T.A. Vermeer

Impact of the interval between short-course radiotherapy and surgery on outcomes of rectal cancer patients ☆

AIMS Pre-operative radiotherapy has proven to reduce local recurrences after curative surgery for rectal cancer. Radiotherapy is generally well tolerated, although postoperative morbidity and mortality was increased in some patients. Current study was undertaken to analyse whether the interval between preoperative radiotherapy and surgery influences post-operative mortality and recurrence for two cohorts. METHODS All Dutch patients included in the total mesorectal excision (TME)-trial receiving radiotherapy for resectable rectal cancer were included in this study (n=642). The verification set consisted of all patients receiving short-course radiotherapy for resectable rectal cancer in two radiotherapy clinics in The Netherlands (n=600). Univariate and multivariable survival analyses for overall survival, disease-free survival, local recurrence-free survival and non-cancer related survival were calculated. RESULTS Patients aged 75 years and older treated during the TME-trial showed a worse overall and non-cancer-related survival when surgically treated 4-7 days after the last fraction of radiotherapy. No differences in survival between the interval groups were found in the verification set. CONCLUSION Present study found that elderly patients aged 75 years and older operated 4-7 days after the last fraction of radiotherapy had a higher chance of dying due to non-cancer-related causes during the TME-trial as compared to patients with an interval of 0-3 days. In the verification set similar differences could not be confirmed, which could be due to awareness of the clinicians who avoided delayed surgery after radiotherapy since the results have been presented during congresses. A longer than recommended interval between radiotherapy and surgery should be avoided. Besides, the verification set suggests that radiotherapy duration of 7 days is acceptable.

Anastomotic leakage and presacral abscess formation after locally advanced rectal cancer surgery: Incidence, risk factors and treatment

PURPOSE OF THE STUDY Anastomotic leakage (AL) and presacral abscess (PA) after rectal cancer surgery are a major concern for the colorectal surgeon. In this study, incidence, prognosis and treatment was assessed. METHODS Patients operated on in our institute, between 1994 and 2011, for locally advanced rectal cancer (LARC, T3+/T4M0) were included. Morbidity was scored using the Clavien-Dindo classification. Prognostic factors were analysed using binary logistic regression. RESULTS 517 patients were included after a low anterior resection (n = 219) or abdominoperineal resection (n = 232). AL occurred in 25 patients (11.4%); 50 patients (9.7%) developed a PA. We identified intraoperative blood loss ≥4500 cc (p = 0.038) and the era of surgery; patients operated on before the year 2006 (p = 0.042); as risk factors for AL. The time between last day of neo-adjuvant treatment and surgery, <8 weeks is significantly associated with the development of PA (p = 0.010). CONCLUSIONS In our population of LARC patients we found an incidence of 9.7% PA and 11.4% AL, with a 12% mortality rate for AL, which is comparable to surgery in general colorectal cancer. Increased intraoperative blood loss and surgery prior to 2006 are associated with AL. Increased intraoperative blood loss and a timing interval <8 weeks increases the risk of PA formation.

Abdominosacral resection: Long-term outcome in 86 patients with locally advanced or locally recurrent rectal cancer

AIMS The purpose of this study is to evaluate the outcome of abdominosacral resections (ASR) in patients with locally advanced or recurrent rectal cancer. METHODS From 1994 until 2012 patients with locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LRRC) underwent a curative ASR and were enrolled in a database. The postoperative complication rates, predictive factors on oncological outcome and survival rates were registered. RESULTS Seventy-two patients with LRRC (mean age 63; 44 male, 28 female) and 14 patients with LARC (mean age 65; 6 male, 8 female) underwent ASR. R0 resection was achieved in 37 patients with LRRC and 11 patients with LARC. Twenty-seven patients underwent an R1 resection (3 in the LARC group). Eight patients had an R2 resection, compared to no patients in the LARC group. In respectively 26 and 1 patients of the LRRC and LARC groups a grade 3 or 4 complication occurred and the 30-days mortality rate was respectively 3% and 7%. The 5-years overall survival was 28% and 24% respectively. CONCLUSION En bloc radical resection remains the primary goal in the treatment of dorsally located (recurrent) rectal cancer. After thorough patient selection, ASR is a safe procedure to perform, shows acceptable morbidity rates and leads to a good oncological outcome.

Clinicopathological characteristics predict lymph node metastases in ypT0-2 rectal cancer after chemoradiotherapy

Changes in rectal cancer treatment include increasing emphasis on organ preservation. Local excision after chemoradiotherapy (CRT) for rectal cancer with excellent clinical response reduces morbidity and mortality compared to total mesorectal excision, although residual lymph node metastases (LNM) may cause local recurrence. Our aim is to identify clinicopathological factors predicting the presence of residual LNM in rectal cancer patients with ypT0‐2 tumours after neoadjuvant CRT. These risk factors may help to select patients who can be spared radical surgery without compromising oncological outcomes.

