№69. Interdisciplinary approach for the diagnosis, treatment and prevention of colorectal cancer
- M. Kornmann, S. PaschkeDOI 10.31917/1801001
Survival of patients with colon and rectal cancer is constantly increasing. In order to further improve prognosis the development of distant metastases after primary tumor resection has to be further reduced. Adjuvant chemotherapy is standard for UICC III colon cancer using fluoropyrimidines or intensified regimens including oxaliplatin. However, many patients receive adjuvant treatment without benefit but suffer from toxicity, in case of oxaliplatin even from life-long chronic neurotoxicity. The aim of this overview is to summarize data for adjuvant treatment of colon and rectal cancer with special focus on UICC substage and age and to discuss points of criticism from a surgical point of view. Adjuvant chemotherapy with 5-fluorouracil (5-FU) and folinic acid (FA) clearly increases survival in colon cancer UICC stage III. Addition of oxaliplatin is especially beneficial for patients with pT3/4pN2 tumors (UICC IIIc). Older patients (≥ 70 years of age) should receive adjuvant treatment as well, because they benefit to the same extent as younger patients. Overall risk reduction by adjuvant treatment is overestimated due to better pre-operative staging (CT) and quality of surgery and pathology resulting in less local recurrence and stage migration. The effects of adjuvant treatment in rectal cancer are less pronounced compared to colon cancer. Especially after the use of neoadjuvant radiochemotherapy in combination with high quality surgery effects of additional adjuvant treatment still have to be clearly established. In summary, adjuvant treatment for colon cancer is well established and should include old patients as well. To reduce side effects and increase efficacy adjuvant treatment should be individualized on the basis of UICC substaging and clinical risk factors, maybe also including molecular subtyping. These strategies may help to further increase the effectiveness of adjuvant treatment in colon and also rectal cancer
Keywords: adjuvant treatment, chemosensitivity, colon cancer, rectal cancer, 5-fluorouracil, oxaliplatin
- D. Baratti, Sh. Kusamura, M. Guaglio, M. DeracoDOI 10.31917/1801010
Peritoneal metastases (PM) from colorectal cancer (CRC) were traditionally associated with bad prognosis. Only recently, cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has resulted in survival improvements. We reviewed the currently available literature regarding the clinical management of colorectal PM. The most relevant and recent studies were selected and their findings were discussed. From these series, the weighted median overall survival was 31,6 months (range 16–51). Major morbidity was 17,6–52,4% (weighted average 32,6%). Mortality was 0–8,1% (weighted average 2,9%). Additional relevant topics, such as CRC-PM prevalence, results by systemic therapies, preoperative work-up, and technical aspects were summarized through a narrative review. The recent literature suggests that CRS/HIPEC is gaining acceptance as standard of care for selected CRC-PM patients. Refinement of selection criteria, and rationalization of comprehensive systemic and local-regional management is ongoing. Prevention and early treatment of PM are new and promising options.
Keywords: colorectal cancer, peritoneal metastasis, cytoreductive surgery, hyperthermic intraperitoneal chemotherapy, HIPEC, liver metastasis
Comparison of laparoscopic and traditional multivisceral resections in locally advanced colorectal cancerI.L. Chernikovskiy, I.I. Aliev, N.V. Savanovich, A.V. GavriliukovDOI 10.31917/1801019
Introduction. The feasibility of the application of laparoscopic surgery in treatment of locally advanced colorectal cancer remains controversial. The aim of our study was to evaluate the safety and efficacy of laparoscopic multivisceral resections for cancer of the colon and rectum.
Materials and methods. The study included 86 patients with T4b tumors of colon and rectum operated from 2013 to 2015. Patients were divided into two groups – 42 into laparoscopic group and 44 into open.
Results. The following miniinvasive procedures were performed: 11 patients underwent laparoscopic resection of primary tumor, combined with hysterectomy (posterior pelvic exenteration), 2 – with liver resections, 8 – with salpingo-oophorectomy, 5 – with small intestine resection, 2 – with splenectomy, 3 – with gastric resection, 2 – with resection of the ureter, 2 – with nephrectomy, 5 – with bladder resection, 3 patients underwent laparoscopic total pelvic exenteration. The average amount of blood loss in laparoscopic group – 205 ml, in open group – 480 ml. Mean operative time was 201 and 150 minutes. Resections within the negative margins were performed in 38 patients in laparoscopic group and 37 in the open group. The average number of lymph nodes was 14. The average postoperative stay was 15 days in laparoscopic group and 23 in the open. Postoperative complications were in 21% and 13% respectively. True invasion (pT4b) according to the morphological study in both groups was 57% and 61%.
