Use Of Preoperative Radiotherapy Research Articles

Cumulative incidence of first recurrence after curative treatment of stage I–III colorectal cancer. Competing risk analyses of temporal and anatomic patterns

Background Updated knowledge about the rates of recurrence and time to recurrence following curative treatment of colorectal cancer is essential to secure better patient information on prognosis, to serve as a premise in the discussion on adjuvant chemotherapy, and help to properly scale the intensity and length of follow-up. Methods This is a population-based study investigating aspects on first recurrence after radical treatment of clinical stages I-III of colorectal cancer in Central-Norway during 2001–2015. To reveal any time-trends, data were stratified by the time periods 2001–2005, 2006–2010 and 2011–2015. The cumulative incidence of first recurrence was calculated, treating death of unrelated causes as a competing event. Multivariable Cox analyses were done to calculate cause specific hazard ratios (HR) for risk of recurrence. Results At a minimum follow-up of six years, a first recurrence was detected in 1,113/5,556 patients at risk (20.0%). The recurrence rate was reduced from 23.6% in the first time period, through 20.0% in the second, and to 17.2% in the last, p < 0.001. The reduction applied to all tumor locations, to pathological disease stages II and III, to both gender, across different tumor differentiations, and to both elective and emergency surgery. In multivariable analyses time period, gender, disease stage, and tumor differentiation were significant determinants for risk of recurrence. Conclusions The rate of first recurrence after curative surgery for colorectal cancer was substantially reduced from 2001 to 2015. The reason for the reduction could not be attributed to a single factor only. A combined effect of several incremental improvements, such as an increased use of preoperative radiation for rectal cancers, improved adjuvant chemotherapy for colon cancer, and a reduced proportion of emergency surgery, is suggested.

Is 5 the New 25? Long-Term Oncologic Outcomes From a Phase II, Prospective, 5-Fraction Preoperative Radiation Therapy Trial in Patients With Localized Soft Tissue Sarcoma

PurposeManagement of adult soft tissue sarcomas entails a multidisciplinary approach with surgery and radiation therapy with or without chemotherapy. The use of preoperative irradiation has been well established, and although conventional fractionation involves daily treatments over the course of 5 weeks, higher doses per fraction may be beneficial due to the radiobiologic profile of sarcoma. In this study we report long-term oncologic outcomes from a single-institution, phase II study evaluating a 5-fraction hypofractionated course of preoperative radiation. Methods and materialsPreoperative hypofractionated radiation therapy was administered to 35 Gy in 5 fractions every other day followed by resection 4 to 6 weeks later. If given, chemotherapy consisted of a doxorubicin-ifosfamide-based regimen delivered neoadjuvantly. The primary endpoint was local control. Additional survival and pathologic outcomes, including overall and distant metastasis-free survival, tumor, and treatment-related pathology, as well as acute and late toxicity were examined. ResultsThirty-two patients were enrolled in this prospective, single-arm phase II trial. At a median follow-up of 36.4 months (range, 3-56), no patient developed a local recurrence, and the 3-year overall and distant metastasis-free survival was 82.2% and 69%, respectively. Major acute postoperative wound complications occurred in 25% of patients. Grade 2 and 3 fibrosis occurred in 21.7% and 13% of patients, respectively. The 2-year median and mean Musculoskeletal Tumor Society score for all patients was 28 and 27.4, respectively. ConclusionsA condensed course of preoperative hypofractionated radiation therapy leads to excellent rates of local control and survival with acceptable toxicity profiles. Potential studies ideally with phase II or III randomized trials would help corroborate these findings and other preoperative hypofractionated results in soft tissue sarcomas.

