Background
While the ACOSOG and ALaCaRT trials found that laparoscopic resections for rectal cancer failed to demonstrate non-inferiority of pathologic outcomes when compared with open resections, ...the COLOR II and COREAN studies demonstrated non-inferiority of clinical outcomes, leading to uncertainty regarding the value of minimally invasive (MIS) techniques in rectal cancer surgery. We analyzed differences in pathologic and clinical outcomes between open versus MIS resections for rectal cancer.
Methods
We identified patients who underwent resection for stage II or III rectal adenocarcinoma from the National Cancer Database (2010–2015). Surgical approach was categorized as open or MIS (laparoscopic or robotic). Logistic regression and Cox proportional hazard analysis were used to assess differences in outcomes and survival. Analysis was performed in an intention-to-treat fashion.
Results
A total of 31,190 patients who underwent rectal adenocarcinoma resection were identified, of whom 52.8% underwent open resection and 47.2% underwent MIS resection (31.0% laparoscopic, 16.2% robotic). After adjustment for patient, tumor, and institutional characteristics, MIS approaches were associated with significantly decreased risk of positive circumferential resection margins (OR 0.82, 95% CI 0.72–0.94), increased likelihood of harvesting ≥ 12 lymph nodes (OR 1.12, 95% CI 1.04–1.21), shorter length of stay (OR 0.57, 95% CI 0.53–0.62), and improved overall survival (HR 0.90, 95% CI 0.83–0.98).
Conclusions
MIS approaches to rectal cancer resection were associated with improved pathologic and clinical outcomes when compared to the open approach. In this nationwide, facility-based sample of cancer cases in the United States, our data suggest superiority of MIS techniques for rectal cancer treatment.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Purpose
The role of positron emission tomography/magnetic resonance (PET/MR) in evaluating the local extent of rectal cancer remains uncertain. This study aimed to investigate the possible role of ...PET/MR versus magnetic resonance (MR) in clinically staging rectal cancer.
Methods
This retrospective two-center cohort study of 62 patients with untreated rectal cancer investigated the possible role of baseline staging PET/MR versus stand-alone MR in determination of clinical stage. Two readers reviewed T and N stage, mesorectal fascia involvement, tumor length, distance from the anal verge, sphincter involvement, and extramural vascular invasion (EMVI). Sigmoidoscopy, digital rectal examination, and follow-up imaging, along with surgery when available, served as the reference standard.
Results
PET/MR outperformed MR in evaluating tumor size (42.5 ± 21.03 mm per the reference standard, 54 ± 20.45 mm by stand-alone MR, and 44 ± 20 mm by PET/MR,
P
= 0.004), and in identifying N status (correct by MR in 36/62 patients 58% and by PET/MR in 49/62 cases 79%;
P
= 0.02) and external sphincter infiltration (correct by MR in 6/10 and by PET/MR in 9/10;
P
= 0.003). No statistically significant differences were observed in relation to any other features.
Conclusion
PET/MR provides a more precise assessment of the local extent of rectal cancers in evaluating cancer length, N status, and external sphincter involvement. PET/MR offers the opportunity to improve clinical decision-making, especially when evaluating low rectal tumors with possible external sphincter involvement.
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DOBA, EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, IZUM, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, SIK, UILJ, UKNU, UL, UM, UPUK, VKSCE, VSZLJ, ZAGLJ
Background
Patients with ulcerative colitis (UC) are at increased risk for infections such as Clostridium difficile and cytomegalovirus (CMV) colitis due to chronic immunosuppression. These patients ...often undergo multiple surgeries putting them at risk for recurrence of the infection. However, rates of recurrence in this setting and outcomes are not well understood.
Aim
The aim of this study is to determine rates of recurrence of C difficile and CMV infection in patients undergoing multistage UC surgeries and effects of antibiotic prophylaxis on outcomes.
Methods
All patients with UC who underwent IPAA between 2001 and 2017 (at two tertiary referral centers were identified. History of C. difficile or CMV colitis prior to any surgery and recurrence after IPAA was noted
Results
A total of 633 patients with UC who underwent IPAA were identified, of whom 8.1% patients had C. difficile and 2.7% had CMV infections. 9.8% of C. difficile and 5.9% of CMV patients recurred after IPAA. Rates of abdominal sepsis (14.7% vs. 12.7%), 90-day mortality (0% vs. 0.4%), pouchitis (36.8% vs. 45.0%), or return to stoma (7.4% vs. 5.4%) were similar between patients who did or did not have infections. In patients with C. difficile infection prior to first surgery, none of the patients who received prophylaxis had recurrent infection.
