OUTCOMES OF INCIDENTAL VERSUS PREOPERATIVELY DIAGNOSED COLORECTAL CANCER DURING TOTAL PROCTOCOLECTOMY WITH ILEAL POUCH ANAL ANASTOMOSIS FOR INFLAMMATORY BOWEL DISEASE
Marianna Maspero*, Ana Otero Pineiro, Olga Lavryk, Emre Gorgun, Jeremy M. Lipman, David Liska, Hermann Kessler, Michael Valente, Stefan D. Holubar, Scott Steele, Tracy L. Hull
Cleveland Clinic, Cleveland, OH
Background: Patients with inflammatory bowel diseases (IBD) are at increased risk for colorectal cancer (CRC). Total proctocolectomy with ileal pouch anal anastomosis (IPAA) is the treatment of choice in patients with IBD-associated dysplasia or CRC; however, CRC may also be discovered incidentally in a small percentage of cases of IPAA performed for other IBD-related indications. The aim of our study was to determine whether incidentally found CRC in the proctocolectomy specimen was associated with worse oncological and pouch-related outcomes compared to preoperatively diagnosed CRC.
Methods: Our prospectively maintained institutional pelvic pouch registry (1983 – 2021) was retrospectively reviewed. Patients with finding of colorectal adenocarcinoma at final pathology after proctocolectomy were included. Patients were divided into two groups: preoperative diagnosis (PreD) group if they had a preoperative biopsy positive for either dysplasia or adenocarcinoma, and incidental diagnosis (InD) group, if all their preoperative biopsies were negative for both dysplasia and adenocarcinoma and indication for IPAA was not related to dysplasia or cancer. The long term outcomes of the two groups were compared.
Results: A total of 164 patients were included: 53 (32%) in the InD group and 111 (68%) in the PreD. Patients in the InD group were younger than in the PreD group (median 44 years vs 49, p=0.05). Other demographic characteristics were similar between the two groups (Table 1). In the PreD group, 5% patients had low grade dysplasia at preoperative biopsy, 40% high grade dysplasia, 55% cancer (of which 9% in situ), 5% indeterminate. In the PreD group, 6 (6%) patients underwent neoadjuvant treatment. There were no differences in cancer staging, differentiation, and location between the groups. Nine (17%) patients in the InD and 25 (23%) in the PreD group underwent adjuvant chemotherapy (p = 0.446). After a median follow up of 11 (IQR 3 – 25) years for InD and 9 (IQR 3 – 20) years for PreD group, deaths were 14 (26%) in the InD and 18 (16%) in the PreD group, of which 3 (6%) and 7 (6%) cancer-related. Recurrences were 2 (4%) in the InD and 12 (11%) in the PreD group. Pouch failures were 5 (9%) in the InD and 9 (8%) in the PreD groups, of which 2 (5%) and 4 (4%) cancer-related. Ten-year overall survival (Figure 1a) was 94% for InD and 89% for PreD (p=0.41), cancer-specific survival was 96% for InD and 94% for PreD, disease-free survival 95% for InD and 88% for PreD (p=0.15), pouch survival (Figure 1b) 89% for InD and 97% for PreD (p=0.80).
Conclusion: IBD patients with an incidental finding of colorectal cancr during total proctocolectomy with IPAA appear to have similarly excellent oncological and pouch outcomes as patients with a preoperative cancer diagnosis.
Table 1. Characteristics of the two cohorts
Figure 1. Kaplan Meier curve for a) Overall survival; b) Pouch survival
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