The abdominoperineal resection itself is associated with an adverse outcome: The European experience based on a pooled analysis of five European randomised clinical trials on rectal cancer

Dulk, Marcel den; Putter, Hein; Collette, Laurence; Marijnen, Corrie A.M.; Folkesson, Joakim; Bosset, Jean-François; Rödel, Claus; Bujko, Krzysztof; Påhlman, Lars; Velde, Cornelis J.H. van de

doi:10.1016/j.ejca.2008.11.039

Cited by 167 publications

(87 citation statements)

References 26 publications

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“…As incomplete mesorectal excisions are still encountered 13 and tumour involvement of the CRM is most frequently reported in anterior tumours 14 or advanced low rectal tumours, 15,16 there is a need to elucidate the anatomy of the fasciae and nerves at these sites. We studied the perirectal fasciae along the whole length of the mesorectum in whole mount microscopic sections of en-bloc cadaveric pelvic exenteration specimens and concentrate on the mesorectal fascia and its relation to the autonomic nerves, specifically at the anterolateral mesorectum and towards the pelvic floor.…”

Section: Introductionmentioning

confidence: 99%

Understanding the surgical pitfalls in total mesorectal excision: Investigating the histology of the perirectal fascia and the pelvic autonomic nerves

Kraima

West

Treanor

et al. 2015

European Journal of Surgical Oncology (EJSO)

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AimExcellent understanding of the arrangement of fasciae and nerves surrounding the rectum is necessary for total mesorectal excision (TME). However, the fasciae anterolateral to the mesorectum and surrounding the low-rectum are still poorly understood. We studied the perirectal fascia along the complete length of the rectum in en-bloc cadaveric specimens and the University Medical Center Utrecht (UMCU) pelvic dataset, and describe implications for TME. MethodsFour donated human adult cadaveric specimens (two males, two females) were obtained through the Leeds GIFT Research Tissue Programme. Paraffin-embedded blocks were produced and serially sectioned at 50 and 250 m intervals. Whole mount sections were stained with haematoxylin & eosin,Masson's trichrome and Millers' elastin. Additionally, the UMCU pelvic dataset including digitalised cryosections of a female pelvis in three axes was studied. ResultsMultiple fascial layers surrounded the upper rectum. In the 'holy plane' of TME, laminae merged with the mesorectal and parietal fascia. Nerves ran directly laterally to the mesorectal fascia. More caudally, the mesorectal fascia approached the longitudinal layer of the rectal muscularis propria with the neurovascular bundles situated anterolaterally. The mesorectal fascia had a variable appearance in terms of thickness and completeness, which was most prominent anterolaterally. Conclusion 3Optimal TME requires dissection on the mesorectal fascia to preserve the nerves. Rectal surgeons are challenged in doing so as the mesorectal fascia varies in thickness and is often absent in some areas. More caudally, a wider excision may be needed to avoid incomplete specimens.4

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Section: Introductionmentioning

confidence: 99%

Understanding the surgical pitfalls in total mesorectal excision: Investigating the histology of the perirectal fascia and the pelvic autonomic nerves

Kraima

West

Treanor

et al. 2015

European Journal of Surgical Oncology (EJSO)

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“…At present, low lying rectal cancers are associated with relatively high local recurrence rates and a poor quality of life following sphincter ablation (4,26). In the current cohort, all patients, excluding one, received complete resection and 91 (86.7%) patients underwent sphincter-preserving surgery.…”

Section: Discussionmentioning

confidence: 99%

Tumor volume reduction rate is superior to RECIST for predicting the pathological response of rectal cancer treated with neoadjuvant chemoradiation: Results from a prospective study

Xiao

Tan

et al. 2015

Oncology Letters

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Abstract. The aim of the present study was to compare the tumor volume reduction rate (TVRR), as determined by three-dimensional region-of-interest magnetic resonance volumetry, and Response Evaluation Criteria in Solid Tumors (RECIST) data for predicting the pathological tumor response (PTR) of locally advanced rectal cancer (LARC) following treatment with neoadjuvant chemoradiation (CRT). The current cohort consisted of 105 patients with LARC [clinical tumor stage (cT)3-4 or clinical lymph node stage (cN)+] from a prospective randomized trial who had undergone pre-operative CRT and radical proctectomy. Tumor volumes were measured prior to and following CRT to determine TVRR. Furthermore, receiver operating characteristic (ROC) curves of TVRR and RECIST were constructed to predict the PTR in terms of tumor regression grade (TRG) and downstaging. Values for the area under the ROC curve (AUC) were compared and TVRR cut-off levels were determined. RECIST was used to identify 5 (4.8%) cases of complete response, 44 (41.9%) of partial response, 55 (52.4%) of stable disease and 1 (0.9%) of progressive disease. The mean TVRR was 58.6±24.4%, and a good TRG (0-1) and downstaging occurred in 54 (51.4%) and 59 (56.2%) patients, respectively. In addition, TVRR and RECIST were significantly correlated with TRG and downstaging (P<0.01). The TVRR AUC was significantly larger than that of RECIST for TRG (P=0.020). For downstaging, TVRR also exhibited a larger AUC than RECIST, however, the difference was not significant (P=0.180). The sensitivity and specificity of TVRR in predicting a good TRG were 70.4 and 80.4%, respectively, therefore, the optimal TVRR cut-off value was determined to be 65%. TVRR appeared to be more accurate than RECIST in predicting PTR, particularly for TRG associated with survival. Thus, TVRR may be considered as a novel parameter for evaluating the efficacy of CRT for patients with LARC. IntroductionColorectal cancer is the third most commonly diagnosed type of cancer worldwide (1). In China, ~50% of cases of colorectal cancer arise in the rectum, accounting for >100,000 new diagnoses of rectal cancer in 2012 (2). Despite the advent of total mesorectal excision (TME) (3) facilitating major improvements in the management of locally advanced rectal cancer (LARC), which is defined as clinical tumor stage (cT)3-4 or clinical lymph node stage (cN)+, management remains a challenge following Miles' procedure due to the high recurrence rate and poor quality of life (4).Neoadjuvant chemoradiation (CRT) has been established as the standard treatment strategy for LARC, as it appears to be associated with improved local control and a higher rate of sphincter-sparing procedures (5). Pathological tumor response (PTR), including tumor regression grade (TRG) and downstaging, has been indicated to be an important prognostic factor for LARC following CRT (6-8). PTR may be useful to stratify patients with different prognoses and to tailor surgical treatment strategies, particularly for sphincter-sparing candidates (9). Th...

