5-year Local Recurrence Rate Research Articles

Does oncological outcome differ between restorative and nonrestorative low anterior resection in patients with primary rectal cancer?

AimNonrestorative low anterior resection (n‐rLAR) (also known as low Hartmann’s) is performed for rectal cancer when a poor functional outcome is anticipated or there have been problems when constructing the anastomosis. Compared with restorative LAR (rLAR), little oncological outcome data are available for n‐rLAR. The aim of this study was to compare oncological outcomes between rLAR and n‐rLAR for primary rectal cancer.MethodThis was a nationwide cross‐sectional comparative study including all elective sphincter‐saving LAR procedures for nonmetastatic primary rectal cancer performed in 2011 in 71 Dutch hospitals. Oncological outcomes of patients undergoing rLAR and n‐rLAR were collected in 2015; the data were evaluated using Kaplan–Meier survival analysis and the results compared using log‐rank testing. Uni‐ and multivariable Cox regression analysis was used to evaluate the association between the type of LAR and oncological outcome measures.ResultsA total of 1197 patients were analysed, of whom 892 (75%) underwent rLAR and 305 (25%) underwent n‐rLAR. The 3‐year local recurrence (LR) rate was 3% after rLAR and 8% after n‐rLAR (P < 0.001). The 3‐year disease‐free survival and overall survival rates were 77% (rLAR) vs 62% (n‐rLAR) (P < 0.001) and 90% (rLAR) vs 75% (n‐rLAR) (P < 0.001), respectively. In multivariable Cox analysis, n‐rLAR was independently associated with a higher risk of LR (OR = 2.95) and worse overall survival (OR = 1.72).ConclusionThis nationwide study revealed that n‐rLAR for rectal cancer was associated with poorer oncological outcome than r‐LAR. This is probably a noncausal relationship, and might reflect technical difficulties during low pelvic dissection in a subset of those patients, with oncological implications.

Safety and efficacy of percutaneous radiofrequency ablation for hepatocellular carcinoma patients with haemophilia.

This study aimed to evaluate the safety and efficacy of RFA for HCC in haemophilia patients. From July 2008 to June 2019, 217 patients with HCC underwent 300 RFA sessions. Of these, 18 sessions were performed in ten haemophilia patients (H group) and 282 in 207 non-haemophilia patients (NH group). The patients' characteristics, incidence of haemorrhagic complications and rates of local tumour recurrence were compared between the groups. A majority of the haemophilia patients received clotting factor concentrate replacement therapy before and after RFA treatment, with the aim of reaching a plasma clotting factor level of higher than 60%-80%. Twelve haemorrhagic complications were observed in the NH group (4.2%; 12/282). Major bleeding requiring control procedures was observed in two patients and minor bleeding with careful observation was noted in ten patients. No bleeding complications were observed in the H group (0/18). There were no significant differences in the 5-year local tumour recurrence rates after RFA treatment between the groups (35.0% in the H group and 32.1% in the NH group). RFA could be an effective and a safe method for HCC treatment in patients with haemophilia.

A case-control study to identify molecular risk factors for local recurrence in young breast cancer patients

PurposeTo investigate risk factors for local recurrence (LR) after breast conserving therapy in young breast cancer patients randomized in the “Young Boost Trial”. Material & methodsIn the “Young Boost Trial” 2421 patients ≤50 years old were randomized between a 16 Gy and 26 Gy boost after breast conserving surgery and whole breast radiation (50 Gy). We performed a case-control study comparing patients who developed a LR (cases) and for each of them three control patients free of recurrence (controls). Clinicopathological factors, copy number- and gene expression profiles of primary tumors were compared between cases and controls, and between primary tumors and local recurrences. ResultsThe cumulative 5-year LR rate was 1.07% (95% CI 0.72-1.59%) and 10-year LR rate 2.56% (1.81–3.62%). Analysis of a subset of primary tumors and local recurrences showed similar histopathological characteristics (n = 15), copy number (n = 13) and gene expression profiles (n = 14). Basal subtype was strongly associated with LR in univariable and multivariable analysis. Gains of CCND1 were identified more frequently among controls, while more frequent gains of FGFR1 and IGF1R were observed among cases. Upregulation of genes involved in the p53-pathway was observed in recurring tumors compared to non-recurring tumors. We could not identify a genomic classifier for LR. ConclusionsAll investigated local recurrences were true genomic recurrences. Although differences in copy number variation and gene expression pathways were observed in recurring tumors compared to non-recurring tumors, no genomic classifier for LR could be identified.

