after restoration of intestinal continuity. ARP measurements were recorded at T0 , T3 and T12 . Endoanal ultrasound was performed at T0 and T12 . RESULTS Eighty-nine patients were included. CCI score increased postoperatively then normalized, whereas stool frequency did not change. Patients who had neoadjuvant radiotherapy or a lower anastomosis had increased incontinence and stool frequency in the postoperative period, whereas those with defunctioning stomas or open surgery had increased stool frequency alone. Maximum resting pressure, volume at first urge and maximum rectal tolerance were reduced throughout the postoperative period. Radiotherapy, lower anastomosis and defunctioning stoma (but not operative approach) altered manometric parameters postoperatively. Maximum rectal tolerance correlated with incontinence and first urge with stool frequency. The length of the anterior internal anal sphincter decreased postoperatively. CONCLUSIONS Incontinence recovers in the first year after anterior resection. Radiotherapy, lower anastomosis, defunctioning stoma and open surgery have a negative influence on bowel function. ARP may be useful if bowel dysfunction persists beyond 12 months.
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Affiliation(s)
- Sophie A Pilkington
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Rahul Bhome
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK.,University Surgery, Southampton General Hospital, University of Southampton, Southampton, UK.,Cancer Sciences, Southampton General Hospital, University of Southampton, Southampton, UK
| | - Sally Gilbert
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Scott Harris
- Primary Care and Population Studies, Southampton General Hospital, University of Southampton, Southampton, UK
| | - Carl Richardson
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Thomas C Dudding
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - John S Knight
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Andrew T King
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Alex H Mirnezami
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK.,University Surgery, Southampton General Hospital, University of Southampton, Southampton, UK.,Cancer Sciences, Southampton General Hospital, University of Southampton, Southampton, UK
| | - Nicholas E Beck
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Paul H Nichols
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Karen P Nugent
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK.,University Surgery, Southampton General Hospital, University of Southampton, Southampton, UK
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13
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Lin H, Wang L, Zhong X, Zhang X, Shao L, Wu J. Meta-analysis of neoadjuvant chemotherapy versus neoadjuvant chemoradiotherapy for locally advanced rectal cancer. World J Surg Oncol 2021; 19:141. [PMID: 33952287 PMCID: PMC8101236 DOI: 10.1186/s12957-021-02251-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 04/21/2021] [Indexed: 02/06/2023] Open
Abstract
Background and purpose With the advent of more intensive chemotherapy regimens, neoadjuvant chemoradiotherapy (NACRT) for patients with locally advanced rectal cancer (LARC) has always been questioned due to its inevitable radiation toxicity. Hence, we conducted a meta-analysis to compare the clinical efficacy of neoadjuvant chemotherapy (NAC) and NACRT. Materials and methods Eligible studies were searched using PubMed, MEDLINE, Embase, the Cochrane Library, and Web of Science up to 31 July 2020, comparing the clinical efficacy of NAC versus NACRT for LARC. Short- and long-term outcomes were determined using the odds ratio (OR) with 95% confidence interval (CI). Results Six studies with 12,812 patients were eligible for this meta-analysis, including 677 patients in the NAC group and 12,135 patients in the NACRT group. There were no significant differences between the two groups in terms of pathological complete response rate (OR=0.62, 95%CI=0.27~1.41), N down-staging rate (OR=1.20, 95%CI=0.25~5.79), R0 resection rate (OR=1.24, 95%CI=0.78~1.98), and local relapse rate (OR=1.12, 95%CI=0.58~2.14). The pooled OR for the total response rate and T down-staging were in favor of NACRT (OR=0.41, 95%CI=0.22~0.76 versus OR=0.67 95%CI=0.52~0.87). However, the pooled OR for the sphincter preservation rate favored NAC compared with NACRT (OR=1.87, 95%CI=1.24~2.81). Moreover, NAC was found to be superior to NACRT in terms of distant metastasis (14.3% vs. 20.4%), but the difference was not significant (OR=0.84, 95%CI=0.31~2.27). Conclusion We concluded that NAC was superior to NACRT in terms of the sphincter preservation rate, and non-inferior to NACRT in terms of pCR, N down-staging, R0 resection, local relapse, and distant metastasis. However, the conclusion warrants further validation. Supplementary Information The online version contains supplementary material available at 10.1186/s12957-021-02251-0.
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Affiliation(s)
- Huaqin Lin
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, China
| | - Lei Wang
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, China
| | - Xiaohong Zhong
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, China
| | - Xueqing Zhang
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, China
| | - Lingdong Shao
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, China.
| | - Junxin Wu
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, China.
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14
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Flanagan M, Clancy C, Sorensen J, Thompson L, Kranenbarg EMK, van de Velde CJH, Sebag-Montefiore D, Burke J. Neoadjuvant Short-Course Radiotherapy for Upper Third Rectal Tumors: Systematic Review and Individual Patient Data Metaanalysis of Randomized Controlled Trials. Ann Surg Oncol 2021; 28:5238-5249. [PMID: 33712984 DOI: 10.1245/s10434-021-09795-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 01/30/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND There is no consensus on the use of neoadjuvant radiotherapy for tumors of the upper third of the rectum. Due to conflicting findings in high-quality trials and significant long-term side effects associated with neoadjuvant radiotherapy, the benefit of neoadjuvant radiotherapy for upper third rectal tumors is less certain than for lower two third rectal tumors. This metaanalysis compares oncological outcomes with neoadjuvant radiotherapy and surgery versus surgery alone for upper third rectal tumors. PATIENTS AND METHODS PubMed, Embase, and the Cochrane library databases were searched. Randomized controlled trials (RCT) comparing neoadjuvant radiotherapy and surgery versus surgery alone for resectable rectal cancer were included. Individual patient data were sought from the principal investigator of each eligible trial for comparative data on patients with upper third rectal tumors. The main outcomes measured were survival outcomes, oncological outcomes, postoperative morbidity, and late toxicity. RESULTS Individual patient data from two RCTs examining outcomes in 758 patients were obtained. Published data from one further RCT containing comparable data on upper third rectal tumors were included in analysis of local recurrence. In patients with curative surgery, there was no significant reduction in local recurrence or significant improvement in overall survival or disease-free survival with neoadjuvant radiotherapy (LR RR: 0.38, 95% CI 0.14-1.04, p = 0.06) (OS RR: 1.10, 95% CI 0.98-1.24, p = 0.11) (DFS RR: 1.11, 95% CI 0.97-1.26, p = 0.13). CONCLUSIONS The benefit of neoadjuvant radiotherapy for upper third rectal tumors is not certain, and surgery alone for patients with potentially curative disease at preoperative staging may be sufficient.
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Affiliation(s)
- Michael Flanagan
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland
| | - Cillian Clancy
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland
| | - Jan Sorensen
- Healthcare Outcomes Research Centre, Royal College of Surgeons in Ireland (RCSI), Dublin 2, Ireland
| | | | | | | | | | - John Burke
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland.
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15
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Neto PRF, Queiroz FLD, Staino IRFL, Filho AL. Quality of life assessment in the late postoperative period of patients with rectal cancer submitted to total mesorectal excision. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1016/j.jcol.2013.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
AbstractAfter the introduction of total mesorectal excision (TME) and radiochemotherapy, excellent results have been achieved in the treatment of patients with rectal cancer. With better oncologic control of the disease, the functional results of this type of therapeutic approach and their impact on the quality of life (QOL) of patients started to be increasingly valued. The aims of this study were to evaluate the QOL of patients with rectal cancer submitted to TME in the late postoperative period and the possible factors that directly influence their quality of life. A total of 72 patients submitted to TME due to extraperitoneal rectal tumor were assessed, after at least one postoperative year, by applying QOL questionnaires (EORTC QLQ-C30 and EORTC QLQ-CR38), in addition to a specific clinical questionnaire and rectal examination. Patients were evaluated regarding gender, age, indication of radiotherapy and chemotherapy preoperatively, length of postoperative period, distance from the anastomosis to the anal verge and general health status. The mean overall health status of patients was satisfactory (82.06). There was no difference in overall health status between patients with respect to gender, but the male patients had less insomnia (p = 0.002), better future prospects (p = 0.011), fewer effects of chemotherapy (p = 0.020) and better sexual function (p < 0.0001). Patients younger than 50 years had fewer urinary problems (p = 0.035), whereas those older than 65 years reported poorer sexual function (p = 0.012). Patients who underwent neoadjuvant therapy had more diarrhea (p = 0.012). Quality of life did not change significantly with time after surgery and the distance from the anastomosis to the anal verge. We conclude that patients undergoing TME have a good quality of life one year after the surgery and that the factors capable of affecting QOL should be identified and improved.
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16
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Campelo P, Barbosa E. Functional outcome and quality of life following treatment for rectal cancer. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1016/j.jcol.2016.05.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Abstract
Introduction Over the last decades, treatment for rectal cancer has substantially improved with development of new surgical options and treatment modalities. With the improvement of survival, functional outcome and quality of life are getting more attention.
Study objective To provide an overview of current modalities in rectal cancer treatment, with particular emphasis on functional outcomes and quality of life.
Results Functional outcomes after rectal cancer treatment are influenced by patient and tumor characteristics, surgical technique, the use of preoperative radiotherapy and the method and level of anastomosis. Sphincter preserving surgery for low rectal cancer often results in poor functional outcomes that impair quality of life, referred to as low anterior resection syndrome. Abdominoperineal resection imposes the need for a permanent stoma but avoids the risk of this syndrome. Contrary to general belief, long-term quality of life in patients with a permanent stoma is similar to those after sphincter preserving surgery for low rectal cancer.
Conclusion All patients should be informed about the risks of treatment modalities. Decision on rectal cancer treatment should be individualized since not all patients may benefit from a sphincter preserving surgery “at any price”. Non-resection treatment should be the future focus to avoid the need of a permanent stoma and bowel dysfunction.
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Affiliation(s)
- Pedro Campelo
- Universidade do Porto, Faculdade de Medicina, Porto, Portugal
| | - Elisabete Barbosa
- Universidade do Porto, Faculdade de Medicina, Porto, Portugal
- Centro Hospitalar São João, Departamento de Cirurgia Colorretal, Porto, Portugal
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17
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Gadan S, Floodeen H, Lindgren R, Rutegård M, Matthiessen P. What is the risk of permanent stoma beyond 5 years after low anterior resection for rectal cancer? A 15-year follow-up of a randomized trial. Colorectal Dis 2020; 22:2098-2104. [PMID: 32931137 DOI: 10.1111/codi.15364] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 08/24/2020] [Accepted: 08/26/2020] [Indexed: 12/19/2022]
Abstract
AIM Low anterior resection of the rectum for cancer (LAR) entails a risk of symptomatic anastomotic leakage as well as impaired anorectal function, both of which may eventually result in the need for a permanent stoma (PS). The aim was to investigate the incidence of and risk factors for PS beyond 5 years following LAR. METHODS Patients undergoing LAR and included in a multicentre trial with randomization to defunctioning stoma or not were followed for a median of 15 years. The reasons for a PS up to 5 years (PS ≤ 5 years) and beyond 5 years (PS > 5 years) were identified and compared. Risk factors for PS were analysed. RESULTS Of all patients, 25% (57/232) had a PS. PS ≤ 5 years occurred in 19% (44/232) at a median of 12.5 months and PS > 5 years in 6% (13/232) at a median of 118 months following LAR. The main reason for PS ≤ 5 years was impaired anorectal function in 55% (24/44) and the main reason for PS > 5 years was pelvic sepsis related to the colorectal anastomosis in 46% (6/13). The major risk factor for PS was symptomatic anastomotic leakage, which occurred in 56% (32/57) of patients with PS and 10% (17/175) of patients without PS (P < 0.001). CONCLUSION One-fourth of the patients who ended up with a PS had it fashioned beyond 5 years at a median of 10 years following LAR. Symptomatic anastomotic leakage was the major risk factor for PS, and impaired anorectal function was the main overall reason for a PS.
