Robotic versus open and laparoscopic pelvic exenterations for pelvic cancer: a multicenter propensity-matched analysis in Japan.

BACKGROUND: Pelvic exenteration (PE) is the last resort for achieving a complete cure for pelvic cancer; however, it is burdensome for patients. Minimally invasive surgeries, including robot-assisted surgery, have been widely used to treat malignant tumors and have also recently been used in PE. This study aimed to evaluate the safety and efficacy of robot-assisted PE (RPE) by comparing the outcomes of open PE (OPE) with those of conventional laparoscopic PE (LPE) for treating pelvic tumors. METHODS: Following the ethics committee approval, a multicenter retrospective analysis of patients who underwent pelvic exenteration between January 2012 and October 2022 was conducted. Data on patient demographics, tumor characteristics, and perioperative outcomes were collected. A 1:1 propensity score-matched analysis was performed to minimize group selection bias. RESULTS: In total, 261 patients met the study criteria, of whom 61 underwent RPE, 90 underwent OPE, and 110 underwent LPE. After propensity score matching, 50 pairs were created for RPE and OPE and 59 for RPE and LPE. RPE was associated with significantly less blood loss (RPE vs. OPE: 408 mL vs. 2385 ml, p < 0.001), lower transfusion rate (RPE vs. OPE: 32% vs. 82%, p < 0.001), and lower rate of complications over Clavien-Dindo grade II (RPE vs. OPE: 48% vs. 74%, p = 0.013; RPE vs. LPE: 48% vs. 76%, p = 0.002). CONCLUSION: This multicenter study suggests that RPE reduces blood loss and transfusion compared with OPE and has a lower rate of complications compared with OPE and LPE in patients with locally advanced and recurrent pelvic tumors.

Risk factors for and longitudinal course of male sexual dysfunction after robotic rectal cancer surgery.

AIM: The aim of this work was to investigate the risk factors associated with the incidence of sexual dysfunction in patients who underwent robot-assisted surgery with several treatment options, such as neoadjuvant chemoradiotherapy and lateral lymph node dissection, and clarify the longitudinal course of erectile function in risk groups. METHOD: A total of 203 male patients who underwent robot-assisted total mesorectal excision for rectal cancer between 2013 and 2019 were included. The risk factors for erectile and ejaculatory dysfunction as well as the longitudinal course of erectile function were retrospectively investigated in all cohorts and several risk groups, including those who underwent neoadjuvant chemoradiotherapy, lateral lymph node dissection and adjuvant chemotherapy. Erectile dysfunction was assessed using the International Index of Erectile Function and ejaculatory dysfunction was assessed using original questions. The survey was performed preoperatively and at 3, 6 and 12 months postoperatively. RESULTS: Erectile and ejaculatory dysfunction occurred in 46.8% and 15.7% of the patients, respectively. Multivariate analysis showed that neoadjuvant chemoradiotherapy was an independent risk factor for erectile dysfunction. Erectile function recovered longitudinally to the preoperative level overall, as well as in lateral lymph node dissection and postoperative adjuvant chemotherapy subgroups; however, recovery was poor in the neoadjuvant chemoradiotherapy group, even at 12 months postoperatively. CONCLUSION: Neoadjuvant chemoradiotherapy was found to be a risk factor for erectile dysfunction after robot-assisted surgery for rectal cancer. Erectile function recovered postoperatively in patients undergoing lateral lymph node dissection; however, those receiving neoadjuvant chemoradiotherapy showed poor recovery, even at 12 months postoperatively.

Robotic surgery for clinical T4 rectal cancer: short- and long-term outcomes.

BACKGROUND: The optimal surgical approach for clinical T4 (cT4) rectal cancer is unknown. This study was conducted to clarify short- and long-term outcomes of robotic surgery for cT4 rectal cancer. METHODS: In our retrospective cohort study, we enrolled patients who underwent robotic surgery for cT4 rectal cancer within 15 cm from the anal verge between 2011 and 2018. The short- and long-term outcomes were evaluated. RESULTS: Of a total of 122 eligible patients, 70 (57%) had cT4a tumors and 52 (43%) had cT4b tumors. Thirty-five patients (29%) had distant metastasis and 21 (17%) underwent preoperative chemoradiotherapy. Thirty-four patients (28%) underwent combined resection of adjacent organs and 43 (35%) underwent lateral lymph node dissection. The median operative time was 288 min and the median blood loss was 11 ml. No patients required conversion to open surgery. The incidences of postoperative complications of grades II, III, and IV or more according to the Clavien-Dindo classification were 17.2%, 3.5%, and 0%, respectively. Seventy-three patients (60%) had pathological T4 tumors, and the incidence of positive resection margins was 4.9%. The median follow-up time was 42.9 months. The 3-year overall survival, disease-free survival, and cumulative local recurrence rates were 87.5%, 70.4%, and 4.0%, respectively. CONCLUSIONS: The short- and long-term outcomes of robotic surgery for cT4 rectal cancer were favorable. Robotic surgery is considered to be a useful approach for cT4 rectal cancer.