SP1.2.12A meta-analysis of the impact of rectal washout on local recurrence following anterior resection for rectal cancers

Abstract Background Standardisation of surgical technique in form of total mesorectal excision (TME) and the use of preoperative radiotherapy have led to improved oncological outcomes in rectal cancer. However, the effectiveness of rectal washout in reducing local recurrence (LR) following anterior resection remains debatable. The aim of this meta-analysis was to evaluate the effectiveness of rectal washout in reducing incidence of LR after anterior resection for rectal cancer. Methods A literature search of electronic databases including PubMed, Embase, Scopus and Cochrane was performed for studies that compared rectal washout to no washout after anterior resection using TME for rectal cancers. The review included all articles reporting oncological outcome of local recurrence. Meta-analysis was carried out using random effect model. Results A total of 5 studies involving 5315 patients were included in meta-analysis. Median follow-up was 60 (range 33–60) months. Overall local recurrence rate was 6.6 % with no significant difference in LR rate between the rectal washout and no washout groups (5.23% vs. 9 %)(P = 0.93; RR 0.97; 95% CI 0.52- 1.83).Similarly in subgroup analysis including prospective studies only no significant difference in LR was seen after washout (P = 0.06) or in group of patients treated with a curative intent(P = 0.50). LR was significantly lower in patients who had a rectal washout with normal saline (P &amp;lt; 0.00001; RR 0.59; 95% CI 0.47-0.74). Conclusion This meta-analysis shows that there is no benefit of rectal washout in reducing incidence of local recurrence after anterior resection for rectal cancers.

Soft Tissue Sarcomas: Is Pre-operative Radiotherapy Associated With More Acute Wound Complications?

Introduction: Increased wound complication rates are attributed to the use of pre-operative radiotherapy. The purpose of this study is to evaluate the incidence of complications with or without pre-operative radiotherapy in our institution.Methods: We retrospectively evaluated 48 adult patients with high-grade extremity soft tissue sarcoma. Twenty-two patients received pre-operative radiotherapy (group A) while 26 patients underwent initial surgery (group B). Complications were defined as major wound complications if they were severe enough to delay the delivery of adjuvant treatment (chemotherapy or radiotherapy) more than eight weeks after surgery or if their resolution required a new surgical intervention.Results: Mean follow-up in group A and group B was 44.3 and 53.8 months, respectively. The incidence of complications of any grade in group A was 45.5% and 53.8% in group B (p: 0.566). Major wound complications in group A and group B occurred in 18% and 23% of the patients (p=0.630), respectively. All patients in group A completed local treatment - radiotherapy and surgery - in 66 days on average. In contrast, in group B post-operative radiotherapy was either delayed or suspended in four patients due to wound complications. This determined that 15.4% of the patients in group B did not receive the local treatment - surgery + radiotherapy - as planned.Conclusions: An increased risk of severe acute wound complications with the administration of pre-operative radiotherapy was not observed in patients with soft tissue sarcomas of the extremities. In addition, local treatment completion was not jeopardized with preoperative radiotherapy, as opposed to post-operative radiotherapy.

Pelvic Ewing sarcoma: Should all patients receive pre-operative radiotherapy, or should it be delivered selectively?

BackgroundLocally recurrent disease following surgical resection of Ewing sarcoma (ES) confers a poor prognosis. Limited evidence is available evaluating non-selective use of pre-operative radiotherapy (RT) for patients with pelvic ES and its effect on local control and survival. Patients and methods49 consecutive patients with pelvic ES were identified retrospectively from a prospectively collated database. Patients either received non-selective pre-operative RT and surgery (n = 27), or selective post-operative RT (n = 22) (surgery alone (n = 11) or surgery and post-operative RT (n = 11)). ResultsPatients who had non-selective pre-operative radiotherapy appeared to have a higher LRFS, 88.0% compared to 66.5% in the selective RT group (p = 0.096, Kaplan Meier; p = 0.028, Chi-squared). Administration of non-selective, pre-operative RT to all patients with pelvic ES elevates the LFRS to that of the good responder group (≥90% tumour necrosis and margins, p = 0.880). There was no difference in metastasis-free survival, 60.0% and 54.5% (p = 0.728) and overall survival (OS), 57.7% and 63.6% (p = 0.893). The majority of pre-operative RT patients had both good necrosis (≥90%) (p = 0.003) and widely excised tumours, 81.5% vs 59.1% (p = 0.080). Tumour volume ≥250 ml was associated with worse LRFS (p = 0.045) and post-operative complications (p = 0.017). There may be improved LRFS (p = 0.057) with pre-operative proton-beam RT compared to surgery and selective post-operative RT. ConclusionPre-operative photon or proton-beam RT to all pelvic ES may improve LRFS compared to the selective delivery of post-operative RT. Radiotherapy delivered to all patients results in a greater percentage of highly necrotic tumours at surgical excision, enabling a greater proportion of patients with wide resection margins.