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Affiliation(s)
- S Gadan
- Department of Surgery, Örebro University Hospital, Örebro, Sweden.,Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - H Floodeen
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - R Lindgren
- Department of Surgery, Örebro University Hospital, Örebro, Sweden
| | - M Rutegård
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden.,Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
| | - P Matthiessen
- Department of Surgery, Örebro University Hospital, Örebro, Sweden.,Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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18
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Ng KS, Gladman MA. Patient-reported and physician-recorded bowel dysfunction following colorectal resection and radical cystectomy: a prospective, comparative study. Colorectal Dis 2020; 22:1336-1347. [PMID: 32180323 DOI: 10.1111/codi.15041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 02/18/2020] [Indexed: 02/08/2023]
Abstract
AIM Bowel dysfunction following anterior resection (AR) is termed low anterior resection syndrome. It is unclear whether such dysfunction occurs following other bowel/pelvic operations as well. This study aimed to characterize and compare bowel dysfunction following AR, right hemicolectomy (RH) and radical cystectomy (RC). METHOD A prospective study of consecutive patients undergoing AR, RH and RC (2002-2012) was performed at a tertiary referral centre in Sydney, Australia. Outcome measures included (i) patient-reported satisfaction with bowel function, self-described bowel function and self-reported change in bowel function; (ii) objective assessment of bowel function using validated criteria to identify symptoms and stratify patients into those with constipation and/or faecal incontinence (FI); and (iii) health-related quality of life (SF-36v2 Health Survey). RESULTS Of 743 eligible patients, 70% participated [AR, n = 338, mean age 69.6 years (SD 11.9), 59% men; RH, n = 150, 75.8 years (SD 10.5), 54% men; RC, n = 34, 71.1 years (SD 14.1), 71% men]. AR patients were three times more likely to report change in bowel function post-surgery and self-judged their bowel function as abnormal more frequently (64%) than RH patients (35%) and RC patients (35%) (P < 0.01). AR patients were four times more likely to meet criteria for concomitant constipation and FI. Patients with concomitant constipation and FI had lower physical and mental SF-36v2 scores (P < 0.001). CONCLUSION Bowel dysfunction occurred after RH and RC but rates were higher following AR. This suggests that low anterior resection syndrome occurs due to a direct impact of partial/complete loss of the rectum rather than just due to loss of bowel length and/or the consequence(s) of pelvic dissection.
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Affiliation(s)
- K-S Ng
- Academic Colorectal Unit, Sydney Medical School - Concord, University of Sydney, Sydney, New South Wales, Australia
| | - M A Gladman
- Gastrointestinal and Enteric Neuroscience Research Group, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
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19
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Factors impacting oncologic outcomes in patients undergoing surgery for locally recurrent rectal cancer. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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20
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Valadão M, Dias JA, Araújo R, Cesar D. Do We Have to Treat All T3 Rectal Cancer the Same Way? Clin Colorectal Cancer 2020; 19:231-235. [PMID: 32839078 DOI: 10.1016/j.clcc.2020.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 05/20/2020] [Accepted: 07/20/2020] [Indexed: 12/29/2022]
Abstract
Chemoradiotherapy (CRT) followed by surgery is the recommended approach in the last years for stage II and III rectal cancer with the intention to decrease the risk of local recurrence. However, fewer patients benefit from this strategy in terms of overall survival and long-term adverse outcomes because T3 rectal cancer has a broad range of prognosis, as shown by recent publications. Many patients with cT3 rectal cancer have a substantial risk of overtreatment with long-term toxicity related to radiotherapy that could be avoided in a subset group of cT3 tumors with good prognosis. These findings raised the question of whether all cT3 rectal cancer should receive preoperative radiotherapy and if a selected cT3 subgroup could be treated by surgery alone. This review addresses the rationale of selecting good prognosis cT3 rectal cancer for surgery alone and analyzes the data to support this recommendation.
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Affiliation(s)
- Marcus Valadão
- Department of Abdomino-Pelvic Surgery, Instituto Nacional de Câncer (INCA), Rio de Janeiro, Brazil
| | - José Antônio Dias
- Department of Colorectal Surgery, Universidade Federal Fluminense (UFF), Niterói, Brazil
| | - Rodrigo Araújo
- Department of Abdomino-Pelvic Surgery, Instituto Nacional de Câncer (INCA), Rio de Janeiro, Brazil
| | - Daniel Cesar
- Department of Abdomino-Pelvic Surgery, Instituto Nacional de Câncer (INCA), Rio de Janeiro, Brazil
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21
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Haas S, Faaborg PM, Gram M, Lundby L, Brock C, Drewes AM, Laurberg S, Krogh K, Christensen P. Cortical processing to anorectal stimuli after rectal resection with and without radiotherapy. Tech Coloproctol 2020; 24:721-730. [PMID: 32323098 DOI: 10.1007/s10151-020-02210-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 04/06/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Bowel dysfunction is common after surgery for rectal cancer, especially when neoadjuvant radiotherapy is used. The role of sensory function in the pathogenesis remains obscure, and the aim of the present study was to characterize the sensory pathways of the brain-gut axis in rectal cancer patients treated with resection ± radiotherapy compared with healthy volunteers. METHODS Sensory evaluation by (neo)rectal distensions was performed and sensory evoked potentials (SEPs) were recorded during rapid balloon distensions of the (neo)rectum and anal canal in resected patients with (n = 8) or without (n = 12) radiotherapy. Twenty healthy volunteers were included for comparison. (Neo)rectal latencies and amplitudes of SEPs were compared and spectral band analysis from (neo)rectal and anal distensions was used as a proxy of neuronal processing. RESULTS Neorectal sensation thresholds were significantly increased in both patient categories (all p < 0.008). There were no differences in (neo)rectal SEP latencies and amplitudes between groups. However, spectral analysis of (neo)rectal SEPs showed significant differences between all groups in all bands (all p < 0.01). On the other hand, anal SEP analyses only showed significant differences between the delta (0-4 Hz), theta (4-8 Hz) and, gamma 32-50 Hz) bands (all p < 0.02) between the subgroup of patients that also received radiotherapy and healthy volunteers. CONCLUSIONS Surgery for rectal cancer leads to abnormal cortical processing of neorectal sensation. Additional radiotherapy leads to a different pattern of central sensory processing of neorectal and anal sensations. This may play a role in the functional outcome of these patients.
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Affiliation(s)
- S Haas
- Department of Surgery, Aarhus University Hospital, Palle Juul-Jensens Blvd 99, 8200, Århus N, Denmark. .,Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aalborg, Denmark.
| | - P M Faaborg
- Department of Surgery, Vejle Hospital, Vejle, Denmark.,Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aalborg, Denmark
| | - M Gram
- Mech-Sense, Department of Gastroenterology and Hepatology, Clinical Institute, Aalborg University Hospital, Aalborg, Denmark
| | - L Lundby
- Department of Surgery, Aarhus University Hospital, Palle Juul-Jensens Blvd 99, 8200, Århus N, Denmark.,Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aalborg, Denmark
| | - C Brock
- Mech-Sense, Department of Gastroenterology and Hepatology, Clinical Institute, Aalborg University Hospital, Aalborg, Denmark
| | - A M Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Clinical Institute, Aalborg University Hospital, Aalborg, Denmark.,Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aalborg, Denmark
| | - S Laurberg
- Department of Surgery, Aarhus University Hospital, Palle Juul-Jensens Blvd 99, 8200, Århus N, Denmark.,Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aalborg, Denmark
| | - K Krogh
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aalborg, Denmark.,Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aalborg, Denmark
| | - P Christensen
- Department of Surgery, Aarhus University Hospital, Palle Juul-Jensens Blvd 99, 8200, Århus N, Denmark.,Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aalborg, Denmark
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22
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Jootun N, Sengupta S, Cunningham C, Charlton P, Betts M, Weaver A, Jacobs C, Hompes R, Muirhead R. Neoadjuvant radiotherapy in rectal cancer - less is more? Colorectal Dis 2020; 22:261-268. [PMID: 31556218 DOI: 10.1111/codi.14863] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 09/06/2019] [Indexed: 12/12/2022]
Abstract
AIM There is significant international variation in the use of neoadjuvant radiation prior to total mesorectal excision. The MERCURY group advocate selective neoadjuvant chemoradiotherapy (CRT). We have performed a retrospective, single-centre study of patients treated with CRT, where only the circumferential resection margin is threatened, with the aim of identifying whether a more selective approach to CRT provides acceptable local relapse rates (LRRs). METHOD All consecutive patients who underwent radical surgery for rectal adenocarcinoma over a 5-year period (2007-2012) in the Oxford University Trust were considered. Electronic hospital systems were reviewed to obtain patient and tumour demographics, treatment and follow-up information. All patients were classified into risk categories according to National Institute for Health and Care Excellence guidance. Data were analysed using Microsoft Excel and R. RESULTS Two hundred and seventy-two patients were identified: 123, 89 and 60 in the high-, intermediate- and low-risk categories, respectively. Seventy-nine per cent of those in the high-risk group, 6% in the intermediate and 5% in the low-risk group underwent CRT. The overall 5-year LRR and distant recurrence rate (DRR) were 5.2% and 17.8%, respectively. The 5-year LRR for those who went straight to surgery was 2.0% and for those who had neoadjuvant CRT it was 7.4%. The DRR for these two groups was 8.5% and 18.9%, respectively. CONCLUSION Our series demonstrates that the use of CRT only in margin-threatening tumours, results in an exceptionally low LRR for those without margin-threatening disease. In routine clinical care, this strategy can minimize the significant morbidity of multimodal treatment and allow earlier introduction of systemic therapy to minimize distant recurrence.
