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The concept of significant polyps and early colorectal cancer encompasses complex polyps not amenable to routine snare polypectomy or where malignancy cannot be excluded. The assessment and management of these lesions is contentious and increasingly important due to the significant risk of over- or undertreatment.Following the recommendations of the Significant Polyps and Early Colorectal Cancer National Program, we implemented a dedicated multidisciplinary team meeting and analyzed the influence on patient outcomes.This was a retrospective study using a prospectively collected database of patients discussed at the dedicated multidisciplinary team meeting.This study was conducted in a single tertiary-care center.Consecutive patients with significant polyps and early colorectal cancer were identified either through the Bowel Cancer Screening Program or colonoscopy for symptomatic patients.Proportions of patients who had organ preservation, and secondary treatment and recurrence rate served as outcome measures.Overall, 135 patients discussed at the dedicated multidisciplinary team meeting were included, with a median age of 71 years. Median size of the lesions was 25 mm, and 39% were in the rectum. Patients were discussed either after the lesion was removed during the initial colonoscopy (n = 38), of whom 16 (42%) had unexpected cancer, or had no initial treatment with subsequent case review (n = 97). Of these 97 patients, 46 underwent endoscopic excision (26% cancer), 20 trans-anal excision (10% cancer), 23 primary surgical resection (35% cancer), and 8 had no treatment. In 104 (82%) patients, organ preservation was achieved. Secondary surgery was required in 7 of 104 (6.7%) patients after local excision due to radical treatment of high-risk T1 lesions, local recurrence, or patients' decisions. The cumulative hazard estimates for recurrence after a median follow-up of 18.5 months was less than 10% for both benign and malignant lesions.This study was limited by its relatively small sample size and single-center setting.A dedicated multidisciplinary team meeting improved the management of significant polyps and early colorectal cancer, safely refining organ preservation for patients, with low recurrence rates. See Video Abstract at http://links.lww.com/DCR/B826.ANTECEDENTES:El concepto de pólipos complejos y cáncer colorrectal temprano abarca engloba pólipos avanzados que no es posible la reseccion endoscopica rutinaria, o aquellos en los que no se puede excluir malignidad. La evaluación y el manejo de estas lesiones es controversial y cada vez más importante debido al riesgo significativo de ser tratadas o no.OBJETIVO:Siguiendo las recomendaciones del Programa Nacional de Pólipos Complejos y Cáncer Colorrectal Temprano, implementamos reuniónes del equipo multidisciplinario especializado y analizamos el impacto en los resultados de los pacientes.DISEÑO:Estudio retrospectivo sobre una base de datos recopilada prospectivamente de los pacientes discutidos en la reunión del equipo multidisciplinario especializado.AJUSTE:Este estudio se realizó en un centro de atención terciaria.PACIENTES:Pacientes consecutivos con pólipos complejos y cáncer colorrectal temprano identificado a través del Programa de detección de cáncer intestinal o colonoscopia para pacientes sintomáticos.PRINCIPALES MEDIDAS DE RESULTADO:Proporción de pacientes que tuvieron preservación de órganos, tratamiento secundario y tasa de recurrencia.RESULTADOS:En total, se incluyeron 135 pacientes discutidos en la reunión del equipo multidisciplinario especializado dedicada, con una media de edad de 71 años. El tamaño medio de las lesiones fue de 25 mm y el 39% estaban en el recto. Se discutio de los pacientes después de que se resecara la lesión durante la colonoscopia inicial [n = 38, de los cuales 16 (42%) tenían un cáncer imprevisto] o no recibieron tratamiento de inicio, con revisión posterior del caso (n = 97). De estos, 46/97 fueron sometidos a resección endoscópica (26% cáncer), 20/97 resección transanal (10% cáncer), 23/97 resección quirúrgica primaria (35% cáncer) y 8/97 no recibieron tratamiento. En 104 (82%) pacientes, se logró la preservación de órgano. Cirugía secundaria fue requeria en 7/104 (6,7%) pacientes después de la resección local debido a tratamiento radical de lesiones T1 de alto riesgo, recidiva local o decisión del paciente. Las estimaciones de riesgo acumulativo de recurrencia después de una media de seguimiento de 18,5 meses fue inferior al 10% tanto para las lesiones benignas como para las malignas.LIMITACIONES:Tamaño de muestra relativamente pequeño y entorno de un solo centro.CONCLUSIONES:La Reunion del equipo multidisciplinario especializado mejoró el manejo de los pólipos complejos y cáncer colorrectal temprano, refinando de manera segura la preservación de órganos para los pacientes, con bajas tasas de recurrencia. Consulte Video Resumen en http://links.lww.com/DCR/B826. (Traducción- Dr. Francisco M. Abarca-Rendon).

Introduction: The PRODIGE 7-trial investigated the additional value of Hyperthermic Intraperitoneal Chemotherapy (HIPEC) to cytoreductive surgery (CRS) for patients with colorectal peritoneal metastases (CPM). The results of PRODIGE 7 were presented at the 2018 ASCO meeting showing that 30 min oxaliplatin-based HIPEC did not improve overall survival. The current study investigated the impact of PRODIGE 7 on the worldwide practice of CRS and HIPEC. Materials and methods: CRS-HIPEC experts from 19 countries were invited through the Peritoneal Surface Oncology Group International (PSOGI) to complete an online survey concerning the current CRS-HIPEC practice in their hospital and country, and were asked to appraise the effect of PRODIGE 7. Results: The survey was completed by 18/19 experts. Although their personal opinions of CRS-HIPEC were barely influenced by PRODIGE 7, they reported a substantial impact on daily practice. This included a switch towards Mitomycin-C based HIPEC-regimens and prolongation of HIPEC perfusion time, a reduction in the number of referrals from non-HIPEC centers, a reduction in national consensus, the removal of HIPEC from national guidelines, and a reduced reimbursement rate. Conclusion: The PRODIGE 7 has had a major impact on the practice of CRS-HIPEC for CPM worldwide. HIPEC remains an attractive option with potential for control and eradication of disease and further studies into the optimal HIPEC-regimen are urgently needed. Meanwhile, given the complexity of the treatment of patients with CPM, and the proven benefits of optimal CRS, referral of patients with potentially resectable CPM to expert centers is recommended whilst the precise role of HIPEC is further evaluated. (c) 2021 Published by Elsevier Ltd.

Introduction The incidence and patterns of local recurrence of colon cancer are not well reported. The aim of this study was to investigate the contemporary rates and patterns of local recurrence after sigmoid cancer resection, comparing pre and post-operative biomarkers in predicting local disease recurrence. Materials and methods A multi-centre, retrospective analysis of 414 patients undergoing resectional surgery for sigmoid colon cancer was conducted. Multivariable Cox Proportional Hazard models were created to identify variables associated with local disease recurrence. Patterns of recurrence and prognostic significance of pre and post-operative variables were identified. Results In 414 patients, the local recurrence rate was 12.6%. The R1/R2 rate was 2.4%. Local recurrence occurred most commonly within the peri-anastomotic region (50%), followed by the peritoneum (33%). On multivariate analysis, local recurrence was predicted by pathological T stage (HR 1.15) and R1 resection (HR 2.95), but also computerised tomography (CT) identified tumour deposits (HR 2.40) and local peritoneal infiltration (2.70). Conclusions Contemporary local recurrence rates for sigmoid cancer are high at 12.6%. Outcomes may be improved if local recurrence is reduced at the most common sites such as the peri-anastomotic area or peritoneum. Extra-nodal CT-imaging biomarkers of local peritoneal infiltration and tumour deposits were prognostically significant on multivariate analysis in addition to pathology staging variables.

