Objective To examine trends in outcomes of patients undergoing resection at a single tertiary care referral center over a 16-year period. Background Data Hepatic resection is considered the treatment of choice in selected patients with colorectal metastasis confined to the liver. Although a variety of retrospective studies have demonstrated improvements in short-term outcomes in recent years, changes in long-term survival over time are less well-established. Methods Data from 226 consecutive patients undergoing potentially curative liver resection for colorectal metastases between 1984 and 1999 were analyzed. Actuarial survival rates related to prognostic determinants were analyzed using the log-rank test. Results The median survival for the entire cohort was 46 months, with 5- and 10-year survival rates of 40% and 26% respectively. Ninety-three patients operated on between 1984 and 1992 were found to have an overall survival of 31% at 5 years, compared to 58% for the 133 patients operated on during the more recent period (1993-1999). Both overall and disease-free survival were significantly better in the recent time period compared with the earlier period on both univariate and multivariate analyses. Other independent factors associated with improved survival included number of metastatic tumors ≤ 3, negative resection margin, and CEA < 100. Comparisons were made between time periods for a variety of patient, tumor and treatment-related factors. Among all parameters studied, only resection type (anatomical versus nonanatomical), use of intraoperative ultrasonography, and perioperative chemotherapy administration differed between the early and recent time periods. Conclusions Long-term survival following liver resection for colorectal metastases has improved significantly in recent years at our institution. Although the reasons for this survival trend are not clear, contributing factors may include the use of newer preoperative and intraoperative imaging, increased use of chemotherapy, and salvage surgical therapy.

Trends in long-term survival following liver resection for hepatic colorectal metastases.

https://archive-ouverte.unige.ch/unige:37177/ATTACHMENT01

Severe hepatic sinusoidal obstruction associated with oxaliplatin-based chemotherapy in patients with metastatic colorectal cancer

Phase III trial comparing intensive induction chemoradiotherapy (60 Gy, infusional 5-FU and intermittent cisplatin) followed by maintenance gemcitabine with gemcitabine alone for locally advanced unresectable pancreatic cancer. Definitive results of the 2000–01 FFCD/SFRO study

The goals of this review paper on deep learning (DL) in medical imaging and radiation therapy are to (a) summarize what has been achieved to date; (b) identify common and unique challenges, and strategies that researchers have taken to address these challenges; and (c) identify some of the promising avenues for the future both in terms of applications as well as technical innovations. We introduce the general principles of DL and convolutional neural networks, survey five major areas of application of DL in medical imaging and radiation therapy, identify common themes, discuss methods for dataset expansion, and conclude by summarizing lessons learned, remaining challenges, and future directions.

https://aapm.onlinelibrary.wiley.com/doi/epdf/10.1002/mp.13264

Deep learning in medical imaging and radiation therapy.

Application of Artificial Intelligence to Gastroenterology and Hepatology

Treatment of locally advanced rectal cancer involves chemoradiation, followed by total mesorectum excision. Complete response after chemoradiation is an accurate surrogate for long-term local control. Predicting complete response from pre-treatment features could represent a major step towards conservative treatment. Patients with a T2-4 N0-1 rectal adenocarcinoma treated between June 2010 and October 2016 with neo-adjuvant chemoradiation from three academic institutions were included. All clinical and treatment data was integrated in our clinical data warehouse, from which we extracted the features. Radiomics features were extracted from the tumor volume from the treatment planning CT Scan. A Deep Neural Network (DNN) was created to predict complete response, as a methodological proof-of-principle. The results were compared to a baseline Linear Regression model using only the TNM stage as a predictor and a second model created with Support Vector Machine on the same features used in the DNN. Ninety-five patients were included in the final analysis. There were 49 males (52%) and 46 females (48%). Median tumour size was 48 mm (15–130). Twenty-two patients (23%) had pathologic complete response after chemoradiation. One thousand six hundred eighty-three radiomics features were extracted. The DNN predicted complete response with an 80% accuracy, which was better than the Linear Regression model (69.5%) and the SVM model (71.58%). Our model correctly predicted complete response after neo-adjuvant rectal chemoradiotherapy in 80% of the patients of this multicenter cohort. Our results may help to identify patients who would benefit from a conservative treatment, rather than a radical resection.

