Issam Al-Najami

Can we Save the rectum by watchful waiting or TransAnal microsurgery following (chemo) Radiotherapy versus Total mesorectal excision for early REctal Cancer (STAR-TREC study)?: protocol for a multicentre, randomised feasibility study

Introduction Total mesorectal excision (TME) is the highly effective standard treatment for rectal cancer but is associated with significant morbidity and may be overtreatment for low-risk cancers. This study is designed to determine the feasibility of international recruitment in a study comparing organ-saving approaches versus standard TME surgery. Methods and analysis STAR-TREC trial is a multicentre international randomised, three-arm parallel, phase II feasibility study in patients with biopsy-proven adenocarcinoma of the rectum. The trial is coordinated from Birmingham, UK with national hubs in Radboudumc (the Netherlands) and Odense University Hospital Svendborg UMC (Denmark). Patients with rectal cancer, staged by CT and MRI as ≤cT3b (up to 5 mm of extramural spread) N0 M0 can be included. Patients will be randomised to either standard TME surgery (control), organ-saving treatment using long-course concurrent chemoradiation or organ-saving treatment using short-course radiotherapy. For patients treated with an organ-saving strategy, clinical response to (chemo)radiotherapy determines the next treatment step. An active surveillance regime will be performed in the case of a complete clinical regression. In the case of incomplete clinical regression, patients will proceed to local excision using an optimised platform such as transanal endoscopic microsurgery or other transanal techniques (eg, transanal endoscopic operation or transanal minimally invasive surgery). The primary endpoint of this phase II study is to demonstrate sufficient international recruitment in order to sustain a phase III study incorporating pelvic failure as the primary endpoint. Success in phase II is defined as randomisation of at least four cases per month internationally in year 1, rising to at least six cases per month internationally during year 2. Ethics and dissemination The medical ethical committees of all the participating countries have approved the study protocol. Results of the primary and secondary endpoints will be submitted for publication in peer-reviewed journals. Trial registration number ISRCTN14240288, 20 October 2016. NCT02945566; Pre-results, October 2016.

Transanal endoscopic microsurgery for advanced polyps and early cancers in the rectum-Long-term outcome: A STROBE compliant observational study

AbstractTransanal endoscopic microsurgery (TEM) allows for the resection of large adenomas and early stage cancers in the rectum. The rate of complications and recurrence for malignant tumors compared with benign tumors has been questioned.The objective of our study was to analyze the outcome after TEM procedures for adenomas and cancers with focus on local recurrence and complications.All 280 patients who had a TEM procedure between January 2008 and September 2015 were enrolled in a prospective cohort study. Outcome was described for benign and malignant tumors. Mortality, recurrence, and complications were recorded.Two hundred eighty tumors were treated with TEM, 176 (63%) were benign and 104 (37%) were malignant. Complication rates were significantly different in the 2 groups, 10.8% (n = 19) in the benign and 24.0% (n = 25) in the malignant group (P = 0.003). A significant difference in perforation/penetration to the peritoneal cavity was noted (P = 0.034). There were no significant difference in the recurrence rate of 8.3% (n = 13) in the benign and 9.0% (n = 7) in the malignant groups. Thirty days mortality rates were 1.1% in the benign group versus 1.9% in the malignant. Other complications were noted in 2.8% and 3.8% in the benign and malignant group, respectively.TEM seems to be a safe and viable procedure for removing both benign and malignant lesions from the rectum. TEM offers low mortality and complication rates also recurrence after resection of malignant tumors.

Dual-Energy CT of Rectal Cancer Specimens: A CT-based Method for Mesorectal Lymph Node Characterization

BACKGROUND: An accurate method to assess malignant lymph nodes in the mesorectum is needed. Dual-energy CT scans simultaneously with 2 levels of energy and thereby provides information about tissue composition based on the known effective Z value of different tissues. Each point investigated is represented by a certain effective Z value, which allows for information on its composition. OBJECTIVE: We wanted to standardize a method for dual-energy scanning of rectal specimens to evaluate the sensitivity and specificity of benign versus malignant lymph node differentiation. Histopathological evaluation of the nodes was our reference. DESIGN: This was a descriptive and prospective study. SETTINGS: Seventeen rectal specimens were examined in 2 series. The first series was conducted with 3 specimens from patients who were not given perioperative contrast; 3 had iodine-based contrast and 3 had gadolinium-based contrast. We concluded that iodine was the contrast agent of choice and therefore included 8 more patients in a second series, given iodine-based contrast, for further analysis. PATIENTS: Quantitative imaging data were collected from 197 individual lymph nodes from 17 specimens, from patients with rectal cancer. MAIN OUTCOME MEASURES: We measured accuracy of differentiating benign from malignant lymph nodes by investigating the following: 1) gadolinium, iodine, and water concentrations in lymph nodes; 2) dual-energy ratio; 3) dual-energy index; and 4) effective Z value. RESULTS: Optimal discriminations between benign and malignant lymph nodes were obtained using the following cutoff values: 1) effective Z at 7.58 (sensitivity, 100%; specificity, 90%; and accuracy, 93%), 2) dual-energy ratio at 1.0 × 10−4 (sensitivity, 96%; specificity, 87%; and accuracy, 90%), 3) dual-energy index at 0.03 (sensitivity, 97%; specificity, 88%; and accuracy, 91%), and 4) iodine concentration at 2.58 &mgr;g/mL (sensitivity, 86%; specificity, 92%; and accuracy, 89%). LIMITATIONS: The investigation is conducted on isolated surgical specimens from rectal cancer operations. CONCLUSIONS: Dual-energy CT can be performed on rectal specimens. The discrimination between benign and malignant nodes seems promising when using iodine as contrast.

