EP.TU.4973 year oncological outcomes of robotic-assisted versus laparoscopic rectal cancer resections – a single centre experience

Abstract Background Robotic-assisted minimally invasive surgery (MIS) for rectal cancer is a relatively new technique. Studies to date suggest that short term outcomes including TME quality, margin status, lymph node retrieval and 30-day morbidity and mortality are equivalent in robotic-assisted and laparoscopic MIS for rectal cancer. By contrast, there is a paucity of data on the medium and long-term oncologic safety of robotic-assisted comparative to laparoscopic surgery for rectal cancer. Methods A retrospective review was conducted of all robotic-assisted (n = 31) and laparoscopic (n = 23) rectal cancer cases performed at our institution between January 2016 to December 2018. Inclusion criteria were patients scheduled electively for a laparoscopic or robotic-assisted resection of rectal cancer (anterior resection or abdomino-perineal resection). Patients with distant metastases at presentation, those who proceeded to surgery as an emergency and those with a non-colorectal primary were excluded from analysis. Results A total of 54 (n = 54) cases met the inclusion criteria and were included in the final analysis. The median follow-up was 34 months. Of the 54, 21 patients received neoadjuvant chemoradiotherapy prior to definitive surgery. No significant difference was detected in local recurrence rates (p = 0.5), overall survival (p = 0.7) or disease-free survival (p = 0.8) between the robotic-assisted and laparoscopic cohorts. Conclusion In this series, robotic-assisted rectal cancer resections were associated with equivalent medium term oncological outcomes as laparoscopic procedures. However, given the small numbers in this cohort, outcomes from larger scale datasets will be required to confirm these results.

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Oncological and quality of life outcomes following extralevator versus standard abdominoperineal excision for rectal cancer

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2017.0038 ◽

2017 ◽

Vol 99 (5) ◽

pp. 402-409 ◽

Cited By ~ 6

Author(s):

D Kamali ◽

A Sharpe ◽

A Musbahi ◽

A Reddy

Keyword(s):

Quality Of Life ◽

Rectal Cancer ◽

Abdominoperineal Excision ◽

Long Term Effects ◽

Recurrence Rates ◽

Oncological Outcomes ◽

Significant Difference

INTRODUCTION There is increasing and conflicting research debating the oncological benefits of extralevator abdominoperineal excision (ELAPE) compared with standard abdominoperineal excision (SAPE). However, there is very little in the literature on the long-term effects on patients’ wellbeing following the two procedures. The aim of this study was to determine the oncological outcomes and long-term quality of life (QoL) of patients at two hospitals having undergone ELAPE or SAPE. METHODS Consecutive patients with rectal cancer who underwent either ELAPE or SAPE between January 2009 and June 2015 at a single centre were analysed. Oncological outcomes were determined by histology and follow-up imaging. QoL data were obtained prospectively using the QLQ-C30 and QLQ-CR29 questionnaires. RESULTS A total of 48 patients (36 male, 12 female; 27 ELAPE, 21 SAPE) were reviewed. The mean age was 67.4 years and the median follow-up duration was 44 months (range: 6–79 months). Four patients (2 ELAPE, 2 SAPE) developed local recurrence. Rates of distant metastasis were similar (ELAPE: 11%, SAPE: 14%). There was no significant difference in mean global health status score (ELAPE: 77.3, SAPE: 65.3). Impotence was the most frequently reported problem (mean symptom scores of 89.7 and 78.8 for ELAPE and SAPE respectively). CONCLUSIONS This is the largest study with the longest follow-up period that compares QoL after ELAPE with that after SAPE. Although more radical in nature, ELAPE did not demonstrate any significant impact on QoL compared with SAPE. There was no significant difference in long-term oncological outcome between the groups. Impotence remains a significant problem for all patients and they should be well informed of this risk prior to surgery.

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5FU/LV with or without irinotecan in patients with resected stage II-III rectal cancer: Final analysis of R98 intergroup study.

Journal of Clinical Oncology ◽

10.1200/jco.2013.31.15_suppl.3542 ◽

2013 ◽

Vol 31 (15_suppl) ◽

pp. 3542-3542

Author(s):

Catherine Delbaldo ◽

Marc Ychou ◽

Ayman Zawadi ◽

Jean-Yves Douillard ◽

Thierry André ◽

...