Deep Learning and Radiomics predict complete response after neo-adjuvant chemoradiation for locally advanced rectal cancer.

Surgical management of hepatic metastases from colorectal malignancies

Aim Optimal treatment of rectal adenocarcinoma involves total mesorectal excision with nerve-preserving dissection. Urinary and sexual dysfunction is still frequent following these procedures. Improved knowledge of pelvic nerve anatomy may help reduce this and define the key anatomical zones at risk.

Method  The MEDLINE database was searched for available literature on pelvic nerve anatomy and damage after rectal surgery using the key words ‘autonomic nerve’, ‘pelvic nerve’, ‘colorectal surgery’, and ‘genitourinary dysfunction’. All relevant French and English publications up to May 2010 were reviewed. Reviewed data were illustrated using 3D reconstruction of the foetal pelvis.

Results  The ligation of the inferior mesenteric artery and dissection of the retrorectal space can cause damage to the superior hypogastric plexus and/or hypogastric nerve. Anterolateral dissection in the ‘lateral ligament’ area and division of Denonvilliers’ fascia can damage the inferior hypogastric plexus and efferent pathways. Perineal dissection can indirectly damage the pudendal nerve.

Conclusions  In most cases, the pelvic nerves can be preserved during rectal surgery. Complete oncological resection may require dissection close to the nerves where the tumour is located anterolaterally where it is fixed and when the pelvis is narrow.

Where does pelvic nerve injury occur during rectal surgery for cancer

Aim The aim of the study was to determine the impact of primary full-thickness transanal excision (TAE) on the morbidity rate following radical rectal resection for cancer.



Method  Fourteen consecutive patients underwent radical resection for lower third rectal cancer following full-thickness TAE without closure of the defect. They were compared with 25 matched patients from a prospective database of 275 rectal resections who had undergone radical resection without previous TAE for lower third rectal cancer (control group). The confounding factors were: age, sex, body mass index (BMI), classification according to the American Society of Anaesthesiologists, administration of neoadjuvant radiotherapy before rectal resection, tumour stage and type of surgical procedure.



Results  There were no deaths. Overall morbidity was 64.3% in the TAE group and 32% in the control group (P = 0.112). Surgical complications were significantly more frequent in the former (57.1%vs 20%; P = 0.048). The frequency of specific surgical site complications, including anastomotic complications and pelvic abscess formation requiring surgical drainage, was significantly higher in the TAE group than in the control group (42.8%vs 8%; P = 0.032). In univariate analysis, the only factors associated with specific surgical site complications were BMI > 27 and TAE before rectal resection.



Conclusion  This case-matched study suggests that previous full-thickness TAE increases the risk of surgical complications after radical resection for lower third rectal cancer, including anastomotic dehiscence and pelvic sepsis.

Previous transanal full-thickness excision increases the morbidity of radical resection for rectal cancer.

Objective The aim of this study was to describe the presentation, treatment and prognosis of local recurrences following total mesorectal excision for rectal adenocarcinoma.

Method  Between 1999 and 2002, 201 patients were treated with total mesorectal excision for mid or low rectal cancer and were followed up prospectively.

Results  Overall 2-year survival was 85%. The 2-year recurrence rate was 8%. Eighteen patients developed local recurrence at 3–60 months.

Nine recurrences originated from the pelvic sidewall. These recurrences were symptomatic in 90% of patients. Only two patients were reoperated with a R0 resection and were alive without local recurrence after 19 and 31 months. The seven others died within 9 months.

Nine recurrences originated from an anastomotic suture line. Only two had symptoms. A R0 surgical resection was performed in all patients with a 67% sphincter conservation rate. After 26-months of median follow-up (range 7–58), all patients were alive.

Conclusion  Half of the local recurrence after total mesorectal excision was located at the anastomotic site. Rectoscopic examination should be performed regularly to detect these anatomotic recurrences that are accessible to a R0 iterative resection.

B. Nordlinger

Papers

Deep Learning and Radiomics predict complete response after neo-adjuvant chemoradiation for locally advanced rectal cancer.

Surgical management of hepatic metastases from colorectal malignancies

Where does pelvic nerve injury occur during rectal surgery for cancer

Previous transanal full-thickness excision increases the morbidity of radical resection for rectal cancer.

Presentation and prognosis of local recurrence after total mesorectal excision.