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As newly minted colorectal surgeons, you are skilled, driven, and compassionate. But what makes you you in this field? Your personal brand—your unique blend of personality, values, and approach to patient care—sets you apart and help you be successful clinically and professionally. Drawing from my own journey, this article explores how to build a personal brand and find fulfillment as a colorectal surgeon, tailored for those just starting out, but is relevant to those looking for the next step.
BACKGROUND:Although limited trials have demonstrated the feasibility of rectal-preserving approaches in clinical T1-3N0 adenocarcinoma, local excision after neoadjuvant therapy has been associated with high rates of morbidity. We hypothesized that this strategy would be comparable to the standard, total mesorectal excision. The aim of this study was to describe trends of early-stage rectal cancer management. METHODS:cT1-3N0 rectal cancers in the National Cancer Database (2006-2018) were grouped into 5 treatments: total mesorectal excision, total neoadjuvant therapy + local excision, neoadjuvant chemoradiotherapy + local excision, total neoadjuvant therapy + total mesorectal excision, and neoadjuvant chemoradiotherapy + total mesorectal excision. Morbidity was defined as a combination of readmissions and 30- and 90-day mortality. RESULTS:We identified 22,793 patients. Neoadjuvant chemoradiotherapy + local excision had the highest proportion of patients ≥70 years (41%) and those with comorbidities (Charlson-Deyo score ≥2, 9%). Median stay was 1 day for local excision and 5 days for total mesorectal excision. Overall composite morbidity was 9%, which, after adjustment, was not statistically different between local excision and total mesorectal excision (odds ratio = 0.45, 95% confidence interval: 0.17-1.19). Among local excision patients, 56% had pathologic complete response, 33% were pStage I, and 12% pStage II-III. In multivariable analysis, all strategies had similar overall survival compared with total mesorectal excision, except for neoadjuvant chemoradiotherapy + local excision, which was associated with worse prognosis (hazard ratio = 1.57, 95% confidence interval: 1.21-2.03). CONCLUSION:Although infrequent, neoadjuvant chemoradiotherapy/total neoadjuvant therapy + local excision were associated with high rates of tumor downstaging, suggesting that rectal-preserving strategies are feasible. However, 1 in 8 patients had more advanced disease, which may have compromised future total mesorectal excision planes. Together with the similar morbidity and relatively worse prognosis of neoadjuvant chemoradiotherapy + local excision, these observations should prompt careful patient selection for this approach, while cautioning against its widespread use.
BACKGROUND:The vast majority of colon cancers occur in pre-existing adenomas. Little is known about the impact of adenoma type on behavior and outcome of subsequent carcinomas. The present study aimed to assess characteristics, behavior, and outcome of colon adenocarcinoma based on histologic type of pre-existing adenoma. METHODS:US-National Cancer Database was searched between 2005 and 2019 for patients with colonic adenocarcinoma with known adenoma type who underwent colectomy. Patients were divided into 3 groups according to type of adenoma in which carcinoma developed: tubular adenoma (TA), villous adenoma (VA), and tubulovillous adenoma (TVA)-associated carcinomas. The main outcome of the study was 5-year overall survival (OS). RESULTS:66,854 patients were included. 79.3% of carcinomas originated from TVA, 10.2% from VA, and 0.5% from TA. Patients with adenocarcinoma in VA were more often female whereas carcinomas in TA affected patients of Asian race more often. Approximately one-third of carcinomas in villous and tubulovillous adenomas were in the cecum whereas one-third of carcinomas in tubular adenomas were in the sigmoid colon. More TA-associated carcinomas were of clinical T1-2 stage (30.2% vs. 20.8%; P < .001), clinical N0 stage (69% vs. 62.2%, P < .001), and high grade (15.9% vs. 11.5%, P < .001) compared to VA-associated carcinomas. Patients with TA-associated carcinomas had longer mean OS than patients with VA and TVA-associated carcinomas (130.1 vs. 116.9 vs. 123.5 months, P < .0001). CONCLUSIONS:Adenocarcinomas that arose in TA had more T1-2 stage and N0 stage, higher grade, and longer OS than did adenocarcinomas that arose in VA and TVA.
