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Background Colorectal cancer is the second leading cause of cancer-related mortality worldwide. Peritoneal metastases carry the worst prognosis among all sites of colorectal cancer metastases. In recent years, the advent and acceptance of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy have greatly improved survival for selected patients with low-volume peritoneal metastases. Objective Here, we report the evolution of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for colorectal peritoneal metastases at a statewide tertiary referral center over an 8-year period. Design This is a retrospective study from 2009 to 2017. Setting The study was conducted at a single center over 8 years. Patients Patients with colorectal peritoneal metastases undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy were included. Main outcomes Main outcomes included evaluation of grade III/IV morbidity rate, mortality rate, overall and relapse-free survival, and prognostic factors influencing survival on a Cox multivariate analysis model. Results One hundred one cytoreductive surgeries were undertaken on 96 patients during this time for colorectal peritoneal metastases. The median patient age was 60 years with 55.2% being female. The median Peritoneal Carcinomatosis Index was 9, with complete cytoreduction achieved in 76 (75.2%) cases. Grade III or IV complications occurred in 26 cases (25.7%) with 2 (2%) perioperative mortalities. Median overall survival for the entire cohort was 32 months, with a 3-year survival of 38%. For patients who achieved a complete cytoreduction, median overall survival was 37 months, with a relapse-free survival of 13 months and a 3-year survival of 54%. Complete cytoreduction and nonmucinous histology were key factors independently associated with improved overall survival. Limitations The main limitation this study is its retrospective nature. Conclusion Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for isolated low-volume colorectal peritoneal metastases is safe and effective, with low morbidity. It offers selected patients a highly favorable overall and relapse-free survival. See Video Abstract at http://links.lww.com/DCR/B2. EVOLUCION DE LA CIRUGIA CITORREDUCTIVA Y QUIMIOTERAPIA INTRAPERITONEAL HIPERTERMICA (HIPEC) PARA METASTASIS PERITONEALES COLORRECTALES: EXPERIENCIA INSTITUCIONAL DE 8 ANOS: El cancer colorrectal es la segunda causa de mortalidad relacionada con el cancer en todo el mundo. Las metastasis peritoneales tienen el peor pronostico entre todos los sitios de metastasis del cancer colorrectal. En los ultimos anos, el advenimiento y la aceptacion de la cirugia citorreductiva y la quimioterapia intraperitoneal hipertermica ha mejorado enormemente la supervivencia de pacientes seleccionados con metastasis peritoneales de bajo volumen. Objetivo Aqui, informamos sobre la evolucion de la cirugia citorreductiva y la quimioterapia intraperitoneal hipertermica para las metastasis peritoneales colorrectales en un centro de referencia terciario para todo el estado durante un periodo de ocho anos. DISENO:: Estudio retrospectivo del 2009 a 2017. CONFIGURACION:: Centro unico a lo largo de ocho anos. Pacientes Pacientes con metastasis peritoneales colorrectales sometidos a cirugia citorreductiva y quimioterapia intraperitoneal hipertermica. Resultados principales Los resultados principales incluyeron la evaluacion de la tasa de morbilidad de grado III / IV, la tasa de mortalidad, la supervivencia general y libre de recaida y los factores pronosticos que influyen en la supervivencia en el modelo de analisis multivariado Cox. Resultados Se realizaron el ciento uno cirugias citorreductivas en noventa y seis pacientes durante este tiempo por metastasis peritoneales colorrectales. La edad media de los pacientes fue de 60 anos, con un 55.2% de mujeres. El Indice de Carcinomatosis Peritoneal mediano fue de 9, con una citorreduccion completa lograda en 76 (75.2%) casos. Las complicaciones de grado III o IV ocurrieron en 26 casos (25.7%) con dos (2%) de mortalidad perioperatoria. La supervivencia mediana general para toda la cohorte fue de 32 meses, con una supervivencia de 3 anos del 38%. Para los pacientes que lograron una citorreduccion completa, la supervivencia global media fue de 37 meses, con una supervivencia sin recaida de 13 meses y una supervivencia de 3 anos del 54%. La citorreduccion completa y la histologia no mucinosa fueron factores clave asociados de forma independiente con una mejor supervivencia general. Limitaciones La principal limitacion es la naturaleza retrospectiva del estudio. CONCLUSION:: La cirugia citorreductiva y la quimioterapia intraperitoneal hipertermica para las metastasis peritoneales colorrectales aisladas de bajo volumen son seguras y eficaces, con baja morbilidad. Ofrece a los pacientes seleccionados una supervivencia global altamente favorable y libre de recaida. Vea el Resumen del video en http://links.lww.com/DCR/B2.

