Controversies in Radiation for Upper Rectal Cancers

2012 ◽  
Vol 10 (12) ◽  
pp. 1567-1572 ◽  
Author(s):  
Emily Chan ◽  
Paul E. Wise ◽  
A. Bapsi Chakravarthy
Keyword(s):  
Tumor Location ◽  
Substantial Improvement ◽  
Sphincter Preservation ◽  
Radiation Delivery ◽  
Final Treatment ◽  
Pathologic Staging ◽  
Node Positive Disease ◽  
Treatment Paradigm ◽  
Rectal Cancers ◽  
Close Cooperation

Over the past few decades substantial improvement has occurred in the diagnosis and treatment of rectal cancers. This disease requires the close cooperation of a multidisciplinary team, including radiologists, gastroenterologists, surgeons, medical oncologists, and radiation oncologists, to provide optimum treatment with minimal morbidity. The widespread use of total mesorectal excision (TME) and improvements in chemotherapy and radiation delivery have resulted in decreases in locoregional recurrence. Large randomized studies have shown a benefit with the use of preoperative chemoradiation for most patients with transmural and/or node-positive disease. Controversy remains, however, regarding whether this treatment paradigm should be applied uniformly to all patients regardless of tumor location. As the risk of local recurrence decreases with high rectal tumors and the benefit in terms of sphincter preservation is not applicable to this subgroup of patients, up-front surgery to allow for more accurate pathologic staging prior to making final treatment decisions is recommended. In patients with pathologically staged T3,N0,M0 tumors of the upper rectum who have undergone TME with 12 or more nodes removed, the addition of chemoradiation has very little benefit.

Safety and feasibility of sphincter preservation surgery in low lying rectal cancers

2021 ◽  
Author(s):  
Swapnil Patel ◽  
Vivek Sukumar ◽  
Mufaddal Kazi ◽  
Avanish Saklani
Keyword(s):  
Sphincter Preservation ◽  
Rectal Cancers

scholarly journals Retrospective study of the functional and oncological outcomes of conformal sphincter preservation operation in the treatment of very low rectal cancer

2020 ◽  
Vol 24 (10) ◽  
pp. 1025-1034 ◽  
Author(s):  
G. Sun ◽  
Z. Lou ◽  
H. Zhang ◽  
G. Y. Yu ◽  
K. Zheng ◽  
...  
Keyword(s):  
Rectal Cancer ◽  
Rectal Wall ◽  
Anal Verge ◽  
Disease Free Survival ◽  
Sphincter Preservation ◽  
Low Rectal Cancer ◽  
Anal Function ◽  
Oncological Outcomes ◽  
Rectal Cancers ◽  
Very Low Rectal Cancer

Abstract Background Conformal sphincter preservation operation (CSPO) is a new surgical procedure for very low rectal cancers (within 4–5 cm from the anal verge). CSPO preserves more of the dentate line and distal rectal wall and also avoids injuring nerves in the intersphincteric space, resulting in satisfactory anal function after resection. The aim of this study was to analyze the short-term surgical results and long-term oncological and functional outcomes of CSPO. Methods Consecutive patients with very low rectal cancer, who had CSPO between January 2011 and October 2018 at Changhai Hospital, Shanghai were included. Patient demographics, clinicopathological features, oncological outcomes and anal function were analyzed. Results A total of 102 patients (67 men) with a mean age of 56.9 ± 10.8 years were included. The median distance of the tumor from the anal verge was 3 (IQR, 3–4) cm. Thirty-five patients received neoadjuvant chemoradiation (nCRT). The median distal resection margin (DRM) was 0.5 (IQR, 0.3–0.8) cm. One patient had a positive DRM. All circumferential margins were negative. There was no perioperative mortality. The postoperative complication rate was 19.6%. The median duration of follow-up was 28 (IQR, 12–45.5) months. The local recurrence rate was 2% and distant metastasis rate was 10.8%. The 3-year overall survival and disease-free survival rates were 100% and 83.9%, respectively. The mean Wexner incontinence and low anterior resection syndrome scores 12 months after ileostomy reversal were 5.9 ± 4.3, and 29.2 ± 6.9, respectively. Conclusions For patients with very low rectal cancers, fecal continence can be preserved with CSPO without compromising oncological results.