Conclusions
Rates of C. difficile and CMV infections remain high in patients undergoing surgery for UC, with substantial minority developing recurrent infection during subsequent surgical procedures. Antibiotic prophylaxis in patients with a history of C difficile may reduce the rate of recurrent infection.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
The incidence and mortality rates of colorectal cancer (CRC) have been steadily decreasing, largely attributable to screening colonoscopies that either remove precancerous lesions or ...identify CRC earlier. We aimed to assess the prognostic difference between colorectal cancers diagnosed by screening (SC), diagnostic (DC), or surveillance (SU) colonoscopies.
Methods
All 1809 surgically treated patients with primary CRC diagnosed through colonoscopy at our tertiary center (2004–2015) were extracted from a prospectively maintained database. Oncologic outcomes were compared, including multivariate Cox regression.
Results
Diagnostic patients presented with more advanced disease (15.0% vs. 53.2% (SC) and 55.3% (SU) AJCC I,
P
< 0.001), subsequently leading to impaired survival and higher recurrence rates (
P
< 0.001). After adjustment for age, ASA-score and gender, oncologic outcomes remained significantly worse after DC. Hazard ratios (HR) of overall mortality (OS) compared to DC were 0.36 for SC and 0.58 for SU (
P
< 0.001). Adjusted HRs of disease-free survival (DFS) were 0.43 and 0.32, respectively (
P
< 0.001). Worse outcomes in OS withstood adjustment for stage, tumor site and (neo)adjuvant treatment (SC: HR 0.46,
P
< 0.001; SU: HR 0.73,
P
= 0.036). The benefits of SC were particularly seen in colon cancer, stages I–II and female patients. With regard to DFS, outcomes were less profound and mainly true in early stage disease and surveillance patients.
Conclusions
This study demonstrates the enormous impact of asymptomatic screening in CRC. Patients with CRC diagnosed through screening or surveillance had a significantly better prognosis compared to patients who presented symptomatically. This emphasizes the importance of screening.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Introduction
Tumor border configuration (TBC) is a prognostic factor in colorectal adenocarcinoma; however, the significance of TBC is not well-documented in colon adenocarcinoma alone.
Objective
Our ...aim was to study the effect of TBC on overall and disease-free survival in stage II and III colon adenocarcinoma.
Methods
We included patients with stage II and III colon adenocarcinoma who were surgically treated at a tertiary medical center between 2004 and 2015, to ensure long-term follow-up. Patients were stratified into four groups based on stage and TBC. A Cox regression was used to model the relationship of groups while accounting for relevant confounders.
Results
The cohort consisted of 700 patients (371 stage II and 329 stage III). Infiltrating TBC was statistically significantly associated with stage (
p
< 0.001) and extramural vascular invasion (
p
< 0.001), but not histologic grade (
p
= 0.7). Compared with pushing TBC, infiltrating TBC increased the hazard of death by a factor of 1.8 95% confidence interval (CI) 1.4–2.4;
p
< 0.001 and 1.7 (95% CI 1.3–2.2;
p
< 0.001). The hazard of death in patients with stage II disease (infiltrating TBC) or stage III disease (pushing TBC) was not significantly different (adjusted hazard ratio 1.1, 95% CI 0.7–1.7;
p
= 0.8).
Conclusion
Infiltrating TBC is a high-risk feature in patients with stage II and III colon adenocarcinoma. Stage II disease patients with infiltrating TBC and who are node-negative should be considered for adjuvant chemotherapy.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
Patients with diverticular disease complicated by abscess and/or perforation represent the most severely afflicted with the highest mortality and poorest outcomes. This study investigated ...patient and operative factors associated with poor outcomes from diverticulitis complicated by abscess or perforation.
Methods
We analyzed the National Inpatient Sample to identify inpatient discharges for colonic diverticulitis in the United States from 1/1988 to 9/2015. We identified patients with perforation and/or intestinal abscess based on ICD-9 codes. The primary outcome was inpatient mortality.
