Resection For Primary Rectal Cancer Research Articles

An actinomycosis infection resembling peritoneal dissemination of rectal cancer: a case report

BackgroundActinomycosis is a suppurative and granulomatous inflammation commonly caused by Actinomyces israelii. Due to its rarity and the paucity of characteristic clinical features, diagnosis of intra-abdominal actinomycosis is challenging, especially when the patient has a treatment history of abdominal cancer.Case presentationThe patient is a 72-year-old man who has a history of multiple abdominal surgeries for rectal cancer, including low anterior resection for primary rectal cancer, partial hepatic resection for metachronous liver metastasis, and Hartmann surgery for local recurrence. The patient has also undergone parastomal hernia repair using the Sugarbaker method. One year after hernia repair, computed tomography (CT) identified a mass lesion between the abdominal wall and the mesh, suggesting the possibility of peritoneal recurrence of rectal cancer. The accumulation of fluorodeoxyglucose (FDG) was evident via positron emission tomography-CT (PET-CT), while tumor marker levels were within the normal range. On laparotomy, the small intestine, abdominal wall, mesh, colon, and stoma were observed to be associated with the mass lesion, and en bloc resection was carried out. However, postoperative histopathological examination revealed an actinomyces infection without any cancerous cells.ConclusionsThis case highlights the challenges faced by surgeons regarding preoperative diagnosis of actinomycosis, especially when it occurs after the resection of abdominal cancer. Also, this case reminds us of the importance of a histopathological examination for abdominal masses or nodules before starting chemotherapy.

Evolution of clinical nature, treatment and survival of locally recurrent rectal cancer: Comparative analysis of two national cross-sectional cohorts

BackgroundIn the Netherlands, use of neoadjuvant radiotherapy for rectal cancer declined after guideline revision in 2014. This decline is thought to affect the clinical nature and treatability of locally recurrent rectal cancer (LRRC). Therefore, this study compared two national cross-sectional cohorts before and after the guideline revision with the aim to determine the changes in treatment and survival of LRRC patients over time. MethodsPatients who underwent resection of primary rectal cancer in 2011 (n = 2094) and 2016 (n = 2855) from two nationwide cohorts with a 4-year follow up were included. Main outcomes included time to LRRC, synchronous metastases at time of LRRC diagnosis, intention of treatment and 2-year overall survival after LRRC. ResultsUse of neoadjuvant (chemo)radiotherapy for the primary tumour decreased from 88.5% to 60.0% from 2011 to 2016. The 3-year LRRC rate was not significantly different with 5.1% in 2011 (n = 114, median time to LRRC 16 months) and 6.3% in 2016 (n = 202, median time to LRRC 16 months). Synchronous metastasis rate did not significantly differ (27.2% vs 33.7%, p = 0.257). Treatment intent of the LRRC shifted towards more curative treatment (30.4% vs. 47.0%, p = 0.009). In the curatively treated group, two-year overall survival after LRRC diagnoses increased from 47.5% to 78.7% (p = 0.013). ConclusionPrimary rectal cancer patients in 2016 were treated less often with neoadjuvant (chemo)radiotherapy, while LRRC rates remained similar. Those who developed LRRC were more often candidate for curative intent treatment compared to the 2011 cohort, and survival after curative intent treatment also improved substantially.

The role of preoperative mechanical bowel preparation and oral antibiotics in prevention of anastomotic leakage following restorative resection for primary rectal cancer - a systematic review and meta-analysis.

