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Bao QR, Ferrari S, Capelli G, Ruffolo C, Scarpa M, Agnes A, Chiloiro G, Palazzari E, Urso EDL, Pucciarelli S, Spolverato G. Rectal Sparing Approaches after Neoadjuvant Treatment for Rectal Cancer: A Systematic Review and Meta-Analysis Comparing Local Excision and Watch and Wait. Cancers (Basel) 2023; 15:cancers15020465. [PMID: 36672414 PMCID: PMC9856629 DOI: 10.3390/cancers15020465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/04/2023] [Accepted: 01/06/2023] [Indexed: 01/15/2023] Open
Abstract
Local Excision (LE) or Watch and Wait (WW) for patients with complete clinical response or near-complete clinical response after neoadjuvant chemoradiotherapy (nCRT) were proposed to avoid morbidity and impairment of quality of life after rectal resection. The aim of this study is to perform a systematic review of the literature, and to compare rectal-sparing approaches, in terms of rectum-preservation rate, local control, and distant recurrences. A systematic review and meta-analysis were performed of studies published until July 2022 (PROSPERO, registration CRD42022341480), and the quality of evidence was assessed using a GRADE approach. Seven retrospective studies and one prospective trial were included. In six studies, patients were treated with standard long-course nCRT, and in two with Total Neoadjuvant Therapy (TNT). Overall, there were 213 and 188 patients in WW and LE group, respectively, and no difference was found between WW and LE when considering rectum-preservation rate (OR 0.80 95%CI 0.31-2.01, p = 0.63), local disease (OR 1.60 95%CI 0.75-3.42, p = 0.22), locoregional failure (OR 0.85 95%CI 0.20-3.66, p = 0.83) and distant recurrence (OR 0.76 95%CI 0.37-1.55, p = 0.45). Studies directly comparing WW and LE are still lacking, even though no differences between WW and LE in terms of rectum-preservation, local control, and distant recurrences have been found.
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Affiliation(s)
- Quoc Riccardo Bao
- General Surgery 3, Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padova, 35128 Padova, Italy
| | - Stefania Ferrari
- General Surgery 3, Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padova, 35128 Padova, Italy
| | - Giulia Capelli
- General Surgery 3, Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padova, 35128 Padova, Italy
- Department of Surgery, ASST Bergamo Est, 24068 Bergamo, Italy
| | - Cesare Ruffolo
- General Surgery 3, Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padova, 35128 Padova, Italy
| | - Marco Scarpa
- General Surgery 3, Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padova, 35128 Padova, Italy
- Correspondence:
| | - Amedea Agnes
- Department of Surgery, Fondazione Policlinico Universitario A. Gemelli—IRCCS, 00168 Roma, Italy
| | - Giuditta Chiloiro
- Department of Radiation Oncology, Fondazione Policlinico Universitario A. Gemelli—IRCCS, 00168 Roma, Italy
| | - Elisa Palazzari
- Department of Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO)—IRCCS, 33081 Aviano, Italy
| | - Emanuele Damiano Luca Urso
- General Surgery 3, Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padova, 35128 Padova, Italy
| | - Salvatore Pucciarelli
- General Surgery 3, Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padova, 35128 Padova, Italy
| | - Gaya Spolverato
- General Surgery 3, Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padova, 35128 Padova, Italy
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Steinke J, Jordan C, Rossides S, Minnaar H, Yu J, Franklin A, Rockall T, Dhadda AS, Andrew Hunter I, Mills J, Chadwick E, Silverman R, Folkesson J, Radu C, Myint AS, Stewart AJ. Planned organ preservation for elderly patients with rectal cancer using short course radiotherapy and a contact brachytherapy boost-an International multi-institution analysis. Clin Transl Radiat Oncol 2023; 39:100580. [PMID: 36686563 PMCID: PMC9852541 DOI: 10.1016/j.ctro.2023.100580] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/06/2023] [Accepted: 01/09/2023] [Indexed: 01/13/2023] Open
Abstract
Background and purpose The use of external beam radiotherapy (EBRT) and contact X-Ray brachytherapy (CXB) is emerging as an effective alternative in patients with early stage rectal cancer with the intent of organ preservation (OP). Short course radiotherapy (SCRT) is an alternative EBRT schedule for patients not fit for chemotherapy or for longer courses of EBRT. There are no multicentre studies that have reported on the outcomes of SCRT with a CXB boost, therefore we present these from patients from centres from the UK and Sweden. Materials and methods From the Guildford Colorectal Database or local databases, 258 patients who underwent SCRT and CXB with the intent of OP from five centres treated between 2007 and 2019 were identified. Response and survival data was analysed and presented. Results With a median age of 81, 226 patients were treated with radiotherapy alone (RTA) and 32 immediately after local excision (ILE). Median follow-up was 24 months. 70% and 97% of patients in the RTA and ILE groups respectively had a complete clinical response (cCR) after SCRT with CXB. Of those, local relapse was seen in 16% of the RTA and 3% of the ILE group. Median survival was 40 months after CXB in the RTA and 52 months in the ILE group. 94% of patients remained stoma-free to the point of latest follow-up. Conclusion This data suggests that CXB when combined with SCRT, in a mainly elderly and comorbid population, provides good palliation with stoma-avoidance. Oncological outcomes compare with previously published work. A greater focus is required on quality of life outcomes after OP.