Neoadjuvant chemoradiotherapy for borderline resectable low rectal cancer: short- and long-term outcomes at a single Japanese center.

PURPOSE: Rectal cancers pose a threat to the mesorectal fascia or invade neighboring structures or organs. Some tumors are potentially resectable but are likely to be positive at the resection margin for cancer involvement and are thus recognized as "borderline resectable (BR)" tumors. This study aimed to clarify the short- and long-term outcomes of neoadjuvant chemoradiotherapy (nCRT) for BR low rectal cancer at a single Japanese center. METHODS: Data of 55 patients, who received nCRT followed by BR low rectal cancer surgery between April 2010 and December 2019, were evaluated for the short-term outcomes. The oncological outcomes of 42 patients who underwent surgery between April 2010 and December 2018 were evaluated. RESULTS: Thirty-six (65.5%) patients had cT4 tumors, and 53 (96.4%) patients had a clinical-stage III or IV. Lateral lymph node dissection was performed in 42 (76.4%) patients. The incidence of severe post-operative complications (Clavien-Dindo grade ≥ III) was 18.2%. Fifty-two (94.5%) patients had a pathological negative resection margin. The 3-year overall survival rate, disease-free survival rate, and cumulative incidence of local recurrence were 100%, 70.3%, and 5.3%, respectively. CONCLUSION: The short- and long-term outcomes of nCRT for BR low rectal cancer were acceptable. In particular, reasonable local control was achieved.

The Eastern Cooperative Oncology Group Performance Status as a prognostic factor of stage I-III colorectal cancer surgery for elderly patients: a multi-institutional retrospective analysis.

PURPOSES: The relationship between the general condition and long-term prognosis in elderly patients with colorectal cancer (CRC) undergoing curative surgery remains unclear. This study investigated the risk factors for poor long-term outcomes in elderly patients with CRC. METHODS: Data of pStage I to III patients with CRC ≥ 80 years old who underwent curative surgery were collected from a multi-institutional database of the Japanese study group for postoperative follow-up of CRC. We retrospectively investigated the poor prognostic factors for the overall survival (OS) and relapse-free survival (RFS). RESULTS: A total of 473 patients with a median age of 83 years were investigated (315, 121, 34, and 3 with an Eastern Cooperative Oncology Group Performance Status [ECOG-PS] 0, 1, 2, and 3, respectively). Multivariate Cox regression analysis showed that ECOG-PS ≥ 2 and positive lymph node metastasis were independently associated with a poor OS (both p < 0.01). Positive lymph node metastasis (p < 0.01) and tumor depth (T3 or T4) (p = 0.02) were independently associated with a poor RFS. In Stages I and II, but not Stage III patients, the OS was significantly worse in those with ECOG-PS ≥ 2 than in those with ECOG-PS ≤ 1. CONCLUSION: Preoperative ECOG-PS was a significant prognostic factor for elderly patients with CRC after curative surgery.

Advantages of robotic abdominoperineal resection compared with laparoscopic surgery: a single-center retrospective study.

PURPOSE: Although robotic surgery for rectal cancer can overcome the shortcomings of laparoscopic surgery, studies focusing on abdominoperineal resection are limited. The aim of this study was to compare the operative outcomes between robotic and laparoscopic abdominoperineal resection. METHODS: This retrospective cohort study was conducted from April 2010 to March 2020. Patients with rectal cancer who underwent robotic or laparoscopic abdominoperineal resection without lateral lymph node dissection were enrolled. The perioperative and oncological outcomes were compared. RESULTS: We evaluated 33 and 20 patients in the robotic and laparoscopic groups, respectively. The median operative time and blood loss were comparable between the two groups. No significant differences in the overall complication rates were noted, whereas the rates of urinary dysfunction (3% vs. 26%, p = 0.02) and perineal wound infection (9% vs. 35%, p = 0.03) in the robotic group were significantly lower in comparison to the laparoscopic group. The median postoperative hospital stay was significantly shorter in the robotic group (8 days vs. 11 days, p < 0.01). The positive resection margin rates were comparable between the two groups. CONCLUSION: Robotic abdominoperineal resection demonstrated better short-term outcomes than laparoscopic surgery, suggesting that it could be a useful approach.

