Basingstoke, United Kingdom
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Sondenaa K.,Haraldsplass Deaconess Hospital | Sondenaa K.,University of Bergen | Quirke P.,University of Leeds | Hohenberger W.,Friedrich - Alexander - University, Erlangen - Nuremberg | And 13 more authors.
International Journal of Colorectal Disease | Year: 2014

Background: It has been evident for a while that the result after resection for colon cancer may not have been optimal. Several years ago, this was showed by some leading surgeons in the USA but a concept of improving results was not consistently pursued. Later, surgeons in Europe and Japan have increasingly adopted the more radical principle of complete mesocolic excision (CME) as the optimal approach for colon cancer. The concept of CME is a similar philosophy to that of total mesorectal excision for rectal cancer and precise terminology and optimal surgery are key factors. Method: There are three essential components to CME. The main component involves a dissection between the mesenteric plane and the parietal fascia and removal of the mesentery within a complete envelope of mesenteric fascia and visceral peritoneum that contains all lymph nodes draining the tumour area (Hohenberger et al., Colorectal Disease 11:354-365, 2009; West et al., J Clin Oncol 28:272-278, 2009). The second component is a central vascular tie to completely remove all lymph nodes in the central (vertical) direction. The third component is resection of an adequate length of bowel to remove involved pericolic lymph nodes in the longitudinal direction. Result: The oncological rationale for CME and various technical aspects of the surgical management will be explored. Conclusion: The consensus conference agreed that there are sound oncological hypotheses for a more radical approach than has been common up to now. However, this may not necessarily apply in early stages of the tumour stage. Laparoscopic resection appears to be equally well suited for resection as open surgery. © 2014 Springer-Verlag Berlin Heidelberg.


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.


Battersby N.J.,Pelican Cancer Foundation | How P.,Pelican Cancer Foundation | Moran B.,North Hampshire Hospital | Stelzner S.,Dresden Friedrichstadt General Hospital | And 9 more authors.
Annals of Surgery | Year: 2016

Objective: This study aimed to validate a magnetic resonance imaging (MRI) staging classification that preoperatively assessed the relationship between tumor and the low rectal cancer surgical resection plane (mrLRP). Background: Low rectal cancer oncological outcomes remain a global challenge, evidenced by high pathological circumferential resection margin (pCRM) rates and unacceptable variations in permanent colostomies. Methods: Between 2008 and 2012, a prospective, observational, multicenter study (MERCURY II) recruited 279 patients with adenocarcinoma 6 cm or less from the anal verge. MRI assessed the following: mrLRP "safe or unsafe," venous invasion (mrEMVI), depth of spread, node status, tumor height, and tumor quadrant. MRI-based treatment recommendations were compared against final management and pCRM outcomes. Results: Overall pCRM involvement was 9.0% [95% confidence interval (CI), 5.9-12.3], significantly lower than previously reported rates of 30%. Patients with no adverse MRI features and a "safe" mrLRP underwent sphincter-preserving surgery without preoperative radiotherapy, resulting in a 1.6% pCRM rate. The pCRM rate increased 5-fold for an "unsafe" compared with "safe" preoperative mrLRP [odds ratio (OR) = 5.5; 95% CI, 2.3-13.3)]. Posttreatment MRI reassessment indicated a "safe" ymrLRP in 33 of 113 (29.2%), none of whom had ypCRM involvement. In contrast, persistent "unsafe" ymrLRP posttherapy resulted in 17.5% ypCRM involvement. Further independent MRI assessed risk factors were EMVI (OR = 3.8; 95% CI, 1.5-9.6), tumors less than 4.0 cm from the anal verge (OR = 3.4; 95% CI, 1.3-8.8), and anterior tumors (OR = 2.8; 95% CI, 1.1-6.8). Conclusions: The study validated MRI low rectal plane assessment, reducing pCRM involvement and avoiding overtreatment through selective preoperative therapy and rationalized use of permanent colostomy. It also highlights the importance of posttreatment restaging. © 2015 Wolters Kluwer Health, Inc. All rights reserved.


