Conor Delaney

188 statements · 3 topics

Colorectal / ARM & Hirschsprung · guest expert Soft Tissue Sarcoma (lymph nodes) · guest expert

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when you do an operation, and we'll come back to the neoadjuvant treatment, but when you do the operation on these patients, you've got to do it in a way that they have a negative pathological margin. If you have a negative pathological margin, the chance of local recurrence is low.

quote · Rectal Cancer

If you look back in the literature for rectal cancer, local recurrence rates in series from good institutions were 20 to 38 percent and some up to 50 percent. Nowadays, really, it should be under 10 percent. And if you look at our last 10 years, Jeff, it was about 3 percent.

quote · Colorectal / ARM & Hirschsprung

if you look back in the literature for rectal cancer. Local recurrence rates in series from good institutions were 20 to 38% and some up to 50%. Nowadays, really it should be under 10%, and if you look at our last 10 years, Jeff, it was about 3%.

quote · Rectal Cancer

over the last five to ten years, particularly, as we've found out more, it's become clear that these weren't actually hyperplastic, and they were really polyps that are better described as serrated adenomas.

quote · Colorectal / ARM & Hirschsprung

For young, curable patients, radical resection is generally favored over transanal resection; transanal resection is typically reserved for patients unfit for radical surgery or those who would require permanent stoma.

guideline · Soft Tissue Sarcoma (lymph nodes)

Genetic assessment is indicated for colorectal cancer patients with Bethesda criteria risk factors, cancer under age 40, first-degree relatives with cancer, or multiple cancers in the family.

guideline · Soft Tissue Sarcoma (lymph nodes)

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Conor's statements about Colorectal / ARM & Hirschsprung 37 statements

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Colorectal Cancer

Quotation Colonoscopy is still very important. It's still the best test that we have. There is no perfect test, and we know that colonoscopy doesn't find every cancer, although it finds the vast majority, every polyp, although it finds the vast majority. But it's certainly the best thing we have. Open

Statement Colonoscopy is still the best test available for colon cancer detection, finding the vast majority of cancers and polyps, though not perfect. Open

Quotation these polyps have a really high risk of cancer, so it's very important to deal with them. Open

Statement Serrated adenomas (previously misclassified as hyperplastic polyps) have good evidence of genetic predisposition and tie into many family cancer syndromes. Open

Statement Serrated polyps have a very high risk of cancer and require family assessment to determine if patients have a family cancer syndrome. Open

Quotation over the last five to ten years, particularly, as we've found out more, it's become clear that these weren't actually hyperplastic, and they were really polyps that are better described as serrated adenomas. Open

Statement Serrated adenomas are often flat and difficult to see; retroflexion in the cecum is useful because they are often on the inferior or superior side of the valve or on folds. Open

Quotation six centimeters can be a very different thing in many surgeons' minds or gastroenterologists, and it can also be a very different thing depending on the patient. Open

Statement Distal margin requirements for rectal resection: 5 centimeters if possible, 2 centimeters if possible, and for very lowest tumors perhaps 1 centimeter as long as they are not poorly differentiated. Open

Statement Six centimeters from the anal verge can be mid-rectum in a small patient (90-pound, 80-year-old female) or close to the dentate line in a large patient (6'6", 300 pounds). Open

Quotation you can take out a whole rectum with about 5 mils of blood loss because it's a bloodless plane. And if you've got bleeding, you hopefully are deliberately outside of that plane, but otherwise you're in the wrong plane. Open

Statement With optimized surgery, imaging, and patient selection, local recurrence rates for rectal cancer should be under 10 percent; Cleveland Clinic's rate over the last 10 years was about 3 percent. Open

Statement For total mesorectal excision, the circumferential resection margin should be one to two millimeters; if threatened, this is an indication for neoadjuvant therapy or extended resection. Open

Statement A total mesorectal excision can be performed with about 5 milliliters of blood loss because it is a bloodless plane; bleeding indicates being outside that plane or in the wrong plane. Open

Statement Most accepted guidelines for neoadjuvant therapy in rectal cancer are for tumors that are T3 (outside the wall of the rectum) or node positive. Open

Quotation If you look back in the literature for rectal cancer, local recurrence rates in series from good institutions were 20 to 38 percent and some up to 50 percent. Nowadays, really, it should be under 10 percent. And if you look at our last 10 years, Jeff, it was about 3 percent. Open

Statement Historical local recurrence rates for rectal cancer from good institutions were 20 to 38 percent, with some up to 50 percent. Open

Statement For node-negative T1 or T2 rectal tumors (stage one), particularly if upper third, neoadjuvant therapy can be omitted. Open

Statement Endoscopic ultrasound is much more operator dependent and probably only 70% accurate for predicting nodal involvement in rectal cancer. Open

