Search Results (63)

Rectal cancer management necessitates a rigorous multidisciplinary strategy, emphasizing precise staging and detailed risk stratification to inform optimal therapeutic decision-making. Obtaining an accurate histological diagnosis before initiating treatment is essential. Comprehensive staging integrates clinical evaluation, thorough medical history analysis, assessment of carcinoembryonic antigen (CEA) levels, and computed tomography (CT) imaging of the abdomen and thorax. High-resolution pelvic magnetic resonance imaging (MRI), utilizing dedicated rectal protocols, is critical for identifying recurrence risks and delineating precise anatomical relationships. Endoscopic ultrasound further refines staging accuracy by determining the tumor infiltration depth in early-stage cancers, while preoperative colonoscopy effectively identifies synchronous colorectal lesions. In early-stage rectal cancers (T1–T2, N0, and M0), radical surgical resection remains the standard of care, although transanal local excision can be selectively indicated for certain T1N0 tumors. In contrast, locally advanced rectal cancers (T3, T4, and N+) characterized by microsatellite stability or proficient mismatch repair are optimally managed with total neoadjuvant therapy (TNT), which combines chemoradiotherapy with oxaliplatin-based systemic chemotherapy. Additionally, tumors exhibiting high microsatellite instability or mismatch repair deficiency respond favorably to immune checkpoint inhibitors (ICIs). The evaluation of tumor response following neoadjuvant therapy, utilizing MRI and endoscopic assessments, facilitates individualized treatment planning, including non-operative approaches for patients with confirmed complete clinical responses who comply with rigorous follow-up. Recent advancements in molecular characterization, targeted therapies, and immunotherapy highlight a significant evolution towards personalized medicine. The effective integration of these innovations requires enhanced interdisciplinary collaboration to improve patient prognosis and quality of life. Full article

Background/Objectives: Innovations in robotic prostatectomy have transformed a highly morbid operation to a procedure with fewer complications and shorter hospital stays, yet techniques continue to evolve. Our objective is to discuss the most recent advances in robotic prostatectomy techniques designed to minimize morbidity related to urinary incontinence and erectile dysfunction. Methods: This review is adapted from a comprehensive committee chapter on published in the 3rd WUOF/SIU (World Urologic Oncology Federation/Société Internationale d’Urologie) International Consultation on Urologic Diseases on Localized Prostate Cancer. Results: This review article describes both traditional and emerging techniques in robotic prostatectomy techniques and discusses their respective outcomes. Conclusions: Improved understanding of pelvic anatomy has enabled robotic-assisted techniques to preserve key structures and enhance recovery and functional outcomes while preserving oncologic safety Full article

Objectives: In patients undergoing a radical hysterectomy, uterine corpus invasion worsens cervical cancer prognosis. However, the prognostic role of the invasion in locally advanced stages remains elusive. Due to the inadequacy of typical corpus biopsies, corpus invasion is diagnosed using magnetic resonance imaging (MRI). In this study, we investigated the prognostic role of MRI-detected uterine corpus invasion in patients undergoing radiotherapy for cervical cancer. Methods: This retrospective analysis involved 259 patients without extrapelvic metastases, diagnosed with FIGO 2009 stages IB–IVA cervical carcinoma from January 2011 to December 2020. The corpus invasion extent was classified as exocervical-confined (group 1), endocervical (group 2), or uterine corpus invasion (group 3). The rates of overall survival, cancer-specific survival, locoregional recurrence, para-aortic lymph node recurrence, and extrapelvic metastases after pelvic radiotherapy were analyzed. Kaplan–Meier and Cox regression analyses were used to determine recurrence-associated risks. Optimal risk stratification was predicted using a receiver operating characteristic curve with the area under the curve. Results: Groups 1, 2, and 3 included 66.0%, 18.9%, and 15.1% of patients, respectively. The 5-year para-aortic lymph node recurrence rates were 6.3%, 17.2%, and 34.2% (p < 0.001). Uterine corpus invasion was an independent factor for overall survival, cancer-specific survival, locoregional recurrence, extrapelvic metastases, and para-aortic lymph node recurrence. Including uterine corpus invasion in the risk stratification led to higher areas under the curve for overall survival, cancer-specific survival, locoregional recurrence, extrapelvic metastases, and para-aortic lymph node recurrence than using single parameters. Conclusions: In cervical cancer, following pelvic radiotherapy, uterine corpus invasion is a significant prognostic factor. More-aggressive treatments such as extended-field radiotherapy, adjuvant chemotherapy, and immune checkpoint inhibitors as an alternative to standard pelvic radiotherapy with concurrent chemotherapy may be considered in these patients. Full article