Anastomotic leakage after colorectal cancer resection is a feared postoperative complication seen among up till 10-20% of patients, with a higher risk following rectal resection than colon resection. Recent studies suggest that the combined use of preoperative mechanical bowel preparation and oral antibiotics may have a preventive effect on anastomotic leakage. This systematic review aims to explore the association between preoperative mechanical bowel preparation combined with oral antibiotics and the risk of anastomotic leakage following restorative resection for primary rectal cancer. Three databases were systematically searched in February 2022. Studies reporting anastomotic leakage rate in patients, who received mechanical bowel preparation and oral antibiotics before elective restorative resection for primary rectal cancer, were included. A meta-analysis was conducted based on the risk ratios of anastomotic leakage. Among 839 studies, 5 studies met the eligibility criteria. The median number of patients were 6111 (80-29,739). The combination of preoperative mechanical bowel preparation and oral antibiotics was associated with a decreased risk of anastomotic leakage (risk ratio = 0.52 (95% confidence interval 0.39-0.69), p-value < 0.001). Limitations included a low number of studies, small sample sizes and the studies being rather heterogenous. This systematic review and meta-analysis found that the use of mechanical bowel preparation and oral antibiotics is associated with a decreased risk of anastomotic leakage among patients undergoing restorative resection for primary rectal cancer. The limitations of the review should be taken into consideration when interpreting the results.

Foley balloons' tamponade is an effective method for controlling massive pelvic bleeding during colorectal surgery.

PurposeHemostasis can be achieved by various methods, but it can be difficult to stop active bleeding in the pelvis. An effective method is described to stop massive active bleeding in the pelvis during colorectal surgery.MethodsWhen there were massive bleedings in the pelvis, 3 to 5 Foley catheters were inserted through stab wounds on the abdomen. The tips of catheters were placed in the pelvis. Each balloon was inflated with 40 mL of sterile water. The water inside each balloon was removed gradually from the third postoperative day. If there is no further bleeding, all catheters were removed on the 7th postoperative day.ResultsThere were 8 patients (4 males and 4 females) with massive pelvic bleeding encountered from January 1998 to December 2018. Four patients underwent low anterior resection for primary rectal cancer, 2 patients for colon cancer with pelvic recurrence, 1 patient for ovary cancer with pelvic recurrence, and 1 patient for presacral parachordoma with a bleeding tendency. All of the patients survived without further bleeding after surgery.ConclusionThe technique is a simple method to control massive pelvic bleeding during colorectal surgery. It is also inexpensive and effective even in patients with a bleeding tendency.

The efficiency of 18F-FDG-PET/CT in the assessment of tumor response to preoperative chemoradiation therapy for locally recurrent rectal cancer

BackgroundLocally recurrent rectal cancer (LRRC) remains a major problem after curative resection of primary rectal cancer. A noninvasive, prognostic biomarker with which to accurately evaluate disease status and assess the treatment response is critically needed to optimize treatment plans. This study assesses the effectiveness of PET/CT evaluation of preoperative chemoradiation therapy (CRT) in patients with LRRC.MethodsSince 2004, we have been performing preoperative CRT to improve local tumor control and survival. Between 2004 and 2013, 40 patients with LRRC underwent preoperative CRT (radiation: 50 Gy/25 fractions; chemotherapy: irinotecan plus UFT [tegafur and uracil]/leucovorin) and radical surgery, and underwent 18F-FDG-PET/CT before and 3 weeks after the completion of CRT. The maximum standardized uptake values (SUVmax) of the pre-CRT scan (Pre-SUV) and the post-CRT scan (Post-SUV) were measured. The predictive value of the 18F-FDG-PET and CT/MRI response assessments was evaluated.ResultsThe mean Pre-SUV was significantly higher than the Post-SUV (8.2 ± 6.1, vs. 3.8 ± 4.0; P < 0.0001). Following CRT, 17/40 patients (42.5%) were classified as responders according to the Mandard tumor regression grade (TRG1–2). The mean Post-SUV was significantly lower in responders than in nonresponders (2.0 ± 1.7 vs. 5.1 ± 3.9; P = 0.0038). Pathological response was not correlated with the response as evaluated by CT (P > 0.9999) or MRI (P > 0.9999). Multivariate regression analysis identified Post-SUV as an independent predictor of local re-recurrence-free survival (P = 0.0383) and for overall survival (P = 0.0195).ConclusionsPET/CT is useful in assessing tumor response to preoperative CRT for LRRC and predicting prognosis after surgery.

