A cohort study of local excision followed by adjuvant therapy incorporating a contact X-ray brachytherapy boost instead of radical resection in 180 patients with rectal cancer.

AIM: Recent data have suggested near-equivalent oncological results when treating early rectal cancer by local excision followed by radio- ± chemotherapy rather than salvage radical surgery. The aim of this retrospective study was to assess the use of contact X-ray brachytherapy within this paradigm. METHOD: All patients had undergone local excision and were referred to our radiotherapy centre for treatment with contact X-ray brachytherapy. Postoperative (chemo)radiotherapy was also given in their local hospital in most cases. Variables assessed were local excision method, postoperative therapy received, follow-up duration, disease-free survival, salvage surgery and stoma-free survival. RESULTS: In total, 180 patients with a median age of 70 (range 36-99) years were assessed. Following local excision, pT stages were pT1 = 131 (72%), pT2 = 44 (26%), pT3 = 5 (2%). All patients received contact X-ray brachytherapy boosting at our centre and, in addition, 110 received chemoradiotherapy and 60 received radiotherapy alone. After a median follow-up of 36 months (range 6-48), 169 patients (94%) remained free of local recurrence. Of the 11 patients with local recurrence (three isolated nodal), five underwent salvage abdominoperineal excision. Eight patients developed distant disease, of whom five underwent metastasis surgery. At last included follow-up 173 (96%) patients were free of all disease and 170 (94%) were stoma free. CONCLUSIONS: Contact therapy can be offered in addition to external beam radio (±chemo) therapy instead of radical surgery as follow-on treatment after local excision of early rectal cancer. This combination can provide equivalent outcomes to radical surgery. The added value of contact therapy should be formally assessed in a clinical trial.

A training programme for operating theatre personnel in transanal endoscopic operation procedures for local excision of rectal tumours.

The transanal endoscopic operation (TEO) is a minimal access surgical procedure for the removal of benign and early malignant rectal tumours (Nieuwenhuis et al 2009). This surgery involves specialist equipment, set up and positioning by the perioperative team. We report on and evaluate the first ever TEO course designed specifically for theatre practitioners.

Combined modality treatment of early rectal cancer: the UK experience.

With the introduction of colorectal screening in the UK, more patients will probably be diagnosed with early rectal cancer. The UK has an increasingly elderly population and not all patients diagnosed with early rectal cancer will be suitable for radical surgery. Therefore, a national plan is needed to develop the provision of alternative local treatment with equity of access across the country. Here we review the Clatterbridge Centre for Oncology multimodality treatment policy, which has been in clinical practice since 1993 and we discuss its rationale. Clatterbridge is the only centre in the UK offering Papillon-style contact radiotherapy. In total, 220 patients have been treated over 14 years, most of whom were referred from other centres. One hundred and twenty-four patients received Papillon (contact radiotherapy) as part of their multimodality management. The guidelines of the Association of Coloproctology of Great Britain and Ireland recommend local treatment for T1 tumours<3 cm in diameter, but this refers to treatment by surgery alone. There are no published national guidelines for radiotherapy. We plan each treatment in stages and achieve excellent local control (93% at 3 years) with low morbidity. We conclude that radical local treatment for cure can be offered safely to carefully selected elderly patients. Close follow-up is necessary so that effective salvage treatment can be offered. Because of a lack of randomised trial evidence, at present local radiotherapy is not yet accepted as an alternative option to the gold standard surgical treatment. Even with international collaboration, a randomised trial will be difficult to complete as the number of cases requiring local radiotherapy is small due to the highly selective nature of the treatment involved. However, an observational phase II trial is planned. In addition, the Transanal Endoscopic Microsurgery Users Group is also planning a phase II trial using preoperative radiotherapy. These studies will provide evidence to help establish the true role of radiotherapy in early rectal cancer.

Salvage surgery after inadequate combined local treatment for early rectal cancer.

The outcome of salvage surgery after failed local treatment of early rectal cancer is crucial because it determines the overall survival and therefore influences the initial choice of local therapy. The published results of salvage surgery are controversial and unclear. We treated 220 patients with early rectal cancer between 1992 and 2007 and report our experience of salvage surgery. There was an overall salvage rate of 68% (30/44) and a salvage cure rate of 87% (26/30). Immediate surgical salvage was carried out for incompletely eradicated local disease no longer than 6 months after the completion of treatment and had an 87.5% (21/24) salvage rate with a 90% (19/21) cure rate. Delayed salvage was carried out when local recurrence occurred after an apparent cure was sustained for at least 3 months and was undertaken in nine of 11 (82%) patients with local recurrence alone with an 86% (6/7) cure rate for salvage surgery. These data suggest that salvage surgery is effective management after failed local treatment. These high cure rates may reflect the fact that local recurrence is usually intraluminal after multimodality treatment, as initially involved lymph nodes are often sterilised. Follow-up after initial local treatment must be thorough and intensive, particularly during the first 3 years, in order to identify patients who are suitable for salvage and to enable prompt surgery.

Multi-modality approach in curative local treatment of early rectal carcinomas.