Keyword(s):

Rectal Cancer ◽

Mayo Clinic ◽

Disease Free Survival ◽

Final Analysis ◽

Patient Characteristics ◽

Stage Ii ◽

Significant Difference ◽

Grade 3 ◽

Resected Stage

3542 Background: The goal of the study was to test whether adding Irinotecan to a 5-FU/LV adjuvant regimen improves disease free survival (DFS) or overall survival (OS) in optimally resected stages II-III rectal cancers. Primary end-point was DFS. Methods: Six hundred patients were planned to be randomized between 5-FU/LV (control arm) or 5-FU/LV + irinotecan (experimental arm). As only 357 patients had been included from 03/1999 to 12/2005 (178 in control and 179 in experimental arm), the IDMC recommended to close accrual. The trial was stratified by control arm: Mayo-Clinic regimen (A: LV 20 mg/m², 5-FU 425 mg/m² bolus days (d) 1- 5 reapeted at d29,57,92,127 and 162) or LV5-FU2 regimen (A’: LV 200 mg/m², 5-FU 400 mg/m² bolus and 5-FU 600 mg/m² 22-hours infusion d1-2, q 2 w for 12 cycles). The experimental arm (B) was LV5-FU2 + irinotecan 180 mg/m² d1. Results: All 357 randomized patients were evaluable for efficacy. Patient characteristics were well balanced (median age 62 years, stage II 31 %, stage III 69 %, N0 31 %, 68 % received preoperative radiotherapy, and 80 % had sphincter conservation). With follow-up of 156 months, DFS and OS are not statistically increase (81vs 92 events for DFS in experimental and control arm, hazard ratio (HR)=0.805, p=0.154;63 vs 72 events for OS, HR=0.874, p=0.433). Patients allocated to the experimental arm had more grade 3-4 neutropenia when compared with the LV5FU2 control (33 % vs 16 %, p=0.03), but not when compared with the Mayo Clinic arm (32% vs 36%, p=0.84). Grade 3-4 diarrhea tend to be higher in the experimental arm, but analyses stratified by control arm or by radiotherapy failed to show significant differences across strata (test for interaction p=0.44). Conclusions: In patients with resected stage II-III rectal cancer, adding irinotecan to 5FU/LV led to a non significant increase of DFS and OS. The analysis was planned to have a 60 % power to detect a significant difference with 220 events. With a long term follow up of 8 years only 173 events were observed in our trial. Lack of power and good patient prognosis (thirty one percent of node negative patients) may have impacted the results.

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Analysis of patients diagnosed as rectal carcinoma treated with neoadjuvant chemoradiotherapy and radiotherapy alone

Journal of Clinical Oncology ◽

10.1200/jco.2007.25.18_suppl.14582 ◽

2007 ◽

Vol 25 (18_suppl) ◽

pp. 14582-14582

Author(s):

B. Askaroglu ◽

M. H. Akboru ◽

S. T. Dincer ◽

T. Hancilar ◽

A. Yoney ◽

...

Keyword(s):

Rectal Cancer ◽

Local Recurrence ◽

Rectal Carcinoma ◽

Meta Analysis ◽

Neoadjuvant Chemoradiotherapy ◽

Disease Free Survival ◽

Chemotherapeutic Agents ◽

Randomised Trials ◽

Significant Difference ◽

Fraction Dose

14582 Background: Surgery is the standart of the treatment in rectal carcinoma with the help of radiotherapy and chemotherapy applied before or after the operation. Neoadjuvant usage of radiochemotherapy had promising results in randomised trials and in meta-analysis. Methods: We evaluated rectal cancer patients admitted to our center between January 1999-December 2004 retrospectively. Sixty-eight patients were documented. Seventy-five percent of them were male. All of them had adenocarcinoma in histology (19.1% and 5.9% had mucinous and signet ring components respectively). Most of the patients were in Stage II (83.8%). Median 50.4 Gy (45–72 Gy) radiotherapy was delivered in 1.8 Gy fraction dose. Chemoradiotherapy was applied in 86.8% of cases (5-fluorouracil in 35.3% and raltitrexed in 51.5% of them). In operated patients 4 cycle bolus 5-fluorouracil and leucovorin were delivered as adjuvant treatment. Results: Median follow up was 23 months (1–70 months). Downstaging was seen in 54.4 % of cases. In ten (14.7%) patients total response were detected. Six of them (8.8%) were clinically total responders and were not operated. Downstaging was recorded better in 5-fluorouracil group (66.7% versus 37.1%) and it was statistically significant (p< 0.05). Local recurrence and metastasis were seen in 16.2% and 17.6% of the cases respectively. Highest local recurrence rate was seen in T4 stage (42.9%) and highest rate of metastasis was seen in poorly differentiated histology. Regarding all patients; disease free survival and overall survival in three years were 77.7% and 81.4% respectively. There were no statistically significant difference between subgroups of different chemotherapy schedules. Grade I, II and III gastrointestinal system toxicities were seen 16.7%, 48.5% and 15.2% respectively. They were 70.6%, 11.8% when considering Grade I and II hematological toxicities. Conclusions: Neoadjuvant chemoradiotherapy regimens provide downstaging, preserve anal sphincter functions and make easier the surgical approach. In our study 5- fluorouracil seems to be better than raltitrexed but further larger scale randomised trials must be done with different chemotherapeutic agents to state the advantages of neodjuvant chemoradiotherapy in rectal cancer. No significant financial relationships to disclose.