ISR for T1-2 Low Rectal Cancer: A Japanese Approach.

The evolution over the past 20 years of anal preservation in rectal cancer surgery has been truly remarkable. Intersphincteric resection (ISR) reported by Schiessel in 1994 in Australia has been shown to enable anal preservation even for cancers quite close to the anus. In Japan, ISR via the detachment of the anal canal between the internal and external sphincters and excision of the internal sphincter first began to be practiced in the latter half of 1990. A multicenter Phase II trial of ISR in Japan suggested that 70% of the cases had relatively good function with less than 10 points of Wexner score but around 10% had severe incontinence that would not be improved for long term. The primary end point of the clinical study, 3-year local recurrence rate, was 13.2% across the overall cohort (T1, 0%; T2, 6.9%; and T3, 21.6%). When ISR is performed on T1/T2 rectal cancers, sufficient circumferential resection margin can be obtained even without preoperative chemoradiotherapy, and local recurrence rate was acceptably low. Based on these evidences, ISR is a currently important, standard treatment option among anal-preserving surgeries for T1/T2 low-lying rectal cancers. In Japan, a feasibility study (LapRC trial) of laparoscopic ISR on Stage 0 and Stage 1 low rectal cancer showed excellent outcomes. A prospective Phase II clinical trial targeting low rectal cancers within 5 cm from the anal verge (ultimate trial) is being performed and awaiting the results in near future.

Image guided thermal ablation in lung cancer treatment

Lung ablation has been introduced into lung cancer treatment for about two decades. Currently, 3 main choices of thermal energy for lung ablation are radiofrequency ablation (RFA), microwave ablation (MWA), and cryoablation. As a mostly palliative, occasionally curative intent local treatment, the feasibility and safety of lung ablation have been validated in small size lung cancer treatment, especially in lung tumor ≤3 cm. Improved techniques and experience in recent years help render outcomes much better than before for lung cancer patients who are medically inoperable with early stage primary lung cancer, and patients with oligometastasis or local recurrence. For stage IA non-small cell lung cancer (NSCLC) patients underwent RFA, 1- and 2-year overall survival rate were reported as 86.3% and 69.8%. And 1- and 2-year local recurrence rate were reported as 68.9% and 59.8%. Limitations, including heat sink, skin burn, and inconsistent heat conduction, are observed in the first applied ablation technique, RFA. MWA and cryoablation are developed to overcome these limitations and achieve the goal of less morbidity. Generally, imaged guided thermal ablation has a good safety profile, with pneumothorax as the most common morbidity. This article will mainly discuss the current features and application of these ablation techniques in lung cancer treatment.

Oncologic Safety of Sentinel Lymph Node Biopsy Alone After Neoadjuvant Chemotherapy for Breast Cancer

The oncologic safety of sentinel lymph node biopsy (SLNB) alone for clinically node-positive (cN1-2) patients who convert to pathologic node-negativity (ypN0) after neoadjuvant chemotherapy (NAC) is not well established. This study retrospectively identified 244 consecutive patients with a diagnosis of cT1-3cN0-2 breast cancer who underwent NAC followed by SLNB at the authors' institution between 2013 and 2018. The patients were categorized as clinically node-negative (cN0) or cN1-2 before the onset of NAC, and the Kaplan-Meier method was used to compare locoregional and distant recurrence rates after SLNB alone for ypN0 patients. Among 244 patients who underwent NAC followed by surgery with SLNB for axillary staging, 112 (45.9%) were cN0 at presentation, whereas 132 (54.5%) had biopsy-proven cN1-2 disease and converted to cN0 after treatment. Of the patients presenting with cN0 disease, 102 (91.1%) were ypN0 on SLNB pathology compared with 60 cN1/2 patients (45.5%; p < 0.001). Regional nodal irradiation was administered to 5% of the cN0/ypN0 patients compared with 70.7% of the cN1-2/ypN0 patients (p < 0.001). Overall, 211 patients were treated with SLNB alone and had a median follow-up period of 36months (interquartile range [IQR], 24-53months). For 101 cN0/ypN0 patients who underwent SLNB alone, the 5-year local and regional recurrence rates were respectively 5.7% (95% confidence interval [CI], 2.4-13.8) and 1% (95% CI 0.1-7.0). For 58 cN1-2/ypN0 patients who underwent SLNB alone, the 5-year local and regional recurrence rates were respectively 4.1% (95% CI 1.0-15.5) and 0%, with no axillary recurrences noted. For ypN0 patients, SLNB alone after NAC is associated with low and acceptable short-term axillary recurrence rates. Additional follow-up data from prospective clinical trials are needed to confirm long-term oncologic safety and define optimal local therapy recommendations.