While locally advanced rectal cancer is the first clinical suspicion for severe rectal stenosis, in extremely unusual cases a lower bowel obstruction may be related to bladder metastasis. We present the case of a 64-year-old male who was admitted for occlusive rectal tumor (4 cm from the anal verge), for which an emergency loop-colostomy was performed. After two inconclusive endoscopic biopsies, a transanal rectal tru-cut biopsy allowed for the detection of high-grade urothelial carcinoma with signet ring cells. Furthermore, primary origin was detected in a small bladder tumor. In imaging reassessment after neoadjuvant chemotherapy, regression of the lesions both from the bladder and rectum was observed. Radical surgery with total pelvic exenteration was considered in the absence of other secondary tumors, but the patient declined and continued with radiotherapy. Subsequently he developed malignant chylous ascites and unfortunately died three months later. Reviewing the literature, we found twenty-five cases of urothelial metastasis to the rectum, originating from the bladder, including this newly present case. Rectal metastasis of urothelial origin poses a two-fold challenge in terms of both diagnosis and treatment. Determining the specific features of this uncommon manifestation of a common disease will improve future approaches. Full article

Over the past two decades, surgical techniques in colorectal cancer (CRC) have improved patient outcomes through precision and reduced invasiveness. Open colectomy, laparoscopic surgery, robotic-assisted procedures, and advanced rectal cancer treatments such as total mesorectal excision (TME) and transanal TME are discussed in this article. Traditional open colectomy offers reliable resection but takes longer to recover. Laparoscopic surgery transformed CRC care by improving oncological outcomes, postoperative pain, and recovery. Automated surgery improves laparoscopy’s dexterity, precision, and 3D visualisation, making it ideal for rectal cancer pelvic dissections. TME is the gold standard treatment for rectal cancer, minimising local recurrence, while TaTME improves access for low-lying tumours, preserving the sphincter. In metastatic CRC, palliative procedures help manage blockage, perforation, and bleeding. Clinical examples and landmark trials show each technique’s efficacy in personalised care. Advanced surgical techniques and multidisciplinary approaches have improved CRC survival and quality of life. Advances in CRC treatment require creativity and customised surgery. Full article

Background: A strong body of evidence exists demonstrating deleterious relationships between abnormal body composition (BC) and outcomes in non-complex colorectal cancer. Complex rectal cancer (RC) includes locally advanced and locally recurrent tumours. This scoping review aims to summarise the current evidence examining BC in complex RC. Methods: A literature search was performed on Ovid MEDLINE, EMBASE, and Cochrane databases. Original studies examining BC in adult patients with complex RC were included. Two authors undertook screening and full-text reviews. Results: Thirty-five studies were included. Muscle quantity was the most commonly studied BC metric, with sarcopenia appearing to predict mortality, recurrence, neoadjuvant therapy outcomes, and postoperative complications. In particular, 10 studies examined relationships between BC and neoadjuvant therapy response, with six showing a significant association with sarcopenia. Only one study examined interventions for improving BC in patients with complex RC, and only one study specifically examined patients undergoing pelvic exenteration. Marked variation was also observed in terms of how BC was quantified, both in terms of anatomical location and how cut-off values were defined. Conclusions: Sarcopenia appears to predict mortality and recurrence in complex RC. An opportunity exists for a meta-analysis examining poorer BC and neoadjuvant therapy outcomes. There is a paucity of studies examining interventions for poor BC. Further research examining BC specifically in patients undergoing pelvic exenteration surgery is also lacking. Pitfalls identified include variances in how BC is measured on computed tomography and whether external cut-off values for muscle and adipose tissue are appropriate for a particular study population. Full article