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Affiliation(s)
- Jacqueline Steinke
- St Luke’s Cancer Centre, Royal Surrey County Hospital, Guildford, England, United Kingdom,University of Surrey, Guildford, England, United Kingdom,Corresponding author at: Minimal Access Therapy Training Unit, The Leggett Building, Daphne Jackson Road, Guildford, Surrey GU2 7WG, United Kingdom.
| | - Chloe Jordan
- St Luke’s Cancer Centre, Royal Surrey County Hospital, Guildford, England, United Kingdom
| | - Savvas Rossides
- St Luke’s Cancer Centre, Royal Surrey County Hospital, Guildford, England, United Kingdom
| | - Helen Minnaar
- St Luke’s Cancer Centre, Royal Surrey County Hospital, Guildford, England, United Kingdom
| | - Jimmy Yu
- St Luke’s Cancer Centre, Royal Surrey County Hospital, Guildford, England, United Kingdom
| | - Adrian Franklin
- St Luke’s Cancer Centre, Royal Surrey County Hospital, Guildford, England, United Kingdom
| | - Tim Rockall
- St Luke’s Cancer Centre, Royal Surrey County Hospital, Guildford, England, United Kingdom,University of Surrey, Guildford, England, United Kingdom
| | - Amandeep Singh Dhadda
- Queens Centre for Oncology and Haematology, Castle Hill Hospital, Hull, England, United Kingdom
| | - Iain Andrew Hunter
- Queens Centre for Oncology and Haematology, Castle Hill Hospital, Hull, England, United Kingdom
| | - Jamie Mills
- Nottingham City Hospital, Nottingham, England, United Kingdom
| | - Eliot Chadwick
- Nottingham City Hospital, Nottingham, England, United Kingdom
| | | | - Joakim Folkesson
- Uppsala University Hospital, Akademiska sjukhuset S-751 85, Uppsala, Sweden
| | - Calin Radu
- Uppsala University Hospital, Akademiska sjukhuset S-751 85, Uppsala, Sweden
| | - Arthur Sun Myint
- Clatterbridge Cancer Centre, Liverpool, England, United Kingdom,University of Liverpool, Liverpool, England, United Kingdom
| | - Alexandra J. Stewart
- St Luke’s Cancer Centre, Royal Surrey County Hospital, Guildford, England, United Kingdom,University of Surrey, Guildford, England, United Kingdom
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Chen PJ, Wang L, Sun TT, Yao YF, Peng YF, Zhao J, Zhan TC, Leng J, Cai Y, Li YH, Zhang XY, Sun YS, Li ZW, Wang WH, Wu AW. Total neoadjuvant treatment for MRI-stratified high-risk rectal cancer: a single-center, single-arm, prospective Phase II trial (PKUCH-R02). Gastroenterol Rep (Oxf) 2023; 11:goad017. [PMID: 37082450 PMCID: PMC10112957 DOI: 10.1093/gastro/goad017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 02/22/2023] [Accepted: 03/16/2023] [Indexed: 04/22/2023] Open
Abstract
Background Induction chemotherapy combined with neoadjuvant chemoradiotherapy has been recommended for patients with high-risk, locally advanced rectal cancer. However, the benefit of more intensive total neoadjuvant treatment (TNT) is unknown. This study aimed to assess the safety and efficacy of induction chemotherapy combined with chemoradiotherapy and consolidation chemotherapy for magnetic resonance imaging-stratified high-risk rectal cancer. Methods This was a single-center, single-arm, prospective Phase II trial in Peking University Cancer Hospital (Beijing, China). Patients received three cycles of induction oxaliplatin and capecitabine (CapeOX) followed by chemoradiotherapy and two cycles of consolidation CapeOX. The primary end point was adverse event rate and the second primary end points were 3-year disease-free survival rate, completion of TNT, and pathological downstaging rate. Results Between August 2017 and August 2018, 68 rectal cancer patients with at least one high risk factor (cT3c/3d/T4a/T4b, cN2, mesorectal fascia involvement, or extramural venous invasion involvement) were enrolled. The overall compliance of receiving the entire treatment was 88.2% (60/68). All 68 patients received induction chemotherapy, 65 received chemoradiotherapy, and 61 received consolidation chemotherapy. The Grade 3-4 adverse event rate was 30.8% (21/68). Nine patients achieved clinical complete response and then watch and wait. Five patients (7.4%) developed distant metastasis during TNT and received palliative chemotherapy. Fifty patients underwent surgical resection. The complete response rate was 27.9%. After a median follow-up of 49.2 months, the overall 3-year disease-free survival rate was 69.7%. Conclusions For patients with high-risk rectal cancer, this TNT regimen can achieve favorable survival and complete response rates but with high toxicity. However, it is necessary to pay attention to the possibility of distant metastasis during the long treatment period.
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Affiliation(s)
| | | | | | - Yun-Feng Yao
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Cancer Unit III, Peking University Cancer Hospital & Institute, Beijing, P. R. China
| | - Yi-Fan Peng
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Cancer Unit III, Peking University Cancer Hospital & Institute, Beijing, P. R. China
| | - Jun Zhao
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Cancer Unit III, Peking University Cancer Hospital & Institute, Beijing, P. R. China
| | - Tian-Cheng Zhan
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Cancer Unit III, Peking University Cancer Hospital & Institute, Beijing, P. R. China
| | - Jia–Hua Leng
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Cancer Unit III, Peking University Cancer Hospital & Institute, Beijing, P. R. China
| | - Yong Cai
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing, P. R. China
| | - Yong-Heng Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing, P. R. China
| | - Xiao-Yan Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Radiology, Peking University Cancer Hospital & Institute, Beijing, P. R. China
| | - Ying-Shi Sun
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Radiology, Peking University Cancer Hospital & Institute, Beijing, P. R. China
| | - Zhong-Wu Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Pathology, Peking University Cancer Hospital & Institute, Beijing, P. R. China
| | - Wei-Hu Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing, P. R. China
| | - Ai-Wen Wu
- Corresponding author. Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Cancer Unit III, Peking University Cancer Hospital & Institute, Beijing Cancer Hospital, #52, Fucheng Road, Haidian District, Beijing 100142, P. R. China. ; Tel: +86-10-88196086
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Kim B, Lee CM, Jang JK, Kim J, Lim SB, Kim AY. Deep learning-based imaging reconstruction for MRI after neoadjuvant chemoradiotherapy for rectal cancer: effects on image quality and assessment of treatment response. ABDOMINAL RADIOLOGY (NEW YORK) 2023; 48:201-210. [PMID: 36261505 DOI: 10.1007/s00261-022-03701-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 10/01/2022] [Accepted: 10/03/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE To investigate the effects of deep learning-based imaging reconstruction (DLR) on the image quality of MRI of rectal cancer after chemoradiotherapy (CRT), and its accuracy in diagnosing pathological complete responses (pCR). METHODS We included 39 patients (men: women, 21:18; mean age ± standard deviation, 59.1 ± 9.7 years) with mid-to-lower rectal cancer who underwent a long-course of CRT and high-resolution rectal MRIs between January 2020 and April 2021. Axial T2WI was reconstructed using the conventional method (MRIconv) and DLR with two different noise reduction factors (MRIDLR30 and MRIDLR50). The signal-to-noise ratio (SNR) of the tumor was measured. Two experienced radiologists independently made a blind assessment of the complete response on MRI. The sensitivity and specificity for pCR were analyzed using a multivariable logistic regression analysis with generalized estimating equations. RESULTS Thirty-four patients did not have a pCR whereas five (12.8%) had pCR. Compared with the SNR of MRIconv (mean ± SD, 7.94 ± 1.92), MRIDLR30 and MRIDLR50 showed higher SNR (9.44 ± 2.31 and 11.83 ± 3.07, respectively) (p < 0.001). Compared to MRIconv, MRIDLR30 and MRIDLR50 showed significantly higher specificity values (p < 0.036) while the sensitivity values were not significantly different (p > 0.301). The sensitivity and specificity for pCR were 48.9% and 80.8% for MRIconv; 48.9% and 88.2% for MRIDLR30; and 38.8% and 86.7% for MRIDLR50, respectively. CONCLUSION DLR produced MR images with higher resolution and SNR. The specificity of MRI for identification of pCR was significantly higher with DLR than with conventional MRI.
