Circumferential Margin Research Articles

Influence of dosimetric and clinical criteria on the requirement of artificial nutrition during radiotherapy of head and neck cancer patients

Purpose/objective(s)Intensification of radiotherapy and chemotherapy for head-and-neck cancer (HNC) may lead to increased rates of long term dysphagia as a severe side effect. Mucositis and consequent swallowing problems require artificial nutrition in many HNC patients undergoing radiotherapy or chemoradiation. It is unknown, which predict factors for prophylactic PEG tube insertion appear useful. Materials/methodsFrom an institutional database, 101 patients (72 male, 29 female, mean age 59.5years) were identified who underwent radiotherapy or chemoradiation for HNC. Primary end point of the investigation was the need for artificial nutrition for more than 4days during radiotherapy. Dose volume parameters of defined normal tissue structures potentially of relevance for swallowing ability as well as clinical factors were used to develop a predictive model using a binary multiple logistic regression model. ResultsWhereas several dosimetric and clinical factors were significant predictors for the need of artificial nutrition on univariate analysis, on multivariate analysis only three factors remained independently significant: mean dose to the oropharynx+1cm circumferential margin, ECOG performance state (0–1 vs. 2–4), and the use of chemotherapy (yes vs. no). ConclusionsUsing a 3 parameter model we could distinguish HNC-patients with different risks for the need of artificial nutrition during radiotherapy. After independent validation, the model could be helpful to decision on prophylactic PEG tube insertion.

Gigapixel surface imaging of radical prostatectomy specimens for comprehensive detection of cancer-positive surgical margins using structured illumination microscopy.

Achieving cancer-free surgical margins in oncologic surgery is critical to reduce the need for additional adjuvant treatments and minimize tumor recurrence; however, there is a delicate balance between completeness of tumor removal and preservation of adjacent tissues critical for normal post-operative function. We sought to establish the feasibility of video-rate structured illumination microscopy (VR-SIM) of the intact removed tumor surface as a practical and non-destructive alternative to intra-operative frozen section pathology, using prostate cancer as an initial target. We present the first images of the intact human prostate surface obtained with pathologically-relevant contrast and subcellular detail, obtained in 24 radical prostatectomy specimens immediately after excision. We demonstrate that it is feasible to routinely image the full prostate circumference, generating gigapixel panorama images of the surface that are readily interpreted by pathologists. VR-SIM confirmed detection of positive surgical margins in 3 out of 4 prostates with pathology-confirmed adenocarcinoma at the circumferential surgical margin, and furthermore detected extensive residual cancer at the circumferential margin in a case post-operatively classified by histopathology as having negative surgical margins. Our results suggest that the increased surface coverage of VR-SIM could also provide added value for detection and characterization of positive surgical margins over traditional histopathology.

Laparoscopy combined with transperineal extralevator abdominoperineal excision for locally advanced low rectal cancer

To evaluate the laparoscopy combined with transperineal extralevator abdominoperineal excision (TP-ELAPE) for locally advanced low rectal caner. Clinical data of 12 patients with locally advanced low rectal cancer undergoing laparoscopy combined with TP-ELAPE in our department from May 2013 to March 2015 were retrospectively analyzed. There were 8 male and 4 female patients with median aged of 63 (46 to 72) years. The median distance from tumor lower margin to anal verge was 3.5(2.0 to 4.0) cm. A self-made transanal suit for minimally invasive operation was used to make a sealed lacuna outside the sphincter, thus laparoscope can be applied to perform transperineal operation. All the patients underwent operations successfully without conversion to open abdominal operation. The median operating time was 206 (180 to 280) minutes with perineal operating time 95(80 to 120) minutes. The median intraoperative blood loss was 120(50 to 200) ml. The median postoperative hospital stay was 12(9 to 18 ) days. Postoperative pathology revealed that all circumferential margins (CRM) were negative. The area of sample horizontal section was (2 824±463) mm(2), and of outer muscularis propria was(2 190±476) mm(2). Postoperative complications included chronic sacrococcygeal region pain in 2 cases, urinary retention in 3 cases, perineal wound infection in 1 case. No perineal seroma, perineal hernia, wound dehiscence and sinus tract formation were observed. Among 8 patients with preoperative normal sexual function, sexual dysfunction occurred in 2 patients. There was no local recurrence and metastasis during a median follow-up of 21(12 to 34) months. Laparoscopy combined with TP-ELAPE has the potential to simplify the operation procedure for low rectal cancer, can ensure the radical treatment and safety of operation, and may be carried out in experienced centers.