Time interval between rectal cancer resection and reintervention for anastomotic leakage and the impact of a defunctioning stoma: A Dutch population‐based study

In the Netherlands, a selective policy of faecal diversion after rectal cancer surgery is generally applied. This study aimed to evaluate the timing, type, and short-term outcomes of reoperation for anastomotic leakage after primary rectal cancer resection stratified for a defunctioning stoma. Data of all patients who underwent primary rectal cancer surgery with primary anastomosis from 2013-2019 were extracted from the Dutch ColoRectal Audit. Primary outcomes were new stoma construction, mortality, ICU admission, prolonged hospital stay, and readmission. In total, 10,772 rectal cancer patients who underwent surgery with primary anastomosis were included, of whom 46.6% received a primary defunctioning stoma. The reintervention rate for anastomotic leakage was 8.2% and 11.6% for patients with and without a defunctioning stoma (p<0.001). Reintervention consisted of reoperation in 44.0% and 85.3% (p<0.001), with a median time interval from primary resection to reoperation of sevendays (IQR 4-14) vs. fivedays (IQR 3-13), respectively. In the presence of a defunctioning stoma, early reoperation (<5days; n=47) was associated with significantly more end-colostomy construction (51% vs. 33%) and ICU admission (66% vs. 38%) than late reoperation (≥5days; n=127). Without defunctioning stoma, early reoperation (n=252) was associated with significantly higher mortality (4% vs. 1%), and more ICU admissions (52% vs.34%) than late reoperation (n=302). Early reoperations after rectal cancer resection are associated with worse outcomes reflected by a more frequent ICU admission in general, more colostomy construction, and higher mortality in patients with primary defunctioned and nondefunctioned anastomosis.

Is radiological psoas muscle area measurement a predictor of postoperative complications after rectal resection for rectal cancer? A retrospective study.

Previous studies have reported that sarcopenia increases the risk of postoperative complications following colorectal resection. This retrospective study assessed the postoperative complications of rectal resection associated with sarcopenia. We retrospectively analyzed 262 patients who underwent curative low anterior resection for primary rectal cancer from January 2008 to May 2020 at our institution. The patients were divided into a sarcopenia group (normalized total psoas muscle area < 6.36cm2/m2 in males and < 3.92cm2/m2 in females; N = 49) and a non-sarcopenia group (N = 213). The overall rate of postoperative complications within 30days of surgery was higher in the sarcopenia group than in the non-sarcopenia group (46.9 vs. 29.6%; P = 0.028). The rate of postoperative remote infections was higher in the sarcopenia group than in the non-sarcopenia group (12.2 vs. 2.8%; P = 0.012). Sarcopenia was found to be a predictor of remote infection by a multivariate analysis (odds ratio, 4.08; 95% confidence interval, 1.12-14.80; P = 0.033). Sarcopenia diagnosed using the psoas muscle index was found to be an independent predictive factor for postoperative remote infection after curative low anterior resection for rectal cancer.

Stoma reversal after intended restorative rectal cancer resection in Denmark: nationwide population-based study.

BackgroundData on stoma reversal following restorative rectal resection (RRR) with a diverting stoma are conflicting. This study investigated a Danish population‐based cohort of patients undergoing RRR to evaluate factors predictive of stoma reversal during 3 years of follow‐up.MethodsPatients from national registries with rectal cancer undergoing RRR or Hartmann's procedure with curative intent between May 2001 and April 2012 were included. Patients with a diverting stoma were followed from the time of primary rectal cancer resection to date of stoma reversal, death, emigration, or end of 3‐year follow‐up. The cumulative incidence proportion (CIP) of stoma reversal at 1 and 3 years was calculated, treating death as a competing risk. Factors predictive of stoma reversal were explored using Cox regression analysis.ResultsOf 6859 patients included, 35·7, 41·9 and 22·4 per cent respectively had a RRR with a diverting stoma, RRR without a stoma, and Hartmann's procedure with an end‐colostomy. In patients with a diverting stoma, the CIP of stoma reversal was 70·3 (95 per cent c.i. 68·4 to 72·1) per cent after 1 year, and 74·3 (72·5 to 76·0) per cent after 3 years. Neoadjuvant treatment (hazard ratio (HR) 0·75, 95 per cent c.i. 0·66 to 0·85), blood loss greater than 300 ml (HR 0·86, 0·76 to 0·97), anastomotic leak (HR 0·41, 0·33 to 0·50), T3 category (HR 0·63, 0·47 to 0·83), T4 category (HR 0·62, 0·42 to 0·90) and UICC stage IV (HR 0·57, 0·41 to 0·80) were possible predictors of delayed stoma reversal.ConclusionIn one‐quarter of the patients the diverting stoma had not been reversed 3 years after the intended RRR procedure.