Efficacy of a robotic stapler on symptomatic anastomotic leakage in robotic low anterior resection for rectal cancer.

PURPOSE: Clinical evidence demonstrating risk factors for anastomotic leakage including robotic staplers has remained limited, even though the use of robotic surgery has increased substantially. The purpose of this study was to evaluate the effects of robotic staplers on symptomatic anastomotic leakage in robotic low anterior resection for rectal cancer. METHODS: A total of 427 consecutive patients with primary rectal cancer who underwent robotic low anterior resection without diverting stoma were investigated retrospectively. Symptomatic anastomotic leakage was defined as anastomotic leakage of Clavien-Dindo Grade ≥ II. We compared the symptomatic anastomotic leakage rates between manual and robotic staplers using propensity score matching and investigated the risk factors for symptomatic anastomotic leakage. RESULTS: After propensity score matching, 168 pairs of manual and robotic stapler cases were selected. The symptomatic anastomotic leakage rate was significantly higher for manual staplers (6.5%) than for robotic staplers (1.2%, p = 0.02). In a multivariate analysis, the use of a manual stapler (p = 0.04, OR 4.86, 95% CI 1.08-21.8) and anastomosis < 4 cm from the anal verge (p < 0.01, OR 4.36, 95% CI 1.48-12.9) were identified as independent risk factors for symptomatic anastomotic leakage. CONCLUSIONS: Robotic stapler use was associated with a significantly decreased rate of anastomotic leakage in robotic low anterior resection without diverting stoma for rectal cancer.

Short- and Long-Term Outcomes of Robotic Surgery for Rectal Neuroendocrine Tumor.

Background. The optimal radical surgical approach for rectal neuroendocrine tumor (NET) is unknown. Methods. This study evaluated the short- and long-term outcomes of 27 patients who underwent robotic radical surgery for rectal NET between 2011 and 2019. Results. The median distance from the lower border of the tumor to the anal verge was 5.0 cm. The median tumor size was 9.5 mm. Six patients (22%) had lymph node metastasis. The incidences of postoperative complications of grade II and grade III or more according to the Clavien-Dindo classification were 11% and 0%, respectively. All patients underwent sphincter-preserving surgery, and no patients required conversion to open surgery. The median follow-up time was 48.9 months, and both the 3-year overall survival and relapse-free survival rates were 100%. Conclusions. Short- and long-term outcomes of robotic surgery for rectal NET tumor were favorable. Robotic surgery may be a useful surgical approach for rectal NET.

Minimally invasive surgery for colorectal cancer with persistent descending mesocolon: radiological findings and short-term outcomes.

BACKGROUND: Persistent descending mesocolon (PDM) is typically asymptomatic. However, features such as adhesion and variations in vessel anatomy could affect the surgical techniques for colorectal cancer (CRC). This study aimed to investigate the frequency and radiological features of PDM. Short-term outcomes after conventional laparoscopic surgery (CLS) for CRC with PDM were also investigated to assess the feasibility of CLS and identify strategies for minimally invasive surgery (MIS) in CRC with PDM. METHODS: Patients who underwent MIS, including CLS and robot-assisted laparoscopic surgery (RALS), for left-sided CRC between April 2016 and June 2019, were investigated. PDM was defined as the existence of the right border of the descending colon inside the right border of the left kidney based on preoperative computed tomography findings. RESULTS: Radiological findings of 837 patients were examined, and PDM was found in 19 (2.3%) patients. Radiality of the inferior mesenteric artery (IMA) was found in 5 of 19 (26.3%) PDM cases, which was significantly higher than that in non-PDM cases. The median lengths between the IMA and inferior mesenteric vein (IMV) and between the IMV and descending colon in PDM cases were 14.8 mm and 17.2 mm, respectively, which were significantly shorter than those in non-PDM cases. Short-term outcomes were evaluated only in CLS cases since the rate of hybrid surgery among RALS cases differed between non-PDM and PDM cases (0% vs. 44.4%), which would affect the surgical outcomes. The short-term outcomes in 447 CLS cases were similar between PDM and non-PDM cases. The frequency of extracorporeal division of the left colic artery (LCA) and IMV was significantly higher in PDM than in non-PDM cases (70.0% vs. 5.7%). CONCLUSIONS: This radiological definition of PDM was feasible. CLS for left-sided CRC with PDM was feasible, and dividing the LCA and IMV extracorporeally would be vital for safe surgery.