Pancreatic cancer surgery: The new R-status counts

Objective To assess the relevance of resection margin status for survival outcome after resection and adjuvant therapy for pancreatic cancer. Background The definitions for R0 and R1 margin status after resection for pancreatic cancer are controversial. The strict definition of R0 requiring a 1 mm tumor-free margin is not commonly accepted. Reported R0/R1 rates and associated survival are highly heterogeneous. Methods A standardized protocol with rigorous assessment of circumferential margins and the R0 definition with a 1 mm free margin were introduced into clinical routine in 2005. From a prospective database, patients undergoing pancreatoduodenectomy for pancreatic adenocarcinoma between January 1, 2006 and December 12, 2012 were identified. The rates of R0 (≥1 mm margin), R1 ( Results Of 561 patients included, 112 patients (20.0%) had R0 and 449 patients (80.0%) had R1 resections, including 123 (21.9%) R1 (≤1 mm) and 326 (58.1%) R1 (direct) resections. A total of 438 (85.9%) received adjuvant therapy. With R0, R1 ( Conclusions In the context of adjuvant therapy, the resection margin status remains an important independent determinant of postresection survival. R0/R1 resection rates and associated survival vary significantly with the definitions used. An international consensus is urgently needed to achieve comparability with respect to studies and protocols on patients with adjuvant therapy.

Propensity score matching-based analysis of short-term outcomes of Laparoscopic-assisted Natural Orifice Specimen Extraction for left colorectal cancer radical resection

To explore short-term outcomes obtained with Laparoscopic-assisted Natural Orifice Specimen Extraction for left colorectal cancer radical resection. A total of 123 patients with left colorectal tumor who had undergone laparoscopic surgery between Jan.2014 and Jun.2015 were reviewed. According to surgical approach, transanal specimen extraction using the Cai Tube (study group, n=29) and trans-abdominal incision specimen extraction (control group, n=123) were studied. Propensity score matching was applied at a ratio of 1∶1 comparing the study (n=23) and control (n=23) groups. The two matched groups had similar baseline characteristics. There was no significant difference in the length of distal or proximal resection margin, the rate of circumferential resection negative margin, the estimated blood loss, the levels of C-reactive protein on 2nd day after surgery, the postoperative time to take liquid, the postoperative hospital day, the hospital fee and the postoperative anal function. The study group presented longer operative time[(237.8±68.1)min vs (168.9±47.5)min, P<0.05], less number of lymph nodes dissected (12.4±5.4 vs 16.4±7.2, P<0.05), higher white cell count on 2nd day after surgery[(11.7±3.4)×10(9)/L vs (9.4±2.6)×10(9)/L, P<0.05], but quicker postoperative recovery of bowel function[(2.6±0.7)d vs (3.4±0.7)d, P<0.05], shorter postoperative ambulation time[(2.3±0.6)d vs (3.6±0.7)d, P<0.05], lower rate of postoperative complications (0/23 vs 6/23, P<0.05) and lower rate of utilization of painkillers in addition to postoperative analgesia pump (1/20 vs 9/23, P<0.05). Laparoscopic-assisted left colorectal cancer radical resection using the Cai Tube is in line with oncologic principle, less pain, quicker recovery and better cosmetic results.

Single-port endoscopic mesocolic and mesorectal excision using an extraperitoneal approach.

The extraperitoneal rectal dissection via a transanal approach facilitates the mesorectal dissection. The retroperitoneal approach for mesocolic excision may also offer some similar advantages. To complete the lymphadenectomy of extraperitoneal mesorectal resection, we developed an innovative approach for upper rectal and mesocolic excision via an exclusive retroperitoneal dissection using a single-port access at the site of the future stomy. This study was a prospective pilot study and was conducted between 2013 and 2015 at two oncologic centers. Five consecutive patients, with ano-rectal cancer requiring permanent stoma, underwent this procedure. The bowel was never touched or mobilized to perform the lymphadenectomy, and no Trendelenburg was required. The median operative duration was 300min (range 205-310). The quality of the surgical plane was classified as good (mesorectal) in the five patients. The median circumferential and distal margins were, respectively, 5mm (range 1-20) and 20mm (range 5-25). The median number of harvested lymph nodes was 11 (range 5-18). No laparotomy or multiport laparoscopy was required. There was no death. Two patients had perineal wound dehiscence (one minor and one major). The mesocolic excision via a retroperitoneal approach is feasible, completes naturally the transanal mesorectal excision and may confer several advantages including no morbidity of small bowel manipulation or Trendelenburg position. Further studies are required to analyze this approach.

