Nishit Shah

Complete Neoadjuvant Treatment for Rectal Cancer: The Brown University Oncology Group CONTRE Study.

Purpose: Following preoperative chemoradiation and surgery, many patients with stage II to III rectal cancer are unable to tolerate full-dose adjuvant chemotherapy. BrUOG R-224 was designed to assess the impact of COmplete Neoadjuvant Treatment for REctal cancer (CONTRE), primary chemotherapy followed by chemoradiation and surgery, on treatment delivery, toxicities, and pathologic response at surgery. Methods: Patients with clinical stage II to III (T3 to T4 and/or N1 to N2) rectal cancer received 8 cycles of modified FOLFOX6 followed by capecitabine 825 mg/m2 bid concurrent with 50.4 Gy intensity-modulated radiation therapy. Surgery was performed 6 to 10 weeks after chemoradiation. Results: Thirty-nine patients were enrolled between August 2010 and June 2013. Median age was 61 years (30 to 79 y); 7 patients (18%) were clinical stage II and 32 (82%) stage III. Thirty-six patients (92%) received all 8 cycles of mFOLFOX6, of whom 35 completed subsequent chemoradiation; thus 89% of patients received CONTRE as planned. No unexpected toxicities were reported. All patients had resolution of bleeding and improvement of obstructive symptoms, with no complications requiring surgical intervention. Pathologic complete response (ypT0N0) was demonstrated in 13 patients (33%; 95% CI, 18.24%-47.76%). Conclusions: CONTRE seems to be a well-tolerated alternative to the current standard treatment sequence. Evaluating its impact on long-term outcomes would require a large randomized trial, but using pathologic response as an endpoint, it could serve as a platform for assessing the addition of novel agents to preoperative treatment in stage II to III rectal cancer.

Colorectal Kaposi Sarcoma in an Immunosuppressed Ulcerative Colitis Patient

A 49-year-old man with a long history of left-sided ulcerative colitis (UC), treated primarily with mesalamine and intermittent steroid enemas, developed recurrent flares associated with worsening bloody diarrhea. This resulted in the need for repeated courses of steroids (between 15 and 30 mg of prednisone daily) and the initiation of azathioprine. Although biologic therapy was recommended, the patient had declined this option due to concerns of possible side-effects and also refused surgical intervention. On routine surveillance colonoscopy, after almost 2 years of steroid-dependency, he was noted to have two inflammatory mass-like lesions, one in the proximal sigmoid colon and one in the distal rectum, both of which were biopsied (see Fig. 1). The biopsy results revealed spindle cell tumors with prominent capillary and slit-like vascular spaces, which tested positive on immunohistochemistry for human herpesvirus-8 (HHV-8). On physical examination, the patient had no cutaneous manifestations of Kaposi sarcoma (KS). His abdominal exam was notable for a palpable mass on digital rectal exam, 4 cm from the anal verge. The patient reported no risks factors for AIDS, tested negative for HIV, and had a normal complete blood count with differential. At that point, the patient agreed to surgery but was keen to have a restorative option and avoid a permanent stoma. Accordingly, he underwent an initial laparoscopic subtotal colectomy with end ileostomy. Pathological examination revealed focally active left-sided colitis with aphthous mucosal ulceration, mild chronic changes consistent with ulcerative colitis, and a focus of KS in the sigmoid colon submucosa (see Fig. 2). Over the next 2 months, the patient was successfully weaned from steroids and immunosuppressive agents. Proctoscopic surveillance over the next 6 months showed full resolution of his distal rectal KS lesion. Subsequently, a completion proctectomywith an ileal pouch to anal anastomosis in a double-stapled fashion was performed with creation of a temporary loop ileostomy. There was no evidence of KS on the rectum specimen on pathology. The ileostomy was ultimately reversed 3 months later to restore intestinal continuity. At 2year follow-up, the patient reported good pouch function with a normal pouch endoscopy.

Colon and rectal surgery surgical site infection reduction bundle: To improve is to change

BACKGROUND Despite the introduction of the Surgical Care Improvement Project, surgical site infections remain a source of morbidity. The aim of this study was to determine the value of implementing a colorectal bundle on SSI rates. METHODS Between 2011 and 2016 a total of 1351 patients underwent colorectal operations. Patients were grouped into pre-implementation (Group A, January 1, 2011-December 31, 2012), implementation (Group B, January 1, 2013-December 31, 2014) and post-implementation (Group C, January 1, 2015-December 31, 2016). Primary endpoints were superficial SSI, deep SSI, wound separation and total SSI. RESULTS After the bundle was implemented, there was a significant reduction in superficial (6.6%-4%, p < 0.05), deep (3.7%-1.1%, p < 0.05), and total SSI rates (10.9%-4.7%, p < 0.05). Comparing Group A to Group C there was a decrease in total SSI (9.4%-4.7%, p < 0.05). CONCLUSION Implementation of the bundle resulted in a reduction in overall SSI rates particularly as compliance increased. This study offers evidence that small changes can lead to significant decreases in surgical site infections.