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2.
Artigo em Inglês | MEDLINE | ID: mdl-34988641

RESUMO

PURPOSE: Evidence-based management of positive pathological circumferential resection margin (pCRM) following preoperative radiation and an adequate rectal resection for rectal cancers is lacking. METHODS: Retrospective analysis of prospectively maintained single-centre institutional database was done to study the patterns of failure and management strategies after a rectal cancer surgery with a positive pCRM. RESULTS: A total of 86 patients with rectal adenocarcinoma with a positive pCRM were identified over 8 years (2011-2018). Majority had low-lying rectal cancers (90.7%) and were operated after preoperative radiotherapy (95.3%). Operative procedures included abdomino-perineal resections, inter-sphincteric resections, low anterior resections and pelvic exenteration in 61 (70.9%), 9 (10.5%), 11(12.8%) and 5 (5.8%) patients respectively. A total of 83 (96.5%) received chemotherapy as the sole adjuvant treatment modality while 2 patients (2.3%) were given post-operative radiotherapy and 1 patient underwent revision surgery. A total of 53 patients (61.6%) had recurrence, with 16 (18.6%), 20 (23.2%), 8(9.3%) and 9 (10.5%) patients having locoregional, systemic, peritoneal and simultaneous local-systemic relapse. Systemic recurrences were more often detected either by surveillance in an asymptomatic patient (20.1%) while local (13.1%) and peritoneal (13.2%) recurrences were more often symptomatic (p = 0.000). The 2-year overall survival (OS) and disease-free survival (DFS) of the cohort was 82.4% and 74.0%. Median local recurrence-free survival (LRFS) was 10.3 months. CONCLUSIONS: Patients with a positive pCRM have high local and distal relapse rates. Systemic relapses are more often asymptomatic as compared to peritoneal or locoregional relapse and detected on follow-up surveillance. Hence, identification of such recurrences while still salvageable via an intensive surveillance protocol is desirable.

3.
ANZ J Surg ; 2021 Dec 05.
Artigo em Inglês | MEDLINE | ID: mdl-34866308

RESUMO

BACKGROUND: Comparative bowel functional outcomes between ultralow anterior resections (ULAR) and inter-sphincteric resection (ISR) for similar tumour and patient characteristics is not known. METHODS: Single centre study of low rectal caners (<5cm from anal verge) with 1:1 propensity matching of age, sex, body mass index, prior radiation, and surgical approach (open vs. minimally invasive) was performed for the ULAR and ISR groups. Primary outcome measure was Wexner Incontinence scores and Low Anterior Resection Syndrome (LARS) score at a single time point after stoma reversal. RESULTS: Seventy-two matched patients were included. Median Wexner scores were five and eight for the ULAR and ISR cohorts (p = 0.006). Major incontinence (Wexner >11) was found in 5.6% versus 33% after ULAR and ISR, respectively. Major LARS (score > 29) was demonstrated in 11% versus 25% in ULAR versus ISR (p = 0.293). Majority in both groups has no LARS (score < 20), that is, 72.2% versus 63.9% in ULAR against ISR. Besides these, stool fragmentation (p < 0.001), nocturnal defecation (p < 0.001) and use of anti-diarrhoeal medications (p = 0.023) were significantly more after ISR. CONCLUSIONS: Bowel continence was relatively inferior after ISR as compared to an ULAR for low rectal cancers in matched cohorts. Major LARS in ISR was twice as prevalent without statistical differences.

4.
Colorectal Dis ; 2021 Dec 03.
Artigo em Inglês | MEDLINE | ID: mdl-34860464

RESUMO

Lateral lymph node dissection is a critical part of the armamentarium in the treatment of pelvic malignancy. In recent years there seems to be a greater acceptance of lateral pelvic lymph node dissection as a treatment modality for remnant nodes following chemoradiation. The lateral lymph node dissection presents a unique challenge of performing surgery in a compact space with a high risk of intraoperative as well as post-operative complications such as bleeding, nerve injury and post-operative lymph oedema as well as urogenital deficits. Here we present a step by step demonstration of lateral pelvic lymph node dissection in a case of rectal cancer.

