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Trial registered on ANZCTR
Registration number
ACTRN12612000835842
Ethics application status
Approved
Date submitted
4/08/2012
Date registered
8/08/2012
Date last updated
28/05/2014
Type of registration
Retrospectively registered
Titles & IDs
Public title
Proctectomy with sphincter preservation in very low rectal cancer that traditionally need abdominoperineal resection with permanent colostomy
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Scientific title
Effect of changing decision of abdominoperineal resection to sphincter preserving technique in very low rectal cancer after downstaging by neoadjuvant chemoradiation on recurrence and survival
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Secondary ID [1]
280974
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Nil known
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Universal Trial Number (UTN)
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Trial acronym
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Linked study record
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Health condition
Health condition(s) or problem(s) studied:
Low rectal cancer
287086
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Condition category
Condition code
Surgery
287414
287414
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0
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Surgical techniques
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Cancer
287434
287434
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0
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Bowel - Back passage (rectum) or large bowel (colon)
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Intervention/exposure
Study type
Interventional
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Description of intervention(s) / exposure
Patients with stage II and III low rectal cancer less than 5 cm from anal verge usually need abdominoperineal resection. Preoperative neoadjuvant chemoradiation(54 grays of radiation divided over 5 weeks with chemotherapy by intravenous 5-fu and leucovorin 1 day a week for 5 weeks; 5-FU 425 mg/m2 plus LV 45 mg ) helps in tumor downstaging and downsizing that might help to resect the tumor with safety margin without removing the anal sphincters. Patients with T3, T4 low rectal tumors 5 cm or less from anal verge receive neoadjuvant preoperative chemoradiation. Patient assessment is done 8 weeks after the end of chemoradiation by digital rectal examination and endorectal ultrasound. If there is tumor downsizing that leaves safety margin above the anal sphincters, , then very low anterior resection with coloanal anastomosis is performed (120-180 minutes) . If no sufficient safety margin, intersphincteric resection (120-180 minutes) with coloanal anastomosis is done if the external anal sphincter is not involved (yT2), if the external sphincter was involved so abdominoperineal resection is done and excluded from study.
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Intervention code [1]
285420
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Treatment: Surgery
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Intervention code [2]
285432
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Treatment: Drugs
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Comparator / control treatment
nil
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Control group
Uncontrolled
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Outcomes
Primary outcome [1]
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Perioperative morbidity assesed by clinical examination of the abdomen to diagnose wound problems, chest x ray and Ultrasound abdomen
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Assessment method [1]
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Timepoint [1]
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1-30 days postoperative
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Primary outcome [2]
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Perioperative mortailty
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Assessment method [2]
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Timepoint [2]
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1-30 days postoperative
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Primary outcome [3]
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Tumor recurrence assessed by clinical examination and abdominal CT scan
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Assessment method [3]
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Timepoint [3]
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every 6 months postoperative for 2 years
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Secondary outcome [1]
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Morbidity and mortality after salvage surgery in case of recurrence by clinical examination of the abdomen to diagnose wound problems, chest x ray and Ultrasound abdomen
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Assessment method [1]
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Timepoint [1]
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1-30 days postoperative after salvage surgery
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Secondary outcome [2]
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Continence assessed by wexner score
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Assessment method [2]
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Timepoint [2]
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6 months and 1 year postoperative
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Eligibility
Key inclusion criteria
Adult male or female 18-80 years
low rectal tumor, 5 cm or less from anal verge
Stage II or III
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Minimum age
18
Years
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Maximum age
80
Years
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Sex
Both males and females
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Can healthy volunteers participate?
No
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Key exclusion criteria
Stage IV tumors
fecal incontinence assessed by wexner score
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Study design
Purpose of the study
Treatment
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Allocation to intervention
Non-randomised trial
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Procedure for enrolling a subject and allocating the treatment (allocation concealment procedures)
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Methods used to generate the sequence in which subjects will be randomised (sequence generation)
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Masking / blinding
Open (masking not used)
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Who is / are masked / blinded?
