Laparoscopic cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: Long term oncologic outcomes from the international PSOGI registry.

The laparoscopic approach for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (L-CRS + HIPEC) in highly selected patients was previously reported from the PSOGI registry with a demonstrable reduction in length of stay and post-operative morbidity. This study aims to update this international PSOGI registry with a larger cohort of patients and a longer follow-up period. METHODS: An international registry was designed through a networking database (REDCAP®). All centers performing L-CRS + HIPEC were invited through PSOGI to submit data on their cases. Variables such as demographics, clinical outcomes, and survival were analyzed. RESULTS: A total of 315 L-CRS + HIPEC cases were provided by 14 worldwide centers. A total of 215 patients were included in the L-CRS + HIPEC group. The median peritoneal cancer index (PCI) was 3 (3-5). The median length of stay was 7 days (5-10) and the major morbidity (Clavien-Dindo ≥3) was 6.1% after 30 days. The 5-year disease-free survival (DFS) per tumor origin was: 94% for PMP-LG, 85% for PMP-HG, 100% for benign multicyst peritoneal mesothelioma (MPM), 37.4% for colonic origin, and 54%(at 3 years) for ovarian origin. The 5 years overall survival (OS) per tumor origin was: 100% for PMP-LG, PMP-HG and MPM; 61% for colonic origin, and 74% (at 3 years) for ovarian origin. In addition, a total of 85 patients were analyzed in the laparoscopic risk-reducing HIPEC (L-RR + HIPEC). The median length of stay was 5 days (4-6) and the major morbidity was 6% after 30 days. The 5-year DFS per tumor origin was: 96% for perforated low grade appendiceal mucinous neoplasm (LAMN II) and 68.1% for colon origin. The 5 years OS per tumor origin was: 98% for LAMN II and 83.5% for colonic origin. CONCLUSIONS: Minimally invasive CRS + HIPEC is a safe procedure for selected patients with peritoneal carcinomatosis in specialized centers. It improves perioperative results while providing satisfactory oncologic outcomes. L-RR + HIPEC represents a promising strategy that could be evaluated in patients with high risk of developing peritoneal carcinomatosis into prospective randomized trials.

Follow-up of colorectal cancer and patterns of recurrence.

Colorectal cancer is one of the commonest cancers detected as also amongst the most common causes of cancer death. Survival has improved due to better disease understanding and treatment; however, a substantial proportion of patients recur after curative intent therapy. In this article, we will discuss the imaging features of recurrent colorectal cancer and the role of the radiologist in its management.

Minimally invasive versus open pelvic exenterations for rectal cancer: a comparative analysis of perioperative and 3-year oncological outcomes.

BACKGROUND: This study compared the surgical and oncological outcomes of open and minimally invasive pelvic exenteration. METHODS: Patients who underwent pelvic exenterations for primary locally advanced rectal cancers with invasion of the urogenital organs (central and anterior disease) between August 2013 and September 2020 were reviewed retrospectively. Patients were categorized as undergoing open or minimally invasive surgery (MIS) and these groups were compared for perioperative outcomes and 3-year survival (overall, recurrence-free and local relapse-free survival). Multivariable Cox regression analysis was performed to assess the independent influence of approach of surgery and cancer features on recurrence-free survival (RFS). RESULTS: Of the 158 patients who underwent pelvic exenteration, 97 (61.4 per cent) had open exenterations and 61 (38.6 per cent) patients had an MIS resection (44 patients (72 per cent) using laparoscopy and 17 (28 per cent) using robotic surgery). There were 96 (60.8 per cent) total pelvic exenterations and 62 (39.2 per cent) posterior pelvic exenterations. MIS exenterations had significantly longer operative times (MIS versus open: 640 mins versus 450 mins; P < 0.001) but reduced blood loss (MIS versus open: 900 ml versus 1600 ml; P < 0.001) and abdominal wound infections (MIS versus open: 8.2 versus 17.5 per cent; P = 0.020) without a difference in hospital stay (MIS versus open: 11 versus 12 days; P = 0.620). R0 resection rates and involvement of circumferential resection margins were similar (MIS versus open: 88.5 versus 91.8 per cent, P = 0.490 and 13.1 versus 8.2 per cent, P = 0.342 respectively). At a median follow-up of 29 months, there were no differences in 3-year overall survival (MIS versus open: 79.4 versus 60.2 per cent; P = 0.251), RFS (MIS versus open: 51.9 versus 47.8 per cent; P = 0.922) or local relapse-free survival (MIS versus open: 89.7 versus 75.2 per cent; P = 0.491. On multivariable analysis, approach to surgery had no bearing on RFS, and only known distant metastasis, aggressive histology and inadequate response to neoadjuvant radiation (pathological tumour regression grade greater than 3) predicted worse RFS. CONCLUSION: MIS exenterations documented longer procedures but resulted in less blood loss and fewer wound infections compared with open surgeries. In the setting of an experienced centre, the hospital stay, R0 resection rates and oncological outcomes at 3 years were similar to those of open exenterations.