The European and American colonoscopy guidelines recommend mandatory photodocumentation of caecal intubation to allow retrospective analysis and improve outcomes. We aim to demonstrate whether photodocumentation of caecal intubation improves colonoscopy outcomes. We extracted images and procedural data from 317 consecutive colonoscopies. Images were anonymised and reviewed by four expert reviewers who scored their certainty that caecal intubation was achieved. Statistical analysis correlated adequately and inadequately photodocumented cases with polyp detection rate (PDR) and adenoma detection rate (ADR). The patients’ mean age was 59.4 years and 52% were male. Eighty-one percent were performed by consultant endoscopists and 19% by specialist registrar. Sixty-five percent of these procedures were performed by gastroenterologists and 35% by surgical endoscopists. Fifty-three percent were deemed to have adequately demonstrated photographic evidence of caecal intubation. Statistical analysis comparing adequately and inadequately photodocumented cases: the PDR of procedures with confirmed caecal intubation was greater than procedures without photographic evidence (40% vs 34%). Similarly, the ADR of photographically confirmed cases was greater than that of inadequately photodocumented cases (25% vs 18%). The number of images taken per procedure positively correlated with photographic documentation of caecal intubation. While failing to reach statistical significance, there was a nominal difference in ADR and PDR demonstrated between the two groups, and with predominantly positive confidence intervals, this might suggest that a larger sample size could result in significance in favour of photodocumentation of caecal intubation. Future studies would be warranted. However, endoscopists that take more images were more likely to have proven caecal intubation.

Background Recurrence-free patients after esophageal cancer surgery face long-term nutritional consequences, occurring in the context of an exaggerated postprandial gut hormone response. Acute gut hormone suppression influences brain reward signaling and eating behavior. This study aimed to suppress gut hormone secretion and characterize reward responses and eating behavior among postesophagectomy patients with unintentional weight loss. Methods This pilot study prospectively studied postoperative patients with 10% or greater body weight loss (BWL) beyond 1 year who were candidates for clinical treatment with long-acting octreotide (LAR). Before and after 4 weeks of treatment, gut hormone secretion, food cue reactivity (functional magnetic resonance imaging), eating motivation (progressive ratio task), ad libitum food intake, body composition, and symptom burden were assessed. Results Eight patients (7 male, age: mean ± SD 62.8 ± 9.4 years, postoperative BWL: 15.5 ± 5.8%) participated. Octreotide LAR did not significantly suppress total postprandial plasma glucagon-like peptide-1 response at 4 weeks (P = .08). Postprandial symptom burden improved after treatment (Sigstad score median [range]: 12 [2-28] vs 8 [3-18], P = .04) but weight remained stable (pre: 68.6 ± 12.8 kg vs post: 69.2 ± 13.4 kg, P = .13). There was no significant change in brain reward system responses, during evaluation of high-energy or low-energy food pictures, nor their appeal rating. Moreover, treatment did not alter motivation to eat (P = .41) nor ad libitum food intake(P = .46). Conclusion The protocol used made it feasible to characterize the gut-brain axis and eating behavior in this cohort. Inadequate suppression of gut hormone responses 4 weeks after octreotide LAR administration may explain the lack of gut-brain pathway alterations. A higher dose or shorter interdose interval may be required to optimize the intervention.

OBJECTIVE The aim of this study was to propose and test a novel adverse pathology classification in AEG. BACKGROUND Recent scientific advances show genomic and molecular concordance across all AEG types, suggesting a rationale for a biologic classification. We tested a 3-dimension adverse pathology classification across the entire junction and per Siewert anatomic subtype. METHODS Of 1625 patients with AEG, 650 underwent radical surgery, 55% post-neoadjuvant therapy (NeoT). Adverse features defined a priori were poor differentiation (PD), lymphatic invasion (LI), vascular invasion (VI), and perineural invasion (PN), with 3 groupings: 0 (no adverse feature), 1 to 2, and 3 to 4. Multivariable logistic and Cox proportional hazards regression were applied. RESULTS For adverse pathology, 31%, 46%, and 23% had 0, 1 to 2, and 3 to 4, respectively. Fifty percent of cases were AEG I, 25% AEG II, and 25% AEG III. Median survival was not reached, 49 and 17 months for 0, 1 to 2, and 3 to 4 adverse pathology, respectively (P < 0.001), and 76, 51, and 34 months for AEG I, II, and III, respectively (P < 0.001); AEG I was significantly (P< 0.001) associated with lower c (y)pT and c (y)pN stages, and LI, VI, PN, and PD (poor vs other). The pathology model was significant for survival along with (y)pT and (y)pN, and predicted response to chemotherapy and chemoradiation irrespective of anatomic subtype (P < 0.001). CONCLUSION A novel classification using standard pathology as proxy for poor biology is associated with survival and response to therapy. This effect is observed across the entire AEG spectrum, highlighting how biology should be aligned with anatomy in the modern paradigm of AEG management and design of clinical trials.

This study aimed to describe short- and medium-term longitudinal quality-of-life (QoL) outcomes after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Consecutive patients undergoing CRS and HIPEC were recruited. The primary outcome was QoL, measured using the short-form 36 questionnaire and expressed as a physical component score (PCS) and a mental component score (MCS), with higher scores representing better QoL. Data were collected prospectively at baseline and before discharge, then 3, 6, and 12 months postoperatively. Trajectories of the PCS and MCS were described for the study period and grouped according to a peritoneal carcinomatosis index (PCI) (≤ 12 vs. ≥ 13) and a completeness of cytoreduction (CC) score (CC0 vs. CC1–CC3). Overall, 117 patients underwent CRS and HIPEC and 115 (98.3%) of the 117 patients participated in the study. The main primary pathology was colorectal in 52 (45%) of the 115 patients and appendiceal in 27 (23.5%) of the 115 patients. The median baseline PCS [48.16; interquartile range (IQR), 38.6–54.9] had decreased at pre-discharge (35.34; IQR, 28.7–41.8), then increased slightly at 3 months (42.54; IQR, 37.6–51.6), before returning to baseline within 6 months (48.35; IQR, 39.1–52.5) and remaining unchanged 12 months after surgery (48.55; IQR, 40.8–55.5). The MCS remained unchanged during the study period. The patients with a PCI of 13 or higher had worse PCS and MCS during the postoperative period than the patients with a PCI of 12 or lower. The CRS and HIPEC procedures impaired PCS, with scores returning to baseline within 6 months after surgery, whereas MCS remained unchanged. The patients with a lower PCI had better postoperative QoL outcomes. For patients with peritoneal malignancy, CRS and HIPEC can be performed with acceptable short- to medium-term QoL outcomes.

