Use Of Neoadjuvant Chemoradiotherapy Research Articles

The Clinical and Economic Costs of Delirium After Surgical Resection for Esophageal Malignancy

The aim of this study was to identify preoperative risk factors and postoperative consequences that are associated with the occurrence of delirium after esophagectomy for malignancy. Delirium is an underdiagnosed, serious complication after major surgery, particularly in the elderly population. All patients undergoing esophagectomy for cancer (1991-2011) were included. Patients with and without delirium were compared with respect to medical comorbidities, use of neoadjuvant therapy, operative outcomes, postoperative complications, overall cost, and survival. Of the 500 patients included in this analysis, 46 (9.2%) patients developed postoperative delirium. Patients with delirium had higher ASA and Charlson comorbidity index scores. Delirium was associated with a longer hospital (14 ± 7.5 vs 10.9 ± 5.7; P < 0.05) and intensive care unit stay (3.6 ± 3.8 vs 2.7 ± 16.9; P < 0.05) and an increased incidence of pulmonary complications and increased hospital costs. Delirium was preceded by another complication in 32.6% of cases but by a septic complication in only 19.6% of cases. Age was the only preoperative predictor of postoperative delirium in multivariate modeling (P < 0.05). No differences were noted in the use of neoadjuvant chemoradiotherapy or survival. This study demonstrates that postoperative delirium is associated with a more complicated and costly recovery after esophagectomy and that age is independently predictive of its development. Delirium has often been thought to be the sequela of other complications; however, this study demonstrates that it presents in isolation or precedes other complications in 67.4% of cases. Focused screening will likely allow targeted preventative strategies to be used in the perioperative period to reduce complications and costs associated with delirium.

Impact of Obesity on Operation Performed, Complications, and Long-term Outcomes in Terms of Restoration of Intestinal Continuity for Patients With Mid and Low Rectal Cancer

The impact of obesity per se on the surgical strategy, ie, sphincter sacrifice (abdominoperineal resection) vs sphincter-preserving resection, outcomes, and long-term maintenance of intestinal continuity has been poorly studied in patients with mid and low rectal cancer. The aim of this study is to compare the outcomes and long-term maintenance of intestinal continuity for obese and nonobese patients treated surgically for mid and low rectal cancers. This is a retrospective cohort study from a prospectively collected database. The investigation took place in a high-volume specialized colorectal surgery department. All patients who underwent curative surgery for mid or low rectal adenocarcinoma at a single institution from 1976 to 2011 were identified. Obese (BMI ≥ 30 kg/m) and nonobese patients were matched 1:2 for age, sex, ASA class, location, and stage of tumor. Demographics, use of neoadjuvant chemoradiotherapy, operative and perioperative outcomes, pathology, long-term outcomes including oncologic outcomes, and whether restoration of intestinal continuity was obtained were compared. One hundred fifty-seven obese patients and 314 nonobese patients were included in the study. The groups were similar for matched characteristics. The use of neoadjuvant chemoradiotherapy (p = 0.048) and anastomotic leak (p = 0.0003) rates were higher in obese patients. A similar proportion of nonobese and obese patients underwent sphincter-preserving resection (p > 0.99), and postoperative hospital stay (p = 0.23), 30-day postoperative reoperation (p = 0.83), mortality (p > 0.99), and readmissions (p = 0. 13) were similar. The obese and nonobese groups had similar overall (p = 0.61) and disease-free survival (p = 0.74) at a mean follow-up of 5 years for both groups. This study was limited by its retrospective and nonrandomized nature. At a high-volume specialized colorectal unit, proctectomy can be performed in obese patients with similar long-term oncologic outcomes and ability to restore intestinal continuity in comparison with nonobese patients. Proctectomy in obese patients, however, is associated with an increased risk of anastomotic leak in comparison with nonobese patients.

