Pilot trial of a STOMA psychosocial intervention programme for colorectal cancer patients with stomas.

AIMS: To evaluate preliminary effects of a newly developed STOMA psychosocial intervention programme that was delivered via a multi-modal and multi-dimensional approach on the improvement of outcomes of colorectal cancer patients with stoma. BACKGROUND: With a distorted body image and the loss of an essential body function, stoma patients face difficulties in everyday life in terms of physical, psychological, and social aspects. Few studies have explored effects of psychosocial interventions on improving stoma-related health outcomes. DESIGN: This was a two-group pre-test-post-test pilot randomized controlled trial. METHODS: Fifty-three participants were recruited from July 2015-November 2016 in a tertiary public hospital in Singapore. They were randomized into either intervention group (N = 29) or control group (N = 24). Stoma care self-efficacy, acceptance of stoma, stoma proficiency, length of hospital stay, anxiety and depression and quality of life were measured. IBM SPSS 24.0 was used to analyse the data. RESULTS: There was an improvement in acceptance of stoma in the intervention group (p < 0.05). Significant effects on stoma care self-efficacy, stoma proficiency, length of hospital stay, anxiety and depression level and quality of life were not shown. CONCLUSION: This study developed a feasible and applicable psychosocial intervention programme and generated preliminary evidence in the positive outcomes of colorectal cancer patients with stoma. Future studies can explore technology-based interventions to provide a more sustainable support for patients with stoma.

A qualitative evaluation of the STOMA psychosocial intervention programme for colorectal cancer patients with stoma.

AIMS: To explore the experiences of patients who underwent a Support availability, Thinking positively with acceptance, Overcoming social stigma, Minimizing negative feelings, Analyzing self-efficacy in stoma care (STOMA) psychosocial intervention programme for people with colorectal cancer with stoma. BACKGROUND: The STOMA psychosocial intervention programme was developed to improve stoma-related health outcomes for patients with colorectal cancer and stoma. Evaluation was carried out to explore their experiences. DESIGN: A qualitative exploratory approach was adopted. METHODS: A total of 13 people with colorectal cancer, who were: (a) scheduled for surgery that resulted in a surgical formation of stoma at a tertiary public hospital in Singapore, and (b) were allocated to the intervention group and received the STOMA psychosocial intervention programme, were recruited for the qualitative evaluation study (September to November 2016). Participants were asked to comment on the contents and delivery methods of the intervention, and the effect of the presence of family members during the sessions. Thematic analysis was used to analyse the data. FINDINGS: Four themes were generated: (a) individual attitudes towards stoma, (b) benefits of the STOMA psychosocial intervention programme, (c) strengths of the STOMA psychosocial intervention programme, and (d) recommendations for future programmes. CONCLUSION: The qualitative evaluation reflected the benefits of the intervention programme in improving the outcome of people with colorectal cancer with stoma with its multimodal and multidimensional approach. TRIAL REGISTRATION NUMBER: ISRCTN41915584.

Totally-laparoscopic versus laparoscopic-assisted low anterior resection for rectal cancer: are outcomes different?

BACKGROUND: Laparoscopic low anterior resection for rectal cancer has superior short-term benefits compared to open surgery. When operative conditions do not favour a totally-laparoscopic (TL) approach, a hybrid operation can be performed. In this laparoscopic-assisted (LA) approach, mobilization and vessel ligation are performed laparoscopically, with total mesorectal excision and distal transection performed either partially or totally in an extra-corporeal fashion. We compared short-term post-operative and oncological outcomes of both approaches. METHODS: A prospectively collected database of patients who underwent laparoscopic low anterior resection for rectal cancer between January 2009 and December 2014 was retrospectively analysed. Demographics, post-operative and oncological outcomes were compared. RESULTS: Of 174 patients, 97 were completed by TL, 62 by LA and the remaining 15 were converted to open. Baseline demographics were similar. LA group compared to TL group had bulkier rectal cancers (6.75 cm3 versus 4.50 cm3 , P = 0.04) which were lower (6 cm versus 7 cm from anal verge, P = 0.02). They were of a more advanced tumour grade and had greater incidence of lymphovascular invasion. Yet, post-operative outcomes such as time to diet, pain scores, hospitalization duration, wound-related and anastomotic complications, 30-day morbidity and mortality were similar. There was no difference in oncological adequacy, including circumferential resection margins, distal margins, lymph node harvest and 2-year local recurrence rates. CONCLUSION: Laparoscopic-assisted low anterior resection enables minimally invasive rectal surgery to be performed despite unfavourable tumour factors and technical challenges; and compares favourably with TL approach in terms of short-term outcomes and oncological safety.

