Circumferential Margin Research Articles

Use of Preoperative Magnetic Resonance Imaging to Select Patients with Rectal Cancer for Neoadjuvant Chemoradiation—Interim Analysis of the German OCUM Trial (NCT01325649)

IntroductionIntroduction of total mesorectal excision (TME) surgery for rectal cancer decreased local recurrence dramatically. Additional neoadjuvant chemoradiation (nCR) is frequently given in UICC II and III tumors based on TNM staging which is of limited accuracy. We aimed to evaluate determination of circumferential margin by magnetic resonance imaging (mrCRM) as an alternative criterium for nCR. MethodsMulticenter prospective cohort study which enrolled 642 patients in 13 centers with non-metastasized rectal adenocarcinoma. Patients with T4 tumors or patients with a mrCRM of 1 mm or less were treated by neoadjuvant chemoradiation. All others proceeded directly to surgery when inclusion criteria and no exclusion criteria were met. Quality of TME and accuracy of mrCRM determination were assessed during pathology workup. ResultsTME was complete in 381 of 389 patients after surgery without nCR (97.9 %) and in 245 of 253 patients (96.8 %) after nCR. Negative pathology circumferential margins (pCRM) were seen in 97.4 % without nCR and in 89 % of patients after nCR. Negative pCRM was predicted by negative mrCRM in 98.3 % of rectal cancers. NCR was given to 253 of 642 patients (39.5 %). Lymph node count was 23 (range 7–79; median/range) for surgery without nCR and 19 (range 2–56) for surgery after nCR. ConclusionsSurgical quality determined by pathology workup of specimen was very good in this study. Magnetic resonance imaging guided indication for nCR allows to achieve superb results concerning surrogate parameters for good oncological outcome. Thus, use of neoadjuvant chemoradiation with its potential detrimental side effects may be substantially reduced in selected patients.

COLOR III: a multicentre randomised clinical trial comparing transanal TME versus laparoscopic TME for mid and low rectal cancer.

IntroductionTotal mesorectal excision (TME) is an essential component of surgical management of rectal cancer. Both open and laparoscopic TME have been proven to be oncologically safe. However, it remains a challenge to achieve complete TME with clear circumferential resections margin (CRM) with the conventional transabdominal approach, particularly in mid and low rectal tumours. Transanal TME (TaTME) was developed to improve oncological and functional outcomes of patients with mid and low rectal cancer.MethodsAn international, multicentre, superiority, randomised trial was designed to compare TaTME and conventional laparoscopic TME as the surgical treatment of mid and low rectal carcinomas. The primary endpoint is involved CRM. Secondary endpoints include completeness of mesorectum, residual mesorectum, morbidity and mortality, local recurrence, disease-free and overall survival, percentage of sphincter-saving procedures, functional outcome and quality of life. A Quality Assurance Protocol including centralised MRI review, histopathology re-evaluation, standardisation of surgical techniques, and monitoring and assessment of surgical quality will be conducted.DiscussionThe difference in involvement of CRM between the two treatment strategies is thought to be in favour of the TaTME. TaTME is therefore expected to be superior to laparoscopic TME in terms of oncological outcomes in case of mid and low rectal carcinomas.

Mesorectal pathologic assessment in two grades predicts accurately recurrence, positive circumferential margin, and correlates with survival

We aimed to determine the prognostic value of the mesorectum quality assessed in a two-grade system compared with a classic system. Consecutive patients undergoing surgery for rectal cancer were included (n = 103). Mesorectum was assessed into three grades (classic system: complete, nearly complete, incomplete) and compared with a two-grade system (adequate, inadequate). Mesorectum was complete in 62 (60.25%) patients, nearly complete in 21, and incomplete in 20. Reassessment showed adequate mesorectum in 83 (80.5%) patients and inadequate in 20. A R0 resection was achieved in 90.4% of adequate mesorectum and in 65% of inadequate mesorectum (P = 0.006). Recurrence was present in 18% of adequate mesorectum patients as compared with 50% of inadequate mesorectum (P = 0.003). The classic system failed to accurately predict the 5-year survival rate between complete (78.9%) and nearly complete (86.2%) categories (P = 0.235); whereas a two grading system showed a 5-year survival rate of 80.8% for adequate versus 39.3% for inadequate (P = 0.034). High recurrence occurred in inadecuate mesorectum patients and was correlated with R1/R2 resections, positive margins, and decreased survival. We propose a simplified classification of mesorectum that correlates with survival and overall recurrence.