Disparities between young and elderly patients in the first course of treatment for stage II and III rectal cancers.

e14546 Background: The use of neoadjuvant chemoradiation for stage II and III rectal cancers is associated with higher rates of resectability, sphincter preservation and improved local control. In elderly patients, however, the feasibility and benefits of this approach are less understood. In this study, we determined disparities in the first course of therapy between young and elderly patients with rectal cancer using the National Cancer Data Base (NCDB). Methods: The NCDB was queried for cases of rectal cancer diagnosed from 2000-2009. Analyzed variables included tumor staging, age group and first course of treatment. For analytical purposes, study groups were divided in young (≤ 69 years of age) or elderly patients (≥ 70 years of age). Results: A total of 8,237 patients that received chemoradiation as the first treatment approach were identified from the NCDB during the study period. During the same time, 15,468 patients were treated with surgery first. Fifty-eight percent of patients in the neoadjuvant-first treatment group were equal or younger than 69 years of age. Subgroup analysis showed that elderly patients were treated with surgery first more frequently than with neoadjuvant chemoradiation therapy (surgery-first 72% vs. chemoradiation first 28%, p&lt;0.04). In the contrary, no differences were noted in the first course of treatment received among younger patients (surgery-first 53% vs. chemoradiation first 47%, p=NS). Conclusions: This data shows that there is an age-bias after the age of 70 for surgery only as the first treatment approach for patients with stage II and III rectal cancers. This is probably confirmatory that patients are brought to surgery without neoadjuvant therapy because they are perceived as not being able to tolerate chemoradiation.

Staging of colorectal cancer

•. Colonic cancer should be routinely staged with multidetector CT of the chest, abdomen and pelvis to assess complications, metastatic disease and high-risk patients. •. MRI should be offered to rectal cancer patients, unless contra-indicated, to guide selective use of neoadjuvant chemoradiotherapy and optimise delayed surgical treatment. •. Optimised MRI technique and interpretation allows assessment of tumour and lymph node staging, and investigation of the potential circumferential resection margin. •. Restaging with MRI after neoadjuvant therapy aids MDT decisions. •. Developments in diffusion-weighted imaging may have a role in assessing local disease. Colorectal cancer requires different modalities for accurate staging. Pre-operative staging with multidetector CT (MDCT) for colonic cancer and MRI to assess local disease in rectal cancer are central to multidisciplinary meetings to plan treatment strategy. MRI has shown increased relevance for neoadjuvant chemoradiotherapy in order to optimise delayed surgical treatment. A systematic approach to reporting helps define high-risk patients, particularly those with potential for local recurrence or curative total mesorectal excision. This review highlights the use of MDCT and MRI, including their techniques in pre-operative, post-operative or post-neoadjuvant treatments. Illustrated examples of TNM staging and complications of disease are used. Future developments with the use of diffusion-weighted imaging are also discussed.

Pre-operative hypoalbuminaemia predicts poor overall survival in rectal cancer: a retrospective cohort analysis

BackgroundSerum albumin is a marker of nutrition and inflammation. It has recently emerged as a predictor of outcome after surgery for rectal cancer. Our aim was to evaluate if pre-operative serum albumin would predict survival after resection for rectal cancer.Method226 Patients with rectal cancer of all stages undergoing resection with curative intent were studied. Kaplan-Meier curves analysed survival based on a pre-operative albumin level of <35 g/L vs. >35 g/L. We sought for significant associations of survival with age, sex, stage, tumour site, use of neoadjuvant chemoradiation, microscopic positive resection margins, differentiation, angio, peri-neural, and lymphovascular invasion using individual variable analysis. Multifactorial analysis was performed using type III analysis with Weibull hazard model and Cox-proportional hazard model. Significance was assigned to a P value <0.05.ResultsOf 226 patients (median age- 59 years; range 19 – 88, Male - 54%), forty five (20%) had an albumin level < 35 g/L and was associated with a poor overall survival (P = 0.02). Mean survival in months for <35 g/L vs. >35 g/L was 64.7 (SE - 9.3) vs. 95.8 (SE – 7.0) and 5 year overall survival rates were 49% and 69%. Individual variable analysis revealed age, circumferential margin, stage, perineural, lympho-vascular and angio invasion to be also significant. With multifactorial analysis hypoalbuminaemia (HR = 0.58; 95% CI: 0.35 - 0.95, P = 0.03), advanced stage (HR = 2.0; 95% CI: 1.26 - 3.23, P < 0.01) and positive circumferential margin (HR = 2.2; 95% CI: 1.26 - 3.89, P < 0.01) remained significant.ConclusionPreoperative hypoalbuminaemia is an independent risk factor for poor overall survival in rectal cancer. Advanced tumour stage and circumferential margin positivity were the other associations with poor survival.