Conclusions. Laparoscopic multivisceral resections in patients with locally-advanced colorectal cancer are effective in terms of oncological radicality.
Keywords: locally-advanced colorectal cancer, multivisceral resections, laparoscopic colorectal surgery, T4 cancer of colon and rectum, laparoscopic resections of colon and rectum
- A.O. Rasulov, Z.Z. Mamedli, H.E. Jumabaev, V.M. Kulushev, N.A. KozlovDOI 10.31917/1801027
Introduction. Total mesorectal excision (TME) is a standard of rectal cancer surgery. Oncological results of laparoscopic surgery similar to open. High rate of conversion (16–33%) especially in case of obesity, narrow pelvis and prostate hypertrophy required needs for alternative approaches. Transanal TME – minimal invasive approach that offers advantage of comfortable mobilization and improvement of long term results, accordingly.
Aim. To evaluate advantage of trans-anal TME (TA-TME) in comparison to laparoscopic (Lap-TME).
Material and methods. From October 2013 – 88 patients with rectal carcinoma (cT2-4aNo-2Mo) were enrolled in prospective clinical study. 48 of them were operated with TA-TME and 40 – with traditional laparoscopic. Selection criteria included primary operable rectal cancer patients. Groups were equal in terms of tumor stage, age and BMI.
Results. Duration of surgery was 285 min (TA-TME), 295 min (Lap-TME) and median blood loss less than 100 ml. Postoperative stay was equal – 7 days. Transanal extraction of specimen was possible in 62% in TA-TME vs 34% in Lap-TME. Complications (Clavien-Dindo) were in 33,3% and 25,0% (TA-TME and Lap-TME), no statistically significant differences. Grade IIIb, IVb and V complications were 4,1% in TA-TME and 7,5% in Lap-TME, accordingly. With respect to final pathology – TA-TME group grade 3 TME – 65%, grade 2 – 25%, grade 1 – 10% vs 68%, 12% and 20% – Lap-TME group (p=0,398). «Positive» lateral margin was 6% in TA-TME group vs 10% in Lap-TME.
Conclusion. Short-term results of TA-TME had showed similar outcome that traditional laparoscopic. Further investigations of functional and long-term oncologic results are needed
Keywords: trans-anal TME, laparoscopic TME, rectal cancer, minimal invasive surgery, neoadjuvant chemoradiation
Concept of 3D lymph node dissection and complete mesocolic excision in surgical treatment of colon cancerA.M. Karachun, D.V. Samsonov, A.S. Petrov, S.M. Pazhitnov, L.L. PanayottiDOI 10.31917/1801041
Embryology-oriented surgery is gaining popularity among surgeons nowadays. Such approach is introduced almost for all GI cancers. Complete mesocolic excision (CME) is a relatively new term in modern western European literature, appearing as translation of well known total mesorectal excision concept to colon. Opposed to the latter, CME concept is not recognized as widely as TME. This is mostly due to the lack of evidence to support any benefits of more complicated procedure, associated with higher morbidity rate. D3 concept, being introduced long ago, also failed to demonstrate unequivocal superiority compared to standard dissection level. Current trend towards standardization of surgical treatment require development of unified indications for extended dissections as well as the surgical technique itself.
Keywords: colorectal cancer, surgical treatment, extended lymph node dissection, D3 lymph node dissection, complete mesocolic excision, central ligation of vessels
- I.A. Nechai, E.P. Afanasyieva, N.P. MaltsevDOI 10.31917/1801048
The question about local transanal tumor excision of the vining type of growth (LST) and rectum early cancer Tis-T2 remain to be of current interest today.
The aim of the analysis is to estimate the safety and efficiency of the LST and rectum early cancer excision using the methods of TEO and transanal excision by anoretractor.