OBJECTIVE: Despite recent advances, surgery remains the mainstay for the management of rectal carcinoma. The conventional surgical treatment for low rectal carcinoma is total mesorectal excision. This results in either abdomino-perineal excision of the rectum (APER) with permanent colostomy or low anterior resection (LAR) usually with a covering stoma. Local resection is an alternative treatment option and this could be offered either using manual trans-anal resection (TAR) or transanal endoscopic microsurgery (TEM) if the tumour is situated higher. PATIENTS: Patient selection is an important factor if local resection is used. No further treatment is necessary for T1 tumours with clear surgical resection margins. Conventional radical surgery should be offered for T1 tumours with close resection margins (<1 mm) or T2 tumours with higher risk of lymph node metastases. Patients were treated by postoperative chemo-radiotherapy or radiotherapy, if further radical surgery was not considered appropriate or if the patient refused further surgery. Using this approach, we describe our experience of 100 patients treated from January 1992 to June 2002. RESULTS: Only 13 patients had surgery alone and 87 patients had radiotherapy either pre-operative (33 patients), postoperative (25 patients) or radical radiotherapy alone (29 patients). Local recurrence occurred in 10% of patients and salvage surgery was offered in over half (6 patients) of these patients. At median follow up of 33 months (range 3-120 months), the overall survival was 77% reflecting the fact that the majority of these patients were elderly with coexisting medical problems. However, cancer specific survival was 96%. More importantly, only 9 patients had colostomies and colostomy-free survival in our cohort of patients from Liverpool was 91%. CONCLUSION: We concluded that in selected patients, who were not medically fit (ASA 111 or above) or those who were unable to accept a permanent colostomy, local treatment could be offered with curative intent using a multimodality approach. In our experience, relapses can be salvaged effectively and we recommend a long-term close follow up policy.

The aetiology and epidemiology of faecal incontinence.

Faecal incontinence is experienced by at least 2% of the population and 7% of those over 65 years of age. The true incidence is probably much higher because of the stigmata of the affliction leading to underreporting. The common causes of faecal incontinence are discussed.

The surgical management of faecal incontinence.

The surgical management of faecal incontinence is complex and technically demanding. Surgery should only be offered once the aetiology has been correctly identified and the patient has been counselled regarding outcomes of success. This may only approach 80%, with long-term results declining with time.

Recent developments in the treatment of faecal incontinence.

Many patients with faecal incontinence can be cured using a simple anal sphincter repair. Some patients are unsuitable for this either because the sphincter is absent, too extensively damaged or anal sphincter repair has failed. In these patients novel treatments have been introduced to augment, replace and stimulate the anal sphincter.

The management of retroperitoneal soft tissue sarcoma: a single institution experience with a review of the literature.

AIM: Ten percent of soft tissue sarcomas (STS) arise in the retroperitoneal tissues. The prognosis for patients with retroperitoneal sarcoma is poor with a 5-year survival rate between 12% and 70%. Stage at presentation, high histological grade, unresectable primary tumour and incomplete resection are associated with a less favourable outcome. METHODS: Complete follow-up data were available on 22 patients who underwent surgery for retroperitoneal STS in our institution between 1990 and 2000. Patient, tumour and treatment variables were analysed including use of adjuvant therapy and survival status. RESULTS: Eighteen patients underwent surgery for primary disease, four patients were treated for recurrent disease or metastases. Ten patients presented with pain, seven with an abdominal mass, other presentation included weight loss and haematuria. Thirteen patients presented with tumours larger than 10 cm. The tumours were seven liposarcomas, six leiomyosarcomas, three malignant fibrous histiocytomas, two rhabdomyosarcomas, two malignant schwannomas and two undifferentiated sarcomas. Six primary tumours were completely excised, five patients received radiotherapy and five received chemotherapy. Local recurrence rate was 45% and recurrence-free interval for 10 patients with recurrence was 11 months. Five patients received radiotherapy and five received chemotherapy. The median survival for patients with primary tumours was 36 months, and 5-year survival was 44%. Adjuvant therapy was not associated with higher survival rates. CONCLUSION: This study re-emphasizes the poor outcome of patients with retroperitoneal STS. Adjuvant radiotherapy and chemotherapy do not appear to be any proven benefit and the single most important prognostic factor is aggressive successful en bloc resection of the primary tumour. Our resection rate and 5-year survival rates are comparable with previous reported UK series although lower than large reports from North American centres. This might partly be explained by difficulty in data collection in a retrospective analysis, but may reflect inadequate subspecialization in UK centres.

Improving outcomes in colonic cancer.

Many of the symptoms of colon cancer do not start until the tumour has spread outside the bowel, and treatment at this stage has reduced chances of cure. Early detection and the optimum combination of surgery and adjuvant treatment can make a significant impact on outcome.

Improving outcomes in rectal cancer.

Concerted efforts are being made to improve the poor surgical outcomes in rectal carcinomas and this includes the use of total mesorectal excision by specially trained colorectal surgeons, in addition to the use of pre- or postoperative radiotherapy and chemotherapy. The role of each modality should be carefully evaluated, and benefits weighed against toxicity and added costs.

Transanal endoscopic microsurgery.

The anatomy of the pelvis makes it difficult to perform local excisions in the rectum when a tumour is some distance from the anal verge. Transanal endoscopic microsurgery, a minimally invasive procedure, has been developed. It provides an alternative to the transsacral or transabdominal approach, with subsequent shorter hospital stay and fewer complications.

Endorectal magnetic resonance imaging of a rectal duplication cyst.

A case of a duplication cyst of the rectum is presented. This case highlights the potential role of endoluminal magnetic resonance imaging in the diagnosis of this uncommon condition. Alternative imaging modalities and differential diagnoses are discussed.