Intraoperative Radiotherapy Without External Beam Radiotherapy in the Management of Primary Soft Tissue Sarcomas of the Extremities

Intraoperative radiation therapy (IORT) is frequently used in conjunction with conventional external-beam radiation therapy (EBRT) to treat soft tissue sarcomas (STS) of the extremities as part of a limb sparing approach. We sought to investigate the efficacy of limb preservation surgery and IORT alone in the management of primary extremity STS. This is a single institutional retrospective study of patients diagnosed with primary STS of the extremity who received surgery and IORT without neoadjuvant or adjuvant EBRT between January 2008 and April 2018. Survival analyses were performed using the Kaplan-Meier method with log-rank testing for significance. Adverse event data were assessed per CTCAE v5 guidelines. Thirty-two patients were diagnosed with primary extremity STS and underwent limb sparing surgery and IORT without neoadjuvant or adjuvant radiotherapy. Four (12.5%) patients received neoadjuvant chemotherapy and two (6.3%) received chemotherapy in the postoperative setting. Twenty-five patients (78%) had Stage I-II disease, 63% of tumors were intermediate or high grade, and 91% had negative resection margins. With a median follow up of 5.3 years, the 5-year local recurrence rate was 9.1%, and the 5-year overall survival rate was 97%. Overall, treatment was well tolerated: the most common adverse effects included postoperative infections (12.5%), grade 1 neuropathies (9.4%), and delayed wound healing (9.4%). With respect to Grade 3-5 toxicities, one Grade 3 (infection) and one Grade 5 toxicity (in a 95-year-old patient with unfavorable preoperative performance status) were observed. Limb preservation surgery and IORT alone may provide adequate local control in the management of select primary extremity STS, with acceptable toxicity.

Long Term Outcomes And Patterns Of Failure After Single Fraction Preoperative Radiosurgery For Brain Metastases

Postoperative (post-op) radiosurgery (SRS) after resection of brain metastases (BM) is associated with up to 30% risk of leptomeningeal disease (LMD). Approximately 60-70% of LMD is nodular pattern in this setting, which is thought to be associated with surgical tumor spillage. We have previously demonstrated that preoperative (pre-op) SRS is a feasible alternative to post-op SRS. Herein we report patterns of failure and long terms outcomes for patients (pts) treated with pre-op SRS. The records for pts with BM treated with pre-op SRS and planned surgical resection were reviewed. Pts with classically radiosensitive tumors, prior or planned adjuvant whole brain radiotherapy (WBRT), or no cranial imaging ≥ 1 month after surgery were excluded. Pre-op SRS dose was based on lesion size and was reduced approximately 10-20% from standard. No gross tumor volume (GTV) margin expansion was used. Surgery generally followed within 48 hours. Overall survival (OS) was estimated using the Kaplan-Meier method. Intracranial event rates were estimated using cumulative incidence with competing risk of death. Radiographic pattern of LMD was classified as classical “sugarcoating” (cLMD) vs. nodular (nLMD). The study cohort consisted of 141 pts with 150 lesions treated with single fraction pre-op SRS followed by planned surgery between 2005 – 2018. Most pts had a single BM (67%), underwent gross total resection (GTR, 96%), and had non-small cell lung cancer (41%). Median interval between pre-op SRS and surgery was 2 days, median SRS dose was 15 Gy, and median GTV volume was 8.4 cc (approximately equivalent to 2.5 cm diameter lesion). The 2-year cavity local recurrence (LR) rate was 23% overall and 20% in pts status post GTR. Five of 6 pts status post subtotal resection experienced LR. Multivariate analysis demonstrated GTR and renal cell histology as significantly associated with reduced risk of LR. SRS dose, lesion volume, and time between pre-op SRS and surgery were not significant. The 2-year LMD rate was 5%. Two of the 9 patients with LMD (22%) had nLMD while 78% had cLMD. The 2-year radiation necrosis (RN), symptomatic RN, and non-LMD distant brain failure rate was 7%, 4%, and 58%, respectively. Median OS was 19 months. Thirty-seven pts with 40 lesions had long term (≥2 years of cranial imaging) follow-up. In this subset, the 5-year cavity LR, symptomatic RN, and LMD rate was 25%, 8%, and 12%, respectively. Single fraction pre-op SRS is an effective treatment for surgically resected BM with low rates of cavity LR, RN, and LMD. LMD after pre-op SRS seems to be distinct from post-op SRS with a lower overall rate and lower proportion of nLMD pattern, which supports pre-op SRS sterilization of surgical tumor spillage. Outcomes in pts with long term imaging follow-up are consistent with the overall cohort. These data support further studies of pre-op SRS, including a randomized trial of pre-op vs. post-op SRS.