Statement MRI is probably 90 to mid-90s percent accurate at T staging and high 80s to 90% accurate for nodal staging in rectal cancer. Open

Statement For young, curable patients, most surgeons favor radical resection over transanal resection; transanal resection is generally kept for patients unfit for rectal resection or those whose tumor is so close to the dentate line that a permanent stoma would be required. Open

Statement Historical local recurrence rates for transanally excised rectal cancers were about 18%, remarkably consistent across outcome data from several big centers. Open

Quotation if you look at the historical local recurrence rates for these transanally excised rectal cancers, it was about 18%. And it was remarkably consistent across outcome data from several big centers, about 18%. Open

Statement Transanal resection is generally appropriate for tumors less than a third of the circumference, ideally less than two centimeters, that are T1. Open

Statement For rectal cancer, full-thickness excision is required; ESD (endoscopic submucosal dissection) would never be done for a proven cancer, only for benign polyps. Open

Quotation 25 gray over a short period is equivalent to 40 to 45 over a longer period. But it can make a big difference for tumor response. Open

Statement In Europe, short-course radiation is five times five gray given over five days, with surgery about one to two weeks later. Open

Statement In the U.S., long-course radiation is 40 to 45 gray given with chemotherapy over six weeks, followed by a six to eight week waiting period. Open

Statement Twenty-five gray over a short period is radiotherapeutically equivalent to 40 to 45 gray over a longer period, but longer course can make a big difference for tumor response and physical downstaging. Open

Statement Scandinavian data showed local recurrence rates for colon cancer were even higher than for rectal cancer (which was high 20s percent) because they realized they weren't doing adequate colon cancer surgery. Open

Quotation if you look at the Scandinavian data, I mentioned their local recurrence rates were 27%, high 20s, when they were doing some very good rectal cancer trials. They focused on rectal cancer surgical technique and got the local recurrence rate down to under 10%. While their local recurrence rate for colon cancer was even higher than their rectal cancer local recurrence rate, because they realized they weren't doing adequate colon cancer surgery. Open

Statement For colon cancer surgery, goals include at least a 5 centimeter proximal and distal margin (usually determined by blood supply) and at least 12 lymph nodes, with many surgeons hoping for at least 16. Open

Statement Total mesocolic excision should be performed in the plane between the embryological peritoneum of the retroperitoneum (Toldt's fascia) and the embryological peritoneum on the mesocolon, keeping the mesocolon complete. Open

Statement For a cecal tumor or lesion near the ileocecal valve, 10 centimeters of small bowel should be taken; for mid-ascending colon, 5 centimeters should be taken. Open

Statement Extracorporeal stapled anastomosis for right colectomy has reported leak rates of 0.8% over 1,000 cases at Cleveland Clinic. Open

Statement Genetic findings may change the surgical operation: a patient with a right colon cancer plus multiple polyps or significant family history may be better served with a subtotal colectomy rather than segmental resection. Open

Statement Genetic workup should be considered for patients with cancer under age 40, first-degree relatives with cancer, multiple cancers in a family, or non-GI cancers in a family. Open

Conor's statements about Rectal Cancer 75 statements

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Colon Cancer with Conor Delaney

Statement Colonoscopy is still the best test for colon cancer detection, finding the vast majority of cancers and polyps, though not perfect. Open

Quotation colonoscopy is still very important. It's still the best test that we have. There is no perfect test, and we know that colonoscopy doesn't find every cancer, although it finds the vast majority, every polyp, although it finds the vast majority, but it's certainly the best thing we have Open

Statement Serrated adenomas (previously misclassified as hyperplastic polyps, particularly large ones in the right colon) have genetic predisposition, tie into family cancer syndromes, and carry very high cancer risk. Open

Quotation these polyps have a really high risk of cancer. So it's very important to deal with them, but third is that it's very important to be able to tell the patient that they're at higher risk Open

Statement Finding serrated adenomas requires family assessment for hereditary cancer syndromes and may necessitate changes in colonoscopy frequency and family member screening. Open

Statement Serrated polyps can be flat and difficult to visualize; retroflexion in the cecum is increasingly used because they are often on the inferior or superior side of folds. Open

Statement For rectal cancer, distal margin requirements are 5 cm if achievable, 2 cm if necessary, and 1 cm for very low tumors as long as they are not poorly differentiated. Open

Statement The measurement '6 centimeters from the anal verge' varies significantly by patient body habitus and can represent different anatomical locations (anorectal ring vs. near dentate line). Open

Quotation 6 centimeters doesn't mean 6 centimeters. It's not the same to everybody and it's not the same to every patient. Open

