Summary Background The TME trial investigated the value of preoperative short-term radiotherapy in combination with total mesorectal excision (TME). Long-term results are reported after a median ...follow-up of 12 years. Methods Between Jan 12, 1996, and Dec 31, 1999, 1861 patients with resectable rectal cancer without evidence of distant disease were randomly assigned to TME preceded by 5 × 5 Gy radiotherapy or TME alone (ratio 1:1). Randomisation was based on permuted blocks of six with stratification according to centre and expected type of surgery. The primary endpoint was local recurrence, analysed for all eligible patients who underwent a macroscopically complete local resection. Findings 10-year cumulative incidence of local recurrence was 5% in the group assigned to radiotherapy and surgery and 11% in the surgery-alone group (p<0·0001). The effect of radiotherapy became stronger as the distance from the anal verge increased. However, when patients with a positive circumferential resection margin were excluded, the relation between distance from the anal verge and the effect of radiotherapy disappeared. Patients assigned to radiotherapy had a lower overall recurrence and when operated with a negative circumferential resection margin, cancer-specific survival was higher. Overall survival did not differ between groups. For patients with TNM stage III cancer with a negative circumferential resection margin, 10-year survival was 50% in the preoperative radiotherapy group versus 40% in the surgery-alone group (p=0·032). Interpretation For all eligible patients, preoperative short-term radiotherapy reduced 10-year local recurrence by more than 50% relative to surgery alone without an overall survival benefit. For patients with a negative resection margin, the effect of radiotherapy was irrespective of the distance from the anal verge and led to an improved cancer-specific survival, which was nullified by an increase in other causes of death, resulting in an equal overall survival. Nevertheless, preoperative short-term radiotherapy significantly improved 10-year survival in patients with a negative circumferential margin and TNM stage III. Future staging techniques should offer possibilities to select patient groups for which the balance between benefits and side-effects will result in sufficiently large gains. Funding The Dutch Cancer Society, the Dutch National Health Council, and the Swedish Cancer Society.
Highlights • One fifth of operated colorectal cancer patients will develop metachronous metastases. • Colon and rectal cancer patients have different patterns of metastatic spread. • Median time to ...diagnosis depends on site of metastasis. • The risk for metastases is associated with patient and tumour characteristics.
Axillary reverse mapping (ARM) is a technique by which the lymphatic drainage of the upper extremity that traverses the axillary region can be differentiated from the lymphatic drainage of the breast ...during axillary lymph node dissection (ALND). Adding this procedure to ALND may reduce upper extremity lymphedema by preserving upper extremity drainage. This review of the current literature on the ARM procedure discusses the feasibility, safety and relevance of this technique. A PubMed literature search was performed until 12 August 2015. A total of 31 studies were included in this review. The studies indicated that the ARM procedure adequately identifies the upper extremity lymph nodes and lymphatics in the axillary basin using blue dye or fluorescence. Preservation of ARM lymph nodes and corresponding lymphatics was proven to be oncologically safe in clinically node-negative breast cancer patients with metastatic lymph node involvement in the sentinel lymph node (SLN) who are advised to undergo a completion ALND. The ARM procedure is technically feasible with a high visualisation rate using blue dye or fluorescence. ALND combined with ARM can be regarded as a promising surgical refinement in order to reduce the incidence of upper extremity lymphedema in selected groups of patients.
Purpose
Sexual dysfunction among patients with colorectal cancer is frequently reported. Studies examining patients’ sexual health care needs are rare. We examined the sexual health care needs after ...colorectal cancer treatment according to patients, partners, and health care professionals (HCPs). Factors that impede or facilitate the quality of this care were identified.
Method
Participants were recruited from three Dutch hospitals: St. Elisabeth, TweeSteden, and Catharina hospitals. Patients (
n
= 21), partners (
n
= 9), and 10 HCPs participated in eight focus groups.
Results
It is important to regularly evaluate and manage sexual issues. This does not always occur. Almost all participants reported a lack of knowledge and feelings of embarrassment or inappropriateness as barriers to discuss sexuality. HCPs reported stereotypical assumptions regarding the need for care based on age, sex, and partner status. The HCPs debated on whose responsibility it is that sexuality is discussed with patients. Factors within the organization, such as insufficient re-discussion of sexuality during (long-term) follow-up and unsatisfactory (knowledge of the) referral system impeded sexual health care. The HCPs could facilitate adequate sexual health care by providing patient-tailored information and permission to discuss sex, normalizing sexual issues, and establishing an adequate referral system. It is up to the patients and partners to demarcate the extent of sexual health care needed.