Outcomes of Definitive Treatment of Signet Ring Cell Carcinoma of the Rectum: Is Minimal Invasive Surgery Detrimental in Signet Ring Rectal Cancers?

The outcome of surgery for signet ring adenocarcinoma of rectum is suboptimal with high predilection for locoregional and peritoneal metastases. Lack of intercellular adhesion due to focal loss of epithelial cell adhesion molecule (EpCAM) may account for this. In such patients, whether minimal invasive surgery carries a high risk of dissemination by pneumoperitoneum and tumor implantation remains uncertain. The aim of this study was to compare the outcomes of patients undergoing minimally invasive surgery (MIS) versus open surgery in patients with signet ring cell adenocarcinoma of rectum. A retrospective study was conducted at a tertiary care center over 3 years on 39 patients undergoing open surgery and 40 patients undergoing MIS diagnosed with signet ring cell carcinoma (SRCC) identified from our surgical database. Patient characteristics in terms of demographics, clinicoradiological staging, neoadjuvant therapy, and type of surgery with morbidity were compared in the two groups. Data on patients undergoing adjuvant therapy and 3 years disease-free survival (DFS) and overall survival (OS) were analyzed. Recurrence patterns in both groups were separately identified as locoregional, peritoneal, or systemic. The number of patients undergoing surgery in the two arms was 40 (MIS) and 39 (open). In the MIS arm, mean DFS was 29 months whereas in the open arm, it was 25.8 months. The mean OS was 33.65 months for the MIS arm and that for the open arm was 36.34 months. This retrospective study reveals no significant difference in outcomes of surgery for signet ring cell rectal cancers with either MIS or open approach.

Can Post-Treatment MRI Features Predict Pathological Circumferential Resection Margin (pCRM) Involvement in Low Rectal Tumors.

The MERCURY II study demonstrated the use of MRI-based risk factors such as extramural venous invasion (EMVI), tumor location, and circumferential resection margin (CRM) involvement to preoperatively predict pCRM (pathological CRM) outcomes for lower rectal tumors in a mixed group of upfront operated patients and patients who received neoadjuvant treatment. We aim to study the applicability of results of MERCURY II study in a homogeneous cohort of patients who received neoadjuvant chemoradiation (NACTRT) prior to surgery. After Institutional Review Board approval, post NACTRT restaging MRI of 132 patients operated for low rectal cancer between 2014 and 2018 were retrospectively reviewed by two radiologists for site of tumor, EMVI status, distance from anal verge (< 4 or > 4 cm), and mrCRM positivity. Findings were compared with post surgery pCRM outcomes using Fisher's exact test. Only 9/132(7%) patients showed pCRM involvement on histopathology, 8 of them being CRM positive on MRI (p = 0.01). The positive predictive value (PPV) of mrCRM positive status and pCRM status was 12.7% (95% CI: 9.7-16.5%), while the negative predictive value was 98.5% (95% CI: 91.4-99.8%) (p = 0.01). EMVI positive and anteriorly located tumors showed higher incidence of pCRM positivity but were not found to be significant (15% vs 5.2% and p = 0.13 and 8.6% vs 2.1% and p = 0.28, respectively). Unsafe mrCRM was the only factor significantly associated with pCRM positivity on post neoadjuvant restaging MRI. Tumors less than 4 cm from anal verge, anterior tumor location, and mrEMVI positivity did not show statistically significant results to predict pCRM involvement.

Novel use of the Bakri balloon to minimize empty pelvis syndrome following laparoscopic total pelvic exenteration.