Effect of Fluorescence Visualization–Guided Surgery on Local Recurrence of Oral Squamous Cell Carcinoma

High local recurrence rates with aggressive disease remain the main concern in oral cancer survival. Use of a translational device using fluorescence visualization (FV) approved by the US Food and Drug Administration and Health Canada, has shown a marked reduction in the 3-year local recurrence rate of high-grade oral lesions in a single-center observational study. To determine whether FV- guided surgery can improve local control rates in the treatment of in situ or T1 to T2 category oral squamous cell carcinoma (OSCC). A multicenter randomized clinical trial was conducted in a surgical setting. A total of 457 patients were enrolled between January 18, 2010, and April 30, 2015. Data analysis of the intention-to-treat population was performed from April 3, 2019, to March 20, 2020. Patients with histologically confirmed high-grade dysplasia/carcinoma in situ or T1 to T2 category OSCC were randomized to receive traditional peroral surgery or FV-guided surgery. Fluorescence visualization during surgery. The primary outcome was local recurrence of OSCC. Secondary outcomes were failure of the first-pass margin, defined as a histologically confirmed positive margin for severe dysplasia or greater histologic change of the main specimen (ie, not the margins taken from the resection bed), regional or distant metastasis, and death due to disease. Of the 457 patients enrolled in the study, 443 patients (264 [59.6%] men; mean [SD] age, 61.5 [13.3] years) completed the randomized treatment: 227 FV-guided and 216 non-FV guided surgery. The median follow-up was 52 (range, 0.29-90.8) months. In total, 45 patients (10.2%) experienced local recurrence. The 3-year local recurrence rate was 9.4% in the FV-guided group and 7.2% in the non-FV group (difference, 2.2%; 95% CI, -3.2% to 7.4%). Other similarities between the FV vs non-FV groups included failure of first-pass margin (68/227 [30.0%]) vs 65/216 [30.1%]), regional failure (39/227 [17.2%] vs 37/216 [17.1%]), disease-specific survival (23/227 [10.1%] vs 19/26 [8.8%]), and overall survival (41/227 [18.1%] vs 38/216 [17.6%]) were also similar between groups. No adverse events were judged to be related to the intervention. In this randomized clinical trial, FV-guided surgery did not improve local control rates in the treatment of patients with in situ or T1 to T2 category oral cancer. Under a controlled environment, FV-guided surgery did not have an evident effect in reduction of local recurrence for localized OSCC. This result suggests that attention be directed to strategies other than improving definitions of nonapparent disease at clinical margins to identify the sources of local recurrence. ClinicalTrial.gov Identifier: NCT01039298.

Results of intraoperative radiotherapy given as a boost after breast conserving-surgery.

Whole breast irradiation after breast-conserving surgery (BCS) with an external beam boost of 10-16 Gy is currently the standard treatment in breast cancer. Various modalities have been used for tumor bed boost irradiation. This study aimed to evaluate the local recurrence rate, overall survival rate (OSR), toxicity and cosmetic outcome of intraoperative radiotherapy (IORT) as a boost followed by whole breast irradiation in patients who received BCS. This is a retrospective study. Between December 2009 and March 2017, 81 patients who underwent BCS with IORT as a boost were enrolled in this study. For IORT, a single dose of 20 Gy was delivered using a 30-50 kV photon beam, intraoperatively. All patients received whole breast radiation therapy (WBRT) of 42.5-50 Gy over 4-5 weeks. The primary endpoint was a 3-year local recurrence rate. Secondary endpoints included the OSR, toxicity and cosmetic outcome at 6 months after radiation treatment. At a median follow-up of 43 months, ipsilateral local recurrence was observed in one of the 81 patients (1.2%) which occurred in the same quadrant of the breast index. The 3-year OSR was 89.8%. Treatment was well-tolerated with no grade 3-4 acute and late toxicity, and 87% of patients were recorded as excellent-good cosmesis. The use of BCS with IORT as a boost resulted in a low local recurrence rate and excellent cosmetic outcome in early breast cancer. Thus, IORT as a boost could be considered as an alternative to an external beam boost. Prospective studies are needed to confirm this data.