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The consensus Immunoscore adapted to biopsies in patients with locally advanced rectal cancer: Potential clinical significance for a “Watch and Wait” strategy.

Journal of Clinical Oncology ◽

10.1200/jco.2019.37.15_suppl.2628 ◽

2019 ◽

Vol 37 (15_suppl) ◽

pp. 2628-2628

Author(s):

Carine El Sissy ◽

Amos Kirilovsky ◽

Marc Van Den Eynde ◽

Alfredo Romero ◽

Florence Marliot ◽

...

Keyword(s):

Rectal Cancer ◽

Locally Advanced ◽

Neoadjuvant Treatment ◽

Neoadjuvant Chemoradiotherapy ◽

Disease Free Survival ◽

Advanced Rectal Cancer ◽

Locally Advanced Rectal Cancer ◽

Reliable Estimate ◽

Watch And Wait ◽

Significant Difference

2628 Background: We investigated whether an adaptation to rectal biopsies of the recently validated consensus Immunoscore, could predict the response to neoadjuvant treatment and delineate clinical responders that could benefit from a “Watch and Wait” (W&W) strategy with acceptable outcomes. Methods: Initial biopsies from 273 patients with locally advanced rectal cancer (LARC) treated by neoadjuvant chemoradiotherapy (nCRT) followed by Total Mesorectal Excision (TME), were immunostained for CD3+ and cytotoxic CD8+ T cells and quantified by digital pathology to determine the Immunoscore within pre-treatment Biopsy (ISB). Expression level of 44 immune related genes post-neoadjuvant treatment was investigated by Nanostring technology (n = 64 patients). Results were correlated with response to neoadjuvant treatment, disease free survival (DFS) and time to recurrence (TTR). Prognostic performance of ISB was finally assessed in 73 LARC treated by W&W strategy. Results: ISB Low, Intermediate and High were respectively observed in 23.3, 50.4 and 26.3 % of the cohort. ISB was positively and significantly correlated with the response to nCRT, as evaluated by Dworak classification (P = .0034), ypTNM (P = .0003), down-staging (P = .0014), and neoadjuvant rectal (NAR) score, (P < .0001). ISB status was also positively associated with the degree of local immune activation post-neoadjuvant treatment. ISB High patients were at low risk of relapse, with 5-year DFS rates of 81.1 % (CI, 71.3-92.1 %) as compared to 57.8 % (CI, 45.9-72.9 %) in ISB low patients. In multivariate analysis, ISB was the only significant parameter at presentation associated with DFS (High vs Low: P = .001). Among W&W patients, significant difference was observed for TTR according to ISB status (High vs Low: P = .025). Conclusions: ISB could provide a reliable estimate of the response to nCRT and risk of recurrence in LARC patients' treated by TME or W&W strategy.

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Robotic-Assisted Laparoscopic Surgery for Rectal Cancer (RALS): A Review of the Literature

Journal of Biomedical and Clinical Research ◽

10.2478/jbcr-2020-0014 ◽

2020 ◽

Vol 13 (2) ◽

pp. 100-109

Author(s):

Emil T. Filipov ◽

Tsvetomir M. Ivanov

Keyword(s):

