Wait Policy Research Articles

PCN150 Watch and WAIT Policy Versus Robotic Surgery for Rectal Cancer: A Cost-Utility (RECCOSTE)

Chemoradiotheray (CR) followed by standard Surgical Resection (SR) is the standard treatment for distal locally-advanced rectal cancer (LARC) patients after a clinical compete response (cCR). Some novel approach suggested better functional results using robotic rectal resection (RRR) or avoiding surgical procedure, called Watch and Wait (WW) strategy. The aim of this study is to compare the clinical outcomes and cost-effective outcomes of WW versus RRR in the treatment of LARC. A Markov model-based, cost-utility analysis estimating mean costs and QALYs per patient was performed to compare SR, RRR and WW strategies for patients achieving a cCR to CRT. Rates of local regrowth, recurrence and distant metastasis were derived from series comparing WW to SR and from our previous comparative study of RRR versus SR. Lifetime incremental cost-utility ratio was calculated between strategies, and sensitivity analysis were performed to study model uncertainly. A willingness-to-pay of 30.000 per Quality Adjusted-Life Year (QALY) was used as a threshold to determine the most cost-effective treatment. The base case 15-years cancer-specific survival was 93.5% (95% confidence interval [CI] 91.5-94.9] on a WW program, compared to 95.9% [95%CI 93.6-97.7] after RRR. WW was dominant relative to RRR with cost savings of $48,566.58 (95%CI $47,635.77 - $49,497.39 ) and incremental QALY of 7.47 (95%CI 1.46 – 7.48). WW was also dominant relative to LRR, with cost savings of $48,764.49 (95%CI $47,768.49 - $49,760.48 ) and incremental QALY of 7.44 (95%CI 7,43 – 7.45). WW remained dominant in sensitivity analysis unless the rate of SR fell to 73.0%). This study provides data of cost-effectiveness differences between SR, RRR, WW approaches in LARC after cCR, showing a benefit for WW.

Lymphocyte predominant Hodgkin lymphoma, antigen-driven after all?

Nodular lymphocyte predominant Hodgkin lymphoma (NLPHL) was suggested as an entity separate from other types of Hodgkin lymphoma 40 years ago and recognized in the WHO classification in 2001. Based on its relatively benign course with late distant relapses, relation with lymph node hyperplasia with progressively transformed germinal centers, presence of clonal immunoglobulin gene rearrangements with somatic hypermutations and ongoing mutations, and relation with a number of inherited defects affecting the immune system, it has been suspected that NLPHL might be antigen-driven. Recent evidence has shown that cases of IgD-positive NLPHL are associated with infection by Moraxella catarrhalis, a common bacterium in the upper respiratory tract and in lymph nodes. This review summarizes the evidence for NLPHL as a B-cell lymphoma involving follicular T-lymphocytes normally found in germinal centers, its molecular features and relation to inherited immune defects, and its relation and differential diagnosis from similar entities. Finally, it discusses the evidence that in many cases a watch and wait policy might be a viable initial management strategy. © 2020 The Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Comparison of Oncological and Surgical Outcomes Between Formal Pancreatic Resections and Parenchyma-Sparing Resections for Small PanNETs (

Pancreatic neuroendocrine tumors (PanNETs) are rare tumors but incidence is increasing. An increasing number of these tumors are diagnosed incidentally when they are small (<2 cm) and when patients are asymptomatic. The European Neuroendocrine Tumor Society (ENETS) recommends conservative watch and wait policy for these patients. However, best surgical approach (parenchyma-sparing or formal oncological resection) for these small tumors when surgery is indicated is currently unknown. Parenchyma-sparing resections such as enucleation is associated with higher risk of post-operative morbidity compared to formal oncological resections. They are also be associated with potentially inadequate surgical margin clearance and with lack of lymphadenectomy for full pathological staging.Method: This study is a retrospective study and the aim is to analyze pre-operative clinical predictors of nodal metastases for small PanNETs to identify which patients are at a lower risk of lymph node metastases and are therefore suitable for parenchyma-sparing resection.Conclusion: The primary endpoint of this study is to determine if pre-operative clinical predictors such as tumor size are associated with lymph node involvement in small PanNETs.