Different Treatment Modalities of Colo-Rectal Cancer (Retrospective Study)

Background: Colorectal Cancer (CRC) is the most common type affecting the gastrointestinal tract accounting for about 13% of all malignancy diagnosed each year. Although Surgery stays the most effective treatment in managing colorectal carcinoma, there is a rapid increase in the use of preoperative radiotherapy and chemotherapy. Objective: So, the present study was conducted to identify the different therapeutic modalities used in the treatment. Patients and Methods: This study was a retrospective study that included CRC patients treated at the Clinical Oncology Department, Zagazig University Hospital during the period from 2012 to 2017. Medical records of 385 patients, who were referred to the Clinical Oncology Department after being diagnosed with CRC were obtained and used to collect data about different treatments and then analyzed. Results: Chemotherapy regimen FOLFOX was received in (45.5%) of cases and partial response in 41 % of cases was observed. Patients received at least one line of chemotherapy with either adjuvant or palliative intent. Rectal cancer patients who received neoadjuvant concurrent chemo& radiotherapy showed a partial response in 45.5 % of cases. Xeloda was the most common chemotherapy received in most cases who received either adjuvant or neoadjuvant CCRT. Recurrence occurred in (81%) of cases. Conclusion: Chemotherapy regimen FOLFOX was received in most cases. Patients received at least one line of chemotherapy with either adjuvant or palliative intent, FOLFOX was the most chosen protocol. Xeloda was the most common chemotherapy received in most cases

Different Treatment Modalities of Colo-Rectal Cancer (Retrospective Study)

Background: Colorectal Cancer (CRC) is the most common type affecting the gastrointestinal tract accounting for about 13% of all malignancy diagnosed each year. Although Surgery stays the most effective treatment in managing colorectal carcinoma, there is a rapid increase in the use of preoperative radiotherapy and chemotherapy. Objective: So, the present study was conducted to identify the different therapeutic modalities used in the treatment. Patients and Methods: This study was a retrospective study that included CRC patients treated at the Clinical Oncology Department, Zagazig University Hospital during the period from 2012 to 2017. Medical records of 385 patients, who were referred to the Clinical Oncology Department after being diagnosed with CRC were obtained and used to collect data about different treatments and then analyzed. Results: Chemotherapy regimen FOLFOX was received in (45.5%) of cases and partial response in 41 % of cases was observed. Patients received at least one line of chemotherapy with either adjuvant or palliative intent. Rectal cancer patients who received neoadjuvant concurrent chemo& radiotherapy showed a partial response in 45.5 % of cases. Xeloda was the most common chemotherapy received in most cases who received either adjuvant or neoadjuvant CCRT. Recurrence occurred in (81%) of cases. Conclusion: Chemotherapy regimen FOLFOX was received in most cases. Patients received at least one line of chemotherapy with either adjuvant or palliative intent, FOLFOX was the most chosen protocol. Xeloda was the most common chemotherapy received in most cases

Pathologic complete response following neoadjuvant therapy for pancreatic ductal adenocarcinoma: defining the incidence, predictors, and outcomes

BackgroundNeoadjuvant therapy (NT) is increasingly utilized for patients with pancreatic ductal adenocarcinoma (PDAC) but the nationwide incidence and long-term prognosis of a pathologic complete response (pCR) remains poorly understood. MethodsPatients with localized PDAC and known cT and pT stage who received NT prior to pancreatectomy from 2004 to 2016 were identified using the National Cancer Database. The clinicopathologic characteristics and long-term outcomes of patients who did and did not experience a pCR were compared. ResultsAmong 7,902 patients who underwent NT prior to pancreatectomy, 244 (3.1%) experienced a pCR while 7,658 (96.9%) did not. On multivariable regression, longer duration of NT (OR 1.20, 95% CI 1.14–1.27 per month) and use of preoperative radiation (OR 9.98, 95% CI 3.05–32.71) were independently associated with a pCR. Median overall survival (OS) was longer among patients who experienced a pCR (77 vs 26 months, p < 0.001). On multivariate analysis, pCR was the strongest predictor of improved OS (HR 0.43, 95%CI 0.32–0.58, p < 0.001). ConclusionA pCR following NT for PDAC occurs infrequently but is associated with significantly improved OS. Better predictors of response and more effective preoperative regimens should be aggressively sought.