The coronavirus disease 19 (COVID-19) pandemic has become the focus of attention worldwide, and herein we seek to highlight the potential problem of ‘collateral mortality’ from delayed or deferred treatments in patients with cancer. We propose potential solutions to ensure continuity of care in the field of surgical oncology.

Background Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy for pseudomyxoma peritonei (PMP) is associated with excessive bleeding and acquired fibrinogen deficiency. Maintaining plasma fibrinogen may support hemostasis. Objectives To compare hemostatic efficacy and safety of human fibrinogen concentrate (HFC) vs cryoprecipitate as fibrinogen sources for bleeding patients with acquired fibrinogen deficiency undergoing PMP CRS. Methods FORMA‐05 was an off‐label single‐center, prospective, randomized, controlled phase 2 study. Patients undergoing PMP surgery with predicted intraoperative blood loss ≥2 L received human fibrinogen concentrate (HFC; 4 g) or cryoprecipitate (two pools of 5 units, containing approximately 4.0‐4.6 g fibrinogen), repeated as needed. The primary endpoint was a composite of intraoperative and postoperative efficacy, graded using objective 4‐point scales and adjudicated by an independent committee. Results One hundred percent of patients receiving HFC (95% confidence interval: 83.9‐100.0, n = 21) or cryoprecipitate (84.6‐100.0, n = 22) achieved hemostatic success. HFC demonstrated noninferior efficacy (P = .0095; post hoc) and arrived in the operating room 46 minutes faster. There were significantly greater mean increases with HFC vs cryoprecipitate in plasma fibrinogen (0.78 vs 0.35 g/L; P

Background: Cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy (HIPEC) is a complex surgical intervention with associated risks. Central venous catheter (CVC) line ...

Visceral obesity, metabolic syndrome and non-alcoholic fatty liver disease (NAFLD) represent risk factors for esophageal adenocarcinoma (EAC). The prevalence of NAFLD, and its impact on the hepatic response to esophageal cancer surgery, has never been systematically evaluated, and was the focus of this study. Methods Consecutive patients (n = 547) treated with curative intent for esophageal cancer from 2007–2017 were studied. In an unselected subgroup (n = 138), liver biopsies were collected intraoperatively and assessed for NAFLD, defined as ≥5% macrovesicular steatosis. Postoperative complications were recorded prospectively, including Clavien-Dindo grade (CD) and comprehensive complications index (CCI). Liver function tests were monitored in the first postoperative week, with hepatocellular dysfunction defined as a transaminase rise ≥3-times the upper limit of normal. Multivariable logistic and Cox proportional hazards regression were utilised to determine independent predictors of operative and oncologic outcome. The study was registered on clinicaltrials.gov (NCT04152044). Results NAFLD was evident in 62 patients (47.7%) who had biopsies, with a mean (SD) score of 10.1(9.3)%. NAFLD was associated with metabolic syndrome (41.9 vs 25%, P = 0.04), obesity (44.1 vs 11.9%, P Conclusion A marker of metabolic dysregulation in obesity-associated carcinogenesis, NAFLD is prevalent among patients with esophageal cancer. Liver dysfunction post esophagectomy is common, and although temporary, is associated with worse oncologic outcomes. Baseline NAFLD did not incur an adverse long-term oncologic outcome.

The peritoneal cavity is the second commonest site of mesothelioma after the pleural cavity. There are five histological types of peritoneal mesothelioma with variable symptomatology, clinical presentation and prognosis. Cystic mesothelioma is a borderline malignant neoplasm with a favourable prognosis, well-differentiated papillary mesothelioma is generally a low-grade malignancy, and all other varieties such as epithelioid, sarcomatoid and biphasic mesothelioma are highly malignant types of peritoneal mesothelioma with poor prognosis. Malignant peritoneal mesothelioma was considered inevitably fatal prior to the introduction of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in selected cases where long-term survival and cure could be achieved. However, the survival benefits following CRS and HIPEC mainly depend on completeness of cytoreduction, which come at the cost of high morbidity and potential mortality. Using the acronym ‘PAUSE’, we aimed at describing the key imaging findings that impact surgical decision-making in patients with peritoneal mesothelioma. PAUSE stands for peritoneal cancer index, ascites and abdominal wall disease, unfavourable sites of involvement, small bowel and mesenteric disease and extraperitoneal disease. Reporting components of ‘PAUSE’ is crucial for patient selection. Despite limitations of CT in accurately depicting the volume of disease, describing findings in terms of PAUSE plays an important role in excluding patients who might not benefit from CRS and HIPEC.

IntroductionDespite optimal patient selection and surgical effort, recurrence is seen in over 70% of patients undergoing cytoreductive surgery (CRS) for peritoneal metastases (PM). Apart from the Peritoneal Cancer Index (PCI), completeness of cytoreduction and tumour grade, there are other factors like disease distribution in the peritoneal cavity, pathological response to systemic chemotherapy (SC), lymph node metastases and morphology of PM which may have prognostic value. One reason for the underutilisation of these factors is that they are known only after surgery. Identifying clinical predictors, specifically radiological predictors, could lead to better utilisation of these factors in clinical decision making and the extent of peritoneal resection performed for different tumours. This study aims to study these factors, their impact on survival and identify clinical and radiological predictors.Methods and analysisThere is no therapeutic intervention in the study. All patients with biopsy-proven PM from colorectal, appendiceal, gastric and ovarian cancer and peritoneal mesothelioma undergoing CRS will be included. The demographic, clinical, radiological, surgical and pathological details will be collected according to a prespecified format that includes details regarding distribution of disease, morphology of PM, regional node involvement and pathological response to SC. In addition to the absolute value of PCI, the structures bearing the largest tumour nodules and a description of the morphology in each region will be recorded. A correlation between the surgical, radiological and pathological findings will be performed and the impact of these potential prognostic factors on progression-free and overall survival determined. The practices pertaining to radiological and pathological reporting at different centres will be studied.Ethics and disseminationThe study protocol has been approved by the Zydus Hospital ethics committee (27 July, 2020) and Lyon-Sud ethics committee (A15-128).Trial registration numberCTRI/2020/09/027709; Pre-results.

AIMS Patients with abdominal cancer requiring major surgical intervention are at high risk of venous thromboembolic events (VTE), particularly pulmonary emboli (PE). A proportion of patients with cancer can present with, or have had, major VTEs prior to definitive surgical treatment. Preoperative percutaneous inferior venal caval filters (IVCF) may reduce the risk of PE. The aim of this study was to assess the indications, complications, retrieval rates, and long-term outcome of IVCFs in patients undergoing major abdominal surgery. METHODS This was a retrospective analysis of a prospective IVCF database between 2007 and 2018 of all patients with IVCF insertion prior to major abdominal surgery. The indications for an IVCF, procedural complications and surgical interventions were recorded. RESULTS Overall, 111 patients had IVCF insertion. IVCF placement failed in one patient with gross abdominal disease. Indications for an IVCF were: prior PE in 65/111 (59%) and major vein thrombus in 42 (38%). Overall, 26/111 (23%) had the IVCF removed at a median of 91 days. In two patients IVCF removal failed. At follow-up of the 85 patients who had the IVCF left in situ, six developed filter-related thrombus and 13 a deep vein thrombosis (DVT). Four patients had a PE with an indwelling IVCF. CONCLUSION Preoperative IVCF may reduce perioperative PE in patients at high risk of thrombosis undergoing major abdominal surgery where early anticoagulation is contraindicated. Long-term follow-up of retained IVCF suggests that major problems are infrequent, though further thrombosis may occur and long-term anticoagulation may be needed.

