Background & purpose: Involved internal iliac and obturator lateral lymph nodes (LLNs) are a known risk factor for ipsi-lateral local recurrences (LLR) in rectal cancer. This study examined... Show moreBackground & purpose: Involved internal iliac and obturator lateral lymph nodes (LLNs) are a known risk factor for ipsi-lateral local recurrences (LLR) in rectal cancer. This study examined coverage of LLNs with routine radiotherapy practice in the Netherlands and associated LLR rates. Materials & methods: Patients with a primary tumor ≤8cm of the anorectal junction, cT3-4 stage and at least one internal iliac or obturator LLN with short-axis ≥5mm who received neoadjuvant (chemo)radiotherapy, were selected from a national, cross-sectional study of rectal cancer patients treated in the Netherlands in 2016. MR-images and radiotherapy treatment plans were reviewed regarding segmented LLNs as gross-tumor volume (GTV), location of LLNs within clinical target volume (CTV), and received proportion of the planned radiotherapy dose. Results: A total of 223 out of 3057 patients with at least one LLN ≥5mm were selected. Of those, 180 (80.7%) LLNs were inside the CTV, of which 60 (33.3%) were segmented as GTV. Overall, 202 LLNs (90.6%) received >95% of the planned dose. Four-year LLR rates were not significantly higher for LLNs situated outside the CTV compared to inside (4.0% vs. 12.5%, p=.092) or when receiving <95% versus >95% of the planned radiotherapy dose (7.1% vs. 11.3%, p=.843), respectively. Two of seven patients who received a dose-escalation of 60Gy developed a LLR (4-year LLR rate 28.6%). Conclusion: This evaluation of routine radiotherapy practice showed that adequate coverage of LLNs was still associated with considerable 4-year LLR rates. Techniques resulting in better local control for patients with involved LLNs need to be explored further. Show less
BACKGROUND: Acute resection for left-sided obstructive colon carcinoma is thought to be associated with a higher mortality risk than a bridge-to-surgery approach using decompressing stoma or self... Show moreBACKGROUND: Acute resection for left-sided obstructive colon carcinoma is thought to be associated with a higher mortality risk than a bridge-to-surgery approach using decompressing stoma or self-expandable metal stent, but prediction models are lacking.OBJECTIVE: This study aimed to determine the influence of treatment strategy on mortality within 90 days from the first intervention in patients presenting with left-sided obstructive colon carcinoma.DESIGN: This was a national multicenter cohort study that used data from a prospective national audit.SETTINGS: The study was performed in 75 Dutch hospitals.PATIENTS: Patients were included if they underwent resection with curative intent for left-sided obstructive colon carcinoma between 2009 and 2016.INTERVENTIONS: First intervention was either acute resection, bridge to surgery with self-expandable metallic stent, or bridge to surgery with decompressing stoma.MAIN OUTCOME MEASURES: The main outcome measure was 90-day mortality after the first intervention. Risk factors were identified using multivariable logistic analysis. Subsequently, a risk model was developed.RESULTS: In total, 2395 patients were included, with the first intervention consisting of acute resection in 1848 patients (77%), stoma as bridge to surgery in 332 patients (14%), and stent as bridge to surgery in 215 patients (9%). Overall, 152 patients (6.3%) died within 90 days from the first intervention. A decompressing stoma was independently associated with lower 90-day mortality risk (HR, 0.27; 95% CI, 0.094–0.62). Other independent predictors for mortality were age, ASA classification, tumor location, and index levels of serum creatinine and C-reactive protein. The constructed risk model had an area under the curve of 0.84 (95% CI, 0.81–0.87).LIMITATIONS: Only patients who underwent surgical resection were included.CONCLUSIONS: Treatment strategy had a significant impact on 90-day mortality. A decompressing stoma considerably lowers the risk of mortality, especially in older and frail patients. The developed risk model needs further external validation. Show less