Endorectal ultrasound does not reliably identify patients with uT3 rectal cancer who can avoid neoadjuvant chemoradiotherapy

Neoadjuvant chemoradiation (NCRT) may be avoided in some patients with T3-staged rectal cancer undergoing radical resection. We aimed to evaluate the accuracy of endorectal ultrasound (ERUS) in the nodal staging of uT3 tumors and hence the decision for administration of NCRT. Patients with uT3-staged rectal cancer who underwent proctectomy were retrospectively identified. The accuracy of ERUS for detecting nodal involvement was determined for patients who did not undergo NCRT. In order to evaluate the impact of use of NCRT, oncologic outcomes, functional outcomes, and quality of life (QOL) were compared for patients who received NCRT (group A) and those who did not (group B). For 384 patients who were included, ERUS overstaging rate for nodal involvement was 6.3% while understaging rate was 23.2%. For the 289 patients in group A and 95 in group B, Kaplan-Meier analysis showed similar 5-year local recurrence rates (3.5%), overall survival (76.9 vs 75.6%), and disease-free survival (87.9 vs 88.1%). Node positivity on final pathology was however associated with worse 5-year local recurrence (9.3 vs 4.3%). For patients undergoing restorative resection, NCRT was associated with worse functional outcomes but QOL was similar. ERUS identification of nodal involvement used as a criterion for NCRT carries a greater risk for undertreatment than overtreatment. Undertreatment adversely affects oncologic outcomes. While there is functional impairment related to NCRT, its effect on QOL is non-significant. The decision for omitting neoadjuvant chemoradiation for uT3 rectal cancer should hence not be based on ERUS nodal staging alone.

Abstract B58: Limited esophageal cancer care access among African American patients in Michigan.

Abstract Background: The incidence of esophageal cancer (EC) in Michigan (MI) is among the highest in the nation. Moreover, even higher rates are observed among the state's most vulnerable minority populations. The purpose of this study was to quantify the utilization of resources by African-American (AA) EC patients at the University of Michigan Medical Center (UMMC), a state sponsored hospital tasked with providing cancer care for all MI residents. Methods: All patients presenting with a diagnosis of stage I-III EC from April 2007 to April 2012 were identified using the UMMC information technology department. A retrospective chart review was performed eliciting information on demographics, comorbid conditions and treatments received. We used multivariable logistic regression to examine patient demographics, comorbid conditions and tumor specific characteristics as predictors of receipt of neoadjuvant chemoradiation and esophagectomy. Patients with cervical esophageal cancers and stage IV disease were excluded. Results: A total of 718 patient charts (95.1% white, 2.26% AA, 2.64% asian/hispanic/other) were reviewed. Overall, only 14 of the 16 AA patients were MI residents. White patients were more likely to travel greater distances compared with AA patients (median distance in miles 242.1 vs. 81.0, respectively, p&amp;lt;0.001). Although UMMC is approximately 30 miles from Metro Detroit, only 5 AA patients from this area sought care at UMMC. AA patients were more likely to report current tobacco use (56.3% vs. 23.4%, p&amp;lt;0.01) at the time of diagnosis, have squamous cell histology (62.5% vs. 7.82%, p&amp;lt;0.001) and have tumors located in the mid-esophagus (43.8% vs. 6.1%, p&amp;lt;0.001), compared with white patients. AA and white patients were largely indistinguishable in terms of age at the time of diagnosis, the number of comorbid conditions, insurance status and stage at diagnosis. After adjusting for patient factors, comorbid conditions and tumor characteristics, AA patients (OR 0.12, 95%CI 0.02-0.55), patients with congestive heart failure (OR 0.21, 95%CI 0.08-0.60) and pulmonary disease (OR 0.45, 95%CI 0.23-0.91) were significantly less likely to undergo esophagectomy. There were no race-related differences in the use of neoadjuvant chemoradiation. Conclusions: Racial disparities in the treatment of EC are widely recognized and considered an important public health and policy concern. UMMC provides care for more than 50% of all EC patients in MI. However, relatively few AA patients seek care at UMMC, a high volume regional center. Our ability to estimate racial differences in care within UMMC was limited by sample size constraints among the AA population. Efforts to reduce racial disparities in treatment and ultimately improve EC outcomes will require providers to assure that patients are referred for the appropriate treatments and have assistance navigating the cancer care system. Citation Format: Sha'Shonda L. Revels, Charles A. Mouch, Rishindra M. Reddy. Limited esophageal cancer care access among African American patients in Michigan. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr B58.

612P - Are Patients with Resectable Rectal Cancer Better Off in the Era of Multidisciplinary Care?