Background/Objectives: Cervical cancer primarily disseminates through the lymphatic system, with the metastatic involvement of pelvic and para-aortic lymph nodes significantly impacting prognosis and treatment decisions. Sentinel lymph node (SLN) mapping is critical in guiding surgical management. However, resource-limited settings often lack advanced detection tools like indocyanine green (ICG). This study evaluated the feasibility and effectiveness of SLN biopsy using alternative techniques in a high-risk population with a high prevalence of large tumours. Methods: This prospective, observational study included 42 patients with FIGO 2018 stage IA1–IIA1 cervical cancer treated between November 2019 and April 2024. SLN mapping was performed using methylene blue alone or combined with a technetium-99m radiotracer. Detection rates, sensitivity, and false-negative rates were analysed. Additional endpoints included tracer technique comparisons, SLN localization patterns, and factors influencing detection success. Results: SLNs were identified in 78.6% of cases, with bilateral detection in 57.1%. The combined technique yielded higher detection rates (93.3% overall, 80% bilateral) compared to methylene blue alone (70.4% overall, 40.7% bilateral, p < 0.05). The sensitivity and negative predictive values were 70% and 93.87%, respectively. Larger tumours (>4 cm), deep stromal invasion, and prior conization negatively impacted detection rates. False-negative SLNs were associated with larger tumours and positive lymphovascular space invasion. Conclusions: SLN biopsy is feasible in resource-limited settings, with improved detection rates using combined tracer techniques. However, sensitivity remains suboptimal due to a steep learning curve and challenges in high-risk patients. Until a high detection accuracy is achieved, SLN mapping should complement, rather than replace, pelvic lymphadenectomy in high-risk cases. Full article

Background/Objectives: The optimal treatment for locally advanced cervical cancer (LACC) is debated. The proposed treatments are concomitant chemoradiotherapy plus brachytherapy (cCTRT-B) or neoadjuvant chemotherapy (NACT) followed by radical surgery (RS). The prediction NACT response is crucial for identifying responder patients who may benefit from subsequent radical surgery. The aim of this study was to find ultrasound characteristics to predict the response to NACT in patients with LACC. Methods: Consecutive patients with diagnoses of LACC were prospectively enrolled. According to FIGO staging criteria, all IB2-IIIC patients underwent three cycles of platinum-based NACT followed by radical surgery. Patients were evaluated by pelvic ultrasound one week before NACT (T0) and three weeks after the last cycle of chemotherapy (T1). The parameters analysed were volume of the lesion, tumor/uterus volume ratio, parametrial infiltration, color score, resistance (RIUA) and pulsatility (PIUA) indices of uterine arteries (UA). Results: From July 2019 to April 2023, 40 patients were enrolled. A significant decrease in tumor volume (p < 0.01) and a reduced parametrial infiltration after NACT were observed (p < 0.01). The results of the unadjusted and adjusted logistic models showed that age and RIUA positively affect the estimated probability of treatment response (p < 0.01). According to the univariate and multivariate model, RIUA greater than 0.72 ensures 87% sensitivity and 70% specificity with 82.5% accuracy in predicting tumor reduction. Conclusions: Patients over 54 with a RIUA above 0.72 are more likely to respond to NACT. Pelvic ultrasound proved to be a useful tool for predicting NACT response in LACC patients. Full article

The role of neoadjuvant and adjuvant hormonal or chemotherapy-based treatments before or after radical prostatectomy in localized or locally advanced high-risk prostate cancer (PCa) is currently debatable. European guidelines recommend adjuvant androgen deprivation therapy (ADT) only in pN1 patients after extended pelvic lymph node dissection based on outdated evidence on standard hormonal agents. The introduction of new-generation androgen receptor targeting agents (ARTAs) has revolutionized the treatment of metastatic PCa and might also impact the perioperative management of patients with high-risk localized disease. In the last years, a renewed interest has also arisen in chemotherapy-based neoadjuvant or adjuvant treatments alone or in combination with ADT and/or ARTAs. In the present review, we gathered the current evidence on the oncological outcomes of neoadjuvant and adjuvant systemic treatments in surgically treated patients with localized or locally advanced PCa. Despite mild benefits in terms of pathologic responses or oncological outcomes reported in some studies investigating ADT and/or chemotherapy in this setting of patients, strong evidence to support their use in clinical practice is lacking. Promising data in favor of ARTAs have been gathered from phase II trials and prospective series, but definitive results from phase III trials are awaited to confirm these findings. Full article