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Affiliation(s)
- Bona Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Chul-Min Lee
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.,Department of Radiology, Hanyang University Medical Center, 222-1, Wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea
| | - Jong Keon Jang
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
| | - Jihun Kim
- Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Seok-Byung Lim
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Ah Young Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
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Cerdán-Santacruz C, Vailati BB, São Julião GP, Habr-Gama A, Perez RO. Local tumor regrowth after clinical complete response following neoadjuvant therapy for rectal cancer: what happens when organ preservation falls short. Tech Coloproctol 2023; 27:1-9. [PMID: 35986804 DOI: 10.1007/s10151-022-02654-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 06/09/2022] [Indexed: 01/12/2023]
Abstract
Organ preservation strategies, especially watch and wait, after neoadjuvant treatment in locally advanced rectal cancer, have become topics that generate significant interest, for both patients and clinicians. The obvious advantage of these strategies is the avoidance of surgery with its associated risks and functional consequences. Over time, it has become evident that these strategies offer acceptable safety in oncological terms and, in most patients, allows preservation of the rectum without harming patients in terms of distant metastasis or survival. However, there is a small group of patients in whom the tumor returns after an initially diagnosed clinical complete response; patients with local tumor regrowth. The main threat in these patients is not simply local disease, which can be successfully managed in most cases, but the possible effects it may have on distant metastases. The pathophysiology of the phenomenon of local tumor regrowth is not well known and, therefore, strategies to minimize possible impact on survival are not well defined. Our aim is to review key issues in this subgroup that pose a substantial threat to the safety and viability of organ-preserving and watch-and-wait strategies. We also explore possible pathophysiologic explanations and future directions and perspectives that may improve both local and systemic disease control.
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Affiliation(s)
- C Cerdán-Santacruz
- Colorectal Surgery, Hospital Universitario de la Princesa, Madrid, Spain
| | - B B Vailati
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil
- Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
- Angelita and Joaquim Gama Institute, Praça Amadeu Amaral 47, con. 111, São Paulo, 01327-904, Brazil
| | - G P São Julião
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil
- Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
- Angelita and Joaquim Gama Institute, Praça Amadeu Amaral 47, con. 111, São Paulo, 01327-904, Brazil
| | - A Habr-Gama
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil
- Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
- Angelita and Joaquim Gama Institute, Praça Amadeu Amaral 47, con. 111, São Paulo, 01327-904, Brazil
| | - R O Perez
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brazil.
- Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil.
- Angelita and Joaquim Gama Institute, Praça Amadeu Amaral 47, con. 111, São Paulo, 01327-904, Brazil.
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Fernandez LM, São Julião GP, Renehan AG, Beets GL, Papoila AL, Vailati BB, Bahadoer RR, Kranenbarg EMK, Roodvoets AGH, Figueiredo NL, Van De Velde CJH, Habr-Gama A, Perez RO. The Risk of Distant Metastases in Patients With Clinical Complete Response Managed by Watch and Wait After Neoadjuvant Therapy for Rectal Cancer: The Influence of Local Regrowth in the International Watch and Wait Database. Dis Colon Rectum 2023; 66:41-49. [PMID: 36515514 DOI: 10.1097/dcr.0000000000002494] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Nearly 30% of patients with rectal cancer develop local regrowth after initial clinical complete response managed by watch and wait. These patients might be at higher risk for distant metastases. OBJECTIVE This study aimed to investigate risk factors for distant metastases using time-dependent analyses. DESIGN Data from an international watch and wait database were retrospectively reviewed. Cox regression analysis was used to determine risk factors for worse distant metastases-free survival. Conditional survival modeling was used to investigate the impact of risk factors on the development of distant metastases. SETTING Retrospective, multicenter database. PATIENTS A total of 793 patients (47 institutions) with rectal cancer and clinical complete response to neoadjuvant treatment from the International Watch & Wait Database were included. MAIN OUTCOME MEASURES Distant metastases-free survival. RESULTS Of the 793 patients managed with watch and wait (median follow-up 55.2 mo)' 85 patients (10.7%) had distant metastases. Fifty-one of 85 patients (60%) had local regrowth at any time. Local regrowth was an independent factor associated with worse distant metastases-free survival in the multivariable model. Using conditional estimates, patients with local regrowth without distant metastases for 5 years (from decision to watch and wait) remained at higher risk for development of distant metastases for 1 subsequent year compared to patients without local regrowth (5-year conditional distant metastases-free survival 94.9% vs 98.4%). LIMITATIONS Lack of information on adjuvant chemotherapy, salvage surgery for local regrowth, and heterogeneity of individual surveillance/follow-up strategies used may have affected results. CONCLUSIONS In patients with clinical complete response managed by watch and wait, development of local regrowth at any time is a risk factor for distant metastases. The risk of distant metastases remains higher for 5 years after development of local regrowth. See Video Abstract at http://links.lww.com/DCR/C53. EL RIESGO DE METSTASIS A DISTANCIA EN PACIENTES CON RESPUESTA CLNICA COMPLETA MANEJADA POR WATCH AND WAIT DESPUS DE LA TERAPIA NEOADYUVANTE PARA EL CNCER DE RECTO LA INFLUENCIA DEL NUEVO CRECIMIENTO LOCAL EN LA BASE DE DATOS INTERNACIONAL WATCH AND WAIT ANTECEDENTES:Casi el 30 % de los pacientes con cáncer de recto desarrollan un nuevo crecimiento local después de la respuesta clínica completa inicial manejada por watch and wait. Estos pacientes podrían tener un mayor riesgo de metástasis a distancia.OBJETIVO:Investigar los factores de riesgo de metástasis a distancia mediante análisis dependientes del tiempo.DISEÑO:Se revisó retrospectivamente los datos de la base de datos internacional de Watch and Wait. Se utilizó el análisis de regresión de Cox para determinar los factores de riesgo de peor sobrevida libre de metástasis a distancia. Se utilizó un modelo de sobrevida condicional para investigar el impacto de los factores de riesgo en el desarrollo de metástasis a distancia. El tiempo transcurrido hasta el evento se calculó utilizando la fecha de decisión para watch and wait y la fecha del nuevo crecimiento local para el diagnóstico de metástasis a distancia.ESCENARIOBase de datos multicéntrica retrospectiva.PACIENTES:Se incluyeron un total de 793 pacientes (47 instituciones) con cáncer de recto y respuesta clínica completa al tratamiento neoadyuvante de la base de datos internacional de Watch and Wait.PRINCIPALES MEDIDAS DE RESULTADO:Desarrollo de metástasis a distancia.RESULTADOS:De los 793 pacientes tratados con watch and wait (mediana de seguimiento de 55,2 meses), 85 (10,7%) tenían metástasis a distancia. 