Consensus statement on the multidisciplinary management of patients with recurrent and primary rectal cancer beyond total mesorectal excision planes (original) (raw)
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Acta chirurgica iugoslavica, 2010
PURPOSE: Although surgery remains the most important treatment of rectal cancer, the management of this disease has evolved to become more multidisciplinary to offer the best clinical outcome. The International Conference on Multidisciplinary Rectal Cancer Treatment: Looking for an European Consensus' (EURECA-CC2) had the due to identify the degree of consensus that could be achieved across a wide range of topics relating to the management of rectal cancer helping shape future programs, investigational protocols and guidelines for staging and treatment throughout Europe. MATERIALS AND METHODS: Consensus was achieved using the Delphi method. Eight chapters were identified: epidemiology, diagnostics, pathology, surgery, radiotherapy and chemotherapy, treatment toxicity and quality of life, follow-up, and research questions. Each chapter was subdivided by topic, and a series of statements were developed. Each committee member commented and voted, sentence by sentence three times. Sentences which did not reach agreement after voting round # 2 were openly debated during the Conference in Perugia (Italy) December 2008. The Executive Committee scored percentage consensus based on three categories: "large consensus", "moderate consensus", "minimum consensus". RESULTS: The total number of the voted sentences was 207. Of the 207, 86% achieved large consensus, 13% achieved moderate consensus, and only 3 (1%) resulted in minimum consensus. No statement was disagreed by more than 50% of members. All chapters were voted on by at least 75% of the members, and the majority was voted on by 85%. CONCLUSIONS: This Consensus Conference represents an expertise opinion process that may help shape future programs, investigational protocols, and guidelines for staging and treatment of rectal cancer throughout Europe. In spite of substantial progress, many research challenges remain.
Multidisciplinary Management of Rectal Cancer - a Retrospective Study
2006
MULTIDISCIPLINARY MANAGEMENT OF RECTAL CANCER - A R ETROSPECTIVE STUDY - (Abstract): Background: The procedure of low or very low anterior resection of the rectum with total mesorectal excision (TME) it is now widely accepted for tumours of the middle and lower third of the r ectum. It has become the gold standard for the treatment of c ancer of the rectum, except where the tumor is clos e to or is involving the anal sphincter complex. Patients and methods: A retrospective study on 120 patients diagnosed with colorectal cancer and operated on between 2000 and 2004 was carried out. There were 120 anterior resection of the rectum, in 34 cases the total meso rectal excision has been performed and in 11 cases a very low anterior resection was made. All 45 cases where tot al mesorectal excision was made, had undertaken preoperative radiotherapy, surgery being performed after 4 to 6 weeks from the last session of radioth erapy. Results : The overall operative morbidity rate was 16.10% i n...
Optimizing Rectal Cancer Management
Diseases of the Colon & Rectum, 2014
C olorectal carcinoma remains the second leading cause of cancer-related deaths in Western countries, with rectal carcinoma accounting for ≈25% of cases arising from the large bowel. Rectal cancer affects more than 40,000 patients annually in the united states, and a majority of these patients undergo surgery, with approximately half dying as a consequence of their disease. 1-3 therefore, rectal cancer represents a significant healthcare problem in terms of incidence, seriousness, and use of resources. historically a huge variation among surgeons has been described in results of colorectal cancer surgery, with statistically significant differences in curative resection, postoperative morbidity and mortality, and long-term survival. 4 Rectal cancer surgery is considered more technically challenging compared with colon cancer surgery, mainly because of the anatomy of the pelvis and the resulting challenge that a surgeon faces in achieving good resection margins in a confined, fixed bony space in close proximity to vital structures. historically these challenges have been reflected in poorer oncologic results, with local recurrence rates approaching 30% and worse overall survival in comparison with that of colon cancer. 5 in the united states, the majority of rectal cancer surgeries have traditionally been performed by trained general surgeons, who may or may not have a colorectal subspecialty interest. studies indicate that there is significant room for improvement in the outcomes of rectal cancer surgery, with significant variation in results including rates of margin positivity, local recurrence, use of neoadjuvant and adjuvant therapy, and permanent stomas. some reports indicate variations in local recurrence rates of between 0% and 13% for colorectal surgeons and between 21% and 37% for general surgeons. 6-8 Differences in mortality also exist, with rates of 1.4% for colorectal surgeons and >7.0% for general surgeons being reported. 8 in a recent study of proctectomies, restorative techniques were used in 50% of patients, with abdominoperineal resection rates as high as 60% in some regions. 8,9 in addition, approximately one fifth of proctectomies were performed by a specialist colorectal surgeon, and ≈40% of the surgeons only performed nonrestorative surgery. 10,11 the management of rectal cancer has fundamentally changed in the last 3 decades with the introduction of staging, total mesorectal excision (tme), chemoradiotherapy (CRt), and multidisciplinary management. since the 1980s, 5 main principles have been developed that, when combined, have led to significant reductions in rates of local recurrence, increases in disease-free and overall survival, and reduction in permanent stoma rates. in countries and centers that have implemented such programs, the cancer-specific outcomes from rectal cancer now match those of colon cancer for the first time. 12 the principles include the following: 1) rectal surgery according to the principles of tme, 2) measurement of quality of surgery and accurate staging by specific techniques of pathology assessment, 3) specialist imaging techniques identifying Optimizing Rectal Cancer Management: Analysis of Current Evidence
