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How P.,Pelican Cancer Foundation | Evans J.,University of Surrey | Moran B.,North Hampshire Hospital | Swift I.,University of Surrey | Brown G.,Royal Marsden Hospital
Colorectal Disease | Year: 2012

Aim Good functional outcome following anterior resection (AR) for rectal cancer is an important clinical goal, but its prediction has proven difficult. Assessments such as anal manometry have been advocated as a potential tool but functional anatomy as depicted on MRI has not been investigated. This study looked at whether sphincter complex measurements recorded from preoperative staging MRIs and preoperative anal manometry have any correlation with functional outcome. Method Consecutive patients with rectal adenocarcinoma underwent preoperative manometric assessment and MRI staging. MRIs were assessed with regard to anorectal angle, puborectalis thickness, canal length and external and internal anal sphincter thickness. Functional outcome was categorized into three groups according to the number of adverse postoperative symptoms (frequency, urgency, leakage, diarrhoea, use of pads, use of antidiarrhoeal medication): 0, 1 and ≥2. This was evaluated 1year following surgery and 6months following stoma reversal where applicable. Univariate analysis of an ordinal regression model was performed with significance at the 5% level. Results Thirty patients were assessed. No single preoperative manometric parameter proved significant (P>0.05). Only puborectalis thickness showed a significant (P=0.01) relationship with the number of adverse symptoms suffered postoperatively. On receiver operating characteristics analysis, a cut-off value of 3.5mm gave an optimal sensitivity of 0.5 (95% CI, 0.17-0.83) and specificity of 0.86 (95% CI, 0.64-0.96). Conclusions Measurements of the puborectalis thickness on preoperative staging MRIs for rectal cancer may help predict functional outcome following AR. Prospective assessment of larger numbers with a fully validated continence score are required to evaluate these findings further. © 2012 The Authors. Colorectal Disease © 2012 The Association of Coloproctology of Great Britain and Ireland.

Ahmed H.U.,University College London | Akin O.,Sloan Kettering Cancer Center | Coleman J.A.,Sloan Kettering Cancer Center | Crane S.,Pelican Cancer Foundation | And 11 more authors.
BJU International | Year: 2012

OBJECTIVE • To reach consensus on key issues for clinical practice and future research in active surveillance and focal therapy in managing localized prostate cancer. PATIENTS AND METHODS • A group of expert urologists, oncologists, radiologists, pathologists and computer scientists from North America and Europe met to discuss issues in patient population, interventions, comparators and outcome measures to use in both tissue-preserving strategies of active surveillance and focal therapy. • Break-out sessions were formed to provide agreement or highlight areas of disagreement on individual topics which were then collated by a writing group into statements that formed the basis of this report and agreed upon by the whole Transatlantic Consensus Group. RESULTS • The Transatlantic group propose that emerging diagnostic tools such as precision imaging and transperineal prostate mapping biopsy can improve prostate cancer care. These tools should be integrated into prostate cancer management and research so that better risk stratification and more effective treatment allocation can be applied. • The group envisaged a process of care in which active surveillance, focal therapy, and radical treatments lie on a continuum of complementary therapies for men with a range of disease grades and burdens, rather than being applied in the mutually exclusive and competitive way they are now. CONCLUSION • The changing landscape of prostate cancer epidemiology requires the medical community to re-evaluate the entire prostate cancer diagnostic and treatment pathway in order to minimize harms resulting from over-diagnosis and over-treatment. Precise risk stratification at every point in this pathway is required alongside paradigm shifts in our thinking about what constitutes cancer in the prostate. © 2011 BJU International.

Lacy A.M.,University of Barcelona | Tasende M.M.,University of Barcelona | Delgado S.,University of Barcelona | Fernandez-Hevia M.,University of Barcelona | And 6 more authors.
Journal of the American College of Surgeons | Year: 2015

Background The anatomic difficulties that we have to deal with in open surgery for rectal cancer have not been overcome with the laparoscopic approach. In the search for a solution, a change of concept arose: approaching the rectum from below. The main objectives of this study were to show the potential advantages of the hybrid transabdominal-transanal total mesorectal excision (taTME). This approach may improve quality of the mesorectal specimens. Second, proctectomy can be technically easier and more safely performed "down to up," which would result in shorter surgical times, lower conversion rates, and less morbidity. Study Design A prospective series of hybrid taTME was conducted from October 2011 to November 2014. Results During the study period, 140 procedures were performed. Mean operative time was 166 minutes. There were no conversions or intraoperative complications. Macroscopic quality assessment of the resected specimen was complete in 97.1% and nearly complete in 2.1%. Thirty-day morbidity was minor (Clavien-Dindo I + II) in 24.2% and major (Clavien-Dindo III + IV) in 10 %. No patient died within the first 30 days postsurgery (Clavien-Dindo V). The mean follow-up was 15 months, with a 2.3% local recurrence rate and a 7.6% rate of systemic recurrence. Conclusions Pathologic analysis showed a very good macroscopic quality of TME specimens, which is the most important prognostic factor in rectal cancer. Intraoperative outcomes regarding conversion, surgical times, and intraoperative complications are very satisfactory. Short-term morbidity and oncologic outcomes are as good as in other laparoscopic TME series. © 2015 American College of Surgeons.