The effects of implementing synoptic pathology reporting in cancer diagnosis: a systematic review.

Pathology reporting is evolving from a traditional narrative report to a more structured synoptic report. Narrative reporting can cause misinterpretation due to lack of information and structure. In this systematic review, we evaluate the impact of synoptic reporting on completeness of pathology reports and quality of pathology evaluation for solid tumours. Pubmed, Embase and Cochrane databases were systematically searched to identify studies describing the effect of synoptic reporting implementation on completeness of reporting and quality of pathology evaluation of solid malignant tumours. Thirty-three studies met the inclusion criteria. All studies, except one, reported an increased overall completeness of pathology reports after introduction of synoptic reporting (SR). Most frequently studied cancers were breast (n = 9) and colorectal cancer (n = 16). For breast cancer, narrative reports adequately described ‘tumour type’ and ‘nodal status’. Synoptic reporting resulted in improved description of ‘resection margins’, ‘DCIS size’, ‘location’ and ‘presence of calcifications’. For colorectal cancer, narrative reports adequately reported ‘tumour type’, ‘invasion depth’, ‘lymph node counts’ and ‘nodal status’. Synoptic reporting resulted in increased reporting of ‘circumferential margin’, ‘resection margin’, ‘perineural invasion’ and ‘lymphovascular invasion’. In addition, increased numbers of reported lymph nodes were found in synoptic reports. Narrative reports of other cancer types described the traditional parameters adequately, whereas for ‘resection margins’ and ‘(lympho)vascular/perineural invasion’, implementation of synoptic reporting was necessary. Synoptic reporting results in improved reporting of clinical relevant data. Demonstration of clinical impact of this improved method of pathology reporting is required for successful introduction and implementation in daily pathology practice.Electronic supplementary materialThe online version of this article (doi:10.1007/s00428-016-1935-8) contains supplementary material, which is available to authorized users.

Structured pathology reporting improves the macroscopic assessment of rectal tumour resection specimens

We examined whether introduction of a structured macroscopic reporting template for rectal tumour resection specimens improved the completeness and efficiency in collecting key macroscopic data elements. Fifty free text (narrative) macroscopic reports retrieved from 2012 to 2014 were compared with 50 structured macroscopic reports from 2013 to 2015, all of which were generated at John Hunter Hospital, Newcastle, NSW. The six standard macroscopic data elements examined in this study were reported in all 50 anatomical pathology reports using a structured macroscopic reporting dictation template. Free text reports demonstrated significantly impaired data collection when recording intactness of mesorectum (p<0.001), relationship to anterior peritoneal reflection (p=0.028) and distance of tumour to the non-peritonealised circumferential margin (p<0.001). The number of words used was also significantly (p<0.001) reduced using pre-formatted structured reports compared to free text reports. The introduction of a structured reporting dictation template improves data collection and may reduce the subsequent administrative burden when macroscopically evaluating rectal resections.

A Systematic Review of Outcomes After Transanal Mesorectal Resection for Rectal Cancer.

Transanal mesorectal resection has been developed to facilitate minimally invasive proctectomy for rectal cancer. The purpose of this study was to evaluate the evidence regarding technical parameters, oncological outcomes, morbidity, and mortality after transanal mesorectal resection. The Cochrane Library, PubMed, and MEDLINE databases were reviewed. Systematic review of the literature from January 2005 to September 2015 was used for study selection. Intervention included transanal mesorectal resection for rectal cancer. Technical parameters, histological outcomes, morbidity, and mortality were the outcomes measured. Fifteen predominately retrospective studies involving 449 patients were included (mean age, 64.3 years; 64.1% men). Different platforms were used. The operative mortality rate was 0.4% and the cumulative morbidity rate 35.5%. Circumferential resection margins were clear in 98%, and the resected mesorectum was grade III in 87% of patients. Median follow-up was 14.7 months. There were 4 local recurrences (1.5%) and 12 patients (5.6%) with metastatic disease. No study followed patients long enough to report on 5-year overall and disease-free survival rates. Functional outcome was only reported in 3 studies. A low number of procedures were performed by expert early adopters. There are no comparative or randomized data included in this study and inconsistent reporting of outcome variables. Transanal mesorectal resection for rectal cancer may enhance negative circumferential margin rates with a reasonable safety profile. Contemporary randomized, controlled studies are required before there can be universal recommendation.