HCC Liver Transplantation Wait List Dropout Rates Before and After the Mandated 6-Month Wait Time.

Studies have shown significant improvement in hepatocellular carcinoma (HCC) recurrence rates after liver transplantation since the united network of organ sharing (UNOS) implementation of a 6-month wait period prior to accrued exception model for end-stage liver disease (MELD) points enacted on October 8, 2015. However, few have examined the impact on HCC dropout rates for patients awaiting liver transplant. Our objective is to evaluate the outcomes of HCC dropout rates before and after the mandatory 6-month wait policy enacted. We conducted a retrospective cohort study on adult patients added to the liver transplant wait list between January 1, 2012, and March 8, 2019 (n = 767). Information was obtained through electronic medical records and organ procurement and transplant network (OPTN) publicly available national data reports. In response to the 2015 UNOS-mandated 6-month wait time, dropout rates in the HCC patient population at our center increased from 12% pre-mandate to 20.8% post-mandate This increase was similarly reflected in the national dropout rate, which also increased from 26.3% pre-mandate to 29.0% post-mandate. From these changes, it is evident that the UNOS mandate achieved its goal of increasing equity of liver organ allocation, but HCC patients are nonetheless dropping off of the wait list at an increased rate and are therefore disadvantaged.

Markov Decision Process Modeling for Multi-stage Optimization of Intervention and Treatment Strategies in Breast Cancer.

The breast cancer is a prevalent problem that undermines quality of patients' lives and causes significant impacts on psychosocial wellness. Advanced sensing provides unprecedented opportunities to develop smart cancer care. The available sensing data captured from individuals enable the extraction of information pertinent to the breast cancer conditions to construct efficient and personalized intervention and treatment strategies. This research develops a novel sequential decision-making framework to determine optimal intervention and treatment planning for breast cancer patients. We design a Markov decision process (MDP) model for both objectives of intervention and treatment costs as well as quality adjusted life years (QALYs) with the data-driven and state-dependent intervention and treatment actions. The state space is defined as a vector of age, health status, prior intervention, and treatment plans. Also, the action space includes wait, prophylactic surgery, radiation therapy, chemotherapy, and their combinations. Experimental results demonstrate that prophylactic mastectomy and chemotherapy are more effective than other intervention and treatment plans in minimizing the expected cancer cost of 25 to 60 years-old patient with in-situ stage of cancer. However, wait policy leads to an optimal quality of life for a patient with the same state. The proposed MDP framework can also be generally applicable to a variety of medical domains that entail evidence-based decision making.

Is It Wise to Wait for Ear to Become Dry in Indian Scenario?

Tympanoplasty is the standard and well-established procedure for closure of tympanic membrane perforations. Tympanoplasty in wet ear is still a topic of debate among ENT surgeons. This study discusses the balance between wait and watch policy and early intervention in wet ear. It also compares the rate of graft uptake and hearing improvement in Type I tympanoplasty in dry and wet ears. This is a hospital based, observational, descriptive and comparative study. Total 246 patients enrolled in the study. Two groups were created with 123 patients in each group. One included dry ears and another included wet ears. All patients had mucosal type of chronic otitis media. They all underwent Type I tympanoplasty. Graft uptake rate and hearing was compared between both groups. The overall success rate (graft uptake) was 91.06% (224). The success rate in dry ear group was 93.50% (115) and in wet ear group it was 88.62% (109). This study concluded that there is no added advantage of drying the ear rather the delay in treatment increases morbidity and drop outs in Indian scenario.

Identifying Factors Influencing Decision Making in Patients Diagnosed with Carotid Body Tumors: An Exploratory Study

Carotid body tumors (CBTs) are rare highly vascularized and slow enlarging tumors arising from the paraganglionic tissue at the carotid bifurcation. Main treatment options for CBTs are surgical resection or "wait and scan" strategy. The choice for either strategy may be equally good medically in many patients. A structured "shared decision making" (SDM) might be helpful for guiding patients. To develop an SDM strategy for the surgical treatment, we aim to (1) identify considerations and factors involved in the decision making of patients with CBTs and (2) evaluate the current practice in our clinic and explore the opinions of patients on their treatment. This exploratory study was conducted in patients of the Leiden University Medical Centre (LUMC), The Netherlands. Patients who met the inclusion criteria were invited for a semi-structured interview. All conversations were fully audiotaped and transcripted. Fifteen patients were included and interviewed. Ten of these patients underwent previously surgical resection of at least one tumor. Five patients underwent the wait and scan policy. The most important factors influencing decision making in CBT treatment are family, fears, co-consultants, and doctor-patient relationship. This study has identified the factors influencing decision making in CBT and should be considered during consultations. The decision for surgery or not was mainly influenced by physician preferences and family members' prior experiences.