Simultaneous pelvic exenteration and liver resection for primary rectal cancer with synchronous liver metastases: results from the PelvEx Collaborative

Aim At presentation, 15-20% of patients with rectal cancer already have synchronous liver metastases. The aim of this study was to determine the surgical and survival outcomes in patients with advanced rectal cancer who underwent combined pelvic exenteration and liver (oligometastatic) resection. Method Data from 20 international institutions that performed simultaneous pelvic exenteration and liver resection between 2007 and 2017 were accumulated. Primarily, we examined perioperative outcomes, morbidity and mortality. We also assessed the impact that margin status had on survival. Results Of 128 patients, 72 (56.2%) were men with a median age of 60 years [interquartile range (IQR) 15 years]. The median size of the liver oligometastatic deposits was 2 cm (IQR 1.8 cm). The median duration of surgery was 406 min (IQR 240 min), with a median blood loss of 1090 ml (IQR 2010 ml). A negative resection margin (R0 resection) was achieved in 73.5% of pelvic exenterations and 66.4% of liver resections. The 30-day mortality rate was 1.6%, and 32% of patients had a major postoperative complication. The 5-year overall survival for patients in whom an R0 resection of both primary and metastatic disease was achieved was 54.6% compared with 20% for those with an R1/R2 resection (P = 0.006). Conclusion Simultaneous pelvic exenteration and liver resection is feasible, with acceptable morbidity and mortality. Simultaneous resection should only be performed where an R0 resection of both pelvic and hepatic disease is anticipated.

Risk factors for outlet obstruction after laparoscopic surgery and diverting ileostomy for rectal cancer.

Outlet obstruction is defined as bowel obstruction at the stoma opening. The aim of this study was to evaluate the risk factors for outlet obstruction in patients with rectal cancer who underwent laparoscopic surgery and diverting ileostomy. Among consecutive patients who underwent laparoscopic curative resection for primary rectal cancer between 2013 and 2015, 261 patients with diverting ileostomy were included in the analysis. The thickness of the abdominal wall, including the thickness of the rectus abdominis muscle, was measured using preoperative computed tomography. The clinicopathological factors were compared between the patients with and without outlet obstruction. Fourteen (5.4%) patients were diagnosed with outlet obstruction, but reoperation was not required. The rectus abdominis muscle was significantly thicker in male patients with outlet obstruction compared to those without outlet obstruction, but not in females. In a multivariate analysis, a rectus abdominis muscle thickness of 10mm or more was determined to be an independent risk factor for outlet obstruction (odds ratio, 7.0482; p = 0.0061). The thickness of the rectus abdominis muscle may be used to predict the occurrence of outlet obstruction in male patients with rectal cancer who undergo laparoscopic surgery and diverting ileostomy.

Preoperative Nutritional Status Predicts Major Morbidity After Primary Rectal Cancer Resection