The Need for Consensus and Transparency in Assessing Population-Based Rates of Positive Circumferential Radial Margins in Rectal Cancer: Data from Consecutive Cases in a Large Region of Ontario, Canada.

A positive circumferential radial margin (CRM) after rectal cancer surgery is an important predictor of local recurrence. The definition of a positive CRM differs internationally, and reported rates vary greatly in the literature. This study used time-series population-based data to assess positive CRM rates in a region over time and to inform future methods of CRM analysis in a defined geographic area. Chart reviews provided relevant data from consecutive patients undergoing rectal cancer surgery between 2006 and 2012 in all hospitals of the authors' region. Outcomes included rates for pathologic examination of CRM, CRM distance reporting, and positive CRM. The rate of positive CRM was calculated using various definitions. The variations included positive margin cutoffs of CRM at 1 mm or less versus 2 mm or less and inclusion or exclusion of cases without CRM assessment. In this study, 1222 consecutive rectal cancer cases were analyzed. The rate for pathology reporting of CRM distance increased from 54.7 to 93.2 % during the study. Depending on how the rate of positive CRM was defined, its value varied 8.5 to 19.4 % in 2006 and 6.0 to 12.5 % in 2012. Using a pre-specified definition, the rate of positive CRM decreased over time from 14.0 to 6.3 %. A marked increase in CRM distance reporting was observed, whereas the rates of positive CRM dropped, suggesting improved pathologist and surgeon performance over time. Changing definitions greatly influenced the rates of positive CRM, indicating the need for more transparency when such population-based rates are reported in the literature.

Effect of Laparoscopic-Assisted Resection vs Open Resection of Stage II or III Rectal Cancer on Pathologic Outcomes: The ACOSOG Z6051 Randomized Clinical Trial.

Evidence about the efficacy of laparoscopic resection of rectal cancer is incomplete, particularly for patients with more advanced-stage disease. To determine whether laparoscopic resection is noninferior to open resection, as determined by gross pathologic and histologic evaluation of the resected proctectomy specimen. A multicenter, balanced, noninferiority, randomized trial enrolled patients between October 2008 and September 2013. The trial was conducted by credentialed surgeons from 35 institutions in the United States and Canada. A total of 486 patients with clinical stage II or III rectal cancer within 12 cm of the anal verge were randomized after completion of neoadjuvant therapy to laparoscopic or open resection. Standard laparoscopic and open approaches were performed by the credentialed surgeons. The primary outcome assessing efficacy was a composite of circumferential radial margin greater than 1 mm, distal margin without tumor, and completeness of total mesorectal excision. A 6% noninferiority margin was chosen according to clinical relevance estimation. Two hundred forty patients with laparoscopic resection and 222 with open resection were evaluable for analysis of the 486 enrolled. Successful resection occurred in 81.7% of laparoscopic resection cases (95% CI, 76.8%-86.6%) and 86.9% of open resection cases (95% CI, 82.5%-91.4%) and did not support noninferiority (difference, -5.3%; 1-sided 95% CI, -10.8% to ∞; P for noninferiority = .41). Patients underwent low anterior resection (76.7%) or abdominoperineal resection (23.3%). Conversion to open resection occurred in 11.3% of patients. Operative time was significantly longer for laparoscopic resection (mean, 266.2 vs 220.6 minutes; mean difference, 45.5 minutes; 95% CI, 27.7-63.4; P < .001). Length of stay (7.3 vs 7.0 days; mean difference, 0.3 days; 95% CI, -0.6 to 1.1), readmission within 30 days (3.3% vs 4.1%; difference, -0.7%; 95% CI, -4.2% to 2.7%), and severe complications (22.5% vs 22.1%; difference, 0.4%; 95% CI, -4.2% to 2.7%) did not differ significantly. Quality of the total mesorectal excision specimen in 462 operated and analyzed surgeries was complete (77%) and nearly complete (16.5%) in 93.5% of the cases. Negative circumferential radial margin was observed in 90% of the overall group (87.9% laparoscopic resection and 92.3% open resection; P = .11). Distal margin result was negative in more than 98% of patients irrespective of type of surgery (P = .91). Among patients with stage II or III rectal cancer, the use of laparoscopic resection compared with open resection failed to meet the criterion for noninferiority for pathologic outcomes. Pending clinical oncologic outcomes, the findings do not support the use of laparoscopic resection in these patients. clinicaltrials.gov Identifier: NCT00726622.

