Relation between skeletal muscle volume and prognosis in rectal cancer patients undergoing neoadjuvant therapy

The prognostic role of body composition indexes,and specifically sarcopenia,has recently been explored in different cancer types.However,conflicting results have been reported.Heterogeneity in cancer type,cancer stage or oncological treatments,as well as different methodology and definition of sarcopenia,could be accounted for different conclusions retrieved from literature.When focusing on colorectal cancer,it clearly appears that colon and rectal cancers are often treated as a single entity though they have different behaviors and treatments.Particularly,patients with advanced rectal cancer represent a peculiar group of patients that according to current guidelines are treated with neoadjuvant chemotherapy and radiotherapy followed by radical surgery.This review was restricted to a homogeneous group of patients with advanced lower rectal cancer and the aim of exploring whether there is a correlation between skeletal muscle depletion and prognosis.Literature was searched for articles related to patients with advanced rectal cancer undergoing neoadjuvant chemo-radiotherapy(NCRT)followed by radical surgery,in whom muscle mass and/or change in muscle mass during neoadjuvant treatment were measured.Eight full-text articles were selected and included in the present review.The main findings of our review were:(1)The majority of the studies defined sarcopenia as muscle mass alone over muscle strength or physical performance;(2)There was a great deal of heterogeneity in the definition and measures of sarcopenia,in the definition of cut-off values,and in the method to measure change in muscle mass;(3)There was not full agreement on the association between sarcopenia at baseline and/or after chemoradiotherapy and prognosis,and only few studies found a significance in the multivariate analysis;and(4)It seems that a loss in skeletal muscle mass during NCRT is associated with the worst outcomes in terms of disease-free survival.In conclusion,analysis of muscle mass might provide prognostic information on patients with rectal cancer,however more robust evidence is needed to define the role of muscle depletion and/or muscle change during neoadjuvant treatments,related to this specific group of patients.If a prognostic role would be confirmed by future studies,the role of preoperative intervention aimed at modifying muscle mass could be explored in order to improve outcomes.

New approach to anal cancer:Individualized therapy based on sentinel lymph node biopsy

Oncological treatment is currently directed toward a tailored therapy concept.Squamous cell carcinoma of the anal canal could be considered a suitable platform to test new therapeutic strategies to minimize treatment morbidity.Standard of care for patients with anal canal cancer consists of a combination of radiotherapy and chemotherapy.This treatment has led to a high rate of local control and a 60% cure rate with preservation of the anal sphincter,thus replacing surgical abdominoperineal resection.Lymph node metastases represent a critical independent prognostic factor for local recurrence and survival.Mesorectal and iliac lymph nodes are usually included in the radiation field,whereas the inclusion of inguinal regions still remains controversial because of the subsequent adverse side effects.Sentinel lymph node biopsies could clearly identify inguinal node-positive patients eligible for therapeutic groin irradiation.A sentinel lymph node navigation procedure is reported here to be a feasible and effective method for establishing the true inguinal node status in patients suffering from anal canal cancer.Based on the results of sentinel node biopsies,a selective approach could be proposed where node-positive patients could be selected for inguinal node irradiation while node-negative patients could take advantage of inguinal sparing irradiation,thus avoiding toxic side effects.

How reliable is current imaging in restaging rectal cancer after neoadjuvant therapy?

In patients with advanced rectal cancer,neoadjuvant chemo radiotherapy provides tumor downstaging and downsizing and complete pathological response in up to 30%of cases.After proctectomy complete pathological response is associated with low rates of local recurrence and excellent long term survival.Several authors claim a less invasive surgery or a non operative policy in patients with partial or clinical complete response respectively,however to identify patients with true complete pathological response before surgical resection remains a challenge.Current imaging techniques have been reported to be highly accurate in the primary staging of rectal cancer,however neoadjuvant therapy course produces deep modifications on cancer tissue and on surrounding structures such as overgrowth fibrosis,deep stroma alteration,wall thickness,muscle disarrangement,tumor necrosis,calcification,and inflammatory infiltration.As a result,the same imaging techniques,when used for restaging,are far less accurate.Local tumor extent may be overestimated or underestimated.The diagnostic accuracy of clinical examination,rectal ultrasound,computed tomography,magnetic resonance imaging,and positron emission tomography using 18F-fluoro-2’-deoxy-Dglucose ranges between 25%and 75%being less than 60%in most studies,both for rectal wall invasion and for lymph nodes involvement.In particular the ability to predict complete pathological response,in order to tailor the surgical approach,remains low.Due to the radio-induced tissue modifications,combined with imaging technical aspects,low rate accuracy is achieved,making modern imaging techniques still unreliable in restaging rectal cancer after chemo-radiotherapy.