How P.,Pelican Cancer Foundation | Shihab O.,Pelican Cancer Foundation | Tekkis P.,Royal Marsden Hospital | Brown G.,Royal Marsden Hospital | And 3 more authors.
Surgical Oncology | Year: 2011

Purpose: It is a widely held view that anterior resection (AR) for rectal cancer is an oncologically superior operation to abdominoperineal excision (APE). However, some centres have demonstrated better outcomes with APE. We conducted a systematic review of high-quality studies within the total mesorectal excision (TME) era comparing outcomes of AR and APE. Methods: A literature search was performed to identify studies within the TME era comparing AR and APE with regard to the following: circumferential resection margin (CRM) status, tumour perforation rates, specimen quality, local recurrence, overall survival (OS; 3 or 5 year), cancer-specific survival (CSS) and disease-free survival (DFS). Additional data regarding patient demographics and tumour characteristics was collected. Results: Twenty four studies fulfilled the eligibility criteria with Newcastle-Ottawa scores of six or greater. Where a significant difference was found, all studies reported lower and more advanced tumours for APE and 4/5 studies observed more frequent use of neoadjuvant and adjuvant therapies in APE patients. Tumour perforation rates and CRM involvement where reported, were significantly greater for APE. 8 out of 10 studies showing significant differences in local recurrence reported higher rates for APE but no differences were observed with distant recurrence. Where differences were noted, AR was reported to have increased DFS, CSS and OS compared to APE. Conclusions: Patients treated with AR have lower rates of tumour perforation and CRM involvement and tend to have better outcomes with regard to disease recurrence and survival. However, tumours treated by APE are lower and more locally advanced. © 2011 Elsevier Ltd. All rights reserved.


PubMed | Hampshire Hospitals NHS Foundation Trust, University of Oxford and Pelican Cancer Foundation
Type: | Journal: Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland | Year: 2016

The LOREC perineal wound healing registry was developed to record data on abdominoperineal excision (APE) for rectal cancer in colorectal units in England between 2012 and 2014 to understand current practice in operative technique and results.Surgeons wishing to participate received secure web-based access to the registry. Collected data included pre-operative staging, neo-adjuvant treatment, operative details, histopathology, early outcome and follow-up at 12 months.42 units entered 266 patients. Of these 172 (65%) underwent extralevator APE (ELAPE) and 94 non-ELAPE. On pre-operative staging 64% were mrT3/4 and 67% received neoadjuvant treatment. For ELAPE the perineal wound was closed primary with mesh in 55%, without mesh in 15% and with a flap in 21% of cases. For non-ELAPEs, 54% of wounds were closed primarily without mesh, 29% primarily with mesh and 5% by a flap. Wound breakdown occurred in 30% of ELAPE and 31% of non-ELAPE, but was more common after neo-adjuvant radiotherapy. Donor site complications occurred in 17% of flap cases. 11% of patients had perineal morbidity at 12 months. On histopathology, the resection margin was positive in 13% of ELAPE and in 4% of non-ELAPE.The LOREC registry provides a picture of current APE practice in England. ELAPE was used in two-thirds of patients but does not appear to confer any additional morbidity. Primary closure with mesh appeared as effective as flap reconstruction. The rate of an involved resection margin was less than reported in many historical series but still remains high in the ELAPE group. This article is protected by copyright. All rights reserved.


PubMed | Royal Marsden Hospital, Imperial College London, University of London, Pelican Cancer Foundation and 2 more.
Type: | Journal: Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland | Year: 2016

MRI-detected extramural venous invasion (mrEMVI) is a poor prognostic factor in rectal cancer. Pre-operative chemoradiotherapy (CRT) can cause regression in the severity of EMVI and subsequently improve survival whereas mrEMVI persisting after CRT confers an increased risk of recurrence. The effect of adjuvant chemotherapy (AC) following CRT on survival in rectal cancer remains unclear. The aim of this study was to determine whether there is a survival advantage for AC given to patients with mrEMVI persisting after CRT.A prospective analysis was conducted of consecutive patients with locally-advanced rectal cancer between 2006-2013. All patients underwent CRT followed by surgery. AC was given to selected patients based on the presence of specific high-risk features. Comparison was made between patients offered AC with observation alone. The primary outcome was three -year disease-free survival (DFS).227 (36.0%) of 631 patients demonstrated persistent mrEMVI following CRT. Patients were grouped on the basis of AC or observation and were matched for age, performance status and final histopathological staging. Three-year DFS in the AC group was 74.6% compared with 53.7% in the observation only group. AC had a survival benefit on multivariate analysis (HR 0.458; 95%CI 0.271-0.775 p=0.004).Patients with persistent mrEMVI following CRT who receive AC may have a decreased risk of recurrence and an improved three-year DFS compared with patients not receiving AC, irrespective of age and performance status. This article is protected by copyright. All rights reserved.