51 de 85 (60%) tuvieron recrecimiento local en algún momento. El recrecimiento local fue un factor independiente asociado a una peor supervivencia libre de metástasis a distancia en el modelo multivariable. Además, al usar estimaciones condicionales, los pacientes con recrecimiento local sin metástasis a distancia durante 5 años (desde la decisión de watch and wait) permanecieron en mayor riesgo de desarrollar metástasis a distancia durante un año subsiguiente en comparación con los pacientes sin recrecimiento local (sobrevida libre de metástasis a distancia a 5 años: recrecimiento local 94,9% frente a no recrecimiento local 98,4%).LIMITACIONES:La falta de información relacionada con el uso de quimioterapia adyuvante, las características específicas de la cirugía de rescate para el nuevo crecimient o local y la heterogeneidad de las estrategias individuales de vigilancia/seguimiento utilizadas pueden haber afectado los resultados observados.CONCLUSIONES:En pacientes con respuesta clínica completa manejados por Watch and Wait, el desarrollo de recrecimiento local en cualquier momento es un factor de riesgo para metástasis a distancia. El riesgo de metástasis a distancia sigue siendo mayor durante 5 años después del desarrollo de un nuevo crecimiento local. Consulte Video Resumen en http://links.lww.com/DCR/C53. (Traducción-Dr. Felipe Bellolio).
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Affiliation(s)
- Laura M Fernandez
- Colorectal Surgery, Digestive Department, Champalimaud Foundation, Lisbon, Portugal
| | - Guilherme P São Julião
- Colorectal Surgery Division, Angelita and Joaquim Gama Institute, São Paulo, Brazil
- Department of Surgical Oncology, Colorectal Surgery Division, Hospital Beneficencia Portuguesa, São Paulo, Brazil
- Colorectal Surgery Division, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Andrew G Renehan
- Manchester Cancer Research Centre, National Institute of Health and Research Manchester Biomedical Research Centre, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, United Kingdom
- Colorectal and Peritoneal Oncology Centre, The Christie National Health Service Foundation Trust, Manchester, United Kingdom
| | - Geerard L Beets
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
- GROW School for Oncology and Developmental Biology, Maastricht University, the Netherlands
| | - Ana L Papoila
- NOVA Medical School, Faculdade de Ciências Médicas (NMS|FCM), Lisbon, Portugal
| | - Bruna B Vailati
- Colorectal Surgery Division, Angelita and Joaquim Gama Institute, São Paulo, Brazil
- Department of Surgical Oncology, Colorectal Surgery Division, Hospital Beneficencia Portuguesa, São Paulo, Brazil
- Colorectal Surgery Division, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Renu R Bahadoer
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Annet G H Roodvoets
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Nuno L Figueiredo
- Colorectal Surgery, Digestive Department, Champalimaud Foundation, Lisbon, Portugal
- Colorectal Surgery, Hospital Lusiadas, Lisbon, Portugal
| | - Cornelis J H Van De Velde
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Angelita Habr-Gama
- Colorectal Surgery Division, Angelita and Joaquim Gama Institute, São Paulo, Brazil
- Colorectal Surgery Division, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
- University of São Paulo School of Medicine, São Paulo, Brazil
| | - Rodrigo O Perez
- Colorectal Surgery Division, Angelita and Joaquim Gama Institute, São Paulo, Brazil
- Department of Surgical Oncology, Colorectal Surgery Division, Hospital Beneficencia Portuguesa, São Paulo, Brazil
- Colorectal Surgery Division, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
- Ludwig Institute for Cancer Research, São Paulo Branch, Brazil
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Lu S, Liu Z, Wang Y, Meng Y, Peng R, Qu R, Zhang Z, Fu W, Wang H. A novel prediction model for pathological complete response based on clinical and blood parameters in locally advanced rectal cancer. Front Oncol 2022; 12:932853. [PMID: 36505836 PMCID: PMC9727231 DOI: 10.3389/fonc.2022.932853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 10/19/2022] [Indexed: 11/24/2022] Open
Abstract
Background The aim of this study was to investigate whether clinical and blood parameters can be used for predicting pathological complete response (pCR) to neoadjuvant chemoradiotherapy (nCRT) in patients with locally advanced rectal cancer (LARC). Methods We retrospectively enrolled 226 patients with LARC [allocated in a 7:3 ratio to a training (n = 158) or validation (n = 68) cohort] who received nCRT before radical surgery. Backward stepwise logistic regression was performed to identify clinical and blood parameters associated with achieving pCR. Models based on clinical parameters (CP), blood parameters (BP), and clinical-blood parameters (CBP) were constructed for comparison with previously reported Tan's model. The performance of the four models was evaluated by receiver operating characteristic (ROC) curve analysis, calibration, and decision curve analysis (DCA) in both cohorts. A dynamic nomogram was constructed for the presentation of the best model. Results The CP and BP models based on multivariate logistic regression analysis showed that interval, Grade, CEA and fibrinogen-albumin ratio index (FARI), sodium-to-globulin ratio (SGR) were the independent clinical and blood predictors for achieving pCR, respectively. The area under the ROC curve of the CBP model achieved a score of 0.818 and 0.752 in both cohorts, better than CP (0.762 and 0.589), BP (0.695 and 0.718), Tan (0.738 and 0.552). CBP also showed better calibration and DCA than other models in both cohorts. Moreover, CBP revealed significant improvement compared with other models in training cohort (P < 0.05), and CBP showed significant improvement compared with CP and Tan's model in validation cohort (P < 0.05). Conclusion We demonstrated that CBP predicting model have potential in predicting pCR to nCRT in patient with LARC.