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Affiliation(s)
- N Jootun
- Department of Colorectal Surgery, Nuffield Department of Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - S Sengupta
- Green Templeton College, University of Oxford, Oxford, UK
| | - C Cunningham
- Department of Colorectal Surgery, Nuffield Department of Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - P Charlton
- Department of Oncology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - M Betts
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A Weaver
- Department of Oncology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - C Jacobs
- Department of Oncology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R Hompes
- Department of Colorectal Surgery, Nuffield Department of Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Department of Surgery, Cancer Centre Amsterdam, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - R Muirhead
- Department of Oncology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Xue W, Wang S, Zhao Z, Li Y, Shang A, Li D, Yang J, Wang T, Wang M. Short-term outcomes of laparoscopic intersphincteric resection with intraoperative radiotherapy using low-energy X-rays for primary locally advanced low rectal cancer: a single center experience. World J Surg Oncol 2020; 18:26. [PMID: 32013978 PMCID: PMC6998155 DOI: 10.1186/s12957-020-1799-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 01/21/2020] [Indexed: 11/30/2022] Open
Abstract
Background Even with the augmentative application of anal-preservation surgery in low rectal cancer, the role and indications of laparoscopic intersphincteric resection (Lap ISR) are still under debate, especially for T3 or node-positive (T3N0M0, T1–3N+M0) cancer, mainly due to the oncological safety and functional outcomes. INTRABEAM (Carl Zeiss, Germany) intraoperative radiotherapy (IORT) using low-energy X-rays features in accurate irradiation, less exposure, and reduced complications. Taking advantages of Lap ISR and INTRABEAM IORT, this innovative approach aims to increase the probability of the anal preservation with acceptable postoperative outcomes. Materials and methods From December 2015 to August 2019, we retrospectively analyzed the short-term outcomes of 12 patients evaluated preoperatively with T3 or node-positive (T3N0M0, T1–3N+M0) primary locally advanced low rectal cancer. They all had received Lap ISR and INTRABEAM IORT with a dose of 16–18 Gy applied by an applicator through the anus (natural orifice). Then, with no pre- or postoperative radiotherapy given, the patients were suggested to receive 6–8 cycles of the XELOX chemotherapy regimen (oxaliplatin, 130 mg/m2 and capecitabine, 1000 mg/m2). Results All patients achieved R0 resection. The median radiation time was 27 min and 15 s, and the mean radiative dose was 17.3 Gy (range 16–18 Gy). The median follow-up time was 18.5 months (range 3–45 months). Two patients experienced local recurrence. Two male patients experienced anastomotic stenosis. Furthermore, one of them experienced perianal abscess and the other one experienced pulmonary metastasis after refusing to receive chemotherapy. One female patient with internal anal sphincter invasion experienced distant metastases to the liver and gluteus maximus muscle 35 months after IORT. No acute radiation injuries or symptoms were observed. Although they experienced a reduction in anal function, every patient was satisfied with the postoperative outcomes. Conclusions For patients evaluated preoperatively with T3 or node-positive (T3N0M0, T1–3N+M0) primary locally advanced low rectal cancer, Lap ISR with INTRABEAM IORT may be a safe and feasible approach for anal preservation without compromising oncological outcomes.
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Affiliation(s)
- Wangsheng Xue
- Department of the General Surgery, The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Shuang Wang
- Department of Dermatology, The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Zeyun Zhao
- Department of the General Surgery, The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Yongbo Li
- Department of the General Surgery, The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - An Shang
- Department of the General Surgery, The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Donglin Li
- Department of the General Surgery, The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Jianzheng Yang
- Department of Radiology, The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Tiejun Wang
- Department of Radiology, The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Min Wang
- Department of the General Surgery, The Second Hospital of Jilin University, Changchun, Jilin Province, China.
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Marinello FG, Curell A, Tapiolas I, Pellino G, Vallribera F, Espin E. Systematic review of functional outcomes and quality of life after transanal endoscopic microsurgery and transanal minimally invasive surgery: a word of caution. Int J Colorectal Dis 2020; 35:51-67. [PMID: 31761962 DOI: 10.1007/s00384-019-03439-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE The introduction of transanal endoscopic or minimally invasive surgery has allowed organ preservation for rectal tumors with good oncological results. Data on functional and quality-of-life (QoL) outcomes are scarce and controversial. This systematic review sought to synthesize fecal continence, QoL, and manometric outcomes after transanal endoscopic microsurgery (TEM) or transanal minimally invasive surgery (TAMIS). METHODS A systematic review of the literature including Medline, Embase, and the Cochrane Library databases was conducted searching for articles reporting on functional outcomes after TEM or TAMIS between January 1995 and June 2018. The evaluated outcome parameters were pre- and postoperative fecal continence (primary endpoint), QoL, and manometric results. Data were extracted using the same scales and measurement units as from the original study. RESULTS A total of 29 studies comprising 1297 patients were included. Fecal continence outcomes were evaluated in 23 (79%) studies with a wide variety of assessment tools and divergent results. Ten studies (34%) analyzed QoL changes, and manometric variables were assessed in 15 studies (51%). Most studies reported some deterioration in manometric scores without major QoL impairment. Due to the heterogeneity of the data, it was not possible to perform any pooled analysis or meta-analysis. CONCLUSIONS These techniques do not seem to affect continence by themselves except in minor cases. The possibility of worsened function after TEM and TAMIS should not be underestimated. There is a need to homogenize or standardize functional and manometric outcomes assessment after TEM or TAMIS.
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Affiliation(s)
- Franco G Marinello
- Colorectal Unit - Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Anna Curell
- Colorectal Unit - Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ingrid Tapiolas
- Colorectal Unit - Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Gianluca Pellino
- Colorectal Unit - Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Francesc Vallribera
- Colorectal Unit - Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Eloy Espin
- Colorectal Unit - Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
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Huang Y, Koh CE. Sacral nerve stimulation for bowel dysfunction following low anterior resection: a systematic review and meta-analysis. Colorectal Dis 2019; 21:1240-1248. [PMID: 31081580 DOI: 10.1111/codi.14690] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 04/12/2019] [Indexed: 02/08/2023]
Abstract
AIM Low anterior resection syndrome (LARS) can affect up to 70% of all patients with rectal cancer. In the last two decades, sacral nerve stimulation (SNS) has emerged as an effective treatment for faecal incontinence. There is some encouraging literature on the use of SNS in patients with LARS. The purpose of this review is to provide an up to date review on the utility of SNS on LARS. METHOD A literature search was conducted using the MEDLINE, Embase and PubMed databases (January 1981-March 2019). Studies identified were appraised with standard selection criteria. Data points were extracted, and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. RESULTS Ten studies met the inclusion criteria and were included in this study. All studies used the Cleveland Clinic Incontinence Score (CCIS), whereas the low anterior resection syndrome score (LARS score) was used in three studies. Overall median improvement in the scoring system was 67.0% (range 35.5%-88.2%) after SNS implantation. There was a significant reduction in CCIS after SNS implantation (mean difference 11.23, 95% confidence interval 9.38-13.07, Z = 11.90, P < 0.00001). The LARS score was also significantly reduced after using SNS in patients with LARS (mean difference 17.87, 95% confidence interval 10.15-25.59, Z = 4.54, P < 0.00001). CONCLUSION Use of SNS may provide symptomatic benefits for patients with LARS refractory to medical therapy. However, the current level of evidence remains limited. A large multicentre study of SNS for LARS using the validated LARS score is warranted. In addition, the cost-effectiveness of SNS for patients with LARS needs further exploration.
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Affiliation(s)
- Y Huang
- SOuRCe (Surgical Outcomes Research Centre), Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - C E Koh
- SOuRCe (Surgical Outcomes Research Centre), Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
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Rigter LS, Rijkmans EC, Inderson A, van den Ende RP, Kerkhof EM, Ketelaars M, van Dieren J, Veenendaal RA, van Triest B, Marijnen CA, van der Heide UA, van Leerdam ME. EUS-guided fiducial marker placement for radiotherapy in rectal cancer: feasibility of two placement strategies and four fiducial types. Endosc Int Open 2019; 7:E1357-E1364. [PMID: 31673605 PMCID: PMC6805181 DOI: 10.1055/a-0958-2148] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 12/03/2018] [Indexed: 12/18/2022] Open
Abstract
Background and study aims To facilitate image guidance during radiotherapy of rectal cancer, we investigated the feasibility of fiducial marker placement. This study aimed to evaluate technical success rate and safety of two endoscopic ultrasound (EUS)-guided placement strategies and four fiducial types for rectal cancer patients. Patients and methods This prospective multicenter study included 20 participants who were scheduled to undergo rectal cancer treatment with neoadjuvant short-course radiotherapy or chemoradiation. EUS-guided endoscopy was used for fiducial placement at the tumor site (n = 10) or in the mesorectal fat and in the tumor (n = 10). Four fiducial types were used (Visicoil 0.75 mm, Visicoil 0.50 mm, Cook, Gold Anchor). The endpoints were technical success rate and retention of fiducials, the latter of which was evaluated on cone-beam computed tomography scans during the first five radiotherapy fractions. Results A total of 64 fiducials were placed in 20 patients. For each fiducial type, at least three fiducials were successfully placed in all patients. Technical failure consisted of fiducial blockage within the needle (n = 2) and ejection of two preloaded fiducials at once (n = 4). No serious adverse events were reported. In three patients, one of the fiducials was misplaced without clinical consequences; two in the prostate and one in the intraperitoneal cavity. After a median time of 17 days after placement (range 7 - 47 days), a total of 42/64 (66 %) fiducials were still present (24/44 intratumoral vs. 18/20 mesorectal fiducials, P = 0.009). Conclusions Placement of fiducials in rectal cancer patients is feasible, however, retention rates for intratumoral fiducials were lower (55 %) than for mesorectal fiducials (90 %).