ABSTRACT Introduction The management of rectal cancer (RC) has evolved with the introduction of Total Mesorectal Excision Surgery (TME), use of Magnetic Resonance Imaging (MRI) for staging, changes in chemotherapy and radiotherapy and multidisciplinary meetings (MDTs). The timing of therapy for T3/4 and/or node positive RC has also changed with neoadjuvant chemoradiotherapy (CRT) becoming standard based on lower local recurrence rates. Given these changes in management over time, we assessed disease free survival (DFS), overall survival (OS) and rates of local and distant recurrences of patients treated at The Queen Elizabeth Hospital (TQEH) between 1992 to 2006. Method Demographic and outcome data of patients diagnosed with early stage RC from TQEH Cancer Registry from 2 different time cohorts 1992-99 (A) and 2000-06 (B) were analysed. Survival analysis was by Kaplan-Meier method and prognostic factors were analysed using cox proportional hazards regression. Results 423 patients were identified; 235 in A, 188 in B. Patient characteristics were generally similar. Median age A 68.1 yrs (range 32-94), B was 67.4 yrs (range 25-92). More patients had stage B in cohort A (47%) v B (39%). 56% of patients had surgery alone in cohort A compared to 47% in cohort B. Rates of any “adjuvant” therapy was similar (A = 41% v B = 46%), although there was a doubling in proportion of patients who received neoadjuvant CRT in the latter cohort (A= 7.2% v B= 16%). There was a significant improvement in rate of 5 year local/distal recurrence; A 87%/71% v B 95%/81%, p Conclusion There has been significant improvement in DFS, OS and local and distant recurrence rates in patients diagnosed with early stage RC. The trend to greater use of neoadjuvant CRT in the latter cohort is consistent with changes in practice, and this may be a factor in improved local control, but does not appear to impact on survival. Other factors likely to have improved overall outcomes include: increased TME rates, improved preoperative staging including use of MRI and potentially the introduction of MDTs. Disclosure All authors have declared no conflicts of interest.

Changes in diagnostic and treatment strategies of oesophageal cancer in the period from 2001 to 2009

In 2005, national guidelines on the diagnosis, staging and treatment of oesophageal cancer were published. We investigated whether staging and treatment strategies of oesophageal cancer had changed over the last decade and indeed followed these guidelines. In 2001, a questionnaire investigating staging and treatment strategies for oesophageal cancer was sent to Dutch clinicians (response rate 64%). In 2009, the same questionnaire (response rate 41%) was repeated, thus enabling comparison of staging and treatment strategies for oesophageal cancer between 2001 and 2009 and comparing this with the nationwide guidelines of 2005. The advice to use endoscopic ultrasound for staging was followed by the majority of clinicians [84% in 2009 compared with 58% in 2001 (P<0.001)], whereas positron emission tomography scanning was used by almost half of clinicians (44% in 2009, not asked in 2001). There was a strong support for the use of neoadjuvant chemoradiation in 2009 (68% preferred this treatment for a young patient in good condition without metastases), whereas the Dutch guidelines did not recommend routine use of neoadjuvant treatment in 2005. Stent placement for palliation of dysphagia was reduced [from 92% in 2001 to 27% in 2009 (P<0.001)] due to an increased use of other palliative measures, including brachytherapy. An increased use of chemotherapy (19%) or chemoradiation (39%) was noticed in younger patients (<55 years) with metastatic disease. Major changes in staging and treatment strategies were observed in patients with oesophageal cancer over the last decade. Although these changes in staging strategies were in concordance to the guidelines introduced in 2005, treatment strategies with curative intent were more often diverse in 2009 and not following guidelines. This suggests that in a rapidly evolving field as oncology, guideline recommendations on treatment should be updated frequently to reflect state-of-the-art knowledge with implementation of results of clinical studies.

Margin status and neoadjuvant chemoradiation in patients with borderline resectable pancreatic cancer.