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Affiliation(s)
- Siyi Lu
- Department of General Surgery, Peking University Third Hospital, Beijing, China
| | - Zhenzhen Liu
- Department of Thoracic Surgery, Beijing Jishuitan Hospital, Beijing, China
| | - Yuxia Wang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Yan Meng
- Department of General Surgery, Peking University Third Hospital, Beijing, China
| | - Ran Peng
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Ruize Qu
- Department of General Surgery, Peking University Third Hospital, Beijing, China
| | - Zhipeng Zhang
- Department of General Surgery, Peking University Third Hospital, Beijing, China,*Correspondence: Hao Wang, ; Wei Fu, ; Zhipeng Zhang,
| | - Wei Fu
- Department of General Surgery, Peking University Third Hospital, Beijing, China,Cancer Center, Peking University Third Hospital, Beijing, China,*Correspondence: Hao Wang, ; Wei Fu, ; Zhipeng Zhang,
| | - Hao Wang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, China,Cancer Center, Peking University Third Hospital, Beijing, China,*Correspondence: Hao Wang, ; Wei Fu, ; Zhipeng Zhang,
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58
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Asoglu O, Bulut A, Aliyev V, Piozzi GN, Guven K, Bakır B, Goksel S. Chemoradiation and consolidation chemotherapy for rectal cancer provides a high rate of organ preservation with a very good long-term oncological outcome: a single-center cohort series. World J Surg Oncol 2022; 20:358. [PMCID: PMC9646475 DOI: 10.1186/s12957-022-02816-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/27/2022] [Indexed: 11/11/2022] Open
Abstract
Abstract
Aim
To report long-term oncological outcomes and organ preservation rate with a chemoradiotherapy-consolidation chemotherapy (CRT-CNCT) treatment for locally advanced rectal cancer (LARC).
Method
Retrospective analysis of prospectively maintained database was performed. Oncological outcomes of mid-low LARC patients (n=60) were analyzed after a follow-up of 63 (50–83) months. Patients with clinical complete response (cCR) were treated with the watch-and-wait (WW) protocol. Patients who could not achieve cCR were treated with total mesorectal excision (TME) or local excision (LE).
Results
Thirty-nine (65%) patients who achieved cCR were treated with the WW protocol. TME was performed in 15 (25%) patients and LE was performed in 6 (10%) patients. During the follow-up period, 10 (25.6%) patients in the WW group had regrowth (RG) and 3 (7.7%) had distant metastasis (DM). Five-year overall survival (OS) and disease-free survival (DFS) were 90.1% and 71.6%, respectively, in the WW group. Five-year OS and DFS were 94.9% (95% CI: 88–100%) and 80% (95% CI: 55.2–100%), respectively, in the RG group. For all patients (n=60), 5-year TME-free DFS was 57.3% (95% CI: 44.3–70.2%) and organ preservation-adapted DFS was 77.5% (95% CI: 66.4–88.4%). For the WW group (n=39), 5-year TME-free DFS was 77.5% (95% CI: 63.2–91.8%) and organ preservation-adapted DFS was 85.0% (95% CI: 72.3–97.8%).
Conclusion
CRT-CNCT provides cCR as high as 2/3 of LARC patients. Regrowths, developed during follow-up, can be successfully salvaged without causing oncological disadvantage if strict surveillance is performed.
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59
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Kim S, Huh JW, Lee WY, Yun SH, Kim HC, Cho YB, Park Y, Shin JK. Correlation between T stage and lymph node metastasis in rectal cancer treated with preoperative chemoradiotherapy. Ther Adv Med Oncol 2022; 14:17588359221132620. [PMID: 36312818 PMCID: PMC9597009 DOI: 10.1177/17588359221132620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 09/27/2022] [Indexed: 11/07/2022] Open
Abstract
Background: Depth of tumor is a risk factor for lymph node metastasis in rectal cancer,
but impact of yield pathologic T (ypT) stage on lymph node involvement in
rectal cancer remains unclear. The aim of this study was to evaluate the
correlation between ypT stage and lymph node metastasis. Methods: From January 2010 to December 2015, 602 patients who were diagnosed with
rectal cancer and treated with neoadjuvant chemoradiotherapy (CRT) followed
by radical operation were reviewed retrospectively. The correlations between
ypT stage and lymph node status and survival were evaluated. Results: On pathology, 179 (29.7%) patients exhibited regional lymph node metastasis.