Nationwide Analysis of Hospital Variation in Preoperative Radiotherapy Use for Rectal Cancer

Background: The Dutch national colorectal cancer guideline was revised in 2014, which led to an overall decrease in radiotherapy (RT) use. This study evaluates hospital variation in the use of preoperative RT for resectable rectal cancer and the influence of guideline revision, with analysis of the impact of changing RT application on short term outcomes at a national level.

Impact of age on the use of adjuvant treatments in patients undergoing surgery for colorectal cancer: patients with stage III colon or stage II/III rectal cancer

BackgroundMany older patients don’t receive appropriate oncological treatment. Our aim was to analyse whether there are age differences in the use of adjuvant chemotherapy and preoperative radiotherapy in patients with colorectal cancer.MethodsA prospective cohort study was conducted in 22 hospitals including 1157 patients with stage III colon or stage II/III rectal cancer who underwent surgery. Primary outcomes were the use of adjuvant chemotherapy for stage III colon cancer and preoperative radiotherapy for stage II/III rectal cancer. Generalised estimating equations were used to adjust for education, living arrangements, area deprivation, comorbidity and clinical tumour characteristics.ResultsIn colon cancer 92% of patients aged under 65 years, 77% of those aged 65 to 80 years and 27% of those aged over 80 years received adjuvant chemotherapy (χ2trends < 0.001). In rectal cancer preoperative radiotherapy was used in 68% of patients aged under 65 years, 60% of those aged 65 to 80 years, and 42% of those aged over 80 years (χ2trends < 0.001). Adjusting by comorbidity level, tumour characteristics and socioeconomic level, the odds ratio of use of chemotherapy compared with those under age 65, was 0.3 (0.1–0.6) and 0.04 (0.02–0.09) for those aged 65 to 80 and those aged over 80, respectively; similarly, the odds ratio of use of preoperative radiotherapy was 0.9 (0.6–1.4) and 0.5 (0.3–0.8) compared with those under 65 years of age.ConclusionsThe probability of older patients with colorectal cancer receiving adjuvant chemotherapy and preoperative radiotherapy is lower than that of younger patients; many of them are not receiving the treatments recommended by clinical practice guidelines. Differences in comorbidity, tumour characteristics, curative resection, and socioeconomic factors do not explain this lower probability of treatment. Research is needed to identify the role of physical and cognitive functional status, doctors’ attitudes, and preferences of patients and their relatives, in the use of adjuvant therapies.

A phase I pilot study of preoperative radiotherapy for prostate cancer: Long-term toxicity and oncologic outcomes.

60 Background: Pre-operative radiotherapy (PreORT) improves local control in various cancer types, and has become an established oncologic treatment strategy. During 2001-2004, we conducted a phase I pilot study assessing the role of short-course PreORT for men with unfavourable intermediate- and high-risk localized prostate cancer (PCa). We present long-term follow-up toxicity and oncologic outcomes. Methods: Eligible patients had histologically proven PCa, cT1-T2N0M0, PSA &gt; 15-35 ng/ml with any Gleason score, or PSA 10-15 ng/ml with Gleason score ≥7. Patients received 25 Gy in five consecutive daily fractions to the prostate, followed by radical prostatectomy (RadP) within 14 days after RT completion. Primary outcomes were intra-operative morbidity, and late genitourinary (GU) and gastrointestinal (GI) toxicities. Acute toxicity was assessed during radiotherapy treatment on daily basis using RTOG grade scoring scale. Patients were assessed post-RadP clinically and with PSA at 1 and 6 months, and every 6 months. Intra- and Post-RadP toxicity was documented prospectively and scored as per Common Terminology Criteria for Adverse Events v4.0. Biochemical failure (BF) was determined based on two consecutive post-RadP PSA &gt; 0.2 ng/ml. Results: Fifteen patients were enrolled; 14 patients completed PreORT followed by RadP, which also included bilateral lymph node dissections in 13 cases. Median follow-up was 12.2 years (range 6.7-16.3 years). Late GU toxicity was common, with 2 patients (14.3%) experiencing G2 toxicity, and 6 patients (42.8%) G3 toxicity. There were no G4-5 late GU toxicity. Late GI toxicity was infrequent, with only 1 patient (7.1%) experiencing transient G2 proctitis. At last follow-up, 8 (57.1%) and 6 (42.8%) patients experienced BF and metastatic disease recurrence, respectively. Conclusions: The use of PreORT in men with high-risk PCa is associated with unexpected high-rates of late GU toxicity. Future studies examining the role of RT pre-RadP must cautiously select RT technique and dose schedule. Importantly, long-term follow-up data is essential to fully determine the therapeutic index of PreORT in the management of localized PCa. Clinical trial information: NCT00252447.