Background: Achieving evidence-based practice change in surgery has always been challenging, with many aspects of common clinical practice evolving through lower-level studies that are susceptible to bias and confounding rather than high-quality evidence. This challenge is even more pronounced in the setting of low-volume, high-complexity surgical oncology. Additionally, when the costs of interventions or technologies are high, designing and developing such studies within financially constrained national healthcare systems becomes even more complicated, potentially widening perceived healthcare inequalities between private and publicly funded systems. However, this is precisely the area where a lack of evidence can either hinder the development of significant new clinical advances or lead to the adoption of expensive and ineffective treatments. Here, we describe the novel approaches adopted in the design, development, and implementation of the ELECTRA trial, a randomised, controlled, double-blinded feasibility study with a planned extension to a late-phase trial. Methods: The Cancer Research UK ELECTRA (NCT05877352) trial is a three-armed randomised, controlled clinical trial designed to evaluate the incremental benefit of adding intraoperative electron beam radiotherapy (IOERT) to pelvic exenteration surgery for locally advanced and locally recurrent rectal cancer. ELECTRA is double-blinded, with patients, surgeons, and oncologists unaware of whether IOERT is administered or not. The primary feasibility outcome focuses on the ability to successfully recruit and randomise participants, while the subsequent primary outcome assesses IOERT field local control. Results: We describe the collaborative process involved in developing the trial, including national and international consultations to determine the best study design and the most optimal outcome measures to evaluate. We outline the extensive patient participation and input into the study design. Given the complexity and evolving nature of the field, with no clear international standardisations, we outline the processes used to address internationally agreed definitions, radiological standardisation, surgical learning curves, quality assurance, and pathological standardisation, as well as the broader impact and benefits of these activities. Finally, we describe the novel design utilised to facilitate the involvement of national and international units with varying levels of equipoise regarding IOERT. Conclusions: Historically, randomised clinical trials have not been the standard approach for evaluating surgical interventions due to their practical and methodological challenges, particularly in high-complexity, low-volume settings. Despite these difficulties, they remain the gold standard for evidence-based practice. The ELECTRA trial exemplifies a complex, innovative trial design that addresses an unmet need in a specialised area of high-complexity surgery. Using ELECTRA as an example, we highlight the genuine challenges in designing such complex trials and provide recommendations to facilitate the conduct of future well-designed surgical studies. Full article

Background: Guidelines recommend the extension of the pelvic radiotherapy volume to the para-aortic region in locally advanced cervical cancer and ≥3 suspicious pelvic lymph nodes (PLN) on imaging. Whether this recommendation is also valid for clinically early stages is uncertain. The objective of this study was to investigate the para-aortic (PAO) lymph node recurrence rate in patients with early-stage cervical cancer, ≥3 metastatic PLN, and negative common iliac nodes after a radical hysterectomy followed by pelvic (chemo)radiotherapy without extension to the PAO region. Methods: Consecutive patients, surgically treated between 2000 and 2020, with FIGO 2009 stage IB2-IIA1 and positive PLN, were included in this retrospective cohort study. The frequency of PAO recurrences, disease-free survival, and overall survival were analyzed in patients with <3 versus ≥3 positive PLN. Results: In 127 patients, the isolated PAO recurrence rate was 2/88 (2.3%) versus 1/39 (2.6%) for patients with <3 versus ≥3 positive PLNs, respectively (p = 0.671). The 5-year disease-free survival (87.3% versus 73.7%; p = 0.088) and the overall survival (90.7% versus 76.5%; p = 0.355) between patients with <3 versus ≥3 positive PLN was not significantly different. Conclusions: Isolated PAO nodal recurrence rate in women with early-stage cervical cancer after radical hysterectomy and pelvic lymphadenectomy, with positive PLN but negative common iliac nodes, followed by pelvic (chemo)radiotherapy, is low and did not differ between the groups with <3 versus ≥3 positive PLN. This makes it unlikely that the inclusion of the PAO region in the adjuvant radiotherapy volume would result in a better oncological outcome. Full article

In recent years, image-guided brachytherapy for cervical cancer has become an important treatment method for patients with locally advanced cervical cancer, and multi-modality image registration technology is a key step in this system. However, due to the patient’s own movement and other factors, the deformation between the different modalities of images is discontinuous, which brings great difficulties to the registration of pelvic computed tomography (CT/) and magnetic resonance (MR) images. In this paper, we propose a multimodality image registration network based on multistage transformation enhancement features (MTEF) to maintain the continuity of the deformation field. The model uses wavelet transform to extract different components of the image and performs fusion and enhancement processing as the input to the model. The model performs multiple registrations from local to global regions. Then, we propose a novel shared pyramid registration network that can accurately extract features from different modalities, optimizing the predicted deformation field through progressive refinement. In order to improve the registration performance, we also propose a deep learning similarity measurement method combined with bistructural morphology. On the basis of deep learning, bistructural morphology is added to the model to train the pelvic area registration evaluator, and the model can obtain parameters covering large deformation for loss function. The model was verified by the actual clinical data of cervical cancer patients. After a large number of experiments, our proposed model achieved the highest dice similarity coefficient (DSC) metric compared with the state-of-the-art registration methods. The DSC index of the MTEF algorithm is 5.64% higher than that of the TransMorph algorithm. It will effectively integrate multi-modal image information, improve the accuracy of tumor localization, and benefit more cervical cancer patients. Full article