[Case Report of Long-Term Clinical Efficacy of Paclitaxel plus Bevacizumab Combination Therapy for Stage â £ AdvancedBreast Cancer].

A 50-year-old woman had noted a mass in her right breast 2 years ago but did not consult a hospital. She consulted our hospital because the mass increased in size and also reddened. The tumor measured 10 cm in diameter and was palpable in the whole right breast. A core needle biopsy was performed, and invasive ductal carcinoma was diagnosed. CT showed multiple lung and liver metastases and bone scintigraphy showed bone metastases in a rib. Because the lung and liver metastases were life-threatening, paclitaxel(PTX)chemotherapy was administered weekly. Biomarkers analysis revealed ER(+), PgR(+), HER2(2+), HER2 FISH 1.27, Ki-67 30%, and bevacizumab (Bev) was added from 2 courses. After 4 courses of chemotherapy, the multiple lung and liver metastases were found to be significantly reduced on CT. Toxicities included alopecia, hypertension, and proteinuria. At this time, 3 years after the treatment started, PTX plus Bev combination therapy was also administered.

Morphologic change of the psoas muscle as a surrogate marker of sarcopenia and predictor of complications after colorectal cancer surgery.

PURPOSE: Sarcopenia is reported to be associated with complications after surgery. However, there is no established optimal parameter to determine sarcopenia affecting surgical outcome. This study investigated whether morphologic change of the psoas muscle (MPM) reflects sarcopenia and could be a predictor of complications after colorectal cancer surgery. METHODS: Colorectal cancer patients who underwent primary tumor resection with anastomosis between 2015 and 2016 were analyzed. MPM score was evaluated as the ratio of the short-to-long axis of the psoas muscle in CT images at the L3 vertebrae and classified into five MPM grades. Then, the impact of MPM grade on development of postoperative complications was investigated. RESULTS: A total of 133 patients were studied. MPM score was significantly correlated to the sectional areas of the psoas muscle at the L3 vertebrae which was evaluated by manual tracing. 21.1% of the subjects were classified into severe MPM (defined as MPM grade 3-4). Overall and infectious complications were noted in 37 (27.8%) and 16 (12.0%) patients. Severe MPM (odds ratio [OR] 2.71, 95% confidence interval [CI] 1.09-6.73), longer operative time (OR 1.01, 95%CI 1.001-1.01), and open surgery (OR 2.73, 95%CI 1.17-6.35) were identified as independent risk factors of overall complications. Severe MPM (OR 4.26,95%CI 1.38-13.10) and open surgery (OR 3.42, 95%CI 1.11-10.48) were identified as independent factors associated with infectious complications. CONCLUSIONS: MPM grade may be used as a simple and convenient marker of sarcopenia and to identify patients at increased risk of complications after colorectal cancer surgery.

[Two Cases of Colon Cancer with Severe Liver Dysfunction Due to Multiple Liver Metastases Effectively Treated with Hepatic Arterial Infusion Chemotherapy plus CetuximabFollowed by Systemic Chemotherapy].

Case 1: An 80-year-old man was diagnosed with cecal cancer plus multiple liver metastases and peritoneal disseminations. He underwent surgical resection of the primary tumor to prevent bowel obstruction. Initially, hepatic arterial infusion(HAI) plus cetuximab(Cmab)was administered to reduce the size of the metastatic tumors and prevent liver failure. A partial response(PR)was observed in the liver metastases after 12 courses of treatment and S-1 plus oxaliplatin(SOX)plus bevacizumab was started. Case 2: A 44-year-old man was diagnosed with sigmoid colon cancer with multiple liver, lung and bone metastases, and with obstructive jaundice and cholangitis due to severe liver hilum lymph node metastases. His performance status(PS)score was 3 because of severe liver damage. Initially, he underwent endoscopic nasobiliary drainage for obstructive jaundice, and HAI plus Cmab was started to prevent liver dysfunction and to control all metastases. A PR in the metastatic liver tumors was observed after 18 courses. His PS increased to 1 and he was treated with mFOLFOX6 plus Cmab. HAI plus Cmab might be a treatment option for patients who have RAS-wild type tumors with severe liver dysfunction due to multiple liver metastases; HAI is intended to have few side effects and has a high local control rate.