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Intervention assignment
Single group
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Other design features
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Phase
Not Applicable
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Type of endpoint/s
Safety/efficacy
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Statistical methods / analysis
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Recruitment
Recruitment status
Recruiting
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Date of first participant enrolment
Anticipated
20/01/2007
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Actual
20/01/2007
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Date of last participant enrolment
Anticipated
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Actual
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Date of last data collection
Anticipated
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Actual
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Sample size
Target
30
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Accrual to date
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Final
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Recruitment outside Australia
Country [1]
4460
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Egypt
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State/province [1]
4460
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Funding & Sponsors
Funding source category [1]
285756
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Self funded/Unfunded
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Name [1]
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Address [1]
285756
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Country [1]
285756
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Egypt
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Primary sponsor type
Individual
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Name
Khaled Madbouly
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Address
Kolet el teb street, Azarita, Faculty of medicine, university of alexandria, Alexandria, 21321, egypt
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Country
Egypt
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Secondary sponsor category [1]
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None
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Name [1]
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Address [1]
284586
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Country [1]
284586
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Ethics approval
Ethics application status
Approved
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Ethics committee name [1]
287769
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Ethics Committee, University of Alexandria
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Ethics committee address [1]
287769
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Kolet el teb street, Azarita, Faculty of medicine, university of alexandria, Alexandria, 21321, egypt
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Ethics committee country [1]
287769
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Egypt
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Date submitted for ethics approval [1]
287769
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Approval date [1]
287769
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Ethics approval number [1]
287769
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Summary
Brief summary
Background: Multimodality treatment of rectal cancer, with the combination of radiation therapy, chemotherapy, and surgery has become the preferred approach to locally advanced rectal cancer.The considerably high local recurrence rates observed after radical surgery alone has led to the use and recommendation for additional therapy either before or after surgery for T3/T4 or N1 tumors. In this setting, to avoid overtreatment of patients with early-stage disease, preoperative treatment with radiation therapy with or without concomitant chemotherapy requires optimal radiological staging because there is no pathologic confirmation of exact TNM parameters. However, there is a theoretic benefit of exposing unscarred tissue with optimal oxygen delivery to both radiation and chemotherapy as opposed to postoperative treatment. The results from randomized controlled trials suggest that the neoadjuvant approach seems to be superior for local disease control, even in the setting of appropriate surgical technique (total mesorectal excision). The use of neoadjuvant chemoradiation therapy (CRT) has resulted in additional benefits such as reduced toxicity rates, significant tumor downsizing and downstaging, better chance of sphincter preservation, and improved functional results (compared with postoperative CRT). In a multicenter study of patients undergoing neoadjuvant CRT for clinically stage II disease (staged by either endorectal ultrasound or magnetic resonance imaging), more than 20% of the patients staged as N0 were found to harbor lymph node metastases in their tumors on pathologic examination. Considering that these patients underwent neoadjuvant CRT, even greater rates of nodal disease underestimation might be expected. Radical surgery with total mesorectal excision remains the mainstay of treatment of distal rectal cancer and is considered by many to be necessary regardless of tumor response to neoadjuvant CRT. However, it has been associated with high rates of immediate morbidity and mortality. With very low tumors, abdominoperineal resection sometimes is necessary with the result of permenant colostomy and disturbance of the quality of life. Up till now, many authors believe that the decision of surgery should be set before any change in the tumor by neoadjuvant chemoradiation, however haber-gama who concluded that with complete pathologic response and restrict criteria, it is safe just to follow up the patient without surgery. Changing decision to sphincter preserving technique in patients who have good response to neoadjuvant chemoradiation with downsizing and downstaging is still contraversail. Aim of the work: To study the safety of changing decision from abdominoperineal resection to sphincter preserving technique in low rectal tumors after downsizing be neoadjuvant chemoradiation. Aspects of safety will include periperative morbidity, mortality, continence, recurrences and results of salvage surgery after recurrence. Study design: Patients with stage II and III low rectal cancer less than 5 cm from anal verge usually need abdominoperineal resection. Preoperative neoadjuvant chemoradiation helps in tumor downstaging and downsizing that might help to resect the tumor with safety margin without removing the anal sphincters. Patients with T3, T4 low rectal tumors 5 cm or less from anal verge receive neoadjuvant preoperative chemoradiation. Patient assessment is done 8 weeks after the end of chemoradiation by digital rectal examination and endorectal ultrasound. If there is tumor downsizing that leaves safety margin above the anal sphincters, , then very low anterior resection with coloanal anastomosis is performed. If no sufficient safety margin, intersphincteric resection with coloanal anastomosis is done if the external anal sphincter is not involved (yT2), if the external sphincter was involved so abdominoperineal resection is done.
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Trial website
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Trial related presentations / publications
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Public notes
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Contacts
Principal investigator
Name
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A/Prof Khaled Madbouly
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Address
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Faculty of Medicine, University of Alexandria. Kolet el teb Street, Azarita, Alexandria. 21321
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Country
34538
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Egypt
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Phone
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+2034802375
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Fax
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Email
34538
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[email protected]
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Contact person for public queries
Name
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Khaled Madbouly
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Address
17785
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Kolet el teb street, Azarita, Faculty of medicine, university of alexandria, Alexandria, 21321, egypt
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Country
17785
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Egypt
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Phone
17785
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+20 34802375
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Fax
17785
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Email
17785
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[email protected]
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Contact person for scientific queries
Name
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Khaled Madbouly
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Address
8713
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Kolet el teb street, Azarita, Faculty of medicine, university of alexandria, Alexandria, 21321, egypt
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Country
8713
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Egypt
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Phone
8713
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+20 34802375
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Fax
8713
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Email
8713
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[email protected]
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No information has been provided regarding IPD availability
What supporting documents are/will be available?
No Supporting Document Provided
Results publications and other study-related documents
Documents added manually
No documents have been uploaded by study researchers.
Documents added automatically
No additional documents have been identified.
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