For preoperative staging of rectal cancer, the best cut-off distance for predicting CRM involvement using MRI is 1 mm. Using a cut-off greater than this does not appear to identify patients at higher risk of local recurrence.
Aim Low anterior resection syndrome (LARS) is pragmatically defined as disordered bowel function after rectal resection leading to a detriment in quality of life. This broad characterization does not allow for precise estimates of prevalence. The LARS score was designed as a simple tool for clinical evaluation of LARS. Although the LARS score has good clinical utility, it may not capture all important aspects that patients may experience. The aim of this collaboration was to develop an international consensus definition of LARS that encompasses all aspects of the condition and is informed by all stakeholders. Method This international patient–provider initiative used an online Delphi survey, regional patient consultation meetings, and an international consensus meeting. Three expert groups participated: patients, surgeons and other health professionals from five regions (Australasia, Denmark, Spain, Great Britain and Ireland, and North America) and in three languages (English, Spanish, and Danish). The primary outcome measured was the priorities for the definition of LARS. Results Three hundred twenty‐five participants (156 patients) registered. The response rates for successive rounds of the Delphi survey were 86%, 96% and 99%. Eighteen priorities emerged from the Delphi survey. Patient consultation and consensus meetings refined these priorities to eight symptoms and eight consequences that capture essential aspects of the syndrome. Sampling bias may have been present, in particular, in the patient panel because social media was used extensively in recruitment. There was also dominance of the surgical panel at the final consensus meeting despite attempts to mitigate this. Conclusion This is the first definition of LARS developed with direct input from a large international patient panel. The involvement of patients in all phases has ensured that the definition presented encompasses the vital aspects of the patient experience of LARS. The novel separation of symptoms and consequences may enable greater sensitivity to detect changes in LARS over time and with intervention.
Demonstration of accurate measurement of the depth of extramural tumor spread in the MERCURY Study enabled accurate preoperative prognostication.
Purpose/Objective(s): Liver transplant, the gold standard treatment for most Hepatocellular carcinomas (HCC), was till recently not being considered as an option in patients having portal vein tumor thrombus (PVTT). These patients were offered only palliative treatments like Radio frequency ablation (RFA), Trans-arterial chemo-embolization (TACE) and conventional external beam radiation therapy (EBRT). With advent of SBRT, precise targeting and motion management has improved local control, making it possible to offer curative liver transplant post SBRT (Stereotactic Body Radiation therapy) to these cases where transplant was ruled out in the past. Materials/Methods: We present 48 of our cases, initially considered unfit for transplant and referred for SBRT to PVTT alone or with HCC lesion from April 2011 till November 2015. Adequate respiratory motion management with either deep inspiratory breath hold (DIBH) or synchrony respiratory tracking was used in all cases. Post SBRT, cases were assessed at 4, 8 and 12 weeks for transplant feasibility. Plan details and follow up data was analyzed with primary end point as amenability to liver transplant. Results: Intent of treatment was curative in 32 (66.6%) cases with limited disease and palliative in remaining 16 (33.3%) cases. Of all the cases, 38 (79%) had multi centric disease and 34 cases (70.8%) had received alternative multimodality treatment in past, before SBRT. Based on Japan cancer group classification 12.5% (n Z 6), 25% (n Z 12), 22.9% (n Z 11) and 39.5% (n Z 19) cases had Vp1, Vp2, Vp3 and Vp4 type PVTT, respectively. Twenty cases (42%) were treated on robotic radiosurgery and 28 cases (58%) on Linac with DIBH. Most frequent dose fractionation used was 60 Gy (range 25 -60 Gy) in 5 fractions (range 3-20 fr). Treatment was well tolerated with mild nausea and fatigue being the most common side effect with no RTOG grade 3 or more toxicity reported. At the time of analyses, amongst 32 curative cases, 23 (71.9%) were alive while 6 (18.8%) had expired and 3 (9.3%) were lost to follow up. Eleven (34.3% of 32 curative) cases underwent successful transplant, 2-3 months post SBRT while 5 (15.6%) are awaiting response assessment. Remaining 2 (6.2%) cases are living with stable disease and 5 (15.6%) with systemic progression. Amongst 16 palliative cases, 7 (43.75%) were still alive, 4 cases (25%) lost to follow up and 5 (31.25%) had expired. Median survival was 13 months in all 48 cases and 26 months (range 8-46 months) for transplant cases. Conclusion: Presence of PVTT is no longer considered a contraindication to liver transplant. Adequately selected cases can be offered SBRT as single modality or as a part of multimodality regime. With growing data from well-designed future studies, PVTT-SBRT promises to improve outcomes in selected HCC cases by making them amenable to liver transplant. SBRT-PVTT therefore merits attention for its potential as an integral part of multidisciplinary treatment approach towards inoperable HCC, realizing the unmet need of adequate local c...
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