304 Background: The objective of this study was to examine the effect of margin status and neoadjuvant therapy in determining outcomes for borderline resectable (BLR) pancreatic cancer and how neoadjuvant chemoradiation impacts margin of resection. Methods: A retrospective chart review was conducted to identify patients who underwent resection for BLR pancreatic cancer based on the AHPBA/SSO/SSAT consensus definition. Outcomes including overall survival (OS) and disease free survival (DFS) were determined based on margin status, location of positive margin (artery, vein, or pancreas), and receipt of neoadjuvant chemoradiation. Results: One hundred and three patients who met the definition of BLR pancreatic cancer and underwent resection between April 1993 and July 2010 were reviewed. Mean age at diagnosis was 65 with a median follow up time of 19.7 months. Neoadjuvant chemoradiation was administered in 49.5% of patients. Twenty-five percent of patients underwent portal and/or superior mesenteric vein resection, and 7% hepatic artery resection. Microscopic positive margin rate was 54%. Median OS was 17.2 months for patients with positive margins versus 24.9 months for patients with negative margins (p=0.003). Median DFS was 13.1 months for patients with positive margins versus 18.6 months for patients with negative margins (p=0.001). There was no difference in OS or DFS for patients with positive margins based on location or number of positive margins. Of the patients who received neoadjuvant chemoradiation, 61.7% had a negative margin of resection versus a 38.3% negative margin of resection rate for patients who did not receive neoadjuvant chemoradiation (p=0.02). Among patients with a positive margin, there was no difference in OS or DFS with or without neoadjuvant chemoradiation. Conclusions: A positive margin of resection, irrespective of location or number, is associated with worse outcome in patients with BLR pancreatic cancer. The use of neoadjuvant chemoradiation is associated with higher rates of margin free resection.

A Systematic Review and Meta-analysis of Survival and Surgical Outcomes Following Neoadjuvant Chemoradiotherapy for Pancreatic Cancer

IntroductionThis systematic review and meta-analysis aims to characterize the surgically important benefits and complications associated with the use of neoadjuvant chemoradiotherapy for the treatment of both resectable and initially unresectable pancreatic cancer. Studies were identified through a systematic literature search and analyzed by two independent reviewers. Survival, peri-operative complications, death rate, pancreatic fistula rate, and the incidence of involved surgical margins were analyzed and subject to meta-analysis. MethodsNineteen studies, involving 2,148 patients were identified. Only cohort studies were included. ResultsThe meta-analysis found that patients with unresectable pancreatic cancer who underwent neoadjuvant chemoradiotherapy achieved similar survival outcomes to patients with resectable disease, even though only 40% were ultimately resected. Neoadjuvant chemoradiotherapy was not associated with a statistically significant increase in the rate of pancreatic fistula formation or total complications. ConclusionPatients receiving neoadjuvant chemoradiotherapy were less likely to have a positive resection margin, although there was an increase in the risk of peri-operative death.

The current landscape of locally advanced rectal cancer

Postoperative adjuvant chemoradiotherapy was recommended as the standard treatment for patients with rectal cancer because it reduces local recurrence. This paradigm shifted with the use of neoadjuvant chemoradiotherapy, which not only reduces local recurrence but also improves sphincter preservation and surgical outcomes. However, the treatment of rectal carcinoma remains complicated. The accuracy of tumor staging can be compromised depending on the imaging modality used. The addition of modern chemotherapeutics and biologics to 5-fluorouracil as radiation sensitizers is questionable. Oxaliplatin as a radiation sensitizer has minimal effects on the pathologic complete response, but improves the radiographical response at the expense of an increased risk of toxicities. The role of biologics in addition to radiation therapy continues to be explored. Attention has focused on improving diagnostic imaging, radiation oncology, and surgical techniques, treatment regimens, and on exploring a role of molecular markers for patients with rectal cancers. We review the pivotal trials that have led to the current treatment paradigm for locally advanced rectal cancer and discuss novel methodologies that are being developed for the treatment of this prevalent malignancy.

Cancer de l’œsophage et de la jonction oeso-gastrique : évolution de la stratégie chirurgicale

