Introduction Of Total Mesorectal Excision Research Articles

Advances in rectal cancer: Real-world evidence suggests limited gains in prognosis for elderly patients

BackgroundRectal cancer treatment has improved considerably due to the introduction of total meso-rectal excision, radio-chemotherapy, and high-resolution imaging. The aim of this observational cohort study was to quantify the effectiveness of these advances using high-quality data from a representative cohort of patients. Methods20 281 non-metastasized cases retrieved from the Munich Cancer Registry database were divided into three time periods corresponding to before (1988–1997), partial (1998–2007), and full implementation (2008–2019) of clinical advances. Early-onset (<50 yrs.), middle-aged, elderly patient subgroups (> 70 yrs.) were compared. The overall effectiveness of evidence-based guideline adherence was also examined. ResultsMedian survival improved by 1.5 yrs. from the first to the last time period. Relative survival increased from 74.9% (5-yr 95%CI[73.3 – 76.6]) to 79.2% (95%CI[77.8 – 80.5]). The incidence of locoregional recurrences was reduced dramatically by more than half (5-yr 17.7% (95%CI[16.5 – 18.8]); 6.7% (95%CI[6.1 – 7.3])). Gains in 5-yr relative survival were limited to early-onset and middle-aged patients with no significant improvement seen in elderly patients (Female 68.6% [63.9 – 73.3] to 67.6% [64.0 – 71.2]; Male 71.7% [65.9 – 77.4] to 74.0% [70.8 – 77.2]). ConclusionsReal-world evidence suggests that recent treatment advances have lead to an increase in prognosis for rectal cancer patients. However, more effort should be made to improve the implementation of new developments in elderly patients. Especially considering, that these cases represent a growing majority of diagnosed patients.

Clinical implication and management of rectal cancer with clinically suspicious lateral pelvic lymph node metastasis: A radiation oncologist's perspective.

Rectal cancer is the eighth most common malignancy worldwide. With the introduction of total mesorectal excision (TME) and neoadjuvant chemoradiation (NCRT), intrapelvic local control has been remarkably improved. However, lateral pelvic recurrence remains problematic, especially in patients with clinically suspicious lateral pelvic lymph node (LPLN). LPLN dissection has been applied for the management of LPLN metastasis, mainly in Japan and other Eastern countries, while the role of NCRT is more emphasized and LPLN dissection is performed in very limited cases in Western countries. However, the optimal management strategy for patients with rectal cancer with suspicious LPLN metastasis has not been determined. Herein, we review the latest studies on the optimal management of LPLN metastasis to suggest the most appropriate treatment policies according to current evidence and discuss future research directions.

Image-Guided Brachytherapy for Rectal Cancer: Reviewing the Past Two Decades of Clinical Investigation.

Simple SummaryWith the introduction of better-quality imaging for tumor visualization and treatment planning, a new conformed radiation treatment was introduced with high-dose-rate endorectal brachytherapy (HDREBT). The advantage of this treatment is allowing for better sparing of normal tissues surrounding the tumor during treatment while delivering higher dose to the tumor. This diminishes the number and severity of side effects and results in more effective treatment. This manuscript summarizes two decades of technological evolution and progress in clinical studies to validate this treatment concept from the pre-operative setting to prevent tumor recurrence and, more recently, the introduction of the objective of cure without surgery; i.e., non-operative management (NOM) for patients with curable rectal cancer. HDREBT is a conformed radiation modality, shown to be safe and efficient both in the pre-operative setting and is presently being explored with interest in NOM in a multicenter study.(1) Background: The introduction of total mesorectal excision (TME) for rectal cancer has led to improvement in local recurrence (LR) outcomes. Furthermore, the addition of preoperative external beam radiotherapy to TME reduces LR to less than 6%. As a trade-off to these gradual improvements in local therapies, the oncology community’s work is now focusing on mitigating treatment-related toxicities. In other words, if a small proportion of 4–6% of rectal cancer patients benefit from additional local therapy beyond TME, the burden of acute and long-term side effects must be considered with care. (2) Methods: With the introduction of better-quality imaging for tumor visualization and treatment planning, a new conformed radiation treatment was introduced with high-dose-rate endorectal brachytherapy. The treatment concept was tested in phase I and II studies: first in the pre-operative setting, and then as a boost after external beam radiation therapy, as a dose-escalation study, to achieve higher local tumor control. (3) Results: HDREBT is safe and effective in achieving a high tumor regression rate and was well tolerated in a phase II multicenter and two matched-pair studies. (4) Conclusions: HDREBT is a conformed radiation therapy that is safe and effective, and is presently explored in a phase III dose-escalation study in the NOM of patients with operable rectal cancer.