Background. Involved lateral lymph nodes (LLNs) have been associated with increased local recurrence (LR) and ipsi-lateral LR (LLR) rates. However, consensus regarding the indication and type of... Show moreBackground. Involved lateral lymph nodes (LLNs) have been associated with increased local recurrence (LR) and ipsi-lateral LR (LLR) rates. However, consensus regarding the indication and type of surgical treatment for suspicious LLNs is lacking. This study evaluated the surgical treatment of LLNs in an untrained setting at a national level.Methods. Patients who underwent additional LLN surgery were selected from a national cross-sectional cohort study regarding patients undergoing rectal cancer surgery in 69 Dutch hospitals in 2016. LLN surgery consisted of either 'node-picking' (the removal of an individual LLN) or 'partial regional node dissection' (PRND; an incomplete resection of the LLN area). For all patients with primarily enlarged (=7 mm) LLNs, those undergoing rectal surgery with an additional LLN procedure were compared to those undergoing only rectal resection.Results. Out of 3057 patients, 64 underwent additional LLN surgery, with 4-year LR and LLR rates of 26% and 15%, respectively. Forty-eight patients (75%) had enlarged LLNs, with corresponding recurrence rates of 26% and 19%, respectively. Node-picking (n = 40) resulted in a 20% 4-year LLR, and a 14% LLR after PRND (n = 8; p = 0.677). Multivariable analysis of 158 patients with enlarged LLNs undergoing additional LLN surgery (n = 48) or rectal resection alone (n = 110) showed no significant association of LLN surgery with 4-year LR or LLR, but suggested higher recurrence risks after LLN surgery (LR: hazard ratio [HR] 1.5, 95% confidence interval [CI] 0.7-3.2, p = 0.264; LLR: HR 1.9, 95% CI 0.2-2.5, p = 0.874).Conclusion. Evaluation of Dutch practice in 2016 revealed that approximately one-third of patients with primarily enlarged LLNs underwent surgical treatment, mostly consisting of node-picking. Recurrence rates were not significantly affected by LLN surgery, but did suggest worse outcomes. Outcomes of LLN surgery after adequate training requires further research. Show less
Background: There is an ongoing discussion regarding the prognostic implications of the presence, short-axis diameter and location of lateral lymph nodes.Objective: To analyze lateral lymph node... Show moreBackground: There is an ongoing discussion regarding the prognostic implications of the presence, short-axis diameter and location of lateral lymph nodes.Objective: To analyze lateral lymph node characteristics, the role of downsizing on restaging MRI and associated local recurrence rates for patients with cT3-4 rectal cancer after MRI re-review and training.Design: Retrospective population-based cross-sectional study. Settings: This collaborative project was led by local investigators from surgery and radiology departments in 60 Dutch hospitals.Patients: 3057 patients underwent rectal cancer surgery in 2016: 1109 had cT3-4 tumor located ≤8cm from the anorectal junction of which 890 received neoadjuvant therapy. Interventions(s): NoneMain Outcome Measures: local recurrence and ipsi-lateral local recurrence rates. Results: Re-review identified 314 patients (35%) with visible lateral lymph nodes. 30 of these patients had either only long-stretched obturator (n=13) or external iliac (n=17) nodes and both did not lead to any lateral local recurrences. The presence of internal iliac/obturator lateral lymph nodes (n=284) resulted in 4-year local recurrence and lateral local recurrence rates of 16.4% and 8.8%, respectively. Enlarged (≥7mm) lateral lymph nodes (n=122) resulted in higher 4-year local recurrence (20.8%, 13.1%, 0%, p<.001) and lateral local recurrence (14.7%, 4.4%, 0%, p<.001) rates compared to smaller and no lateral lymph nodes, respectively. Visible lateral lymph nodes (hazard ratio 1.8(1.1-2.8)) and enlarged lateral lymph nodes (hazard ratio 1.9(1.1-3.5)) were independently associated with local recurrence in multivariable analysis. Enlarged lateral lymph nodes with malignant features had higher 4-year LLR rates of 17.0%. Downsizing had no impact on lateral local recurrence rates. Enlarged lateral lymph nodes were associated with higher univariate 4-year distant metastasis rates (36.4% 24.4%, p=.021), but not in multivariable analysis (hazard ratio 1.3(0.9-1.8)), and did not worsen overall survival. Limitations: This study was limited by the retrospective design and total number of patients with lateral lymph nodes.Conclusions: The risk of lateral local recurrence due to (enlarged) lateral lymph nodes was confirmed, but without prognostic impact of downsizing after neoadjuvant therapy. These results point towards the incorporation of primary lateral lymph node size into treatment planning. Show less