BackgroundMalnutrition has been associated with adverse surgical outcomes, but data regarding its impact specifically in rectal cancer are sparse. The goal of this study was to use national data to determine the effects of malnutrition on surgical outcomes in rectal cancer resection. MethodsData were obtained from the American College of Surgeons National Surgical Quality Initiative Program from the years 2012-2015. Patients were included on the basis of International Classification of Disease 9/10 and Current Procedural Terminology codes for rectal cancer and proctectomy. Malnutrition was defined as body mass index <18.5 kg/m2, weight loss >10% in 6 mo, or preoperative albumin <3.5 mg/dL. Associations between malnutrition and postoperative outcomes were assessed by the Student t-test and chi-square test. Multivariate regression models were constructed to adjust for potential confounders of the association between malnutrition and surgical outcomes. ResultsOf the 9289 patients with primary rectal cancer who underwent resection, 1425 (15%) were in a state of malnutrition at the time of surgery. Patients with malnutrition had longer mean length of stay (LOS), and higher rates of 30-d mortality, wound infection, organ-space infection, sepsis, reoperation, prolonged LOS (>30 d), failure to wean off ventilator, renal failure, and cardiac arrest. With the exception of LOS, renal failure, and organ-space infection, malnutrition was still significantly associated with higher rates of these adverse outcomes after adjustment for confounders in multivariate regression models. ConclusionsMalnutrition is a practical marker associated with a variety of adverse outcomes after rectal cancer surgery, and it represents a potential target for nutritional therapies to improve surgical outcomes.

Simultaneous pelvic exenteration and liver resection for primary rectal cancer with synchronous liver metastases: results from the PelvEx Collaborative.

At presentation, 15-20% of patients with rectal cancer already have synchronous liver metastases. The aim of this study was to determine the surgical and survival outcomes in patients with advanced rectal cancer who underwent combined pelvic exenteration and liver (oligometastatic) resection. Data from 20 international institutions that performed simultaneous pelvic exenteration and liver resection between 2007 and 2017 were accumulated. Primarily, we examined perioperative outcomes, morbidity and mortality. We also assessed the impact that margin status had on survival. Of 128 patients, 72 (56.2%) were men with a median age of 60years [interquartile range (IQR) 15years]. The median size of the liver oligometastatic deposits was 2cm (IQR 1.8cm). The median duration of surgery was 406min (IQR 240min), with a median blood loss of 1090ml (IQR 2010ml). A negative resection margin (R0 resection) was achieved in 73.5% of pelvic exenterations and 66.4% of liver resections. The 30-day mortality rate was 1.6%, and 32% of patients had a major postoperative complication. The 5-year overall survival for patients in whom an R0 resection of both primary and metastatic disease was achieved was 54.6% compared with 20% for those with an R1/R2 resection (P=0.006). Simultaneous pelvic exenteration and liver resection is feasible, with acceptable morbidity and mortality. Simultaneous resection should only be performed where an R0 resection of both pelvic and hepatic disease is anticipated.

A phase III randomized controlled trial comparing surgery plus adjuvant chemotherapy with or without preoperative chemoradiotherapy for locally recurrent rectal cancer: A Japan Clinical Oncology Group study (JCOG1801).

TPS263 Background: Local recurrence is one of the most common forms of recurrence after curative resection for primary rectal cancer. Surgical resection is recommended for locally recurrent rectal cancer (LRRC) to achieve radical cure if the tumor is judged as resectable with negative margins. However, a high local re-recurrent risk after surgery is a major problem due to the difficulty of re-resection and the serious symptoms, such as pain or fistula, resulting from re-recurrence. Preoperative chemoradiotherapy (preCRT) is expected to improve local control after radical surgery for radiation naïve LRRC; however, high frequency of surgical complications after preCRT cannot be ignored. Due to the refractory nature and rarity of LRRC, the true impact of preCRT on oncological and surgical outcomes has not been clarified by clinical trials. The purpose of this study is to confirm the superiority of preCRT followed by surgery plus adjuvant chemotherapy over surgery plus adjuvant chemotherapy alone, in terms of local relapse-free survival for resectable LRRC. Methods: Eligibility criteria include resectable LRRC without distant metastasis, no prior pelvic irradiation, no prior surgery for LRRC, aged 20-80 years, and sufficient organ function. Eligible patients are randomized into the surgery and adjuvant chemotherapy (arm A) or preCRT followed by surgery and adjuvant chemotherapy (arm B). PreCRT consists of the standard dose of capecitabine and radiotherapy (50.4Gy). Adjuvant chemotherapy consists of mFOLFOX6, CAPOX, capecitabine, or 5FU+l-LV. The primary endpoint is local relapse-free survival (LRFS), and the secondary endpoints include overall survival, relapse-free survival, %R0 resection, incidence of adverse events, and quality of life after surgery. The 3-year LRFS of arm A is assumed to be 60% with a 13% increase expected in arm B. The sample size was calculated as 106 (53 per arm) with a one-sided alpha of 10%, power of 70%, and accrual period of 6 years. This trial was initiated on 19 August 2019. Clinical trial information: jRCTs031190076.