Tratamiento del cáncer de recto

Mortality from rectal cancer continues to be a matter of concern and health impact. Worldwide, colorectal cancer is in 3rd place in terms of incidence. In the United States, for the year 2015, 93,090 new cases of colon cancer and 36,610 of the rectum are calculated. In France, the incidence of rectal cancer currently oscillates at 15,000 new cases per year.1 In Uruguay, the National Cancer Registry of the Honorary Commission for the Fight against Cancer 2014, publishes the results of cancer incidence in Uruguay in the period 2007-2011.2 The incidence of colorectal cancer in men showed incidence figures of 38.07 with a mortality of 19.23 (3rd place behind prostate and lung) and in women an incidence of 27.28 with a mortality of 12.73 ( 2nd place, behind breast) per 100.00 inhabitants respectively. The estimate made for the year 2030 marks an increase in incidence close to 25% for both sexes (according to figures from Globocan WHO). This marks a worrying health reality and demands a joint effort and active policies with a view to improving results. Rectal cancer treatment has undergone major changes in the last 30 years. The introduction of total mesorectal excision (TME) in 1982 by R. Heald, associated with the important advances in the field of oncology and radiotherapy have modified the evolution of these patients. The introduction of laparoscopic surgery, new surgical techniques that make it possible to push the limit of sphincter preservation increasingly distal, and the expectations posed by robotic surgery, make distal rectal cancer a current topic. The Advances in associated disciplines such as imaging have allowed precise selection and optimization of treatments.

Development of surgical concepts in rectal cancer resection and challenges in minimally invasive surgical proctectomy

Since the early 1900s there have been dramatic changes in the management of patients with rectal cancer. Surgical approaches initially performed for palliation, have now been adapted, modernised and undertaken as part of a multimodal approach. This has resulted in significant improvements in long-term oncological survival and patient quality of life. With the introduction of total mesorectal excision (TME) in the 1980's, and its global acceptance by the surgical community, local and distant disease-free survival in patients with rectal malignancy has significantly improved. Since the inception of minimally invasive surgery, laparoscopy has seen dramatic changes both in the evolution of technological advances and application in multiquadrant surgery for colorectal malignancy. Favorable short-term clinical benefits and long-term oncological equivalence from many multicentre randomized controlled trials in laparoscopic colonic cancer resection has led the colorectal surgical community to translate and adapt minimally invasive surgical (MIS) techniques for proctectomy in patients with rectal tumours. MIS proctectomy is technically challenging and is associated with a steep learning curve. Reported challenges in the literature continuously identify a group within three common themes which can be divided into patient/anatomical factors, tumour characteristics and the use of neoadjuvant therapies. Despite a large body of evidence highlighting efficacy of MIS in proctectomy, significant challenges exist in male patients with a narrow pelvis and distal tumors. Such patients are at increased risk of a poor surgical specimen, positive distal and circumferential resection margins (CRMs), and increased local recurrence. Despite advances in laparoscopy and robotic platforms, approaching such lesions from a “top down” approach expose the ongoing limitations to lower pelvic access. This technically challenging issue has led to the colorectal surgical community adopting previously taught MIS techniques to develop a “bottom up” transanal approach to TME, now known as transanal TME (taTME) in order to mitigate this increased margin risk.

