Neoadjuvant Chemoradiation for Rectal Cancer Achieves Satisfactory Tumour Regression and Local Recurrence - Result of a Dedicated Multi-disciplinary Approach from a South Asian Centre.

BACKGROUND: Pre-operative long-course chemoradiotherapy (CRT) for rectal cancer has resulted in improvement in rates of restorative rectal resection and local recurrence by inducing tumour downstaging and downsizing. Total mesorectal excision (TME) is a standardised surgical technique of low anterior resection aimed at the prevention of local tumour recurrence. The purpose of this study was to evaluate tumour response following CRT in a standardised group of patients with rectal cancer. METHODS: One hundred and thirty-one patients (79 male; 52 female, median age 57; interquartile range 47-62 years) of 153 with rectal cancer who underwent pre-operative long-course CRT were treated by standardised open low anterior resection at a median of 10 weeks post-CRT. Sixteen of 131 (12%) were 70 years or older. Median follow-up at the time of analysis was 15 months (interquartile range 6-45 months). Pathology reports were analysed based on AJCC-UICC classification using the TNM system. Data recorded were overall/subgrades of tumour regression; good, moderate or poor, lymph node harvest, local recurrence, disease-free and overall survival using standard statistical methods. RESULTS: 78% showed tumour regression post-CRT; 43% displayed good tumour regression/response while 22% had poor tumour regression/response. All patients had a pre-operative T-stage of either T3 or T4. Post-operation, good responders had a median T stage of T2 vs. T3 in poor responders (P = 0.0002). Overall, the median lymph node harvest was < 12. There was no difference in the number of nodes harvested in good vs. poor responders (Good/moderate-6 nodes vs. Poor- 8; P = 0.31). Good responders tended to have a lesser number of malignant nodes vs. poor responders (P = 0.31). Overall, local recurrence was 6.8% and the anal sphincter preservation rate was 89%. Predicted 5-year disease-free and overall survival were similar between good and poor responders. CONCLUSION: Long-course CRT resulted in satisfactory tumour regression and enabled consideration for safe, sphincter-saving resection in rectal cancer. A dedicated multi-disciplinary team approach achieved a global benchmark for local recurrence in a resource-limited setting.

Risk factors for locally advanced cancer associated with ulcerative colitis: Results of a retrospective multicentric study in the era of biologics.

BACKGROUND: Patients affected by ulcerative colitis (UC) are more likely to develop colorectal cancer, and are often diagnosed with lymph node involvement (N+) at surgery. AIM: To identify the risk factors for N+ cancer in UC patients. METHODS: Patients undergoing surgery from 2001 to 2018 in six European tertiary centres were included. N+ patients were compared to the control group (N-) for clinical variables. The evaluation of risk factors for N+ was assessed using univariate and multivariable logistic regression analyses. RESULTS: A total of 130 patients were included. Median duration of disease was 21 years (1-52). Forty patients (30.8%) were N+ at surgery. Eighteen (13.8%) developed cancer within 10 years from the onset of UC. Younger age at surgery (Odds ratio -OR- 0.96, p = 0.042), left colon location (OR 2.44, p = 0.045) and the presence of stricture (OR 5.07, p = 0.002) were associated with N+. CONCLUSION: Location in the left colon, presence of strictures and younger age strongly correlated with a higher risk of N+ cancer, which could develop before the starting point of surveillance. Duration, extension and severity of disease were not associated with N+. These results should be considered in the evaluation of risk of advanced cancer in UC patients.

Single Port Laparoscopic Surgery for Complex Crohn's Disease Is Safe with a Lower Conversion Rate.

PURPOSE: Single port laparoscopic surgery (SPLS) is a technique which is increasing in popularity. The benefit of SPLS in complex Crohn's disease (CD), which includes a significant cohort of young patients sometimes needing multiple operations, has not been comprehensively assessed. This study analyses our early experience with this technique. METHODS: Patients who underwent SPLS for CD were included. Data were collected prospectively from January 2013 to December 2015. Ileocolic resections, right hemicolectomy, small bowel stricturoplasties, and resections were included in the complex CD cohort. Primary and redo operations were analyzed separately. RESULTS: Forty-five patients were included in the study (39 ileocolic resections and 6 small bowel stricturoplasty/resections). Of the total, 27 were primary resections and 18 were redo resections. The median age was 41 years (range 14-72 years), and the median hospital stay was 8 days (range 3-28 days). The total complication rate was 35.5% most of which were Clavien-Dindo type 1 and 2. There was no difference in operating time, average blood loss, conversion rates, complication rate, and hospital stay, between those who had primary or redo surgery. CONCLUSIONS: SPLS can be performed safely in patients with complex CD even in redo surgery. There may be some technical advantages to the procedure in this group of patients.

Colorectal cancer in the young, many questions, few answers.