Currently there is no reliable test to predict pathological complete response following neoadjuvant chemoradiotherapy for rectal cancer. However, there is increasing interest in using clinical complete response as a surrogate marker, allowing a subset of patients with locally advanced rectal cancer to be allocated into a "watch and wait" pathway. Little is known about the oncological safety of the "watch and wait" approach or the rate of salvage surgery in cases of tumor regrowth. This information is critical for the implementation of this approach.The aim of this study is to assess the rate of salvage surgery and associated oncological outcomes for patients who develop a tumor regrowth with the "watch and wait" approach.Relevant studies were identified through PubMed, Embase, and Google Scholar search.A systematic review was undertaken of studies assessing patients selected for the "watch and wait" approach according to PRISMA guidelines.The associated tumor regrowth, salvage surgery, and disease-free and overall survival rates were assessed.Five retrospective and 4 prospective observational studies were included into the analysis, with a total of 370 patients in the "watch and wait" group, of which 256 (69.2%) had persistent clinical complete response. Of those who had tumor regrowth, salvage surgery was possible in 83.8%. There was no difference in overall survival and disease-free survival between patients who received immediate surgery and the "watch and wait" group.The limitations of this study include its retrospective nature and small sample size. Furthermore, there is significant heterogeneity between study protocols, including the short median follow-up, given that tumor regrowth and distant metastasis may manifest at a later time point.The majority of patients with tumor regrowth can be salvaged with definite surgery after "watch and wait." However, there is insufficient evidence to draw firm conclusions on the oncological safety of this approach; therefore, it is currently not the standard of care for locally advanced rectal cancer.

Management of rectal cancer has become multidisciplinary and is driven by the stage of the disease, with increased focus on restaging rectal cancer after neoadjuvant therapy.The purpose of this study was to assess the relative impact of restaging after preoperative chemoradiation with FDG-PET scan, CT, and MRI in the management of patients with rectal cancer.This was a retrospective study from a single institution.This study was conducted at a tertiary cancer center.A total of 199 patients met the inclusion criteria: patients with rectal adenocarcinoma; staged with positron emission tomography, CT, and MRI; T2 to T4, N0 to N2, M0 to M1; treated with neoadjuvant chemoradiation 50.4 Gy and infusional 5-fluorouracil; and restaged 4 weeks after chemoradiation before surgery between 2003 and 2013.Comparisons of the tumor stage among different imaging modalities before and after neoadjuvant chemoradiation were performed. The impact of restaging on the management plan was assessed.The stage at presentation was T2, 8.04%; T3, 65.33%; T4, 26.63%; N0, 17.09%; N1, 47.74%; N2, 34.67%; M0, 81.91%; and M1, 18.09%. Changes in disease stage postneoadjuvant chemoradiation were observed in 99 patients (50%). The management plans of 29 patients (15%) were changed. The impact of each restaging modality on management for all of the patients was positron emission tomography, 11%; CT, 4%; and MRI, 4%. In patients with metastatic disease at primary staging, the relative impact of each restaging modality in changing management was positron emission tomography, 32%; CT, 18%; and MRI, 6%.This study was limited by its single-center and retrospective design. Operations were performed 4 weeks after restaging.Changes in the extent of disease after long-course chemoradiotherapy result in changes of management in a significant percentage of patients. Positron emission tomography has the most significant impact in the change of management overall, and its use in restaging advanced rectal cancer should be further explored.