scholarly journals Elevated MUC5AC expression is associated with mismatch repair deficiency and proximal tumor location but not with cancer progression in colon cancer

2020 ◽  
Author(s):  
Sebastian Dwertmann Rico ◽  
Doris Höflmayer ◽  
Franziska Büscheck ◽  
David Dum ◽  
Andreas M. Luebke ◽  
...  
Keyword(s):  
Colon Cancer ◽  
Mismatch Repair ◽  
Cancer Progression ◽  
Strong Association ◽  
Tumor Location ◽  
Colorectal Cancers ◽  
Mismatch Repair Deficiency ◽  
Repair Deficiency ◽  
Cancer Aggressiveness ◽  
Rectal Cancers

AbstractMucin 5AC (MUC5AC) is a secreted gel-forming mucin expressed by several epithelia. In the colon, MUC5AC is expressed in scattered normal epithelial cells but can be abundant in colorectal cancers. To clarify the relationship of MUC5AC expression with parameters of tumor aggressiveness and mismatch repair deficiency (dMMR) in colorectal cancer, a tissue microarray containing 1812 colorectal cancers was analyzed by immunohistochemistry. MUC5AC expression was found in 261 (15.7%) of 1,667 analyzable colorectal cancers. MUC5AC expression strongly depended on the tumor location and gradually decreased from proximal (27.4% of cecum cancers) to distal (10.6% of rectal cancers; p < 0.0001). MUC5AC expression was also strongly linked to dMMR. dMMR was found in 21.3% of 169 cancers with MUC5AC positivity but in only 4.6% of 1051 cancers without detectable MUC5AC expression (p < 0.0001). A multivariate analysis showed that dMMR status and tumor localization predicted MUC5AC expression independently (p < 0.0001 each). MUC5AC expression was unrelated to pT and pN status. This also applied to the subgroups of 1136 proficient MMR (pMMR) and of 84 dMMR cancers. The results of our study show a strong association of MUC5AC expression with proximal and dMMR colorectal cancers. However, MUC5AC expression is unrelated to colon cancer aggressiveness.

Preoperative Radiotherapy With or Without Concurrent Fluorouracil and Leucovorin in T3-4 Rectal Cancers: Results of FFCD 9203

2006 ◽  
Vol 24 (28) ◽  
pp. 4620-4625 ◽  
Author(s):  
Jean-Pierre Gérard ◽  
Thierry Conroy ◽  
Franck Bonnetain ◽  
Olivier Bouché ◽  
Olivier Chapet ◽  
...  
Keyword(s):  
Overall Survival ◽  
Acute Toxicity ◽  
Preoperative Radiotherapy ◽  
Rectal Adenocarcinoma ◽  
Digital Rectal Examination ◽  
Concurrent Chemotherapy ◽  
Sphincter Preservation ◽  
Moderate Increase ◽  
Operative Specimen ◽  
Rectal Cancers

Purpose In 1992, preoperative radiotherapy was considered in France as the standard treatment for T3-4 rectal cancers. The present randomized trial compares preoperative radiotherapy with chemoradiotherapy. Patients and Methods Patients were eligible if they presented a resectable T3-4, Nx, M0 rectal adenocarcinoma accessible to digital rectal examination. Preoperative radiotherapy with 45 Gy in 25 fractions during 5 weeks was delivered. Concurrent chemotherapy with fluorouracil 350 mg/m2/d during 5 days, together with leucovorin, was administered during the first and fifth week in the experimental arm. Surgery was planned 3 to 10 weeks after the end of radiotherapy. All patients should receive adjuvant chemotherapy with the same fluorouracil/leucovorin regimen. The primary end point of the trial was overall survival. Results A total of 733 patients were eligible. Grade 3 or 4 acute toxicity was more frequent with chemoradiotherapy (14.6% v 2.7%; P < .05). There was no difference in sphincter preservation. Complete sterilization of the operative specimen was more frequent with chemoradiotherapy (11.4% v 3.6%; P < .05). The 5-year incidence of local recurrence was lower with chemoradiotherapy (8.1% v 16.5%; P < .05). Overall 5-year survival in the two groups did not differ. Conclusion Preoperative chemoradiotherapy despite a moderate increase in acute toxicity and no impact on overall survival significantly improves local control and is recommended for T3-4, N0-2, M0 adenocarcinoma of the middle and distal rectum.