Oncological outcomes of lateral lymph node dissection (LLND) for locally advanced rectal cancer: is LLND alone sufficient?

Lateral lymph node dissection (LLND) has been considered as the standard treatment strategy for locally advanced lower rectal cancer in Japan. Controversy remains around whether all patients require LLND. This study aims to examine the long-term outcomes of patients in which LLND was performed and clarify the value of LLND. Consecutive 458 patients with lower rectal cancer who underwent total mesorectal excision (TME) plus LLND from 1992 to 2012 were included. The long-term outcomes and risk factors for recurrent in patients performed TME + LLND were examined. We assessed the impact of LLND on survival using an estimated therapeutic index. The incidence of LLNM was 15.5%. The 5-year RFS and OS rates of patients with LLNM were 40.9% and 47.7%, while patients without LLNM had a good prognosis. The 5-year local recurrence (LR) rate was 9.2%, and independent risk factors for LR were T4 and LLNM. The LR rate of patients with LLNM was high (22.8%). The LLNM rate of the groups with 0, 1, 2, 3, or 4 risk factors (male, tumor location < 4 cm from anal verge, T4, and MLNM) was 3.8%, 9.2%, 18.1%, and 50.0%. The 5-year OS of the groups was 96.2%, 86.1%, 69.7%, and 48.5%. Although patients with locally advanced lower rectal cancer who received LLND had a good prognosis, LLND alone was insufficient to control local recurrence in patients with metastatic lateral nodes.

Optimal selection of endoscopic resection in patients with esophageal squamous cell carcinoma: endoscopic mucosal resection versus endoscopic submucosal dissection according to lesion size.

En bloc resection is essential for accurate pathological evaluation in patients with superficial esophageal squamous cell carcinoma (SESCC). This retrospective study aimed to clarify optimal treatment selection of endoscopic resection according to lesion size. A total of 760 patients underwent endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) between January 2011 and December 2015. Among them, this retrospective study included 196 solitary index SESCC lesions ≤20mm, with the deepest invasion to the mucosa or superficial submucosa endoscopically. The lesions were classified according to size measured via endoscopy as follows; group A: lesions ≤10mm, group B: lesions ≥11mm but ≤15mm, and group C: lesions ≥16mm but ≤20mm. The short- and long-term outcomes were investigated for EMR and ESD subgroups. In patients undergoing EMR and ESD, en bloc resection rates for group A and B were not different (98.8 vs. 100%, 93.3 vs. 100%, respectively). However, the en bloc resection rate was significantly lower in EMR than that in ESD for group C (64.3 vs. 100%, P< 0.001). Furthermore, the use of adjunctive ablative therapy rate was significantly higher in EMR than that in ESD in group C (35.7 vs. 0%, P< 0.001). The 5-year cumulative local recurrence rate of group C was significantly higher than that of group A + B after EMR (P< 0.01). EMR was an adequate treatment for SESCC lesions ≤15mm. On the other hand, ESD could be necessary to achieve en bloc resection for lesions ≥16mm to avoid local recurrence.

Conjunctival melanoma treatment outcomes in 288 patients: a multicentre international data-sharing study

BackgroundTo relate conjunctival melanoma characteristics to local control.MethodsRetrospective, registry-based interventional study with data gathered from 10 ophthalmic oncology centres from 9 countries on 4 continents. Conjunctival melanoma patients diagnosed between...