Anastomotic leaks after restorative resections for rectal cancer may lead to worse long-term outcomes.The purpose of this study was to evaluate the best current evidence assessing anastomotic leaks in rectal cancer resections with curative intent and their impact on survival and cancer recurrence.A meta-analysis was performed using MEDLINE, EMBASE, and Cochrane search engines for relevant studies published between January 1982 and January 2015.Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology was used to screen and select relevant studies for the review using key words "colorectal surgery; colorectal neoplasm; rectal neoplasm" and "anastomotic leak."Anastomotic leak groups were compared with nonanastomotic leak groups.ORs were calculated from binary data for local recurrence, distant recurrence, and cancer-specific mortality. A random-effects model was then used to calculate pooled ORs with 95% CIs.Eleven studies with 13,655 patients met the inclusion criteria. This included 5 prospective cohort and 6 retrospective cohort studies. Median follow-up was 60 months. Higher cancer-specific mortality was noted in the leak group with an OR of 1.30 (95% CI, 1.04-1.62; p0.05). Local recurrences were more likely in rectal cancer resections complicated by anastomotic leaks (OR = 1.61 (95% CI, 1.25-2.09); p0.001). Distant recurrence was not more likely in the anastomotic leak group (OR = 1.07 (95% CI, 0.87-1.33); p = 0.52).All 11 studies are level 3 evidence cohort studies. Additional sensitivity analyses were performed to minimize cross-study heterogeneity.Anastomotic leaks after restorative resections for rectal cancer adversely impact cancer-specific mortality and local recurrence.

Elective proctocolectomy has been recommended for patients at high risk of desmoids based on the possibility that cancer in a retained rectum may be unresectable because of desmoid disease. There are no data to support the reality of this concern.The aim of this study was to see how often proctectomy was prevented by desmoids.This retrospective, descriptive, database study was augmented by chart review.This study was conducted at a hereditary colorectal cancer clinic in a tertiary referral center.Those presenting for proctectomy after colectomy and ileorectal anastomosis for familial adenomatous polyposis were selected.Patients underwent a proctectomy.The primary outcomes measured were the rate of proctectomy, rate of IPAA, and the incidence of desmoid disease.Sixty- seven patients, 34 men and 33 women, underwent an operation with the intent of performing proctectomy. Mean age at surgery was 39.7 years, an average of 175 months from ileorectal anastomosis. Indications for proctectomy were uncontrollable adenomas in 56, cancer in 8, and high-grade dysplasia in 3. Proctectomy was always possible. Ileal pouch-anal anastomosis was planned in 62 patients; 54 had this operation. Desmoid disease was found in 26 patients (38.8%) and influenced surgery in 13 cases, stopping pouch-anal anastomosis in 8. One patient had no resection, 2 had a pouch-low rectal anastomosis, and 5 had proctectomy and ileostomy. Proctectomy and ileostomy was planned in 5 patients and performed in all.This is a retrospective review from a single institution.The fear of an unresectable rectum or an impossible pouch-anal anastomosis should not be an indication for proctectomy in patients with low rectal polyp counts but a high risk for desmoid disease.

BACKGROUND: DNA mismatch repair immunohistochemistry on tumor tissue is a simple, readily available, and cost-effective method of identifying patients with Lynch syndrome in the postoperative setting. The aim of the study was to assess whether the mismatch repair status of a colorectal cancer can be confirmed by mismatch repair immunohistochemistry on preoperative biopsy. DESIGN: Germline positive patients with Lynch syndrome were identified from a prospectively collected Familial Cancer Clinic database. Preoperative colorectal cancer biopsy specimens were obtained from the source pathology provider to generate a cohort of matched preoperative and postoperative specimens. The specimens were sectioned and stained for 4 mismatch repair proteins (MLH1, MSH2, MSH6, PMS2). An age-matched cohort to compare specimens was selected from Bethesda positive but mismatch repair immunohistochemistry negative patients. All slides were reviewed by a single blinded pathologist. The Wilson method was used to calculate a true underlying proportion of patients for whom the preoperative result matched the postoperative test result with a 95% confidence interval. RESULTS: Of 128 germline positive mutation carriers, 40 patients (mean age 41, SD 11.3) had colorectal resections. Thirty-three preoperative specimens were retrievable and were matched with biopsies from 33 controls. The germline mutations included in the study were 8 MLH1, 19 MSH2, 3 MSH6, and 2 PMS2. In patients where germline positive status was known, sensitivity was 100% (95% CI 89.2–100) and specificity was 100% (95% CI 89.2–100). Identical sensitivity and specificity were observed in 33 age-matched patients. The sensitivity of the endoscopic biopsy in predicting germline status was 94.9% (95% CI 80.4–98.3). CONCLUSION: The mismatch repair disease status of a colorectal cancer can be reliably confirmed by mismatch repair immunohistochemistry on a diagnostic colorectal cancer biopsy sample before definitive surgery. Ascertaining a diagnosis of Lynch syndrome before definitive surgery can influence surgical planning.