This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol. A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly. The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.

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Guidelines for perioperative care in elective colonic surgery: Enhanced recovery after surgery (ERAS®) society recommendations

Ductal carcinoma in situ (DCIS) of the breast represents a heterogeneous group of neoplastic lesions in the breast ducts. The goal for management of DCIS is to prevent the development of invasive breast cancer. This manuscript focuses on the NCCN Guidelines Panel recommendations for the workup, primary treatment, risk reduction strategies, and surveillance specific to DCIS.

https://www.unitypoint.org/desmoines/filesimages/Cancer%20Education/Oncology%20Nursing%20Conference/2015/2014%20NCCN%20Clin%20Pract%20Guidelines%20Male%20Sex%20Dysf.pdf

Clinical practice guidelines in oncology

Summary Background Laparoscopic surgery as an alternative to open surgery in patients with rectal cancer has not yet been shown to be oncologically safe. The aim in the COlorectal cancer Laparoscopic or Open Resection (COLOR II) trial was to compare laparoscopic and open surgery in patients with rectal cancer. Methods A non-inferiority phase 3 trial was undertaken at 30 centres and hospitals in eight countries. Patients (aged ≥18 years) with rectal cancer within 15 cm from the anal verge without evidence of distant metastases were randomly assigned to either laparoscopic or open surgery in a 2:1 ratio, stratified by centre, location of tumour, and preoperative radiotherapy. The study was not masked. Secondary (short-term) outcomes—including operative findings, complications, mortality, and results at pathological examination—are reported here. Analysis was by modified intention to treat, excluding those patients with post-randomisation exclusion criteria and for whom data were not available. This study is registered with ClinicalTrials.gov, number NCT00297791. Findings The study was undertaken between Jan 20, 2004, and May 4, 2010. 1103 patients were randomly assigned to the laparoscopic (n=739) and open surgery groups (n=364), and 1044 were eligible for analyses (699 and 345, respectively). Patients in the laparoscopic surgery group lost less blood than did those in the open surgery group (median 200 mL [IQR 100–400] vs 400 mL [200–700], p vs 188 min [150–240]; p vs 3·0 days [2·0–4·0]; p vs 9·0 days [7·0–14·0]; p=0·036). Macroscopically, completeness of the resection was not different between groups (589 [88%] of 666 vs 303 [92%] of 331; p=0·250). Positive circumferential resection margin ( vs 3·0 cm [1·8–5·0], respectively; p=0·676). In the laparoscopic and open surgery groups, morbidity (278 [40%] of 697 vs 128 [37%] of 345, respectively; p=0·424) and mortality (eight [1%] of 699 vs six [2%] of 345, respectively; p=0·409) within 28 days after surgery were similar. Interpretation In selected patients with rectal cancer treated by skilled surgeons, laparoscopic surgery resulted in similar safety, resection margins, and completeness of resection to that of open surgery, and recovery was improved after laparoscopic surgery. Results for the primary endpoint—locoregional recurrence—are expected by the end of 2013. Funding Ethicon Endo-Surgery Europe, Swedish Cancer Foundation, West Gothia Region, Sahlgrenska University Hospital.

https://www.thelancet.com/pdfs/journals/lanonc/PIIS1470-2045(13)70016-0.pdf

Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial

Cetuximab Monotherapy and Cetuximab plus Irinotecan in Irinotecan-Refractory Metastatic Colorectal Cancer

Background Laparoscopic resection of colorectal cancer is widely used. However, robust evidence to conclude that laparoscopic surgery and open surgery have similar outcomes in rectal cancer is lacking. A trial was designed to compare 3-year rates of cancer recurrence in the pelvic or perineal area (locoregional recurrence) and survival after laparoscopic and open resection of rectal cancer. Methods In this international trial conducted in 30 hospitals, we randomly assigned patients with a solitary adenocarcinoma of the rectum within 15 cm of the anal verge, not invading adjacent tissues, and without distant metastases to undergo either laparoscopic or open surgery in a 2:1 ratio. The primary end point was locoregional recurrence 3 years after the index surgery. Secondary end points included disease-free and overall survival. Results A total of 1044 patients were included (699 in the laparoscopic-surgery group and 345 in the open-surgery group). At 3 years, the locoregional recurrence rate was 5.0% in the ...