Conclusions
Our findings illustrate the need for patient-tailored sexual health care and the complexity of providing/receiving this care. An adequate referral system and training are needed to help HCPs engage in providing satisfactory sexual health care.
Anastomotic leakage is one of the most severe early complications after colorectal surgery, and it is associated with a high reoperation rate-, and increased in short-term morbidity and mortality ...rates. It remains unclear whether anastomotic leakage is associated with poor oncologic outcomes. The aim of this study was to determine the impacts of anastomotic leakage on long-term oncologic outcomes, disease-free survival and overall mortality in patients who underwent curative surgery for colorectal cancer.
This single-centre, retrospective, observational cohort study included patients who underwent curative surgery for colorectal cancer between 2005 and 2015 and who had a primary anastomosis. Survival- and multivariate cox regression analyses were performed to adjust for confounding.
A total of 1984 patients had a primary anastomosis after surgery. The overall incidence of anastomotic leakage was 7.5%; 19 patients were excluded because they were lost to follow-up. Of the remaining 1965 patients, 41 (2.1%) developed local recurrence associated with anastomotic leakage adjusted hazard ratio (HR) = 2.25; 95% confidence interval (CI) 1.14–5.29; P = 0.03. Distant recurrence developed in 291(14.8%) patients with no association with anastomotic leakage adjusted HR = 1.30 (95% CI: 0.85–1.97) P = 0.23. Anastomotic leakage was associated with increased long-term mortality adjusted HR = 1.69 (95% CI 1.32–2.18) P < 0.01. Five year disease-free survival was significantly decreased in patients with anastomotic leakage, (log rank test P < 0.01).
Anastomotic leakage was significantly associated with increased rates of local recurrence, disease free-survival and overall mortality. Associations of anastomotic leakage with distant recurrence was not found.
Previous studies have shown that older patients benefited less than younger patients from surgical treatment for colorectal cancer (CRC). However, CRC care has advanced over time, and it is time to ...assess whether the difference in postoperative mortality between older and younger CRC patients is still present.
Patients with primary stage I-III CRC diagnosed between 2005 and 2016 were selected from the Netherlands Cancer Registry (N = 111,778). Trends in postoperative mortality and 1-year postoperative relative survival (RS) were analysed, stratified according to age (<75 versus ≥75 years) and tumour location (colon versus rectum). One-year postoperative RS was analysed to correct for background mortality in the older population.
Between 2005 and 2016, 30-day postoperative mortality showed a stronger decrease for older patients (from 10.0% to 4.0% for colon cancer p < 0.001 and from 8.3% to 2.7% for rectal cancer p < 0.001) compared with younger patients (from 2.0% to 0.9% for colon cancer p < 0.001 and from 1.4% to 0.7% for rectal cancer p = 0.01). Between 2005 and 2016, also 1-year RS increased more for older patients (from 84.8% to 94.6% for colon cancer and from 86.1% to 97.2% for rectal cancer) compared with younger patients (from 94.0% to 97.8% for colon cancer and from 96.3% to 98.8% for rectal cancer).
Between 2005 and 2016, differences in postoperative mortality between older and younger CRC patients decreased. One-year postoperative RS was almost equal for older and younger patients in 2015–2016. This information is crucial for shared decision-making on surgical treatment.
•Differences in mortality between older and younger CRC patients decreased.•One-year relative survival became nearly equal for older and younger patients.•Previous literature is no longer representative of the current clinical practice.
Differences exist between Japan and The Netherlands in the treatment of low rectal cancer. The purpose of this study is to analyze these, with focus on the patterns of local recurrence.
In The ...Netherlands, 755 patients were operated by total mesorectal excision (TME) for low rectal cancer, 379 received preoperative radiotherapy (RT+TME). Applying the same selection criteria resulted in 324 patients in the Japanese (NCCH) group, who received extended surgery consisting of lateral lymph node dissection and a wider abdominoperineal excision. The majority received no (neo) adjuvant therapy. Local recurrence images were examined by a radiologist and a surgeon.
Five-year local recurrence rates were 6.9% for the Japanese NCCH group, 5.8% in the Dutch RT+TME group, and 12.1% in the Dutch TME group. Recurrence rate in the lateral pelvis is 2.2%, 0.8%, and 2.7% in the Japanese, RT+TME group, and TME group, respectively. The incidence of presacral recurrences was low in the NCCH group (0.6%), compared with 3.7% and 3.2% in the RT+TME and TME groups, respectively.
Both extended surgery and RT+TME result in good local control, as compared with TME alone. Preoperative radiotherapy can sterilize lateral extramesorectal tumor particles. A wider abdominoperineal resection probably results in less presacral local recurrence. Comparison of the results is difficult because of differences in patient groups.
