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Techniques in Coloproctology May 2024
Topics: Humans; Rectal Neoplasms; Robotic Surgical Procedures; Surgical Stapling; Male; Proctectomy; Middle Aged; Female
PubMed: 38762703
DOI: 10.1007/s10151-024-02935-1 -
Scandinavian Journal of Surgery : SJS :... May 2024Rectal cancer patients commonly benefit from neoadjuvant therapy before resection surgery. For these patients, an elective ostomy diversion is frequently considered,...
BACKGROUND
Rectal cancer patients commonly benefit from neoadjuvant therapy before resection surgery. For these patients, an elective ostomy diversion is frequently considered, despite the absence of conclusive evidence when a diversion is advantageous. This is a retrospective observational single-center study on a 4-year consecutive rectal cancer cohort undergoing neoadjuvant therapy, aiming at improving the understanding of risks and benefits associated with ostomy diversion.
MATERIAL AND METHOD
Baseline characteristics, tumor-specific data, clinical events, and outcomes were collected using the Swedish Colorectal Cancer Registry and medical records.
RESULTS
Thirty-two (30.2%) of the 106 included patients presented with endoscopic impassable tumors at diagnosis, of which 18 (56.2%) had diverting ostomy. Three out of 14 with impassable tumor and no diversion developed a bowel obstruction. None of the patients with an endoscopically passable tumor at diagnosis (n = 74) experienced a bowel obstruction. The elective diversions (n = 40) were not associated with serious complications (Clavien-Dindo grade ⩾ 3b). Patients with a diverting ostomy (n = 30) had similar time intervals from diagnosis to neoadjuvant treatment and to definite tumor resection as those without diversion but experienced more complex primary tumor resections in terms of blood loss and operation time.
CONCLUSION
An elective diverting ostomy is a relatively safe procedure in rectal cancer patients requiring neoadjuvant therapy. More than one out of five non-diverted patients with endoscopically impassable rectal tumors developed bowel obstruction and would potentially have benefited from an elective diversion.
PubMed: 38751171
DOI: 10.1177/14574969241252481 -
Asian Journal of Surgery May 2024
PubMed: 38724370
DOI: 10.1016/j.asjsur.2024.04.178 -
World Journal of Surgical Oncology May 2024The primary treatment for non-metastatic rectal cancer is curative resection. However, sphincter-preserving surgery may lead to complications. This study aims to develop...
BACKGROUND
The primary treatment for non-metastatic rectal cancer is curative resection. However, sphincter-preserving surgery may lead to complications. This study aims to develop a predictive model for stoma non-closure in rectal cancer patients who underwent curative-intent low anterior resection.
METHODS
Consecutive patients diagnosed with non-metastatic rectal cancer between January 2005 and December 2017, who underwent low anterior resection, were retrospectively included in the Chang Gung Memorial Foundation Institutional Review Board. A comprehensive evaluation and analysis of potential risk factors linked to stoma non-closure were performed.
RESULTS
Out of 956 patients with temporary stomas, 10.3% (n = 103) experienced non-closure primarily due to cancer recurrence and anastomosis-related issues. Through multivariate analysis, several preoperative risk factors significantly associated with stoma non-closure were identified, including advanced age, anastomotic leakage, positive nodal status, high preoperative CEA levels, lower rectal cancer presence, margin involvement, and an eGFR below 30 mL/min/1.73m2. A risk assessment model achieved an AUC of 0.724, with a cutoff of 2.5, 84.5% sensitivity, and 51.4% specificity. Importantly, the non-closure rate could rise to 16.6% when more than two risk factors were present, starkly contrasting the 3.7% non-closure rate observed in cases with a risk score of 2 or below (p < 0.001).
CONCLUSION
Prognostic risk factors associated with the non-closure of a temporary stoma include advanced age, symptomatic anastomotic leakage, nodal status, high CEA levels, margin involvement, and an eGFR below 30 mL/min/1.73m2. Hence, it is crucial for surgeons to evaluate these factors and provide patients with a comprehensive prognosis before undergoing surgical intervention.