Material and methods. 41 patients with LST and rectum early cancer (Tis-T2) were included to examinated group. During the prehospital stage 33 patients (80,4%) were diagnosed with tubulovillous-villiferous or villiferous-vining adenoma, 10 patients (24,4%) – adenocarcinoma Tis-T2. Average size of the tumor was 3,6±1,5 sm. All the patients were executed the full ply excision of the intestinal side with the tumor followed by suture of the wound.
Results. Totally 41 formations were extracted. Postoperative sequela occurred in 2 (4,9%) cases (1 – bleeding from postoperative wound, 1 – perforation of the intestinal side). 3 (7,3%) patients were determined with discrepancy of histological (tissular) examination of the biopsy and removed preparation. 4 patients (9,7%) had the relapse in the remote postoperative period. The received results let us make the conclusion that transanal tumor excision using anoretractor and operating proctoscope on the rigid platform (TEO) are effective and safe methods of the large villiferous adenoma surgery, LST and rectum early cancer.
Keywords: villous laterally spreading tumor, rectal cancer, transanal excision, transanal endoscopic microsurgery
Nature and perfusion dynamics of peritumoral ring enhancement of small (5-9 mm) and very small (less than 5 mm) hypovascular liver metastases: dynamic CT during hepatic arteriography data analysisP.V. Balakhnin, A.S. Shmelev, E.G. Shachinov, M.J. Tsikoridze, A.V. Pozdnyakov, D.E. Matsko, V.M. MoiseyenkoDOI 10.31917/1801058
Aim. To study the nature and perfusion dynamics of peritumoral ring enhancement (PRE) of small (5–9 mm) and very small (<5mm) hypovascular liver metastases during prolonged contrast materials injection into the hepatic artery with dynamic CT during hepatic arteriography.
Material and methods. Dynamic CT during hepatic arteriography was performed in 10 patients with histologically proven colorectal (n=4), pancreatic (n=1), lung (n=1), prostate (n=1) and breast (n=2) cancer liver metastases and GIST (n=1) liver metastases during 40 sec on one breath-hold. Duration of contrast materials injection into the hepatic artery was 40 sec (n=2), 35 sec (n=2), 30 sec (n=4) and 25 sec (n=2) with rate 2 ml/sec.
Results. All small and very small metastases regardless of their morphological affiliation had a PRE. During prolonged contrast materials injection density of PRE gradually increased and eventually has always been much higher than density of the liver parenchyma, and, especially, than density of tumor tissue. Dynamic of contrasting of PRE zone has always been a clear correlation with the dynamics of contrasting of the tumor tissue, i.e. it was a derivative from her function. Vascularization of metastases, intratumoral perfusion parameters and, consequently, the intensity of the PRE, were directly dependent on the tumor diameter. Therefore, PRE of small and particularly, very small metastases «appeared» considerably later and it was significantly less pronounced, compared with PRE of metastases medium (10–19 mm) and large (20–29 mm) diameter, situated in the same liver.
Conclusion. PRE of small and very small hypovascular liver metastases occurs due to the accumulation of contrast materials in the peritumoral area of venous stasis, caused by uncontrolled retrograde discharge of blood, flowing from the metastases to the surrounding sinusoids and portal venules of healthy liver parenchyma, on the one hand, and compression of draining hepatic venules by the tumor, on the other hand
Keywords: peritumoral ring enhancement, blood supply of liver metastases, detection of liver metastases, dynamic CT, CT during hepatic arteriography
Advanced minimally invasive (traditional, laparoscopic and robot-assisted) methods of surgical treatment of diseases of the right colon. А review of the literatureD.V. Gladyshev, D.S. Shelegetov, M.E. Moiseev, I.I. Dzidzava, S.A. Kovalenko, S.S. GnedashDOI 10.31917/1801079
If conventional laparoscopy in colon diseases treatment has recently become a well-recognized technique, preferable by most specialists over the world, the feasibility of robotic operations is still questioned. This is due to the relatively recent introduction of this technique and it is not as wide spread as opposed to conventional laparoscopic surgery. Currently, the literature shows the results of many studies comparing these techniques for operations on the colon. In our article, we present a review of the current literature, which presents the comparative analysis of the short-term outcomes of robotic and conventional laparoscopic surgery of the right colon.
Keywords: robot-assisted colectomy, colon cancer, surgical complex «Da Vinci», robot-assisted right hemicolectomy, laparoscopic-assisted right hemicolectomy, a review of the literature