MRI Local Staging and Restaging in Rectal Cancer.

Magnetic resonance imaging (MRI) with rectal protocol modification is a reliable staging modality which is rapidly replacing transrectal ultrasound for staging. The added information delivered by MRI includes wide circumferential radial margin compromise, distant lymph node metastasis in the pelvis, and level of sphincter compromise in the low rectum. As more information becomes available through ongoing studies, MRI may be able to contribute the decision to treat rectal cancer nonoperatively.

The Petersen prognostic index revisited in Dukes B colon cancer – Inter-institutional differences

A prognostic index (Petersen index, PI) was created for patients with pT3-4 pN0 M0 (Stage II, Dukes’ B) colon cancers to distinguish between patients with better and worse outcome, and to help in recommending adjuvant chemotherapy for high risk patients in this stage.The prognostic value of the PI was evaluated in two independent retrospective series of stage II (Dukes’ B) colon cancer patients. The parameters defining the PI (venous invasion, peritoneal involvement, circumferential margin involvement, perforation through the tumour) and performance of the PI were compared in two institutions.The two series of patients consisted of 127 and 87 patients. Venous invasion was more frequently detected at one of the centres (p<0.01) and tumour perforation was more frequent at the other (p<0.01). There were no significant differences in the 5-year survival estimates of all patients (p=0.19), and of either the low PI value groups (p=0.52) or that of the high PI value groups (p=0.99) between the two sites. In contrast, there were significant differences in the survival estimates between patients of the low PI category and those of the high PI category altogether (p<0.01) and in either centre.Although, it was expected that differences in the frequency of the parameters involved in the PI would influence its performance, this was not confirmed by the data. Our results suggest that using the PI may be of value in prognostic factor based therapy selection of colon carcinoma patients.

Reporting of the circumferential tumour margin involvement and preoperative levels of carcinoembryonic antigen as prognostic risk factors in colorectal cancer patients

Background and study aimsThe two very important prognostic risk factors of colorectal cancer are circumferential tumour margin (CTM) involvement and preoperative levels of carcinoembryonic antigen (CEA). The aim of this study is to monitor the frequency of reporting of the CTM in the postoperative pathology reports after colorectal cancer resection in addition to monitoring the frequency of reporting of preoperative levels of CEA and exploring the possibility of improving the frequency of reporting of both. Patients and methodsReports of the CTM and preoperative level of CEA were found in 730 (664 retrospective and 66 prospective) patients with colorectal cancer. The possibility of improving the incidence of reporting was estimated by comparing the reporting frequency of both (retrospective and prospective) groups. ResultsThe percentage of reporting the involvement of the CTM was 46.08% and 81.81% for the retrospective group and the prospective group, respectively. The percentage of reporting the preoperative CEA levels was 40.9% and 68.7% for the retrospective and the prospective groups, respectively. There was a statistically significant difference in reporting both CTMs and the preoperative level of CEA between retrospective and prospective groups to the side of prospective group in which the p-value was <0.0001 for both groups. ConclusionThere was inadequate reporting of both the CTM involvement and preoperative levels of CEA in the retrospective patients with statistically significant improvement of this reporting in patients in the prospective group. This may point to the unawareness of the importance of both in the prognosis of colorectal cancer, which may be because both are not involved in the widely used tumour, node, metastasis (TNM) staging system.

Rectal cancer patients after neoadjuvant radiotherapy (30Gy/10f) with negative lymph node may not benefit from postoperative adjuvant chemotherapy: a retrospective study.