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Affiliation(s)
- Lisanne S. Rigter
- Department of Gastroenterology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Eva C. Rijkmans
- Department of Radiotherapy, Leiden University Medical Center, Leiden, The Netherlands
| | - Akin Inderson
- Leiden Center for Interventional Endoscopy, Department of Gastroenterology, Leiden University Medical Center, Leiden, The Netherlands
| | - Roy P.J. van den Ende
- Department of Radiotherapy, Leiden University Medical Center, Leiden, The Netherlands
| | - Ellen M. Kerkhof
- Department of Radiotherapy, Leiden University Medical Center, Leiden, The Netherlands
| | - Martijn Ketelaars
- Department of Radiotherapy, Leiden University Medical Center, Leiden, The Netherlands
| | - Jolanda van Dieren
- Department of Gastroenterology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Roeland A. Veenendaal
- Leiden Center for Interventional Endoscopy, Department of Gastroenterology, Leiden University Medical Center, Leiden, The Netherlands
| | - Baukelien van Triest
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Corrie A.M. Marijnen
- Department of Radiotherapy, Leiden University Medical Center, Leiden, The Netherlands
| | - Uulke A. van der Heide
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Monique E. van Leerdam
- Department of Gastroenterology, the Netherlands Cancer Institute, Amsterdam, The Netherlands,Corresponding author Dr. M. E. van Leerdam Department of GastroenterologyNetherlands Cancer InstitutePlesmanlaan 1211066 CX Amsterdam+31 20 5122566
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Lee KH, Kim JS, Kim JY. Efficacy of biofeedback therapy for objective improvement of pelvic function in low anterior resection syndrome. Ann Surg Treat Res 2019; 97:194-201. [PMID: 31620393 PMCID: PMC6779952 DOI: 10.4174/astr.2019.97.4.194] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 07/22/2019] [Accepted: 08/13/2019] [Indexed: 12/26/2022] Open
Abstract
Purpose There is no established treatment of choice for low anterior resection syndrome (LARS). To evaluate the efficacy of biofeedback therapy for objective improvement of pelvic function in LARS, we performed the present study. Methods The primary endpoint was the change of Wexner score. Consenting patients between 20 and 80 years old with major LARS at least 2 months after sphincter preserving proctectomy for rectal cancer were enrolled. After recommendation of biofeedback therapy, patients who accept it were enrolled in the biofeedback group and patients who refuse were enrolled in the control group. Initial and follow-up evaluations were performed and analyzed. Results Fifteen and sixteen patients were evaluated in the control group and the biofeedback group, respectively. There was no statistically significant difference of LARS score between both groups. Decrease in Wexner score and increase in rectal capacity were significantly higher in the biofeedback group (odds ratio [OR], 5.386; 95% confidence interval [CI], 1.194–24.287; P = 0.028 and OR, 1.061; 95% CI, 1.002–1.123; P = 0.042). Conclusion Biofeedback therapy was superior for objective improvement of pelvic function to observation in LARS. It can be considered to induce more rapid improvement of major LARS.
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Affiliation(s)
- Kyung Ha Lee
- Department of Surgery, Chungnam National University College of Medicine, Daejeon, Korea
| | - Jin Soo Kim
- Department of Surgery, Chungnam National University College of Medicine, Daejeon, Korea
| | - Ji Yeon Kim
- Department of Surgery, Chungnam National University College of Medicine, Daejeon, Korea
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Simunovic M, Grubac V, Zbuk K, Wong R, Coates A. Role of the status of the mesorectal fascia in the selection of patients with rectal cancer for preoperative radiation therapy: a retrospective cohort study. Can J Surg 2019; 61:332-338. [PMID: 30247008 DOI: 10.1503/cjs.009417] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Background Patients with rectal cancer in whom the mesorectal fascia is threatened by tumour are more likely than all patients with stage II/III disease to benefit from preoperative radiotherapy (RT). The objective of this study was to assess whether the
status of the mesorectal fascia versus a stage II/III designation can best inform the use of preoperative RT in patients undergoing major rectal cancer resection. Methods We reviewed the charts of consecutive patients with primary rectal cancer treated by a single surgeon at McMaster University, Hamilton, Ontario, between March 2006 and December 2012. The status of the mesorectal fascia was assessed by digital rectal examination, pelvic computed tomography and, when needed, pelvic magnetic resonance imaging (MRI). Patients whose mesorectal fascia was threatened or involved by tumour received preoperative RT. The study outcomes were rates of positive circumferential radial margin (CRM) and local tumour recurrence. Results A total of 153 patients were included, of whom 76 (49.7%) received preoperative RT because of concerns of a compromised mesorectal fascia. The median length of follow-up was 4.5 years. The number of CRM-positive cases in the RT and no-RT groups was 16 (22%) and 1 (1%), respectively (p < 0.01), and the number of cases of local tumour recurrence was 5 (7%) and 2 (3%), respectively (p = 0.2). Rates were similar when only patients with stage II/III tumours were included. Overall, 26 patients (17.0%) received MRI. Conclusion The status of the mesorectal fascia, not tumour stage, may best identify patients for preoperative RT.
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Affiliation(s)
- Marko Simunovic
- From the Department of Surgery, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Simunovic, Grubac, Coates); the Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Simunovic); the Department of Oncology, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Simunovic, Zbuk, Wong); and the Escarpment Cancer Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ont. (Simunovic)
| | - Vanja Grubac
- From the Department of Surgery, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Simunovic, Grubac, Coates); the Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Simunovic); the Department of Oncology, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Simunovic, Zbuk, Wong); and the Escarpment Cancer Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ont. (Simunovic)
| | - Kevin Zbuk
- From the Department of Surgery, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Simunovic, Grubac, Coates); the Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Simunovic); the Department of Oncology, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Simunovic, Zbuk, Wong); and the Escarpment Cancer Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ont. (Simunovic)
| | - Raimond Wong
- From the Department of Surgery, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Simunovic, Grubac, Coates); the Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Simunovic); the Department of Oncology, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Simunovic, Zbuk, Wong); and the Escarpment Cancer Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ont. (Simunovic)
| | - Angela Coates
- From the Department of Surgery, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Simunovic, Grubac, Coates); the Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Simunovic); the Department of Oncology, Faculty of Health Sciences, McMaster University, Hamilton, Ont. (Simunovic, Zbuk, Wong); and the Escarpment Cancer Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ont. (Simunovic)
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Buccafusca G, Proserpio I, Tralongo AC, Rametta Giuliano S, Tralongo P. Early colorectal cancer: diagnosis, treatment and survivorship care. Crit Rev Oncol Hematol 2019; 136:20-30. [PMID: 30878125 DOI: 10.1016/j.critrevonc.2019.01.023] [Citation(s) in RCA: 122] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 12/29/2018] [Accepted: 01/29/2019] [Indexed: 12/11/2022] Open
Abstract
CRC is the third most commonly diagnosed malignancy and the fourth leading cause of cancer-related death in the world. With advances in treatment, colorectal cancer is being transformed from a deadly disease to an illness that is increasingly curable. With this transformation has come increased interest in the unique problems, risks, needs, and concerns of survivors who have completed treatment and are cancer-free. They often suffer late/long-term side effects of therapies that may compromise their QoL such as fatigue, sleep difficulty, fear of recurrence, anxiety, depression, negative body image, sensory neuropathy, gastrointestinal problems, urinary incontinence, and sexual dysfunction. In this review, we discuss what is known about early colorectal diagnosis, staging, treatments and their long-term effects on quality of life and survivorship care.
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Affiliation(s)
- Gabriella Buccafusca
- UOC Oncologia Medica, Ospedale Umberto I, Via Giuseppe Testaferrata 1, 96100, Siracusa, Italy
| | - Ilaria Proserpio
- UOC Oncologia Medica, ASST Settelaghi, Ospedale di Circolo e Fondazione Macchi, Via Francesco Guicciardini 9, 21100, Varese, Italy
| | - Antonino Carmelo Tralongo
- UOC Oncologia Medica, ASST Settelaghi, Ospedale di Circolo e Fondazione Macchi, Via Francesco Guicciardini 9, 21100, Varese, Italy
| | | | - Paolo Tralongo
- UOC Oncologia Medica, Ospedale Umberto I, Via Giuseppe Testaferrata 1, 96100, Siracusa, Italy.
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Enker WE. Reprint of: The natural history of rectal cancer 1908-2008: the evolving treatment of rectal cancer into the twenty-first century. SEMINARS IN COLON AND RECTAL SURGERY 2018. [DOI: 10.1053/j.scrs.2018.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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D'Ambrosio G, Picchetto A, Campo S, Palma R, Panetta C, De Laurentis F, La Rocca S, Lezoche E. Quality of life in patients with loco-regional rectal cancer after ELRR by TEM versus VLS TME after nChRT: long-term results. Surg Endosc 2018; 33:941-948. [PMID: 30421081 DOI: 10.1007/s00464-018-6583-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 11/02/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Endoluminal loco-regional resection (ELRR) by transanal endoscopic microsurgery (TEM) may be an alternative treatment option to Laparoscopic total mesorectal excision (LTME), in selected patients with N0 rectal cancer. Post-operative quality of life (QoL) evaluation is an important parameter of outcomes related to high percentage of functional sequelae. We reported, in a previous paper, the short and medium term results of QoL in patients who underwent ELRR or LTME. The aim is to evaluate the 3 year QoL in patients with iT2-T3 N0/+ rectal cancer who underwent ELRR by TEM or LTME after neoadjuvant radio-chemotherapy (nChRT) in a retrospective analysis of prospectively collected data. METHODS We enrolled in this study, 39 patients with iT2-T3 rectal cancer who underwent ELRR (n = 19) or LTME (n = 20), according to predefined criteria. QoL was evaluated by EORTC QLQ-C30 and QLQ-CR38 questionnaires at admission, after n-RCT and 1, 6, 12, and 36 months after surgery. RESULTS No statistically significant differences in QoL evaluation were observed between the two groups, both at admission and after n-RCT. In short term (1-6 months) period, significantly better results were observed in ELRR group by QLQ-C30 in global health status (p = 0.03), physical functioning (p = 0.026), role functioning (p = 0.04), emotional functioning (p = 0.04), cognitive functioning, fatigue (p < 0.05), dyspnoea (p < 0.001), insomnia (p < 0.05), appetite loss (p < 0.05), constipation (≤ 0.05), and by QLQ-CR38 in: body image (p = 0.03) and defecation (p = 0.025). At 1 year, the two groups were homogenous as assessed by QLQ-C30, whereas the QLQCR38 still showed better results of ELRR versus LTME in body image (p = 0.006), defecation problems (p = 0.01), and weight loss (p = 0.005). At 3 years, no statistically significant differences were observed between the two groups. CONCLUSIONS In selected patients with rectal cancer, who underwent ELRR by TEM or LTME, QoL tests at 3 years do not show any statistical differences on examined items.