scholarly journals Carcinoma of the anal canal

2011 ◽  
Vol 3 (1) ◽  
pp. 27
Author(s):  
David T. Marshall ◽  
Charles R. Thomas Jr
Keyword(s):  
Anal Canal ◽  
Locally Advanced ◽  
The United States ◽  
Sphincter Preservation ◽  
Tumor Control ◽  
Anal Canal Cancer ◽  
Permanent Colostomy ◽  
Anti Cancer ◽  
Treatment Paradigm ◽  
Technological Developments

There are around 5,000 new cases of anal canal cancer each year in the United States. It is of particular risk in HIV-positive populations. Many cases are related to persistent infection with human papillomavirus (HPV). The treatment of anal cancer has progressed from abdominoperineal resection mandating permanent colostomy in the 1940s through the 1970s to modern chemoradiation with sphincter preservation in around 80% of patients, even with locally advanced disease. The evolution of the treatment paradigm of this disease is a model for the treatment of malignant disease with organ preservation. Multiple randomized trials have been conducted to guide this evolution. Technological developments in the delivery of radiotherapy and anti-cancer pharmaceuticals harbor hope for further improvements in outcomes with possible reductions in toxicity and increases in tumor control. Perhaps most inspiring is the recent development of HPV vaccines that

scholarly journals Clinical and Molecular Comparative Study of Colorectal Cancer Based on Age-of-onset and Tumor Location: Two Main Criteria for Subclassifying Colorectal Cancer

2019 ◽  
Vol 20 (4) ◽  
pp. 968 ◽  
Author(s):  
Edurne Álvaro ◽  
Juana M. Cano ◽  
Juan L. García ◽  
Lorena Brandáriz ◽  
Susana Olmedillas-López ◽  
...  
Keyword(s):  
Colorectal Cancer ◽  
Early Onset ◽  
Age Of Onset ◽  
Late Onset ◽  
Cpg Island ◽  
Low Frequency ◽  
Tumor Location ◽  
Molecular Characteristics ◽  
Braf Mutations ◽  
Rectal Cancers

Our aim was to characterize and validate that the location and age of onset of the tumor are both important criteria to classify colorectal cancer (CRC). We analyzed clinical and molecular characteristics of early-onset CRC (EOCRC) and late-onset CRC (LOCRC), and we compared each tumor location between both ages-of-onset. In right-sided colon tumors, early-onset cases showed extensive Lynch syndrome (LS) features, with a relatively low frequency of chromosomal instability (CIN), but a high CpG island methylation phenotype. Nevertheless, late-onset cases showed predominantly sporadic features and microsatellite instability cases due to BRAF mutations. In left colon cancers, the most reliable clinical features were the tendency to develop polyps as well as multiple primary CRC associated with the late-onset subset. Apart from the higher degree of CIN in left-sided early-onset cancers, differential copy number alterations were also observed. Differences among rectal cancers showed that early-onset rectal cancers were diagnosed at later stages, had less association with polyps, and more than half of them were associated with a familial LS component. Stratifying CRC according to both location and age-of-onset criteria is meaningful, not only because it correlates the resulting categories with certain molecular bases, but with the confirmation across larger studies, new therapeutical algorithms could be defined according to this subclassification.