Elective surgery wait time reduction in Canada: A synthesis of provincial initiatives

In an effort to reduce wait times, Canadian provincial governments have introduced numerous wait time reduction programs and policies. The objective of this study was to provide an overview of elective surgery wait time reduction initiatives across the Canadian provinces from 2000 to 2018. Each of the 10 provincial government web sites were searched. A theoretical framework for elective surgery wait time reduction policies was developed. The final framework is broadly organized into a supply-demand-performance management model. The majority were categorized as supply-oriented initiatives, which have been implemented by all the provinces in some form. Demand-oriented initiatives have been implemented the least. Our conceptual framework may be used to categorize wait time reduction initiatives for the purpose of policy development and evaluation.

Podoplanin is an efficient predictor of neck lymph node metastasis in tongue squamous cell carcinoma with low tumor budding grade.

The current study investigated the efficacy of podoplanin expression in tumor budding cells as a predictor of neck lymph node metastasis (NLM) in patients with tongue squamous cell carcinoma (SCC) of low tumor budding grade (TBG). A total of 99 patients with early T-stage tongue SCC of any clinical N status who received the initial curative treatment were enrolled. The association between podoplanin expression and NLM was immunohistochemically analyzed, with a focus on tongue SCC with low TBG. The disease-specific survival (DSS) rate was 77% at 5 years, and a significant difference was observed between the NLM-positive and NLM-negative groups, and between the low (n=77) and high (n=22) TBG groups. In the low TBG group, there was a significant difference in DSS between the NLM-positive and NLM-negative groups. The multivariate analysis showed that lymphatic vessel invasion (ly) [odds ratio (OR)=11.5, 95% confidence interval (CI): 1.50–87.6; P=0.02] and podoplanin expression (OR=7.07, 95% CI: 1.80–27.7; P=0.005) were significantly correlated with NLM. Furthermore, negative predictive values (NPV) of ly and podoplanin expression for NLM were 75% and 88%, respectively. Considering the balance of stratification case number adding to ratio, NLM-negative prediction by podoplanin was more significant than that by ly for the low TBG group. The results of the present study demonstrated that podoplanin expression in tumor budding is an independent and efficient predictor of NLM in the tongue SCC with low TBG. The low TBG and podoplanin-negative cases may be candidates for the wait and watch policy, therefore, reducing inappropriate elective neck lymph node dissections.

Consensus on the Watch and Wait policy in rectal cancer patients after neoadjuvant treatment (2020 version)

Patients with clinical complete response(cCR) after neoadjuvant treatment receiving the Watch and Wait('W&W') policy can achieve similar survival of those with yeild pathological complete response (ypCR), and have significantly improved quality of life compared to those undergoing radical operation. Based on thoroughly reviewing the literatures and guidelines at home and abroad, and referring associated clinical experiences from a lot of domestic medical centers, the present version of Chinese Consensus on W&W was established by a panel of many experts of gastrointestinal surgery, medical oncology, radiation oncology, pathology, endoscopy, radiology. This consensus mainly elucidates important conceptions of the W&W policy, current key evidences, risks and benefits for patients, conditions to carry out W&W, criteria of cCR diagnosis, timing of evaluation, follow - up plan, salvage treatment for local relapse and distant metastasis, associated problems of local resection, and is expected to facilitate the clinical practice and research of W&W policy in China.

Cholecystectomy after Endoscopic Papillotomy for Choledocholithiasis in the Elderly—Is It Necessary?