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Affiliation(s)
- Giancarlo D'Ambrosio
- General and ColoRectal Surgery Division, Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Rome, Italy
| | - Andrea Picchetto
- General and ColoRectal Surgery Division, Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Rome, Italy.
| | | | - Rossella Palma
- Department of Surgical Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Cristina Panetta
- Department of Surgical Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Francesca De Laurentis
- General and ColoRectal Surgery Division, Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Rome, Italy
| | - Stefania La Rocca
- General and ColoRectal Surgery Division, Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Rome, Italy
| | - Emanuele Lezoche
- General and ColoRectal Surgery Division, Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Rome, Italy
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Abraha I, Aristei C, Palumbo I, Lupattelli M, Trastulli S, Cirocchi R, De Florio R, Valentini V. Preoperative radiotherapy and curative surgery for the management of localised rectal carcinoma. Cochrane Database Syst Rev 2018; 10:CD002102. [PMID: 30284239 PMCID: PMC6517113 DOI: 10.1002/14651858.cd002102.pub3] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND This is an update of the original review published in 2007.Carcinoma of the rectum is a common malignancy, especially in high income countries. Local recurrence may occur after surgery alone. Preoperative radiotherapy (PRT) has the potential to reduce the risk of local recurrence and improve outcomes in rectal cancer. OBJECTIVES To determine the effect of preoperative radiotherapy for people with localised resectable rectal cancer compared to surgery alone. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; Issue 5, 2018) (4 June 2018), MEDLINE (Ovid) (1950 to 4 June 2018), and Embase (Ovid) (1974 to 4 June 2018). We also searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) for relevant ongoing trials (4 June 2018). SELECTION CRITERIA We included randomised controlled trials comparing PRT and surgery with surgery alone for people with localised advanced rectal cancer planned for radical surgery. We excluded trials that did not use contemporary radiotherapy techniques (with more than two fields to the pelvis). DATA COLLECTION AND ANALYSIS Two review authors independently assessed the 'Risk of bias' domains for each included trial, and extracted data. For time-to-event data, we calculated the Peto odds ratio (Peto OR) and variances, and for dichotomous data we calculated risk ratios (RR) using the random-effects method. Potential sources of heterogeneity hypothesised a priori included study quality, staging, and the use of total mesorectal excision (TME) surgery. MAIN RESULTS We included four trials with a total of 4663 participants. All four trials reported short PRT courses, with three trials using 25 Gy in five fractions, and one trial using 20 Gy in four fractions. Only one study specifically required TME surgery for inclusion, whereas in another study 90% of participants received TME surgery.Preoperative radiotherapy probably reduces overall mortality at 4 to 12 years' follow-up (4 trials, 4663 participants; Peto OR 0.90, 95% CI 0.83 to 0.98; moderate-quality evidence). For every 1000 people who undergo surgery alone, 454 would die compared with 45 fewer (the true effect may lie between 77 fewer to 9 fewer) in the PRT group. There was some evidence from subgroup analyses that in trials using TME no or little effect of PRT on survival (P = 0.03 for the difference between subgroups).Preoperative radiotherapy may have little or no effect in reducing cause-specific mortality for rectal cancer (2 trials, 2145 participants; Peto OR 0.89, 95% CI 0.77 to 1.03; low-quality evidence).We found moderate-quality evidence that PRT reduces local recurrence (4 trials, 4663 participants; Peto OR 0.48, 95% CI 0.40 to 0.57). In absolute terms, 161 out of 1000 patients receiving surgery alone would experience local recurrence compared with 83 fewer with PRT. The results were consistent in TME and non-TME studies.There may be little or no difference in curative resection (4 trials, 4673 participants; RR 1.00, 95% CI 0.97 to 1.02; low-quality evidence) or in the need for sphincter-sparing surgery (3 trials, 4379 participants; RR 0.99, 95% CI 0.94 to 1.04; I2 = 0%; low-quality evidence) between PRT and surgery alone.Low-quality evidence suggests that PRT may increase the risk of sepsis from 13% to 16% (2 trials, 2698 participants; RR 1.25, 95% CI 1.04 to 1.52) and surgical complications from 25% to 30% (2 trials, 2698 participants; RR 1.20, 95% CI 1.01 to 1.42) compared to surgery alone.Two trials evaluated quality of life using different scales. Both studies concluded that sexual dysfunction occurred more in the PRT group. Mixed results were found for faecal incontinence, and irradiated participants tended to resume work later than non-irradiated participants between 6 and 12 months, but this effect had attenuated after 18 months (low-quality evidence). AUTHORS' CONCLUSIONS We found moderate-quality evidence that PRT reduces overall mortality. Subgroup analysis did not confirm this effect in people undergoing TME surgery. We found consistent evidence that PRT reduces local recurrence. Risk of sepsis and postsurgical complications may be higher with PRT.The main limitation of the findings of the present review concerns their applicability. The included trials only assessed short-course radiotherapy and did not use chemotherapy, which is widely used in the contemporary management of rectal cancer disease. The differences between the trials regarding the criteria used to define rectal cancer, staging, radiotherapy delivered, the time between radiotherapy and surgery, and the use of adjuvant or postoperative therapy did not appear to influence the size of effect across the studies.Future trials should focus on identifying participants that are most likely to benefit from PRT especially in terms of improving local control, sphincter preservation, and overall survival while reducing acute and late toxicities (especially rectal and sexual function), as well as determining the effect of radiotherapy when chemotherapy is used and the optimal timing of surgery following radiotherapy.
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Affiliation(s)
- Iosief Abraha
- Regional Health Authority of UmbriaHealth Planning ServicePerugiaItaly06124
| | - Cynthia Aristei
- University of Perugia and Perugia General HospitalRadiation Oncology Section, Department of Surgical and Biomedical SciencePerugiaItaly
| | - Isabella Palumbo
- University of Perugia and Perugia General HospitalRadiation Oncology Section, Department of Surgical and Biomedical SciencePerugiaItaly
| | | | | | | | - Rita De Florio
- Local Health Unit of PerugiaGeneral MedicineAzienda SanitariaLocale USL 1, Medicina GeneralePerugiaItaly
| | - Vincenzo Valentini
- Fondazione Policlinico Universitario A.Gemelli IRCCSRadiation Oncology DepartmentRomeItaly
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Jørgensen JB, Bondeven P, Iversen LH, Laurberg S, Pedersen BG. Pelvic insufficiency fractures frequently occur following preoperative chemo-radiotherapy for rectal cancer - a nationwide MRI study. Colorectal Dis 2018; 20:873-880. [PMID: 29673038 DOI: 10.1111/codi.14224] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 03/19/2018] [Indexed: 12/12/2022]
Abstract
AIM The aim of this prospective case-control study was to evaluate the rate of pelvic insufficiency fractures (PIFs) in Denmark using MRI at the 3-year follow-up. All patients had rectal cancer and had undergone surgery with or without preoperative chemo-radiotherapy (CRT). METHOD Patients registered with primary rectal cancer in the Danish Colorectal Cancer Group database, who underwent rectal cancer resection from April 2011 through August 2012, were invited to participate in a national MRI study aiming to detect local recurrence and evaluate quality of the surgical treatment. Pelvic MRI including bone-specific sequences 3 years after treatment was obtained. The primary outcome was the rate of PIFs; secondary outcome was risk factors of PIFs evaluated in multivariate analysis. RESULTS During the study period, 890 patients underwent rectal cancer surgery. Of these, 403 patients were included in the MRI study and had a 3-year follow-up MRI. PIFs were detected in 49 (12.2%; 95% CI 9.0-15.4) patients by MRI. PIFs were detected in 39 patients (33.6%; 95% CI 24.9-42.3) treated with preoperative CRT compared to 10 (3.5%; 95% CI 1.3-5.6) non-irradiated patients (P < 0.001). In a multivariate analysis female gender (OR = 3.52; 95% CI 1.7-7.5), age above 65 years (OR = 3.20; 95% CI 1.5-6.9) and preoperative CRT (OR = 14.20; 95% CI 6.1-33.1) were significant risk factors for PIFs. CONCLUSION Preoperative CRT in the treatment of rectal cancer was associated with a 14-fold higher risk of PIFs after 3 years, whereas female gender and age above 65 years each tripled the risk of PIFs.
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Affiliation(s)
- J B Jørgensen
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - P Bondeven
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - L H Iversen
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - S Laurberg
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - B G Pedersen
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark
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Nuytens F, Develtere D, Sergeant G, Parmentier I, D'Hoore A, D'Hondt M. Perioperative radiotherapy is an independent risk factor for major LARS: a cross-sectional observational study. Int J Colorectal Dis 2018; 33:1063-1069. [PMID: 29696348 DOI: 10.1007/s00384-018-3043-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/04/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE Sphincter-preserving surgery for rectal cancer is often associated with low anterior resection syndrome (LARS). The aim of our study was to determine the prevalence of LARS in our institution and identify possible risk factors for LARS. Furthermore, we evaluated which of the LARS symptoms was considered most disabling by patients and whether or not there is an adaptation of the LARS score over time. METHODS This study includes a prospective database of 100 patients who underwent total or partial mesorectal excision between January 2009 and September 2014. Patients were contacted after a median postoperative time of 38 (5-45) months to determine the LARS score and to identify LARS symptoms that were considered most disabling. Uni- and multivariate regression analysis was performed to identify risk factors for LARS and major LARS. Finally, the LARS score was evaluated over time after restoration of bowel continuity. RESULTS Out of the 100 patients, 16 had minor LARS (score 21-29) and 51 patients had major LARS (score 30-42). Radiotherapy was an independent risk factor for major LARS (p = 0.04). For the majority of patients with major LARS (22%), fragmentation was considered the most disabling complaint. There was no correlation between interval after restoration of bowel continuity and the severity of the LARS score. CONCLUSIONS Perioperative radiotherapy is an independent risk factor for major LARS. Fragmentation is considered the most disabling complaint in the majority of patients with major LARS. There is no significant adaptation of the LARS score over time.
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Affiliation(s)
- Frederiek Nuytens
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium
| | | | - Gregory Sergeant
- Department of Abdominal and Hepatobiliary Surgery, Jessa Hospital, Hasselt, Belgium
| | - Isabelle Parmentier
- Department of Oncology and Statistics, Groeninge Hospital, Kortrijk, Belgium
| | - André D'Hoore
- Department of Abdominal Surgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Mathieu D'Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium.
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Narang AK, Meyer J. Neoadjuvant Short-Course Radiation Therapy for Rectal Cancer: Trends and Controversies. Curr Oncol Rep 2018; 20:68. [DOI: 10.1007/s11912-018-0714-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Mak JCK, Foo DCC, Wei R, Law WL. Sphincter-Preserving Surgery for Low Rectal Cancers: Incidence and Risk Factors for Permanent Stoma. World J Surg 2018; 41:2912-2922. [PMID: 28620675 DOI: 10.1007/s00268-017-4090-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Advances in surgical techniques and paradigm changes in rectal cancer treatment have led to a drastic decline in the abdominoperineal resection rate, and sphincter-preserving operation is possible in distal rectal cancer. OBJECTIVE The aim of this study is to evaluate the long-term incidence of permanent stoma after sphincter-preserving surgery for low rectal cancer and its corresponding risk factors. METHOD From 2000 to 2014, patients who underwent sphincter-preserving low anterior resection for low rectal cancer (within 5 cm from the anal verge) were included. The occurrence of permanent stoma over time and its risk factors were investigated by using a Cox proportional hazards regression model. RESULTS This study included 194 patients who underwent ultra-low anterior resection for distal rectal cancer, and the median follow-up period was 77 months for the surviving patients. Forty-six (23.7%) patients required a permanent stoma eventfully. Anastomotic-related complications and disease progression were the main reasons for permanent stoma. Clinical anastomotic leakage (HR 5.72; 95% CI 2.31-14.12; p < 0.001) and neoadjuvant chemoradiation (HR 2.34; 95% CI 1.12-4.90; p = 0.024) were predictors for permanent primary stoma. Local recurrence (HR 16.09; 95% CI 5.88-44.03; p < 0.001) and T4 disease (HR 11.28; 95% CI 2.99-42.49; p < 0.001) were predictors for permanent secondary stoma. The 5- and 10-year cumulative incidence for permanent stoma was 24.1 and 28.0%, respectively. CONCLUSION Advanced disease, prior chemoradiation, anastomotic leakage and local recurrence predispose patients to permanent stoma should be taken into consideration when contemplating sphincter-preserving surgery.