https://www.nejm.org/doi/pdf/10.1056/NEJMoa1414882

A Randomized Trial of Laparoscopic versus Open Surgery for Rectal Cancer

// Madhawa Neranjan Gunathilake 1 , Jeonghee Lee 2 , Young Ae Cho 2 , Jae Hwan Oh 3 , Hee Jin Chang 3 , Dae Kyung Sohn 3 , Aesun Shin 4 and Jeongseon Kim 2 1 Department of Cancer Control and Population Health, Graduate School of Cancer Science and Policy, Goyang-si, Gyeonggi-do 10408, South Korea 2 Department of Biomedical Science, Graduate School of Cancer Science and Policy, Goyang-si, Gyeonggi-do 10408, South Korea 3 Center for Colorectal Cancer, National Cancer Center Hospital, National Cancer Center, Goyang-si, Gyeonggi-do 10408, South Korea 4 Department of Preventive Medicine, Seoul National University College of Medicine, Jongno-gu, Seoul 03080, South Korea Correspondence to: Jeongseon Kim, email: jskim@ncc.re.kr Aesun Shin, email: shinaesun@snu.ac.kr Keywords: physical activity; PITX1; genetic polymorphism; colorectal cancer; interaction Received: June 21, 2017      Accepted: December 26, 2017      Published: January 10, 2018 ABSTRACT This study assessed the interaction between physical activity and colorectal cancer (CRC) risk based on a polymorphism in the paired-like homeodomain 1 ( PITX1 ) gene in Koreans. In total, 923 cases and 1,846 controls were enrolled at the National Cancer Center, Korea. Subjects who did regular exercise showed a significantly reduced risk of CRC than those did not exercise regularly (OR = 0.37, 95% CI = 0.30–0.45). Subjects in the highest tertile of metabolic equivalents of task (MET)-minutes per week showed a significantly lower risk of CRC (OR = 0.62, 95% CI = 0.48–0.79, p-trend < 0.001). In the dominant model, minor allele carriers showed a significantly higher risk of CRC than subjects homozygous for the major allele (OR = 1.46, 95% CI = 1.18–1.80). The PITX1 genetic variant showed significant interactions with regular exercise and CRC risk (p-interaction = 0.018) and colon cancer risk (p-interaction = 0.029) among all subjects. Subjects who carried at least one minor allele and did not regularly exercise showed a greater risk of CRC (OR = 1.81, 95% CI = 1.37–2.41). Subjects who were homozygous for the major allele with high physical activity showed a significantly reduced risk of CRC (OR = 0.56, 95% CI = 0.38–0.82). Thus, individuals with PITX1 genetic variants can have benefit from physical activity regarding prevention of CRC risk in a Korean population.

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Interaction between physical activity, PITX1 rs647161 genetic polymorphism and colorectal cancer risk in a Korean population: a case-control study.

BACKGROUND:Total mesorectal excision has become the standard treatment for rectal cancer, and several investigators have shown that a transanal approach is a feasible option.OBJECTIVE:This study aimed to evaluate the efficacy of transanal endoscopic total mesorectal excision in patients with rectal

Phase II Clinical Trial to Evaluate the Efficacy of Transanal Endoscopic Total Mesorectal Excision for Rectal Cancer