Rectal Cancer ◽

Laparoscopic Surgery ◽

Randomized Clinical Trials ◽

Recurrence Rates ◽

Robotic Assisted ◽

Anastomotic Complications ◽

Oncological Outcomes ◽

Conventional Laparoscopic ◽

The Usa

Summary Surgical treatment of rectal cancer is still difficult even in big centers. The limited pelvic space, problematic operative exposure, complex surgeries with more common anastomotic complications make the results unsatisfying. After the concept of total mesorectal excision (TME) was introduced by Heald, the results have improved dramatically. Advances in technology added further excitement about awaited promising results. Surgeons tried to apply all new methods to search for the best treatment: – atraumatic, painless, safe, with low recurrence rates, fast recovery, with an acceptable price, and easy to learn or teach. Robotic-assisted laparoscopic surgery (RALS) was introduced to overcome the limitations of conventional laparoscopic and open surgery and improve on their main advantages. A non-systematic literature review on the articles on RALS in the PubMed and Scopus database was performed. RALS, robotic-assisted laparoscopic surgery, and rectal cancer keywords were used. The search was restricted to articles in English, with main endpoints of interest on short-term and long-term surgical results and oncological outcomes. Fifty-seven articles from Europe, the USA, and Asia were identified. RALS was tried in large series in patients with different pathology and showed its values. However, there are still many controversies on its superiority, cost, and advantages. RALS is safe and efficient in experienced hands. It could be superior to conventional laparoscopic surgery (CLS). Its advantages in oncological outcomes over CLS are to be proven in structured randomized clinical trials (RCTs).

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Molecular and Dynamic Evaluation of Proteins Related to Resistance to Neoadjuvant Treatment with Chemoradiotherapy in Circulating Tumor Cells of Patients with Locally Advanced Rectal Cancer

Cells ◽

10.3390/cells10061539 ◽

2021 ◽

Vol 10 (6) ◽

pp. 1539

Author(s):

Virgílio Souza e Silva ◽

Emne Ali Abdallah ◽

Bianca de Cássia Troncarelli Flores ◽

Alexcia Camila Braun ◽

Daniela de Jesus Ferreira Costa ◽

...

Keyword(s):

Rectal Cancer ◽

Tumor Cells ◽

Circulating Tumor Cells ◽

Transforming Growth Factor ◽

Locally Advanced ◽

Neoadjuvant Treatment ◽

Neoadjuvant Chemoradiotherapy ◽

Disease Free Survival ◽

Advanced Rectal Cancer ◽

Locally Advanced Rectal Cancer

The heterogeneity of response to neoadjuvant chemoradiotherapy (NCRT) is still a challenge in locally advanced rectal cancer (LARC). The evaluation of thymidylate synthase (TYMS) and RAD23 homolog B (RAD23B) expression in circulating tumor cells (CTCs) provides complementary clinical information. CTCs were prospectively evaluated in 166 blood samples (63 patients) with LARC undergoing NCRT. The primary objective was to verify if the absence of RAD23B/TYMS in CTCs would correlate with pathological complete response (pCR). Secondary objectives were to correlate CTC kinetics before (C1)/after NCRT (C2), in addition to the expression of transforming growth factor-β receptor I (TGF-βRI) with survival rates. CTCs were isolated by ISET and evaluated by immunocytochemistry (protein expression). At C1, RAD23B was detected in 54.1% of patients with no pCR and its absence in 91.7% of patients with pCR (p = 0.014); TYMS− was observed in 90% of patients with pCR and TYMS+ in 51.7% without pCR (p = 0.057). Patients with CTC2 > CTC1 had worse disease-free survival (DFS) (p = 0.00025) and overall survival (OS) (p = 0.0036) compared with those with CTC2 ≤ CTC1. TGF-βRI expression in any time correlated with worse DFS (p = 0.059). To conclude, RAD23B/TYMS and CTC kinetics may facilitate the personalized treatment of LARC.

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Multimodal Treatment of cT3 Rectal Cancer in a Prospective Multi-Center Observational Study: Can Neoadjuvant Chemoradiation Be Omitted in Patients with an MRI-Assessed, Negative Circumferential Resection Margin?

Visceral Medicine ◽

10.1159/000514800 ◽

2021 ◽

pp. 1-8

Author(s):

Henry Ptok ◽

Frank Meyer ◽

Ingo Gastinger ◽

Benjamin Garlipp

Keyword(s):