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Affiliation(s)
- Joanna Chung Kiu Mak
- Department of Surgery, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong
| | - Dominic Chi Chung Foo
- Department of Surgery, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong
| | - Rockson Wei
- Department of Surgery, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong
| | - Wai Lun Law
- Department of Surgery, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong.
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Rosa C, Di Tommaso M, Caravatta L, Vinciguerra A, Augurio A, Perrotti F, Allajbej A, Regoli M, Zecca IA, Di Nicola M, Genovesi D. Assessment of bowel and anal sphincter function after neoadjuvant chemoradiotherapy in locally advanced rectal cancer. TUMORI JOURNAL 2018; 104:121-127. [PMID: 29714663 DOI: 10.1177/0300891618765580] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To report long-term effects on anorectal function and bowel disorders and late toxicity rate of preoperative chemoradiotherapy in patients with locally advanced rectal cancer. METHODS Between 2000 and 2016, 201 patients treated with different neoadjuvant schedules of chemotherapy and radiotherapy doses were retrospectively analyzed. The Memorial Sloan-Kettering Cancer Center score was used for the evaluation of anal sphincter function. RESULTS The median follow-up time was 68 months (interquartile range 35-113 months). Radical resection was performed in 188 (93.5%) patients with a pathologic complete response rate of 26.4%. Overall sphincter function resulted excellent in 105 (52.2%) patients, good in 13 (6.5%), fair in 10 (5.0%), and poor (incontinence) in 40 (19.9%), with a persistent stoma rate of 16.4%. A further evaluation on 194 patients showed an improvement of sphincter function after 2 years in 11.9% of them. Seventy-three patients presenting stoma or poor sphincter function were re-evaluated for quality of life (QoL) indexes. Twenty-one (29%), 19 (26%), and 24 (33%) of them declared some variations concerning well-being, fatigue, and ability to perform daily activities. The 5-year overall survival, disease-free survival, and local recurrence rates were 88.0% ± 2.6%, 86.3% ± 2.5%, and 94.6% ± 1.9%, respectively. CONCLUSIONS In our study, neoadjuvant chemoradiotherapy was associated with good results in terms of sphincter function, late toxicities, and QoL indexes. A routine use of assessment scales could contribute to a better selection of patients with increased risk of developing functional disorders who could benefit from neoadjuvant therapy.
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Affiliation(s)
- Consuelo Rosa
- 1 Department of Radiation Oncology, SS Annunziata Hospital, G. D'Annunzio University, Chieti, Italy
| | - Monica Di Tommaso
- 1 Department of Radiation Oncology, SS Annunziata Hospital, G. D'Annunzio University, Chieti, Italy
| | - Luciana Caravatta
- 1 Department of Radiation Oncology, SS Annunziata Hospital, G. D'Annunzio University, Chieti, Italy
| | - Annamaria Vinciguerra
- 1 Department of Radiation Oncology, SS Annunziata Hospital, G. D'Annunzio University, Chieti, Italy
| | - Antonietta Augurio
- 1 Department of Radiation Oncology, SS Annunziata Hospital, G. D'Annunzio University, Chieti, Italy
| | - Francesca Perrotti
- 1 Department of Radiation Oncology, SS Annunziata Hospital, G. D'Annunzio University, Chieti, Italy
| | - Albina Allajbej
- 1 Department of Radiation Oncology, SS Annunziata Hospital, G. D'Annunzio University, Chieti, Italy
| | - Marco Regoli
- 1 Department of Radiation Oncology, SS Annunziata Hospital, G. D'Annunzio University, Chieti, Italy
| | - Isaia Al Zecca
- 2 Laboratory of Biostatistics, Department of Medical, Oral and Biotechnological Sciences, G. D'Annunzio University, Chieti, Italy
| | - Marta Di Nicola
- 2 Laboratory of Biostatistics, Department of Medical, Oral and Biotechnological Sciences, G. D'Annunzio University, Chieti, Italy
| | - Domenico Genovesi
- 1 Department of Radiation Oncology, SS Annunziata Hospital, G. D'Annunzio University, Chieti, Italy
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De Paoli A, Innocente R, Buonadonna A, Boz G, Sigon R, Canzonieri V, Frustaci S. Neoadjuvant Therapy of Rectal Cancer New Treatment Perspectives. TUMORI JOURNAL 2018; 90:373-8. [PMID: 15510978 DOI: 10.1177/030089160409000402] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
During the past two decades, significant advances have been made in the management of patients with rectal cancer. A number of clinical studies have demonstrated the efficacy of preoperative chemoradiation therapy with 5-fluorouracil (5-FU)-based regimens in decreasing local recurrences and improving survival and the likelihood of sphincter preservation. Although 5-FU has been the standard drug used in combination with radiation therapy for many years, new effective drugs including capecitabine, raltitrexed, irinotecan and oxaliplatin have been recently investigated in combination with radiation therapy in the preoperative setting. In addition, novel targeted biological agents including epidermal growth factor receptor inhibitors and vascular endothelial growth factor inhibitors have been shown to enhance the antitumor effect of both radiation and chemotherapy and are currently being explored in initial clinical trials. In the present review we summarize the results of adjuvant therapy. In addition, we will discuss the recently reported phase I-II trials with new drug plus radiation combinations in the preoperative treatment of patients with rectal cancer.
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Affiliation(s)
- Antonino De Paoli
- Department of Radiation Oncology, Centro di Riferimento Oncologico, National Cancer Institute, Aviano, Italy.
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Battersby NJ, Bouliotis G, Emmertsen KJ, Juul T, Glynne-Jones R, Branagan G, Christensen P, Laurberg S, Moran BJ. Development and external validation of a nomogram and online tool to predict bowel dysfunction following restorative rectal cancer resection: the POLARS score. Gut 2018; 67:688-696. [PMID: 28115491 DOI: 10.1136/gutjnl-2016-312695] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 12/22/2016] [Accepted: 12/28/2016] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Bowel dysfunction is common following a restorative rectal cancer resection, but symptom severity and the degree of quality of life impairment is highly variable. An internationally validated patient-reported outcome measure, Low Anterior Resection Syndrome (LARS) score, now enables these symptoms to be measured. The study purpose was: (1) to develop a model that predicts postoperative bowel function; (2) externally validate the model and (3) incorporate these findings into a nomogram and online tool in order to individualise patient counselling and aid preoperative consent. DESIGN Patients more than 1 year after curative restorative anterior resection (UK, median 54 months; Denmark (DK), 56 months since surgery) were invited to complete The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire - Core 30 version3 (EORTC QLQ-C30 v3), LARS and Wexner incontinence scores. Demographics, tumour characteristics, preoperative/postoperative treatment and surgical procedures were recorded. Using transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) guidelines, risk factors for bowel dysfunction were independently assessed by advanced linear regression shrinkage techniques for each dataset (UK:DK). RESULTS Patients in the development (UK, n=463) and validation (DK, n=938) datasets reported mean (SD) LARS scores of 26 (11) and 24 (11), respectively. Key predictive factors for LARS were: age (at surgery); tumour height, total versus partial mesorectal excision, stoma and preoperative radiotherapy, with satisfactory model calibration and a Mallow's Cp of 7.5 and 5.5, respectively. CONCLUSIONS The Pre-Operative LARS score (POLARS) is the first nomogram and online tool to predict bowel dysfunction severity prior to anterior resection. Colorectal surgeons, gastroenterologist and nurse specialists may use POLARS to help patients understand their risk of bowel dysfunction and to preoperatively highlight patients who may require additional postoperative support.
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Affiliation(s)
- Nick J Battersby
- The Pelican Cancer Foundation, The Ark, Basingstoke, Hampshire, UK.,Department of Colorectal and Peritoneal Malignancy Surgery, Hampshire Hospitals NHS Foundation Trust, Basingstoke, Hampshire, UK
| | - George Bouliotis
- Department of Clinical Statistics, Imperial College London, London, UK
| | | | - Therese Juul
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Rob Glynne-Jones
- Radiotherapy Department, Mount-Vernon Cancer Centre, Mount-Vernon Hospital, Northwood, UK
| | - Graham Branagan
- Department of Colorectal Surgery, Salisbury NHS Foundation Trust, Salisbury, Wiltshire, UK
| | | | - Søren Laurberg
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Brendan J Moran
- The Pelican Cancer Foundation, The Ark, Basingstoke, Hampshire, UK.,Department of Colorectal and Peritoneal Malignancy Surgery, Hampshire Hospitals NHS Foundation Trust, Basingstoke, Hampshire, UK
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Bowden DL, Sutton PA, Wall MA, Jithesh PV, Jenkins RE, Palmer DH, Goldring CE, Parsons JL, Park BK, Kitteringham NR, Vimalachandran D. Proteomic profiling of rectal cancer reveals acid ceramidase is implicated in radiation response. J Proteomics 2018. [PMID: 29518574 DOI: 10.1016/j.jprot.2018.02.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy (CRT) is used in locally advanced rectal cancer when tumours threaten the circumferential resection margin, with varying response to treatment. This experimental study aimed to identify significantly differentially expressed proteins between patients responding and not responding to CRT, and to validate any proteins of interest. METHODS Mass spectrometry (with isobaric tagging for relative quantification) analysis of rectal cancers pre- and post-CRT, and at resection. Validation of proteins of interest was performed by assessing tissue microarray (TMA) immunohistochemistry expression in a further 111 patients with rectal cancer. RESULTS Proteomic data are available via ProteomeXchange with identifier PXD008436. Reduced abundance of contributing peptide ions for acid ceramidase (AC) (log fold change -1.526, p = 1.17E-02) was observed in CRT responders. Differential expression of AC was confirmed upon analysis of the TMAs. Cancer site expression of AC in stromal cells from post-CRT resection specimens was observed to be relatively low in pathological complete response (p = 0.003), and relatively high with no response to CRT (p = 0.017). CONCLUSION AC may be implicated in the response of rectal cancer to CRT. We propose its further assessment as a novel potential biomarker and therapeutic target. SIGNIFICANCE There is a need for biomarkers to guide the use of chemoradiotherapy in rectal cancer, as none are in routine clinical use. We have determined acid ceramidase may have a role in radiation response, based on novel proteomic profiling and validation in a wider dataset using tissue microarrays. The ability to predict or improve response would positively select those patients who will derive benefit, prevent delays in the local and systemic management of disease in non-responders, and reduce morbidity associated with chemoradiotherapy.