Objectives The presence and size of lateral lymph nodes (LLNs) are important factors influencing treatment decisions for rectal cancer. Awareness of the clinical relevance and describing LLNs in... Show moreObjectives The presence and size of lateral lymph nodes (LLNs) are important factors influencing treatment decisions for rectal cancer. Awareness of the clinical relevance and describing LLNs in MRI reports is therefore essential. This study assessed whether LLNs were mentioned in primary MRI reports at a national level and investigated the concordance with standardised re-review. Methods This national, retrospective, cross-sectional cohort study included 1096 patients from 60 hospitals treated in 2016 for primary cT3-4 rectal cancer <= 8 cm from the anorectal junction. Abdominal radiologists re-reviewed all MR images following a 2-h training regarding LLNs. Results Re-review of MR images identified that 41.0% of enlarged (>= 7 mm) LLNs were not mentioned in primary MRI reports. A contradictory anatomical location was stated for 73.2% of all LLNs and a different size (>=/< 7 mm) for 41.7%. In total, 49.4% of all cases did not mention LLNs in primary MRI reports. Reporting LLNs was associated with stage (cT3N0 44.3%, T3N+/T4 52.8%, p = 0.013), cN stage (N0 44.1%, N1 48.6%, N2 59.5%, p < 0.001), hospital type (non-teaching 34.6%, teaching 52.2%, academic 53.2% p = 0.006) and annual rectal cancer resection volumes (low 34.8%, medium 47.7%, high 57.3% p < 0.001). For LLNs present according to original MRI reports (n = 226), 64.2% also mentioned a short-axis size, 52.7% an anatomical location and 25.2% whether it was deemed suspicious. Conclusions Almost half of the primary MRI reports for rectal cancer patients treated in the Netherlands in 2016 did not mention LLNs. A significant portion of enlarged LLNs identified during re-review were also not mentioned originally, with considerable discrepancies for location and size. These results imply insufficient awareness and indicate the need for templates, education and training. Show less
Objectives: Presence and size of lateral lymph nodes (LLNs) are important factors influencing treatment decisions for rectal cancer. Awareness of the clinical relevance and describing LLNs in MRI... Show moreObjectives: Presence and size of lateral lymph nodes (LLNs) are important factors influencing treatment decisions for rectal cancer. Awareness of the clinical relevance and describing LLNs in MRI-reports, is therefore essential. This study assessed whether LLNs were mentioned in primary MRI-reports at a national level and investigated the concordance with standardized re-review. Methods: This national, retrospective, cross-sectional cohort study included 1096 patients from 60 hospitals treated in 2016 for primary cT3-4 rectal cancer ≤8cm from the anorectal junction. Abdominal radiologists re-reviewed all MR-images after following a 2-hour training regarding LLNs. Results: Re-review of MR-images identified 41.0% of enlarged (≥7mm) LLNs were not mentioned in primary MRI-reports and a contradictory anatomical location was stated for 73.2% of all LLNs and a different size (≥/<7mm) for 41.7%. In total, 49.4% of cases did not mention LLNs in primary MRI-reports. Reporting LLNs was associated with stage (cT3N0 44.3%, T3N+/T4 52.8%, p=.013), cN-stage (N0 44.1%, N1 48.6%, N2 59.5%, p<.001), hospital type (non-teaching 34.6%, teaching 52.2%, academic 53.2% p=.006) and annual rectal cancer resection volumes (low 34.8%, medium 47.7%, high 57.3% p<.001). For LLNs identified during re-review (n=226), 64.2% original reports mentioned short-axis size, 52.7% location and 25.2% suspiciousness. Conclusions: Almost half of primary MRI-reports for rectal cancer patients treated in the Netherlands in 2016, did not mention LLNs. A significant portion of enlarged LLNs identified during re-review were also not mentioned originally, with considerable discrepancies for location and size. These results imply insufficient awareness and indicate the need for templates, education and training. Show less