Use of tumor site as a prognosticator: Population-based analysis of rectosigmoid and rectum cancers

2009 ◽  
Vol 27 (15_suppl) ◽  
pp. 4123-4123
Author(s):  
K. P. Raj ◽  
A. Ziogas ◽  
A. R. Barleben ◽  
M. J. Stamos ◽  
J. A. Zell
Keyword(s):  
Large Population ◽  
Prognostic Significance ◽  
Tumor Location ◽  
Population Based ◽  
Stage Ii ◽  
Clinical Factors ◽  
Distal Rectum ◽  
Kaplan Meier ◽  
Rectal Cancers ◽  
Using Data

4123 Background: The study examines the prognostic significance of tumor location exclusively in rectosigmoid and rectal cancers. Although tumor location has traditionally been regarded as a prognostic determinant, data in support of this claim are lacking. We set out to determine this using data from a large population-based California Cancer Registry (CCR). Methods: A retrospective analysis of surgically treated cancer cases involving the rectum and rectosigmoid from 1994–2006 with a follow-up until January 2008 in CCR was conducted. Sub-site tumor location of the cancers involving the rectum was either defined as rectosigmoid or mid/distal rectum. Site-specific survival analyses were conducted by Kaplan-Meier method and hazard ratio calculated using Cox proportional hazard ratios (HR). Results: A total of 33,418 rectal cancer cases were identified, including 12,407 (37.1%) rectosigmoid cancers and 21,011 (62.9%) mid/distal rectum cancers. No significant differences by tumor location were noticed for age, gender, stage, histological type, grade or socioeconomic status. Fewer rectosigmoid cancers received radiation (81.9% vs. 62.3% p=<0.0001)) compared to mid/distal rectum cancers. After adjustment for treatment and relevant clinical factors, an improved rate of CRC-specific survival was noticed in non-metastatic rectosigmoid cancers when compared to cancers involving the mid/distal rectum. A significant decrease in mortality was observed in Stage-I [HR- 0.74(0.63–0.86)], Stage-II [HR-0.76(0.69–0.85)] and Stage-III [HR- 0.90 (0.83–0.98)] rectosigmoid cancers when compared to mid/distal rectum cancers. Number of lymph nodes examined (>12 vs. <12) was an independent prognostic factor for survival in Stage-II patients [HR-0.74 (0.63–0.87)]. Conclusions: Among locoregional cases, rectosigmoid cancers were found to have an improved CRC-specific survival compared to mid/distal rectum cancers, which was independent of other relevant clinical factors. [Table: see text] No significant financial relationships to disclose.

Impact of inaccurate clinical staging for gastric cancer on patient survival outcomes.

2020 ◽  
Vol 38 (4_suppl) ◽  
pp. 345-345
Author(s):  
Michelle Ju ◽  
Matthew R. Porembka
Keyword(s):  
Gastric Cancer ◽  
Adjuvant Therapy ◽  
Patient Survival ◽  
Early Stage ◽  
Tumor Location ◽  
Clinical Staging ◽  
Survival Outcomes ◽  
Adjuvant Therapies ◽  
Pathologic Staging ◽  
The Impact

345 Background: Accurate clinical staging (CS) in gastric cancer is critical for appropriate treatment selection and prognostication, but CS remains highly ineffective. Our study aims to evaluate the factors associated with inaccurate CS, the impact of inaccurate CS on patient outcomes, and effect of adjuvant therapy in patients with inaccurate CS. Methods: We conducted a retrospective review of the NCDB of patients diagnosed with clinical early-stage gastric adenocarcinoma based on AJCC 8th edition (cT1-2, N0, M0) between 2004-2016. Those who did not undergo upfront surgery or had missing pathologic staging data were excluded. Patients were classified into 3 groups: accurately staged (AS) if pathologic staging confirmed early-stage cancer, inaccurately staged with receipt of adjuvant therapy (IS+), and inaccurately staged with no receipt of adjuvant therapy (IS-). Logistic regression using stepwise selection was utilized to assess the impact of factors on CS accuracy and receipt of adjuvant therapies. Kaplan-Meier and Cox Proportional Hazard methods were used to compare survival outcomes. Results: Approximately 39% of patients (2841/7199) were understaged. T2 tumors, non-well differentiated tumors, and diffuse type histology were associated with increased likelihood of inaccurate CS. Age >60, female sex, Asian/Black race, and non-cardia tumor location were associated with decreased likelihood of inaccurate CS. Only 44% of patients who were inaccurately staged received adjuvant chemotherapy/radiation. Age >75 and fundus/body tumor location were associated with decreased likelihood of receiving adjuvant therapies, while more advanced pT and pN stage were associated with increased likelihood. Treatment facility type (community vs. academic) had no impact on likelihood of accurate CS or receipt of adjuvant treatment after inaccurate CS. 5-year overall survival was significantly different between groups (71.7% AS, 48.3% IS+, 51.1% AS-; p<0.001). Conclusions: CS is inadequate, and understaging has detrimental effects on patient survival outcomes. Novel strategies for improved CS are needed to improve patient care.