World Journal of Surgery, 2020
Background: Management of rectal cancer has a number of potentially appropriate alternatives for each patient. Despite acceptance of standards, practices may vary among regions. There is significant paucity of data in this area. The objective was to create a snapshot of the regional differences. Design: This online survey included 10 questions. Enquiries focused on controversial topics, on surgeon and hospital volume, surgical margins, appropriateness of surgical approaches and techniques, Watch and Wait strategies and total neoadjuvant therapy. Major colorectal surgery societies around the world were asked to invite their members to complete the survey. Outcomes measures: Frequency of responses across regions within each question was compared by Fisher's exact test. Results: 753 participants from 60 countries responded. 8 regions were identified, 4 had sufficient representation for comparisons. Similarities and differences in the therapies amongst these regions were identified. Robotic surgery penetrance is higher in North America, watch and wait is more accepted in South America. Patients in Oceania are more likely to be diverted, Europe has more usage of taTME. Discussion: This online survey was practical as a mean to provide a rapid assessment of the international picture on consistency and variability of rectal cancer patients care, and to potentially identify opportunities to standardized care to patients. Medical surveys have inherent limitations, pertinent to our study is selection bias is one. Conclusions: The management of rectal cancer varies among different regions. Identification of differences is important when considering global efforts to improve management and interpret data.
Total mesorectal excision for rectal cancer - what can be achieved by a national audit
Colorectal Disease, 2003
Objective The results of rectal cancer surgery in Norway have been poor. In a national audit for the period 1986-88, 28% of the patients developed local recurrence (LR) following treatment with a curative intent. Five-year overall survival was 55% for patients younger than 75 years. The aim of this study is to report how an initiative focusing on better surgery can improve the prognosis for rectal cancer patients on a national level.
BMC cancer, 2016
Among patients with rectal cancer, 5-10 % have a primary rectal cancer beyond the total mesorectal excision plane (PRC-bTME) and 10 % recur locally following primary surgery (LRRC). In both cases, patients 'care remains challenging with a significant worldwide variation in practice regarding overall management and criteria for operative intervention. These variations in practice can be explained by structural and organizational differences, as well as cultural dissimilarities. However, surgical resection of PRC-bTME and LRRC provides the best chance of long-term survival after complete resection (R0). With regards to the organization of the healthcare system and the operative criteria for these patients, France and Australia seem to be highly different. A benchmarking-type analysis between French and Australian clinical practice, with regards to the care and management of PRC-bTME and LRRC, would allow understanding of patients' care and management structures as well as indi...
Annals of Gastroenterology, 2016
In rectal cancer management, accurate staging by magnetic resonance imaging, neo-adjuvant treatment with the use of radiotherapy, and total mesorectal excision have resulted in remarkable improvement in the oncological outcomes. However, there is substantial discrepancy in the therapeutic approach and failure to adhere to international guidelines among different Greek-Cypriot hospitals. The present guidelines aim to aid the multidisciplinary management of rectal cancer, considering both the local special characteristics of our healthcare system and the international relevant agreements (ESMO, EURECCA). Following background discussion and online communication sessions for feedback among the members of an executive team, a consensus rectal cancer management was obtained. Statements were subjected to the Delphi methodology voting system on two rounds to achieve further consensus by invited multidisciplinary international experts on colorectal cancer. Statements were considered of high, moderate or low consensus if they were voted by ≥80%, 60-80%, or <60%, respectively; those obtaining a low consensus level after both voting rounds were rejected. One hundred and two statements were developed and voted by 100 experts. The mean rate of abstention per statement was 12.5% (range: 2-45%). In the end of the process, all statements achieved a high consensus. Guidelines and algorithms of diagnosis and treatment were proposed. The importance of centralization, care by a multidisciplinary team, adherence to guidelines, and personalization is emphasized.
Surgical resection for rectal cancer: a gold standard or a last resort
In recent times, the management of rectal cancer has evolved and a multimodal approach utilising selective combinations of chemotherapy, radiotherapy and surgery are employed. Surgery may be local excision or proctectomy which in turn can be open, laparoscopic or robotic. Improvement in neoadjuvant treatment has demonstrated that some patients ultimately do not need to undergo surgery or may only require local excision of their tumour. However, this is a complex field where many treatment options exist and selecting the correct approach is reliant on accurate pre-operative staging and then tailoring treatments to each individual patient. It is imperative that patients are informed of the advantages and disadvantages of each approach allowing them to make an informed decision based on the evidence. It is also crucial that in treating rectal cancer, the surgical team has all these tools in their armamentarium in order to treat all stages of the disease. In the present case, the patient underwent maximal neoadjuvant treatment with chemotherapy and chemoradiotherapy and ultimately required pelvic exenteration. The decision making in this process is truly multidisciplinary and requires many specialties and allied health teams to support the patient through this process.