The multidisciplinary management of rectal cancer Keller, Deborah S; Berho, Mariana; Perez, Rodrigo O ...
Nature reviews. Gastroenterology & hepatology,
07/2020, Letnik:
17, Številka:
7
Journal Article
Recenzirano
Odprti dostop
Rectal cancer treatment has evolved during the past 40 years with the use of a standardized surgical technique for tumour resection: total mesorectal excision. A dramatic reduction in local ...recurrence rates and improved survival outcomes have been achieved as consequences of a better understanding of the surgical oncology of rectal cancer, and the advent of adjuvant and neoadjuvant treatments to compliment surgery have paved the way for a multidisciplinary approach to disease management. Further improvements in imaging techniques and the ability to identify prognostic factors such as tumour regression, extramural venous invasion and threatened margins have introduced the concept of decision-making based on preoperative staging information. Modern treatment strategies are underpinned by accurate high-resolution imaging guiding both neoadjuvant therapy and precision surgery, followed by meticulous pathological scrutiny identifying the important prognostic factors for adjuvant chemotherapy. Included in these strategies are organ-sparing approaches and watch-and-wait strategies in selected patients. These pathways rely on the close working of interlinked disciplines within a multidisciplinary team. Such multidisciplinary forums are becoming standard in the treatment of rectal cancer across the UK, Europe and, more recently, the USA. This Review examines the essential components of modern-day management of rectal cancer through a multidisciplinary team approach, providing information that is essential for any practising colorectal surgeon to guide the best patient care.
Introduction
Colorectal cancer is the second most common cause of death from neoplastic disease in men and third in women of all ages. Globally, life expectancy is increasing, and consequently, an ...increasing number of operations are being performed on more elderly patients with the trend set to continue.
Elderly patients are more likely to have cardiovascular and pulmonary comorbidities that are associated with increased peri-operative risk. They further tend to present with more locally advanced disease, more likely to obstruct or have disseminated disease.
The aim of this review was to investigate the feasibility of laparoscopic colorectal resection in very elderly patients, and whether there are benefits over open surgery for colorectal cancer.
Methods
A systematic literature search was performed on Medline, Pubmed, Embase and Google Scholar. All comparative studies evaluating patients undergoing laparoscopic versus open surgery for colorectal cancer in the patients population over 85 were included.
The primary outcomes were 30-day mortality and 30-day overall morbidity. Secondary outcomes were operating time, time to oral diet, number of retrieved lymph nodes, blood loss and 5-year survival.
Results
The search provided 1507 citations. Sixty-nine articles were retrieved for full text analysis, and only six retrospective studies met the inclusion criteria. Overall mortality for elective laparoscopic resection was 2.92% and morbidity 23%. No single study showed a significant difference between laparoscopic and open surgery for morbidity or mortality, but pooled data analysis demonstrated reduced morbidity in the laparoscopic group (
p
= 0.032). Patients undergoing laparoscopic surgery are more likely to have a shorter hospital stay and a shorter time to oral diet.
Conclusion
Elective laparoscopic resection for colorectal cancer in the over 85 age group is feasible and safe and offers similar advantages over open surgery to those demonstrated in patients of younger ages.
The positive surgical margin (PSM) and biochemical recurrence (BCR) are two main factors associated with poor oncotherapeutic outcomes after prostatectomy. This is an Asian population study based on ...a single-surgeon experience to deeply investigate the predictors for PSM and BCR. We retrospectively included 419 robot-assisted radical prostatectomy cases. The number of PSM cases was 126 (30.1%), stratified as 22 (12.2%) in stage T2 and 103 (43.6%) in stage T3. Preoperative prostate-specific antigen (PSA) > 10 ng/mL (p = 0.047; odds ratio OR 1.712), intraoperative blood loss > 200 mL (p = 0.006; OR 4.01), and postoperative pT3 stage (p < 0.001; OR 6.901) were three independent predictors for PSM while PSA > 10 ng/mL (p < 0.015; hazard ratio HR 1.8), pT3 stage (p = 0.012; HR 2.264), International Society of Urological Pathology (ISUP) grade > 3 (p = 0.02; HR 1.964), and PSM (p = 0.027; HR 1.725) were four significant predictors for BCR in multivariable analysis. PSMs occurred mostly in the posterolateral regions (73.8%) which were associated with nerve-sparing procedures (p = 0.012) while apical PSMs were correlated intraoperative bleeding (p < 0.001). A high ratio of pT3 stage after RARP in our Asian population-based might surpass the influence of PSM on BCR. PSM was less significant than PSA and ISUP grade for predicting PSA recurrence in pT3 disease. Among PSM cases, unifocal and multifocal positive margins had a similar ratio of the BCR rate (p = 0.172) but ISUP grade > 3 (p = 0.002; HR 2.689) was a significant BCR predictor. These results indicate that PSA and pathological status are key factors influencing PSM and BCR.