5.
Eur J Surg Oncol ; 2021 Dec 05.
Artigo em Inglês | MEDLINE | ID: mdl-34893365

RESUMO

INTRODUCTION: Lateral pelvic lymph node dissection (LPLND) is a technically challenging procedure and its learning curve has not been analysed against an oncologically relevant outcome. The purpose of the study was to determine the learning curve for LPLND in rectal cancers using nodal retrieval as performance measure. METHODS: Consecutive LPLND for rectal adenocarcinomas from a single institution were retrospectively analysed. Cumulative sum (CUSUM) control charts were used to detect difference in performance with respect to lymph node yield. Negative binomial regression was used to determine factors influencing nodal harvest using Incidence Risk Ratios (IRR). Separate CUSUM curves were generated for open and minimally invasive surgeries (MIS). RESULTS: One-hundred and twenty patients were included and all received preoperative radiation. MIS was used in 53.3%. Median lymph node yield was 6 with 20% nodal positivity. Increasing experience (IRR - 1.196) and MIS (IRR - 1.586) were the only factors that influenced nodal harvest. CUSUM charts revealed that learning curve was achieved after the 83rd case overall and after the 19 operations in MIS. There was a 20% increase in nodal yield after every 30 MIS LPLND performed. CONCLUSIONS: Learning curve for LPLND is relatively long and only increasing experience and minimally invasive operations increased nodal yield.

6.
Surgery ; 2021 Dec 15.
Artigo em Inglês | MEDLINE | ID: mdl-34922745

RESUMO

BACKGROUND: Neoadjuvant therapy (NAT) is increasingly being used in the management of borderline resectable pancreatic cancer (BRPC). We compared the outcomes of patients with BRPC treated either with upfront surgery (UPS) or NAT to assess whether increased use of NAT has helped improve perioperative and long-term outcomes. METHODS: Prospectively maintained database of 201 consecutive patients with BRPC treated at Tata Memorial Center, India, from 2007-2019 was analyzed. RESULTS: NAT was offered to 148 patients and 53 were planned for UPS. Progression on NAT was seen in 47 (31.8%) patients. Resection was performed in 103 patients (51.24%). The resection rate was significantly lower after NAT as compared with upfront explorations (42.56% vs 75.47%, P = .00) however, R0 resection rate after NAT was significantly better (74.6% vs 42.5%, P = .001). NAT group showed a significant decrease in the pT stage (P = .004), node positivity (60%-31.7%, P = .005%), and perineural invasion (70%-41.6% P = .026). There was no significant difference in the median overall survival (OS) of patients offered NAT versus UPS on an intention-to-treat basis (15 vs 18 months P = .431). However, OS (22 vs 19 months, P = .205) and disease-free survival (DFS) (16 vs 11 months, P = .135) were higher for resected patients in the NAT group and OS was significantly superior in patients completing the course of treatment (34 vs 22 months, P = .010) CONCLUSION: The progression rate with NAT in patients with BPRC was 31.8%. NAT was associated with significant pathologic downstaging, improvement in R0 resection rate, and survival in resected patients.

