Comment
Minimally-invasive approach for rectal cancer surgery Rectal surgery is the reference treatment for patients with non-metastatic rectal cancer. High-quality surgery, including total mesorectal excision,1 is particularly needed for patients with mid-rectal and low-rectal cancer to have potentially good oncological results and a low risk of complications. In the past two decades, substantial improvements in both rectal surgery and perioperative management of locally advanced rectal cancer, including preoperative chemoradiotherapy, have contributed to reductions in the risk of local recurrence and to increases in the rate of sphincter-saving surgery.2,3 Along with these improvements, efforts have been made to decrease the risk of postoperative morbidity and to restrict long-term side-effects of surgery.4,5 Minimally-invasive surgical approaches including laparoscopy have been postulated to further improve surgical management of patients with rectal cancer. Laparoscopy has been widely accepted as a standard of care for colectomy in patients with colon cancer.6 Conversely, preliminary results of studies assessing laparoscopy for total mesorectal excision have raised various questions regarding the safety and effectiveness of this approach in patients with rectal cancer.7 More recent data have shown that laparoscopic surgery for rectal cancer is safe and associated with postoperative morbidity rates compared with the conventional open surgical approach;8,9 however, results regarding the longterm oncological outcome of laparoscopy in patients with rectal cancer are scarce. In The Lancet Oncology, Seung-Yung Jeong and colleagues10 reported the long-term survival outcomes of their open-label, non-inferiority, randomised controlled trial comparing open versus laparoscopic surgery for patients with mid-rectal or low-rectal cancer after neoadjuvant chemoradiotherapy. 340 patients were randomly assigned to undergo laparoscopic or open surgery for mid-rectal or low-rectal cancer over 3 years. Patients were stratified by sex and preoperative chemotherapy regimen and the primary endpoint was 3-year disease-free survival. Regarding the quality of surgery, positive circumferential resection margins were similar in both treatment groups (seven [4%] patients in the open surgery group and five [3%] in the laparoscopic surgery group; p=0·077). 3-year diseasefree survival was 79·2% (95% CI 72·3–84·6) in patients
in the laparoscopic surgery group and 72·5% (65·0–78·6; p=0·0001) in those in the open surgery group. 3-year overall survival was similar in both treatment groups (90·4% [95% CI 84·9–94·0] vs 91·7% [86·3–95·0]), as was local recurrence after surgery (4·9% [–2·5 to 9·6] vs 2·6% [1·0–6·7]). The present study is of major importance because it is specifically dedicated to the assessment of long-term outcome. The findings confirm that laparoscopy allows high-quality surgical resection in patients with mid-rectal and low-rectal cancer on the basis of on pathological analysis of surgical specimens. Disease-free survival was improved in patients undergoing laparoscopic surgery for rectal cancer compared with those undergoing open surgery. Several factors might explain the improvement of oncological results of patients undergoing laparoscopic surgery for rectal cancer. A laparoscopic approach might reduce the extent of surgical insult that could favour tumour progression. Furthermore, laparoscopy might magnify visualisation of surgical planes and could therefore facilitate a high-quality total mesorectal excision. Finally, early recovery after laparoscopic surgery might facilitate the administration of postoperative treatment in patients with advanced stage. In the present study, despite the process of randomisation, patients in the open surgery group had significantly more advanced ypT and ypN tumor stage than did those in the laparoscopic surgery group. The imbalance between the groups in tumour stage might have contributed to the difference in 3-year disease-free survival in favour to the laparoscopic surgery group. Although this result was not expected, it shows the challenge and the difficulties that can be encountered in the design of clinical trials especially when treatment modalities are combined. As stated by the investigators, ypT and ypN that were not preoperatively predictable could not be used to stratify treatment groups. In conclusion, Jeong and colleagues’ study shows the effectiveness of laparoscopy in terms of long-term oncological outcome is acceptable and equivalent to conventional open surgery in patients with mid-rectal and low-rectal cancer after chemoradiotherapy. Further studies are now needed to better define the role of the laparoscopic approach in improving oncological outcome in patients undergoing rectal cancer surgery.