Taylor F.G.M.,Mayday University Hospital | Quirke P.,University of Leeds | Heald R.J.,Pelican Cancer Foundation | Moran B.J.,Pelican Cancer Foundation | And 5 more authors.
Journal of Clinical Oncology | Year: 2014

Purpose: The prognostic relevance of preoperative high-resolution magnetic resonance imaging (MRI) assessment of circumferential resection margin (CRM) involvement is unknown. This follow-up study of 374 patients with rectal cancer reports the relationship between preoperative MRI assessment of CRM staging, American Joint Committee on Cancer (AJCC) TNM stage, and clinical variables with overall survival (OS), disease-free survival (DFS), and time to local recurrence (LR). Patients and Methods: Patients underwent protocol high-resolution pelvic MRI. Tumor distance to the mesorectal fascia of ≤ 1 mm was recorded as an MRI-involved CRM. A Cox proportional hazards model was used in multivariate analysis to determine the relationship of MRI assessment of CRM to survivorship after adjusting for preoperative covariates. Results: Surviving patients were followed for a median of 62 months. The 5-year OS was 62.2% in patients with MRI-clear CRM compared with 42.2% in patients with MRI-involved CRM with a hazard ratio (HR) of 1.97 (95% CI, 1.27 to 3.04; P < .01). The 5-year DFS was 67.2% (95% CI, 61.4% to 73%) for MRI-clear CRM compared with 47.3% (95% CI, 33.7% to 60.9%) for MRI-involved CRM with an HR of 1.65 (95% CI, 1.01 to 2.69; P < .05). Local recurrence HR for MRI-involved CRM was 3.50 (95% CI, 1.53 to 8.00; P < .05). MRI-involved CRM was the only preoperative staging parameter that remained significant for OS, DFS, and LR on multivariate analysis. Conclusion: High-resolution MRI preoperative assessment of CRM status is superior to AJCC TNM-based criteria for assessing risk of LR, DFS, and OS. Furthermore, MRI CRM involvement is significantly associated with distant metastatic disease; therefore, colorectal cancer teams could intensify treatment and follow-up accordingly to improve survival outcomes. © 2013 by American Society of Clinical Oncology.

Meisner S.,Copenhagen University | Lehur P.-A.,University of Nantes | Moran B.,Pelican Cancer Foundation | Martins L.,London Health Sciences Center | Jemec G.B.E.,Copenhagen University
PLoS ONE | Year: 2012

Background: Peristomal skin complications (PSCs) are the most common post-operative complications following creation of a stoma. Living with a stoma is a challenge, not only for the patient and their carers, but also for society as a whole. Due to methodological problems of PSC assessment, the associated health-economic burden of medium to longterm complications has been poorly described. Aim: The aim of the present study was to create a model to estimate treatment costs of PSCs using the standardized assessment Ostomy Skin Tool as a reference. The resultant model was applied to a real-life global data set of stoma patients (n = 3017) to determine the prevalence and financial burden of PSCs. Methods: Eleven experienced stoma care nurses were interviewed to get a global understanding of a treatment algorithm that formed the basis of the cost analysis. The estimated costs were based on a seven week treatment period. PSC costs were estimated for five underlying diagnostic categories and three levels of severity. The estimated treatment costs of severe cases of PSCs were increased 2-5 fold for the different diagnostic categories of PSCs compared with mild cases. French unit costs were applied to the global data set. Results: The estimated total average cost for a seven week treatment period (including appliances and accessories) was 263€ for those with PSCs (n = 1742) compared to 215€ for those without PSCs (n = 1172). A co-variance analysis showed that leakage level had a significant impact on PSC cost from 'rarely/never' to 'always/often' p<0.00001 and from 'rarely/never' to 'sometimes' p = 0.0115. Conclusion: PSCs are common and troublesome and the consequences are substantial, both for the patient and from a health economic viewpoint. PSCs should be diagnosed and treated at an early stage to prevent long term, debilitating and expensive complications. © 2012 Meisner et al.

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