Although elective laparoscopic cholecystectomy is the accepted strategy after endoscopic retrograde cholangiopancreatography (ERCP), papillotomy, and common bile duct (CBD) clearance, the decision to perform a cholecystectomy in high-risk elderly comorbid patients remains subjective and is controversial. The aim of this study was to examine the outcome of elderly patients with cholecystectomy deferral after successful initial endoscopic removal of CBD stones. The study examined a retrospective patient database, which included all patients aged &gt;60 years who underwent an ERCP for CBD stones at the Chaim Sheba Medical Center. The study cohort was divided according to whether a subsequent cholecystectomy was performed and also by age 60 to 80 or &gt;80 years. All biliary-related complications were recorded. The primary outcome measures were biliary complications, perioperative and periprocedural mortality, CBD stone recurrence, and the need for future surgical intervention. There were 111 patients (mean age 79.4 ± 9.1 years) who underwent ERCP with follow-up. After excluding 11 patients, 100 patients were left for analysis, 46 of whom underwent a cholecystectomy and 54 were observed without operation. There were significant longer term biliary complications in five of the operated patients (10.9%) and in four of the unoperated cases (7.4%). All biliary-related complications were managed successfully by conservative means except for one fatality in the nonoperated group. Biliary-related complications after successful ERCP for CBD stones were unaffected by surgery but were more commonly observed in older cases. A watch and wait policy may be justified in elderly comorbid patients.

400PD - Characteristics and patterns of care of high-grade IDH-mutant gliomas in elderly patients: A French POLA network study

BackgroundThe characteristics of elderly patients with IDH-mutant (IDHm) high-grade gliomas (HGG) remain to be described. This study aims to describe characteristics and patterns of care of elderly patients with IDHm HGG included in the French POLA network dedicated to HGG. MethodsThe characteristics and patterns of care of elderly (≥70 years) patients IDHm HGG were compared to those of younger patients (<70 years) with IDHm gliomas and to those of elderly patients with IDH wild-type (IDHwt) gliomas. ResultsOut of the 1433 HGG patients included, 119 (8.3%) occurred in elderly patients. Histology consisted of 1p/19q codeleted anaplastic oligodendroglioma (71.8%), anaplastic IDHm astrocytomas (12.8%) and IDHm glioblastoma (15.4%). Median age at diagnosis was 74 years (70.2-87.1), median Karnofsky Performans Status (KPS) was 80 (50-100). Treatments consisted of a wait and scan policy (7.7%), radiotherapy (RT) alone (7.7%), chemotherapy (CT) alone (41%), RT-CT (RT-TMZ: 25.6%, RT-PCV: 15.4%) or palliative care (2.6%). The clinical, radiological and histological presentations of elderly patients IDHm HGG were different from those of elderly patients IDHwt HGG. Compared to elderly patients IDHwt HGG, elderly patients IDHm were less frequently associated with cognitive impairment (p=0.045), contrast enhancement (p=0.01) and had a lower proliferative index (Ki67) (p=0.005). In contrast, there was no difference regarding clinical, radiological and histological presentations of elderly and younger patients IDHm HGG but their management was different. Elderly patients IDHm less frequently underwent gross total resection (p=0.002) and radiotherapy (p<0.001). The median progression-free survival (PFS) and overall survival (OS) were longer for IDHm elderly patients (29.2 and 62.1 months respectively) than IDHwt elderly patients (8.2 and 13.2 months respectively) but shorter than younger IDHm patients (69 months and not reached respectively). ConclusionsIDHm HGG in elderly show prolonged survival. However, their poorer outcome compared to younger IDHm gliomas may results from patient or tumor characteristics or from under-treatment, suggesting a role for geriatric assessment. Legal entity responsible for the studyFrench POLA network. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

Oncological and Survival Outcomes in Watch and Wait Patients With a Clinical Complete Response After Neoadjuvant Chemoradiotherapy for Rectal Cancer: A Systematic Review and Pooled Analysis.