Background Classification of pelvic local recurrence (LR) after surgery for primary rectal cancer is not currently standardized and optimal imaging is required to categorize anatomical site and plan treatment in patients with LR. The aim of this review was to evaluate the systems used to classify locally recurrent rectal cancer (LRRC) and the relevant published outcomes. Methods A systematic review of the literature prior to April 2020 was performed through electronic searches of the Science Citation Index Expanded, EMBASE, MEDLINE and CENTRAL databases. The primary outcome was to review the classifications currently in use; the secondary outcome was the extraction of relevant information provided by these classification systems including prognosis, anatomy and prediction of R0 after surgery. Results A total of 21 out of 58 eligible studies, classifying LR in 2086 patients, were reviewed. Studies used at least one of the following eight classification systems proposed by institutions or institutional groups (Mayo Clinic, Memorial Sloan-Kettering – original and modified, Royal Marsden and Leeds) or authors (Yamada, Hruby and Kusters). Negative survival outcomes were associated with increased pelvic fixity, associated symptoms of LR, lateral compared with central LR and involvement of three or more pelvic compartments. A total of seven studies used MRI with specifically defined anatomical compartments to classify LR. Conclusion This review highlights the various imaging systems in use to classify LRRC and some of the prognostic indicators for survival and oncological clearance based on these systems. Implementation of an agreed classification system to document pelvic LR consistently should provide more detailed information on anatomical site of recurrence, burden of disease and standards for comparative outcome assessment.

Objective: To determine the relationship between body composition (BC), specifically low skeletal muscle mass (sarcopenia) and poor muscle quality (myosteatosis) and outcomes in emergency laparotomy patients. Background: Emergency laparotomy has one of the highest morbidity and mortality rates of all surgical interventions. BC objectively identifies patients at risk of adverse outcomes in elective cancer cohorts, however evidence is lacking in emergency surgery. Methods: An observational cohort study of patients undergoing emergency laparotomy at ten English hospitals was performed. BC analyses were performed at the third lumbar vertebrae level using pre-operative CT images to quantify skeletal muscle index (SMI) and skeletal muscle radiation attenuation (SM-RA). Sex-specific SMI and SM-RA were determined, with the lower tertile splits defining sarcopenia (low SMI) and myosteatosis (low SM-RA). Accuracy of mortality risk prediction, incorporating SMI and SM-RA variables into risk models was assessed with regression modelling. Results: Six hundred and ten patients were included. Sarcopenia and myosteatosis were both associated with increased risk of morbidity (52.1% vs. 45.1%, p = 0.028; 57.5% vs. 42.6%, p = 0.014), 30-day (9.5% vs. 3.6%, p = 0.010; 14.9% vs. 3.4%, p < 0.001), and 1-year mortality (27.4% vs. 11.5%, p < 0.001; 29.7% vs.12.5%, p < 0.001). Risk-adjusted 30-day mortality was significantly increased by sarcopenia (OR 2.56 (95%CI 1.12-5.84), p = 0.026) and myosteatosis (OR 4.26 (2.01-9.06), p < 0.001), similarly at 1-year (OR 2.66 (95%CI 1.57-4.52), p < 0.001; OR 2.08 (95%CI 1.26-3.41), p = 0.004). BC data increased discrimination of an existing mortality risk-prediction model (AUC 0.838, 95%CI 0.835-0.84). Conclusion: Sarcopenia and myosteatosis are associated with increased adverse outcomes in emergency laparotomy patients.

IntroductionDespite optimal patient selection and surgical effort, recurrence is seen in over 70% of patients undergoing cytoreductive surgery(CRS) for peritoneal metastases (PM). Apart from the peritoneal cancer index(PCI), completeness of cytoreduction and tumor grade, there are other factors like disease distribution in the peritoneal cavity, pathological response to systemic chemotherapy(SC), lymph node metastases and morphology of PM which may have prognostic value. One reason for the underutilization of these factors is that they are known only after surgery. Identifying clinical predictors, specifically radiological predictors, could lead to better utilization of these factors in clinical decision making and the extent of peritoneal resection performed for different tumors. This study aims to study these factors, their impact on survival and identify clinical and radiological predictors. Methods and analysisThere is no therapeutic intervention in the study. All patients with biopsy proven PM from colorectal, appendiceal, gastric and ovarian cancer and peritoneal mesothelioma undergoing CRS will be included. The demographic, clinical, radiological, surgical and pathological details will be collected according to a pre-specified format that includes details regarding distribution of disease, morphology of PM, regional node involvement and pathological response to SC. In addition to the absolute value of PCI, the structures bearing the largest tumor nodules and a description of the morphology in each region will be recorded. A correlation between the surgical, radiological and pathological findings will be performed and the impact of these potential prognostic factors on progression-free and overall survival determined. The practices pertaining to radiological and pathological reporting at different centers will be studied. Ethics and disseminationThe study protocol has been approved by the Zydus Hospital ethics committee (27th July, 2020) and Lyon-sud ethics committee (A15-128). It is registered with the clinical trials registry of India (CTRI/2020/09/027709).The results will be published in peer-reviewed scientific journals.Strength and limitationsA prospective correlation between the radiological, surgical and pathological findings in patients undergoing CRS will be performed which has not been done before.Being prospective in nature it will also enable us to evaluate the impact of the current treatment practices on the clinical end-pointsThere is fixed protocol for radiological and pathological evaluation for which there are no specific guidelinesThe data collection format will capture all the relevant data but this may affect compliance.Despite the large sample size planned for each primary site, the heterogeneity of treatment protocols may be a limiting factor while evaluating the impact on survival.