Better understanding of interfacial planes in colorectal cancer surgery and the value of small vessels on fascia in the identification of interfacial planes

The introduction of total mesorectal excision and wider use of laparoscopic surgery pushed the field of colorectal surgery into an era of interfasical dissection. The Japanese suggestion of fascial arrangement of the trunk in a multilaminar, symmetrical and parallel way helps in better understanding of fascial relationship and interfascial planes surrounding the colon and the rectum. However, different interpretations of the multilayer retroperitoneal fascial relationship, complexity of fascial structures within the pelvis and dense adhesion between two apposed fasciae at special points make it still challenging for the surgeon to decide on the precise interfascial plane for colorectal mobilization. Small vessels on fasica propria of the rectum and various retroperitoneal fascia, especially ureterohypogastric fascia show distinctive features. The root of small vessels on fascia propria of the rectum helps to identify the anterolateral and posterolateral interfascial plane in the middle and low rectum. The longitudinal trajectory of small vessel on ureterohypogastric fascia and scarcity interfascial vascular communication between mesocolic and retroperitoneal fascia help the surgeon to find and stay in the interfacial plane during colorectal mobilization. More knowledge of fascial and interfascial plane will certainly help achieve better mesocolic mesorectal integrity and reduce the risk of injuries to autonomic nerves. More anatomical, histological and embryological studies are warranted with respect to relationship between small vessels and fasciae.

Survival after Laparoscopic Versus Open Curative Excision for Rectal Cancer

Background: Management of rectal cancer has been evolved over the past two decades with the introduction of total mesorectal excision (TME) and laparoscopic resection. Objective: This study aims to assess the difference in the long-term outcomes after laparoscopic and open resection for potentially curable, non-metastatic rectal cancer patients.Methods: This is a retrospective study which has been conducted in a single tertiary care center where the patients were recruited from the colorectal database of the Section of Colon and Rectal Surgery at King Faisal Specialist Hospital &amp; Research Centre (KFSH&amp;RC). It included all the patients who had non-metastatic rectal cancer and underwent laparoscopic or open curative resection regardless of their age or the comorbid status during the period from January 2012 – December 2015. We studied the long-term outcomes for those patients which included the completeness of resection of the tumor, overall 3-year survival, 3-year disease-free survival, local recurrence, and distal recurrence of cancer.Results:120 patients were included in this study, 69 of them were males and 51 were females. 86 (71.7%) of them underwent open surgery while 34 (28.3%) underwent laparoscopic surgery. After a mean follow-up of 32.4 months: 104 patients were alive, 7 deceased, and 9 were lost of follow-up. Local recurrence in the open approach (OA), and laparoscopic approach (LA) groups was 3/86 (3.5%) and 4/34 (11.8%) respectively. Distal recurrence occurred in 12/86 (14%) of OA and 5/34 (14.7%) of LA. Overall 3-years survival for OA and LA was 89% and 97% respectively and the 3-years disease-free survival was 49% and 57% respectively.Conclusion: Laparoscopic and open rectal excision were similar in their outcome.

Short term outcomes of minimally invasive selective lateral pelvic lymph node dissection for low rectal cancer.