Management of esophageal cancer has evolvedmarkedly in the last two decades. Advances in neoadjuvant treatment combined with refinements in surgical techniques and perioperative care have resulted in better postoperative outcomes and long-term survival. We investigated trends in the outcome of esophagectomy for esophageal cancer over the past 20 years at our high-volume institution. We studied patients who underwent surgery for primary cancer of the esophagus or gastroesophageal junction from 1988 through 2008 (N = 1153). Four study periods (P) were compared: 1988-1993 (P1), 1994-1998 (P2), 1999-2003 (P3) and 2004-2008 (P4). Demographic parameters, tumor characteristics, post-operative morbidity, in-hospital mortality and long-term survival were recorded prospectively and the four periods were compared retrospectively. Squamous cell carcinoma accountedfor 77.4% of the 1153 malignancies. The ratio of squamous cell carcinoma to adenocarcinoma fell from 12.0 to 1.3 during the study period (P1 vs P4, P < 0.001), with aparallel increase in the number tumors of the lower esophagus or gastroesophageal junction. The post-operative mortality and morbidity rates were respectively 5.6% and 42.7% overall and remained stable during the study period. The five-year survival rate among all resected patients improved significantly, from 24.3% to 42.7% (P1 vs P4, P< 0.001). The complete (RO) resection rate was 80.7% overall and increased from 74.1% to 82.1% (P1 vs P4, P < 0.05). The five-year survival rate improved significantly among RO-resected patients, from 32.7 % to 52.3 % (PI vs P4, P<.0001). The proportion of patients who received neoadjuvant treatment (mainly chemoradiotherapy) rose from 46.8% to 66.5%. The completeness of the pathologic response after neoadjuvant chemoradiotherapy correlated with long-term survival (P < 0.001): five-year survival rates among pathologically complete, partial and non responders were 52.1%, 24.8% and 10%, respectively. Short-term outcomes after resection remained stable during the study period and comparedfavorably with those reported by other high-volume institutions. Long-term survival improved significantly. Advances in staging methods andsurgical management, combined with more stringent patient selection and use of neoadjuvant chemoradiation, may explain this progress. More reliable predictors of complete RO resection and of the response to chemoradiation therapy are needed in order to tailor management to the individual patient.

When Reporting on Older Patients with Cancer, Frailty Information is Needed

Any effort to bring new light on the management of older patients with cancer should be welcomed and considered with interest. A large amount of evidence has now been gathered, proving significant delays in cancer detection, under-staging, and substandard treatment of this age subgroup, resulting in inferior survival. We have no standard of care and no evidence-based guidelines available for this age group because it has regularly been excluded from clinical trials: our knowledge on cancer management simply has never been validated in the older subsetting. One note of concern rests on the fact that world-renowned centers of excellence omit data on frailty, hence failing to identify which patients have been involved in their studies.1–3 Several editorial notes also lack the same information. Reports from these researchers only include age and ASA, with no reference to comorbidities, frailty, or performance status.4–6 Consequently, these series most frequently present highly biased findings retrieved from super-selected cohorts: it is only the superfit onco-geriatric patient that reaches surgical theater. This implies that all considerations and conclusions cannot be applied to the overall geriatric population. It would be totally unacceptable to present series without clearly stating patients’ stage. The TNM staging system is fundamental in drafting treatment plans, comparing series, testing new drugs, drafting guideline, consenting patients, etc. In a very similar way, we are no longer justified to present series of older patients without frailty data. Anagraphic age is not sufficient to characterize these patients; after a decade of discussion with geriatricians, it is now clear that Comprehensive Geriatric Assessment is the most accurate instrument. Unfortunately, this is not adequate for our busy clinical practice because it requires several hours per patient. For this reason, quicker tools have been tested and validated.7–9 These tools are capable of identifying those frail individuals who should be referred to special geriatric care before surgical management. A modern approach should take advantage of the few available days/weeks before elective cancer surgery is planned to correct anemia, dehydration, malnourishment, and depression; optimizing the patient’s conditions, as highlighted by frailty assessment tools, will eventually reduce the occurrence of operative complications. The use of neoadjuvant chemoradiation for several malignancies offers an excellent window of opportunity to this purpose. Interestingly, present research is moving one step forward and the already available tools are being tested against quicker ones, only taking 3–5 min to administer, hence being informative and appropriate to use in our busy routine.10 We entirely agree with the authors statement that the “involvement of physicians and affiliated caregivers equipped to evaluate and apply multidisciplinary treatment programs tailored to preexisting comorbidities rather than age per se may hold the best promise for improved prognosis in this challenging clinical circumstance.”6 We need to bring this into clinical practice as well as scientific reporting. The lack of frailty data makes the conclusions meaningless.

Surgery for oesophageal cancer at Galway University Hospital 1993–2008

Surgical volume and outcome remain controversial in the management of oesophageal cancer. To assess the outcome of oesophagectomy for cancer at Galway University Hospital (GUH). Between 1994 and 2008, patients who underwent oesophagectomy were analysed. During the study period, 126 oesophagectomies were performed for cancer. The average surgeon volume was 9 cases per year. The 30-day and overall in-hospital mortality rates were 6.3 and 7.9%, respectively. Restructuring of our critical care services has led to a reduction in 30-day mortality from 8.2 to 5.1%. The use of neoadjuvant chemoradiotherapy has increased from 17 to 35% during the study period. In patients who underwent resection, the 3 and 5-year overall survival rates were 45 and 29%, respectively. Operative morbidity and mortality at GUH are comparable with worldwide outcomes. Improved resources and national restructuring of cancer services have significantly improved the quality of care and outcomes of patients.