Summary Background Radical surgery via total mesorectal excision might not be the optimal first-line treatment for early-stage rectal cancer. An organ-preserving strategy with selective total mesorectal excision could reduce the adverse effects of treatment without substantially compromising oncological outcomes. We investigated the feasibility of recruiting patients to a randomised trial comparing an organ-preserving strategy with total mesorectal excision. Methods TREC was a randomised, open-label feasibility study done at 21 tertiary referral centres in the UK. Eligible participants were aged 18 years or older with rectal adenocarcinoma, staged T2 or lower, with a maximum diameter of 30 mm or less; patients with lymph node involvement or metastases were excluded. Patients were randomly allocated (1:1) by use of a computer-based randomisation service to undergo organ preservation with short-course radiotherapy followed by transanal endoscopic microsurgery after 8–10 weeks, or total mesorectal excision. Where the transanal endoscopic microsurgery specimen showed histopathological features associated with an increased risk of local recurrence, patients were considered for planned early conversion to total mesorectal excision. A non-randomised prospective registry captured patients for whom randomisation was considered inappropriate, because of a strong clinical indication for one treatment group. The primary endpoint was cumulative randomisation at 12, 18, and 24 months. Secondary outcomes evaluated safety, efficacy, and health-related quality of life assessed with the European Organisation for Research and Treatment of Cancer (EORTC) QLQ C30 and CR29 in the intention-to-treat population. This trial is registered with the ISRCTN Registry, ISRCTN14422743. Findings Between Feb 22, 2012, and Dec 19, 2014, 55 patients were randomly assigned at 15 sites; 27 to organ preservation and 28 to radical surgery. Cumulatively, 18 patients had been randomly assigned at 12 months, 31 at 18 months, and 39 at 24 months. No patients died within 30 days of initial treatment, but one patient randomly assigned to organ preservation died within 6 months following conversion to total mesorectal excision with anastomotic leakage. Eight (30%) of 27 patients randomly assigned to organ preservation were converted to total mesorectal excision. Serious adverse events were reported in four (15%) of 27 patients randomly assigned to organ preservation versus 11 (39%) of 28 randomly assigned to total mesorectal excision (p=0·04, χ2 test). Serious adverse events associated with organ preservation were most commonly due to rectal bleeding or pain following transanal endoscopic microsurgery (reported in three cases). Radical total mesorectal excision was associated with medical and surgical complications including anastomotic leakage (two patients), kidney injury (two patients), cardiac arrest (one patient), and pneumonia (two patients). Histopathological features that would be considered to be associated with increased risk of tumour recurrence if observed after transanal endoscopic microsurgery alone were present in 16 (59%) of 27 patients randomly assigned to organ preservation, versus 24 (86%) of 28 randomly assigned to total mesorectal excision (p=0·03, χ2 test). Eight (30%) of 27 patients assigned to organ preservation achieved a complete response to radiotherapy. Patients who were randomly assigned to organ preservation showed improvements in patient-reported bowel toxicities and quality of life and function scores in multiple items compared to those who were randomly assigned to total mesorectal excision, which were sustained over 36 months’ follow-up. The non-randomised registry comprised 61 patients who underwent organ preservation and seven who underwent radical surgery. Non-randomised patients who underwent organ preservation were older than randomised patients and more likely to have life-limiting comorbidities. Serious adverse events occurred in ten (16%) of 61 non-randomised patients who underwent organ preservation versus one (14%) of seven who underwent total mesorectal excision. 24 (39%) of 61 non-randomised patients who underwent organ preservation had high-risk histopathological features, while 25 (41%) of 61 achieved a complete response. Overall, organ preservation was achieved in 19 (70%) of 27 randomised patients and 56 (92%) of 61 non-randomised patients. Interpretation Short-course radiotherapy followed by transanal endoscopic microsurgery achieves high levels of organ preservation, with relatively low morbidity and indications of improved quality of life. These data support the use of organ preservation for patients considered unsuitable for primary total mesorectal excision due to the short-term risks associated with this surgery, and support further evaluation of short-course radiotherapy to achieve organ preservation in patients considered fit for total mesorectal excision. Larger randomised studies, such as the ongoing STAR-TREC study, are needed to more precisely determine oncological outcomes following different organ preservation treatment schedules. Funding Cancer Research UK.

"Hands, Face, Space" has become the slogan of our times as the world grapples with the COVID 19 pandemic. While this strategy of washing hands, covering one's face and keeping at a distance from other humans may reduce infectious disease, some aspects of this strategy are the opposite of what best constitutes surgical care of patients with colorectal cancer. The strategy is also at odds with Pelican Cancer Foundation "Face to Face" educational activities over the past two decades.

Cytoreductive Surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is increasingly accepted as the optimal management of selected patients with peritoneal malignancy. There is limited published evidence on outcomes in older patients treated by this complex therapeutic strategy.A retrospective review of a prospective database of all patients who underwent CRS with HIPEC in a single institution over seven years. A comparative analysis of outcomes in patients under 65 undergoing CRS and HIPEC with patients ≥65 years was performed. The key endpoints were morbidity, mortality, reintervention rate and length of stay in the high dependency/intensive care (HDU/ICU) units.Overall, 245 patients underwent CRS and HIPEC during the study period, with 76/245 (31%) ≥65 years at the time of intervention. Tumour burden measured by the peritoneal carcinomatosis index (PCI) score was a median of 11 for both groups. Median length of hospital stay in the ≥65-year-old group was 14.5 days versus 13 days in the65-year-old group (∗p = 0.01). Patients aged ≥65-years spent a median of one more day in the critical care unit ∗(p = 0.001). Significant morbidity (Clavien-Dindo ≥ Grade IIIa) was higher in the ≥65-year than the65-year group (18.4% versus 11.2%). There were no perioperative deaths in the ≥65-year group.This study demonstrates higher perioperative major morbidity in ≥65-year group, but with low mortality in patients undergoing CRS/HIPEC for disseminated intraperitoneal malignancy. This increased morbidity does not translate into higher rates of re-interventions and highlights the importance of optimal patient selection.

Contains fulltext : 238902.pdf (Publisher’s version ) (Closed access) AIMS: Tumour deposits (TDs) are an important prognostic marker in colorectal cancer. However, the classification, and inclusion in staging, of TDs has changed significantly in each tumour-node-metastasis (TNM) edition since their initial description in TNM-5, and terminology remains controversial. Expert consensus is needed to guide the future direction of precision staging. METHODS AND RESULTS: A modified Delphi consensus process was used. Statements were formulated and sent to participants as an online survey. Participants were asked to rate their agreement with each statement on a five-point Likert scale and also to suggest additional statements for discussion. These responses were circulated together with anonymised comments, and statements were modified prior to carrying out a second online round. Consensus was set at 70%. Overall, 32 statements reached consensus. There were concerns that TDs were currently incorrectly placed in the TNM system and that their prognostic importance was being underestimated. There were concerns regarding interobserver variation and it was felt that a clearer, more reproducible definition of TDs was needed. CONCLUSIONS: Our main recommendations are that the number of TDs should be recorded even if lymph node metastases (LNMs) are also present and that nodules with evidence of origin [extramural venous invasion (EMVI), perineural invasion (PNI), lymphatic invasion (LI)] should still be categorised as TDs and not excluded, as TNM-8 specifies. Whether TDs should continue to be included in the N category at all is controversial, and did not achieve consensus; however, participants agreed that TDs are prognostically worse than LNMs and the N1c category is suboptimal, as it does not reflect this.