Pathologic and clinical outcomes in cT2N0 esophageal cancer: A cohort study.

2016 ◽  
Vol 34 (4_suppl) ◽  
pp. 157-157
Author(s):  
Gauri Bhuchar ◽  
Mohammad Altujjar ◽  
Siva Raja ◽  
Sudish C. Murthy ◽  
Daniel Raymond ◽  
...  
Keyword(s):  
Esophageal Cancer ◽  
Cohort Study ◽  
Gastroesophageal Junction ◽  
Cleveland Clinic ◽  
Clinical Staging ◽  
Hazard Ratios ◽  
Pathologic Staging ◽  
Node Positive Disease ◽  
Ct Radiation ◽  
Study Population

157 Background: The management of clinically staged T2N0 (cT2N0) esophageal cancer remains controversial and clinical staging can be inaccurate. We evaluated concordance between clinical and pathologic staging as well as outcomes in a cohort study of patients initially staged as cT2N0. Methods: We conducted a cohort study of consecutive patients with esophageal cancer staged as cT2N0 after imaging (CT, PET scans) and endoscopic ultrasound, who underwent surgical resection and were followed at the Cleveland Clinic from Jan 2000 to Jun 2014. Clinical, chemotherapy (CT), radiation (RT), pathologic, and survival details were evaluated. For statistically significant associations, adjusted hazard ratios (HR) with 95% confidence intervals (CI) and 2-sided p-values are presented. Results: The study population comprised 66 consecutive patients with cT2N0 esophageal cancer. Median age was 60 years; 76% were male; 97% were Caucasian. Gastroesophageal junction was the primary site in 56%; distal esophagus in 29%; middle esophagus in 14%; histology was adenocarcinoma in 62 (94%) cases. 20 patients received preop treatment (Rx): CT+RT (15), CT (5). In patients without preoperative Rx (n = 46, 70%), pathologic staging was > T2N0 in 54% (n = 25; T3 = 17, T4 = 1, N+ = 20), < T2N0 in 37% (n = 17), and T2N0 in 9% (n = 4). No < T2N0 or T2N0 patient received postop Rx. Of 25 > T2N0, 15 received postop Rx: CT+RT (14), CT (1). 5-fluourouracil-cisplatin was the most common CT regimen. Median overall survival (mOS) after 7 years of median follow-up was: overall, 48 mths (34 deaths, 52%); < T2N0/T2N0, 93 mths; > T2N0 with postop Rx, 69 mths; > T2N0 without postop Rx, 15 mths (p > 0.05 for comparison). Only node-positive disease on pathology was associated with mortality (mOS for N+ vs. N- was 28 vs. 118 mths, HR for mortality = 2.74, 95% CI = 1.30-5.76, p = 0.008); T-stage, surgical margins, timing or type of therapy were not. Conclusions: Clinical staging of cT2N0 esophageal cancer is concordant with pathologic staging in less than 10% of patients; a majority are under-staged. Strong consideration should be given to pre- or post-operative treatment in this population. Improvements in clinical staging approaches are urgently needed to avoid over- and under-treatment in this setting.

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