8.
J Surg Oncol ; 2021 Nov 03.
Artigo em Inglês | MEDLINE | ID: mdl-34729779

RESUMO

BACKGROUND AND OBJECTIVES: There are reports of outcomes of elective major cancer surgery during the COVID-19 pandemic. We evaluated if reinforcement of hand hygiene, universal masking, and distancing as a part of pandemic precautions led to a decrease in the incidence of surgical site infections (SSIs) in major oncologic resections. METHODS: Propensity score matching using the nearest neighbor algorithm was performed on 3123 patients over seven covariates (age, comorbidities, surgery duration, prior treatment, disease stage, reconstruction, and surgical wound type) yielding 2614 matched (pre-COVID 1612 and COVID 1002) patients. Conditional logistic regression was used to identify if SSI incidence was lower amongst patients operated during the pandemic. RESULTS: There was a 4.2% (p = 0.006) decrease in SSI in patients operated during the pandemic. On multivariate regression, surgery during the COVID-19 period (odds ratio [OR] = 0.77; 95% confidence interval [CI] = 0.61-0.98; p = 0.03), prior chemoradiation (OR = 2.46; CI = 1.45-4.17; p < 0.001), duration of surgery >4 h (OR = 2.17; 95%CI = 1.55-3.05; p < 0.001) and clean contaminated wounds (OR = 2.50; 95% CI = 1.09-2.18; p = 0.012) were significantly associated with SSI. CONCLUSION: Increased compliance with hand hygiene, near-universal mask usage, and social distancing during the COVID-19 pandemic possibly led to a 23% decreased odds of SSI in major oncologic resections. Extending these low-cost interventions in the post-pandemic era can decrease morbidity associated with SSI in cancer surgery.

9.
Artigo em Inglês | MEDLINE | ID: mdl-34654962

RESUMO

INTRODUCTION: The management of patients with elevated CEA after curative treatment of colorectal cancers without structural disease is uncertain. The aim was to study the clinical risk factors, CEA thresholds, and kinetics that could predict relapses. METHODS: Retrospective study of colorectal cancers patients that were detected to have an elevated CEA (> 5 ng/ml on 2 separate occasions) and normal clinical exam, colonoscopy, and positron emission tomography (PET). Receiver operating characteristic (ROC) curves were generated to determine the optimal cutoff for absolute CEA values and proportional rise that could predict recurrences. RESULTS: 162 patients were followed for a median of 42 months. 32 patients (19.7%) relapsed of which 11 (34.4%) had a peritoneal disease. Besides known clinical risk factors, higher CEA at the time of negative PET and rising CEA trend predicted disease recurrence on multivariate logistic regression. CEA threshold of 10.05 ng/ml provided a sensitivity/specificity of 53%/86.2%, while CEA velocity of 1.36 ng/ml over 3 months presented a sensitivity/specificity of 80%/70.6% for subsequent relapse. CONCLUSIONS: The discriminatory value of CEA kinetics was more than that of a single absolute value. An algorithm for managing these patients based on clinical risk factors, absolute CEA value, and its kinetics is suggested.

10.
Colorectal Dis ; 2021 Oct 30.
Artigo em Inglês | MEDLINE | ID: mdl-34716986

RESUMO

AIM: The outcome of radical surgery in nonmetastatic anorectal melanoma (AM) patients is studied infrequently. Here, we aimed to explore the stage-wise outcomes and the impact of radical resections in these patients. METHODS: In this single-centre retrospective study, data of 154 eligible patients were recorded and analysed. Data were obtained from November 2010 to September 2019 with follow-up until November 2020. Overall survival (OS) and disease-free survival (DFS) was calculated by Kaplan Meir method and univariate analysis of prognostic factors by Cox regression. RESULTS: Of 154 patients, 110 were metastatic (stage III) and 44 were nonmetastatic (stage I:22, stage II:22) and underwent curative resections. Median follow-up was 48 months (14-119 months). A total of 39 patients underwent total mesorectal excisions (TME) and five transanal excision (TAE) were performed. Seven patients underwent extended resections. Stage I and II patients had 3- and 5-year OS of 40% and 36%; and DFS of 45% and 33.2%, respectively. Median OS and DFS were 31 and 24 months, respectively. Stage II (node-positive) patients had better median OS compared to stage III (21 vs. 4 months; p = 0.000), and 54.5% patients had recurrences, most commonly both systemic and nodal (45.83%). Median OS of patients without recurrence was 34 months. CONCLUSION: In this large surgical series of AMs, outcome in stage I and II patients was significantly better than stage III and patients with stage II disease can have acceptable oncological outcomes. Radical surgical resections with or without lymphadenectomy could be considered in these patients. The role of adjuvant systemic therapy and radiation needs to be explored as part of multimodality treatment.