Reprint of: Important imaging considerations in the pre-operative assessment of rectal cancer

The role of imaging has become central in the pre-operative decision-making process for patients with rectal cancer. The detailed information that is available from high-resolution imaging studies not only provides prognostic information but also allows the surgeon to anticipate potential pitfalls during the operation. The greater the amount of detail known about the tumour, the more selective one can be in the use of pre-operative radiotherapy, which can reduce unnecessary morbidity for minimal gain. Magnetic resonance imaging (MRI) is the most useful modality for the local staging of rectal cancer as it provides the most detail on the important prognostic factors that influence treatment. These include height of tumour from the anal verge, tumour depth of penetration, nodal disease, venous invasion, involvement of the circumferential resection margin. However, endoanal ultrasound (EAUS) is particularly good at staging early tumours and aids in identifying those that are suitable for local excision. We review the important considerations in the pre-operative staging of rectal cancer.

Role of the status of the mesorectal fascia in the selection of patients with rectal cancer for preoperative radiation therapy: a retrospective cohort study

Patients with rectal cancer in whom the mesorectal fascia is threatened by tumour are more likely than all patients with stage II/III disease to benefit from preoperative radiotherapy (RT). The objective of this study was to assess whether the status of the mesorectal fascia versus a stage II/III designation can best inform the use of preoperative RT in patients undergoing major rectal cancer resection. We reviewed the charts of consecutive patients with primary rectal cancer treated by a single surgeon at McMaster University, Hamilton, Ontario, between March 2006 and December 2012. The status of the mesorectal fascia was assessed by digital rectal examination, pelvic computed tomography and, when needed, pelvic magnetic resonance imaging (MRI). Patients whose mesorectal fascia was threatened or involved by tumour received preoperative RT. The study outcomes were rates of positive circumferential radial margin (CRM) and local tumour recurrence. A total of 153 patients were included, of whom 76 (49.7%) received preoperative RT because of concerns of a compromised mesorectal fascia. The median length of follow-up was 4.5 years. The number of CRM-positive cases in the RT and no-RT groups was 16 (22%) and 1 (1%), respectively (p < 0.01), and the number of cases of local tumour recurrence was 5 (7%) and 2 (3%), respectively (p = 0.2). Rates were similar when only patients with stage II/III tumours were included. Overall, 26 patients (17.0%) received MRI. The status of the mesorectal fascia, not tumour stage, may best identify patients for preoperative RT.

Treatment and survival of rectal cancer patients over the age of 80 years: a EURECCA international comparison

BackgroundThe optimal treatment strategy for older rectal cancer patients remains unclear. The current study aimed to compare treatment and survival of rectal cancer patients aged 80+.MethodsPatients of ≥80 years diagnosed with rectal cancer between 2001 and 2010 were included. Population-based cohorts from Belgium (BE), Denmark (DK), the Netherlands (NL), Norway (NO) and Sweden (SE) were compared side by side for neighbouring countries on treatment strategy and 5-year relative survival (RS), adjusted for sex and age. Analyses were performed separately for stage I–III patients and stage IV patients.ResultsOverall, 19 634 rectal cancer patients were included. For stage I–III patients, 5-year RS varied from 61.7% in BE to 72.3% in SE. Proportion of preoperative radiotherapy ranged between 7.9% in NO and 28.9% in SE. For stage IV patients, 5-year RS differed from 2.8% in NL to 5.6% in BE. Rate of patients undergoing surgery varied from 22.2% in DK to 40.8% in NO.ConclusionsSubstantial variation was observed in the 5-year relative survival between European countries for rectal cancer patients aged 80+, next to a wide variation in treatment, especially in the use of preoperative radiotherapy in stage I–III patients and in the rate of patients undergoing surgery in stage IV patients.