[A Case of Metastasis to the Base of the Skull after Rectal Cancer Operation with Symptom Management via Radiotherapy].

In 2009, A 67-year-old woman underwent high anterior resection for rectal cancer(RS, type 2, pT3, pN1, cM0, pStage III a). U FT/LV was administered for 6 months as adjuvant chemotherapy after the operation. Because peritoneum dissemination and pelvic lymph node metastasis developed 9 months after the operation, CapeOX plus Bmab therapy was started, and we monitored the cancer partial response for the next 6 years. Six years and 9 months after the operation, we detected metastasis to the sacrum; thus, radiotherapy was started. Seven years after the first operation, we detected pulmonary, liver, distant lymph node, and subcutaneous metastasis. Additionally, in the next month, she complained of double vision and dysarthria, and metastasis to the base of the skull was diagnosed via head MRI scanning. We started radiotherapy, and the symptoms gradually improved. Although we started IRIS plus Bmab therapy for pulmonary, liver, distant lymph node, and subcutaneous metastasis, it became a progressive disease(PD). She passed away 7 years and 6 months after the first operation. In this case, radiotherapy was useful for symptom management of metastasis to the base of the skull after surgery for rectal cancer, which is an extremely rare occurrence.

[A Rare Case of Retroperitoneal Metastasis from Ascending Colon Cancer That Required Multimodal Treatment].

A patient in his 70's underwent a right hemi-colectomy due to an ascending colon cancer in a previous hospital. The tumor had widely infiltrated the retroperitoneal space(pT3, pN0[0/12], pPM0, pDM0, pRM1, Stage II ). He was referred to our institute 1 month after primary surgery to receive chemotherapy for his residual tumor. Abdominal computed tomography (CT)showed a 24mm tumor in his retroperitoneal space before chemotherapy. After 4 cycles of mFOLFOX6 and panitumumab, the tumor partially responded, and after 7 cycles, he achieved a complete response(CR). After an additional 10 cycles, he had maintained the CR, and chemotherapy was discontinued. Two years and 11 months after discontinuation of chemotherapy, an abdominal CT revealed a tumor that gradually grew behind the right kidney. The tumor was resected, and pathological findings showed it was recurrence of the past colon cancer. Seven months after resection of recurrent tumor, CT revealed 2 newly recurrent tumors that gradually grew in the retroperitoneal space again. Therefore, we performed resection of newly recurrent tumors along with the right kidney, Gerota's fascia, diaphragm, and lumbar quadrate muscle for R0 resection. Pathological findings revealed recurrence of the past colon cancer with extensive lymphatic invasion. The recurrent tumor had grown in a retroperitoneal space that was not covered in the primary surgical procedure. Therefore, this is considered a rare case of retroperitoneal metastasis.

Successful distal gastrectomy after distal pancreatectomy combined with splenectomy by assuring the blood flow to the remnant stomach from the left inferior phrenic artery.

BACKGROUND/AIMS: The current literature would suggest that patients with gastric cancer who have a previous history of ligation of the splenic artery undergo total gastrectomy. However, an analysis of the risk factors for postoperative complications in elderly patients showed a higher rate of morbidities for total gastrectomy compared to subtotal gastrectomy. Case REPORT: We herein report a rare case of successful distal gastrectomy in a 78-year-old female diagnosed with gastric cancer with a previous history of distal pancreatectomy combined with splenectomy, because an adequate blood flow was provided by the fundic branches from the left inferior phrenic artery. Preoperative computed tomography demonstrated a ligated splenic artery and left gastric artery with developed fundic branches from the left inferior phrenic artery. The intraoperative findings showed a sufficient blood flow to the proximal stomach after ligation of all main gastric arteries, thus suggesting that the gastric remnant could be supplied by the fundic branches from the LIPA. The patient's postoperative course was uneventful. CONCLUSION: This case suggests that a distal gastrectomy is a possible treatment modality even after distal pancreatectomy combined with splenectomy.

Rhabdomyosarcoma of the duodenum: report of a case.