Background: The aim is to propose a model for predicting occult paraaortic lymph node (PALN) involvement in locally advanced cervical cancer (LACC) patients by including parameters such as reconstruction detection technology (use of time-of-flight) and parameters related to the primary tumor. This model will then be compared with the scores used in routine clinical practice; Methods: This retrospective observational cohort study included patients diagnosed with LACC who underwent ¹⁸F-FDG PET/CT prior to PALN surgical staging between February 2012 and May 2020. The following parameters were collected on PET/CT: tumor SUVmax, tumor MTV, number of common and distal pelvic node involvements. A multivariate regression analysis estimating the probability of PALN involvement was performed, with optimal thresholds determined via ROC curves; Results: In total, 71 patients met the inclusion criteria. Occult PALN involvement was detected in 12.7% of patients. A derived multivariate PET model selected four variables: number of common and distal iliac lymph nodes (OR 5.9 and 2.7, respectively), tumor-to-liver SUV ratio (OR 0.9) and the use of time-of-flight technology (OR 21.4 if no time-of-flight available). At the optimal threshold, a sensitivity of 77.8% and specificity of 88.7% was found. The model’s performances varied significantly between patients whose PET/CT used time-of-flight and those whose PET/CT did not. No significant differences were found between our model and the one used in clinical practice (p = 0.55); Conclusions: This study shows that PET/CT technology influences the ability to detect occult PALN involvement in LACC. This parameter should be considered in the regular revision of PET-based scores. Full article

First described some 80 years ago, pelvic exenteration remain controversial interventions with variable results and ever-changing indications. The previous studies are not homogenous and have different inclusion criteria (different populations and different disease characteristics) and methodologies (including evaluation of results), making it extremely difficult to properly assess the role of pelvic exenteration in cancer treatment. This study aims to describe the indications of pelvic exenterations, the main prognostic factors of oncologic results, and the possible complications of the intervention. Methods: For this purpose, we conducted a retrospective study of 132 patients who underwent various forms of pelvic exenterations in the Institute of Oncology “Prof. Dr. Al. Trestioreanu” in Bucharest, Romania, between 2013 and 2022, collecting sociodemographic data, characteristics of patients, information on the disease treated, data about the surgical procedure, complications, additional cancer treatments, and oncologic results. Results: The study cohort consists of gynecological, colorectal, and urinary bladder malignancies (one hundred twenty-seven patients) and five patients with complex fistulas between pelvic organs. An R0 resection was possible in 76.38% of cases, while on the rest, positive margins on resection specimens were observed. The early morbidity was 40.63% and the mortality was 2.72%. Long-term outcomes included an overall survival of 43.7 months and a median recurrence-free survival of 24.3 months. The most important determinants of OS are completeness of resection, the colorectal origin of tumor, and the presence/absence of lymphovascular invasion. Conclusions: Although still associated with high morbidity rates, pelvic exenterations can deliver important improvements in oncological outcomes in the long-term and should be considered on a case-by-case basis. A good selection of patients and an experienced surgical team can facilitate optimal risks/benefits. Full article

The standard treatment for locally advanced cervical cancer typically includes concomitant chemoradiation, a regimen known to induce severe hematologic toxicity (HT). Particularly, pelvic bone marrow dose exposure has been identified as a contributing factor to this hematologic toxicity. Chemotherapy further increases bone marrow suppression, often necessitating treatment interruptions or dose reductions. A systematic search for original articles published between 1 January 2006 and 7 January 2024 that reported on chemoradiotherapy for locally advanced cervical cancer and hematologic toxicities was conducted. Twenty-four articles comprising 1539 patients were included in the final analysis. HT of grade 2 and higher was observed across all studies and frequently exceeded 50%. When correlating active pelvic bone marrow and HT, significant correlations were found for volumes between 10 and 45 Gy and HT of grade 3 and higher. Several dose recommendations for pelvic bone and pelvic bone marrow sparing to reduce HT were established, including V10 < 90–95%, V20 < 65–86.6% and V40 < 22.8–40%. Applying dose constraints to the pelvic bone/bone marrow is a promising approach for reducing HT, and thus reliable implementation of therapy. However, prospective randomized controlled trials are needed to define precise dose constraints and optimize clinical strategies. Full article