Pelvic recurrence after rectal cancer surgery is still a significant problem despite the introduction of total mesorectal excision and chemoradiation treatment (CRT), and one of the most common areas of recurrence is in the lateral pelvic lymph nodes. Hence, there is a possible role for lateral pelvic lymph node dissection (LPND) in rectal cancer. To evaluate the short-term outcomes of patients who underwent minimally invasive LPND during rectal cancer surgery. Secondary outcomes were to evaluate for any predictive factors to determine lymph node metastases based on pre-operative scans. From October 2016 to November 2019, 22 patients with stage II or III rectal cancer underwent minimally invasive rectal cancer surgery and LPND. These patients were all discussed at a multidisciplinary tumor board meeting and most of them received neoadjuvant chemoradiation prior to surgery. All patients had radiologically positive lateral pelvic lymph nodes on the initial staging scans, defined as lymph nodes larger than 7 mm in long axis measurement, or abnormal radiological morphology. LPND was only performed on the involved side. Majority of the patients were male (18/22, 81.8%), with a median age of 65 years (44-81). Eighteen patients completed neoadjuvant CRT pre-operatively. 18 patients (81.8%) had unilateral LPND, with the others receiving bilateral surgery. The median number of lateral pelvic lymph nodes harvested was 10 (3-22) per pelvic side wall. 8 patients (36.4%) had positive metastases identified in the lymph nodes harvested. The median pre-CRT size of these positive lymph nodes was 10mm. Median length of stay was 7.5 d (3-76), and only 2 patients failed initial removal of their urinary catheter. Complication rates were low, with only 1 lymphocele and 1 anastomotic leak. There was only 1 mortality (4.5%). There have been no recurrences so far. Chemoradiation is inadequate in completely eradicating lateral wall metastasis and there are still technical limitations in accurately diagnosing metastases in these areas. A pre-CRT lymph node size of ≥ 10 mm is suggestive of metastases. LPND may be performed safely with minimally invasive surgery.

Experience beyond the learning curve of transanal total mesorectal excision (taTME) and its effect on the incidence of anastomotic leak

BackgroundThe most important advancement in the surgical management of rectal cancer has been the introduction of total mesorectal excision (TME). Technical limitations to approaching mid and distal lesions remain. The recently described transanal TME makes it possible to minimize some of the difficulties by improving access. Anastomotic leak is a persistent concern after colorectal surgery no matter what technique is used. The objective of this study was to explore the impact of experience on the incidence of anastomotic leak after transanal TME. Secondary endpoints were local recurrence and margin status.MethodsA retrospective cohort study was conducted over a period of 3 years at a tertiary care center in Northern Ontario with high volume of rectal cancer patients. The initial 100 consecutive patients with rectal neoplasia who had transanal TME surgery were included. All cases were performed by a single team. The main outcome assessed was the incidence of anastomotic leak beyond a pre-determined learning curve, as previously established in the literature. For statistical analysis, associations between patient characteristics and outcomes were estimated using ordinary least squares and logistic regression.ResultsSix cases of anastomotic leak occurred over the course of the study, the last of which occurred in the 37th patient. Relative to a baseline anastomotic leak rate of 7.8%, cumulative sum (CUSUM) analysis indicated that a 50% improvement in risk occurred at trial 50 of 85 patients that had an anastomosis performed. Two patients developed local recurrence during the study period. No correlation between learning curve and oncologic outcomes was identified.ConclusionsProficiency is likely to have a positive effect on the 30-day occurrence of anastomotic leak. Larger studies are required to explore the impact of experience on local recurrence.

Pathologists’ Role in the Evaluation of the Prognostic Implications of Circumferential Resection Margin in Resected Rectal Carcinoma

Colorectal cancer is one of the most common malignancies in Sri Lanka as well as in other parts of the world and has a high incidence of cancer related deaths. Recent advances have been made with regard to the biological understanding of this disease and its treatment. Furthermore, new surgical, chemotherapeutic and radiotherapeutic strategies have been developed over the last decade in view of improving the quality of care. The worldwide introduction of total mesorectal excision (TME) in combination with the increasing use of neoadjuvant therapy has significantly improved the overall outcome. An important prognostic factor in rectal cancer is the status of the circumferential resection margin (CRM). The involvement of this margin has been associated with a poor prognosis. Pathologists play a vital role by providing important information for the clinical management of the patient and for the evaluation of health care as a whole. For the patient it confirms the diagnosis and describes the variables that will affect the prognosis, all of which will be relevant for the future management. For health care evaluation, pathology reports provide information for cancer registration and audit related to diagnostic and surgical procedures. Accurate evaluation of CRM in rectal carcinoma is important to determine the risk of local recurrence, which might subsequently be prevented by additional therapy. An increased risk was seen when the distance to CRM was < 2 mm.