Abstract 673: Preoperative radiation therapy in advanced carcinoma colon with post-colostomy intestinal obstruction: The first report

Abstract Introduction We report the use of preoperative radiotherapy in a moribund patient with advanced carcinoma colon with complete intestinal obstruction who had undergone colostomy for a previous episode of intestinal obstruction. Methods Fifty-five-year-old man presented in Dec 2016 with acute intestinal obstruction with pain in abdomen and vomiting for 3 months. On exploratory laparotomy, a 12x15 cm hard mass in splenic flexure of colon was found involving root of mesentery, superior mesenteric vein and third part of duodenum and abutting tail of pancreas. Finding it unresectable, loop transverse colostomy was performed. He was started on Capecitabine. In Mar 2017, he presented to us in emaciated condition weighing 28 kilograms with acute intestinal obstruction with a large abdominal mass. He was started on nasogastric aspiration with total parenteral nutrition. Imaging revealed a 14x19 cm large abdominal mass involving pancreas, duodenum, spleen and transverse colon with dilated stomach. In view of poor general condition and advanced disease, the prognosis was discussed with the family and the idea of radiotherapy to relieve intestinal obstruction was discussed with family. After taking the consent, he was started on radiation therapy with 1.8 Gy per fraction after three-dimensional conformal radiation planning to spare maximum bowel. After 11 fractions, the patient started passing stools through the stoma. He was gradually started on enteral nutrition and was discharged to continue radiation therapy on outpatient basis. After 15 fractions, planning PET-CT scan was taken for adaptive therapy to make changes as per the reducing tumor size. He was also started on capecitabine as he was taking orally well. He completed 45 Gy in 25 fractions over 5 weeks. One month after completion of radiation therapy, he was found to be doing well and was planned for definitive surgery. Six weeks after the radiation therapy completion, extended left hemicolectomy with distal pancreatico-splenectomy and colostomy closure was performed. Histopathology showed residual viable poorly differentiated adenocarcinoma invading full thickness of colonic wall into pericolic soft tissues with a discontinuous microscopic nodular tumor deposit in pericolic soft tissue with all margins and nodes negative. Postoperatively, he developed biliary leak which healed with conservative management. Six weeks after the surgery, he recovered completely and was started on adjuvant Capecitabine. Five months after the surgery, he is doing well and is on oral Capecitabine. Conclusion To our knowledge, this is the first reported case of preoperative radiation therapy in advanced carcinoma colon and also in the setting of intestinal obstruction. Radiotherapy should be further tested in setting of malignant intestinal obstruction due to unresectable carcinoma colon and may spare patients with ileo/colostomy. Citation Format: Amit Jain, Elumalai L, Punam Goswami. Preoperative radiation therapy in advanced carcinoma colon with post-colostomy intestinal obstruction: The first report [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 673.

Trends in the Utilization of Pre-operative vs Post-operative Radiation Therapy for Soft-Tissue Sarcomas: A Surveillance, Epidemiology, and End Result Analysis

Patients with soft-tissue sarcomas are often treated with a combination of surgery and radiotherapy (RT). Published in 2005, NCI of Canada data suggests that pre-operative RT has comparable local control and overall survival to post-operative RT but is associated with less long-term toxicity. This study evaluates subsequent changes in RT patterns over time. This population-based study utilized the Surveillance, Epidemiology, and End Result (SEER) database. Data from a total of 17,584 patients diagnosed with soft-tissue sarcoma in 2004-2013 was collected. Patients with a high likelihood of receiving RT as a part of definitive treatment with surgery were analyzed. Patients diagnosed with favorable disease (T1), regional, or metastatic disease were excluded. The time trend was evaluated using univariable and multivariable logistic regression models with year at diagnosis as a continuous variable. Covariates included race, ethnicity, age at diagnosis, marital status, insurance status, stage, and grade. There was no change in the use of surgery over time, while post-operative RT declined in use from 2004 to 2013 (univariable: OR= 0.97, p< 0.001; multivariable: OR= 0.97, p= 0.003). The use of pre-operative RT increased over the same time period (univariable: OR= 1.08, p< 0.001; multivariable: OR= 1.13, p< 0.001). The use of post-operative RT has declined while pre-operative RT has appropriately seen an increase in utilization following the emergence of data supporting this shift in the treatment paradigm for soft-tissue sarcoma.

