The Multimodality Treatment of Locally Advanced and Locally Recurrent Rectal Cancer

This thesis focused on several aspects to further improve locally advanced and recurrent rectal cancer management. During last decade, rectal cancer treatment has shifted increasingly towards a personalized treatment depending on the local tumor and the presence of distant metastases. A multimodality treatment can result in relatively good long-term outcomes for both Locally advanced rectal cancer (LARC)and locally recurrent rectal cancer (LRRC). This thesis aimed to further improve the multimodality treatment in order to offer patients the best oncological care. Briefly, the _first part_ of this thesis, focusing on staging, showed a beneficial effect of restaging by thoraco-abdominal CT-scan after (chemo-)radiotherapy. It resulted in newly discovered distant metastases altering treatment in a substantial number of patients. Unfortunately, the beneficial effect of adding DCE sequences to local restaging by MR imaging after (chemo-)radiotherapy was limited. The _second part,_ which focused on LARC, suggested that applying IOR

Endoscopic bilateral adrenalectomy in patients with ectopic Cushing’s syndrome

Background: Bilateral adrenalectomy (BLA) is a treatment option to alleviate symptoms in patients with ectopic Cushing's syndrome (ECS) for whom surgical treatment of the responsible nonpituitary tumor is not possible. ECS patients have an increased risk for complications, because of high cortisol levels, poor clinical condition, and metabolic disturbances. This study aims to evaluate the safety and long-term efficacy of endoscopic BLA for ECS. Methods: From 1990 to present, 38 patients were diagnosed and treated for ECS in the Erasmus University Medical Center, a tertiary referral center. Twenty-four patients were treated with BLA (21 endoscopic, 3 open), 9 patients were treated medically, and 5 patients could be cured by complete resection of the adrenocorticotropic hormone (ACTH)-producing tumor. The medical records were retrospectively reviewed and entered into a database. For evaluation of the efficacy of BLA, preoperative biochemical and physical symptoms were assessed and compared with postoperative data. Results: Endoscopic BLA was successfully completed in 20 of the 21 patients; one required conversion to open BLA. Intraoperative complications occurred in two (10%) patients, and postoperative complications occurred in three (14%) patients. Median hospitalization was 9 (2-95) days, and median operating time was 246 (205-347) min. Hypercortisolism was resolved in all patients. Improvements of hypertension, body weight, Cushingoid appearance, impaired muscle strength, and ankle edema were achieved in 87, 90, 65, 61, and 78% of the patients, respectively. Resolution of diabetes, hypokalemia, and metabolic alkalosis was achieved in 33, 89, and 80%, respectively. Conclusion: Endoscopic BLA is a

Muscle wasting and survival following pre-operative chemoradiotherapy for locally advanced rectal carcinoma

Background & aims: Neoadjuvant chemoradiotherapy (NACRT) has increased local control in locally advanced rectal cancer. Reduced skeletal muscle mass (sarcopenia), or ongoing muscle wasting, is associated with decreased survival in cancer. This study aims to assess the change in body composition during NACRT and its impact on outcome using computed tomography (CT) imaging in locally advancedrectal cancer (LARC) patients. Methods: LARC patients treated with NACRT were selected from a prospectively maintained database and retrospectively analyzed. One-hundred twenty-two patients who received treatment between 2004 and 2012 with available diagnostic CT imaging obtained before and after NACRT were identified. Cross-sectional areas for skeletal muscle was determined, and subsequently normalized for patient height. Differences between skeletal muscle areas before and after NACRT were computed, and their influenceon overall and disease-free survival was assessed. Results: A wide distribution in change of body composition was observed. Loss of skeletal muscle mass during chemoradiotherapy was independently associated with disease-free survival (HR0.971; 95% CI:0.946e0.996; p¼0.025) and distant metastasis-free survival (HR0.942; 95% CI: 0.898e0.988; p¼0.013).No relation was observed with overall survival in the current cohort. Conclusions:Loss of skeletal muscle mass during NACRT in rectal cancer patients is an independent prognostic factor for disease-free survival and distant metastasis-free survival following curative intentresection

The Prognostic Value of the Primary Tumor's Nodal Status after Surgery for Colorectal Liver Metastases in the Era of Effective Systemic Therapy

Background: The nodal status of primary colorectal cancer is of prognostic value for survival after the resection for colorectal liver metastases (CRLM). However, in the past decade, effective adjuvant chemotherapy for lymph node positive primary colon cancer was introduced. This study evaluated the prognostic value of primary lymph node status in patients with resectable metachronous CRLM in the era of effective systemic therapy. Methods: Between January 2000 and December 2011, all consecutive patients undergoing curative liver resection for CRLM were retrospectively analyzed. Overall survival (OS) was analyzed by the localization of the primary tumor (colon vs. rectum) and by lymph node status (positive vs. negative) of the primary tumor. Results: A total of 286 patients with metachronous CRLM's were selected. Five-year OS was similar for colon and rectal primaries (42 and 40%, p = 0.62). Lymph node positivity was only a prognostic factor in rectal primaries (N+ 32% vs. N0 49%, p = 0.04) and not in colon primaries (N+ 42% vs. N0 41%, p = 0.99). In multivariate analysis, these results were confirmed. Conclusion: The current study demonstrates that the nodal status of primary colon malignancies does not have prognostic value in patients undergoing resection for nnetachronous CRLM. A possible explanation might be the administration of effective adjuvant chemotherapy in node positive colon cancer. (C) 2015 S. Karger AG, Base

Endoscopic bilateral adrenalectomy in patients with ectopic Cushing's syndrome

Background Bilateral adrenalectomy (BLA) is a treatment option to alleviate symptoms in patients with ectopic Cushing's syndrome (ECS) for whom surgical treatment of the responsible nonpituitary tumor is not possible. ECS patients have an increased risk for complications, because of high cortisol levels, poor clinical condition, and metabolic disturbances. This study aims to evaluate the safety and long-term efficacy of endoscopic BLA for ECS. Methods From 1990 to present, 38 patients were diagnosed and treated for ECS in the Erasmus University Medical Center, a tertiary referral center. Twenty-four patients were treated with BLA (21 endoscopic, 3 open), 9 patients were treated medically, and 5 patients could be cured by complete resection of the adrenocorticotropic hormone (ACTH)-producing tumor. The medical records were retrospectively reviewed and entered into a database. For evaluation of the efficacy of BLA, preoperative biochemi Results Endoscopic BLA was successfully completed in 20 of the 21 patients; one required conversion to open BLA. Intraoperative complications occurred in two (10%) patients, and postoperative complications occurred in three (14%) patients. Median hospitalization was 9 (2-95) days, and median operating time was 246 (205-347) min. Hypercortisolism was resolved in all patients. Improvements of hypertension, body weight, Cushingoid appearance, impaired muscle strength, and ankle edema were achieved Conclusion Endoscopic BLA is a safe and effective treatment for patients with ectopic Cushing's syndrome