Valentin Ignatov

The Role of 3-D Endorectal Ultrasound in Rectal Cancer: Our Experience

In the last 20 years, endorectal ultrasound (ERUS) has been one of the main diagnostic methods for locoregional staging of rectal cancer. ERUS is accurate modality for evaluating local invasion of rectal carcinoma into the rectal wall layers (T category). Adding the three-dimensional modality (3-D) increases the capabilities of this diagnostic tool in rectal cancer patients. We review the literature and report our experience in preoperative 3-D ERUS in rectal cancer staging. In the group of 71 patients, the staging of preoperative 3-D endorectal ultrasonography was compared with the postoperative morphologic examination. Three-dimensional ERUS preoperative staging was confirmed with morphologic evaluation in 66 out of 71 cases (92.9%). The detection sensitivities of rectal cancer with 3-D ERUS were as follows: T1, 92.8%; T2, 93.1%; T3, 91.6%; and T4, 100.0%; with specificity values of T1, 98.2%; T2, 95.4%; T3, 97.8%; and T4, 98.5%. Three-dimensional ERUS correctly categorized patients with T1, 97.1%; T2, 94.3%; T3, 95.7%; and T4, 98.5%. The percentage of total overstaged cases was 2.75% and that of understaged cases was 6.87%. The metastatic status of the lymph nodes was determined with a sensitivity of 79.1% (19 of 24), specificity of 91.4% (43 of 47), and diagnostic accuracy of 87.3% (62 of 71). In our experience, 3-D ERUS has the potential to become the diagnostic modality of choice for the preoperative staging of rectal cancer.

Adjuvant Treatment in Colon Cancer

Worldwide, more than 1 million people develop colorectal cancer (CRC) annually. CRC is a major health problem in the Western world and the second most common cause of cancer mortality. To improve performance, the role of chemotherapy for CRC has increased dramatically over the last decade. The vast majority of CRC patients now receive chemotherapy with multiple agents that are currently approved for the treatment in the appropriate setting [1]. However, it is a complex process to select the optimal chemotherapy for each patient and practice evidence gap is still a problem. Some guidelines for the treatment of CRC have been developed to promote the standardization of CRC treatment. Postoperative, or “adjuvant,” systemic therapy has become standard for stage III colon cancer. Adjuvant therapy should also be strongly considered in stage II patients. It is generally recommended for any medically fit patient with stage II cancer with unfavorable factors. The hypothesis that the antitumor activity of the combination agent, including oxaliplatin, irinotecan, bevacizumab, cetuximab in metastatic cure rates, would result in increased adjuvant proved to be often wrong. Although new drug development takes years, targeted drug use can occur more quickly with advanced tests and will be a focus of future work. In addition, efforts will focus on identifying biomarkers that predict response to systemic therapy so that tailored therapy can be initiated. The future of oncology will come with the better understand‐ ing of the biology and genetics of the tumor and its host. This will help to develop tailored approach to the patients, including more specific systemic therapy, aimed at molecular targets of the malignant tumor, thus reducing the negative effects. At that time, the treatment of oncological diseases will experience a new era, comparable to the introduction of antibiotics.

Laparoscopy in the Management of Colon Cancer

The minimally invasive techniques in surgical practice have been well introduced and widely accepted for certain procedures, including surgery for colon cancer. The advantages of the laparoscopic approach in terms of early and late postoperative results and the oncological safety have been established by numerous reports, including randomized controlled trials. The application of laparoscopic colon surgery for cancer has been adopted in various institutions. This chapter reviews the available literature data regarding the use of minimally invasive surgery for colon cancer, including early and late surgical and oncological results and new trends. Retrospective and prospec‐ tive trials published in the last 20 years are reviewed to address the issues. Technolog‐ ical advantages such as intracorproreal anastomosis, single incision, and natural orifice surgery are commented in the chapter.

Endoscopic Submucosal Dissection for Early Colon Cancer

Endoscopic submucosal dissection (ESD) was first implemented in early gastric cancer allowing for en-bloc resection of the lesions. With the experience came the expertise to introduce ESD for early colon cancer (ECC). ESD demonstrates several advantages in comparison with the endoscopic mucosa resection. It allows accurate histological assessment of the depth of invasion, minimizes the risk of local recurrence and helps in the determination of additional therapy. Indications for ESD are placed only after adequate endoscopic morphological classification of the lesions excluding higher risk of nodal metastases. This chapter provides an overview of the application of ESD techniques in ESD for ECC and provides assessment on its technical aspects and complications. In order to decrease the rate of complications a standard protocol for the ESD should be adopted. The protocol includes recommendations for patient selection, bowel and patient preparation, appropriate equipment (knives, endoscopes, and power devices). The chapter will review the current ESD techniques and oncological results. ESD could have great impact on the treatment of early colon cancer. Its role is already proven in rectal localizations and despite the challenges it should be adopted for the colon. Safe strategy for ESD is the cornerstone in decreasing complications, which includes suitable resection of specialized ESD devices.

Simultaneous Surgery for Synchronous Colorectal Liver Metastases

Colon cancer is one of the leading malignant diseases in the Western world, leading to significant morbidity and has significant predilection for liver metastases. Synchronous metastases account for approximately 15–25% of the newly discovered liver lesions. The only curative treatment for colon cancer liver metastases (CLM) remains surgery. Several strategies have been developed for the treatment of synchronous CLM, including simultaneous resection, two-stage liver surgery, and liver-first approach. The timing of surgery is not universally determined. Even more reports support the simultaneous resection strategy with results showing similar morbidity, length of hospital stay, and perioperative mortality comparable to staged resection. In conclusion, SCLM patients can successfully be treated with simultaneous approach or stages, both having similar perioperative and long-term outcomes. With the advance of liver surgery techniques, minor and major liver surgeries can be performed safely with low morbidity and mortality as part of either a simultaneous or a staged operative strategy.

Diagnostic Modalities in Colorectal Cancer –Endoscopy, Ct and Pet Scanning, Magnetic Resonance Imaging (Mri), Endoluminal Ultrasound and Intraoperative Ultrasound

Colorectal cancer (CRC) is the third most diagnosed cancer in men, next to prostate and lung cancer. In women it is the second most diagnosed cancer, next to breast cancer. In a time of limited resources in health care, there has been considerable debate which imaging modality offers the best non-invasive examination of colorectal cancer, offering both detection and characterization. The use of multiple diagnostic modalities is both costly and time-consuming. Clinical evidence amassed over the last several decades indicates that routine colorectal cancer (CRC) screening, compared to no screening, detects CRC at an earlier stage, reduces the incidence of CRC or the progression early CRC through polypectomy, and reduces CRC mortality.