The aim of this study was to evaluate the oncological and survival outcomes of a Watch and Wait policy in rectal cancer after a clinical complete response (cCR) following neoadjuvant chemoradiotherapy. The detection of a cCR after neoadjuvant treatment may facilitate a nonoperative approach in selected patients. However, the long-term safety of this strategy remains to be validated. This is a systematic review of the literature to determine the oncological outcomes in Watch and Wait patients. The primary outcome was the cumulative rate of local regrowth, success of salvage surgery, and incidence of metastases. We also evaluated survival outcomes. A pooled analysis of manually extracted summary statistics from individual studies was carried out using inverse variance weighting. Seventeen studies comprising 692 patients were identified; incidence of cCR was 22.4% [95% confidence interval (CI),14.3-31.8]. There were 153 (22.1%) local regrowths, of which 96% (n = 147/153) manifested in the first 3 years of surveillance. The 3-year cumulative risk of local regrowth was 21.6% (95% CI, 16.0-27.8). Salvage surgery was performed in 88% of patients, of which 121 (93%) had a complete (R0) resection. Fifty-seven metastases (8.2%) were detected, and 35 (60%) were isolated without evidence of synchronous regrowths; 3-year incidence was 6.8% (95% CI, 4.1-10.2). The 3-year overall survival was 93.5% (95% CI, 90.2-96.2). In rectal cancer patients with a cCR following neoadjuvant chemoradiotherapy, a Watch and Wait policy appears feasible and safe. Robust surveillance with early detection of regrowths allows a high rate of successful salvage surgery, without an increase in the risk of systemic disease, or adverse survival outcomes.

Results of a randomized controlled trial of level IIb preserving neck dissection in clinically node-negative squamous carcinoma of the oral cavity

BackgroundThe lymphatic spread from the cancers of the oral cavity follows an orderly progression and involvement of lower nodes without involvement of upper nodes and skip metastasis is rare. Selective neck dissections are increasingly being performed for node-positive patients; however, in node-negative patients the options of wait and watch, prophylactic radiotherapy, and prophylactic elective node dissections are debated. Quality of life and shoulder functions are important to choose the appropriate therapeutic modality.Patients and methodsPatients with oral squamous carcinoma with clinically and radiologically negative neck were randomized to IIb preserving superselective neck dissection or conventional supraomohyoid neck dissection. The primary end point of the study was recurrence of disease (clinical or radiological) and shoulder function as demonstrated by the clinical examination and electromyography. The secondary end point was quality of life as measured by the FACT-HN version 4 questionnaire at the end of 1 year follow-up.ResultsThe mean number of lymph node harvested per patient was 25.6 (range 8–85). Of the 32 patients, 3 had histologically positive node in level Ib, one of these patients had single positive node while the remaining two had three positive nodes in level Ib. At median follow-up of 36 months disease-free survival in IIb, sparing group was 83% compared to 91% in control arm, the difference in survival between two groups was statistically not significant (p = 0.694). EMG of the shoulder showed denervation pattern in 45% patients undergoing IIb preserving surgery at 1 month follow-up compared to 95% in conventional surgery group, this recovered in all patients but one at 3 months and 100% recovery was seen at 6 months.ConclusionsThe results of the present study indicate that superselective IIb preserving neck dissections are technically feasible and appear to be oncologically safe procedures when performed as elective prophylactic procedures in highly select group of patients. A significant number of occult metastasis seen in the present study suggests prophylactic dissection to be better than wait and watch policy. Results also show initial higher shoulder morbidity at 1 month in patients undergoing IIb preserving dissections; however, at the end of 1 year recovery is complete and both procedures are comparable.Trial registrationThe trial is registered at clinicaltrials.gov with registration no NCT00847717; registered on February 19, 2009.

Recent advances of neoadjuvant chemoradiotherapy in rectal cancer: Future treatment perspectives.

Neoadjuvant chemoradiotherapy (nCRT) has been widely used as a multidisciplinary approach for stage II/III rectal cancer. However, its safety and efficacy are controversial because previous studies have shown conflicting outcomes. The present review aimed to elucidate the benefits and limitations of nCRT for patients with rectal cancer. Future perspectives of nCRT are also described. No recent randomized trials have been able to show a survival benefit, although many studies have demonstrated good local control with the use of fluoropyrimidine (e.g. 5‐fluorouracil [FU] or capecitabine)‐based nCRT. Addition of oxaliplatin (OX) to FU‐based nCRT might improve overall survival by preventing distant metastasis, as shown in recent meta‐analyses. However, control of adverse effects is an important concern with this treatment. New treatment strategies such as nonoperative management (watch and wait policy) and total neoadjuvant therapy (TNT) are promising, but the establishment of reliable diagnostic methods of metastasis is essential. Development of new biomarkers is also necessary to select patients who are more likely to benefit from nCRT.