Dual-energy CT can detect malignant lymph nodes in rectal cancer

BACKGROUND There is a need for an accurate and operator independent method to assess the lymph node status to provide the most optimal personalized treatment for rectal cancer patients. This study evaluates whether Dual Energy Computed Tomography (DECT) could contribute to the preoperative lymph node assessment, and compared it to Magnetic Resonance Imaging (MRI). The objective of this prospective observational feasibility study was to determine the clinical value of the DECT for the detection of metastases in the pelvic lymph nodes of rectal cancer patients and compare the findings to MRI and histopathology. MATERIALS AND METHODS The patients were referred to total mesorectal excision (TME) without any neoadjuvant oncological treatment. After surgery the rectum specimen was scanned, and lymph nodes were matched to the pathology report. Fifty-four histology proven rectal cancer patients received a pelvic DECT scan and a standard MRI. The Dual Energy CT quantitative parameters were analyzed: Water and Iodine concentration, Dual-Energy Ratio, Dual Energy Index, and Effective Z value, for the benign and malignant lymph node differentiation. RESULTS DECT scanning showed statistical difference between malignant and benign lymph nodes in the measurements of iodine concentration, Dual-Energy Ratio, Dual Energy Index, and Effective Z value. Dual energy CT classified 42% of the cases correctly according to N-stage compared to 40% for MRI. CONCLUSION This study showed statistical difference in several quantitative parameters between benign and malignant lymph nodes. There were no difference in the accuracy of lymph node staging between DECT and MRI.

Rapid diagnosis of ethylene glycol poisoning by urine microscopy

Patient: Male, 57 Final Diagnosis: Ethylene glycol poisoning Symptoms: Unconsciousness and high anion gap Medication: Bicarbonate • electrolyte correction • intravenous ethyl alcohol infusion • hemodialysis Clinical Procedure: icroscopy of calcium oxalate monohydrate crystals Specialty: Nephrology • Intensive Care Unit • Biochemistry and Immunology Objective: Challenging differential diagnosis Background: Ethylene glycol poisoning remains an important presentation to Emergency Departments. Quick diagnosis and treatment are essential to prevent renal failure and life-threating complications. Case Report: In this case report, we present a patient who was admitted unconscious to the hospital. Ethylene glycol poisoning was immediately suspected, because the patient had previously been hospitalized with similar symptoms after intake of antifreeze coolant. A urine sample was sent for microscopy and showed multiple calcium oxalate monohydrate (COM) crystals, which supported the clinical suspicion of ethylene glycol poisoning. The patient was treated with continuous intravenous ethyl alcohol infusion and hemodialysis. Two days after admission, the patient was awake and in clinical recovery. Conclusions: Demonstration of COM crystals using microscopy of a urine sample adds valuable information supporting the clinical suspicion of ethylene glycol poisoning, and may serve as an easy, quick, and cheap method that can be performed in any emergency setting.

Dual energy CT: a possible new method to assess regression of rectal cancers after neoadjuvant treatment

The measurement of tumor regression after neoadjuvant oncological treatment has gained increasing interest because it has a prognostic value and because it may influence the method of treatment in rectal cancer. The assessment of tumor regression remains difficult and inaccurate with existing methods. Dual Energy Computed Tomography (DECT) enables qualitative tissue differentiation by simultaneous scanning with different levels of energy. We aimed to assess the feasibility of DECT in quantifying tumor response to neoadjuvant therapy in loco‐advanced rectal cancer.

The Diagnostic Yield of Colonoscopy Stratified by Indications

Introduction Danish centers reserve longer time for screening colonoscopies and allocate the most experienced endoscopists to these cases. The objective of this study is to determine the diagnostic yield in colonoscopies for different indications to improve planning of colonoscopy activity and allocation of the highly skilled endoscopists. Methods Nine hundred and ninety-nine randomly collected patients from a prospectively maintained database were grouped in defined referral indication groups. Five groups were compared in respect of the detection rate of adenomas and cancers. Results Two hundred and eighty-nine of 1098 colonoscopies in 999 patients showed significant neoplastic findings, resulting in 591 adenoma resections. Eighty-five percent were treated with a snare resection, and 15% with endoscopic mucosa resection (EMR). Positive findings in the indication groups were (1) symptoms, 25%; (2) positive screening, 17%; (3) previous resection of adenomas, 45%; (4) previous resection of colorectal cancer, 15%; and (5) surveillance of patients with high-risk family history of cancer, 35%. Conclusion The majority of adenomas found during colonoscopy can be treated with simple techniques. If individualized time slots are considered, the adenoma follow-up colonoscopies are likely to be the most time-consuming group with more than twice the number of adenomas detected as compared to other indications.