Battersby N.J.,Pelican Cancer Foundation | Battersby N.J.,Imperial College London | Moran B.,Pelican Cancer Foundation | Moran B.,Hampshire Hospitals NHS FT | And 4 more authors.
Expert Review of Gastroenterology and Hepatology | Year: 2014

Pre-operative staging is an essential aspect of modern rectal cancer management and radiological assessment is central to this process. An ideal radiological assessment should provide sufficient information to reliably guide pre-operative decision-making. Technical advances allow high-resolution imaging to not only provide prognostic information but to define the anatomy, helping the surgeon to anticipate potential pitfalls during the operation. The main imaging modality for local staging of rectal cancer is Magnetic Resonance Imaging (MRI), as it defines the tumour and relevant anatomy providing the most detail on the important prognostic factors that influence treatment choice. In addition, there is an emerging role for MRI in the assessment of the response to neoadjuvant therapy. This article is an evidence-based review of rectal cancer staging focusing on post-treatment assessment of response using MRI. The discussion extends into the implications for reliably assessing response and how this may influence future rectal cancer management. © 2014 Informa UK, Ltd.


How P.,Pelican Cancer Foundation | Stelzner S.,Dresden Friedrichstadt General Hospital | Branagan G.,Salisbury District Hospital | Bundy K.,Frimley Park Hospital | And 3 more authors.
Diseases of the Colon and Rectum | Year: 2012

BACKGROUND: It is widely believed that quality of life is worse after abdominoperineal excision then after low anterior resection. However, this view is not supported unequivocally. OBJECTIVE: The aim of this study was to compare quality of life in patients 1 year following low anterior resection and abdominoperineal excision for low rectal cancer. DESIGN: Data were collected prospectively on 62 patients undergoing low anterior resection (32) and abdominoperineal excision (30) for low rectal adenocarcinoma within 6 cm of the anal verge. Patients with metastatic disease were excluded. Quality of life was assessed by the use of the European Organization for Research and Treatment of Cancer's QLQ-C30 and QLQ-CR38 modules and Coloplast stoma quality-of-life questionnaire. Bowel function was assessed by using the St Mark's bowel function questionnaire. Quality of life in patients who had low anterior resection was compared with those who had abdominoperineal excision both preoperatively and 1 year after surgery. SETTINGS: This study was conducted at 3 centers in the United Kingdom and 1 center in Europe. PATIENTS: Included were consecutive patients with rectal cancer within 6 cm of the anal verge, all of whom provided written consent for participation. MAIN OUTCOME MEASURES: Mann-Whitney U test comparisons of QLQ-C30 and QLQ-CR38 module scores for patients undergoing low anterior resection and abdominoperineal excision were the main outcomes measured. RESULTS: Patients undergoing low anterior resection were younger (median age, 59.5 vs 67, p = 0.03) with higher tumors (4 vs 3, p < 0.001) and less likely to receive neoadjuvant therapy (p = 0.02). At 1 year postoperatively, global quality-of-life ratings were comparable, but patients undergoing abdominoperineal excision reported better cognitive (100 vs 83, p = 0.018) and social (100 vs 67, p = 0.012) function, and less symptomatology with respect to pain (0 vs 17, p = 0.027), sleep disturbance (0 vs 33, p = 0.013), diarrhea (0 vs 33, p = 0.017), and constipation (p = 0.021). Patients undergoing low anterior resection reported better sexual function (33 vs 0, p = 0.006), but 72% experienced a degree of fecal incontinence. LIMITATIONS: This study was limited by its relatively small sample size. CONCLUSION: Abdominoperineal excision should not be regarded as an operation that is inferior to low anterior resection in the management of low rectal cancer on the basis of quality of life alone. © The ASCRS 2012.


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.

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