Medication of Diseases News - Part 81

Predicting residual rectal adenocarcinoma in the surgical specimen: Results (Part 3)

Median follow-up was 6.5 months from the time of recruitment (range two to 14 months). One patient died at nine months without local tumour recurrence; this patient had residual post-BT T3N1 disease by both EUS and pathology and had undergone an anterior resection with negative margins. No other recurrences have been documented.

Performance of post-BT EUS in predicting residual tumour

Predicting residual rectal adenocarcinoma in the surgical specimen: Results (Part 2)

carcinoma in situOne additional patient had only carcinoma in situ. Three of the 11 patients (27%) with residual tumour only had tiny foci of malignant cells, seen in selected blocks. One of the 18 (5.6%) treated had residual T1 disease, one (5.6%) had stage T2 disease and eight (44%) had stage T3 disease. Significant downstaging occurred with significantly fewer patients having stage T3 disease after BT, in the surgical specimen (P<0.001; 95% Cl for difference: 17% to 72%). Mean MWT on EUS decreased from 14 mm to 9.2 mm (P<0.001).

Predicting residual rectal adenocarcinoma in the surgical specimen: Results (Part 1)

Factors predicting residual tumour were assessed from both the pre-BT EUS (proportion with stage T3 disease, proportion with nodal involvement, MWT) and the post-BT EUS (proportion down-staged, absolute reduction in MWT). Unpaired Student’s t tests were used for hypothesis testing involving continuous variables, and the %2 test (or Fisher’s Exact test where appropriate) was used for comparisons of proportions.

Eighteen patients underwent a post-BT EUS assessment for the presence of residual tumour and none had endoclips remaining at this assessment.

Predicting residual rectal adenocarcinoma in the surgical specimen: Surgery and pathological examination

The resected colorectal specimens were fixed in 10% buffered formalin for one to three days, then described and sectioned according to a uniform protocol: multiple longitudinal 5 mm-thick slices were made throughout the abnormal areas, either ulcerated or containing macroscopically visible tumour, and multiple tissue blocks were taken from all of these areas; in most cases, the entire abnormal-appearing regions were submitted for histological examination.

Predicting residual rectal adenocarcinoma in the surgical specimen: EUS

repeat EUS examinationPatients underwent a repeat EUS examination, performed by a single dedicated endosonographer, six weeks (range four to eight weeks) after completion of BT, and within two weeks before the planned surgical resection. The endosonographer was not blinded to the pre-BT EUS results. Patients with mild circumferential thickening of all wall layers, with layer blurring but without a focal hypoechoic mass, were considered to have inflammatory changes but no residual tumour; those thought to have residual tumour were re-staged according the American Joint Committee on Cancer (TNM) classification.

Predicting residual rectal adenocarcinoma in the surgical specimen: BT protocol

All patients were examined by flexible sigmoidoscopy and rectal EUS after completion of their MRI and CT; a pre-BT clinical staging was assigned using the American Joint Committee on Cancer TNM classification . During this examination, after the EUS was completed, endoclips (Olympus Co, USA) were endoscopically placed at the proximal and distal margins of the tumour mass to facilitate BT planning and imaging whenever technically possible.

Predicting residual rectal adenocarcinoma in the surgical specimen: Patient population

patients recruited into the trialBetween October 1998 and October 2000, 33 patients were recruited into the study protocol to assess the feasibility and effectiveness of a novel conformal high-dose rate BT protocol for locally invasive rectal adenocarcinoma. Local institutional review board approval was obtained and all patients gave informed consent.

Patients with newly diagnosed, locally advanced (stage T2 or T3) rectal adenocarcinoma who presented to the McGill University Health Centre and fulfilled the entry criteria, were recruited for the study protocol.

Predicting residual rectal adenocarcinoma in the surgical specimen (Part 2)

Endoluminal ultrasound has been used since the early 1980s to stage rectal adenocarcinoma. In 14 studies reviewed by Heriot et al , many of which involved a nonoptical probe, this modality demonstrated a tumour (T)-staging accuracy of 75% to 93% (except for one study showing an accuracy of 67%), and a lymph node (N)-staging accuracy of 77% to 88% (except for one study showing an accuracy of 62%). Endoscopic ultrasound (EUS) also appears to be marginally more accurate than T- and N-staging by pelvic magnetic resonance imaging (MRI).

Predicting residual rectal adenocarcinoma in the surgical specimen (Part 1)

Cancer of the colon and rectumCancer of the colon and rectum is diagnosed in over 100,000 new patients each year in the United States. The surgical therapy for rectal adenocarcinoma can be particularly disabling to patients, because it involves abdominoperineal resection (APR) for cases in which a 2 cm distal tumour-free margin is not felt to be possible using an anterior approach. Selective pre- or postoperative chemoradiotherapy has traditionally been regarded as adjuvant, in an attempt to reduce local recurrence and perhaps improve survival, but it has not been intended to achieve cure as primary therapy.

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