Epithelial appendiceal neoplasms are uncommon peritoneal malignancies causing a spectrum of disease including pseudomyxoma peritonei (PMP). The optimal management is cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC). Despite complete CRS (CCRS), recurrence develops in almost 45% of patients. No consensus exists for the optimal treatment of recurrent disease, with treatment strategies including repeat CRS, watch-and-wait, and palliative chemotherapy. This report aims to describe evolving management strategies for a large cohort with recurrence after CCRS. This retrospective study analyzed a prospective database of patients with recurrence after CCRS for appendiceal neoplasms from 1994 to 2017 who had long-term follow-up evaluation with tumor markers and computed tomography (CT). Overall, 430 (37.6%) of 1145 PMP patients experienced recurrence at a median of 19 months. Of these 430 patients 145 (33.7%) underwent repeat CRS, 119 (27.7%) had a watch-and-wait approach, and 119 (27.7%) had palliative chemotherapy. The patients with recurrence had a median overall survival (OS) of 39 months, a 3-year survival of 74.6%, a 5-year survival of 57.4%, and a 10-year survival of 36.5%. In the multivariate analysis, the patients who had recurrence within 1 year after primary CRS (hazard ratio [HR], 3.55), symptoms at recurrence (HR, 3.08), a high grade of disease or adenocarcinoma pathology (HR, 2.94), signet ring cells (HR, 1.91), extraperitoneal metastatic disease (HR, 1.71), or male gender (HR, 1.61) had worse OS. The OS was longer for the patients who had repeat CRS (HR, 0.41). The patients who underwent repeat CCRS had a 3-year OS of 87.5%, a 5-year OS of 78.1%, and a 10-year OS of 67.9%. Dilemmas persist around the optimal management of patients with recurrence after CRS and HIPEC for appendiceal tumors. Selected patients benefit from repeat CRS, particularly those with favorable tumor biology and focal disease.

Multimodal therapy incorporating cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) improve survival for selected patients with colorectal peritoneal metastases (CPMs). Many countries have centralised management of these patients, aiming to improve outcomes. There is ongoing debate on the need for and complications associated with HIPEC administration. We report indications and outcomes after CRS/HIPEC treated in a national centre in the modern era. A retrospective review of all CPM patients who underwent CRS and HIPEC since the initiation of an Irish national program in 2013. The primary endpoint was the overall survival associated with CRS/HIPEC. During the study period (April 2013–June 2020), 123 patients proceeded to planned CRS/HIPEC for CPM. Median age was 58 (IQR 47–67) and 55 patients (44.7%) were male. In 65 patients (52.8%), CPM was synchronous. In 7/123 (5.8%), disease was unresectable. The median peritoneal cancer index (PCI) was 10 (IQR 5–17). Overall, 104/123 (84.5%) underwent a complete cytoreduction (CC0/CC1). Thirteen out of 123 (10.5%) patients also had a synchronous liver resection. Forty out of 123 (32.5%) patients had adverse pathological features (poorly differentiated or signet ring cells). The median survival in patients after CC0, CC1 and CC2/3 resection was 50, 18 and 11 months respectively (*p =

The majority of patients with colorectal tumors will present via the elective route. However, one-fifth of patients will present as an emergency. The most common cause of emergency presentation of colorectal cancer is obstruction followed by perforation, and in many cases, patients will present with both. We discuss the management of the patient presenting with a perforated colorectal tumor covering the acute presentation and also how to deal with consequences of a perforated tumor, namely, the management of colorectal peritoneal metastasis (CPM). CPM used to be considered a terminal condition; however, a strategy of early detection of CPM, careful patient selection for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy, leads to much improved outcomes and even cure, in some patient compared with systemic chemotherapy alone.

Cost-effective cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for treatment of patients with peritoneal malignancy remains an ongoing financial challenge for healthcare systems, hospitals and patients. This study aims to describe the detailed in-hospital costs of CRS and HIPEC compared with an Australian Activity Based Funding (ABF) system, and to evaluate how the learning curve, disease entities and surgical outcomes influence in-hospital costs.A retrospective descriptive costing review of all CRS and HIPEC cases undertaken at a large public tertiary referral hospital in Sydney, Australia from April 2017 to June 2019. In-hospital cost variables included staff, critical care, diagnosis, operating theatre, and other costs. Univariate and multivariate analyses were conducted to investigate the differences between actual cost and the provision of funding, and potential factors associated with these costs.Of the 118 CRS and HIPEC procedures included in the analyses, the median total cost was AU$130,804 (IQR: 105,744 to 153,972). Provision of funding via the ABF system was approximately one-third of the total CRS and HIPEC costs (p 0.001). Surgical staff proficiency seems to reduce the total CRS and HIPEC costs. Surgical time, length of intensive care unit and hospital stay are the main predictors of total CRS and HIPEC costs.Delivery of CRS and HIPEC is expensive with high variability. A standard ABF system grossly underestimates the specific CRS and HIPEC funding required with supplementation essential to sustaining this complex highly specialised service.

Objectives: To assess the individual treatment strategies among international experts in peritoneal carcinosis, specifically their decision-making in the process of patient selection for hyperthermic intraperitoneal chemotherapy (HIPEC) in women suffering from ovarian cancer, to identify relevant decision-making criteria, and to quantify the level of consensus for or against HIPEC. Methods: The members of the executive committee of the Peritoneal Surface Oncology Group International (PSOGI) were asked to describe the clinical conditions under which they would recommend HIPEC in patients with ovarian cancer and to describe any disease or patient characteristics relevant to their decision. All answers were then merged and converted into decision trees. The decision trees were then analyzed by applying the objective consensus methodology. Results: Nine experts in surgical oncology provided information on their multidisciplinary treatment strategy including HIPEC for patients with advanced ovarian cancer. Three of the total of 12 experts did not perform HIPEC. Five criteria relevant to the decision on whether HIPEC is performed were applied. In patients with resectable disease, a peritoneal cancer index (PCI) Discussion and Conclusion: Among surgical oncology experts in peritoneal surface malignancy and HIPEC, HIPEC plays an important role in primary and recurrent ovarian cancer, and the PCI is the most important criterion in this decision.

Mini: A radiological, anatomic distinction between the rectum and sigmoid colon was agreed by consensus of international experts in rectal cancer using the Delphi Technique. Use of this landmark, “the sigmoid take-off,” may harmonize efforts in research and clinical practice to improve patient outcomes. Background: The wide global variation in the definition of the rectum has led to significant inconsistencies in trial recruitment, clinical management, and outcomes. Surgical technique and use of preoperative treatment for a cancer of the rectum and sigmoid colon are radically different and dependent on the local definitions employed by the clinical team. A consensus definition of the rectum is needed to standardise treatment. Methods: The consensus was conducted using the Delphi technique with multidisciplinary colorectal experts from October, 2017 to April, 2018. Results: Eleven different definitions for the rectum were used by participants in the consensus. Magnetic resonance imaging (MRI) was the most frequent modality used to define the rectum (67%), and the preferred modality for 72% of participants. The most agreed consensus landmark (56%) was “the sigmoid take-off,” an anatomic, image-based definition of the junction of the mesorectum and mesocolon. In the second round, 81% of participants agreed that the sigmoid take-off as seen on computed tomography or MRI achieved consensus, and that it could be implemented in their institution. Also, 87% were satisfied with the sigmoid take-off as the consensus landmark. Conclusion: An international consensus definition for the rectum is the point of the sigmoid take-off as visualized on imaging. The sigmoid take-off can be identified as the mesocolon elongates as the ventral and horizontal course of the sigmoid on axial and sagittal views respectively on cross-sectional imaging. Routine application of this landmark during multidisciplinary team discussion for all patients will enable greater consistency in tumour localisation.