Summary The cornerstone of treatment for rectal cancer is resectional treatment according to the principles of total mesorectal excision (TME). However, population-based registries show that ...improvements in outcome after resectional treatment occur mainly in younger patients. Furthermore, 6-month postoperative mortality is significantly increased in elderly patients (≥75 years of age) compared with younger patients (<75 years of age). Several confounding factors, such as treatment-related complications and comorbidity, are thought to be responsible for these disappointing findings. Thus, major resectional treatment is not advantageous for all older patients with rectal cancer. However, the Dutch TME trial showed a good response to a short course of neoadjuvant radiotherapy in elderly patients. Biological responses to cancer treatment seem to change with age, and, therefore, individualised cancer treatments should be used that take into account the heterogeneity of ageing. For elderly patients who retain a good physical and mental condition, treatment that is given to younger patients is deemed appropriate, whereas for those with diminished physiological reserves and comorbid conditions, alternative treatments that keep surgical trauma to a minimum and optimise the use of radiotherapy might be more suitable.
Abstract Evidence is scarce about the influence of comorbidity on outcome of surgery, whereas this information is highly relevant for estimating the surgical risk of cancer patients, and for ...optimising pre-, peri- and postoperative care. In this paper, the prognostic role of increasing age and comorbid conditions in patients diagnosed with stage I–III colorectal, stage I–II NSCLC or stage I–III breast cancer between 1995 and 2004 in the southern part of the Netherlands is summarised. Almost all patients with stage I–III colon cancer or rectal cancer underwent surgery regardless of age or comorbidity. In contrast, the resection rate among elderly patients with stage I–II NSCLC was clearly lower than among younger patients and was significantly lower when COPD, cardiovascular diseases or diabetes were present. Among patients with stage I–III breast cancer, those aged 80 or older underwent less surgery, and the resection rate appeared to be lower when cardiovascular diseases or diabetes were present. Among patients with resected colorectal cancer, postoperative morbidity and mortality were higher among those undergoing emergency surgery, and also among those with reduced pulmonary function, cardiovascular disease or neurological comorbidity. Among those with resected NSCLC, postoperative morbidity and mortality were related to reduced pulmonary function or cardiovascular disease. Since surgery for breast cancer is low risk, elective surgery, morbidity and mortality were not higher for elderly or those with comorbidity. Among patients with colorectal or breast cancer, comorbidity in general, cardiovascular diseases, COPD, diabetes (only colon and breast cancer) and venous thromboembolism had a negative effect on overall survival, whereas the effect of comorbidity on survival of stage I–II NSCLC was less clear. Elderly and those with comorbidity (especially cardiovascular diseases and COPD) among colorectal cancer and NSCLC patients had more postoperative morbidity and mortality. Prospective randomised studies are needed for refining selection criteria for surgery in elderly cancer patients and for anticipation and prevention of complications.
Introduction
Pretreatment enlarged lateral lymph nodes (LLN) in patients with locally advanced low rectal cancer are predictive for local recurrences after neoadjuvant (chemo)radiotherapy (n(C)RT) ...followed by total mesorectal excision (TME). Not much is known of the impact on oncological outcomes when in addition malignant features are present in enlarged LLN.
Patients and Methods
A multicenter retrospective cohort study was conducted at five tertiary referral centers in the Netherlands and Australia. All patients were diagnosed with locally advanced low rectal cancer with LLN on pretreatment magnetic resonance imaging (MRI) and underwent n(C)RT followed by TME. LLN were considered enlarged with a short axis of ≥ 5 mm. Malignant features were defined as nodes with internal heterogeneity and/or border irregularity. Outcomes of interest were local recurrence-free survival (LRFS), distant metastatic-free survival (DMFS), and overall survival (OS).
Results
Out of 115 patients, the majority was male (75%) and the median age was 64 years (range 26–85 years). Median pretreatment LLN short axis was 7 mm (range 5–28 mm), and 60 patients (52%) had malignant features. After a median follow-up of 47 months, patients with larger LLN (7 + mm) had a worse LRFS (
p
= 0.01) but no difference in DMFS (
p
= 0.37) and OS (
p
= 0.54) compared with patients with smaller LLN (5–6 mm). LLN patients with malignant features had no difference in LRFS (
p
= 0.20) but worse DMFS (
p
= 0.004) and OS (
p
= 0.006) compared with patients without malignant features in the LLN. Cox regression analysis identified LLN short axis as an independent factor for LR. Malignant features in LLN were an independent factor for DMFS.
Conclusion
The current study suggests that pretreatment enlarged LLN that also harbor malignant features are predictive of a worse DMFS. More studies will be required to further explore the role of malignant features in LLN.
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