Short- and mid-term outcomes of robotic-assisted total mesorectal excision for the treatment of rectal cancer. Our experience after 198 consecutive cases

BackgroundRobot-assisted total mesorectal excision is a safe alternative for rectal cancer treatment. Nevertheless, substantial data is still missing. Our aim was to assess the perioperative and oncological outcomes of the routine use of the robotic-assisted approach for rectal cancer treatment. Patients and methods198 Consecutive robotic rectal resections were performed between January 2011 and April 2015 in patients with stage I–IV disease. We prospectively evaluated peri and postoperative data, pathological findings and mid-term oncological outcomes. Results36 Abdominoperineal Amputations, 28 High Anterior Resections, 131 Low Anterior Resections and 3 Hartmann operations were performed. Mean age, ASA, BMI and distance form anal verge were respectively 67.5 years, ASA II, 26.95 kg/m2 and 5.9 cm. 71.2% Patients received neoadjuvant therapy. Mean OR time was 294 minutes. Conversion occurred in 4.5%. Mean postoperative stay was 8 days. 36 Patients required blood transfusion with a mean of 162 ml. Complications Clavien III–IV were 12.1%. 8 complete responses were observed, 50 UICC class I, 84 class II, 51 class III and 13 class IV. Mean lymph node harvested were 11.7. Mean distal margin was 3.3 cm. 11 Circumferential margins were affected in UICC class III–IV patients. Postoperative mortality was 0.5%. Local recurrence was observed in 5% patients. Median follow-up was 27.6 months. LimitationsSingle institution descriptive study. ConclusionsThe routine use of robotic assisted laparoscopic surgery may help to achieve lower conversion rates with lower ventral hernia rates and similar oncological outcomes using a minimally invasive approach in a non-selected group of patients with non-selected rectal tumours.

The circumferential resection margins status: A comparison of robotic, laparoscopic and open total mesorectal excision for mid and low rectal cancer

IntroductionMinimally invasive surgery for rectal cancer (RC) is now widely performed via the laparoscopic approach, but robotic-assisted surgery may overcome some limitations of laparoscopy in RC treatment. We compared the rate of positive circumferential margins between robotic, laparoscopic and open total mesorectal excision (TME) for RC in our institution. MethodsMid and low rectal adenocarcinoma patients consecutively submitted to robotic surgery were compared to laparoscopic and open approach. From our prospective database, 59 patients underwent robotic-assisted rectal surgery from 2012 to 2015 (RTME group) were compared to our historical control group comprising 200 open TME (OTME group) and 41 laparoscopic TME (LTME group) approaches from July 2008 to February 2012. Primary endpoint was to compare the rate of involved circumferential resection margins (CRM) and the mean CRM between the three groups. Secondary endpoint was to compare the mean number of resected lymph nodes between the three groups. ResultsCRM involvement was demonstrated in 20 patients (15.5%) in OTME, 4 (16%) in LTME and 9 (16.4%) in the RTME (p = 0.988). The mean CRM in OTME, LTME and RTME were respectively 0.6 cm (0–2.7), 0.7 cm (0–2.0) and 0.6 cm (0–2.0) (p = 0.960). Overall mean LN harvest was 14 (0–56); 16 (0–52) in OTME, 13 (1–56) in LTME and 10 (0–45) in RTME (p = 0.156). ConclusionOur results suggest that robotic TME has the same oncological short-term results when compared to the open and laparoscopic technique, and it could be safely offered for the treatment of mid and low rectal cancer.