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Affiliation(s)
- D L Bowden
- The University of Liverpool, Department of Molecular and Clinical Pharmacology, Ashton Street, Liverpool L69 3GE, United Kingdom.
| | - P A Sutton
- The University of Liverpool, Department of Molecular and Clinical Pharmacology, Ashton Street, Liverpool L69 3GE, United Kingdom
| | - M A Wall
- The Countess of Chester Hospital, Liverpool Road, Chester CH2 1UL, United Kingdom
| | - P V Jithesh
- Sidra Medical and Research Centre, PO Box 26999, Doha, Qatar
| | - R E Jenkins
- The University of Liverpool, Department of Molecular and Clinical Pharmacology, Ashton Street, Liverpool L69 3GE, United Kingdom
| | - D H Palmer
- The University of Liverpool, Department of Molecular and Clinical Cancer Medicine, London Road, Liverpool L3 9TA, United Kingdom
| | - C E Goldring
- The University of Liverpool, Department of Molecular and Clinical Pharmacology, Ashton Street, Liverpool L69 3GE, United Kingdom
| | - J L Parsons
- The University of Liverpool, Department of Molecular and Clinical Cancer Medicine, London Road, Liverpool L3 9TA, United Kingdom
| | - B K Park
- The University of Liverpool, Department of Molecular and Clinical Pharmacology, Ashton Street, Liverpool L69 3GE, United Kingdom
| | - N R Kitteringham
- The University of Liverpool, Department of Molecular and Clinical Pharmacology, Ashton Street, Liverpool L69 3GE, United Kingdom
| | - D Vimalachandran
- The Countess of Chester Hospital, Liverpool Road, Chester CH2 1UL, United Kingdom; The University of Liverpool, Department of Molecular and Clinical Cancer Medicine, London Road, Liverpool L3 9TA, United Kingdom
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Wang L, Wang X, Lo A, Raval M, Brown C, Karimuddin A, Phang PT. Effects of radiation and surgery on function and quality of life (QOL) in rectal cancer patients. Am J Surg 2018; 215:863-866. [PMID: 29366486 DOI: 10.1016/j.amjsurg.2018.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 01/10/2018] [Accepted: 01/12/2018] [Indexed: 02/05/2023]
Abstract
Pre-operative radiotherapy (PRT) and total mesorectal excision surgery (TME) for rectal cancer yield the lowest risk for local recurrence. However, both treatments negatively impact quality of life (QOL). To understand individual treatment effects, we ask whether PRT affects function and quality of life before TME. Function and QOL were prospectively assessed in 26 patients using EORTC QLQ-C30/-CR38, and Wexner scale at three time points: before PRT, 6 weeks after PRT and before TME, and one year after stoma closure. Wexner score did not change post-PRT but did increase post-TME (p < .01). Micturition score did not change with PRT or TME (p = .29). Sexual function score improved post-PRT (p = .03) but did not change post-TME. Global health status did not change post-treatments (p = .45). Future perspective improved post-surgery (p = .04). PRT did not affect micturition, bowel function, or QOL. Future perspective improved despite increased bowel problems and fecal incontinence. QOL was maintained after curative rectal cancer treatments, radiation and TME surgery. This information may help patients and physicians better understand effects of PRT and TME treatments for rectal cancer.
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Affiliation(s)
- Linda Wang
- St. Paul's Hospital, Vancouver, BC, Canada; University of British Columbia, Vancouver, BC, Canada
| | | | - Ada Lo
- St. Paul's Hospital, Vancouver, BC, Canada; University of British Columbia, Vancouver, BC, Canada
| | - Manoj Raval
- St. Paul's Hospital, Vancouver, BC, Canada; University of British Columbia, Vancouver, BC, Canada
| | - Carl Brown
- St. Paul's Hospital, Vancouver, BC, Canada; University of British Columbia, Vancouver, BC, Canada
| | - Ahmer Karimuddin
- St. Paul's Hospital, Vancouver, BC, Canada; University of British Columbia, Vancouver, BC, Canada
| | - P Terry Phang
- St. Paul's Hospital, Vancouver, BC, Canada; University of British Columbia, Vancouver, BC, Canada.
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Lupattelli M, Mascioni F, Bellavita R, Draghini L, Tarducci R, Castagnoli P, Russo G, Aristei C. Long-term Anorectal Function after Postoperative Chemoradiotherapy in High-Risk Rectal Cancer Patients. TUMORI JOURNAL 2018; 96:34-41. [DOI: 10.1177/030089161009600106] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Aims and background After sphincter-preserving surgery for rectal cancer and postoperative radiochemotherapy, many patients have unsatisfactory anorectal functional results which are not considered by the most common toxicity scales. The aim of the present study was to retrospectively assess the long-term incidence of impaired anorectal function in rectal cancer patients who underwent anterior resection and postoperative radiochemotherapy. Methods Ninety-nine patients who underwent sphincter-saving surgery and postoperative radiochemotherapy for stage II-III rectal cancer from July 1991 to January 2002 were given a questionnaire on anorectal function. Postoperative incontinence was evaluated according to a scale proposed by Jorge and Wexner. Factors influencing anorectal function were examined. Results The median follow-up from surgery was 10 years. Ten (10.1%) patients reported ≥ 5 bowel movements per day and 26 (26.3%) experienced clustering. The median frequency of bowel movements per 24 h was 2 (range, 1–10). Stool fragmentation was recorded in 56 (56.6%) cases, and 36 (36.4%) patients experienced urgency to defecate with inability to delay defecation for more than 15 min. The mean continence score was 4.91 (median 1, range 0–18). Incontinence to flatus, liquid and solid stools was reported at least once a week in 24 (24.2%), 11 (11.1%) and 5 (5.1%) patients, respectively. According to the study criteria, 61% of patients had good functional results. None of the variables analyzed showed a significant correlation with functional outcome. Conclusions Although retrospective, the present study included a large selected series that had undergone uniform adjuvant treatment and was followed for a median of 10 years. Our data demonstrated that 39% of patients did not have good functional results and suffered some degree of urgency, increased frequency and occasional incontinence even many years after the surgery. Anorectal function assessment should enter routinely in clinical practice and should have importance in the therapeutic decisions.
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Affiliation(s)
- Marco Lupattelli
- Radiation Oncology Centre, University and Hospital of Perugia, Perugia, Italy
| | - Francesca Mascioni
- Radiation Oncology Centre, University and Hospital of Perugia, Perugia, Italy
| | - Rita Bellavita
- Radiation Oncology Centre, University and Hospital of Perugia, Perugia, Italy
| | - Lorena Draghini
- Radiation Oncology Centre, University and Hospital of Perugia, Perugia, Italy
| | - Roberto Tarducci
- Medical Physics, University and Hospital of Perugia, Perugia, Italy
| | - Paolo Castagnoli
- Surgery Division, University and Hospital of Perugia, Perugia, Italy
| | - Giuseppe Russo
- Department of Gastroenterology, University and Hospital of Perugia, Perugia, Italy
| | - Cynthia Aristei
- Radiation Oncology Centre, University and Hospital of Perugia, Perugia, Italy
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Eftaiha SM, Nordenstam JF. Sacral neuromodulation and the low anterior resection syndrome. SEMINARS IN COLON AND RECTAL SURGERY 2017. [DOI: 10.1053/j.scrs.2017.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Eftaiha SM, Balachandran B, Marecik SJ, Mellgren A, Nordenstam J, Melich G, Prasad LM, Park JJ. Sacral nerve stimulation can be an effective treatment for low anterior resection syndrome. Colorectal Dis 2017; 19:927-933. [PMID: 28477435 DOI: 10.1111/codi.13701] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 02/05/2017] [Indexed: 02/08/2023]
Abstract
AIM Sacral nerve stimulation has become a preferred method for the treatment of faecal incontinence in patients who fail conservative (non-operative) therapy. In previous small studies, sacral nerve stimulation has demonstrated improvement of faecal incontinence and quality of life in a majority of patients with low anterior resection syndrome. We evaluated the efficacy of sacral nerve stimulation in the treatment of low anterior resection syndrome using a recently developed and validated low anterior resection syndrome instrument to quantify symptoms. METHOD A retrospective review of consecutive patients undergoing sacral nerve stimulation for the treatment of low anterior resection syndrome was performed. Procedures took place in the Division of Colon and Rectal Surgery at two academic tertiary medical centres. Pre- and post-treatment Cleveland Clinic Incontinence Scores and Low Anterior Resection Syndrome scores were assessed. RESULTS Twelve patients (50% men) suffering from low anterior resection syndrome with a mean age of 67.8 (±10.8) years underwent sacral nerve test stimulation. Ten patients (83%) proceeded to permanent implantation. Median time from anterior resection to stimulator implant was 16 (range 5-108) months. At a median follow-up of 19.5 (range 4-42) months, there were significant improvements in Cleveland Clinic Incontinence Scores and Low Anterior Resection Syndrome scores (P < 0.001). CONCLUSION Sacral nerve stimulation improved symptoms in patients suffering from low anterior resection syndrome and may therefore be a viable treatment option.
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Affiliation(s)
- S M Eftaiha
- Division of Colon and Rectal Surgery, University of Illinois, Chicago, Illinois, USA
| | - B Balachandran
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
| | - S J Marecik
- Division of Colon and Rectal Surgery, University of Illinois, Chicago, Illinois, USA.,Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA.,Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois, USA
| | - A Mellgren
- Division of Colon and Rectal Surgery, University of Illinois, Chicago, Illinois, USA
| | - J Nordenstam
- Division of Colon and Rectal Surgery, University of Illinois, Chicago, Illinois, USA
| | - G Melich
- Department of General Surgery, Royal Columbian Hospital, University of British Columbia, New Westminster, BC, Canada
| | - L M Prasad
- Division of Colon and Rectal Surgery, University of Illinois, Chicago, Illinois, USA.,Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois, USA
| | - J J Park
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA.,Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois, USA
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45
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Use of a nomogram to predict the closure rate of diverting ileostomy after low anterior resection: A retrospective cohort study. Int J Surg 2017; 47:83-88. [PMID: 28951289 DOI: 10.1016/j.ijsu.2017.09.057] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 09/17/2017] [Accepted: 09/18/2017] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Although temporary ileostomy is widely used to prevent complications due to anastomotic leakage after middle and low rectal cancer surgery, some patients fail to achieve stoma closure after primary surgery. The aim of this study was to identify the risk factors for permanent stoma following low anterior resection (LAR) or intersphincteric resection (ISR) with a temporary ileostomy for rectal cancer, while focusing on the time course, to develop a nomogram that can predict the rate of unreversed ileostomy 1 year after initial surgery. METHOD A total of 212 consecutive rectal cancer patients who underwent LAR or ISR with or without a temporary stoma between 2012 and 2015 at the University of Tokyo Hospital were retrospectively reviewed. Data analyses were performed using JMP Pro 11.0 and R 3.0.1 with rms and Hmisc packages to identify the risk factors for diverting ileostomy resulting in un-reversed stoma, and to develop a nomogram using these factors. RESULTS Among 212 patients, diverting ileostomy and colostomy were performed in 116 and 11 patients, respectively, and a stoma was not created in 85 patients. Among the ileostomy cases, 94 underwent stoma reversal, and the median interval from initial surgery to stoma closure was 6.9 months. Three patients eventually underwent stoma re-creation, and hence, 25 patients had permanent stoma. The following variables were correlated with the stoma non-reversal rate and were included in the nomogram: depth of invasion (p = 0.02), presence of metastatic organs (p = 0.07), and preoperative chemoradiotherapy (p = 0.03). The nomogram C-index was 0.612, indicating moderate predictive ability. CONCLUSIONS The most common factors preventing stoma closure included distant metastasis or rectal cancer recurrence. The nomogram developed in the present study can help identify rectal cancer patients with high risk of stoma non-reversal.