This report presents a case of primary pleomorphic rhabdomyosarcoma arising in the duodenum. A 63-year-old male with persistent melena was referred for a solid tumor in his right upper abdomen detected using ultrasonography. Gastrofiberscopy revealed a protrusion in the upper part of the duodenum, with a large ulcer on the top of it. Enhanced computed tomography showed that the tumor extended to the pancreas. Pancreaticoduodenectomy was performed, despite the absence of malignant cells in the biopsy specimen, with a preoperative diagnosis of duodenal cancer. The tumor consisted of multiple cell types, and immunohistochemical staining was positive for desmin, HHF-35 and alpha smooth muscle actin. Electron microscopy revealed primitive Z-band structures in the tumor. The final diagnosis was pleomorphic rhabdomyosarcoma of the duodenum. This is the first report of primary rhabdomyosarcoma occurring in the duodenum, confirmed by immunohistochemical staining and electron microscopy.

Standardization of robot-assisted pelvic lymph node dissection-Development of a common understanding of regional anatomy and surgical technique based on cross-disciplinary discussion among colorectal surgery, urology, and gynecology.

BACKGROUND: Pelvic lymph node dissection is a procedure performed in gastroenterological surgery, urology, and gynecology. However, due to discrepancies in the understanding of pelvic anatomy among these departments, cross-disciplinary discussions have not been easy. Recently, with the rapid spread of robotic surgery, the importance of visual information in understanding pelvic anatomy has become even more significant. In this project, we attempted to clarify a shared understanding of pelvic anatomy through cross-disciplinary discussions. METHOD: From May 2020 to November 2021, a total of 11 discussions were held entirely online with 5 colorectal surgery specialists, 4 urologists, and 4 gynecologists. The discussions focused on evidence from each specialty and surgical videos, aiming to create a universally understandable pelvic anatomical illustration. RESULTS: The common area of dissection recognized across the three departments was identified as the obturator lymph nodes. A dynamic illustration of pelvic anatomy was created. In addition to a bird's-eye view of the pelvis, a pelvic half view was developed to enhance understanding of the deeper pelvic anatomy. The following insights were incorporated into the illustration: (1) the cardinal ligament in gynecology partly overlaps with the vesicohypogastric fascia in colorectal surgery; (2) the obturator lymph nodes continue cephalad into the fossa of Marcille in urology; and (3) the deep uterine vein in gynecology corresponds to the inferior vesical vein in colorectal surgery. CONCLUSION: Based on the dynamic illustration of pelvic anatomy from cross-disciplinary discussions, we anticipate advancements in pelvic lymph node dissection aiming for curative and safe outcomes.

Localized colorectal cancer database integrating 4 randomized controlled trials; (JCOG2310A).

Although phase III randomized controlled trials (RCTs) represent the most robust statistical approach for answering clinical questions, they require massive expenditures in terms of time, labor, and funding. Ancillary and supplementary analyses using RCTs are sometimes conducted as alternative approaches to answering clinical questions, but the available integrated databases of RCTs are limited. In this background, the Colorectal Cancer Study Group (CCSG) of the Japan Clinical Oncology Group (JCOG) established a database of ancillary studies integrating four phase III RCTs (JCOG0212, JCOG0404, JCOG0910 and JCOG1006) conducted by the CCSG to investigate specific clinicopathological factors in pStage II/III colorectal cancer (JCOG2310A). This database will be updated by adding another clinical trial data and accelerating several analyses that are clinically relevant in the management of localized colorectal cancer. This study describes the details of this database and planned and ongoing analyses as an initiative of JCOG cOlorectal Young investigators (JOY).

Reduction of toxicity by reversing the order of infusion of docetaxel and cyclophosphamide.

BACKGROUND: This retrospective study aimed to determine whether adverse events are more common in docetaxel followed by cyclophosphamide (TC) as compared to the reverse infusion order (rTC). METHODS: A retrospective analysis was undertaken at a single institution for 92 consecutive cases treated with TC or rTC for stage I-III breast cancer in a neoadjuvant/adjuvant setting between December 2006 and June 2011. TC was administered during the first 2.5 years and rTC in the latter 2 years. RESULTS: Among the 92 cases, 50 were in the TC arm and 42 in the rTC arm. Fatigue (72.0 vs. 23.8%), edema (48.0 vs. 16.7%), peripheral neuropathy (66.0 vs. 14.3%), myalgia (48.0 vs. 9.5%) and stomatitis (48.0 vs. 16.7%) occurred significantly more often in cases receiving TC compared to rTC, respectively. CONCLUSION: Nonhematological toxicities are less common in cases receiving rTC in comparison to those receiving TC.