Rectal cancer - avoiding surgery?

Nonoperative treatment of rectal cancer is gaining popularity. Several trials recently demonstrated advantages in disease-free survival with total neoadjuvant treatment (TNT) with the addition of the watch and wait (WW) strategy for locally advanced rectal cancer. On longer follow-up, an unexpected increased risk in local recurrence in the TNT group at the RAPIDO trial suggested early surgery for nonresponding tumours. The WW option is globally accepted for a complete clinical response; however, a high rate of regrowth was found in a registry with an increased risk of distant metastases, questioning the deleterious effect of deferral of surgery in this group. The short- and long-term toxic effects of neoadjuvant treatment are costs to consider in the National Comprehensive Cancer Network guidelines compared with the European Society for Medical Oncology guidelines, which favour surgery alone if good mesorectal resection is assured with increasing surgical proficiency adjusted to the precise anatomical location.

Pancreas- and Pylorus-Preserving Duodenectomy for Advanced Familial Duodenal Polyposis.

Most patients with familial adenomatous polyposis (FAP) will develop duodenal polyps and 5% progress to cancer. Those with Spigelman stage IV have a 36% risk of cancer at 10 years. Endoscopic surveillance is necessary with local ablation for early disease. Unresectable duodenal disease and severe dysplasia are an indication for prophylactic radical surgery by pancreaticoduodenectomy or pancreas-sparing duodenectomy. Some preliminary results have shown better outcomes with duodenectomy. A 45-year-old female with FAP had restorative proctocolectomy at 24 years, desmoid of the mesentery with regression after sulindac, two pregnancies, and at the age of 37 years had duodenal polyposis stage III carpeting the periampullary region. Endoscopic papillectomy and extensive piecemeal mucosectomy was performed but was unsuccessful due to recurrence. After 7 years of regular endoscopic surveillance, focal high-grade dysplasia was diagnosed at the last evaluation. Some diminutive polyps were seen in the small-bowel capsule endoscopy. MRCP showed a normal biliary and pancreatic duct without visualization of the Santorini duct. A pancreas and pylorus-preserving duodenectomy was performed with 3 main steps: (1) duodenectomy with preservation of the pancreas and the pylorus; (2) reconstruction with an advanced jejunal limb and duodenojejunostomy; (3) reimplantation of the biliary and pancreatic duct in the jejunal loop. The patient was discharged on the 11th postoperative day without complications. In conclusion, pancreas- and pylorus-preserving duodenectomy is a promising alternative to pancreaticoduodenectomy for advanced duodenal polyposis that allows complete endoscopic surveillance.

A maioria dos doentes portadores de polipose adenomatosa familiar (FAP) vem a desenvolver pólipos duodenais que poderão degenerar em 5% dos casos. Os casos que apresentem um estádio IV de Spigelman têm um risco de degenerescência de 36% ao fim de 10 anos. É necessária vigilância endoscópica e excisão das lesões iniciais. Os pólipos considerados irressecáveis e com displasia de alto grau têm indicação para exérese cirúrgica radical através de duodenopancreatectomia ou de duodenectomia com conservação do pâncreas. Existem alguns resultados preliminares a revelar melhores resultados com a duodenectomia. Uma doente de 45 anos portadora de FAP efetuou proctocolectomia reconstrutiva aos 24 anos. Desenvolveu tumor desmoide mesentérico após um ano e que regrediu com sulindac, teve dois filhos e aos 37 anos apresentou polipose duodenal, em toalha periampular, com estádio III. Foi submetida a papilectomia endoscópica e mucosectomia fragmentada da lesão circundante tendose verificado recorrência. Durante 7 anos procedeu-se a vigilância endoscópica regular com presença de displasia de alto grau focal na última avaliação. Na cápsula endoscópica foram observados alguns pólipos diminutos no intestino delgado. A CPRM revelou normalidade nos canais pancreático e biliar, sem evidência do Santorini. Foi efetuada uma duodenectomia com conservação do pâncreas e do piloro cujos passos cirúrgicos principais foram: (a) duodenectomia com conservação do pâncreas e do piloro; (b) reconstrução com ansa jejunal e duodenojejunostomia; (c) reimplantação dos canais biliar e pancreático à ansa jejunal. A doente teve alta ao 11o dia pós-operatório sem complicaçõs. Em conclusão, a duodenectomia com conservação do pâncreas e do piloro constitui uma boa alternativa à duodenopancreatectomia permitindo vigilância endoscópica completa.

Usefulness of perfusion CT to assess response to neoadjuvant combined chemoradiotherapy in patients with locally advanced rectal cancer.

RATIONALE AND OBJECTIVES: To prospectively evaluate perfusion computed tomography (CT) for assessment of changes in tumor vascularity after chemoradiation therapy (CRT) in locally advanced rectal cancer and to analyze the correlation between baseline perfusion parameters and tumor response. MATERIALS AND METHODS: Twenty patients with rectal cancer underwent baseline perfusion CT before CRT, and in 11 an examination after CRT was also performed. For each tumor, blood flow (BF), blood volume (BV), mean transit time (MTT), and permeability-surface area product (PS) were quantified. The Mann-Whitney U test compared baseline perfusion parameters of responders and nonresponders and pre- and post-CRT measurements were compared by the Wilcoxon signed-rank test (P < .05 statistically significant for both tests). RESULTS: Baseline BF was significantly lower (P = .013) and MTT was significantly higher (P = .006) in responders. Both were able to discriminate responders from nonresponders with a sensitivity of 80% and 100% and a specificity of 73.3% and 86.7%, respectively, for BF and MTT. Baseline BV and PS were not significantly different in responders and nonresponders. Perfusion parameters changed significantly in post-CRT scans compared to baseline: BF (P = .003), BV (P = .003), and PS (P = .008) decreased, whereas MTT increased (P = .006). CONCLUSION: Baseline BF and MTT can discriminate patients with a favorable response from those that fail to respond to CRT, potentially selecting high-risk patients with resistant tumors that may benefit from an aggressive preoperative treatment approach.