Peritoneal surface malignancies comprise a heterogeneous group of primary tumours, including peritoneal mesothelioma, and peritoneal metastases of other tumours, including ovarian, gastric, ...colorectal, appendicular or pancreatic cancers. The pathophysiology of peritoneal malignancy is complex and not fully understood. The two main hypotheses are the transformation of mesothelial cells (peritoneal primary tumour) and shedding of cells from a primary tumour with implantation of cells in the peritoneal cavity (peritoneal metastasis). Diagnosis is challenging and often requires modern imaging and interventional techniques, including surgical exploration. In the past decade, new treatments and multimodal strategies helped to improve patient survival and quality of life and the premise that peritoneal malignancies are fatal diseases has been dismissed as management strategies, including complete cytoreductive surgery embedded in perioperative systemic chemotherapy, can provide cure in selected patients. Furthermore, intraperitoneal chemotherapy has become an important part of combination treatments. Improving locoregional treatment delivery to enhance penetration to tumour nodules and reduce systemic uptake is one of the most active research areas. The current main challenges involve not only offering the best treatment option and developing intraperitoneal therapies that are equivalent to current systemic therapies but also defining the optimal treatment sequence according to primary tumour, disease extent and patient preferences. New imaging modalities, less invasive surgery, nanomedicines and targeted therapies are the basis for a new era of intraperitoneal therapy and are beginning to show encouraging outcomes.
The Pneumatic Fast Transfer System irradiation channel of KAMINI reactor was characterized using Høgdahl and Westcott formalism. The neutron spectrum parameters like epi-thermal flux shape factor (
...α)
, thermal to epi-thermal neutron flux ratio (
f
), Modified Spectral Index (
r
0
T
n
/
T
0
) and Westcott factor
g
Lu
(
T
n
) were determined by measuring the activity corresponding to the (n,γ) product of nuclides having cross-section behavior “l/v” (
197
Au,
94
Zr, and
58
Fe) and “non-l/v” (
176
Lu). The obtained
g
Lu
(
T
n
) value was used to determine the neutron temperature (
T
n
) and further validated by fitting the thermal neutron spectrum, computed using MCNP. The Westcott parameters were validated by analyzing the reference materials.
Intracorporeal lymph node mapping in colon cancer surgery Soares, Antonio S.; Lovat, Laurence B.; Chand, Manish
European journal of surgical oncology,
December 2019, 2019-Dec, 2019-12-00, 20191201, Letnik:
45, Številka:
12
Journal Article
Recenzirano
Odprti dostop
The best approach to lymphadenectomy in colon cancer is still unknown. The debate has centred around different options of standardised “one size fits all” lymph node harvest techniques. A different ...approach is tailoring lymph node harvest to the patient's lymphatic drainage pattern.
A technique for individualised lymph node mapping is proposed, which can guide the surgeon intraoperatively. It consists in the intracorporeal injection of 10 mg of indocyanine green at 4 points in the periphery of the colonic tumour. A near infrared camera is used to assess the fluorescence after specimen mobilisation but before extraction, allowing lymphadenectomy based on the patient's own lymphatic drainage.
a video demonstration of the technique and preliminary results in 6 patients is presented in this short report.
intracorporeal lymph node mapping is feasible and safe. Further studies are required to determine the place of this technique in modern oncologic colon surgery.
Introduction
The protection of intellectual property (IP) is one of the fundamental elements in the process of medical device development. The significance of IP, however, is not well understood ...among clinicians and researchers. The purpose of this study was to evaluate the current status of IP awareness and IP-related behaviors among EAES members.
Methods
A web-based survey was conducted via questionnaires sent to EAES members. Data collected included participant demographics, level of understanding the need, new ideas and solutions, basic IP knowledge, e.g., employees' inventions and public disclosure, behaviors before and after idea disclosures.