Topics: Humans; Rectal Neoplasms; Retrospective Studies; Female; Male; Middle Aged; Surgical Stomas; Aged; Prognosis; Risk Factors; Follow-Up Studies; Anastomotic Leak; Neoplasm Recurrence, Local; Postoperative Complications; Adult; Proctectomy; Aged, 80 and over
PubMed: 38715036
DOI: 10.1186/s12957-024-03403-8 -
Surgical Case Reports May 2024Colorectal cancer (CRC) often metastasizes to the liver, lungs, lymph nodes, and peritoneum but rarely to the bladder, small intestine, and skin. We here report the rare...
BACKGROUND
Colorectal cancer (CRC) often metastasizes to the liver, lungs, lymph nodes, and peritoneum but rarely to the bladder, small intestine, and skin. We here report the rare metastasis of anal cancer in the left bladder wall, followed by metastases to the small intestine and skin, after abdominoperineal resection and left lateral lymph node dissection with chemotherapy in a patient with clinician Stage IVa disease.
CASE PRESENTATION
A 66-year-old man presented with 1-month history of bloody stool and anal pain and diagnosed with clinical Stage IVa anal cancer with lymph node and liver metastases (cT3, N3 [#263L], M1a [H1]). Systemic chemotherapy led to clinical complete response (CR) for the liver metastasis and clinical near-CR for the primary tumor. Robot-assisted laparoscopic perineal rectal resection and left-sided lymph node dissection were performed. Computed tomography during 18-month postoperative follow-up identified a mass in the left bladder wall, which was biopsied with transurethral resection, was confirmed as recurrent anal cancer by histopathologic evaluation. After two cycles of systemic chemotherapy, partial resection of the small intestine was performed due to bowel obstruction not responding to conservative therapy. The histopathologic evaluation revealed lymphogenous invasion of the muscularis mucosa and subserosa of all sections. Ten months after the first surgery for bowel obstruction and two months before another surgery for obstruction of the small intestine, skin nodules extending from the lower abdomen to the thighs were observed. The histopathologic evaluation of the skin biopsy specimen collected at the time of surgery for small bowel obstructions led to the diagnosis of skin metastasis of anal cancer. Although panitumumab was administered after surgery, the patient died seven months after the diagnosis of skin metastasis.
CONCLUSIONS
This case illustrates the rare presentation of clinical Stage IVa anal cancer metastasizing to the bladder wall, small intestine, and skin several years after CR to chemotherapy.
PubMed: 38714637
DOI: 10.1186/s40792-024-01913-x -
MedRxiv : the Preprint Server For... Apr 2024Recent data have demonstrated that in locally advanced rectal cancer (LARC), a total neoadjuvant therapy (TNT) approach improves compliance with chemotherapy and...
ALLIANCE A022104/NRG-GI010: The Janus Rectal Cancer Trial: a randomized phase II/III trial testing the efficacy of triplet versus doublet chemotherapy regarding clinical complete response and disease-free survival in patients with locally advanced rectal cancer.
BACKGROUND
Recent data have demonstrated that in locally advanced rectal cancer (LARC), a total neoadjuvant therapy (TNT) approach improves compliance with chemotherapy and increases rates of tumor response compared to neoadjuvant chemoradiation (CRT) alone. They further indicate that the optimal sequencing of TNT involves consolidation (rather than induction) chemotherapy to optimize complete response rates. Data, largely from retrospective studies, have also shown that patients with clinical complete response (cCR) after neoadjuvant therapy may be managed safely with the watch and wait approach (WW) instead of preemptive total mesorectal resection (TME). However, the optimal consolidation chemotherapy regimen to achieve cCR has not been established, and a randomized clinical trial has not robustly evaluated cCR as a primary endpoint. Collaborating with a multidisciplinary oncology team and patient groups, we designed this NCI-sponsored study of chemotherapy intensification to address these issues and to drive up cCR rates, to provide opportunity for organ preservation, improve quality of life for patients and improve survival outcomes.