Clinical factors affecting the distal margin in rectal cancer surgery.

In rectal cancer surgery, an insufficient distal margin (DM) is associated with a high risk of local recurrence, whereas an excessive DM will cause low anterior resection syndrome, impairing quality of life. This study aimed to identify the factors that affect the distance between the colorectal resection site and the tumor to optimize achieving the correct DM. The subjects of this study were 219 patients who underwent resection for primary rectal cancer in our department between January 2006 and July 2014. According to Japanese guidelines, DM (rDM) was based on the tumor location, but the pathological DM (pDM) was measured from surgical specimens. The patients were divided into two groups: the pDM-less-than-rDM group (pDM < rDM) and the pDM-greater-or-equal-to-rDM group (pDM ≥DM). The factors associated with the DM in the two groups were compared. In the pDM < rDM group, the tumor distance from the anal verge was shorter (p = 0.001) and significantly more patients underwent laparotomy (p = 0.047). The DM tended to be shorter than that planned by the surgeon in patients with lower rectal cancers and those treated by laparotomy,; therefore, when performing rectal resection, care must be taken to ensure that the pDM is not shorter than the rDM.

Propensity Score Adjusted Comparison of Pelviperineal Morbidity With and Without Omentoplasty Following Abdominoperineal Resection for Primary Rectal Cancer

Abdominoperineal resection is associated with a high incidence of perineal complications, and whether this is reduced by an omentoplasty is still unclear. This study aimed to investigate the impact of omentoplasty on pelviperineal morbidity in patients undergoing abdominoperineal resection for rectal cancer. This was a retrospective comparative cohort study using propensity score analyses to reduce potential confounding. The study was undertaken in 2 teaching hospitals and 1 university hospital. Patients who underwent abdominoperineal resection for primary rectal cancer between 2000 and 2017 were included. The main end points were primary perineal wound healing at 30 days and overall and specific pelviperineal morbidity until the end of the study period. Among 254 included patients, 106 had an omentoplasty. The primary perineal wound healing rate at 30 days was similar for omentoplasty and no omentoplasty (65% vs 60%; p = 0.422), also after adjusting for potential confounding by propensity score analysis (OR, 0.89; 95% CI, 0.45-1.75). Being free from any pelviperineal complication at 6 months (75% vs 79%; p = 0.492), absence of any pelviperineal morbidity until 1 year (54% vs 49%; p = 0.484), and incidence of persistent perineal sinus (6% vs 10%; p = 0.256) were also similar in both groups. The unadjusted higher perineal hernia rate after omentoplasty (18% vs 7%; p = 0.011) did not remain statistically significant after regression analysis including the propensity score (OR, 1.34; 95% CI, 0.46-3.88). Complications related to the omentoplasty itself were observed in 8 patients, of whom 6 required reoperation. This study was limited by the retrospective and nonrandomized design causing some heterogeneity between the 2 cohorts. In this multicenter study using propensity score analyses, the use of omentoplasty did not lower the incidence or the duration of pelviperineal morbidity in patients undergoing abdominoperineal resection for rectal cancer, and omentoplasty itself was associated with a risk of reoperation. See Video Abstract at http://links.lww.com/DCR/A918.

Population-based study of surgical treatment with and without tumour resection in patients with locally recurrent rectal cancer.