Results
One hundred and seventy-nine completed forms were obtained through an email campaign conducted twice in 2019 (response rate = 4.8%). There was a dominancy in male, formally-trained gastrointestinal surgeons, working at teaching hospitals in European countries. Of the respondents, 71% demonstrated a high level of understanding the needs (frustration with current medical devices), with 66% developing specific solutions by themselves. Active discussion with others was done by 53%. Twenty-one percent of respondents presented their ideas at medical congresses, and 12% published in scientific journals. Only 20% took specific precautions or appropriate actions to protect their IPs before these disclosures.
Conclusions
The current level of awareness of IP and IP-related issues is relatively low among EAES members. A structured IP training program to gain basic IP knowledge and skill should be considered a necessity for clinicians. These skills would serve to prevent the loss of legitimate IP rights and avoid failure in the clinical implementation of innovative devices for the benefit of patients.
AIM To define good and poor regression using pathology and magnetic resonance imaging(MRI) regression scales after neo-adjuvant chemotherapy for rectal cancer.METHODS A systematic review was ...performed on all studies up to December 2015, without language restriction, t h a t w e r e i d e n t i f i e d f r o m M E D L I N E, C o c h r a n e Controlled Trials Register(1960-2015), and EMBASE(1991-2015). Searches were performed of article bibliographies and conference abstracts. MeS H and text words used included 'tumour regression', 'mr TRG', 'poor response' and 'colorectal cancers'. Clinical studies using either MRI or histopathological tumour regression grade(TRG) scales to define good and poor responders were included in relation to outcomes (local recurrence(LR), distant recurrence(DR), disease-free survival(DFS), and overall survival(OS))There was no age restriction or stage of cancer restriction for patient inclusion. Data were extracted by two authors working independently and using pre-defined outcome measures.RESULTS Quantitative data(prevalence) were extracted and analysed according to meta-analytical techniques using comprehensive meta-analysis. Qualitative data(LR, DR, DFS and OS) were presented as ranges. The overall proportion of poor responders after neo-adjuvant chemoradiotherapy(CRT) was 37.7%(95%CI: 30.1-45.8). There were 19 different reported histopathological scales and one MRI regression scale(mrT RG). Clinical studies used nine and six histopathological scales for poor and good responders, respectively. All studies using MRI to define good and poor response used one scale. The most common histopathological definition for good response was the Mandard grades 1 and 2 or Dworak grades 3 and 4; Mandard 3, 4 and 5 and Dworak 0, 1 and 2 were used for poor response. For histopathological grades, the 5-year outcomes for poor responders were LR 3.4%-4.3%, DR 14.3%-20.3%, DFS 61.7%-68.1% and OS 60.7-69.1. Good pathological response 5-year outcomes were LR 0%-1.8%, DR 0%-11.6%, DFS 78.4%-86.7%, and OS 77.4%-88.2%. A poor response on MRI(mr TRG 4,5) resulted in 5-year LR 4%-29%, DR 9%, DFS 31%-59% and OS 27%-68%. The 5-year outcomes with a good response on MRI(mrT RG 1,2 and 3) were LR 1%-14%, DR 3%, DFS 64%-83% and OS 72%-90%.CONCLUSION For histopathology regression assessment, Mandard 1, 2/Dworak 3, 4 should be used for good response and Mandard 3, 4, 5/Dworak 0, 1, 2 for poor response. MRI indicates good and poor response by mr TRG1-3 and mrT RG4-5, respectively.
Therapeutic radiopharmaceutical
89
SrCl
2
is used for bone pain palliation in metastatic bone cancer. No carrier added
89
Sr is being produced using
89
Y(n, p)
89
Sr reaction in FBTR, IGCAR, ...Kalpakkam. Standardization, demonstration of chemical processing of irradiated yttria inside hotcell and quality control of
89
SrCl
2
radiopharmaceutical have been described in this work in detail. Two stage extraction with 0.1M DtBuCH18C6/ 1-Octanol followed by two stage scrubbing and three stage back extraction yielded a pure fraction of
89
Sr, which was free from other impurities produced during the irradiation. Detailed physicochemical and biological quality control of the final product have been standardised, demonstrated and meeting the recommendations according to the US, EU and International pharmacopeia.
PDF