Effect of preoperative treatment strategies on the outcome of patients with clinical T3, non-metastasized rectal cancer: A comparison between Dutch and Canadian expert centers

AIM High-dose-rate brachytherapy (HDRBT) appears to be associated with less treatment-related toxicity compared with external beam radiotherapy in patients with rectal cancer. The present study compared the effect of preoperative treatment strategies on overall survival, cancer-specific deaths, and local recurrences between a Dutch and Canadian expert center with different preoperative treatment strategies. PATIENTS AND METHODS We included 145 Dutch and 141 Canadian patients with cT3, non-metastasized rectal cancer. All patients from Canada were preoperatively treated with HDRBT. The preoperative treatment strategy for Dutch patients consisted of either no preoperative treatment, short-course radiotherapy, or chemoradiotherapy. Cox proportional hazards models were used to estimate hazard ratios (HR) with 95% confidence intervals (CIs) comparing overall survival. We adjusted for age, cN stage, (y)pT stage, comorbidity, and type of surgery. Primary endpoint was overall survival. Secondary endpoints were cancer-specific deaths and local recurrences. RESULTS Five-year overall survival was 70.9% (95% CI 62.6%-77.7%) in Dutch patients compared with 86.9% (80.1%-91.6%) in Canadian patients, resulting in an adjusted HR of 0.70 (95% CI 0.39-1.26; p = 0.233). Of 145 Dutch patients, 6.9% (95% CI 2.8%-11.0%) had a local recurrence and 17.9% (95% CI 11.7%-24.2%) patients died of rectal cancer, compared with 4.3% (95% CI 0.9%-7.5%) local recurrences and 10.6% (95% CI 5.5%-15.7%) rectal cancer deaths out of 141 Canadian patients. CONCLUSION We did not detect statistically significant differences in overall survival between a Dutch and Canadian expert center with different treatment strategies. This finding needs to be further investigated in a randomized controlled trial.

Psoas hitch ureteral reimplantation after surgery for locally advanced and locally recurrent colorectal cancer: Complications and oncological outcome

INTRODUCTION The most important prognostic factor for oncological outcome of rectal cancer is radical surgical resection. In patients with locally advanced T4 rectal cancer (LARC) or locally recurrent rectal cancer (LRRC) (partial) resection of the urinary tract is frequently required to achieve radical resection. The psoas bladder hitch (PBH) technique is the first choice for reconstruction of the ureter after partial resection and this bladder-preserving technique should not influence the oncological outcome. METHODS Demographic and clinical data were collected prospectively for all patients operated on for LARC or LRRC between 1996 and 2014 who also underwent a psoas hitch ureter reconstruction. Urological complications and oncological outcome were assessed. RESULTS The sample comprised 70 patients, 30 with LARC and 40 with LRRC. The mean age was 62 years (range: 39-86). Postoperative complications occurred in 38.6% of patients, the most frequent were urinary leakage (22.9%), ureteral stricture with hydronephrosis (8.6%) and urosepsis (4.3%). Surgical re-intervention was required in 4 cases (5.7%), resulting in permanent loss of bladder function and construction of a ureter-ileo-cutaneostomy in 3 cases (4.3%). Oncological outcome was not influenced by postoperative complications. CONCLUSION The rate of complications associated with the PBH procedure was higher in our sample than in previous samples with benign conditions, but most complications were temporary and did not require surgical intervention. We conclude that the bladder-sparing PBH technique of ureter reconstruction is feasible in locally advanced and recurrent rectal cancer with invasion of the urinary tract after pelvic radiotherapy.

Stoma placement in obstructive rectal cancer prior to neo-adjuvant treatment and definitive surgery: A practical guideline

INTRODUCTION Mechanical bowel obstruction in rectal cancer is a common problem, requiring stoma placement to decompress the colon and permit neo-adjuvant treatment. The majority of patients operated on in our hospital are referred; after stoma placement at the referring centre without overseeing final type of surgery. Stoma malpositioning and its effects on rectal cancer care are described. METHODS All patients who underwent surgery for locally advanced or locally recurrent rectal cancer between 2000 and 2013 in our tertiary referral centre were reviewed and included if they received a stoma before curative surgery. Patients with recurrent rectal cancer were only included if the stomas from the primary surgery had been restored. The main outcome measures are stoma malpositioning, postoperative and stoma-related complications. RESULTS A total of 726 patients were included; of these, 156 patients (21%) had a stoma before curative surgery. In the majority of patients, acute or pending large bowel obstruction was the main indication for emergent stoma creation; some of the patients had tumour-related fistulae. In 53 patients (34%), the stoma required revision during definitive surgery. No significant differences were found regarding postoperative complications. CONCLUSION One-third of the previously placed emergency stomas were considered to be located inappropriately and required revision. We were able to avoid increased complication rates in patients with a malpositioned stoma, however unnecessary surgery for an inappropriately placed stoma should be avoided to decrease patient inconvenience and risks. An algorithm is proposed for the placement of a suitable stoma.

T4 Rectal Cancer: Do We Always Need an Exenteration?

The management of rectal cancer has changed dramatically over the last few decades. Due to improvements in the multimodality treatment and the introduction of neoadjuvant chemoradiation, previously irresectable tumours can nowadays be cured by extensive multivisceral resections. These highly complex operations are associated with significant morbidity and mortality. Due to optimization of chemoradiotherapy, the introduction of IORT, increasing knowledge of tumour pathology and patterns of recurrence the need for extensive surgery diminishes. The question arises which patients with T4 rectal cancer really need extensive surgery and who can safely be considered for an organ preserving approach.

Surgery for Rectal Cancer—What is on the Horizon?

The management of rectal cancer has improved considerably in recent decades. Surgery remains the cornerstone of the treatment. However, the role of preoperative imaging has made it possible to optimize the treatment plan in rectal patients. Neoadjuvant treatment may be indicated in efforts to sterilize possible tumor deposits outside the surgical field, or may be used to downsize and downstage the tumor itself. The optimal sequence of treatment modalities can be determined by a multidisciplinary team, who not only use pretreatment imaging, but also review pathologic results after surgery. The pathologist plays a pivotal role in providing feedback about the success of surgery, i.e., the distance between the tumor and the circumferential resection margin, the quality of surgery, and the effect of neoadjuvant treatment. Registry and auditing of all treatment variables can further improve outcomes. In this century, rectal cancer treatment has become a team effort.