Lymph node metastasis was seen in 8.5% of ypT0 patients, 20% of ypT1, 18.4%
of ypT2, 47.5% of ypT3, and 27.3% of ypT4. Positive lymph node metastasis
was correlated with ypT stage. In addition, the difference of lymph node
metastasis in ypT stage subgroups was statistically significant
(p < 0.001). Five-year disease-free survival was
significantly different in the ypT stage subgroups (88.7%
versus 86.7% versus 82.6%
versus 64.7% versus 72.7%,
p < 0.001), as was 5-year overall survival (96.2%
versus 90.0% versus 95.8%
versus 80.0% versus 90.9%,
p < 0.001). Conclusion: YpT stage is associated with lymph node metastasis in rectal cancer treated
with neoadjuvant CRT and radical operation, and ypT0 patients exhibited an
8.5% lymph node metastasis rate. Therefore, the decision for local excision
or the watch-and-wait strategy for rectal cancer treated with neoadjuvant
CRT and predicted to show a pathologic complete response should be
considered with caution.
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Affiliation(s)
- Seijong Kim
- Department of Surgery, Samsung Medical Center,
Sungkyunkwan University School of Medicine, Seoul, Korea
| | | | - Woo Yong Lee
- Department of Surgery, Samsung Medical Center,
Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Hyeon Yun
- Department of Surgery, Samsung Medical Center,
Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Cheol Kim
- Department of Surgery, Samsung Medical Center,
Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Beom Cho
- Department of Surgery, Samsung Medical Center,
Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoonah Park
- Department of Surgery, Samsung Medical Center,
Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Kyong Shin
- Department of Surgery, Samsung Medical Center,
Sungkyunkwan University School of Medicine, Seoul, Korea
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60
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Wyatt J, Powell S, Ahmed S. Watch and Wait in Rectal Cancer After a Complete Response to Chemoradiotherapy – Is It Safe and Are We Doing Enough? Clin Oncol (R Coll Radiol) 2022. [DOI: 10.1016/j.clon.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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61
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Costa B, Fernandez LM, Parés O, Rio-Tinto R, Santiago I, Castillo-Martin M, Parvaiz A, Fior R. Zebrafish Avatars of rectal cancer patients validate the radiosensitive effect of metformin. Front Oncol 2022; 12:862889. [PMID: 36249066 PMCID: PMC9554544 DOI: 10.3389/fonc.2022.862889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 08/23/2022] [Indexed: 11/13/2022] Open
Abstract
Neoadjuvant chemoradiation (nCRT) followed by surgery represents the standard of care in patients with locally advanced rectal cancer. Increasing radiotherapy (RT) doses and chemotherapy cycles with 5FU have been associated with increased rates of complete response, however these strategies imply significant toxicity. In the last years, epidemiologic findings have demonstrated that metformin is associated with significantly higher rates of pathological complete response to nCRT. Also, pre-clinical studies using cell lines provide evidence for the radiosensitive effect of metformin. However, no studies have been performed using rectal cancer patient samples to test this radiosensitive effect of metformin and compared it to the standard 5FU. Here, we designed an experimental study to compare both radiosensitizers in the zebrafish xenograft model (zAvatar), using rectal cancer surgical specimens and diagnostic biopsies. Patient zAvatars confirmed that metformin has indeed a powerful in vivo radiosensitizer effect, similar to 5FU. Our work confirms that metformin constitutes a promising less toxic alternative to the standard 5FU, which could be game changing in elderly/frail patients to optimize tumor regression.
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Affiliation(s)
- Bruna Costa
- Champalimaud Research, Champalimaud Foundation, Lisbon, Portugal
- *Correspondence: Bruna Costa, ; Laura M. Fernandez, ; Rita Fior,
| | - Laura M. Fernandez
- Colorectal Surgery Department, Champalimaud Clinical Centre, Champalimaud Foundation, Lisbon, Portugal
- *Correspondence: Bruna Costa, ; Laura M. Fernandez, ; Rita Fior,
| | - Oriol Parés
- Radiation Oncology Department, Champalimaud Clinical Centre, Champalimaud Foundation, Lisbon, Portugal
| | - Ricardo Rio-Tinto
- Gastroenterology Department, Champalimaud Clinical Centre, Champalimaud Foundation, Lisbon, Portugal
| | - Inês Santiago
- Radiology Department, Champalimaud Clinical Centre, Champalimaud Foundation, Lisbon, Portugal
| | - Mireia Castillo-Martin
- Pathology Service, Champalimaud Clinical Centre, Champalimaud Foundation, Lisbon, Portugal
| | - Amjad Parvaiz
- Colorectal Surgery Department, Champalimaud Clinical Centre, Champalimaud Foundation, Lisbon, Portugal
| | - Rita Fior
- Champalimaud Research, Champalimaud Foundation, Lisbon, Portugal
- *Correspondence: Bruna Costa, ; Laura M. Fernandez, ; Rita Fior,
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Chen M, Lin H, Zhang J, Pang X, Fan X, Luo S, Liu Z, Hu H, Lai S, Hou Y, Kang L, Huang L. Presence and clinical significance of acellular mucin pools in resected rectal cancer with pathological complete response after preoperative chemoradiotherapy. Histopathology 2022; 81:569-576. [DOI: 10.1111/his.14795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 07/25/2022] [Accepted: 08/06/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Mian Chen
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat‐sen University 510655 Guangzhou Guangdong China
- Guangdong Institute of Gastroenterology 510655 Guangzhou Guangdong China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat‐sen University 510655 Guangzhou Guangdong China
| | - Hongcheng Lin
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat‐sen University 510655 Guangzhou Guangdong China
- Guangdong Institute of Gastroenterology 510655 Guangzhou Guangdong China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat‐sen University 510655 Guangzhou Guangdong China
| | - Jianwei Zhang
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat‐sen University 510655 Guangzhou Guangdong China
- Department of Medical Oncology, The Sixth Affiliated Hospital, Sun Yat‐sen University 510655 Guangzhou Guangdong China
| | - Xiaolin Pang
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat‐sen University 510655 Guangzhou Guangdong China
- Department of Radiation Oncology, The Sixth Affiliated Hospital, Sun Yat‐sen University 510655 Guangzhou Guangdong China
| | - Xinjuan Fan
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat‐sen University 510655 Guangzhou Guangdong China