Locoregional recurrence patterns in women with breast cancer who have not undergone post-mastectomy radiotherapy

BackgroundTo analyze the patterns of locoregional recurrence in breast cancer patients after mastectomy.MethodsThe retrospective study included 7073 women with breast cancer without post-mastectomy radiotherapy: 4604 (65.1%) had pT1–2 N0 disease (low risk); 2042 (28.9%), pT1–2 N1 (intermediate risk); and 427 (6.0%), pT3–4 and/or pN2–3, or pT1–2 N1 after neoadjuvant chemotherapy (high risk). The distribution of cumulative locoregional recurrence was analyzed. The local recurrence and regional recurrence rates were estimated by the Kaplan-Meier method, and differences were compared with the log-rank test. Multivariate analysis was performed using Cox logistic regression analysis.ResultsIn the median follow-up of 63.0 months, 469 patients had locoregional recurrence: chest wall recurrence in 238 (50.7%) cases, supraclavicular/infraclavicular nodes in 236 (50.3%) cases, axilla in 92 (19.6%), and internal mammary nodes in 50 (10.7%) cases. The 5-year local recurrence and regional recurrence rates were 2.5 and 4.4%, respectively. Subgroup analysis of the three risk groups and five molecular subtypes (luminal A, luminal B-Her2 negative, luminal B-Her2 positive, Her2-enriched, and triple negative) also showed that the chest wall and supraclavicular/infraclavicular nodes were the most common recurrence sites. Age, tumor location, T stage, N stage, and hormone receptor status were independent prognostic factors for both local recurrence and regional recurrence (p < 0.05).ConclusionsThe chest wall and supraclavicular/infraclavicular nodes are common sites of locoregional recurrence in breast cancer, irrespective of disease stage or molecular subtype, and the prognostic factors for local recurrence and regional recurrence are similar. Therefore, chest wall and supraclavicular/infraclavicular nodes irradiation should always be considered in post-mastectomy radiotherapy.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Rectal Cancer.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Rectal Cancer.

A Multi-Institutional Retrospective Study of Repeated Stereotactic Body Radiation Therapy for Intrahepatic Recurrent Hepatocellular Carcinoma

Through this multi-institutional study, we aimed to retrospectively evaluate the safety and efficacy of repeated stereotactic body radiation therapy (SBRT) for intrahepatic recurrent hepatocellular carcinoma (HCC). Between 2005 and 2017, 709 patients with 835 HCCs underwent SBRT; those treated with repeated SBRT were eligible. The median prescribed dose was 40 Gy in 5 fractions. Eighty-one patients with 189 tumors underwent repeated SBRT (≥ 2 courses [median 2 times; range, 2-5 times]). The median follow-up periods from the first to the second SBRT were 41.5 (range, 12-99) and 20 (range, 1-81) months, respectively. The median interval between the first and second SBRT was 18 (range, 3-74) months. The 5-year local recurrence rate was 6.3% (95% confidence interval [CI], 2.3%-13.4%). The 5-year overall survival (OS) and liver-related death rates from the first SBRT were 60.4% (95% CI, 47.0%-73.8%) and 32.9% (95% CI, 20.3%-46.0%), respectively, and the 3-year rates from the second SBRT were 61.0% (95% CI, 49.9%-75.2%) and 34.5% (95% CI, 20.6%-48.9%), respectively. The frequency of grade 3 toxicity was not significantly different between the first and second SBRT (first: 11% [95% CI, 5.2%-20%]; second: 15% [95% CI, 7.9%-24%]; P = .48). Among 39 patients with no intrahepatic recurrence for 1 year after the first and second SBRT, the deterioration in liver function after the first and second SBRT was not significantly different; the albumin-bilirubin score increased 1 year after the first versus second SBRT (first, 0.143 ± 0.23; second, 0.195 ± 0.38; P = .48). Multivariate analysis revealed that the intrahepatic recurrence-free interval was the only significant factor for OS. Repeated SBRT for intrahepatic recurrent HCC resulted in high local control with safety and a satisfactory OS comparable with that of other curative local treatments for patients with well-preserved liver function.

