Effect of neoadjuvant therapy regimens on lymph nodes yield in rectal cancer.

BACKGROUND AND OBJECTIVES: Pathological nodal staging is relevant to postoperative decision-making and a prognostic marker of cancer survival. This study aimed to assess the effect of different total neoadjuvant therapy (TNT) regimens on lymph node status following total mesorectal excision (TME) for locally advanced rectal cancer (LARC). METHODS: A retrospective cohort study of patients treated for node-positive clinical stage 3 LARC with TNT between January 2015 and August 2022. Patients were stratified into induction therapy and consolidation therapy groups. Variables collated included patient demographics, clinical and radiological characteristics of the tumor, and pathology of the resected specimen. Primary outcome was total harvested lymph nodes. RESULTS: Ninety-seven patients were included (57 [58.8%] males; mean age of 58.5 ± 11.4 years). The induction therapy group included 85 (87.6%) patients while 12 (12.4%) patients received consolidation therapy. A median interquartile range value of 22.00 (5.00-72.00) harvested lymph nodes was recorded for the induction therapy group in comparison to 16.00 (16.00-47.00) in the consolidation therapy arm (p = 0.487). Overall pathological complete response rate was 34%. CONCLUSION: Total harvested nodes from resected specimens were marginally lower in the consolidation therapy group. Induction therapy may be preferrable to optimize postoperative specimen staging.

How reliable is restaging MRI after neoadjuvant therapy in rectal cancer?

BACKGROUND: Despite the pivotal role of magnetic resonance imaging (MRI) in rectal cancer staging and evaluation, the reliability of restaging MRI after neoadjuvant therapy is still debatable. This study aimed to assess the accuracy of restaging MRI by comparing post-neoadjuvant MRI findings with those of the final pathology. METHODS: This study was a retrospective review of the medical records of adult rectal cancer patients who had restaging MRI following neoadjuvant therapy and prior to rectal cancer resection in a NAPRC-certified rectal cancer centre between 2016 and 2021. The study compared findings of preoperative, post-neoadjuvant MRI with final pathology relative to T stage, N stage, tumour size, and circumferential resection margin (CRM) status. RESULTS: A total of 126 patients were included in the study. We found fair concordance (kappa -0.316) for T stage between restaging MRI and pathology report, and slight concordance for N stage and CRM status (kappa -0.11, kappa = 0.089, respectively). Concordance rates were lower for patients following total neoadjuvant treatment (TNT) or with a low rectal tumour. In total, 73% of patients with positive N pathology status had negative N status in the restaging MRI. Sensitivity and specificity regarding positive CRM in post-neoadjuvant treatment MRI were 45.45% and 70.4%, respectively. CONCLUSION: We found low concordance levels between restaging MRI and pathology regarding TN stage and CRM status. Concordance levels were even lower for patients after TNT regimen and with a low rectal tumour. In the era of TNT and watch-and-wait approach, we should not rely solely on restaging MRI to make post-neoadjuvant treatment decisions.

Assessment of mesorectal fascia status in MRI compared with circumferential resection margin after total mesorectal excision and predictors of involved margins.