Background The optimal timing of resection after decompression of left-sided obstructive colon cancer is unknown. Revised expert-based guideline recommendations have shifted from an interval of 5... Show moreBackground The optimal timing of resection after decompression of left-sided obstructive colon cancer is unknown. Revised expert-based guideline recommendations have shifted from an interval of 5-10 days to approximately 2 weeks following self-expandable metal stent (SEMS) placement, and recommendations after decompressing stoma are lacking. We aimed to evaluate the recommended bridging intervals after SEMS and explore the timing of resection after decompressing stoma.Methods This nationwide study included patients registered between 2009 and 2016 in the prospective, mandatory Dutch ColoRectal Audit. Additional data were collected through patient records in 75 hospitals. Only patients who underwent either SEMS placement or decompressing stoma as a bridge to surgery were selected. Technical SEMS failure and unsuccessful decompression within 48 hours were exclusion criteria.Results 510 patients were included (182 SEMS, 328 decompressing stoma). Median bridging interval was 23 days (interquartile range [IQR] 13-31) for SEMS and 36 days (IQR 22-65) for decompressing stoma. Following SEMS placement, no significant differences in post-resection complications, hospital stay, or laparoscopic resections were observed with resection after 11-17 days compared with 5-10 days. Of SEMS-related complications, 48% occurred in patients operated on beyond 17 days. Compared with resection within 14 days, an interval of 14-28 days following decompressing stoma resulted in significantly more laparoscopic resections, more primary anastomoses, and shorter hospital stays. No impact of bridging interval on mortality, disease-free survival, or overall survival was demonstrated.Conclusions Based on an overview of the data with balancing of surgical outcomes and timing of adverse events, a bridging interval of approximately 2 weeks seems appropriate after SEMS placement, while waiting 2-4 weeks after decompressing stoma further optimizes surgical conditions for laparoscopic resection with restoration of bowel continuity. Show less
Veld, J.V.; Amelung, F.J.; Borstlap, W.A.A.; Halsema, E.E. van; Consten, E.C.J.; Dekker, J.W.T.; ... ; Dutch Snapshot Res Grp 2020
Objective: The purpose of this population-based study was to compare decompressing stoma (DS) as bridge to surgery (BTS) with emergency resection (ER) for left-sided obstructive colon cancer (LSOCC... Show moreObjective: The purpose of this population-based study was to compare decompressing stoma (DS) as bridge to surgery (BTS) with emergency resection (ER) for left-sided obstructive colon cancer (LSOCC) using propensity-score matching.Summary Background Data: Recently, an increased use of DS as BTS for LSOCC has been observed in the Netherlands. Unfortunately, good quality comparative analyses with ER are scarce.Methods: Patients diagnosed with nonlocally advanced LSOCC between 2009 and 2016 in 75 Dutch hospitals, who underwent DS or ER in the curative setting, were propensity-score matched in a 1:2 ratio. The primary outcome measure was 90-day mortality, and main secondary outcomes were 3-year overall survival and permanent stoma rate.Results: Of 2048 eligible patients, 236 patients who underwent DS were matched with 472 patients undergoing ER. After DS, more laparoscopic resections were performed (56.8% vs 9.2%, P < 0.001) and more primary anastomoses were constructed (88.5% vs 40.7%, P < 0.001). DS resulted in significantly lower 90-day mortality compared to ER (1.7% vs 7.2%, P = 0.006), and this effect could be mainly attributed to the subgroup of patients over 70 years (3.5% vs 13.7%, P 1/4 0.027). Patients treated with DS as BTS had better 3-year overall survival (79.4% vs 73.3%, hazard ratio 0.36, 95% confidence interval 0.20-0.65) and fewer permanent stomas (23.4% vs 42.4%, P < 0.001).Conclusions: In this nationwide propensity-score matched study, DS as a BTS for LSOCC was associated with lower 90-day mortality and better 3-year overall survival compared to ER, especially in patients over 70 years of age. Keywords: decompressing stoma, emergency resection, obstructive colon cancer, propensity score matching Show less