AIM: Pelvic exenteration is the only surgical option for locally advanced pelvic malignancies infiltrating the surrounding organs. The resultant pelvic void after the procedure is responsible for a number of complications, collectively termed empty pelvis syndrome (EPS). We aim to show how EPS can be minimized by presenting a case series demonstrating the surgical technique of laparoscopic total pelvic exenteration with bilateral pelvic node dissection along with a novel use of the Bakri balloon. METHOD: This is a case series of three successive patients undergoing laparoscopic total pelvic exenteration for locally advanced primary, nonmetastatic rectal adenocarcinoma over a period of 1 month in a specialized colorectal unit at a tertiary cancer centre. The Bakri balloon was deployed in all three patients and retained for variable time intervals postoperatively. Features of EPS were prospectively documented. RESULTS: In the first patient, the Bakri balloon was completely deflated and removed on postoperative day (POD) 5. The patient developed subacute intestinal obstruction which resolved with conservative management by POD 12. In the second and third patients, the Bakri balloon was deflated in a sequential manner, beginning on POD 8, until it was finally removed on POD 11. Neither of these patients had any abdominal complaints. A postoperative CT scan of both these patients showed the small bowel loops clearly above the pelvic inlet. CONCLUSIONS: The Bakri balloon is a simple, safe and cost-effective method to reduce the complications of EPS following laparoscopic total pelvic exenteration. A prospective study is ongoing to objectively quantify the benefits of this technique.

Patients with extensive regional lymph node involvement (pN2) following potentially curative surgery for colorectal cancer are at increased risk for developing peritoneal metastases: a retrospective single-institution study.

AIM: Our goal was to determine the incidence and clinical behaviour of peritoneal metastases (PM) in patients with colorectal cancer undergoing potentially curative surgery, comparing patients with extensive locoregional lymph node involvement (pN2) with those who have serosal involvement (pT4), a known risk factor for developing PM. METHOD: A retrospective analysis of a prospectively maintained database was performed. All patients with pT4 and pN2 were included in the analysis. The diagnostic criteria were the finding of PM during surgery with biopsy confirmation as well as imaging features suggestive of PM, including ovarian metastases and omental deposits. RESULTS: Two hundred and fourteen patients treated between May 2010 and October 2015 were included. Of these, 110 (51.4%) had pT4 and 131 (61.2%) pN2 tumours: 17.2% of patients with pT4 tumours and 20.2% of patients with pN2 tumours developed PM (P = 0.53). The median time to detection of PM was 16.6 months and 11.8 months for pT4 and pN2 tumours, respectively. PM were isolated in 51.8% of patients with pN2 tumours. Nonperitoneal metastases developed in 37.5% of patients with pN2 tumours. In pN2 tumours, the incidence of PM was higher in signet ring cell and mucinous tumours (P < 0.01), positive surgical margins (P = 0.02), colonic versus rectal tumours (P = < 0.01) and right colon primary tumours (P = 0.01). CONCLUSION: Patients with pN2 tumours are at an increased risk of developing PM, which is similar to the risk in pT4 tumours. pN2 tumours should be included in clinical trials evaluating preventive/proactive strategies. There is a need to identify predictive biomarkers for the development of PM versus other sites of metastasis.

Chemo-Radiation After Upfront Rectal Resections-a Clinical Dilemma.

To compare the impact of adjuvant chemo-radiotherapy (ACRT) versus adjuvant chemotherapy (ACT) alone on recurrence and survival in patients with stage II and III rectal adenocarcinoma undergoing upfront curative resection. Prospective observational review of colorectal database at Tata Memorial Hospital from July 2010 to March 2015 identified 84 patients who underwent upfront curative resection for stage II or III rectal cancer. None of the patient received preoperative chemo-radiation. Of these, adjuvant chemo-radiotherapy was administered to 29 patients (ACRT group) and 55 patients received CAPEOX/FOLFOX-based adjuvant chemotherapy (ACT group) alone. At a median follow-up of 20 months, there were 10 recurrences (3 local recurrence) in the ACRT group and 15 (2 local recurrence) in ACT group. The estimated disease-free survival at 3 years in the ACRT group was 62.7% and in ACT group was 49.7% (p = 0.417) with an estimated 3-year overall survival of 74 and 78% in the ACRT and ACT group, respectively (p = 0.241). Subgroup analysis was performed after risk stratifying prognostic features (pT4, pN2, poor differentiation, involved resection margin). Our study does not show any benefit of ACRT over ACT on local control, disease-free and overall survival after upfront rectal cancer resection for low-risk stage II-III. In the subgroup analysis, local recurrence did not occur in patients who did not have poor prognostic features irrespective whether they received ACRT or ACT. Adjuvant chemo-radiation can be avoided in low-risk stage II-III rectal cancer after upfront resection.