Association of Coloproctology of Great Britain & Ireland (ACPGBI): Guidelines for the Management of Cancer of the Colon, Rectum and Anus (2017) - Introduction.

Association of Coloproctology of Great Britain & Ireland (ACPGBI): Guidelines for the Management of Cancer of the Colon, Rectum and Anus (2017) - Introduction.

Changes in nationwide use of preoperative radiotherapy for rectal cancer after revision of the national colorectal cancer guideline

BackgroundThe rate of preoperative radiotherapy (RT) for rectal cancer in the Netherlands has been the highest among European countries. Revision of the national guideline on colorectal cancer, officially published in 2014, specifically focussed on the indication for RT and MRI criteria to evaluate mesorectal lymph nodes. The objective of this study was to evaluate implementation of the revised guideline using a national audit. MethodsData of the Dutch Surgical Colorectal Audit (DSCA) between 2009 and 2014 were used to evaluate RT use and RT regimen for relevant subgroups of cM0 rectal cancer patients, as well as accuracy of pre-operative MRI. Results14,018 patients were included for analysis. Overall RT use in cT1-4N0-2M0 stage ranged from 81.4% to 84.2% between 2009 and 2013, and decreased to 64.4% in 2014. The absolute decrease in RT use from 2013 to 2014 for cT1N0, cT2N0 and cT3N0 stage was 32.8%, 43.5% and 31.6%, respectively. Short course RT with delayed surgery was used as an alternative to chemoradiotherapy up to 2013 in 30.6% of patients over 80 years, and in 12.1% of patients with an ASA score >2; these percentages increased to 45.8% and 19.9% in 2014, respectively. Specificity of MRI for N-stage decreased from 82.9% in 2009 to 62.9% in 2013, with an increase to 73.2% in 2014. ConclusionThe revised national guideline on colorectal cancer was rapidly implemented in the Netherlands with a substantial decrease in RT use for low risk resectable rectal cancer, and increased specificity of MRI for N-staging.

Personalizing Therapy for Locally Advanced Rectal Cancer

Locally advanced rectal cancer is usually treated with chemotherapy, radiation therapy, and total mesorectal excision. Although effective, this trimodality therapy is arduous and associated with treatment-related toxicity. It has become clear that some patients may not need to undergo all three modalities of treatment and can thus avoid some of the treatment-associated morbidity. Two such approaches include selective use of preoperative radiation and nonoperative management. Limiting radiation can reduce treatment related toxicity and eliminate radiation-induced toxicity, fibrosis, and bowel and urogenital dysfunction. As an alternative to radical surgery, nonoperative management offers the considerable advantage of organ preservation. Efforts are under way to identify genetic markers that could be used to predict treatment response and better individualize treatment.

Leiomyosarcoma of Inferior Vena Cava: Resection and Reconstruction

Primary leiomyosarcomas of the inferior vena cava (IVC) are rare tumors with complex anatomical relationships. Surgical resection remains the primary approach for management, with selective use of preoperative radiation and chemotherapy. Given the propensity for local invasion of these tumors, radical resection of surrounding structures is often required. Herein we describe the presentation, work-up, operative management, and outcomes of these lesions through the case of a patient with a tumor involving the middle segment of the IVC. Given the extent of involvement, IVC resection with en bloc right nephrectomy, right adrenalectomy, and partial left renal vein resection was performed with vascular reconstruction using a prosthetic graft. With appropriate preoperative planning and a well-coordinated multidisciplinary approach, aggressive surgical resection can be safely performed and patients can benefit from favorable long-term survival.