Introduction: Optimized treatment of primary rectal cancer might have influenced treatment characteristics and outcome of locally recurrent rectal cancer (LRRC). Subgroup analysis of the Dutch TME... Show moreIntroduction: Optimized treatment of primary rectal cancer might have influenced treatment characteristics and outcome of locally recurrent rectal cancer (LRRC). Subgroup analysis of the Dutch TME trial showed that preoperative radiotherapy (PRT) for the primary tumour was an independent poor prognostic factor after diagnosis of LRRC. This cross-sectional population study aimed to evaluate treatment and overall survival (OS) of LRRC patients, stratified for prior preoperative radiotherapy (PRT) and intention of treatment of LRRC.Methods: All patients developing LRRC were selected from a collaborative Snapshot study on 2095 surgically treated rectal cancer patients from 71 Dutch hospitals in the year 2011. Cox proportional hazard analysis was performed to determine predictors for OS.Results: A total of 107 LRRC patients (5.1%) were included, of whom 88 (82%) underwent PRT for their primary tumour. LRRC was treated with initial curative intent in 31 patients (29%), with eventual resection in 20 patients (19%). Median OS was 22 and 8 months after curative and palliative intent treatment, respectively (p < 0.001). Initial CRM positivity and palliative intent treatment were associated with worse OS after LRRC, while prior PRT was not.Conclusions: This cross-sectional study revealed that rectal cancer patients, who underwent curative resection in the Netherlands in 2011 and subsequently developed local recurrence, were amenable for again curative intent treatment in 29%, with a corresponding median survival of 22 months. Prior PRT was not significantly associated with survival after diagnosis of LRRC. (C) 2019 Elsevier Ltd, BASO similar to The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved. Show less
Background: Although self-expandable metal stent (SEMS) placement as bridge to surgery (BTS) in patients with left-sided obstructing colonic cancer has shown promising short-term results, it is... Show moreBackground: Although self-expandable metal stent (SEMS) placement as bridge to surgery (BTS) in patients with left-sided obstructing colonic cancer has shown promising short-term results, it is used infrequently owing to uncertainty about its oncological safety. This population study compared long-term oncological outcomes between emergency resection and SEMS placement as BTS.Methods: Through a national collaborative research project, long-term outcome data were collected for all patients who underwent resection for left-sided obstructing colonic cancer between 2009 and 2016 in 75 Dutch hospitals. Patients were identified from the Dutch Colorectal Audit database. SEMS as BTS was compared with emergency resection in the curative setting after 1: 2 propensity score matching.Results: Some 222 patients who had a stent placed were matched to 444 who underwent emergency resection. The overall SEMS-related perforation rate was 7.7 per cent (17 of 222). Three-year locoregional recurrence rates after SEMS insertion and emergency resection were 11-4 and 13.6 per cent (P= 0-457), disease-free survival rates were 58-8 and 52.6 per cent (P= 0-175), and overall survival rates were 74-0 and 68-3 per cent (P= 0.231), respectively. SEMS placement resulted in significantly fewer permanent stomas (23.9 versus 45.3 per cent; P < 0-001), especially in elderly patients (29.0 versus 57.9 per cent; P < 0-001). For patients in the SEMS group with or without perforation, 3-year locoregional recurrence rates were 18 and 11.0 per cent (P= 0.432), disease-free survival rates were 49 and 59.6 per cent (P= 0-717), and overall survival rates 61 and 75.1 per cent (P= 0.529), respectively.Conclusion: Overall, SEMS as BTS seems an oncologically safe alternative to emergency resection with fewer permanent stomas. Nevertheless, the risk of SEMS-related perforation, as well as permanent stoma, might influence shared decision-making for individual patients. Show less