Surgical treatment of colorectal cancer

Surgical treatment of colorectal cancer Abstract. For the last two decades, colorectal surgery has been evolving driven by technical innovation, new findings in clinical trials and better understanding of the pathophysiology and biology of the tumours. Efforts to improve oncological outcomes led to a centralisation of care and nowadays surgery for colorectal cancer is mainly performed in certified high-volume centres. Standardised surgical techniques have been developed in order to facilitate training and improve oncological outcome. The introduction of total mesorectal excision (TME) resulted in a better postoperative outcome, reduced local recurrence rate and better overall survival for rectal cancer. Complete mesocolic excision (CME) was described as an attempt to standardise the operative technique for colon cancer and follows the same principles of the TME in order to improve the oncological outcome. In this approach, sharp precise dissection of the embryological planes allows the maintenance of integrity of the mesocolic envelope with its lymphatic drainage. However, CME has not yet been adopted universally by surgeons and data about long-term oncological outcome are awaited. One of the most substantial recent developments in the surgery of colon cancer is the implementation of minimally invasive approach. Randomised controlled trials demonstrated comparability of laparoscopic versus open surgery for colonic cancer. However, with the recent evidence, non-inferiority of the laparoscopic approach for TME could not be proven. Obtaining a clear circumferential resection margin especially in male patients with narrow pelvis is a major issue that has a direct impact on the local recurrence of rectal cancer. In an attempt to improve quality of the TME, new surgical techniques such as transanal total mesorectal excision and robotic surgery are now widely performed. However, oncological long-term data are lacking. Preservation of function and quality of life are factors which need to be addressed when counselling the patient with rectal cancer. Organ preservation with local excision for low-risk lesions is an appropriate approach for selected patients.

Is it time to define complete mesocolic excision as a standardized colon cancer surgery?

We appreciate that Negoi et al . (1) agree with us on the oncological benefit of complete mesocolic excision (CME) in colon cancer, which is one of the primary objectives of our article (2) and the rationale to advocate the standardization and quality control of colon cancer surgery. The general view of colorectal surgeons is that introduction of total mesorectal excision results in revolutionary improvement in rectal cancer surgery, thereby improving prognosis (3). In contrast, in spite of nearly 10 years since the introduction of CME, its safety and efficiency is controversial (4). This may be owing to the lack of quality control in previous studies. Not all surgeries followed the standards of the CME group, which might affect the confounding factors of prognosis (4).

Can we predict surgical difficulty of rectal surgery?

In rectal surgery, the gold standard of surgical technique is total mesorectal excision (TME) (1). Treatment of rectal cancer has improved by the introduction of TME, which resulted in decreased postoperative local recurrence.

Transanal total mesorectal excision (TaTME): Surgical technique description

Treatment of rectal cancer has changed during the last decades. Major advances in the management of rectal cancer include establishment of multimodal therapy, introduction of total mesorectal excision (TME) by Heald in 1979.

Risk factors for anastomotic leakage after rectal cancer surgery

Anastomotic leakage is one of the common complications after rectal cancer surgery. Advances in the field of rectal surgery, such as introduction of total mesorectal excision, double-stapling reconstruction techniques, and minimally invasive surgery have improved oncologic outcomes and resulted in more favorable functional results, with a greater proportion of patients undergoing sphincter-preserving surgeries. Despite technical improvements, the incidence of anastomotic leakage has not decreased significantly. The incidence of anastomotic leakage is related to many factors, including patient-related factors, such as male sex, obesity, low score of nutrition risk screening, and III(-IIIII( grade of ASA grading; disease-related factors, such as lower tumor location, tumor diameter >3 cm, preoperative chemoradiotherapy and comorbidity; surgery-related factors, such as open or laparoscopic surgery, blood supply of anastomosis, tension of anastomosis, preventive stoma, duration of surgery, intraoperative blood loss, intraoperative events, and contamination, as well as selection and use of anastomotic device. Fully understanding the risk factors of anastomotic leakage are very important for reducing the occurrence of anastomotic leakage. For patients with risk factors, appropriate preventive measures should be implemented timely to reduce the risk of anastomotic leakage.