Population-based studies of treatment of locally recurrent rectal cancer (LRRC) are lacking. The aim was to investigate the surgical treatment of patients with LRRC at a national population-based level. All patients undergoing abdominal resection for primary rectal cancer between 1995 and 2002 in Sweden with LRRC as a first event were included. Detailed information about treatment, complications and outcomes was collected from the medical records. The patients were analysed in three groups: patients who had resection of the LRRC, those treated without tumour resection and patients who received best supportive care only. In all, 426 patients were included in the study. Of these, 149 (35·0 per cent) underwent tumour resection, 193 (45·3 per cent) had treatment without tumour resection and 84 (19·7 per cent) received best supportive care. Abdominoperineal resection was the most frequent surgical procedure, performed in 65 patients (43·6 per cent of those who had tumour resection). Thirteen patients had total pelvic exenteration. In total, 63·8 per cent of those whose tumour was resected had potentially curative surgery. After tumour resection, 62 patients (41·6 per cent) had a complication within 30 days. Patients who received surgical treatment without tumour resection had a lower complication rate but a significantly higher 30-day mortality rate than those who underwent tumour resection (10 versus 1·3 per cent respectively; P = 0·002). Of all patients included in the study, 22·3 per cent had potentially curative treatment and the 3-year survival rate for these patients was 56 per cent. LRRC is a serious condition with overall poor outcome. Patients undergoing curative surgery have an acceptable survival rate but substantial morbidity. There is room for improvement in the management of patients with LRRC.

Different clinical features according to the anastomotic leakage subtypes after rectal cancer surgeries: contained vs. free leakages.

BackgroundAnastomotic leakage can be classified by free and contained leakage according to clinical manifestations. The risk factors and their comparison between these leakage subtypes are uncertain. This study aims to evaluate anastomotic leakage patterns and to compare clinical features between free and contained leakages after low anterior resection for rectal cancer.Materials and methodsBetween January 2005 and December 2012, a total of 2035 consecutive patients who underwent low anterior resection for primary rectal cancer were evaluated retrospectively at two-tertiary referral centers. The primary end points of this study were to assess detailed clinical features among leakage subtypes. The secondary end point was to compare risk factors between free and contained leakages.ResultsPatients were subdivided into a no leakage group (n = 1890), free leakage group (n = 73), and contained leakage group (n = 72). Free leakage occurred more frequently in laparoscopic and robotic surgeries than open surgery (p = 0.015). On the other hand, contained leakage was developed in a higher rate of patients who received preoperative chemoradiotherapy (p<0.001). The mean development time was 4.6 days in the free leakage group, and 23.6 days in the contained leakage group. Patients with free leakage had a lower rate of a defunctioning stoma than contained leakage (5.5% vs. 29.2%, p<0.001). Risk factors for free leakage were smoking, tumor location, and laparoscopic surgery. However, tumor location and preoperative chemoradiotherapy increased the risk for contained leakage.ConclusionsContained leakage in rectal cancer surgery showed different clinical manifestations and risk factors compared to free leakage. It is necessary to pay more attention to patients with particular risk factors for anastomotic leakage subtypes.

Treatment of Locally Recurrent Rectal Carcinoma in Previously (Chemo)Irradiated Patients: A Review.

Local recurrence after rectal cancer treatment occurs in ≈5% to 10% of patients. Neoadjuvant (chemo)radiotherapy for primary rectal cancer renders treatment of recurrent disease more difficult. The purpose of this study was to review contemporary multimodality therapies, including their outcome, for locally recurrent rectal carcinoma after (chemo)radiotherapy and complete surgical resection of primary rectal cancer. A comprehensive literature search of PubMed and EMBASE was performed. All English language articles presenting original patient data regarding treatment and the respective outcome of previously irradiated locally recurrent rectal cancer were included. All of the treatment modalities for locally recurrent rectal cancer were reviewed. Primary outcome parameters were local control, metastasis-free survival, and overall survival. Secondary outcome parameters were perioperative morbidity and mortality, and prognostic factors for treatment outcome. Of 854 studies, 9 studies and 474 patients with locally recurrent rectal carcinoma were included. Various treatment regimens were used, most with curative intent. Reirradiation was composed of (neo-)adjuvant external beam radiotherapy (with or without concurrent chemotherapy), additional intraoperative radiotherapy, or intraoperative radiotherapy only. Surgical technique highly varied, depending on the extent of the lesion. Radiation toxicity, perioperative morbidity, and mortality were generally acceptable. Outcome was better after curative intent treatment, any surgical resection, and R0 resections in particular. Moreover, reirradiation is associated with increased complete resection rates, which in turn positively affected local control and overall survival. Most studies were retrospectively designed, with highly variable therapies, patient populations, and duration of follow-up. A complete resection is the most important prognostic factor and should be the goal of treatment in locally recurrent rectal carcinoma. Reirradiation seems safe and of additional value in reaching a complete resection. Considering the available evidence, at present reirradiation should be given on a case-specific basis, with all of the patients entering an international prospective database.