Background. The time interval between CRT and surgery in rectal cancer patients is still the subject of debate. The aim of this study was to first evaluate the nationwide use of restaging magnetic... Show moreBackground. The time interval between CRT and surgery in rectal cancer patients is still the subject of debate. The aim of this study was to first evaluate the nationwide use of restaging magnetic resonance imaging (MRI) and its impact on timing of surgery, and, second, to evaluate the impact of timing of surgery after chemoradiotherapy (CRT) on short- and long-term outcomes.Methods. Patients were selected from a collaborative rectal cancer research project including 71 Dutch centres, and were subdivided into two groups according to time interval from the start of preoperative CRT to surgery (< 14 and ae14 weeks).Results. From 2095 registered patients, 475 patients received preoperative CRT. MRI restaging was performed in 79.4% of patients, with a median CRT-MRI interval of 10 weeks (interquartile range [IQR] 8-11) and a median MRI-surgery interval of 4 weeks (IQR 2-5). The CRT-surgery interval groups consisted of 224 (< 14 weeks) and 251 patients (>= 14 weeks), and the long-interval group included a higher proportion of cT4 stage and multivisceral resection patients. Pathological complete response rate (n = 34 [15.2%] vs. n = 47 [18.7%], p = 0.305) and CRM involvement (9.7% vs. 15.9%, p = 0.145) did not significantly differ. Thirty-day surgical complications were similar (20.1% vs. 23.1%, p = 0.943), however no significant differences were found for local and distant recurrence rates, disease-free survival, and overall survival.Conclusions. These real-life data, reflecting routine daily practice in The Netherlands, showed substantial variability in the use and timing of restaging MRI after preoperative CRT for rectal cancer, as well as time interval to surgery. Surgery before or after 14 weeks from the start of CRT resulted in similar short- and long-term outcomes. Show less
Borstlap, W.A.A.; Deijen, C.L.; Dulk, M. den; Bonjer, H.J.; Velde, C.J. van de; Bemelman, W.A.; ... ; Dutch Snapshot Res Grp 2017
Aim A Snapshot study design eliminates changes in treatment and outcome over time. This population based Snapshot study aimed to determine current practice and outcome of rectal cancer treatment... Show moreAim A Snapshot study design eliminates changes in treatment and outcome over time. This population based Snapshot study aimed to determine current practice and outcome of rectal cancer treatment with published landmark randomized controlled trials as a benchmark.Method In this collaborative research project, the dataset of the Dutch Surgical Colorectal Audit was extended with additional treatment and long-term outcome data. All registered patients who underwent resection for rectal cancer in 2011 were eligible. Baseline characteristics and outcome were evaluated against the results of the Dutch TME trial and the COLOR II trial from which the original datasets were obtained.Results A total of 71 hospitals participated, and data were completed for 2102 out of the potential 2633 patients (79.8%). Median follow-up was 41 (interquartile range 25-47) months. Overall circumferential resection margin (CRM) involvement was 9.3% in the Snapshot cohort and 18.5% in the Dutch TME trial. CRM positivity after laparoscopic resection was 7.8% in the Snapshot and 9.5% in the COLOR II trial. Three-year overall local recurrence rate in the Snapshot was 5.9%, with a disease-free survival of 67.1% and overall survival of 79.5%. Benchmarking with the randomized controlled trials revealed an overall favourable long-term outcome of the Snapshot cohort.Conclusion This study showed that current rectal cancer care in a large unselected Dutch population is of high quality, with less positive CRM since the TME trial and oncologically safe implementation of minimally invasive surgery after the COLOR II trial. Show less