Results
During the study period, a total of 993,220 patients were discharged with diverticulitis from sampled U.S. hospitals. From this group, 10.7% had an abscess and 1.0% had a perforation associated with diverticular disease. Inpatient mortality of diverticulitis patients with a perforation was 5.4% compared to 1.5% in those without a perforation (
p
<0.001). Patients with a perforation who underwent surgery had an inpatient mortality of 6.3% vs. 3.0% mortality amongst patients with a perforation who did not undergo an operation (
p
<0.001). Patients with a perforation that underwent surgery had a 31% increased mortality risk for each day after admission that a procedure was delayed (OR 1.31, CI 1.05–1.78;
p
=0.03). Mortality risk was increased for patients with either abscess or perforation who underwent surgery if they were female, age ≥65, higher comorbidity, were admitted urgently, underwent peritoneal lavage, or had a post-procedural complication.
Conclusions
Patients with perforated diverticular disease had substantial associated inpatient mortality compared to those with uncomplicated diverticulitis. This increased risk may be associated with performance of peritoneal lavage or because of a delay to procedural intervention.
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EMUNI, FZAB, GEOZS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Introduction
Extramural vascular invasion (EMVI) is a poor prognostic factor in colon cancer. However, the benefit of adjuvant chemotherapy in patients with EMVI is not well defined. The objective of ...this study is to determine if there is a survival benefit for using adjuvant chemotherapy in patients with EMVI-positive colon cancers.
Methods
We performed a retrospective review of all patients with stages II and III colon adenocarcinoma who underwent surgical resection between 2004 and 2015. Cox regression was used to determine the effect of chemotherapy on EMVI-positive patients while adjusting for the extent of invasion, regional lymph node metastasis, histologic grade, age, site of tumor, and ASA score.
Results
A total of 750 patients were included in this study. Extramural vascular invasion was present in 93 out of 387 stage II patients (24%) and 187 out of 363 stage III patients (52%). The Cox regression model showed that in patients with EMVI, those who did not receive adjuvant chemotherapy had a 1.6-fold (1.1–2.3) increase in the hazard of death compared with those who received chemotherapy.
Conclusions
Patients who were EMVI-negative fared better than those who were EMVI-positive. In patients who were EMVI-positive, adjuvant chemotherapy improved overall survival.
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EMUNI, FZAB, GEOZS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NUK, OILJ, PNG, SAZU, SBCE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
A 66-year-old woman from Guatemala presented to a community health center for treatment of latent tuberculosis infection. She reported a 2-month history of abdominal pain. Evaluation revealed a ...nonobstructing mass in the ascending colon. A diagnosis was made.
Objective
The purpose of the study was to evaluate the utility of MR texture analysis for differentiating tumor deposits from mesorectal nodes in rectal cancer.
Materials and methods
Pretreatment MRI ...of 40 patients performed between 2006 and 2018 with pathologically proven tumor deposits and/or malignant nodes in the setting of rectal cancer were retrospectively reviewed. In total, 25 tumor deposits (TDs) and 71 positive lymph nodes (LNs) were analyzed for morphological and first-order texture analysis features on T2-weighted axial images. MR morphological features (lesion shape, size, signal heterogeneity, contrast enhancement) were analyzed and agreed in consensus by two experienced radiologists followed by assessment with Fisher’s exact test. Texture analysis of the lesions was performed using TexRAD, a proprietary software algorithm. First-order texture analysis features (mean, standard deviation, skewness, entropy, kurtosis, MPP) were obtained after applying spatial scaling filters (SSF; 0, 2, 3, 4, 5, 6). Univariate analysis was performed with non-parametric Mann–Whitney
U
test. The results of univariate analysis were reassessed with generalized estimating equations followed by multivariate analysis. Using histopathology as a gold standard, diagnostic accuracy was assessed by obtaining area under the receiver operating curve.
Results
MR morphological parameter, lesion shape was a strong discriminator between TDs and LNs with a p value of 0.02 (AUC: 0.76, 95% CI of 0.66 to 0.84, SE: 0.06) and sensitivity, specificity of 90% and 68%, respectively. Skewness extracted at fine filter (SSF-2) was the only significant texture analysis parameter for distinguishing TDs from LNs with p value of 0.03 (AUC: 0.70, 95% CI of 0.59 to 0.79, SE: 0.06) and sensitivity, specificity of 70% and 72%, respectively. When lesion shape and skewness-2 were combined into a single model, the diagnostic accuracy was improved with AUC of 0.82 (SE: 0.05, 95% CI of 0.72 to 0.88 with
p
value of < 0.01). This model also showed a high sensitivity of 91% with specificity of 68%.
Conclusion
Lesion shape on MR can be a useful predictor for distinguishing TDs from positive LNs in rectal cancer patients. When interpreted along with MR texture parameter of skewness, accuracy is further improved.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, VSZLJ, ZAGLJ