Neoadjuvant treatment of rectal cancer: where are we now?

Colorectal cancer is the third leading cause of cancer-related mortality in the United States [1]. Of this group of patients, approximately 39 000 cases of rectal cancer were reported in the US in 20151]. Treatment of rectal cancer truly requires combinatorial therapy with surgery, chemotherapy and radiation (RT), which now comprise the cornerstone of treatment for rectal cancer. Advanced rectal and colon cancers are generally treated similarly, with most clinical trials not distinguishing between these two anatomic origins. This is in contrast to early stage and locally advanced disease in which the natural histories are distinct, stemming from the fact that the vascular supply for the rectum drains into the inferior vena cava instead of the portal vein [2]. The difference in vascular drainage results in an increase in pulmonary metastases rather than liver metastases [2]. Historically, recurrence within the pelvis has been more common than distant metastases. It is not surprising that treatment objectives focus on minimizing and/or eliminating both local recurrence and distant metastases. Early in the 1970s and 1980s, the recurrence rates were extremely high, nearing 50%, which led to numerous clinical studies evaluating the role of postoperative RT and adjuvant therapy with 5-fluorouracil (5FU) as the backbone. Consensus guidelines from 1990 have established trimodality therapy with chemotherapy, RT and surgery as the standard of care for locally advanced rectal cancer (stage II/stage III) [2,3]. Significant improvements in local disease control have been achieved ever since with the introduction of total mesorectal excision and neoadjuvant chemoradiotherapy (CRT). More recently, questions have been raised as to whether trimodality therapy in the neoadjuvant setting is truly required to obtain disease control for all patients with locally advanced rectal cancer. Furthermore, while local recurrence rates have been stable at 5–6% [4] with this trimodality strategy in recent clinical trials, distal recurrence rates for locally advanced rectal cancers remain at around 25% [5]. In fact, metastases now represent the main cause of death. It is for these reasons that new studies are evaluating the role of systemic chemotherapy in the neoadjuvant setting to address micrometastatic disease and hence potentially reduce the rate of distant recurrence [2,6–8]. In this brief review, we summarize the current literature for neoadjuvant treatment of rectal cancer. Staging in rectal cancer Management of locally advanced rectal cancer is complex, in part due to the necessity of integrating multi-modality treatment consisting of chemotherapy, RT and surgery, which are often required for curative intent. The timing and sequencing of these modalities are challenging because the location of the rectal tumor, the extent of spread and nodal involvement all determine optimal delivery of these treatments. The objective of neoadjuvant treatment remains optimization of disease-free survival (DFS) and overall survival (OS) while minimizing toxicity from RT and chemotherapy and eliminating local recurrence [2]. Early-stage disease, defined as T1-2N0, is usually treated with surgery alone. Locally advanced disease, defined as stage II/III disease, requires initial clinical staging with pelvic MRI and endoscopic rectal ultrasound (ERUS) evaluation to determine the extent of disease and nodal involvement. Staging provides critical information about the likelihood of achieving a complete resection (R0) as well as the likelihood of sparing the rectal sphincter and thereby maintaining fecal continence [2]. Colonoscopic evaluation is required for all patients to determine the extent of resection that will be required and to explore for synchronous lesions. MRI is a vital tool for presurgical management assessment as it can better delineate encroachment on the mesorectal fascia and thereby help determine the potential for a positive radial margin at the time of surgery [8]. The precision of MRI in this setting was evaluated in the MERCURY trial in which high-resolution MRI accurately predicted whether the surgical resection margins were clear or affected by tumor [9].

Neoadjuvant chemoradiation therapy and pathological complete response in rectal cancer.

