Restaging rectal cancer following neoadjuvant chemoradiotherapy

Correct tumour restaging is pivotal for identifying the most personalised surgical treatment for patients with locally advanced rectal cancer undergoing neoadjuvant therapy,and works to avoid both poor oncological outcome and overtreatment.Digital rectal examination,endoscopy,and pelvic magnetic resonance imaging are the recommended modalities for local tumour restaging,while chest and abdominal computed tomography are utilised for the assessment of distant disease.The optimal length of time between neoadjuvant treatment and restaging,in terms of both oncological safety and clinical effectiveness of treatment,remains unclear,especially for patients receiving prolonged total neoadjuvant therapy.The timely identification of patients who are radioresistant and at risk of disease progression remains challenging.

Evolving role of FDG-PET/CT in prognostic evaluation of resectable gastric cancer

Gastric cancer(GC) remains a leading cause of cancer death worldwide. Radical gastrectomy is the only potentially curative treatment, and perioperative adjuvant therapies may improve the prognosis after curative resection. Prognosis largely depends on the tumour stage and histology, but the host systemic inflammatory response(SIR) to GC may contribute as well, as has been determined for other malignancies. In GC patients, the potential utility of positron emission tomography/computed tomography(PET/CT) with the imaging radiopharmaceutical 18F-fluorodeoxyglucose(FDG) is still debated, due to its lower sensitivity in diagnosing and staging GC compared to other imaging modalities. There is, however, growing evidence that FDG uptake in the primary tumour and regional lymph nodes may be efficient for predicting prognosis of resected patients and for monitoring tumour response to perioperative treatments, having prognostic value in that it can change therapeutic strategies. Moreover, FDG uptake in bone marrow seems to be significantly associated with SIR to GC and to represent an efficient prognostic factor after curative surgery. In conclusion, PET/CT technology is efficient in GC patients, since it is useful to integrate other imaging modalities in staging tumours and may have prognostic value that can change therapeutic strategies. With ongoing improvements, PET/CT imaging may gain further importance in the management of GC patients.

Simultaneous curative resection of double colorectal carcinoma with synchronous bilobar liver metastases

Synchronous colorectal carcinoma(SCRC) indicates more than one primary colorectal carcinoma(CRC) discovered at the time of initial presentation, accounts for 3.1%-3.9% of CRC, and may occur either in the same or in different colorectal segments. The accurate preoperative diagnosis of SCRC is difficult and diagnostic failures may lead to inappropriate treatment and poorer prognosis. SCRC requires colorectal resections tailored to individual patients, based on the number, location, and stage of the tumours, from conventional or extended hemicolectomies to total colectomy or proctocolectomy, when established predisposing conditions exist. The overall perioperative risks of surgery for SCRC seem to be higher than for solitary CRC. Simultaneous colorectal and liver resection represents an appealing surgical strategy in selected patients with CRC and synchronous liver metastases(CRLM), even though the cumulative risks of the two procedures need to be adequately evaluated. Simultaneous resections have the noticeable advantage of avoiding a second laparotomy, give the opportunity of an earlier initiation of adjuvant therapy, and may significantly reduce the hospital costs. Because an increasing number of recent studies have shown goodresults, with morbidity, perioperative hospitalization, and mortality rates comparable to staged resections, simultaneous procedures can be selectively proposed even in case of complex colorectal resections, including those for SCRC and rectal cancer. However, in patients with multiple bilobar CRLM, major hepatectomies performed simultaneously with colorectal resection have been associated with significant perioperative risks. Conservative or parenchymal-sparing hepatectomies reduce the extent of hepatectomy while preserving oncological radicality, and may represent the best option for selected patients with multiple CRLM involving both liver lobes. Parenchymal-sparing liver resection, instead of major or two-stage hepatectomy for bilobar disease, seemingly reduces the overall operative risk of candidates to simultaneous colorectal and liver resection, and may represent the most appropriate surgical strategy whenever possible, also for patients with advanced SCRC and multiple bilobar liver metastases.

Simultaneous colorectal and parenchymal-sparing liver resection for advanced colorectal carcinoma with synchronous liver metastases:Between conventional and mini-invasive approaches

The optimal timing of surgery in case of synchronous presentation of colorectal cancer and liver metastases is still under debate.Staged approach,with initial colorectal resection followed by liver resection(LR),or even the reverse,liver-first approach in specific situations,is traditionally preferred.Simultaneous resections,however,represent an appealing strategy,because may have perioperative risks comparable to staged resections in appropriately selected patients,while avoiding a second surgical procedure.In patients with larger or multiple synchronous presentation of colorectal cancer and liver metastases,simultaneous major hepatectomies may determine worse perioperative outcomes,so that parenchymal-sparing LR should represent the most appropriate option whenever feasible.Mini-invasive colorectal surgery has experienced rapid spread in the last decades,while laparoscopic LR has progressed much slower,and is usually reserved for limited tumours in favourable locations.Moreover,mini-invasive parenchymal-sparing LR is more complex,especially for larger or multiple tumours in difficult locations.It remains to be established if simultaneous resections are presently feasible with mini-invasive approaches or if we need further technological advances and surgical expertise,at least for more complex procedures.This review aims to critically analyze the current status and future perspectives of simultaneous resections,and the present role of the available miniinvasive techniques.

Virological and histological evaluation of intestinal samples in COVID-19 patients

BACKGROUND Severe acute respiratory syndrome coronavirus-2(SARS-CoV-2)is the pathogen responsible for pandemic coronavirus disease 2019(COVID-19).It is a highly contagious virus which primarily affects the respiratory tract,nevertheless,the lungs are not the only target organs of the virus.The intestinal tract could represent an additional tropism site for SARS-CoV-2.Several observations have collectively suggested that enteric infections can occur in COVID-19 patients.However,the detection of viral RNA in gastrointestinal(GI)tissue samples has not been adequately investigated and results are conflicting.AIM To detect the presence of SARS-CoV-2 RNA in intestinal mucosa samples and to evaluate histological features.METHODS The COVID-19 patients hospitalized at an Italian tertiary hospital from April 2020 to March 2021 were evaluated for enrollment in an observational,monocentric trial.The study population was composed of two groups of adult patients.In the first group(biopsy group,30 patients),patients were eligible for inclusion if they had mild to moderate disease and if they agreed to have a rectal biopsy;in the second group(surgical specimen group,6 patients),patients were eligible for inclusion if they underwent intestinal resection during index hospitalization.Fifty-nine intestinal mucosal samples were analyzed.RESULTS Viral RNA was not detectable in any of the rectal biopsies performed(0/53).Histological examination showed no enterocyte damage,but slight edema of the lamina propria with mild inflammatory lymphoplasmacytic infiltration.There was no difference in inflammatory infiltrates in patients with and without GI symptoms.SARS-CoV-2 RNA was detected in fecal samples in 6 cases out of 14 cases examined(42.9%).In the surgical specimen group,all patients underwent emergency intestinal resection.Viral RNA was detected in 2 surgical specimens of the 6 examined,both of which were from patients with active neoplastic disease.Histological examination also pointed out abundant macrophages,granulocytes and plasma cells infiltrating the muscular layer and adipose tissue,and focal vasculitis.CONCLUSION Mild-moderate COVID-19 may not be associated with rectal infection by the virus.More comprehensive autopsies or surgical specimens are needed to provide histological evidence of intestinal infection.