Probe-Based Confocal Endomicroscopy May Improve the Diagnosis of Clinical Complete Response After Neoadjuvant Chemoradiotherapy for Locally Advanced Rectal Neoplasia

Introduction: Neoadjuvant chemoradiotherapy (nCRxt) followed by surgery represents the optimal approach for medium and distal advanced rectal tumors; however patients with clinical complete response (cCR) may be followed closely without surgery (watch and wait policy). Magnetic resonance imaging (MRI) and endoscopy have low sensitivity for the diagnosis of cCR. Probe-based confocal endomicroscopy (pCLE) represents a real time in vivo method allowing acquisition of optical biopsies with 1000 times magnification, evaluating both cellular and vascular patterns. Aim: to evaluate the contribution of pCLE in the diagnosis of cCR after nCRxt for advanced rectal cancer. Methods: We evaluated 40 patients with locally medium and distal advanced rectal neoplasia (T3 - T4, or N+) between October 2016 and February 2018 who underwent nCRxt (5-fluoroucacil, 5040 cGy), and who were submitted to pCLE. Cell irregularity, atypical glands, vascular enlargement and tortuosity were considered pCLE patterns of malignancy. pCLE was performed pre and post nCRxt, and guided tissue biopsies subsequently. Images of pCLE post nCRxt were recorded and blinded compared to the histology of the surgical specimens. Results: Twenty-one patients had tumor lesions located at medium rectum and 19 patients at distal rectum. Twenty-three (57.5%) patients were men. Mean age was: 63.15 years, varying from 36 to 82 years. Thirty-three had only partial nresponse, all of them confirmed by pCLE. Seven patients (17.5%) had good endoscopic response, and presented only a small ulcer (n=3) or residual scar (n=4). In this subgroup of patients, pCLE post nCRxt correctly diagnosed all but one (6/7 patients). Two negative pCLE patients were confirmed by surgical pathology. Three positive pCLE patients presented pathological residual disease in the surgical specimen. pCLE misdiagnosed one patient who was considered positive, however the surgical pathological result showed only mucin areas without neoplastic cells. One negative pCLE patient has been followed up for one year without any evidence of recurrence at endoscopy and MRI. pTNM stages of the subgroup were: 2 ypT0 ypN0, 1 ypT0 ypN1, 1 ypT1 ypN0, and 2 ypT2ypN0. Conclusion: 1. pCLE could be useful for improving the diagnosis of cCR, and may alter the patient management; 2. pCLE procedure might be valuable for identifying the patients with advanced rectal cancer who will benefit from watch and wait policy, avoiding surgical treatment and consequently achieving better quality of life.

FA03.06: THE COST BENEFIT OF A WATCH AND WAIT POLICY FOR COMPLETE CLINICAL RESPONDERS FOLLOWING NEO-ADJUVANT THERAPY IN ESOPHAGEAL CANCER

Abstract Background Survival for esophageal cancer remains poor despite neo-adjuvant chemo-radiotherapy (nCRT) and surgical resection. The median survival for nCRT plus surgery in the CROSS trial was 48 months with a pathological complete response (pCR) rate of 29%. All pCR patients will have been clinical complete responders (cCR) and while surveillance and salvage surgery (S + SS) for cCR in rectal cancer is well investigated, it is unclear whether the outcomes are similar in esophageal cancer. As morbidity and mortality following esophagectomy is high, avoidance of surgery for predicted pCR would represent a clear advantage. Our unit offers a supported choice for cCR patients to opt for surgery or for surveillance. There is currently no literature on the cost benefit of a watch and wait policy for esophageal cancer patients with a complete clinical response. Methods We identified all cCR patients from a prospectively collected database of esophageal cancer patients offered curative treatment with nCRT from 1999 to 2017. We costed the S + SS group for whom accurate costing data was available and we matched these, according to time of follow up, to a control group of cCR who underwent surgery. Cost (from the National DRG cost manual) was calculated based on cost of surgery, ICU stay, admission length, and follow up radiological and endoscopic procedures. The data was analysed using a two-tailed, equal variance t-test. Results Of 237 patients who received nCRT, 86 had a cCR. Of these, 15 patients in the S + SS fulfilled the selection criteria with a mean follow up of 10.2 compared with 10.4 months in the control group (P = 0.925). The mean number of days in hospital was 19.2 vs. 43.2 days consecutively during the follow up period. The mean estimated cost to the HSE was €91,480 for S + SS compared with €301,280 for the controlled surgery group (P = 0.01). Conclusion This study identified a significant cost benefit for surveillance over surgery. Further studies are required to accurately identify those who cannot benefit from surgery and to assess quality of life years gained and cost per year of life are needed. Disclosure All authors have declared no conflicts of interest.