Multidisciplinary treatment of rectal cancer in 2014: Where are we going?

In the present review we discuss the recent developments and future directions in the multimodal treatment of locally advanced rectal cancer, with respect to staging and re-staging modalities, to the current role of neoadjuvant chemo-radiation and to the conservative and more limited surgical approaches based on tumour response after neoadjuvant combined therapy. When initial tumor staging is considered a high accuracy has been reported for T pre-treatment staging, while preoperative lymph node mapping is still suboptimal. With respect to tumour re-staging, all the current available modalities still present a limited accuracy, in particular in defining a complete response. The role of short vs long-course radiotherapy regimens as well as the optimal time of surgery are still unclear and under investigation by means of ongoing randomized trials. Observational management or local excision following tumour complete response are promising alternatives to total mesorectal excision, but need further evaluation, and their use outside of a clinical trial is not recommended.The preoperative selection of patients who will benefit from neoadjuvant radiotherapy or not, as well as the proper identification of a clinical complete tumour response after combined treatment modalities,will influence the future directions in the treatment of locally advanced rectal cancer.

Short and long-term outcomes of laparoscopic colectomy in obese patients

AIM:To investigate the impact of laparoscopic colectomy on short and long-term outcomes in obese patients with colorectal diseases.METHODS:A total of 98 obese(body mass index>30kg/m2)patients who underwent laparoscopic(LPS)right or left colectomy over a 10 year period were identified from a prospective institutionally approved database and manually matched to obese patients who underwent open colectomy.Controls were selected to match for body mass index,site of primary disease,American Society of Anesthesiologists score,and year of surgery(±3 year).The parameters analyzed included age,gender,comorbid conditions,American Society of Anaesthesiologists class,diagnosis,procedure,and duration of operation,operative blood loss,and amount of homologous blood transfused.Conversion rate,intra and postoperative complications as were as reoperation rate,30 d and long-term morbidity rate were also analyzed.For continuous variables,the Student’s t test was used for normally distributed data the Mann-Whitney U test for nonnormally distributed data.The Pearson’sχ2tests,or the Fisher exact test as appropriate,were used for proportions.RESULTS:Conversion to open surgery was necessary in 13 of 98 patients(13.3%).In the LPS group,operative time was 29 min longer and blood loss was 78 mL lower when compared to open colectomy(P=0.03,P=0.0001,respectively).Overall morbidity,anastomotic leak and readmission rate did not significantly differ between the two groups.A trend toward a reduction of wound complications was observed in the LPS when compared to open group(P=0.09).In the LPS group,an earlier recovery of bowel function(P=0.001)and a shorter length of stay(P=0.03)were observed.After a median follow-up of 62(range 12-132)mo 23patients in the LPS group and 38 in the open group experienced long-term complications(LPS vs open,P=0.03).Incisional hernia resulted to be the most frequent long-term complication with a significantly higher occurrence in the open group when compared to the laparoscopic one(P=0.03).CONCLUSION:Laparoscopic colectomy in obese patients is safe,does not jeopardize postoperative complications and resulted in lower incidence of long-term complications when compared with open cases.

Endoluminal vacuum-assisted therapy to treat rectal anastomotic leakage:A critical analysis

Endoluminal vacuum-assisted therapy(EVT)has been introduced recently to treat colorectal anastomotic leaks in clinically stable non-peritonitic patients.Its application has been mainly reserved to low colorectal and colo-anal anastomoses.The main advantage of this new procedure is to ensure continuous drainage of the abscess cavity,to promote and to accelerate the formation of granulation tissue resulting in a reduction of the abscess cavity.The reported results are promising allowing a higher preservation of the anastomosis when compared to conventional treatments that include trans-anastomotic tube placement,percutaneous drainage,endoscopic clipping of the anastomotic defect or stent placement.Nevertheless,despite this procedure is gaining acceptance among the surgical community,indications,inclusion criteria and definitions of success are not yet standardized and extremely heterogeneous,making it difficult to reach definitive conclusions and to ascertain which are the real benefits of this new procedure.Moreover,long-term and functional results are poorly reported.The present review is focused on critically analyzing the theoretical benefits and risks of the procedure,short-and long-term functional results and future direction in the application of EVT.