BACKGROUND: The interest and adoption of transanal total mesorectal excision (TaTME) is growing worldwide, but evidence on nationwide implementation and short-term outcomes is scarce. This study aims to evaluate national results for this relatively new technique in the UK. METHODS: A l l TaTME procedures performed in the UK and recorded on the international TaTME registry between January 2013 and January 2018 were analyzed. Surgeons who received training on TaTME in the UK were sent a survey regarding their experience with implementation of TaTME in their unit. Primary endpoint was a composite for "optimal pathology" (free resection margin (R0) and TME specimen with no major defects and no rectal wall perforations). Sec¬ ondary outcomes included 30-day clinical course and survey outcomes. RESULTS: Forty-two hospitals entered 513 cases over a 5-year period; 28 of 42 hospitals (66.7%) performed ten cases or less. The indication for surgery was cancer in 364 (71.0%) cases. Optimal pathology was achieved in 295 (92.8%), with an involved resection margin (R1) rate of 13 of 513 (4.1%). A Clavien-Dindo >III within 30 days was 13.4% (N.=45) and 6.8% (N.=10) in the cancer and benign groups, respectively. Based on the survey (response rate 68 of 86; 79%), 76.1% of the surgeons implemented TaTME in their unit after receiving training, all of whom experienced difficulties with performing TaTME. CONCLUSIONS: This study reports acceptable nationwide short-term outcomes of TaTME. However, adoption oc¬ curred in a rapid and non-standardized manner. A structured TaTME training program is therefore recommended.

Colorectal cancer (CRC) treatment has become more personalised, incorporating a combination of the individual patient risk assessment, gene testing, and chemotherapy with surgery for optimal care. The improvement of staging with high-resolution imaging has allowed more selective treatments, optimising survival outcomes. The next step is to identify biomarkers that can inform clinicians of expected prognosis and offer the most beneficial treatment, while reducing unnecessary morbidity for the patient. The search for biomarkers in CRC has been of significant interest, with questions remaining on their impact and applicability. The study of biomarkers can be broadly divided into metabolic, molecular, microRNA, epithelial-to-mesenchymal-transition (EMT), and imaging classes. Although numerous molecules have claimed to impact prognosis and treatment, their clinical application has been limited. Furthermore, routine testing of prognostic markers with no demonstrable influence on response to treatment is a questionable practice, as it increases cost and can adversely affect expectations of treatment. In this review we focus on recent developments and emerging biomarkers with potential utility for clinical translation in CRC. We examine and critically appraise novel imaging and molecular-based approaches; evaluate the promising array of microRNAs, analyze metabolic profiles, and highlight key findings for biomarker potential in the EMT pathway.

Background The WHO classification of mucinous appendix neoplasms and pseudomyxoma peritonei (PMP) describes low- and high-grade histology and is of prognostic importance. The metastatic peritoneal disease grade can occasionally be different from the primary appendix tumor. This analysis aimed to report outcomes from a high-volume center in patients with pathological discordance. Methods This was a retrospective analysis of prospective data of patients treated by cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for PMP at a single institution between January 2016 and December 2020. Reporting was by pathologists with a special interest in peritoneal malignancy. Discordant pathology was classified as a low-grade primary appendix tumor with high-grade peritoneal disease, or a high-grade primary appendix tumor with low-grade peritoneal disease. Outcomes analyzed were overall and recurrence-free survival, and Kaplan-Meier survival curves and the log-rank test were used to analyze the outcomes. Results Between 2016 and 2020, 830 patients underwent CRS and HIPEC for PMP, of whom 37 (4.4%) had discordant pathology. The primary appendix tumors were low-grade in 23 patients and high-grade in 14 patients. The median Peritoneal Cancer Index (PCI) was significantly higher in patients with a low-grade primary tumor (31 vs. 16; p = 0.001), while complete cytoreduction (CC0/1) was achieved in 31/37 (83.8%) patients. The median follow-up was 19 months. Overall survival was worse in those with high-grade peritoneal disease (p = 0.029), whereas recurrence-free survival was similar in both groups (p = 0.075). Conclusion In PMP with pathological discordance, the peritoneal disease grade influences prognosis and survival.

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) benefits selected patients with peritoneal mesothelioma. We present the outcomes of this treatment strategy in a UK peritoneal malignancy national referral centre.Observational retrospective analysis of data prospectively collected in a dedicated peritoneal malignancy database between March 1998 and January 2016.Of 1586 patients treated for peritoneal malignancy, 76 (4.8%) underwent surgery for peritoneal mesothelioma. Median age was 49 years (range 21-73 years). 34 patients (45%) were female. Of the 76 patients, 39 (51%) had low grade histological subtypes (mostly multicystic mesothelioma), and 37 (49%) had diffuse malignant peritoneal mesothelioma (DMPM; mostly epithelioid mesothelioma). Complete cytoreduction was achieved in 52 patients (68%) and maximal tumour debulking (MTD) was performed in 20 patients (26%); the remaining 4 patients (5%) underwent a laparotomy with biopsy only. HIPEC was administered in 67 patients (88%). Median overall (OS) and disease-free survival (DFS) after CRS was 97.8 (80.2-115.4) and 58.8 (47.4-70.3) months, respectively. After complete cytoreduction, 100% overall survival was observed amongst patients with low-grade disease. Ki-67 proliferation index was significantly associated with survival outcomes after complete cytoreduction for DMPM and was an independent predictor of decreased survival.With adequate patient selection (guided by histological classification and Ki-67 proliferation index) and complete cytoreduction with HIPEC, satisfactory outcomes can be achieved in selected patients with peritoneal mesothelioma.

The neutrophil-lymphocyte ratio (NLR) and other inflammation-based scores have been used as a prognostic tool to predict survival in solid tumours including pseudomyxoma peritonei (PMP). The aim was to evaluate the prognostic value of this marker and risk stratify PMP patients undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).Retrospective analysis was conducted of a prospectively collected database of patients with PMP who underwent CRS and HIPEC between 1994 and 2015. The NLR was calculated by dividing the pre-operative neutrophil count by lymphocyte count. Predicted overall survival (OS) and disease-free interval (DFI) were calculated using a Kaplan-Meier survival model.The study included 699 patients, stratified into four groups as defined by their NLR. Group A: 200 (28.6%) patients (NLR = 0.10-2.00), Group B: 160 (22.8%) patients (NLR = 2.10-2.78), Group C: 184 (26.3%) patients (NLR = 2.79-4.31) and Group D: 155 (22.2%) patients (NLR ≥ 4.32). The median follow-up for this cohort was 36 months. The predicted DFI was 132.2, 113.1, 84.4 and 47.9 months and the OS was 141.1, 117.6, 88.7 and 51.2 months for Groups A, B, C and D, respectively. As the NLR increases, there is a reduction in long-term survival.The pre-operative NLR is cost effective and has equivalent prognostic value to pre-operative tumour markers for patients with PMP treated with CRS and HIPEC. The NLR is a reliable tool that may have a role in predicting outcomes following CRS and HIPEC for patients with PMP of appendiceal origin.