Multiregion ultra-deep sequencing reveals early intermixing and variable levels of intratumoral heterogeneity in colorectal cancer.

Intratumor heterogeneity (ITH) contributes to cancer progression and chemoresistance. We sought to comprehensively describe ITH of somatic mutations, copy number, and transcriptomic alterations involving clinically and biologically relevant gene pathways in colorectal cancer (CRC). We performed multiregion, high-depth (384× on average) sequencing of 799 cancer-associated genes in 24 spatially separated primary tumor and nonmalignant tissues from four treatment-naïve CRC patients. We then used ultra-deep sequencing (17 075× on average) to accurately verify the presence or absence of identified somatic mutations in each sector. We also digitally measured gene expression and copy number alterations using NanoString assays. We identified the subclonal point mutations and determined the mutational timing and phylogenetic relationships among spatially separated sectors of each tumor. Truncal mutations, those shared by all sectors in the tumor, affected the well-described driver genes such as APC, TP53, and KRAS. With sequencing at 17 075×, we found that mutations first detected at a sequencing depth of 384× were in fact more widely shared among sectors than originally assessed. Interestingly, ultra-deep sequencing also revealed some mutations that were present in all spatially dispersed sectors, but at subclonal levels. Ultra-high-depth validation sequencing, copy number analysis, and gene expression profiling provided a comprehensive and accurate genomic landscape of spatial heterogeneity in CRC. Ultra-deep sequencing allowed more sensitive detection of somatic mutations and a more accurate assessment of ITH. By detecting the subclonal mutations with ultra-deep sequencing, we traced the genomic histories of each tumor and the relative timing of mutational events. We found evidence of early mixing, in which the subclonal ancestral mutations intermixed across the sectors before the acquisition of subsequent nontruncal mutations. Our findings also indicate that different CRC patients display markedly variable ITH, suggesting that each patient's tumor possesses a unique genomic history and spatial organization.

Excessive fatty acid oxidation induces muscle atrophy in cancer cachexia.

Cachexia is a devastating muscle-wasting syndrome that occurs in patients who have chronic diseases. It is most commonly observed in individuals with advanced cancer, presenting in 80% of these patients, and it is one of the primary causes of morbidity and mortality associated with cancer. Additionally, although many people with cachexia show hypermetabolism, the causative role of metabolism in muscle atrophy has been unclear. To understand the molecular basis of cachexia-associated muscle atrophy, it is necessary to develop accurate models of the condition. By using transcriptomics and cytokine profiling of human muscle stem cell-based models and human cancer-induced cachexia models in mice, we found that cachectic cancer cells secreted many inflammatory factors that rapidly led to high levels of fatty acid metabolism and to the activation of a p38 stress-response signature in skeletal muscles, before manifestation of cachectic muscle atrophy occurred. Metabolomics profiling revealed that factors secreted by cachectic cancer cells rapidly induce excessive fatty acid oxidation in human myotubes, which leads to oxidative stress, p38 activation and impaired muscle growth. Pharmacological blockade of fatty acid oxidation not only rescued human myotubes, but also improved muscle mass and body weight in cancer cachexia models in vivo. Therefore, fatty acid-induced oxidative stress could be targeted to prevent cancer-induced cachexia.

A randomized controlled trial examining the effectiveness of a STOMA psychosocial intervention programme on the outcomes of colorectal patients with a stoma: study protocol.