11.
Front Oncol ; 11: 710585, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34568037

RESUMO

Background: Treatment of malignant melanoma has undergone a paradigm shift with the advent of immune checkpoint inhibitors (ICI) and targeted therapies. However, access to ICI is limited in low-middle income countries (LMICs). Patients and Methods: Histologically confirmed malignant melanoma cases registered from 2013 to 2019 were analysed for pattern of care, safety, and efficacy of systemic therapies (ST). Results: There were 659 patients with a median age of 53 (range 44-63) years; 58.9% were males; 55.2% were mucosal melanomas. Most common primary sites were extremities (36.6%) and anorectum (31.4%). Nearly 10.8% of the metastatic cohort were BRAF mutated. Among 368 non-metastatic patients (172 prior treated, 185 de novo, and 11 unresectable), with a median follow-up of 26 months (0-83 months), median EFS and OS were 29.5 (95% CI: 22-40) and 33.3 (95% CI: 29.5-41.2) months, respectively. In the metastatic cohort, with a median follow up of 24 (0-85) months, the median EFS for BSC was 3.1 (95% CI 1.9-4.8) months versus 3.98 (95% CI 3.2-4.7) months with any ST (HR: 0.69, 95% CI: 0.52-0.92; P = 0.011). The median OS was 3.9 (95% CI 3.3-6.4) months for BSC alone versus 12.0 (95% CI 10.5-15.1) months in any ST (HR: 0.38, 95% CI: 0.28-0.50; P < 0.001). The disease control rate was 51.55%. Commonest grade 3-4 toxicity was anemia with chemotherapy (9.5%) and ICI (8.8%). In multivariate analysis, any ST received had a better prognostic impact in the metastatic cohort. Conclusions: Large real-world data reflects the treatment patterns adopted in LMIC for melanomas and poor access to expensive, standard of care therapies. Other systemic therapies provide meaningful clinical benefit and are worth exploring especially when the standard therapies are challenging to administer.

13.
J Surg Oncol ; 124(8): 1417-1430, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-34351625

RESUMO

INTRODUCTION: The results of total neoadjuvant therapy (TNT) for locally advanced rectal cancers (LARC) cannot be extrapolated to signet-ring cell cancers (SRCC) that have an extremely aggressive biology. METHODS: A retrospective study comparing long course chemoradiation (CTRT) against short course radiation (SCRT) and 12 weeks of chemotherapy for high-risk LARC. Primary endpoints were treatment failure and disease-free survival (DFS) RESULTS: CTRT was given to 74 (59.7%) and SCRT/Chemotherapy to 50 patients (40.3%). Additional chemotherapy was required in 54.1% and 28%, respectively. Except for nodal staging, no other MRI parameter down-staged. Treatment failures were seen in 33.9% and 25.8% had progression. The peritoneum was the commonest site of progression (59.4%). Of the patients that were surgically explored, 63.7% had R0 resections and pathological complete response was seen in 9.7%. At a median follow-up of 35 months, 56.5% had DFS events with a 3-year DFS of 39.5%. Recurrences were noted in 45.1% after curative resections and the 3-year OS/DFS of these patients were 67.2%/56.4%. On multivariate regression, the type of preoperative therapy did not influence treatment failures or DFS. CONCLUSIONS: SRCC is a very aggressive disease and none of the treatment strategies could show superiority over the other with very high peritoneal progression rates and relapses.


Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Carcinoma de Células em Anel de Sinete/tratamento farmacológico , Terapia Neoadjuvante/métodos , Terapia Neoadjuvante/normas , Neoplasias Retais/tratamento farmacológico , Adulto , Carcinoma de Células em Anel de Sinete/patologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Neoplasias Retais/patologia , Estudos Retrospectivos , Taxa de Sobrevida
14.
Langenbecks Arch Surg ; 406(6): 1763-1774, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34341869

RESUMO

Extended and beyond total mesorectal excisions (TME) for advanced and recurrent rectal cancers are increasingly performed with acceptable oncological and functional outcomes. These are undoubtedly due to better understanding of tumor biology and improved patient selection rather than surgical valor and technical refinements alone. In the present review, we attempt to present the current surgical standards for advanced and recurrent cancers requiring surgery outside the TME planes based on involved pelvic compartments. The available procedures, their indications, and extent of resection and reconstruction are highlighted. Emphasis is on formation of dedicated exenteration teams, structured training, and referral systems that increase hospital and surgeon volume to improve patient outcomes and reduce morbidity. Areas of deficiencies in literature were recognized with regards to factors influencing recurrences, patient selection, and quality of life. Finally, the most appropriate preoperative therapy for these tumors is unclear in both the primary and recurrent settings.


Assuntos
Exenteração Pélvica , Neoplasias Retais , Humanos , Recidiva Local de Neoplasia/cirurgia , Qualidade de Vida , Neoplasias Retais/cirurgia , Reto
15.
ANZ J Surg ; 91(11): 2475-2481, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-34427027

RESUMO

BACKGROUND: The safety of inter-sphincteric resection (ISR) for low rectal cancer with adverse histologic subtypes has been incompletely studied. The present study aims at determining the risk of local recurrence with this procedure in poorly differentiated and signet ring cell (PDSR) adenocarcinoma. METHODS: Retrospective analysis from a single tertiary cancer centre of non-metastatic primary rectal cancer <6 cm from the anal verge that underwent ISR. Competing risk analysis and sub-distribution hazard ratios for local recurrence free survivals were calculated to determine factors that influenced local recurrence with the competing risk of death from any cause to overcome the exceeding risk of distant metastasis associated with adverse histologic types. RESULTS: One hundred forty-two patients underwent ISR and 22.6% has PDSR histology. At a median follow up of 61 months, 15.6% of the PDSR cohort developed local recurrence (five patients) compared to 11.7% in the non-PDSR group. PDSR histology influenced overall and disease free survival but not local recurrence on cox regression. On competing risk analysis, only ypT stage ≥3 predicted worse local recurrence free survival and not histology. CONCLUSIONS: The presence of PDSR histology did not increase the risk of local recurrence after ISR in this retrospective competing risk analysis.


Assuntos
Recidiva Local de Neoplasia , Neoplasias Retais , Canal Anal , Humanos , Recidiva Local de Neoplasia/epidemiologia , Neoplasias Retais/cirurgia , Reto , Estudos Retrospectivos , Medição de Risco , Resultado do Tratamento
16.
Abdom Radiol (NY) ; 46(12): 5536-5549, 2021 12.
Artigo em Inglês | MEDLINE | ID: mdl-34427742

RESUMO

PURPOSE: Signet Ring Rectal Cancer (SRRC) of rectum is rare high-grade subtype with poor prognosis and characteristic histopathology. We evaluated its imaging appearance and correlated its outcomes. MATERIALS AND METHODS: We conducted a retrospective review of the rectal MRIs of 97 patients with rectal SRRC, evaluating tumor morphology, T2 signal, length, location, pattern of tumor growth, nodal status and location, EMVI (extramural vascular invasion), site of metastases, and response to chemotherapy. The tumor signal on T2W images was categorized into intermediate, T2 hyperintense, and fluid/mucin bright. Imaging findings were correlated with risk of metastatic/ recurrent disease, disease-free survival, and overall survival. RESULTS: The median age of patients of SRRC in our study was 35 years and more frequently found in male patients. The common imaging features of SRRC were T2-hyperintense signal (63%), infiltrative growth pattern (76%), positive MR CRM (Circumferential Resection Margin on MRI) (84%), presence of EMVI (51%), and advanced T and N stage (97% and 84%, respectively). Peritoneum and nodes were the most common sites of metastases. Raised serum CEA (Carcino-embryonic Antigen) levels, positive MR CRM status, extramesorectal adenopathy, and advanced N stage had statistically significant predictive value for recurrence or metastases. Elevated serum CEA levels (p = 0.019) and intermediate T2 signal (p = 0.012) demonstrated significant independent association with poor overall survival, while advanced N stage (p = 0.033) demonstrated significant independent association with worse disease-free survival in multivariate analysis. CONCLUSION: SRRC affected young patients and demonstrated T2-hyperintense signal and subepithelial spread in an infiltrative pattern. Elevated CEA levels and T2-intermediate signal intensity are independent predictors for worse overall survival and advanced nodal stage is independent prognostic factor of poor disease-free survival. MRI rectum can pinpoint the pathology given the distinct MRI morphology and age of presentation.