- Department of Pathology, The Sixth Affiliated Hospital, Sun Yat‐sen University 510655 Guangzhou Guangdong China
| | - Shuangling Luo
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat‐sen University 510655 Guangzhou Guangdong China
- Guangdong Institute of Gastroenterology 510655 Guangzhou Guangdong China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat‐sen University 510655 Guangzhou Guangdong China
| | - Zhanzhen Liu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat‐sen University 510655 Guangzhou Guangdong China
- Guangdong Institute of Gastroenterology 510655 Guangzhou Guangdong China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat‐sen University 510655 Guangzhou Guangdong China
| | - Huanxin Hu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat‐sen University 510655 Guangzhou Guangdong China
- Guangdong Institute of Gastroenterology 510655 Guangzhou Guangdong China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat‐sen University 510655 Guangzhou Guangdong China
| | - Sicong Lai
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat‐sen University 510655 Guangzhou Guangdong China
- Guangdong Institute of Gastroenterology 510655 Guangzhou Guangdong China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat‐sen University 510655 Guangzhou Guangdong China
| | - Yujie Hou
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat‐sen University 510655 Guangzhou Guangdong China
- Guangdong Institute of Gastroenterology 510655 Guangzhou Guangdong China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat‐sen University 510655 Guangzhou Guangdong China
| | - Liang Kang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat‐sen University 510655 Guangzhou Guangdong China
- Guangdong Institute of Gastroenterology 510655 Guangzhou Guangdong China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat‐sen University 510655 Guangzhou Guangdong China
| | - Liang Huang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat‐sen University 510655 Guangzhou Guangdong China
- Guangdong Institute of Gastroenterology 510655 Guangzhou Guangdong China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat‐sen University 510655 Guangzhou Guangdong China
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63
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Ghadimi M, Rödel C, Hofheinz R, Flebbe H, Grade M. Multimodal Treatment of Rectal Cancer. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:570-580. [PMID: 35791271 PMCID: PMC9743213 DOI: 10.3238/arztebl.m2022.0254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 03/03/2022] [Accepted: 06/14/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Colorectal cancer is one of the three most common types of cancer in Germany. Approximately 30% of these cancers are located in the rectum, corresponding to about 18 000 new cases per year. METHODS This review is based on publications retrieved by a selective search in the PubMed database, including current guidelines and recommendations. RESULTS Specialized imaging, particularly magnetic resonance imaging, is essential for treatment planning. In very early stages of this disease, tumors without risk factors can be excised locally. Otherwise, radical surgical resection with lymphadenectomy remains the standard treatment, and can be performed either minimally invasive or open. At present, neoadjuvant treatment plans are evolving in the direction of total neoadjuvant therapy. In addition, recent studies investigate whether the improved efficacy of neoadjuvant therapy might now enable patients with a complete clinical remission to be spared from surgical resection (organ-preserving watch-and-wait strategy). CONCLUSION The treatment of rectal cancer is a prime example of an interdisciplinary, multimodal approach. In the past, the focus was mainly on improving oncologic outcomes; at present, increasing attention is being devoted to the patients' quality of life as well and the functional aspects of the various modes of treatment.
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Affiliation(s)
- Michael Ghadimi
- Department of General, Visceral and Pediatric Surgery, University Medical Center Göttingen
| | - Claus Rödel
- Department of Radiotherapy and Oncology, Goethe University Frankfurt am Main
| | - Ralf Hofheinz
- Department of Medical Hematology and Oncology, University Hospital Mannheim, University of Heidelberg
| | - Hannah Flebbe
- Department of General, Visceral and Pediatric Surgery, University Medical Center Göttingen
| | - Marian Grade
- Department of General, Visceral and Pediatric Surgery, University Medical Center Göttingen,*Universitätsmedizin Göttingen Klinik für Allgemein-, Viszeral- und Kinderchirurgie Robert-Koch-Strasse 40, D-37075 Göttingen, Germany
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64
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Cooper EA, Hodder RJ, Finlayson A, Filgate R, Coveney A, Balasuriya HD, Warner MW. Cost analysis of a watch-and-wait approach in patients with a complete clinical response to chemoradiotherapy for rectal cancer. ANZ J Surg 2022; 92:2956-2960. [PMID: 35855528 DOI: 10.1111/ans.17914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 06/29/2022] [Accepted: 07/02/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND There is increasing interest in the watch-and-wait approach for patients with rectal cancer who have had a complete clinical response following neoadjuvant long course chemoradiotherapy. This study is a cost analysis of expenditure on patients in the watch-and-wait program versus patients who underwent standard rectal resection followed by routine surveillance. METHODS Data were prospectively collated and retrospectively analysed in all patients who presented with rectal cancer from January 2016 to January 2018 at Sir Charles Gairdner Hospital, Perth, Western Australia. Software developed by the North Metropolitan Health Service was used to capture comprehensive data to calculate the in-hospital expenditure for an individual patient throughout their treatment journey. RESULTS For a patient enrolled in the watch-and-wait pathway, the total cost of surveillance over a 5-year period was $45 246. This was compared with the cost of an ultra-low anterior resection/loop ileostomy/closure of loop and routine postoperative surveillance which came to a total of $87 473. While a patient who had an abdominoperineal resection followed by routine 5-year surveillance had an expenditure of $82 290. CONCLUSION There is growing evidence that the watch-and-wait strategy is a valid management option. In the cost-conscious environment of the current health care system, the watch-and-wait pathway is a cost-effective and economically advantage treatment.