AIMS: To report a study protocol that evaluates the effects of a psychosocial intervention on patients with a newly formed stoma. BACKGROUND: With the loss of a significant body function and distorted body image, stoma patients experience physical, psychological and social challenges. Nurses have an important role in helping patients' make a smooth transition to living with their stoma. Limited studies have examined the effects of psychosocial interventions on improving stoma-related health outcomes. DESIGN: A randomized controlled trial is planned. METHODS: Eighty-four patients with newly formed stoma in a tertiary hospital in Singapore (Research Ethics Committee approval obtained in January 2013) will be recruited. Participants will be randomly assigned to either a control group who receive routine care or an intervention group who receive STOMA psychosocial intervention besides routine care. Outcome variables include stoma care self-efficacy, days to stoma proficiency, length of hospital stay, acceptance of stoma, anxiety and depression and quality of life. Data will be collected at four time points: before randomization and intervention (baseline), on the day of discharge (mid-intervention), at 4 weeks after discharge (postintervention 1) and at 4 months after discharge (postintervention 2). DISCUSSION: This study will develop a psychosocial intervention programme, which may improve patients' stoma-related outcomes. The findings will provide direction to health professionals about education and the type of support that could be offered to patients concerning stoma care in the hospital setting, which will eventually improve their quality of life.

Laparoscopic resection for colorectal polyps: a single institution experience.

BACKGROUND: Endoscopic polypectomy, although routinely used for the treatment of colorectal polyps, may be limited by polyp size, location and histology. Laparoscopic resection for malignant polyps and polyps not amenable to endoscopic removal has the advantage of adequate disease clearance as well as the short-term benefits of laparoscopic surgery. This study evaluates the outcomes of such an approach. METHODS: Patients who had laparoscopic resection for colorectal polyps between January 2005 and July 2008 were identified from a prospective database. Polyps that were malignant, large, difficult to snare or incompletely excised, were included. Demographics, perioperative details and histopathology were analysed. RESULTS: Seventy-eight patients (44 male) with a median age of 62.5 years (range 24-86) were studied. The majority (79%) were laparoscopic anterior resections for sigmoid or rectal polyps. Median operating time was 125 min (range, 65-225). Eight cases (10.3%) were converted to open mainly due to adhesions. There was no post-operative mortality. Perioperative complications occurred in seven patients (8.9%). Median hospital stay was 6 days (range 4-78). Median polyp size was 20 mm (range, 5-75). There were 44 benign polyps (55.7%); majority were tubulovillous adenomas (n= 22), and tubular adenomas (n= 10). Thirty-five patients (44.3%) had invasive cancer, with T1 (n= 27) and T2 (n= 2) tumours. Three of these patients (8.6%) had lymph node metastases. Median number of lymph nodes sampled was six (range 0-23). CONCLUSION: Laparoscopic resection is safe and effective for colorectal polyps not amenable to colonoscopic removal, and is especially important for adequate clearance in the case of malignant polyps.

Cutaneous and subcutaneous metastases of adenocarcinoma of the colon and rectum.

INTRODUCTION: The interesting topic of cutaneous and subcutaneous metastasis from rectal carcinoma is discussed using 3 cases. CLINICAL PICTURE: The first case was a 70-year-old man with T3N2M0 rectal mucinous adenocarcinoma, who developed an inflammatory subcutaneous metastasis at the left scapula 2 years after anterior resection. The second case was a 51-year-old man with T4N2M0 splenic flexure mucinous adenocarcinoma, who developed metastatic disease including a subcutaneous secondary to the back. The third case was a 53-year-old woman who developed vulval recurrence 10 months after abdomino-perineal resection for a low T3N1M0 rectal adenocarcinoma. TREATMENT: All underwent wide resection. CONCLUSION: This entity is rare and usually signifies disseminated disease if found remote from the resection site and warrants a thorough metastatic work up. A high index of suspicion is recommended when encountered with unresolving skin lesions in cancer patients.