METHODS
In this NCI-sponsored multi-group randomized, seamless phase II/III trial (1:1), up to 760 patients with LARC, T4N0, any T with node positive disease (any T, N+) or T3N0 requiring abdominoperineal resection or coloanal anastomosis and distal margin within 12 cm of anal verge will be enrolled. Stratification factors include tumor stage (T4 vs T1-3), nodal stage (N+ vs N0) and distance from anal verge (0-4; 4-8; 8-12 cm). Patients will be randomized to receive neoadjuvant long course chemoradiation (LCRT) followed by consolidation doublet (mFOLFOX6 or CAPOX) or triplet chemotherapy (mFOLFIRINOX) for 3-4 months. LCRT in both arms involves 4500 cGy in 25 fractions over 5 weeks + 900 cGy boost in 5 fractions with a fluoropyrimidine (capecitabine preferred). Patients will undergo assessment 8-12 (+/- 4) weeks post-TNT completion. The primary endpoint for the phase II portion will compare cCR between treatment arms. A total number of 296 evaluable patients (148 per arm) will provide statistical power of 90.5% to detect an 17% increase in cCR rate, at a one-sided alpha=0.048. The primary endpoint for the phase III portion will compare disease-free survival (DFS) between treatment arms. A total of 285 DFS events will provide 85% power to detect an effect size of hazard ratio 0.70 at a one-sided alpha of 0.025, requiring enrollment of 760 patients (380 per arm). Secondary objectives include time-to event outcomes (overall survival, organ preservation time and time to distant metastasis) and adverse effects. Biospecimens including archival tumor tissue, plasma and buffy coat in EDTA tubes, and serial rectal MRIs will be collected for exploratory correlative research. This study, activated in late 2022, is open across the NCTN and has a current accrual of 312. Support: U10CA180821, U10CA180882, U24 CA196171; https://acknowledgments.alliancefound.org .
DISCUSSION
Building off of data from modern day rectal cancer trials and patient input from national advocacy groups, we have designed the current trial studying chemotherapy intensification via a consolidation chemotherapy approach with the intent to enhance cCR and DFS rates, increase organ preservation rates, and improve quality of life for patients with rectal cancer.
TRIAL REGISTRATION
Clinicaltrials.gov ID: NCT05610163 ; Support includes U10CA180868 (NRG) and U10CA180888 (SWOG).
PubMed: 38712176
DOI: 10.1101/2024.04.25.24306396 -
Cureus Apr 2024Hidradenitis suppurativa (HS), also known as acne inversa, is a chronic inflammatory disorder affecting the terminal follicular epithelium within the apocrine skin...
Hidradenitis suppurativa (HS), also known as acne inversa, is a chronic inflammatory disorder affecting the terminal follicular epithelium within the apocrine skin glands. When these lesions develop in the genital and perianal regions, there is a potential risk of progression to squamous cell carcinoma or mucinous adenocarcinoma. The tumor may appear in the perianal area, perineum, or buttocks. Here, we present a rare case of long-standing perianal HS with associated fistula-related mucinous adenocarcinoma and the challenges we faced in managing this condition.
PubMed: 38707052
DOI: 10.7759/cureus.57585 -
Langenbeck's Archives of Surgery May 2024Transanal minimally invasive surgery has theoretical advantages for ileal pouch-anal anastomosis surgery. We performed a systematic review assessing technical approaches... (Meta-Analysis)
Meta-Analysis
PURPOSE
Transanal minimally invasive surgery has theoretical advantages for ileal pouch-anal anastomosis surgery. We performed a systematic review assessing technical approaches to transanal IPAA (Ta-IPAA) and meta-analysis comparing outcomes to transabdominal (abd-IPAA) approaches.
METHODS
Three databases were searched for articles investigating Ta-IPAA outcomes. Primary outcome was anastomotic leak rate. Secondary outcomes included conversion rate, post operative morbidity, and length of stay (LoS). Staging, plane of dissection, anastomosis, extraction site, operative time, and functional outcomes were also assessed.