TNMF versus TNM in staging of colorectal cancer

AimTNM staging and histological grading of rectal cancer has undergone no or minimal changes during the past 20 years despite their major impact on planning, reporting and outcome of the disease. The addition of category ‘F’ to the ‘TNM’ staging of colorectal cancer, which becomes TNMF will accommodate the expanding list of risk factors that may affect the management and thus avoid squeezing them into the TNM categories. MethodsReporting of the following risk factors was traced in 730 (664 retrospective and 66 prospective) cases of colorectal cancer: age, Tumor location, preoperative CEA, intraoperative tumor perforation and blood transfusion, quality of TME, tumor grade, non nodal T.Ds, Lymphovascular invasion, lymph node ratio, circumferential tumor margins, apical lymph nodes, infiltrating or pushing and K-ras gene mutation. ResultsThe reporting of most risk factors was inadequate; also there is marked improvement in reporting in the prospective cases in preoperative CEA, intra operative blood transfusion and tumor perforation, quality of TME, tumor grade and non-nodal T.Ds (P-value <0.0001). ConclusionThe addition of category ‘F’ to the TNM staging system to become TNMF may avoid ignoring already established risk factors due to our inability to accommodate them in the inhospitable TNM categories.

Sparing Sphincters and Laparoscopic Resection Improve Survival by Optimizing the Circumferential Resection Margin in Rectal Cancer Patients.

The goal of rectal cancer treatment is to minimize the local recurrence rate and extend the disease-free survival period and survival. For this aim, obtainment of negative circumferential radial margin (CRM) plays an important role. This study evaluated predictive factors for positive CRM status and its effect on patient survival in mid- and distal rectal tumors.Patients who underwent curative resection for rectal cancer were included. The main factors were demographic data, tumor location, surgical technique, neoadjuvant therapy, tumor diameter, tumor depth, lymph node metastasis, mesorectal integrity, CRM, the rate of local recurrence, distant metastasis, and overall and disease-free survival. Statistical analyses were performed by using the Chi-squared test, Fisher exact test, Student t test, Mann–Whitney U test and the Mantel–Cox log-rank sum test.A total of 420 patients were included, 232 (55%) of whom were male. We observed no significant differences in patient characteristics or surgical treatment between the patients who had positive CRM and who had negative CRM, but a higher positive CRM rate was observed in patients undergone abdominoperineal resection (APR) (P < 0.001). Advanced T-stage (P < 0.001), lymph node invasion (P = 0.001) and incomplete mesorectum (P = 0.007) were encountered significantly more often in patients with positive CRM status. Logistic regression analysis revealed that APR (P < 0.001) and open resection (P = 0.046) were independent predictors of positive CRM status. Moreover, positive CRM was associated with decreased 5-year overall and disease-free survival (P = 0.002 and P = 0.004, respectively).This large single-institution series demonstrated that APR and open resection were independent predictive factors for positive CRM status in rectal cancer. Positive CRM independently decreased the 5-year overall and disease-free survival rates.

True NOTES TME resection with splenic flexure release, high ligation of IMA, and side-to-end hand-sewn coloanal anastomosis.

Natural orifice transluminal endoscopic surgery (NOTES) represents the ultimate expression of minimally invasive surgery. We have developed and present here an initial feasibility and safety study of transanal total mesorectal excision (TME) with splenic flexure release, high ligation of the IMA and IMV, and side-to-end coloanal anastomosis with temporary diverting ileostomy for rectal cancer. A program of full NOTES TME resection with release of the splenic flexure, high ligation of the IMA/IMV, with side-to-end coloanal anastomosis was performed transanally from December 2013 to July 2014. Demographics, preoperative, perioperative, and postoperative data were prospectively obtained. Operative components were broken into TME, colonic mobilization, splenic flexure release, IMA/IMV transection, transanal extraction of specimen, and coloanal anastomosis for analysis of performance completion. There were 3 women and 1 man on whom we operated. Mean age was 56 (46-65). Mean BMI was 26 (23.8-30.2). The operation was completed entirely transanally in 2 patients. Transanal component completion of the operation was as follows: TME in 3/4; colonic mobilization in 4/4; splenic flexure release in 3/4; IMA/IMV transection in 3/4; transanal specimen extraction in 4/4; coloanal anastomosis in 4/4. Abdominal time for completion of component parts was: splenic flexure release 4:53 (min:s), IMA/IMV 19:43, completion of TME 13:41. Mean EBL was 194cc (25-500). Aside from stoma site, there were no abdominal incisions. There were no mortalities. Mesorectum was intact in all 4 patients and with negative circumferential and distal margins. This experience supports the feasibility and safety of a true NOTES TME. The critical anatomic views demonstrated on video affirm the potential of this approach for distal rectal cancer. Colorectal surgery represents the most logical application for NOTES. While highly promising, a great deal of work remains to develop the technique and applicability of NOTES colorectal surgery.