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“…Pooled analysis of 14 European rectal cancer studies found positive CRMs in 10 and 5 % of APR and anterior resection specimens, respectively. 64 Local recurrence rates were significantly elevated (20 versus 11 %) and 5-year overall survival worse (59 versus 70 %) in patients with an APR as compared to an LAR. 64 These inferior outcomes in patients after APR could be due to deficiencies in the surgical technique and/or tumor characteristics.…”

Section: The Role Of the Apr In The Era Of Sphincter-saving Techniquesmentioning

confidence: 99%

“…64 Local recurrence rates were significantly elevated (20 versus 11 %) and 5-year overall survival worse (59 versus 70 %) in patients with an APR as compared to an LAR. 64 These inferior outcomes in patients after APR could be due to deficiencies in the surgical technique and/or tumor characteristics. A review of 24 high quality studies found APR to be associated with higher rates of CRM positivity and tumor perforation and inferior oncologic outcomes, but also found tumors in patients with APRs to be lower and more locally advanced.…”

Section: The Role Of the Apr In The Era Of Sphincter-saving Techniquesmentioning

confidence: 99%

Sphincter-Sparing Surgery in Patients with Low-Lying Rectal Cancer: Techniques, Oncologic Outcomes, and Functional Results

Bordeianou

Maguire

Alavi

et al. 2014

Journal of Gastrointestinal Surgery

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Background Rectal cancer management has evolved into a complex multimodality approach with survival, local recurrence, and quality of life parameters being the relevant endpoints. Surgical treatment for low rectal cancer has changed dramatically over the past 100 years. Discussion Abdominoperineal resection, once the standard of care for all rectal cancers, has become much less frequently utilized as surgeons devise and test new techniques for preserving the sphincters, maintaining continuity, and performing oncologically sound ultra-low anterior or local resections. Progress in rectal cancer surgery has been driven by improved understanding of the anatomy and pathophysiology of the disease, innovative surgical technique, improved technology, multimodality approaches, and increased appreciation of the patient's quality of life. The patient with a low rectal cancer, once almost universally destined for impotence and a colostomy, now has the real potential for improved survival, avoidance of a permanent stoma, and preservation of the normal route of defecation.Keywords Rectal cancer . Sphincter preservation . Total mesorectal excision . Anterior resection . Intersphincteric resection . Local excision rectal cancer Historical BackgroundThe modern era of rectal cancer surgery began with the description of the abdominoperineal resection (APR) by Miles in 1908. Prior perineal and sacral approaches (e.g., Kraske approach) to rectal cancer resection produced high rates of complications, cancer recurrence, poor quality of life (QOL), and poor overall survival. Miles' operation reflected greater understanding of the natural history of rectal cancer that was based on postmortem examination of his patients after perineal resection. He observed cancerous implants in the pelvic peritoneum, mesorectum, and affected nodes of the left common iliac bifurcation. These findings led him to develop a "cylindrical concept" of the spread of rectal cancer to upward, downward, and lateral zones. 1 The original operation included resection of the rectum, sigmoid, mesorectum, nodes of the iliac bifurcation, and a perineal component to include the anus and levator ani muscles. Postoperative mortality was high initially, but local recurrence decreased

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The abdominoperineal resection itself is associated with an adverse outcome: The European experience based on a pooled analysis of five European randomised clinical trials on rectal cancer

Cited by 167 publications

References 26 publications

Understanding the surgical pitfalls in total mesorectal excision: Investigating the histology of the perirectal fascia and the pelvic autonomic nerves

Understanding the surgical pitfalls in total mesorectal excision: Investigating the histology of the perirectal fascia and the pelvic autonomic nerves

Tumor volume reduction rate is superior to RECIST for predicting the pathological response of rectal cancer treated with neoadjuvant chemoradiation: Results from a prospective study

Sphincter-Sparing Surgery in Patients with Low-Lying Rectal Cancer: Techniques, Oncologic Outcomes, and Functional Results

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