Trends in colorectal cancer in the south of the Netherlands 1975–2007: Rectal cancer survival levels with colon cancer survival

Objective. In the Netherlands over 11 200 patients are yearly diagnosed with colorectal cancer (CRC), of who about 4 700 are expected to die of the disease ultimately. Investigating long-term trends is useful for clinicians and policy makers to evaluate the impact of changes in practice and will help predict future developments. Patients. The 26 826 cases of primary CRC (C18.0–C20.9) diagnosed between 1975 and 2007 in the Dutch population-based Eindhoven Cancer Registry area were included. We analysed trends in incidence, prevalence, stage distribution, treatment, survival, and mortality. Results. The age-standardised incidence of colon carcinoma kept increasing, most markedly in males (up to 39 patients per 100 000 inhabitants) and for tumours of the colon ascendens (subsite-specific incidence doubled). The incidence of rectal carcinoma remained stable. The share of patients aged 80 or older rose from 12 to 19% (p<0.0001). The proportion of patients diagnosed with distant metastases increased up to 25% for colon carcinoma (p<0.0001). Resection rates of the primary tumour remained high except for patients with metastasised disease, showing a decrease since 2000. Recently, the use of adjuvant chemotherapy seemed to level off among patients with stage III colon carcinoma, but the use of neo-adjuvant chemoradiation clearly increased among patients with stage II/III rectal cancer (p<0.0001). Five-year relative survival of colon cancer improved from 51% in 1975–1984 to 58% in 2000–2004, for rectal cancer it improved from 44 to 59%. Two-year relative survival of colon cancer in 2005–2006 was 69%, and 77% for rectal cancer. Conclusions. The changes in management of rectal cancer led to a superior increase in survival of these patients compared to patients with colon cancer, even surpassing the latter.

Individualized magnetic resonance imaging-based neoadjuvant chemoradiation for middle and lower rectal carcinoma

In most institutions neoadjuvant chemoradiation for middle and lower rectal carcinoma is currently given to patients with tumours of clinical stages II or III (cT3,4 and/or N1,2). The possibility of a reduction in the use of neoadjuvant chemoradiation by an individualized magnetic resonance imaging (MRI)-based indication for neoadjuvant chemoradiation was analysed. Assessment of the pathological and oncological principles indicating for neoadjuvant treatment was used to determine the prognostic importance of the distance between the tumour and the circumferential resection margin and pretherapeutic assessment using modern MRI. Based on the results of pretreatment MRI scanning, a proposal is presented for the treatment of middle and lower rectal carcinoma with neoadjuvant chemoradiation. Adopting this proposal, the frequency of neoadjuvant chemoradiation decreased from 70% to 35% and the early and late adverse effects of this therapy were reduced. In contrast, the expected locoregional recurrence rate increased from 6% to 11% if all quality criteria were met and to 18% if not. An MRI-based indication for neoadjuvant chemoradiation is justified only for centres with regular quality assurance of MRI, surgery, radiotherapy and pathology. The proposal needs confirmation by long-term follow up and by prospective studies with larger numbers of patients.

Long-Term Results of Transanal Excision After Neoadjuvant Chemoradiation for T2 and T3 Adenocarcinomas of the Rectum