Statement Distant staging for rectal cancer is best performed with CT abdomen (for liver metastases) and CT chest (replacing chest X-ray per current guidelines). Open

Statement MRI has become the standard for local staging of rectal cancer, with high-resolution, high-Tesla magnets using standardized protocols developed by Bill Heald and Gina Brown at the Royal Marsden. Open

Statement MRI is particularly good at distinguishing T3 and T4 tumors and assessing circumferential resection margins, though less accurate at distinguishing T1 from T2. Open

Statement Circumferential resection margin is the most important margin (or many think more important than distal margin) for preventing local recurrence in rectal cancer. Open

Statement Historical local recurrence rates for rectal cancer from good institutions were 20–38%, with some series up to 50%. Open

Quotation if you look back in the literature for rectal cancer. Local recurrence rates in series from good institutions were 20 to 38% and some up to 50%. Nowadays, really it should be under 10%, and if you look at our last 10 years, Jeff, it was about 3%. Open

Statement With optimized surgery and imaging, local recurrence rates for rectal cancer should now be under 10%; Cleveland Clinic's rate over the last 10 years was about 3%. Open

Quotation when you do an operation, and we'll come back to the neoadjuvant treatment, but when you do the operation on these patients, you've got to do it in a way that they have a negative pathological margin. If you have a negative pathological margin, the chance of local recurrence is low. Open

Statement Total mesorectal excision (TME) can be performed with about 5 mL of blood loss because it follows a bloodless embryological plane; bleeding indicates wrong plane unless deliberately outside TME plane. Open

Quotation you can take out a whole rectum with about 5 mL of blood loss because it's a bloodless plane. And if you've got bleeding, you hopefully are deliberately outside of that plane, but otherwise you're in the wrong plane. Open

Statement Neoadjuvant therapy for rectal cancer is indicated for T3 tumors (outside the rectal wall) or node-positive disease. Open

Statement Stage 1 rectal cancer (node-negative, T1 or T2), particularly in the upper third of the rectum, does not require neoadjuvant therapy. Open

Statement MRI is 90 to mid-90s percent accurate for T-staging and high 80s to 90% accurate for nodal staging of rectal cancer. Open

Statement Endoscopic ultrasound is only about 70% accurate for predicting nodal involvement in rectal cancer and is much more operator-dependent than MRI. Open

Statement Transanal resection for rectal cancer is generally limited to T1 tumors less than one-third circumference and ideally less than 2 cm. Open

Statement Historical local recurrence rates for transanally excised rectal cancers were about 18%, remarkably consistent across multiple centers. Open

Statement Transanal endoscopic microsurgery (TEM) may produce better outcomes than traditional transanal excision, though it is unclear whether this is due to technology or improved surgical understanding. Open

Statement For young, curable patients, radical resection is generally favored over transanal resection; transanal resection is typically reserved for patients unfit for radical surgery or those who would require permanent stoma. Open

Statement For rectal cancer, full-thickness excision is required; ESD or EMR is never appropriate for proven cancer, only for benign polyps. Open

Statement Short-course radiation (5×5 Gy over 5 days, surgery 1–2 weeks later) is commonly used in Europe; long-course chemoradiation (40–45 Gy over 6 weeks with 6–8 week wait) is standard in the US. Open

Statement 25 Gy over a short period is radiotherapeutically equivalent to 40–45 Gy over a longer period, but long-course therapy may produce better tumor downstaging for bulky tumors. Open

Statement For colon cancer, at least 12 lymph nodes are required for adequate staging, though many surgeons aim for at least 16. Open

Statement High ligation of the inferior mesenteric artery (above the takeoff of the left colic artery) is standard for sigmoid colectomy, with protection of autonomic nerves to preserve sexual function. Open

Statement Total mesocolic excision for colon cancer should be performed with about 5 mL of blood loss in the embryological plane between retroperitoneal peritoneum (Toldt's fascia) and mesocolic peritoneum. Open

Statement Scandinavian data showed local recurrence rates for colon cancer were even higher than for rectal cancer (high 20s%) before focus on complete mesocolic excision technique. Open

Statement For cecal or ileocecal valve tumors, 10 cm of small bowel should be resected; for mid-ascending colon tumors, 5 cm of small bowel is adequate. Open

Statement Extracorporeal stapled anastomosis for right hemicolectomy achieved a leak rate of 0.8% over 1000 cases at Cleveland Clinic. Open

Statement Genetic assessment is indicated for colorectal cancer patients with Bethesda criteria risk factors, cancer under age 40, first-degree relatives with cancer, or multiple cancers in the family. Open

Statement Genetic diagnosis affects both family screening recommendations and surgical approach; patients with hereditary syndromes may require subtotal colectomy or proctocolectomy rather than segmental resection. Open