At a time where the incidence of colorectal cancer, a disease predominantly of developed nations, is showing a decline in those 50 years of age and older, data from the West is showing a rising incidence of this cancer in young individuals. Central to this has been the 75% increase in rectal cancer incidence in the last four decades. Furthermore, predictive data based on mathematical modelling indicates a 124 percent rise in the incidence of rectal cancer by the year 2030 - a statistic that calls for collective global thought and action. While predominance of colorectal cancer (CRC) is likely to be in that part of the large bowel distal to the splenic flexure, which makes flexible sigmoidoscopic examination an ideal screening tool, the cost and benefit of mass screening in young people remain unknown. In countries where the incidence of young CRC is as high as 35% to 50%, the available data do not seem to indicate that the disease in young people is one of high red meat consuming nations only. Improvement in our understanding of genetic pathways in the aetiology of CRC, chiefly of the MSI, CIN and CIMP pathway, supports the notion that up to 30% of CRC is genetic, and may reflect a familial trait or environmentally induced changes. However, a number of other germline and somatic mutations, some of which remain unidentified, may play a role in the genesis of this cancer and stand in the way of a clear understanding of CRC in the young. Clinically, a proportion of young persons with CRC die early after curative surgery, presumably from aggressive tumour biology, compared with the majority in whom survival after operation will remain unchanged for five years or greater. The challenge in the future will be to determine, by genetic fingerprinting or otherwise, those at risk of developing CRC and the determinants of survival in those who develop CRC. Ultimately, prevention and early detection, just like for those over 50 years with CRC, will determine the outcome of CRC in young persons. At present, aside from those with an established familial tendency, there is no consensus on screening young persons who may be at risk. However, increasing awareness of this cancer in the young and the established benefit of prevention in older persons, must be a message that should be communicated with medical students, primary health care personnel and first contact doctors. The latter constitutes a formidable challenge.

Pre-operative hypoalbuminaemia predicts poor overall survival in rectal cancer: a retrospective cohort analysis.

BACKGROUND: Serum albumin is a marker of nutrition and inflammation. It has recently emerged as a predictor of outcome after surgery for rectal cancer. Our aim was to evaluate if pre-operative serum albumin would predict survival after resection for rectal cancer. METHOD: 226 Patients with rectal cancer of all stages undergoing resection with curative intent were studied. Kaplan-Meier curves analysed survival based on a pre-operative albumin level of <35 g/L vs. >35 g/L. We sought for significant associations of survival with age, sex, stage, tumour site, use of neoadjuvant chemoradiation, microscopic positive resection margins, differentiation, angio, peri-neural, and lymphovascular invasion using individual variable analysis. Multifactorial analysis was performed using type III analysis with Weibull hazard model and Cox-proportional hazard model. Significance was assigned to a P value <0.05. RESULTS: Of 226 patients (median age- 59 years; range 19 - 88, Male - 54%), forty five (20%) had an albumin level < 35 g/L and was associated with a poor overall survival (P = 0.02). Mean survival in months for <35 g/L vs. >35 g/L was 64.7 (SE - 9.3) vs. 95.8 (SE - 7.0) and 5 year overall survival rates were 49% and 69%. Individual variable analysis revealed age, circumferential margin, stage, perineural, lympho-vascular and angio invasion to be also significant. With multifactorial analysis hypoalbuminaemia (HR = 0.58; 95% CI: 0.35 - 0.95, P = 0.03), advanced stage (HR = 2.0; 95% CI: 1.26 - 3.23, P < 0.01) and positive circumferential margin (HR = 2.2; 95% CI: 1.26 - 3.89, P < 0.01) remained significant. CONCLUSION: Preoperative hypoalbuminaemia is an independent risk factor for poor overall survival in rectal cancer. Advanced tumour stage and circumferential margin positivity were the other associations with poor survival.

Obstructive jaundice caused by a biliary mucinous cystadenoma in a woman: a case report.

INTRODUCTION: Mucinous cystadenoma of the liver is a rare (less than 5%) neoplasm. This condition is more common in young women and accounts for non-specific symptoms. Cyst adenomas commonly affect the intrahepatic system (90%) and are rarely found in the extrahepatic biliary system or affecting both the systems. CASE PRESENTATION: A 39-year-old Sinhalese woman presented with features of obstructive jaundice and was found to have a biliary neoplasm on imaging. In the absence of a definitive diagnosis despite extensive imaging she underwent preoperative endoscopic biliary drainage followed by a left hemihepatectomy with Roux-en-Y hepaticojejunostomy. A pathological examination of the specimen revealed an obstruction of the bile duct caused by a biliary mucinous cystadenoma affecting both the intrahepatic and extrahepatic systems. CONCLUSIONS: Biliary mucinous cystadenoma rarely present with obstructive jaundice affecting both intrahepatic and extrahepatic ducts. Exhaustive investigation might not help in the diagnosis and may need to be treated based on clinical judgment. The definitive treatment modality is surgery due to its malignant potential. The operative procedure is technically demanding and is best performed at specialist centers to minimize complications.