BACKGROUND: Circumferential resection margin is an important prognosticator for total mesorectal excision outcome. We investigated the status of mesorectal fascia on magnetic resonance imaging compared with circumferential resection margin on pathology and factors associated with status change. METHODS: This was a retrospective analysis of a prospective database of rectal cancer patients who underwent surgery. Mesorectal fascia status on magnetic resonance imaging done before neoadjuvant therapy and circumferential resection margin status on pathology were compared. The study outcomes were factors associated with a margin status conversion between magnetic resonance imaging and pathology, and predictors of involved circumferential resection margin. RESULTS: In total, 244 patients (average follow-up of 25.4 months) were included. Eighty-one (33.2%) patients had potentially involved mesorectal fascia in magnetic resonance imaging and 12 (4.9%) had involved circumferential resection margin in pathology. A total of 2.8% of patients had a conversion of clear mesorectal fascia in magnetic resonance imaging to involved circumferential resection margin. Abdominoperineal resection was significantly associated with this status change (odds ratio: 25, 95% confidence interval: 2.4-255.8, P = .007). In total, 7.4% of patients with potentially involved mesorectal fascia had persistently involved circumferential resection margin. Lack of total neoadjuvant therapy was associated with higher, yet statistically insignificant, odds of persistently involved circumferential resection margin (odds ratio: 12, 95% confidence interval: 0.65-220.8, P = .09). The significant independent predictors of involved circumferential resection margin were body mass index (odds ratio: 1.2, P = .016) and abdominoperineal resection (odds ratio: 4.22, P = .04). CONCLUSION: Change of clear mesorectal fascia in magnetic resonance imaging to an involved circumferential resection margin in pathology was recorded in 2.8% of patients; abdominoperineal resection might be associated with this change. Approximately 7% of patients had persistent involvement of circumferential resection margin as determined by pathology. Omission of total neoadjuvant therapy might be associated with persistent margin involvement.

A simple difficulty scoring system for laparoscopic total mesorectal excision.

BACKGROUND: The proposed difficulty scoring system (DSS) may aid in preoperative planning for laparoscopic total mesorectal excision (L-TME) for rectal cancer. METHODS: Fifty-three patients [28 males; 59.0 (31.0-88.0) years of age] treated for rectal cancer at our institution from 2/2011-5/2018 were identified. "Difficult operation" (DO) was defined as the presence of ≥3 factors: operative time ≥320 min, estimated blood loss >250 ml, intraoperative complications, conversion to laparotomy, >2 stapler applications, incomplete TME quality, and/or subjective perceived difficulty. Univariate analysis and multivariate logistic regression model with backward elimination method were used to obtain a DSS which consists of two factors: sex (male = 1 and female = 0) and body mass index (BMI) (≥30 kg/m2 = 1, <30 kg/m2 = 0). RESULTS: In univariate analysis, sex (p = 0.0217), BMI (p = 0.0026), American Society of Anesthesiologists (ASA) score (p = 0.0372), and magnetic resonance imaging transverse diameter (p = 0.0441) correlated to DO. Multivariate analysis revealed that sex and BMI were the most important risk factors for a DO [area under the receiver operating characteristic curve [AUC] = 0.7761, 95% CI = (0.6443-0.9080)]. Male patients with a BMI ≥ 30 kg/m2 were more likely to experience a DO (77.8%). The simplified DSS did not weaken the discriminating power compared to multivariate logistic regression model (AUC 0.7696 vs. 0.7761, p = 0.7387). L-TME with a DSS of 0, 1, and 2 had a DO rate of 10%, 33.3%, and 77.8%, respectively. CONCLUSIONS: A simplified DSS may be used preoperatively in preparation for L-TME.

Mucobilia: An Unusual Cause of Persistent Jaundice.

Mucobilia is defined as the abnormal secretion of copious amounts of mucus from within the bile ducts, manifesting as obstructive jaundice or cholangitis. A spectrum of mucin-producing hepatobiliary and pancreatic neoplasms have been associated with mucobilia. We report the case of a 63-year-old male with an intestinal type of intraductal papillary neoplasm of the intrahepatic bile duct.

How Reliable Is CT Scan in Staging Right Colon Cancer?