RESULTS
Searches identified 13 studies with 404 unique Ta-IPAA and 563 abd-IPAA patients. Anastomotic leak rates were 6.3% and 8.4% (RD 0, 95% CI -0.066 to 0.065, p = 0.989) and conversion rates 2.5% and 12.5% (RD -0.106, 95% CI -0.155 to -0.057, p = 0.104) for Ta-IPAA and abd-IPAA. Average LoS was one day shorter (MD -1, 95% CI -1.876 to 0.302, p = 0.007). A three-stage approach was most common (47.6%), operative time was 261(± 60) mins, and total mesorectal excision and close rectal dissection were equally used (49.5% vs 50.5%). Functional outcomes were similar. Lack of randomised control trials, case-matched series, and significant study heterogeneity limited analysis, resulting in low to very low certainty of evidence.
CONCLUSIONS
Analysis demonstrated the feasibility and safety of Ta-IPAA with reduced LoS, trend towards less conversions, and comparable anastomotic leak rates and post operative morbidity. Though results are encouraging, they need to be interpreted with heterogeneity and selection bias in mind. Robust randomised clinical trials are warranted to adequately compare ta-IPAA to transabdominal approaches.
Topics: Humans; Proctocolectomy, Restorative; Anastomotic Leak; Transanal Endoscopic Surgery; Treatment Outcome; Length of Stay; Colonic Pouches; Operative Time; Anastomosis, Surgical
PubMed: 38705912
DOI: 10.1007/s00423-024-03343-7 -
Australian Journal of General Practice May 2024
Topics: Adult; Female; Humans; Male; Colitis, Ulcerative; Colonic Pouches; Proctocolectomy, Restorative
PubMed: 38697065
DOI: 10.31128/AJGP-01-24-7094 -
Journal of Medical Case Reports May 2024Vaginal metastasis from colorectal cancer is a rare occurrence, typically associated with other metastatic lesions. Isolated metastasis is exceedingly uncommon, with...
INTRODUCTION
Vaginal metastasis from colorectal cancer is a rare occurrence, typically associated with other metastatic lesions. Isolated metastasis is exceedingly uncommon, with only a few cases documented in the literature. Vaginal involvement in colorectal cancer primarily results from direct contiguous spread from the primary tumor.
CASE PRESENTATION
We present the case of a 70-year-old African woman diagnosed with adenocarcinoma of the middle rectum. She underwent chemotherapy, radiotherapy, and subsequent anterior resection. After 2 months, an isolated metastasis of rectal cancer was identified in the lower third of the left vaginal wall, confirmed by biopsy. Colonoscopy ruled out colorectal recurrence. Thoraco-abdominal computed tomography scan showed no distant metastases. The patient underwent abdominoperineal resection, removing the lateral and posterior vaginal wall with free macroscopic margins and a definitive colostomy. The final histopathological analysis confirmed the diagnosis of moderately differentiated adenocarcinoma of the vagina, measuring 5 × 4.5 cm. The rectal wall was extrinsically invaded by the tumor down to the muscularis propria while respecting the rectal mucosa. Resection margins were negative. The patient was discharged 1 week postoperation with no complications. Adjuvant chemotherapy was indicated, and the patient is currently tolerating the treatment well.
CONCLUSION
Vaginal metastases from colorectal cancer are extremely rare. A vigilant gynecological examination is recommended during the follow-up of colorectal cancer patients. Diagnosis can be challenging, especially if the metastatic lesion is small and asymptomatic, even after standard radiological examination. Surgical resection followed by chemotherapy is a valid option for patients with early isolated metastases.
Topics: Aged; Female; Humans; Adenocarcinoma; Chemotherapy, Adjuvant; Rectal Neoplasms; Tomography, X-Ray Computed; Treatment Outcome; Vagina; Vaginal Neoplasms
PubMed: 38693541
DOI: 10.1186/s13256-024-04501-7