The purpose of this study is to evaluate whether adjuvant chemotherapy could bring oncologic benefit to all patients who underwent neoadjuvant radiotherapy (30Gy/10f). Rectal cancer patients receiving preoperative radiotherapy between July 2002 and April 2009 were retrospectively identified. A total of 225 patients were enrolled in this study. One hundred thirty-one patients received postoperative adjuvant chemotherapy, and 94 patients did not. The 120 ypN+ and 105 ypN- patients were divided into chemo and non-chemo groups. Two groups of patients did not show any significant difference in terms of gender, age, ypT stage, preoperative serum carcinoembryonic antigen (CEA) level, differentiation, circumferential margin (CRM), lymphovascular invasion (LVI), surgical approach, local recurrence, and distant metastasis (P > 0.05). Survival analysis showed that in ypN+ patients, the 5-year overall survival (OS) rate and 5-year disease-free survival (DFS) rate in chemo group were both significantly higher than non-chemo group (P < 0.05). In ypN- patients, the 5-year OS rate and 5-year DFS rate did not show any significant difference in the two groups (P > 0.05). Subgroup analysis showed that the 5-year OS rate and 5-year DFS rate in ypT0-2 N- patients (P > 0.05) and ypT3-4 N- patients (P > 0.05) did not show any significant difference, either. Based on a Chinese protocol, patients with ypN- stage may not benefit from adjuvant chemotherapy, regardless of the ypT stage, while the ypN+ patients may benefit from adjuvant chemotherapy. More randomized clinical trials are needed in the future.

Rectal cancer threatening or affecting the prostatic plane: is partial prostatectomy oncologically adequate? Results of a multicentre retrospective study.

The management of rectal cancer threatening or affecting the prostatic plane is still under debate. The role of preoperative chemo radiotherapy and the extent of prostatectomy seem to be key points in the treatment of these tumours. The aim of the present study was to evaluate the pathological circumferential margin status and the local recurrence rate following different therapeutic options. A multicentre, retrospective study was conducted of patients with rectal cancer threatening or affecting the prostatic plane, but not the bladder, judged by magnetic resonance imaging (MRI). The use of preoperative chemoradiotherapy and the type of urologic resection were correlated with the status of the pathological circumferential resection margin (CRM) and local recurrence. A consecutive series of 126 men with rectal cancer threatening (44) or affecting (82) the prostatic plane on preoperative staging and operated with local curative intent between 1998 and 2010 was analysed. In patients who did not have chemoradiotherapy but had a preoperative threatened anterior margin the CRM-positive rate was 25.0%. In patients who did not have preoperative chemoradiotherapy but did have an affected margin, the CRM-positive rate was 41.7%. When preoperative radiotherapy was given, the respective CRM infiltration rates were 7.1 and 20.7%. In patients having preoperative chemoradiotherapy followed by prostatic resection the rate of CRM positivity was 2.4%. Partial prostatectomy after preoperative chemoradiotherapy resulted in a free anterior CRM in all cases, but intra-operative urethral damage occurred in 36.4% of patients who underwent partial prostatectomy, resulting in a postoperative urinary fistula in 18.2% of patients. Preoperative chemoradiation is mandatory in male patients with a threatened or affected anterior circumferential margin on preoperative MRI. In patients with preoperative prostatic infiltration, prostatic resection is necessary. In this group of patients partial prostatectomy seems to be oncologically safe.

Oncologic and Clinicopathologic Outcomes of Robot-Assisted Total Mesorectal Excision for Rectal Cancer.

Minimally invasive rectal cancer surgery is challenging and technically difficult. Robotic technology offers a stable surgical platform with magnified 3-dimensional vision and endowristed instruments, which may facilitate the minimally invasive procedure. Data on short-term and long-term outcomes indicate results comparable to laparoscopic and open surgery. We assessed the perioperative, clinicopathologic, and oncologic outcomes of robotic surgery for rectal cancer. This study was a review of a prospective database of patients over a 7-year period. Procedures took place in the colorectal division at a tertiary hospital. From August 2005 to October 2012, 101 patients with rectal cancer were operated on using the robotic approach. Rectal cancers were defined as tumors within 15 cm from the anal verge. Patients received either a totally robotic or a hybrid laparoscopic-robotic operation with rectal dissection performed robotically. Operative and perioperative data, pathologic outcomes, and disease-free and overall survival were examined. There were 63 men (62.4%) and 38 women (37.6%) in the study; the mean age was 61.5 years. Mid rectal and low rectal cancers composed 74.2% of cases. Preoperative chemoradiation was given to 74.3% of patients. Four conversions to open surgery occurred. Circumferential margin positivity was 5%, and median lymph node yield was 15. At a mean follow-up of 34.9 months, the disease-free survival was 79.2% and overall survival 90.1%. The mean cost of robotic surgery was $22,640 versus $18,330 for the hand-assisted laparoscopic approach (p = 0.005). This was a single-institution study with no head-to-head comparative group. Robotic surgery for rectal cancer extirpation is safe and feasible. It has a low conversion rate, satisfies all measures of pathologic adequacy, and offers acceptable oncologic outcomes. Robotic surgery is significantly more expensive than hand-assisted laparoscopic surgery. The absence of randomized data limits recommending it as the standard of care at present.