www.thelancet.com/oncology Published online May 16, 2014 http://dx.doi.org/10.1016/S1470-2045(14)70233-5
Lancet Oncol 2014 Published Online May 16, 2014 http://dx.doi.org/10.1016/ S1470-2045(14)70233-5 See Online/Articles http://dx.doi.org/10.1016/ S1470-2045(14)70205-0
1
Comment
Antoine Brouquet, Bernard Nordlinger* Department of Surgical Oncology and Digestive Surgery, Hôpital Bicêtre, Assistance Publique–Hôpitaux de Paris, Le KremlinBicêtre, Université Paris-Sud INSERM 986, France (AB); and Department of General Surgery and Surgical Oncology, Hôpital Ambroise Paré, Assistance Publique–Hôpitaux de Paris, 92100 Boulogne-Billancourt, France (BN) [email protected] We declare no competing interests. 1 2
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2
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6
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MacFarlane JK, Ryall RD, Heald RJ. Mesorectal excision for rectal cancer. Lancet 1993; 341: 457–60. Kapiteijn E, Marijnen CA, Nagtegaal ID, et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 2001; 345: 638–46. Bosset JF, Collette L, Calais G, et al. Chemotherapy with preoperative radiotherapy in rectal cancer. N Engl J Med 2006; 355: 1114–23. Marijnen CA, Kapiteijn E, van de Velde CJ, et al. Acute side effects and complications after short-term preoperative radiotherapy combined with total mesorectal excision in primary rectal cancer: report of a multicenter randomized trial. J Clin Oncol 2002; 20: 817–25.
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Matthiessen P, Hallböök O, Rutegård J, Simert G, Sjödahl R. Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial. Ann Surg 2007; 246: 207–14. Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 2004; 350: 2050–59. Guillou PJ, Quirke P, Thorpe H, et al. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 2005; 365: 1718–26. Kang SB, Park JW, Jeong SY, et al. Open versus laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): short-term outcomes of an open-label randomised controlled trial. Lancet Oncol 2010; 11: 637–45. van der Pas MH, Haglind E, Cuesta MA, et al. Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol 2013; 14: 210–18. Jeong S-Y, Park JW, Nam BH. Open versus laparscopic surgery for mid-rectal or low-rectal cancer after neoadjuvant chemotherapy (COREAN trial): survival outcomes of an open-label, non-inferiority, randomised controlled trial. Lancet Oncol 2014; published online May 16. http://dx.doi.org/10.1016/S1470-2045(14)70205-0
www.thelancet.com/oncology Published online May 16, 2014 http://dx.doi.org/10.1016/S1470-2045(14)70233-5
Minimally-invasive approach for rectal cancer surgery Rectal surgery is the reference treatment for patients with non-metastatic rectal cancer. High-quality surgery, including total mesorectal excision,1 is particularly needed for patients with mid-rectal and low-rectal cancer to have potentially good oncological results and a low risk of complications. In the past two decades, substantial improvements in both rectal surgery and perioperative management of locally advanced rectal cancer, including preoperative chemoradiotherapy, have contributed to reductions in the risk of local recurrence and to increases in the rate of sphincter-saving surgery.2,3 Along with these improvements, efforts have been made to decrease the risk of postoperative morbidity and to restrict long-term side-effects of surgery.4,5 Minimally-invasive surgical approaches including laparoscopy have been postulated to further improve surgical management of patients with rectal cancer. Laparoscopy has been widely accepted as a standard of care for colectomy in patients with colon cancer.6 Conversely, preliminary results of studies assessing laparoscopy for total mesorectal excision have raised various questions regarding the safety and effectiveness of this approach in patients with rectal cancer.7 More recent data have shown that laparoscopic surgery for rectal cancer is safe and associated with postoperative morbidity rates compared with the conventional open surgical approach;8,9 however, results regarding the longterm oncological outcome of laparoscopy in patients with rectal cancer are scarce. In The Lancet Oncology, Seung-Yung Jeong and colleagues10 reported the long-term survival outcomes of their open-label, non-inferiority, randomised controlled trial comparing open versus laparoscopic surgery for patients with mid-rectal or low-rectal cancer after neoadjuvant chemoradiotherapy. 340 patients were randomly assigned to undergo laparoscopic or open surgery for mid-rectal or low-rectal cancer over 3 years. Patients were stratified by sex and preoperative chemotherapy regimen and the primary endpoint was 3-year disease-free survival. Regarding the quality of surgery, positive circumferential resection margins were similar in both treatment groups (seven [4%] patients in the open surgery group and five [3%] in the laparoscopic surgery group; p=0·077). 3-year diseasefree survival was 79·2% (95% CI 72·3–84·6) in patients