BACKGROUND: The observation of inferior oncologic outcomes after surgery for proximal colon cancers has led to the investigation of alternative treatment strategies, including surgical procedures and neoadjuvant systemic chemotherapy in selected patients. OBJECTIVE: The purpose of this study was to determine the accuracy of CT staging in proximal colon cancer in detecting unfavorable pathologic features that may aid in the selection of ideal candidates alternative treatment strategies, including extended lymph node dissection and/or neoadjuvant chemotherapy. DESIGN: This was a retrospective consecutive series. SETTINGS: Trained abdominal radiologists from 2 centers performed a blinded review of CT scans obtained to locally stage proximal colon cancer according to previously defined prognostic groups, including T1/2, T3/4, N+, and extramural venous invasion. CT findings were compared with histopathologic results as a reference standard. Unfavorable pathologic findings included pT3/4, pN+, or extramural venous invasion. PATIENTS: Consecutive patients undergoing right colectomy in 2 institutions between 2011 and 2016 were retrospectively reviewed from a prospectively collected database. MAIN OUTCOME MEASURES: T status, nodal status, and extramural venous invasion status comparing CT with final histologic findings were measured. RESULTS: Of 150 CT scans reviewed, CT failed to identify primary cancer in 18%. Overall accuracy of CT to identify unfavorable pathologic features was 63% with sensitivity, specificity, positive predictive value, and negative predictive value of 63% (95% CI, 54%-71%), 63% (95% CI, 46%-81%), 87% (95% CI, 80%-94%) and 30% (95% CI, 18%-41%). Only cT3/4 (55% vs 45%; p = 0.001) and cN+ (42% vs 58%; p = 0.02) were significantly associated with correct identification of unfavorable features at final pathology. CT scans overstaged and understaged cT in 23.7% and 48.3% and cN in 28.7% and 53.0% of cases. LIMITATIONS: The study was limited by its retrospective design, relatively small sample size, and heterogeneity of CT images performed in different institutions with variable equipment and technical details. CONCLUSIONS: Accuracy of CT scan for identification of pT3/4, pN+, or extramural venous invasion was insufficient to allow for proper identification of patients at high risk for local recurrence and/or in whom to consider alternative treatment strategies. Locoregional overstaging and understaging resulted in inappropriate treatment strategies in <48%. See Video Abstract at http://links.lww.com/DCR/A935.

The safety of same-day CT colonography following incomplete colonoscopy with polypectomy.

BACKGROUND: Concerns about the risk of bowel perforation for same-day computed tomography colonography (CTC) following an incomplete colonoscopy with polypectomy may lead to unnecessarily postponing the CTC. OBJECTIVE: The objective of this article is to describe the complications including colon perforations associated with same-day CTC in a cohort who had polypectomies but an incomplete colonoscopy. DESIGN: We conducted a retrospective study. SETTING: Our study took place in a single, tertiary referral center. PATIENTS: We studied consecutive patients who had CTC the same day as an incomplete colonoscopy with polypectomy. INTERVENTIONS: Interventions included optical colonoscopy (OC), endoscopic polypectomies, and same-day CTC. MAIN OUTCOME MEASUREMENTS: Our main outcome measurements included perforation rate with long-term follow-up. RESULTS: A total of 3% of patients undergoing colonoscopy from January 2008 to December 2012 had same-day CTC following incomplete OC, and 72 polypectomies were performed in 34 (or 17%) of these patients. Incomplete colonoscopies were due to colon tortuosity and looping (25), severe angulations (five), colon mass (two), colon stenosis (one), bradycardia (one). Fifty-three percent of the OCs were screening for colon neoplasia, 29% diagnostic and 18% were surveillance of colon polyps. Most polyps were ≤ 5 mm, and found in the left colon. There were no reported complications or perforations associated with same-day CTCs during short- and long-term follow-up. LIMITATIONS: Limitations of our analysis included retrospective single-center design, small number of patients for the occurrence, referral to same-day CTC was not standardized, inability to establish safety of CTC for specific scenarios such as after complex polypectomies, strictures, or advanced IBD. CONCLUSIONS: Radiologists' apprehension to perform a CTC the same day as an incomplete colonoscopy following polypectomies because of perceived risk of perforation may be unfounded. More data are needed to determine the safety of same-day CTC in patients with high-risk findings during colonoscopy such as a stricture, severe IBD, and after complex polypectomies.