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Midura EF, Jung AD, Daly MC, Hanseman DJ, Davis BR, Shah SA, Paquette IM. Cancer Center Volume and Type Impact Stage-Specific Utilization of Neoadjuvant Therapy in Rectal Cancer. Dig Dis Sci 2017; 62:1906-1912. [PMID: 28501970 DOI: 10.1007/s10620-017-4610-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 05/04/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Neoadjuvant chemoradiation reduces local recurrence in locally advanced rectal cancer, and adherence to national and societal recommendations remains unknown. OBJECTIVE To determine variability in guideline adherence in rectal cancer treatment and investigate whether hospital volume correlated with variability seen. DESIGN We performed a retrospective analysis using the National Cancer Database rectal cancer participant user files from 2005 to 2010. Stage-specific predictors of neoadjuvant chemotherapy and radiation use were determined, and variation in use across hospitals analyzed. Hospitals were ranked based on likelihood of preoperative therapy use by stage, and observed-to-expected ratios for neoadjuvant therapy use calculated. Hospital outliers were identified, and their center characteristics compared. RESULTS A total of 23,488 patients were identified at 1183 hospitals. There was substantial variability in the use of neoadjuvant chemoradiation across hospitals. Patients managed outside clinical guidelines for both stage 1 and stage 3 disease tended to receive treatment at lower-volume, community cancer centers. CONCLUSIONS There is substantial variability in adherence to national guidelines in the use of neoadjuvant chemoradiation for rectal cancer across all stages. Both hospital volume and center type are associated with over-treatment of early-stage tumors and under-treatment of more invasive tumors. These findings identify a clear need for national quality improvement efforts in the treatment of rectal cancer.
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Affiliation(s)
- Emily F Midura
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA.,Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Cincinnati, OH, USA
| | - Andrew D Jung
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA.,Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Cincinnati, OH, USA
| | - Meghan C Daly
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA.,Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Cincinnati, OH, USA
| | - Dennis J Hanseman
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA.,Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Cincinnati, OH, USA
| | - Bradley R Davis
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Shimul A Shah
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA.,Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Cincinnati, OH, USA
| | - Ian M Paquette
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA. .,Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Cincinnati, OH, USA. .,, 2123 Auburn Avenue, #524, Cincinnati, OH, 45219, USA.
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47
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Keane C, Wells C, O'Grady G, Bissett IP. Defining low anterior resection syndrome: a systematic review of the literature. Colorectal Dis 2017; 19:713-722. [PMID: 28612460 DOI: 10.1111/codi.13767] [Citation(s) in RCA: 135] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 03/29/2017] [Indexed: 12/13/2022]
Abstract
AIM There is increasing awareness of the poor functional outcome suffered by many patients after sphincter-preserving rectal resection, termed 'low anterior resection syndrome' (LARS). There is no consensus definition of LARS and varying instruments have been employed to measure functional outcome, complicating research into prevalence, contributing factors and potential therapies. We therefore aimed to describe the instruments and outcome measures used in studies of bowel dysfunction after low anterior resection and identify major themes used in the assessment of LARS. METHOD A systematic review of the literature was performed for studies published between 1986 and 2016. The instruments and outcome measures used to report bowel function after low anterior resection were extracted and their frequency of use calculated. RESULTS The search revealed 128 eligible studies. These employed 18 instruments, over 30 symptoms, and follow-up time periods from 4 weeks to 14.6 years. The most frequent follow-up period was 12 months (48%). The most frequently reported outcomes were incontinence (97%), stool frequency (80%), urgency (67%), evacuatory dysfunction (47%), gas-stool discrimination (34%) and a measure of quality of life (80%). Faecal incontinence scoring systems were used frequently. The LARS score and the Bowel Function Instrument (BFI) were used in only nine studies. CONCLUSION LARS is common, but there is substantial variation in the reporting of functional outcomes after low anterior resection. Most studies have focused on incontinence, omitting other symptoms that correlate with patients' quality of life. To improve and standardize research into LARS, a consensus definition should be developed, and these findings should inform this goal.
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Affiliation(s)
- C Keane
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - C Wells
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - G O'Grady
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - I P Bissett
- Department of Surgery, University of Auckland, Auckland, New Zealand.,Department of Surgery, Auckland City Hospital, Auckland, New Zealand
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Gollins S, Moran B, Adams R, Cunningham C, Bach S, Myint AS, Renehan A, Karandikar S, Goh V, Prezzi D, Langman G, Ahmedzai S, Geh I. Association of Coloproctology of Great Britain & Ireland (ACPGBI): Guidelines for the Management of Cancer of the Colon, Rectum and Anus (2017) - Multidisciplinary Management. Colorectal Dis 2017; 19 Suppl 1:37-66. [PMID: 28632307 DOI: 10.1111/codi.13705] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
| | - Brendan Moran
- Basingstoke & North Hampshire Hospital, Basingstoke, UK
| | - Richard Adams
- Cardiff University and Velindre Cancer Centre, Cardiff, UK
| | | | - Simon Bach
- University of Birmingham and Queen Elizabeth Hospital, Birmingham, UK
| | | | - Andrew Renehan
- University of Manchester and Christie Hospital, Manchester, UK
| | | | - Vicky Goh
- King's College and Guy's & St Thomas' Hospital, London, UK
| | | | | | | | - Ian Geh
- Queen Elizabeth Hospital, Birmingham, UK
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49
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Bowel Dysfunction After Low Anterior Resection With Neoadjuvant Chemoradiotherapy or Chemotherapy Alone for Rectal Cancer: A Cross-Sectional Study from China. Dis Colon Rectum 2017; 60:697-705. [PMID: 28594719 DOI: 10.1097/dcr.0000000000000801] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Neoadjuvant therapy plays a vital role in the treatment of locally advanced rectal cancer but impairs bowel function after restorative surgery. Optimal decision making requires adequate information of functional outcomes. OBJECTIVE This study aimed to assess postoperative bowel function and to identify predictors for severe dysfunction. DESIGN The study included a cross-sectional cohort and retrospective assessments of pelvic anatomic features. SETTINGS The study was conducted at a tertiary GI hospital in China. PATIENTS Included patients underwent neoadjuvant chemoradiotherapy or chemotherapy without radiation and curative low anterior resection for rectal cancer between 2012 and 2014. MAIN OUTCOME MEASURES Bowel function was assessed using the validated low anterior resection syndrome score. The thicknesses of the rectal wall, obturator internus, and levator ani were measured by preoperative MRI. RESULTS A total of 151 eligible patients were identified, and 142 patients (94.0%) participated after a median of 19 months from surgery. Bowel dysfunction was observed in 71.1% (101/142) of patients, with 44.4% (63/142) reporting severe dysfunction. Symptoms of urgency and clustering were found to be major disturbances. Regression analysis identified preoperative long-course radiotherapy (p < 0.001) and a lower-third tumor (p = 0.002) independently associated with severe bowel dysfunction. Irradiated patients with a lower-third tumor (OR = 14.06; p < 0.001) or thickening of the rectal wall (OR = 11.09; p < 0.001) had a markedly increased risk of developing severe dysfunction. LIMITATIONS The study was based on a limited cohort of patients and moderate follow-up after the primary surgery. CONCLUSIONS Bowel function deteriorates frequently after low anterior resection for rectal cancer. Severe bowel dysfunction is significantly associated with preoperative long-course radiotherapy and a lower-third tumor, and the thickening of rectal wall after radiation is a strong predictor. Treatment decisions and patient consent should be implemented with raising awareness of bowel symptom burdens. See Video Abstract at http://links.lww.com/DCR/A317.
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50
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Biviano I, Balla A, Badiali D, Quaresima S, D'Ambrosio G, Lezoche E, Corazziari E, Paganini AM. Anal function after endoluminal locoregional resection by transanal endoscopic microsurgery and radiotherapy for rectal cancer. Colorectal Dis 2017; 19:O177-O185. [PMID: 28304143 DOI: 10.1111/codi.13656] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 12/29/2016] [Indexed: 12/16/2022]
Abstract
AIM In patients with rectal cancer, surgery and chemoradiotherapy may affect anal sphincter function. Few studies have evaluated anorectal function after neoadjuvant chemoradiotherapy (n-CRT) and/or transanal endoscopic microsurgery (TEM). The aim of this study was to evaluate the effects of n-CRT and TEM on anorectal function. METHOD Thirty-seven patients with rectal cancer underwent anorectal manometry and Wexner scoring for faecal incontinence at baseline, after n-CRT (cT2-T3N0 cancer) and at 4 and 12 months after surgery. Water-perfused manometry measured anal tone at rest and during squeezing, rectal sensitivity and compliance. Twenty-seven and 10 patients, respectively, underwent TEM without (Group A) or with n-CRT (Group B). RESULTS In Group A, anal resting pressure decreased from 68 ± 23 to 54 ± 26 mmHg at 4 months (P = 0.04) and improved 12 months after surgery (60 ± 30 mmHg). The Wexner score showed a significant increase in gas incontinence (59%), soiling (44%) and urgency (37%) rates at 4 months, followed by clinical improvement at 1 year (41%, 26% and 18%, respectively). In group B, anal resting pressure decreased from 65 ± 23 to 50 ± 18 mmHg at 4 months but remained stable at 12 months (44 ± 11 mmHg, P = 0.02 vs preoperative values - no significant difference compared with evaluation at 4 months). Gas incontinence, soiling and urgency were observed in 50%, 50%, 25% and in 38%, 12% and 12% of cases, respectively, 4 and 12 months after treatment. CONCLUSION TEM does not significantly affect anal function. Instead, n-CRT does affect anal function but without causing major anal incontinence.
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Affiliation(s)
- I Biviano
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - A Balla
- Department of General Surgery and Surgical Specialties 'Paride Stefanini', Sapienza University of Rome, Rome, Italy
| | - D Badiali
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - S Quaresima
- Department of General Surgery and Surgical Specialties 'Paride Stefanini', Sapienza University of Rome, Rome, Italy
| | - G D'Ambrosio
- Department of General Surgery and Surgical Specialties 'Paride Stefanini', Sapienza University of Rome, Rome, Italy
| | - E Lezoche
- Department of General Surgery and Surgical Specialties 'Paride Stefanini', Sapienza University of Rome, Rome, Italy
| | - E Corazziari
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - A M Paganini
- Department of General Surgery and Surgical Specialties 'Paride Stefanini', Sapienza University of Rome, Rome, Italy
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