The management of rectal cancer has evolved significantly in the last few decades. Significant improvements in local disease control were achieved in the 1990s, with the introduction of total mesorectal excision and neoadjuvant radiotherapy. Level 1 evidence has shown that, with neoadjuvant chemoradiation therapy (CRT) the rates of local recurrence can be lower than 6% and, as a result, neoadjuvant CRT currently represents the accepted standard of care. This approach has led to reliable tumor down-staging, with 15–27% patients with a pathological complete response (pCR)—defined as no residual cancer found on histological examination of the specimen. Patients who achieve pCR after CRT have better long-term outcomes, less risk of developing local or distal recurrence and improved survival. For all these reasons, sphincter-preserving procedures or organ-preserving options have been suggested, such as local excision of residual tumor or the omission of surgery altogether. Although local recurrence rate has been stable at 5–6% with this multidisciplinary management method, distal recurrence rates for locally-advanced rectal cancers remain in excess of 25% and represent the main cause of death in these patients. For this reason, more recent trials have been looking at the administration of full-dose systemic chemotherapy in the neoadjuvant setting (in order to offer early treatment of disseminated micrometastases, thus improving control of systemic disease) and selective use of radiotherapy only in non-responders or for low rectal tumors smaller than 5 cm.

Improved survival after an educational project on colon cancer management in the county of Stockholm – A population based cohort study

IntroductionOutcomes in rectal cancer have improved dramatically after the introduction of total mesorectal excision (TME). Recently, the TME concept has been transformed into that of complete mesocolic excision (CME) in an attempt to improve prognosis for patients with colon cancer. Patients and methodsMultidisciplinary team (MDT) workshops including the CME concept were held annually between 2004 and 2008 at the Karolinska University Hospital. The workshops focused on preoperative staging, surgery and histopathology and included lectures and live surgery sessions. To compare survival before and after the “Stockholm Colon Cancer Project” all patients diagnosed with a right sided colon cancer between January 1, 2001 and December 31, 2003 (Group 1) and from January 1, 2006 until December 31, 2008 (Group 2) in Stockholm were identified from the Swedish ColoRectal Cancer Registry (SCRCR). ResultsThe proportion of patients having a tumour resection and the proportion having emergency surgery was higher in Group 1. There were more early tumours and more R0 resections in Group 2. Overall survival in all diagnosed patients and disease free survival after tumour resection was improved in the second time period. DiscussionSurgical teaching programmes may have an impact on the management and outcome in colon cancer. The exact impact from the “Stockholm Colon Cancer Project” cannot be established, however it is likely that it contributed to the improved survival.

Neoadjuvant treatment for locally advanced rectal cancer: a systematic review.

We reviewed the history and the current status of neoadjuvant treatment for locally advanced rectal cancer (LARC) in Western countries and Japan. The introduction of total mesorectal excision (TME) and preoperative radiotherapy (RT) were treatment revolutions that resulted in improved local control after curative resection for rectal cancer. However, local relapses still occur, even in the era of TME, and remain a cause of recurrence worldwide. The high rate of distant metastasis after curative resection remains a problem. Furthermore, the introduction of newly developed cytotoxic agents into the LARC treatment strategy continues to be an ongoing challenge. Shifting part of an adjuvant chemotherapy (CTx) regimen to the preoperative period is a promising strategy. Currently, various novel methods, such as induction CTx, consolidation CTx, concomitant administration with RT, and neoadjuvant CTx without RT, have been attempted worldwide. Although some strategies have shown favorable short-term outcomes, the long-term efficacy of the treatments needs be evaluated. At the same time, we must investigate clinical and/or molecular biomarkers to predict the therapeutic effects of each treatment, which is the fastest route to providing ideal personalized therapy for patients with LARC.

Analysis of cancer genomes through microarrays and next- generation sequencing

In rectal surgery, the gold standard of surgical technique is total mesorectal excision (TME) (1). Treatment of rectal cancer has improved by the introduction of TME, which resulted in decreased postoperative local recurrence.