Simple criteria to predict margin involvement after chemoradiotherapy and sphincter-sparing for low rectal cancer

BackgroundLow rectal cancers carry a high risk of circumferential margin involvement (CRM+). The anatomy of the lower part of the rectum and a long course of chemoradiotherapy (CRT) limit the accuracy of imaging to predict the CRM+. Additional criteria are required. MethodsEighty six patients undergoing rectal resection with a sphincter-sparing procedure after CRT for low rectal cancer between 2000 and 2013 were retrospectively reviewed. Risk factors of CRM+ and the cut-off number of risk factors required to accurately predict the CRM+ were analyzed. ResultsThe CRM+ rate was 9.3% and in the multivariate analysis, the significant risk factors were a tumor size exceeding 3 cm, poor response to CRT and a fixed tumor. The best cut-off to predict CRM+ was the presence of 2 risk factors. Patients with 0–1 and 2–3 risk factors had a CRM+ respectively in 1.3% and 50% of cases and a 3-year recurrence rate of 7% and 35% after a median follow-up of 50 months. ConclusionsPoor response, a residual tumor greater than 3 cm and a fixed tumor are predictive of CRM+. Sphincter sparing is an oncological safety procedure for patients with 0–1 criteria but not for patients with 2–3 criteria.

Tumour regression in the randomized Stockholm III Trial ofradiotherapy regimens for rectal cancer.

BackgroundThe Stockholm III Trial randomized patients with primary operable rectal cancers to either short‐course radiotherapy (RT) with immediate surgery (SRT), short‐course RT with surgery delayed 4–8 weeks (SRT‐delay) or long‐course RT with surgery delayed 4–8 weeks. This preplanned interim analysis examined the pathological outcome of delaying surgery.MethodsPatients randomized to the SRT and SRT‐delay arms in the Stockholm III Trial between October 1998 and November 2010 were included, and data were collected in a prospective register. Additional data regarding tumour regression grade, according to Dworak, and circumferential margin were obtained by reassessment of histopathological slides.ResultsA total of 462 of 545 randomized patients had specimens available for reassessment. Patients randomized to SRT‐delay had earlier ypT categories, and a higher rate of pathological complete responses (11·8 versus 1·7 per cent; P = 0·001) and Dworak grade 4 tumour regression (10·1 versus 1·7 per cent; P < 0·001) than patients randomized to SRT without delay. Positive circumferential resection margins were uncommon (6·3 per cent) and rates did not differ between the two treatment arms.ConclusionShort‐course RT induces tumour downstaging if surgery is performed after an interval of 4–8 weeks.

Hand-assisted laparoscopic surgery compared with open resection for mid and low rectal cancer: a case-matched study with long-term follow-up.

BackgroundThis study was designed to compare the long-term surgical outcomes of patients with mid and low rectal cancer after open or hand-assisted laparoscopic surgery (HALS).MethodsA case-matched controlled prospective analysis of 116 patients who underwent hand-assisted laparoscopic surgery (HALS) for stage I to III mid and low rectal cancer from 2005 to 2010 was performed. Contemporary patients who underwent open rectal surgery were matched to the HALS group at the ratio of 1:1. The perioperative clinical outcomes, postoperative pathology, and survival outcomes were compared between the groups.ResultsThe patient characteristics between the two groups were comparable. Ninety patients in the open group and 85 in the HALS group received sphincter-preserving surgery. HALS resulted in less blood loss and wound infection, faster return to oral diet, shorter postoperative hospital stay, and longer operating time. The two groups had similar complication rates. Lymph node retrieval and involvement of circumferential and distal margins were similar for both procedures. Cumulative incidences of locoregional recurrence, disease-free, or overall survival rates were statistically similar.ConclusionsThis study suggests that HALS for mid and low rectal cancer is acceptable in terms of short-term clinical outcomes and long-term survival results.

Application of laparoscopic extralevator abdominoperineal excision in locally advanced low rectal cancer.