Extralevator Abdominoperineal Resection in the Prone Position.

See Article on Page 12-19 The conventional abdominoperineal resection (APR) has been the gold standard for the surgical treatment of low rectal cancer. Regardless of the approach, the APR represented a uniquely challenging procedure where the surgeon is expected to reduce the circumferential resection margin (CRM), local recurrence (LR) and wound complications. For cancer patients, excision of the anal canal with a wide circumferential margin, including a cylindrical cuff of the levator, muscle was introduced. As described by West et al. [1], compared with standard surgery, the extralevator APR (ELAPR) may reduce CRM involvement (from 49.6% to 20.3%, P < 0.001) and intraoperative perforation (IOP) (from 28.2% to 8.2%, P < 0.001), but with an increase in perineal wound complications (from 20% to 38.0%, P = 0.019). In contrast, they did not demonstrate the statistically differences in CRMs and wound complications between the groups. A metaanalysis study by De Nardi et al. [2] found significant differences in the CRM involvement rate (odds ratio [OR], 2.9; P < 0.001), intraoperative perforation (OR, 4.30; P < 0.001), local recurrence rate (OR, 2.52; P = 0.02), and length of hospital stay (OR, 1.06; P < 0.001) in favor of the ELAPR group. Additionally, perineal wound complications were higher in the extended group (OR, 0.62; P = 0.007). Yang et al. [3] reported that ELAPR had a lower rate of intraoperative perforation and local recurrence than APR in terms of short follow-up time. Yang et al. [4] reported better results in laparoscopic ELAPR: a 6.1% CRM rate, 15.2% morbidity, and no mortality. The perineal dissection can be performed in the lithotomy position or in the prone position after closure of the abdomen and creation of the colostomy. The author [5] reported that compared to the conventional APR, the ELAPR in the prone position did not have advantages in terms of perioperative complications and pathologic outcomes such as the CRM. In my opinion, the ELAPR in the prone position for treating patients with lower rectal or locally-recurrent pelvic cancer allows better exposure of the operative field and more precise perineal dissection according to the tissue plane and leaves open the possibility of an en-bloc combined resection of the sacrum or coccyx in difficult cases with sacral invasion. However, we need further randomized controlled studies to clearly identify the advantages and the disadvantages of the ELAPR in the prone position.

A Simple Modified Flip-Flop Flap for the Reconstruction of Antihelix and Triangular Fossa Defects.

A Simple Modified Flip-Flop Flap for the Reconstruction of Antihelix and Triangular Fossa Defects.

Transanal Total Mesorectal Excision With Single-Incision Laparoscopy for Rectal Cancer.

Background and Objectives:There has been great enthusiasm for the technique of transanal total mesorectal excision. Coupled with this procedure, we performed single-incision laparoscopic surgery for left colon mobilization. This is a description of our initial experience with the combined approach.Methods:Patients with distal or mid rectal cancer were included. The operation was performed by 2 teams: one team performed the single-incision mobilization of the left colon via the right lower quadrant ileostomy site, and the other team performed the total mesorectal excision with a transanal platform.Results:During the study period, 10 patients (5 men) with cancer of the rectum underwent the surgery. The mean age was 62.2 ± 11.1 years, and the mean body mass index was 23.4 ± 3.2 kg/m2. The tumor's mean distance from the anal verge was 5.1 ± 2.5 cm. The median operating time was 247.5 minutes (range, 188–462 minutes). The mean estimated blood loss was 124 ± 126 mL (range, 10–188 mL). Conversion to multiport laparoscopy was needed in one case (10%). Postoperative pain, as reflected by the pain score, was minimal. The mean number of lymph nodes harvested was 15.6 ± 3.8. All specimens had clear distal and circumferential radial margins. The overall complication rate was 10%.Conclusion:Our experience showed transanal total mesorectal excision with single-incision laparoscopy to be a feasible option for rectal cancer. Patients reported minimal postoperative pain. Further studies on the long-term outcome are warranted.

Does Extending the Waiting Time of Low-Rectal Cancer Surgery after Neoadjuvant Chemoradiation Increase the Perioperative Complications?