Peritoneal mesothelioma (PM) is an uncommon but a serious, and often, fatal primary peritoneal tumour, with increasing incidence worldwide. Conventional systemic chemotherapy, generally based on experience with pleural mesothelioma, usually has disappointing results considering PM as a terminal condition. Patients usually present with non-specific symptoms of abdominal distension and pain making the diagnosis challenging. As PM is confined to the abdomen for all, or much, of its clinical course, a multimodality treatment combining cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has emerged as a new standard of care, and has been reported to achieve promising survival outcomes and local disease control in selected patients with PM. This review updates the presentation, diagnosis, classification and treatment strategies for PM.

Background Pre-operative chemoradiotherapy (CRT) for MRI-defined, locally advanced rectal cancer is primarily intended to reduce local recurrence rates by downstaging tumours, enabling an improved likelihood of curative resection. However, in a subset of patients complete tumour regression occurs implying that no viable tumour is present within the surgical specimen. This raises the possibility that surgery may have been avoided. It is also recognised that response to CRT is a key determinant of prognosis. Recent radiological advances enable this response to be assessed pre-operatively using the MRI tumour regression grade (mrTRG). Potentially, this allows modification of the baseline MRI-derived treatment strategy. Hence, in a ‘good’ mrTRG responder, with little or no evidence of tumour, surgery may be deferred. Conversely, a ‘poor response’ identifies an adverse prognostic group which may benefit from additional pre-operative therapy. Methods/design TRIGGER is a multicentre, open, interventional, randomised control feasibility study with an embedded phase III design. Patients with MRI-defined, locally advanced rectal adenocarcinoma deemed to require CRT will be eligible for recruitment. During CRT, patients will be randomised (1:2) between conventional management, according to baseline MRI, versus mrTRG-directed management. The primary endpoint of the feasibility phase is to assess the rate of patient recruitment and randomisation. Secondary endpoints include the rate of unit recruitment, acute drug toxicity, reproducibility of mrTRG reporting, surgical morbidity, pathological circumferential resection margin involvement, pathology regression grade, residual tumour cell density and surgical/specimen quality rates. The phase III trial will focus on long-term safety, regrowth rates, oncological survival analysis, quality of life and health economics analysis. Discussion The TRIGGER trial aims to determine whether patients with locally advanced rectal cancer can be recruited and subsequently randomised into a control trial that offers MRI-directed patient management according to radiological response to CRT (mrTRG). The feasibility study will inform a phase III trial design investigating stratified treatment of good and poor responders according to 3-year disease-free survival, colostomy-free survival as well as an increase in cases managed without a major resection. Trial registration ClinicalTrials.gov, ID: NCT02704520. Registered on 5 February 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2085-2) contains supplementary material, which is available to authorized users.

Background Ovarian metastases of GI tumors grow rapidly and are relatively resistant to systemic chemotherapy. They may be unilateral or bilateral and macroscopic or occult. The risk of macroscopic ovarian involvement or occult involvement of macroscopically normal ovaries is unquantified. Objective This study aims to quantify the risks of ovarian involvement in patients with peritoneal malignancy undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. Design This was a retrospective analysis of a dedicated prospective malignancy database. Settings This study was conducted at a high-volume tertiary referral center for peritoneal malignancy. Patients Female patients with at least 1 remaining ovary, undergoing complete cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for appendiceal tumors or colorectal peritoneal metastases between January 2010 and March 2015 were included. Outcome measures Data regarding ovarian involvement was extracted from surgical and histological records. Results Two hundred fifty-eight female patients with at least 1 ovary underwent complete cytoreduction and hyperthermic intraperitoneal chemotherapy during the study period. In total, 141 of 258 (54.7%) patients had ovarian tumor involvement, and 80% with at least 1 macroscopically abnormal ovary had bilateral involvement. Of 40 patients with 1 macroscopic ovarian metastasis, microscopic involvement of the contralateral ovary was found in 18 of 40 (45.0%). Of 141 patients in whom both ovaries were macroscopically normal, 24 of 141 (17.0%) patients had microscopic ovarian involvement. Limitations The retrospective nature limits the interpretation of these results. Conclusions Occult malignancy was present in 17% when both ovaries looked macroscopically normal and in 45% of contralateral normal-looking ovaries if the other ovary was macroscopically involved. These results help to inform preoperative consent and intraoperative decision making in patients with advanced appendiceal and colorectal malignancy, and are of benefit in managing advanced lower GI tract malignancy.

IntroductionTumour deposits (TDs) are a poor prognostic marker when seen on pathology, and are worse than lymph node metastases (LNMs). They are now being reported on MRI as discontinuous nodules of extramural venous invasion but this diagnosis has not been validated and it is unclear how it correlates with the diagnosis of TDs on pathology.Methods and analysisThis is a prospective interventional clinical trial which aims to directly map the location of TDs on MRI and correlate what is seen on MRI with the pathology findings at each location. All patients with rectal cancer undergoing resectional surgery are eligible (including those undergoing preoperative therapy). The primary outcome is the prevalence of TDs seen on pathology. Secondary outcomes are to assess radiological and pathological interobserver agreement, assess the effect of TDs on prognosis and carry out exploratory work looking at differences between TDs and LNMs. The estimated sample size is 100 to detect a twofold increase in the pathological diagnosis of TD when MRI mapping is used.Ethics and disseminationEthical approval has been granted from the South Central—Hampshire B Research and Ethics Committee (IRAS 217627). The study will be carried out under standard operative procedures within the Royal Marsden Hospital.Trial registration numberNCT03303547.

Background A pre-operative imaging landmark to define the rectum would optimise clinical care of rectal cancer patients and research efforts to improve outcomes. The sigmoid take-off has been suggested as an imaging landmark for the rectosigmoid junction (RSJ). This study aimed to investigate whether this imaging definition of the rectum was validated by surgical specimen analysis. Methods This prospective study recruited 20 patients undergoing surgery and undertook radiological and pathological analysis of their rectal specimens. The radiological landmark of the sigmoid take-off was identified on pre-operative magnetic resonance imaging (MRI), and the distance to the anterior peritoneal reflection was measured by two readers. After surgery, the distance from the beginning of the sigmoid mesocolon to the anterior peritoneal reflection to the beginning of the sigmoid mesocolon on the specimen was measured, and compared to the distance on MRI using Pearson's Correlation Coefficient and Bland-Altman plots. Results In 17 patients, the mean distance from the anterior peritoneal reflection to the RSJ on MRI was 20.3 mm and 23.1 mm for two readers, and on pathology was 20.6 mm. The mean differences between MRI and specimen measurements were −0.31 mm (−2.83 to 2.20 mm), and 2.51 mm (95% confidence interval −0.31 to 5.33 mm) for each reader, with correlation coefficients of 0.77 and 0.81. Conclusion The sigmoid take-off has been validated on specimen analysis to be an imaging landmark that defines the termination of the rectum. This anatomical landmark can be used to classify tumours and guide treatment and research of sigmoid colon and rectal cancer.