in the laparoscopic surgery group and 72·5% (65·0–78·6; p=0·0001) in those in the open surgery group. 3-year overall survival was similar in both treatment groups (90·4% [95% CI 84·9–94·0] vs 91·7% [86·3–95·0]), as was local recurrence after surgery (4·9% [–2·5 to 9·6] vs 2·6% [1·0–6·7]). The present study is of major importance because it is specifically dedicated to the assessment of long-term outcome. The findings confirm that laparoscopy allows high-quality surgical resection in patients with mid-rectal and low-rectal cancer on the basis of on pathological analysis of surgical specimens. Disease-free survival was improved in patients undergoing laparoscopic surgery for rectal cancer compared with those undergoing open surgery. Several factors might explain the improvement of oncological results of patients undergoing laparoscopic surgery for rectal cancer. A laparoscopic approach might reduce the extent of surgical insult that could favour tumour progression. Furthermore, laparoscopy might magnify visualisation of surgical planes and could therefore facilitate a high-quality total mesorectal excision. Finally, early recovery after laparoscopic surgery might facilitate the administration of postoperative treatment in patients with advanced stage. In the present study, despite the process of randomisation, patients in the open surgery group had significantly more advanced ypT and ypN tumor stage than did those in the laparoscopic surgery group. The imbalance between the groups in tumour stage might have contributed to the difference in 3-year disease-free survival in favour to the laparoscopic surgery group. Although this result was not expected, it shows the challenge and the difficulties that can be encountered in the design of clinical trials especially when treatment modalities are combined. As stated by the investigators, ypT and ypN that were not preoperatively predictable could not be used to stratify treatment groups. In conclusion, Jeong and colleagues’ study shows the effectiveness of laparoscopy in terms of long-term oncological outcome is acceptable and equivalent to conventional open surgery in patients with mid-rectal and low-rectal cancer after chemoradiotherapy. Further studies are now needed to better define the role of the laparoscopic approach in improving oncological outcome in patients undergoing rectal cancer surgery.
www.thelancet.com/oncology Published online May 16, 2014 http://dx.doi.org/10.1016/S1470-2045(14)70233-5
Lancet Oncol 2014 Published Online May 16, 2014 http://dx.doi.org/10.1016/ S1470-2045(14)70233-5 See Online/Articles http://dx.doi.org/10.1016/ S1470-2045(14)70205-0
1
Comment
Antoine Brouquet, Bernard Nordlinger* Department of Surgical Oncology and Digestive Surgery, Hôpital Bicêtre, Assistance Publique–Hôpitaux de Paris, Le KremlinBicêtre, Université Paris-Sud INSERM 986, France (AB); and Department of General Surgery and Surgical Oncology, Hôpital Ambroise Paré, Assistance Publique–Hôpitaux de Paris, 92100 Boulogne-Billancourt, France (BN) [email protected] We declare no competing interests. 1 2
3 4
2
5
6
7
8
MacFarlane JK, Ryall RD, Heald RJ. Mesorectal excision for rectal cancer. Lancet 1993; 341: 457–60. Kapiteijn E, Marijnen CA, Nagtegaal ID, et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 2001; 345: 638–46. Bosset JF, Collette L, Calais G, et al. Chemotherapy with preoperative radiotherapy in rectal cancer. N Engl J Med 2006; 355: 1114–23. Marijnen CA, Kapiteijn E, van de Velde CJ, et al. Acute side effects and complications after short-term preoperative radiotherapy combined with total mesorectal excision in primary rectal cancer: report of a multicenter randomized trial. J Clin Oncol 2002; 20: 817–25.
9
10
Matthiessen P, Hallböök O, Rutegård J, Simert G, Sjödahl R. Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial. Ann Surg 2007; 246: 207–14. Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 2004; 350: 2050–59. Guillou PJ, Quirke P, Thorpe H, et al. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 2005; 365: 1718–26. Kang SB, Park JW, Jeong SY, et al. Open versus laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): short-term outcomes of an open-label randomised controlled trial. Lancet Oncol 2010; 11: 637–45. van der Pas MH, Haglind E, Cuesta MA, et al. Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol 2013; 14: 210–18. Jeong S-Y, Park JW, Nam BH. Open versus laparscopic surgery for mid-rectal or low-rectal cancer after neoadjuvant chemotherapy (COREAN trial): survival outcomes of an open-label, non-inferiority, randomised controlled trial. Lancet Oncol 2014; published online May 16. http://dx.doi.org/10.1016/S1470-2045(14)70205-0
www.thelancet.com/oncology Published online May 16, 2014 http://dx.doi.org/10.1016/S1470-2045(14)70233-5
