Diseases of the Colon & Rectum最新文献

Background: The extent of neoadjuvant therapy response, prior to surgery, is an important prognosticator in locally advanced rectal cancer. A spectrum of response exists, with a dearth of reliable measurements. The host response to treatment remains unexplored. Within operable colorectal cancer, circulating markers of elevated systemic inflammation associate with poor survival. Studies have suggested that elevated pre-neoadjuvant inflammatory markers, including the modified Glasgow prognostic score and the neutrophil:lymphocyte ratio, associate with poorer response.

Objective: This study aimed to comprehensively evaluate hematological markers of inflammation pre- and post-neoadjuvant therapy.

Design: Longitudinal cohort study.

Settings: Single health board from a prospectively maintained regional cancer database.

Patients: Consecutive locally advanced rectal cancer patients who underwent curative-intent neoadjuvant therapy between; June 2016-July 2021.

Main outcome measures: Elevated markers of the systemic inflammatory response pre- and post-neoadjuvant therapy.

Results: A total of 278 patients (67.3% male, median age 65) were identified. A complete response (clinical or pathological complete response) was achieved in 27.34%, and good tumor regression was achieved in 37.05% (tumor regression grading 0-1). No pre-neoadjuvant marker associated with response or regression. Multivariate analysis of post-neoadjuvant variables revealed an elevated modified Glasgow prognostic score (OR 2.8, 95% CI: 1.22-6.41, p = 0.015), and an elevated carcinoembryonic-antigen (OR 4.09, 95% CI: 1.6-10.44, p = 0.003) independently associated with incomplete response. An elevated post-neoadjuvant modified Glasgow prognostic score (OR 2.14, 95% CI: 1.08-4.23, p = 0.029) also independently associated with poor tumor regression on multivariate analysis.

Limitations: Retrospective design. Slight variation in the timing of post-neoadjuvant blood tests.

Conclusions: We report that post-neoadjuvant modified Glasgow prognostic score associated with poorer response and regression, potentially indicating that radiation resistance is associated with the development of a protumor inflammatory environment. Further work is required to define the local intratumoral processes associated with response and their inter-relationship with systemic parameters. Ultimately, there may be a rationale for testing anti-inflammatory strategies in combination with radiotherapy as an option for optimizing treatment response. See Video Abstract.

Background: Total neoadjuvant therapy has been introduced to enhance oncological outcomes and minimize toxicity in locally advanced rectal cancer, with the superiority between the induction and consolidation of therapy remains unclear.

Objective: Evaluate oncological and postoperative outcomes by comparing induction chemotherapy and consolidation chemotherapy with conventional chemoradiotherapy in patients with locally advanced rectal cancer.

Data sources: Systematic searches of PubMed, Embase, and Cochrane databases were performed for studies published from their inception until June 2023.

Study selection: The inclusion criteria: patients diagnosed with rectal cancer, interventions including induction chemotherapy and consolidation chemotherapy, comparisons were specified as conventional neoadjuvant chemoradiotherapy.

Main outcome measures: Primary outcomes were the rates of pathological or clinical complete response, postoperative results, chemoradiotherapy-related toxicity, and survival outcomes.

Results: Thirty-three studies, encompassing patients from 1991 to 2021, were eligible for analysis. In network meta-analysis, a significantly increased odds ratio for a pathologic complete response was observed in both induction therapy group at 1.65 (95% CrI 1.18-2.30) and the consolidation therapy group at 1.87 (95% CrI 1.40-2.47) compared to conventional chemoradiotherapy. However, no difference was observed in complete response rates, postoperative results, or chemoradiotherapy-related toxicity ≥ 3 between the groups. There were no differences among the groups in local recurrence, distant metastasis, or disease-free survival, while the induction group showing a non-significant improvement in overall survival.

Limitations: There was significant heterogeneity among the studies and the short follow-up period in most studies limits the assessment of long-term survival outcomes.

Conclusions: Both induction and consolidation total neoadjuvant therapy increase the pathologic complete response rate in locally advanced rectal cancer without compromising safety or postoperative outcomes. However, total neoadjuvant therapy was not associated with a significant improvement in survival outcomes. While total neoadjuvant therapy strategies for locally advanced rectal cancer are considered safe, additional long-term studies are needed.REGISTRATION NO: CRD42023445348.

Background: Ileal pouch anal anastomosis is an important part of colorectal surgery training. However, decreasing case numbers create fewer chances to teach the knowledge and skills to trainees.

Objective: This purpose of this study is to define the components and format of an adjunctive curriculum for teaching colon and rectal surgery residents ileal pouch anal anastomosis. More specifically, it aims to create expert consensus on the essential and unique elements of a curriculum, determine which alternative strategies will be an acceptable, and to identify methods of assessment to evaluate the effectiveness of the curriculum.

Design: This was a modified Delphi Consensus study. Semi-structured interviews with thematic analysis were used to develop the initial round of the survey.

Setting/participants: Faculty who were at North American Accreditation Council for Graduate Medical Education colorectal residencies were invited to participate in the electronic surveys, and participants from each round were invited to subsequent rounds.

Outcome measures: Three rounds of surveys were used to select high priority items for inclusion in the curriculum, educational strategies, and assessments. This was followed by a consensus conference to clarify prioritization and acceptable options for teaching and assessment. Participants from the third round of surveys as well as Program Directors from colorectal residencies were invited to the consensus conference.

Results: Twelve semi-structured interviews defined the educational needs of colorectal residents, the appropriateness of alternative educational strategies, and concerns about case minimums as an assessment of readiness for practice for this procedure. The needs were divided into preoperative, intraoperative, and postoperative phases with knowledge and skills in each. The resulting survey was completed by 85 colorectal surgeons in Round 1, 43 in Round 2, and 38 in Round 3. These results were subsequently summarized by a team of 9 participants in a final consensus conference where the participants made suggestions on the recommended educational strategies for each educational need.

Limitations: Inclusion of colorectal surgeons involved in training programs only; bias in respondents; participation rate.

Conclusions: This shared understanding of educational needs for colorectal residents that includes knowledge, judgement, and technical skills is the first step toward developing a curriculum to teach ileal pouch anal anastomosis. A collaborative effort to create the necessary curriculum is underway. See Video Abstract.