Rectal Cancer ◽

Observational Study ◽

Circumferential Resection Margin ◽

Resection Margin ◽

Anal Verge ◽

Final Analysis ◽

Radical Resection ◽

Distant Recurrence ◽

Neoadjuvant Chemoradiation ◽

Recurrence Rates

Background/Aim: Neoadjuvant chemoradiation (nCRT) in rectal cancer is associated with significant long-term morbidity. It is unclear whether nCRT in resectable mesorectal fascia circumferential resection margin (mrCRM)-negative rectal cancer treated by adequate total mesorectal excision (TME) is beneficial. The aim was to determine if nCRT can be omitted in patients with MRI-assessed cT3 rectal cancer and a negative mrCRM undergoing good-quality TME. Methods: By means of a prospective nationwide registry (n = 43.147; prospective multi-center observational study), patients with cT3 rectal cancer <12 cm from the anal verge with a negative (>1 mm) MRI-assessed CRM undergoing radical resection from 2006 to 2008 were selected. Overall, 87 patients were available for the final analysis (TME-alone, n = 25; nCRT+TME, n = 62). Groups were balanced for age, sex, and ASA score, with a nonsignificant predominance of males in the nCRT+TME group. As main outcome measures, local and distant recurrence rates were compared between patients undergoing primary surgery (TME-alone) vs. neoadjuvant chemoradiation + surgery (nCRT+TME). Results: In the TME-alone group, tumors were located closer to the anal verge (p = 0.018) and demonstrated a smaller minimal circumferential distance from the resection margin (p = 0.036). TME quality was comparable, as was median follow-up (48.9 vs. 44.9 months; p = 0.268). Local recurrences occurred at a similar rate in the TME-alone (n = 1; 5.3%) and nCRT+TME groups (n = 3; 5.5%) (p = 0.994) and were diagnosed at 10 months (TME-alone) and at 8, 13, and 18 months (nCRT+TME). Distant recurrences occurred in 28.9 and 17.4% of the cases, respectively (p = 0.626). The analysis was limited to cT3 cancers with a negative mrCRM. In addition, caution is required when appraising these results because of the limited number of evaluable subjects (especially in the TME-alone group), which adds some uncertainty to the statistical analysis. Conclusions: In this cohort of patients with rectal cancer located <12 cm from the anal verge and a negative mrCRM undergoing adequate TME, omission of nCRT had no impact onto the local recurrence rate.

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Rise and fall of total mesorectal excision with lateral pelvic lymphadenectomy for rectal cancer: an updated systematic review and meta-analysis of 11,366 patients

International Journal of Colorectal Disease ◽

10.1007/s00384-021-03946-2 ◽

2021 ◽

Author(s):

Gabriele Anania ◽

Richard Justin Davies ◽

Alberto Arezzo ◽

Francesco Bagolini ◽

Vito D’Andrea ◽

...

Keyword(s):

Systematic Review ◽

Rectal Cancer ◽

Total Mesorectal Excision ◽

Neoadjuvant Therapy ◽

Functional Outcomes ◽

Meta Analysis ◽

Neoadjuvant Chemoradiotherapy ◽

Disease Free Survival ◽

Mesorectal Excision ◽

Timeline Analysis

Abstract The role of lateral lymph node dissection (LLND) during total mesorectal excision (TME) for rectal cancer is still controversial. Many reviews were published on prophylactic LLND in rectal cancer surgery, some biased by heterogeneity of overall associated treatments. The aim of this systematic review and meta-analysis is to perform a timeline analysis of different treatments associated to prophylactic LLND vs no-LLND during TME for rectal cancer. Methods A literature search was performed in PubMed, SCOPUS and WOS for publications up to 1 September 2020. We considered RCTs and CCTs comparing oncologic and functional outcomes of TME with or without LLND in patients with rectal cancer. Results Thirty-four included articles and 29 studies enrolled 11,606 patients. No difference in 5-year local recurrence (in every subgroup analysis including preoperative neoadjuvant chemoradiotherapy), 5-year distant and overall recurrence, 5-year overall survival and 5-year disease-free survival was found between LLND group and non LLND group. The analysis of post-operative functional outcomes reported hindered quality of life (urinary, evacuatory and sexual dysfunction) in LLND patients when compared to non LLND. Conclusion Our publication does not demonstrate that TME with LLND has any oncological advantage when compared to TME alone, showing that with the advent of neoadjuvant therapy, the advantage of LLND is lost. In this review, the most important bias is the heterogeneous characteristics of patients, cancer staging, different neoadjuvant therapy, different radiotherapy techniques and fractionation used in different studies. Higher rate of functional post-operative complications does not support routinely use of LLND.

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

Techniques in Coloproctology ◽

10.1007/s10151-020-02229-2 ◽

2020 ◽

Vol 24 (10) ◽

pp. 1025-1034 ◽

Cited By ~ 1

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.

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