In preoperative imaging, the demarcation of rectal cancer with magnetic resonance images provides an important basis for cancer staging and treatment planning. Recently, deep learning has greatly improved the state-of-the-art method in automatic segmentation. However, limitations in data availability in the medical field can cause large variance and consequent overfitting to medical image segmentation networks. In this study, we propose methods to reduce the model variance of a rectal cancer segmentation network by adding a rectum segmentation task and performing data augmentation; the geometric correlation between the rectum and rectal cancer motivated the former approach. Moreover, we propose a method to perform a bias-variance analysis within an arbitrary region-of-interest (ROI) of a segmentation network, which we applied to assess the efficacy of our approaches in reducing model variance. As a result, adding a rectum segmentation task reduced the model variance of the rectal cancer segmentation network within tumor regions by a factor of 0.90; data augmentation further reduced the variance by a factor of 0.89. These approaches also reduced the training duration by a factor of 0.96 and a further factor of 0.78, respectively. Our approaches will improve the quality of rectal cancer staging by increasing the accuracy of its automatic demarcation and by providing rectum boundary information since rectal cancer staging requires the demarcation of both rectum and rectal cancer. Besides such clinical benefits, our method also enables segmentation networks to be assessed with bias-variance analysis within an arbitrary ROI, such as a cancerous region.

/pdf/reducing-the-model-variance-of-a-rectal-cancer-segmentation-49azu3gidv.pdf

Reducing the Model Variance of a Rectal Cancer Segmentation Network

Objective

We aimed to investigate the association between a family history (FH) of colorectal cancer (CRC) and cancer recurrence and survival in patients with stage III CRC.



Methods

From April 2001 to December 2007, 1102 patients with stage III CRC were enrolled and their data including FH, clinicopathological characteristics of the tumor were retrospectively analyzed.



Results

Of 971 patients that were finally enrolled, 63 (6.5%) reported CRC in at least one first-degree relative. Death occurred in 12.7% of the CRC patients with an FH and 21.8% in those without an FH. A multivariate analysis showed that patients with an FH of CRC, compared with those without FH, had an adjusted hazard ratios (HR) of 0.674 (P = 0.281) for overall survival (OS) and 0.672 (P = 0.220) for disease-free survival (DFS). However, the location of tumor, preoperative carcinoembryonic antigen (CEA) level, tumor invasion (T) stage and lymph node (N) metastasis significantly affected OS and DFS. Furthermore, whereas the FH of CRC patients was associated with a favorable prognosis in stage III colon cancer (HR 0.224, P = 0.040) but not in rectal cancer (HR 1.225, P = 0.640).



Conclusions

In patients with stage III CRC, tumor location (especially in the rectum), a high preoperative CEA level and advanced T and N stages indicate a poor prognosis. However, in stage III colon cancer FH is associated with improved survival.

Influence of family history on survival in patients with colon and rectal cancer

Chronic inflammation is one of the causes of colorectal cancer (CRC), and circulating levels of inflammatory biomarkers have been linked to tumor promotion and progression. We aimed to evaluate the interleukin-6 (IL-6) level in CRC patients and determine whether a diet rich in antioxidants was associated with CRC. This study included 654 cases and 1312 controls matched for age and sex. We measured the plasma IL-6 concentration and estimated dietary antioxidant capacity based on oxygen radical absorbance capacity (ORAC) combined with a 106-item semiquantitative food frequency questionnaire. The IL-6 concentration was significantly increased in individuals with CRC (OR Q4 vs. Q1, 95% CI = 6.23, 4.10-9.45, p < 0.001). High dietary ORAC showed an inverse association with CRC (total ORAC OR Q4 vs. Q1, 95% CI = 0.26, 0.16-0.40, p < 0.001; total phenolics = 0.32, 0.21-0.50, p < 0.001). We found that low dietary ORAC was associated with a significant increase in CRC in the group with elevated IL-6 levels (total ORAC OR Q4 vs. Q1, 95% CI = 4.34, 3.12-6.02, p < 0.001; total phenolics = 4.61, 3.33-6.39, p < 0.001). This study suggested an inverse association between dietary antioxidant capacity and IL-6 level among patients with CRC.

Dae Kyung Sohn

Papers

Interaction between physical activity, PITX1 rs647161 genetic polymorphism and colorectal cancer risk in a Korean population: a case-control study.

Phase II Clinical Trial to Evaluate the Efficacy of Transanal Endoscopic Total Mesorectal Excision for Rectal Cancer

Reducing the Model Variance of a Rectal Cancer Segmentation Network

Influence of family history on survival in patients with colon and rectal cancer

Circulating Interleukin-6 Level, Dietary Antioxidant Capacity, and Risk of Colorectal Cancer