Assuntos
Neoplasias Retais , Reto , Adulto , Humanos , Imageamento por Ressonância Magnética , Masculino , Invasividade Neoplásica/patologia , Recidiva Local de Neoplasia/diagnóstico por imagem , Estadiamento de Neoplasias , Prognóstico , Neoplasias Retais/diagnóstico por imagem , Neoplasias Retais/patologia , Reto/patologia , Estudos Retrospectivos
17.
Indian J Surg Oncol ; 12(2): 241-245, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-34295065

RESUMO

An ideal method of perineal closure after resection for low rectal cancer surgery is a topic of debate. Morbidity associated with primary perineal closure due to wound break down delays recovery from surgery and adjuvant treatment with poor oncological outcome at the end. Herewith, we present our experience with V-Y gluteal advancement fasciocutaneous flap done for 131 patients for reconstruction of perineal and pelvic defect. With our experience, this is a safe and simple method with an acceptable complication rate that can be practiced by colorectal surgeons, even in the absence of a dedicated plastic surgery team.

20.
Langenbecks Arch Surg ; 406(3): 821-831, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33733285

RESUMO

PURPOSE: The aim was to evaluate the oncological outcomes and the prognostic factors following pelvic exenteration (PE) in cT4 and fixed cT3 stage primary rectal adenocarcinoma and to study the impact of consolidation chemotherapy following neoadjuvant concurrent chemoradiotherapy (NACRT). METHODS: A retrospective analysis of a prospectively maintained database of PE from 2013 to 2018. RESULTS: Out of 2900 colorectal resections, there were 131 pelvic exenterations that were performed, and 100 of these patients had undergone exenteration for primary rectal adenocarcinoma. Of these 100 patients, there were 81 patients who had received NACRT followed by surgery, 50 of whom who had received consolidation chemotherapy and 31 who had undergone surgery without consolidation chemotherapy. R0 resection was achieved in 90% cases. At a median follow-up of 32 months, 2-year disease free survival was 61.8% and estimated 5-year overall survival was 62%. The incidence of distant metastases was 44% vs. 19% (p = 0.023), and the 2-year distant recurrence-free survival was 58% vs. 89% (p = 0.025), respectively, in the 'consolidation chemotherapy group' and the 'no chemotherapy group'. The poorly differentiated grade of tumours, presence of lympho-vascular-invasion, consolidation chemotherapy, and disease recurrence were all found to affect the survival. CONCLUSION: PE with R0 resection achieves excellent survival rates in cT4 and fixed cT3 stage primary rectal adenocarcinoma. The distant recurrence rate may not be altered by consolidation chemotherapy in the subset of high-risk patients. However, further research on consolidation chemotherapy following NACRT in cT4 and fixed cT3 stage primary rectal adenocarcinoma will give a definite answer in the future.


Assuntos
Adenocarcinoma , Neoplasias Retais , Adenocarcinoma/patologia , Adenocarcinoma/terapia , Quimiorradioterapia , Quimioterapia de Consolidação , Intervalo Livre de Doença , Humanos , Terapia Neoadjuvante , Recidiva Local de Neoplasia/terapia , Estadiamento de Neoplasias , Neoplasias Retais/patologia , Neoplasias Retais/terapia , Estudos Retrospectivos , Resultado do Tratamento
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