What is the Required Frequency of MRI Scanning in the Wait and Scan Management?

The wait and scan policy is being increasingly used as the first measure after the diagnosis of a vestibular schwannoma (VS) using magnetic resonance imaging (MRI). As part of the European Academy of Otology and Neuro-Otology (EAONO) position statement on VS, the frequency of imaging has been studied in the literature. Among 163 studies, 29 fulfilled the inclusion criteria and were scored using the Grading of Recommendations, Assessment, Development, and Evaluation system. Because tumor growth rate during the first 5 years of follow-up is predictive of further growth during the upcoming years, a protocol for wait and scan is useful for centers dealing with this condition. The EAONO proposal is that after the initial diagnosis by MRI, a first new MRI would take place after 6 months, annually for 5 years, and then every other year for 4 years, followed by a lifelong MRI follow-up every 5 years. The first early MRI is to screen for fast-growing tumors, and the lifelong follow-up with tapered intervals is to detect late repeated growth.

Dose escalation using contact X-ray brachytherapy (Papillon) for rectal cancer: does it improve the chance of organ preservation?

A watch and wait policy for patients with a clinical complete response (cCR) after external beam chemoradiotherapy (EBCRT) for rectal cancer is an attractive option. However, approximately one-third of tumours will regrow, which requires surgical salvage for cure. We assessed whether contact X-ray brachytherapy (CXB) can improve organ preservation by avoiding surgery for local regrowth. From our institutional database, we identified 200 of 573 patients treated by CXB from 2003 to 2012. Median age was 74 years (range 32-94), and 134 (67%) patients were males. Histology was confirmed in all patients and was staged using CT scan, MRI or endorectal ultrasound. All patients received combined CXB and EBCRT, except 17 (8.5%) who had CXB alone. Initial cCR was achieved in 144/200 (72%) patients. 38/56 (68%) patients who had residual tumour received immediate salvage surgery. 16/144 (11%) patients developed local relapse after cCR, and 124/144 (86%) maintained cCR. At median follow up of 2.7 years, 161 (80.5%) patients were free of cancer. The main late toxicity was bleeding (28%). Organ preservation was achieved in 124/200 (62%) patients. Our data suggest that CXB can reduce local regrowth to 11% compared with around 30% after EBCRT alone. Organ preservation of 62% achieved was higher than reported in most published watch and wait studies. Advances in knowledge: CXB is a promising treatment option to avoid salvage surgery for local regrowth, which can improve the chance of organ preservation in patients who are not suitable for or refuse surgery.

Rectal sparing approach after preoperative radio- and/or chemotherapy (RESARCH) in patients with rectal cancer: a multicentre observational study.

Rectum-sparing approaches appear to be appropriate in rectal cancer patients with a major (mCR) or complete clinical response (cCR) after neoadjuvant therapy. The aim of the present study is to evaluate the effectiveness of rectum-sparing approaches at 2years after the completion of neoadjuvant treatment. Patients with rectal adenocarcinoma eligible to receive neoadjuvant therapy will be prospectively enrolled. Patients will be restaged 7-8weeks after the completion of neoadjuvant therapy and those with mCR (defined as absence of mass, small mucosal irregularity no more than 2cm in diameter at endoscopy and no metastatic nodes at MRI) or cCR will be enrolled in the trial. Patients with mCR will undergo local excision, while patients with cCR will either undergo local excision or watch and wait policy. The main end point of the study is to determine the percentage of rectum preservation at 2years in the enrolled patients. This protocol is the first prospective trial that investigates the role of both local excision and watch and wait approaches in patients treated with neoadjuvant therapy for rectal cancer. The trial is registered at clinicaltrials.gov (NCT02710812).