Background:When compared with conventional abdominoperineal resection (APR), extralevator abdominoperineal excision (ELAPE) has been demonstrated to reduce the risk of local recurrence for the treatment of locally advanced low rectal cancer. Combined with the laparoscopic technique, laparoscopic ELAPE (LELAPE) has the potential to reduce invasion and hasten postoperative recovery. In this study, we aim to investigate the advantages of LELAPE in comparison with conventional APR.Methods:From October 2010 to February 2013, 23 patients with low rectal cancer (T3–4N0–2M0) underwent LELAPE; while during the same period, 25 patients were treated with conventional APR. The patient characteristics, intraoperative data, postoperative complications, and follow-up results were retrospectively compared and analyzed.Results:The basic patient characteristics were similar; but the total operative time for the LELAPE was longer than that of the conventional APR group (P = 0.014). However, the operative time for the perineal portion was comparable between the two groups (P = 0.328). The LELAPE group had less intraoperative blood loss (P = 0.022), a lower bowel perforation rate (P = 0.023), and a positive circumferential margin (P = 0.028). Moreover, the patients, who received the LELAPE, had a lower postoperative Visual Analog Scale, quicker recovery of bowel function (P = 0.001), and a shorter hospital stay (P = 0.047). However, patients in the LELAPE group suffered more chronic perineal pain (P = 0.002), which may be related to the coccygectomy (P = 0.033). Although the metastasis rate and mortality rate were similar between the two groups, the local recurrence rate of the LELAPE group was statistically improved (P = 0.047).Conclusions:When compared with conventional APR, LELAPE has the potential to reduce the risk of local recurrence, and decreases operative invasion for the treatment of locally advanced low rectal cancer.

Robotic versus laparoscopic surgery for mid or low rectal cancer in male patients after neoadjuvant chemoradiation therapy: comparison of short-term outcomes.

The aim of our study was to compare short-term outcomes of robotic and laparoscopic sphincter-saving total mesorectal excision (TME) in male patients with mid-low rectal cancer (RC) after neadjuvant chemoradiotherapy (NCRT). The study was conducted as a retrospective review of a prospectively maintained database, and we analyzed 14 robotic and 65 laparoscopic sphincter saving TME (R-TME and L-TME, respectively) performed by one surgeon between 2005 and 2013. Patient characteristics, perioperative recovery, postoperative complications and and pathology results were compared between the two groups. The patient characteristics did not differ significantly between the two groups. Median operating time was longer in the R-TME than in the L-TME group (182 min versus 140 min). Only two conversions occurred in the L-TME group. No difference was found between groups regarding perioperative recovery and postoperative complication rates. The median number of harvested lymph nodes was higher in the RTME than in the L-TME group (32 versus 23, p = 0.008). The median circumferential margin (CRM) was 10 mm in the R-TME group, 6.5 mm in the L-TME group (p = 0.047. The median distal resection margin (DRM) was 27.5 mm in the R-TME, 15 mm in the L-TME group (p = 0.014). Macroscopic grading of the specimen in the R-TME group was complete in all patients. In the L-TME group, grading was complete in 52 (80%) and incomplete in 13 (20%) cases (p = 0.109). R-TME is a safe and feasible procedure that facilitates performing of TME in male patients with mid-low RC after NCRT.

Carotid sparing intensity-modulated radiation therapy achieves comparable locoregional control to conventional radiotherapy in T1-2N0 laryngeal carcinoma

Although intensity-modulated radiotherapy (IMRT) is a standard of care for many head and neck cancers, its use for carotid-sparing (CS) therapy in early-stage laryngeal carcinoma is controversial. 330 consecutive patients with early-stage laryngeal carcinoma were treated from 1/1989 to 5/2011, including 282 conventional radiotherapy (CRT) and 48 CS-IMRT patients. The median follow-up was 43 (CS-IMRT) and 66 (CRT) months. There was no difference in local failure rates comparing patients undergoing CS-IMRT with CRT, with 3-year local control rates of 88% vs. 89%, respectively (p=0.938). Using a 1cm circumferential margin, the average dose to the left and right carotid arteries was 48.3 and 47.9 Gy, respectively. 88% of locoregional recurrences involved the ipsilateral true vocal cord, including all local recurrences in the IMRT group. These results warrant further prospective evaluation of CS-IMRT for early-stage glottic larynx cancer.

