Locally Recurrent Rectal Cancer: Toward a Second Chance at Cure? A Population-Based, Retrospective Cohort Study.

BACKGROUND: In current practice, rates of locally recurrent rectal cancer (LRRC) are low due to the use of the total mesorectal excision (TME) in combination with various neoadjuvant treatment strategies. However, the literature on LRRC mainly consists of single- and multicenter retrospective cohort studies, which are prone to selection bias. The aim of this study is to provide a nationwide, population-based overview of LRRC after TME in the Netherlands. PATIENTS AND METHODS: In total, 1431 patients with nonmetastasized primary rectal cancer diagnosed in the first six months of 2015 and treated with TME were included from the nationwide, population-based Netherlands Cancer Registry. Data on disease recurrence were collected for patients diagnosed in these 6 months only. Competing risk cumulative incidence, competing risk regression, and Kaplan-Meier analyses were performed to assess incidence, risk factors, treatment, and overall survival (OS) of LRRC. RESULTS: Three-year cumulative incidence of LRRC was 6.4%; synchronous distant metastases (LRRC-M1) were present in 44.9% of patients with LRRC. Distal localization, R1-2 margin, (y)pT3-4, and (y)pN1-2 were associated with an increased LRRC rate. No differences in LRRC treatment and OS were found between patients who had been treated with or without prior n(C)RT. Curative-intent treatment was given to 42.9% of patients with LRRC, and 3-year OS thereafter was 70%. CONCLUSIONS: Nationwide LRRC incidence was low. A high proportion of patients with LRRC underwent curative-intent treatment, and OS of this group was high in comparison with previous studies. Additionally, n(C)RT for primary rectal cancer was not associated with differences in treatment and OS of LRRC.

Locoregionally Recurrent Colon Cancer: How Far Have We Come? A Population-Based, Retrospective Cohort Study.

BACKGROUND: The reported outcomes of locoregionally recurrent colon cancer (LRCC) are poor, but the literature about LRCC is scarce and aged. Recent population-based studies to provide current insight into LRCC are warranted. This study aimed to provide an overview of the incidence, risk factors, treatment, and overall survival (OS) of patients with LRCC after curative resection of stage I-III primary colon cancer. METHODS: Data on disease recurrence were collected for all patients with a diagnosis of non-metastasized primary colon cancer in the Netherlands during the first 6 months of 2015. Patients who underwent surgical resection (N = 3544) were included in this study. The 3-year cumulative incidence, risk factors, treatment, and OS for patients with LRCC were determined. RESULTS: The 3-year cumulative incidence of LRCC was 3.8%. Synchronous distant metastases (LRCC-M1) were diagnosed in 62.7% of the patients. The risk factors for LRCC were age of 70 years or older, pT4, pN1-2, and R1-2. Adjuvant chemotherapy was associated with a decreased risk of LRCC for high-risk stage II and stage III patients [hazard ratio (HR), 0.47; 95% confidence interval (CI) 0.31-0.93]. The median OS for the patients with LRCC was 13.1 months (95% CI 9.1-18.3 months). Curative-intent treatment was given to 22.4% of the LRCC patients, and the subsequent 3 years OS was 71% (95% CI 58-87%). The patients treated with palliative treatment and best supportive care showed 3-year OS rates of 15% (95% CI 7.0-31%) and 3.7% (95% CI 1.0-14%), respectively. CONCLUSIONS: The cumulative incidence of LRCC was low, and adjuvant chemotherapy was associated with a decreased risk for LRCC among targeted patients. Curative-intent treatment was given to nearly 1 in 4 LRCC patients, and the OS for this group was high.

Reducing Acquisition Time of Diffusion Weighted MR Imaging of the Rectum with Simultaneous Multi-Slice Acquisition: A Reader Study.

RATIONALE AND OBJECTIVES: To assess the acquisition time and image quality of simultaneous multislice-accelerated diffusion-weighted imaging (SMS-DWI) versus conventional DWI (C-DWI) of the rectum. MATERIALS AND METHODS: In patients scheduled for a magnetic resonance imaging of the rectum, both SMS-DWI and C-DWI were performed on a 3T whole body magnetic resonance scanner. Image quality of the DWI sequences was reviewed by two independent radiologists who were blinded to the method of imaging using a five-point Likert scale: (score ranging from 1 (non-diagnostic) to 5 (excellent). The mean scores of SMS-DWI versus C-DWI were compared for the individual readers using a nonparametric test (Wilcoxon signed ranks). RESULTS: The SMS-DWI protocol acquisition time was 4:08 min vs. 7:24 min per patient, which led to a reduction of 44.1% for the C-DWI protocol, both excluding time for sequence specific adjustments (shimming). No statistical differences between the conventional-, and SMS- diffusion weighted images were seen for both readers. Mean overall image quality of the SMS-DWI TRACE images was 3.5 (SD: 1.3) and 3.3 (SD: 1.0) for reader 1 and reader 2, respectively. Mean overall image quality of the C-DWI TRACE images was 3.4 (SD: 1.3) and 3.2 (SD: 1.1) for reader 1 and reader 2, respectively. CONCLUSION: Optimized SMS-DWI compared to C-DWI in imaging of the rectum showed similar image quality while a significant acquisition time reduction was achieved.

Poor response at restaging MRI and high incomplete resection rates of locally advanced mucinous rectal cancer after chemoradiation therapy.