IntroductionTraditionally, selected early distal rectal cancers have been considered for treatment by transanal excision (TAE) with acceptable oncologic results. With the frequent use of neoadjuvant chemoradiation (NCR) for the treatment of locally advanced rectal cancer, there is growing interest in the application of TAE for such lesions. We report our experience of TAE for T2 and T3 rectal cancers following NCR. Material and MethodsBetween July 1994 and August 2006, 44 patients were identified as having undergone full-thickness TAE of pretreatment ultrasound-staged T2 and T3 rectal cancers that were treated with NCR. Fifteen patients were deemed medically unfit for radical resection, and 29 would have required abdominoperineal resection but were opposed to colostomy. ResultsOur patient population consisted of 26 men and 18 women, with a median age of 69 (range, 43–89) and a median follow up of 64 months (6–153). Thirty-one patients had a clinical complete response (cCR) to NCR of which 19 (61%) had a pathologic CR (pCR). Seven (16%) of 44 patients sustained disease recurrence of which two were local only, two local and systemic, and three systemic only. Only four (9%) patients had died of disease at current follow up. Overall 5-year survival rates for T2/T3N0 and T2/T3N1 patients were 84% and 81%, respectively. Five patients underwent radical resection immediately following TAE for either positive margins or residual cancer. There was minimal morbidity with no perioperative mortality associated with TAE. ConclusionsTAE of T2 and T3 rectal cancers following NCR is a safe alternative to radical resection in a highly select group of patients for which recurrence and survival rates comparable to radical resection can be achieved. This study supports ongoing efforts to assess this approach in prospective, multi-center trials.

Two thousand transhiatal esophagectomies: changing trends, lessons learned.

"Rediscovered" in 1976, transhiatal esophagectomy (THE) has been applicable in most situations requiring esophageal resection and reconstruction. The objective of this study was to review the authors' 30-year experience with THE and changing trends in its use. Using the authors' prospective Esophagectomy Database, this single institution experience with THE was analyzed retrospectively. Two thousand and seven THEs were performed-1063 (previously reported) between 1976 and 1998 (group I) and 944 from 1998 to 2006 (group II), 24% for benign disease, 76%, cancer. THE was possible in 98%. Stomach was the esophageal substitute in 97%. Comparing outcomes between group I and group II, statistically significant differences (P < 0.001) were observed in hospital mortality (4% vs. 1%); adenocarcinoma histology (69% vs. 86%); use of neoadjuvant chemoradiation (28% vs. 52%); mean blood loss (677 vs. 368 mL); anastomotic leak (14% vs. 9%); and discharge within 10 days (52% vs. 78%). Major complications remain infrequent: wound infection/dehiscence, 3%, atelectasis/pneumonia, 2%, intrathoracic hemorrhage, recurrent laryngeal nerve paralysis, chylothorax, and tracheal laceration, <1% each. Late functional results have been good or excellent in 73%. Aggressive preoperative conditioning, avoiding the ICU, improved pain management, and early ambulation reduce length of stay, with 50% in group II discharged within 1 week. THE refinements have reduced the historic morbidity and mortality of esophageal resection. This largest reported THE experience reinforces the value of consistent technique and a clinical pathway in managing these high acuity esophageal patients.

Risk factors for impaired healing of the perineal wound after abdominoperineal resection of rectum for carcinoma

Nonhealing perineal wound is an unpleasant complication of surgical excision of the rectum and anus. The aim of the study was to evaluate the risk factors for impaired perineal wound healing after abdominoperineal resection (APR) of rectum for adenocarcinoma, particularly with the increasing use of neo-adjuvant chemoradiation. The study included 38 consecutive patients (29 men, nine women; median age 66 years, range: 43-86), who underwent surgical excision of rectum and anus for adenocarcinoma from 1999 to 2004. Thirty-seven patients underwent APR of rectum and one patient, who developed carcinoma in the background of chronic ulcerative colitis, had panproctocolectomy. Associations between the failure of the perineal wound to heal and a number of patient, tumour and treatment-related variables were evaluated by Pearson chi-square test or Fisher's exact test, as appropriate. A P-value of <0.05 was considered significant. Multivariate statistical technique of principal component analysis was also used to identify risk factors and their relative contribution to impaired healing. Impaired healing of the perineal wound was observed in 10 (26%) of 38 patients. In four of them (11%) the wound remained nonhealed in 1 year after surgery. Preoperative radiotherapy, delayed primary closure of the wound and alcohol consumption in excess of 28 units/week was statistically significantly associated with impaired wound healing. Principal component analysis identified the following seven factors that cumulatively contributed to 96% of impaired healing: (i) distant metastases, (ii) preoperative radiotherapy, (iii) T-stage of the tumour, (iv) smoking, (v) perioperative blood transfusion, (vi) preoperative chemotherapy and (vii) development of side effects of preoperative chemoradiation. Patients who undergo APR of rectum are prone to impaired healing of the perineal wound if radiotherapy is used to treat malignancy prior to surgery and wound closure is delayed. In addition, the wound may not heal in patients with distant metastases, excessive alcohol consumption, present and past smokers and those who suffer adverse effects of preoperative chemoradiation and require blood transfusion.