A Study of 101 Laparoscopic Colorectal Surgeries: a Single Surgeon Experience. How Important Is the Learning Curve?

This study aims to document demographic and intraoperative variables and short-term postoperative outcomes in patients being operated by laparoscopy-assisted colorectal surgeries and assessing the magnitude of impact of the learning curve on surgical results. This study included 101 patients with colonic or rectal pathology getting operated for laparoscopy-assisted colorectal surgeries carried out by the same surgeon over 5years (2008 to 2013). The patient data was retrospectively analyzed for pre-decided variables. Also, comparison was made between the surgeries performed during the learning curve of initial 30 cases with subsequent operations. Laparoscopic colorectal surgeries give satisfactory results in terms of intraoperative parameters like surgical duration, blood loss, and clinico-pathologic parameters like lymph nodal resection and distal and circumferential margins. Patients undergoing laparoscopic colorectal surgeries fare better in short-term postoperative period while early long-term outcomes appear similar as compared to the standard open colorectal surgeries. The surgical outcomes, both intraoperative and early postoperative, improve significantly once the learning curve is negotiated. Laparoscopic Surgery can be safely used as an alternative to conventional open colorectal surgeries without compromising on oncological principles.

Laparoscopic anterior resection with transanal total mesorectal excision for rectal cancer: preliminary experience and impact on postoperative bowel function.

Transanal total mesorectal excision (TME) and the "down-to-up" mobilization concept might be possible alternatives to the standard TME, particularly in cases of narrow pelvis or bulky tumors in obese patients. Our aim was to test the feasibility and safety of transanal TME and to evaluate its impact on short-term functional outcome. Six consecutive patients with histologically proven low/middle rectal adenocarcinoma were prospectively enrolled. All patients underwent laparoscopic anterior resection with transanal TME. Intraoperative complications, postoperative morbidity, and oncologic adequacy of the surgical specimen were evaluated in all patients. A bowel function questionnaire using information from the Wexner's score continence grading scale was administered to all patients 1 week before surgery and 6 months following operation. Laparoscopically assisted transanal TME was successful in all patients. Mean operative time was 236 minutes (range, 200-270 minutes). There were no intraoperative complications. The anastomotic leak rate was 16.6%. Clear distal and circumferential margins and proper lymphadenectomy were obtained in all surgical specimens (mean number of nodes harvested, 32; range, 19-68). In no patients was a major incontinence observed; the median (range) Wexner score at 6 months after surgery was 3 (1-7). Transanal TME is safe and feasible. Preliminary outcomes meet oncologic criteria. Moreover, the transanal approach does not have an adverse impact on functional outcome. Further long-term evaluation of results and clinical trials should be performed.

The impact of use of an intraoperative margin assessment device on re-excision rates.

Historically there has been a high rate of surgical interventions to obtain clear margins for breast cancer patients undergoing breast conserving local therapy. An intraoperative margin assessment tool (MarginProbe) has been approved for use in the US since 2013. This study is the first compilation of data from routine use of the device, to assess the impact of device utilization on re-excision rates. We present a retrospective, observational, review from groups of consecutive patients, before and after the implementation of intraoperative use of the device during lumpectomy procedures. Lesions were localized by standard methods. The intraoperative margin assessment device was used on all circumferential margins of the main specimen, but not on any additional shavings. A positive reading by the device led to an additional shaving of the corresponding cavity location. Specimens were also, when feasible, imaged intra-operatively by X-ray, and additional shavings were taken if needed based on clinical assessment. For each surgeon, historical re-excision rates were established based on a consecutive set of patients from a time period proximal to initiation of use of the device. From March 2013 to April 2014 the device was routinely used by 4 surgeons in 3 centers. In total, 165 cases lumpectomy cases were performed. Positive margins resulted in additional re-excision procedures in 9.7% (16/165) of the cases. The corresponding historical set from 2012 and 2013 consisted of 186 Lumpectomy cases, in which additional re-excision procedures were performed in 25.8% (48/186) of the cases. The reduction in the rate of re-excision procedures was significant 62% (P < 0.0001). Use of an intraoperative margin assessment device contributes to achieving clear margins and reducing re-excision procedures. As in some cases positive margins were found on shavings, future studies of interest may include an analysis of the effect of using the device on the shavings intra-operatively.