Muscle Loss in Cancer Patients: Pathophysiology and Impact on the Outcome

A generalized loss of skeletal muscle can be associated with malnutrition, cancer, inflammation or neurodegenerative processes. Most cancer patients undergoing surgery are sarcopenic although only a minority of them suffer from severe weight loss. The cancer stage is a major determinant of sarcopenia, while nutritional factors seem to be less important. In cancer patients sarcopenia has been associated with a worse physical performance, a reduced response to chemotherapy and radiotherapy, a higher postoperative morbidity rate, and a reduced life expectancy.

Prognostic role of ultrasonography staging in patients with anal cancer

BACKGROUND Carcinomas of the anal canal are staged according to the size and extent of the disease;however,we propose including a novel ultrasound(US)staging system,based on depth of tumor invasion.In this study the clinical American Joint Committee on Cancer(AJCC)staging guidelines and the US classificationss in patients with anal cancer were compared.AIM To evaluate the prognostic role of the US staging system in patients with anal cancer.METHODS The data of 48 patients with anal canal squamous cells carcinoma,observed at our University Hospital between 2007 and 2017,who underwent pre-treatment assessment with pelvic magnetic resonance imaging(MRI),total body computed tomography(CT)scan and endoanal US were retrospectively reviewed.Anal canal tumors were clinically staged according to AJCC,determined by MRI by measurement of the longest tumor diameter,and CT scan.Endoanal US was performed with a high multi-frequency(9-16 MHz),360°rotational mechanical probe;US classification was based on depth of tumor penetration through the anal wall,according to Giovannini’s study.All patients were treated with definitive radiation combined with 5-fluorouracile and Mitomycin-C.After treatment patients were followed-up regularly.RESULTS At baseline there were 30 and 32 T1-2,18 and 16 T3-4,31 and 19 N+patients classified according to the clinical AJCC and US staging system respectively.After a mean follow-up of 98 months,38 patients(79.1%)are alive and 28(58.3%)are disease free.During follow up 20 patients(41.6%)experienced recurrences.After univariate analysis,American Society of Anesthesiologists(ASA)score(P=0.00000001)and US staging(P=0.009)were significantly related to disease-free survival(DFS).When overall survival and DFS functions were compared,a statistically significant difference was observed for DFS survival when the US staging was applied with respect to the clinical AJCC staging.By combining the 2 significant prognostic variables,namely the US staging with the ASA score,four risks groups with different prognoses were identified.CONCLUSION Our findings suggest that US staging may be superior to traditional clinical staging,since it is significantly associated with DFS in anal cancer patients.

Intra-abdominal myositis ossificans-a clinically challenging disease:A case report

BACKGROUND Myositis ossificans(MO)is an uncommon disorder characterized by heterotopic ossification within soft tissues.Only a few cases of intra-abdominal MO(IMO)have been described in the literature.Histology could be difficult to understand and a wrong diagnosis could lead to an improper cure.CASE SUMMARY We herein report the case of IMO in a healthy 69-year-old man.The patient presented with an abdominal mass in the left lower quadrant.A computed tomography scan showed an inhomogeneous mass with multiple calcifications.The patient underwent radical excision of the mass.Histopathological findings were compatible with MO.Five months later the patient showed a recurrence causing hemorrhagic shock due to intractable intralesional bleeding.The patients eventually died within three months since recurrence.CONCLUSION The case described could be classified as post-traumatic MO that developed close to the previously fractured iliac bone.The subsequent surgical procedure was ineffective and the disease rapidly recurred.The misleading intraoperative diagnosis led to improper surgical treatment with a dramatic evolution.

Impact of Neoadjuvant Therapy on Body Composition and Prognosis in Rectal Cancer Patients

Objectives The aim of this study was to assess the impact of neoadjuvant chemo-radiotherapy (nCRT) on body composition in patients who subsequently underwent curative surgery for low rectal cancer. Methods Thirty-eight consecutive patients who underwent nCRT and subsequent laparoscopic proctectomy for locally advanced low rectal cancer have been studied. In all patients body composition was measured by computed tomography before and after nCRT. Pathology response on CRT, postoperative short-term outcome, overall and disease-free long-term survival were assessed. Results Twelve patients (31.5%) had skeletal muscle loss 2% after nCRT. No correlation was found between changes in body composition and postoperative complications. Skeletal muscle loss after nCRT significantly correlated with a shorter 5-year disease-free survival. Conclusion Preliminary data suggests that skeletal muscle loss after nCRT negatively impacted on disease-free survival in patients with locally advanced rectal cancer.