A phase I–II study on the combination of rapamycin and short course radiotherapy in rectal cancer

PurposeThis phase I/II study sought to determine the safety and maximum tolerated dose (MTD) of the combination of rapamycin, an mTOR inhibitor, with short-course radiotherapy in rectal cancer patients. Antitumor activity, changes in metabolic activity and perfusion on imaging, and changes in phosphorylation status of the mTOR pathway were also assessed. Materials and methodsPatients with primary resectable rectal cancer were treated with short-course hypofractionated radiotherapy (5×5Gy) combined with oral rapamycin 1week before and during radiotherapy, followed by surgical resection. ResultsThirteen patients were entered in phase I. One patient developed a dose-limiting toxicity, consisting of a grade 4 leak and grade 4 bleeding. Because of an unexpected high rate of grade 3 postoperative toxicity, it was decided to treat patients with delayed surgery in phase II. Primary endpoint for phase II was tumor blood flow (Ktrans) assessed by perfusion CT. Thirty-one patients were treated with the MTD of 6mg rapamycin daily. One patient (3%) developed a pathological complete response (pCR) and 3 patients (10%) had a ypT1N0 tumor at the time of resection. No change in tumor perfusion was observed on perfusion CT, but a significant decrease of metabolic activity was found on PET-scan. ConclusionsThe combination of short-course radiotherapy and rapamycin turned out to be feasible, provided that the interval between neo-adjuvant treatment and surgical resection is at least 6weeks. Although from this cohort no clear increase in pCR could be observed, a clear metabolic response after rapamycin run-in was observed, indicating a biological activity of this drug in rectal cancer.

PTH-298 Pre-operative neutrophil lymphocyte ratio (NLR) is a poor predictor of response to neo-adjuvant chemo-radiotherapy in rectal cancer resection

Introduction Previous studies have reported a pre-operative elevated neutrophil lymphocyte ratio (NLR) is associated with poor prognosis in colorectal cancer (CRC) patients. The aim of this study was to assess if elevated NLR can predict the response to neo-adjuvant long course chemo-radiotherapy (CRT) in rectal cancer as assessed by Mandard Regression score and its ultimate outcome of disease free survival (DFS) and overall survival (OS). Method Patients who received neo-adjuvant long course chemo-radiotherapy followed by resection for primary rectal cancer from January 2005 till December 2010 were identified from prospectively maintained cancer database. The NLR was calculated from pre-treatment blood tests. The relationship between the NLR and clinicopathological parameters was analysed. Modified receiver operating characteristic curve were constructed to determine the optimum cut-off NLR to dichotomise the data for pathological response, DFS and OS. The measured cut-off was 2.7. Results There were 143 male and 76 female patients with a median age at diagnosis of 65 (Range 25–85 years). Patients were grouped into favourable response with Mandard regression score of 1 and 2 and unfavourable response with Mandard regression score of 3, 4 and 5. The sensitivity and specificity of NLR to predict complete pathological response or favourable response was 66% and 46%, for disease recurrence was 60% and 39% and for survival was 70% and 50%. NLR did not prove to be a significant predictor of tumour response to CRT and ultimate oncological outcomes. Kaplan Meier survival graph showed a little better OS (p = 0.001) for patients with NLR Conclusion Pre-operative NLR does not appear to offer useful predictive ability for response to CRT, disease free survival and overall survival following rectal cancer resection in patients who received neo-adjuvant long course chemo-radiotherapy. Disclosure of interest None Declared.