AIM: Mucinous carcinoma is a histological subtype of rectal cancer and has been associated with a poor response to neoadjuvant chemoradiotherapy (CRT). The primary aim of this study was to analyse the response on MRI of mucinous locally advanced rectal cancer (LARC) after CRT compared to regular adenocarcinoma. METHOD: Patients with LARC (defined as cT4 and/or cN2), who underwent CRT followed by restaging MRI and surgery in two tertiary referral hospitals were retrospectively included in the study. Pre- and post-treatment MRI was reviewed by an experienced abdominal radiologist. RESULTS: A total of 102 patients, of whom 29 were diagnosed with mucinous carcinoma, were included for analysis. At restaging MRI, adenocarcinoma patients demonstrated significantly less clinical involvement of the mesorectal fascia (37% vs. 62%, P = 0.003) while this was not demonstrated in mucinous carcinoma patients (86% vs. 97%, P = 0.16). Significant downstaging after CRT in adenocarcinoma patients (P = 0.01) was seen while, in mucinous carcinoma patients, no downstaging after CRT (P = 0.89) was seen. Pathology revealed significantly higher rates of an involved circumferential resection margin in mucinous carcinoma versus adenocarcinoma patients (27.6% vs. 1.4%; P < 0.001). After multivariate regression analysis, mucinous carcinoma remained an independent prognostic factor for local recurrence (hazard ratio 3.6; 95% CI 1.1-12.4), although no differences in overall or disease-free survival were observed. CONCLUSION: Mucinous rectal carcinoma is associated with a poor clinical response at restaging MRI after CRT, leading to relatively higher rates of involved circumferential resection margins at pathology. In this cohort, mucinous carcinoma seems to be a prognostic factor for increased risk of local recurrence, without an effect on overall survival.

The immediate impact of the coronavirus disease 2019 (COVID-19) pandemic on burn-out, work-engagement, and surgical training in the Netherlands.

BACKGROUND: The coronavirus disease 2019 pandemic led to major changes in health care and education options for all health care employees. The aim of this study is to achieve insight into coronavirus disease-care participation of surgical residents in the Netherlands, the impact of coronavirus disease 2019 on the experienced quality of surgical training, and the influence on Burn-out and Work Engagement compared with the non-coronavirus disease 2019 period in January 2020. METHODS: In this study, we have conducted 2 digital surveys immediately before and 2 months after the start of the coronavirus disease 2019 pandemic. We surveyed a validated Dutch questionnaire 'Utrecht Burn-out Scale,' derived from the Maslach Burn-out Inventory, and also collected the 'Utrecht Work Engagement Scale' measuring work engagement. Additionally, we describe the coronavirus disease-care participation of surgical residents, the impact on how they experienced the quality of their surgical training, and the influence on 'Burn-out and Work Engagement' compared with the pre-coronavirus disease 2019 period for surgical residents in the Netherlands. RESULTS: In January 2020, a total of 317 residents completed the online survey, and in April 2020, a total of 313 residents completed the online survey. Of the responders, 48.6%, in April, participated in coronavirus disease-care in both the coronavirus disease ward as well as the coronavirus disease intensive care unit. Residents experienced that the coronavirus disease 2019 influenced their surgical training in 85.2% of responders. In only 5% of the residents did the pandemic not affect the exposure to surgical training in the operating theater. More burn-out symptoms were noted amongst coronavirus disease ward deployed residents versus no coronavirus disease ward deployment, (16.0% vs 7.6%, P = .06). The Work-Engagement questionnaire showed a significantly lower work engagement score of 4.2 for residents who were deployed in a coronavirus disease-care intensive care unit versus a score of 4.6 for residents scheduled in a coronavirus disease ward (P = .02). CONCLUSION: This study shows a significant impact of the first months of the coronavirus disease 2019 pandemic on the Dutch surgical trainee program, with a major redistribution of residents with a decrease of surgical exposure and education. We emphasize the need for adequate guidance of all surgical residents and potentially lengthening the surgical training program.

Long-term Outcomes After Surgery Involving the Pelvic Floor in Rectal Cancer: Physical Activity, Quality of Life, and Health Status.

PURPOSE: This study has aimed to evaluate the effects of surgery on physical activity (PA), quality of life (QoL), and disease-specific health status, by analyzing the differences between sphincter-preserving surgery (low anterior resection (LAR)) and abdominoperineal resection (APR) among rectal cancer survivors. METHODS: Individuals who were diagnosed with rectal cancer and who underwent an APR or a LAR between 2000 and 2009 were included. The different questionnaires on QoL, disease-specific health status, and physical activity began their surveys in 2010. Differences in QoL, health status, and physical activity were analyzed between the APR group and the LAR group. RESULTS: The study included 905 rectal cancer survivors (LAR, 632; APR, 273). Besides a higher rate of radiotherapy treatment in the APR group (94% vs. 75%, p < 0.001), there were no differences in clinical characteristics or in comorbid conditions between the LAR group and APR group. No significant differences were found in PA level between the patients who had undergone an APR vs. a LAR. Regarding QoL, APR patients did report a worse physical (p = 0.009) and role functioning (p = 0.03), as well as a worse body image (p = 0.001), compared to patients who had undergone a LAR. However, they reported fewer constipation (p = 0.02) and gastrointestinal problems (p = 0.009). Finally, compared to patients who had undergone a LAR with a permanent ostomy, APR patients reported a better body image (p = 0.048) and less stoma-related problems (p = 0.001). CONCLUSIONS: This study showed no differences in PA level among the patients who had undergone an APR versus a LAR. With respect to their QoL, their physical and role functioning seemed to be worse in the APR patients. However, these differences in outcomes resolved when comparing the APR group with patients after a LAR with a permanent ostomy.