Background. Traditionally, rectal cancer surgery is recommended 6 to 8 weeks after completing neoadjuvant chemoradiation. Extending the waiting time may increase the tumor response rate. However, the perioperative complication rate may increase. The purpose of this study was to determine the association between extending the waiting time of surgery after neoadjuvant chemoradiation and perioperative outcomes. Methods. Sixty patients with locally advanced rectal cancer who underwent neoadjuvant chemoradiation followed by radical resection at Siriraj hospital between June 2012 and January 2015 were retrospectively analyzed. Demographic data and perioperative outcomes were compared between the two groups. Results. The two groups were comparable in term of demographic parameters. The mean time interval from neoadjuvant chemoradiation to surgery was 6.4 weeks in Group A and 11.7 weeks in Group B. The perioperative outcomes were not significantly different between Groups A and B. Pathologic examination showed a significantly higher rate of circumferential margin positivity in Group A than in Group B (30% versus 9.3%, resp.; P = 0.04). Conclusions. Extending the waiting to >8 weeks from neoadjuvant chemoradiation to surgery did not increase perioperative complications, whereas the rate of circumferential margin positivity decreased.

Assessment of the circumferential margins, extraprostatic extension and Gleason score in radical prostatectomy specimens: Comparison of a partial embedding method with supplemental total inclusion of peripheral tissues

BackgroundRecent data suggest that up to 21% of positive circumferential margins (PCM) and 47% of extraprostatic extension (EPE) samples may be missed when partial embedding methods are employed. Kim and colleagues (2009) suggested that total inclusion of the periphery (3mm rim) of the prostate prevented the failure to detect PCM and EPE. DesignRadical prostatectomy specimen (n=148) slides were reviewed after adoption of a protocol that included a ∼3mm rim of peripheral tissues. We evaluated whether the analysis of supplemental slides of prostate periphery changed margin status, presence of EPE, Gleason score and extent of PCM and EPE. ResultsPartial sampling resulted in missing 29% of PCM and 20% of EPE without using data from the supplemental slides of prostate periphery. Changes from focal to extensive disease were found in 11/21 (52%) cases of positive circumferential margins and in 5/13 (38%) cases of extraprostatic extension. Changes in the Gleason score were uncommon. ConclusionsThese results indicate the importance of including all the prostate peripheral tissue for microscopic analysis when partial embedding methods are adopted.

Surgical quality in colorectal cancer.

ObjectiveTo determine the quality of surgical management offered to patients with colorectal cancer (CRC) as measured by adequacy of nodal resections and compare variations across the major hospitals in Jamaica.MethodData was obtained from the CRC Registry of patients diagnosed and treated surgically for CRC during the 3-year period commencing January 1, 2011. Variables analyzed included tumor site, stage and number of lymph nodes resected across hospitals.ResultsDuring the period under review 60% (349) of 586 patients had resections and formed the basis of this study. Of these 49% were treated at the UHWI, 27% from the KPH and STH, 15% from CRH and MRH and 8% from a private laboratory (DPS). Patient distribution was similar at UHWI compared to the others with mean age (61 vs 62) and with slightly more women having surgery (53% Vs 54%) (UHWI vs Others). For tumor grade, margin status, lymphovascular and depth of invasion (majority T3) there was no difference between UHWI and the other sites, although a smaller percentage of tumors treated at UHWI had Crohn's like reaction (p = 0.01). There was a larger proportion of sigmoid cancer at UHWI while the reverse trend was seen in cancers of the rectum (p = 0.027). The tumors treated at UHWI have a larger median number of regional nodes when compared to the other facilities (14 vs 10; p < 0.001) and also more likely to have positive nodes, as were women and younger patients. Comparison across facilities revealed that the proportion of tumors classed as well differentiated, circumferential margin involvement, and having lymphovascular invasion were higher for specimens processed at the private facility (p = 0.021, 0.035, 0.01 respectively). Histopathology reports of tumors treated at UHWI and DPS had median 14 and 18 nodes respectively while at NPH laboratory and CRH they were 9 and 10 respectively (p < 0.001), whilst those of the ascending, descending, sigmoid colon and rectum had median 15, 11, 13, 11 nodes respectively (p < 0.001).ConclusionsThis review demonstrates measurable differences in the surgery and histopathological reports for CRC patients treated across the island. Given adjuvant treatment and prognostic implications there is room for improvement.