Comparative short- and long-term outcomes of three techniques of natural orifice specimen extraction surgery for rectal cancer

BackgroundThe aim of this study was to evaluate the safety of natural orifice specimen extraction surgery (NOSES) and to compare the short- and long-term outcomes of three techniques of NOSES for rectal cancer (RC). Materials and methodsA consecutive series of RC patients in stage I-III who underwent laparoscopic NOSES were enrolled. Three main techniques of NOSES included specimen eversion and extra-abdominal resection (EVER), specimen extraction and extra-abdominal resection (EXER) and intra-abdominal resection and specimen extraction (IREX). The postoperative complications, 5-year disease free survival (DFS), 5-year local recurrence rate (LRR) and 5-year distant metastasis rate (DMR) were compared in three techniques. Results268 RC patients met inclusion criteria, including 83 patients treated with EVER, 75 patients treated with EXER and 110 patients treated with IREX. Tumor location was the most critical factor associated with technique selection, with P < 0.001. Postoperative complication rate was 12.3% for all patients, and it was 18.1% for EVER, 13.3% for EXER and 7.3% for IREX. There were no significant differences for anastomotic leakage, anastomotic bleeding and intraabdominal abscess among three technique groups, with P > 0.05. For long-term outcomes, the 5-year DFS, 5-year LRR and 5-year DMR were 85.03%, 4.22% and 11.00% for all patients. Patients in advanced tumor stage have worse long-term survival compared with patients in early stage, but no significant survival differences were observed among three technique groups. ConclusionThree techniques of NOSES for RC had acceptable short- and long-term outcomes, and tumor location was a determinant of technique selection.

Effect of understaging on local recurrence of rectal cancer.

Background and ObjectivesMagnetic resonance imaging of the pelvis has a limited accuracy to detect positive lymph nodes but does dictate neoadjuvant treatment in rectal cancer. This study aimed to investigate preoperative lymph node understaging and its effects on postoperative local recurrence rate.MethodsPatients were selected from a retrospective cross‐sectional snapshot study. Patients with emergency surgery, cM1 disease, or unknown cN‐ or (y)pN category were excluded. Clinical and pathologic N‐categories were compared and the impact on local recurrence was determined by multivariable analysis.ResultsOut of 1548 included patients, 233 had preoperatively underestimated lymph node staging based on (y)pN category. Out of the 695 patients staged cN0, 168 (24%) had positive lymph nodes at pathology, and out of the 594 patients staged cN1, 65 (11%) were (y)pN2. Overall 3‐year local recurrence rate was 5%. Clinical N‐category was not associated with local recurrence when corrected for pT‐category, neoadjuvant therapy, and resection margin, neither in patients with (y)pN1 (hazard ratio [HR]: 1.67 (95% confidence interval [CI]: 0.68‐4.12) P = .263) nor (y)pN2‐category (HR: 1.91 95% CI: [0.75‐4.84], P = .175).ConclusionPreoperative understaging of nodal status in rectal cancer is not uncommon. No significant effect on local recurrence or overall survival rates were found in the present study.

The ACPGBI recommends pause for reflection on transanal total mesorectal excision.

The ACPGBI recommends pause for reflection on transanal total mesorectal excision.

The effect of preoperative radiotherapy on local control and prognosis in high-grade non-metastatic intramedullary osteosarcoma of the extremities.

This study aimed to analyse the effect of preoperative radiotherapy on survival, recurrence and necrosis rates in osteosarcoma patients treated with neoadjuvant chemotherapy and limb-salvage surgery. Osteosarcoma patients who referred to our clinic from 1998 to 2015 were investigated retrospectively. 141 patients with non-metastatic osteosarcoma of the limb who received neoadjuvant chemotherapy and underwent limb-sparing surgery with or without preoperative radiotherapy were included in the study. 73 patients had neoadjuvant chemotherapy only (CT group), while 68 patients had additional preoperative radiotherapy (CT + RT group). 5-year survival, disease-free survival, limb survival, local recurrence, metastasis, complication and necrosis rates were compared between the two groups. Overall 5-year survival, 5-year disease-free survival, 5-year limb survival rates were 68.5, 64.3, 65.7 for CT group and 72.1, 67.6, 64.7 for CT + RT group, respectively. Preoperative radiotherapy gave similar survival and disease-free survival rates. Limb survival, recurrence and metastasis rates were similar between the groups. The necrosis rate of the lesions was significantly higher in the CT + RT group compared to the CT group. Preoperative radiotherapy can provide a higher necrosis rate and may allow the resection of unresectable lesions in the treatment of osteosarcoma. CT + RT provided similar 5-year survival despite the larger tumour size compared to CT group. Due to the higher wound complication rate (8.2% in CT, 23.5% in CT + RT group, p = 0.01), CT + RT should be restricted to the lesions with large size or close proximity to neurovascular structures. Level III; Therapeutic, Retrospective comparative study.