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Affiliation(s)
- Edward A Cooper
- Department of Colorectal Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Rupert J Hodder
- Department of Colorectal Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Department of Surgery, Curtin University, Perth, Western Australia, Australia
| | - Andrew Finlayson
- Department of Colorectal Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Rhys Filgate
- Department of Colorectal Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Andrew Coveney
- Department of Colorectal Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Hasitha Dinesh Balasuriya
- Department of Colorectal Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Michael W Warner
- Department of Colorectal Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
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65
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Balasuriya HD, Timon C, Entriken F, Neely D, Herron J, Tang C, Van Hazel G, Warner MW. Early results from implementation of a 'watch and wait' protocol for complete clinical response following chemoradiotherapy for rectal cancer. ANZ J Surg 2022; 92:2961-2967. [PMID: 35841184 DOI: 10.1111/ans.17915] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/15/2022] [Accepted: 07/03/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Neoadjuvant long course chemoradiotherapy (NLCRT) for rectal cancer can result in complete pathological response (pCR). In 2017, we started offering patients who had a complete clinical response (cCR), a choice between total mesorectal excision (TME) and an intensive surveillance or 'watch and wait' (W&W) program. We report the early outcomes of this prospective study. METHODS All patients undergoing NLCRT from 2017 to 2019 were included. All patients were restaged at 8 weeks, and those who had a cCR were offered TME or W&W. RESULTS Of 59 patients who underwent NLCRT, 55 had restaging. Eleven of these patients had a cCR (20%). Three chose to have TME and all had a pCR. Eight were enrolled in W&W. Two patients were diagnosed with local regrowth and underwent TME at 7 and 17 months after NLCRT. A further nine patients, who were surgically unfit or refused TME, and had an excellent response to NLCRT, but one that did not reach criteria for a cCR, were also managed with W&W. Of these, two patients developed regrowth with distant metastases. From 2017 to 2019, of the 17 patients who were managed with a W&W approach, 13 patients have remained regrowth free after a median of 28 (13-58) months of W&W. CONCLUSION Preliminary findings suggest management with W&W, following cCR, may be a safe alternative to TME. There have so far been no instances of distant failure, and those with cCR that had regrowth, were identified early and successfully managed with salvage TME.
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Affiliation(s)
- Hasitha D Balasuriya
- Department of Colorectal Surgery, John Hunter Hospital, Newcastle, New South Wales, Australia.,Department of Colorectal Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Charles Timon
- Department of Colorectal Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Fiona Entriken
- Department of Colorectal Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - David Neely
- Department of Colorectal Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - John Herron
- Department of Radiology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Colin Tang
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Guy Van Hazel
- Department of Medical Oncology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia
| | - Michael W Warner
- Department of Colorectal Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
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66
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Capelli G, Campi C, Bao QR, Morra F, Lacognata C, Zucchetta P, Cecchin D, Pucciarelli S, Spolverato G, Crimì F. 18F-FDG-PET/MRI texture analysis in rectal cancer after neoadjuvant chemoradiotherapy. Nucl Med Commun 2022; 43:815-822. [PMID: 35471653 PMCID: PMC9177153 DOI: 10.1097/mnm.0000000000001570] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 04/05/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Reliable markers to predict the response to neoadjuvant chemoradiotherapy (nCRT) in locally advanced rectal cancer (LARC) are lacking. We aimed to assess the ability of 18F-FDG PET/MRI to predict response to nCRT among patients undergoing curative-intent surgery. METHODS Patients with histological-confirmed LARC who underwent curative-intent surgery following nCRT and restaging with 18F-FDG PET/MRI were included. Statistical correlation between radiomic features extracted in PET, apparent diffusion coefficient (ADC) and T2w images and patients' histopathologic response to chemoradiotherapy using a multivariable logistic regression model ROC-analysis. RESULTS Overall, 50 patients were included in the study. A pathological complete response was achieved in 28.0% of patients. Considering second-order textural features, nine parameters showed a statistically significant difference between the two groups in ADC images, six parameters in PET images and four parameters in T2w images. Combining all the features selected for the three techniques in the same multivariate ROC curve analysis, we obtained an area under ROC curve of 0.863 (95% CI, 0.760-0.966), showing a sensitivity, specificity and accuracy at the Youden's index of 100% (14/14), 64% (23/36) and 74% (37/50), respectively. CONCLUSION PET/MRI texture analysis seems to represent a valuable tool in the identification of rectal cancer patients with a complete pathological response to nCRT.
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Affiliation(s)
- Giulia Capelli
- General Surgery 3, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova
| | | | - Quoc Riccardo Bao
- General Surgery 3, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova
| | - Francesco Morra
- Institute of Radiology, Department of Medicine, University of Padova
| | | | - Pietro Zucchetta
- Nuclear Medicine Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Diego Cecchin
- Nuclear Medicine Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Salvatore Pucciarelli
- General Surgery 3, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova
| | - Gaya Spolverato
- General Surgery 3, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova
| | - Filippo Crimì
- Institute of Radiology, Department of Medicine, University of Padova
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67
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Bulens PP, Smets L, Debucquoy A, Joye I, D'Hoore A, Wolthuis A, Debrun L, Dekervel J, Van Cutsem E, Dresen R, Vandecaveye V, Deroose CM, Sagaert X, Haustermans K. Nonoperative versus Operative Approach According to the Response to Neoadjuvant Chemoradiotherapy for Rectal Cancer: A Prospective Cohort Study. Clin Transl Radiat Oncol 2022; 36:113-120. [PMID: 35993092 PMCID: PMC9382364 DOI: 10.1016/j.ctro.2022.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 07/22/2022] [Indexed: 11/29/2022] Open
Abstract
Watch-and-wait patients after chemoradiotherapy for rectal cancer have good functional outcome. No survival differences were seen between patients undergoing surgery versus patients in a watch-and-wait protocol. There is a subset of patients that has initial favorable response but will recur with distant metastases afterwards. A previously published model predicting (near)-complete response could not be validated.
Purpose To report on organ preservation following chemoradiotherapy (CRT) in a prospective cohort of locally advanced rectal cancer patients. Methods and materials Fifty-two patients received CRT. MRI and 18F-FDG-PET/CT were performed prior to CRT. Response assessment was done 6 and 12 weeks after CRT using digital rectal examination, MRI, 18F-FDG-PET/CT and endoscopy. For clinical complete response or minimal residual disease, a watch-and-wait (W&W) protocol was started. Regrowth-free survival (ReFS), Total Mesorectal Excision-free disease-free survival, distant metastasis-free survival (DMFS) and overall survival (OS) were evaluated using Kaplan-Meier method. Functional outcome was compared with the Wilcoxon signed-rank test using EORTC QLQ-C30, MSKCC BFI, LARS and IIEF-5/FSFI-5 questionnaires. A previously developed prediction model performance was tested using receiver operating characteristic analysis. Results 29/52 patients entered a W&W protocol. There was no difference in two-year DMFS (81.1 % vs 78.8 %, p = 0.82), two-year OS (96.4 % vs 100 %, p = 0.38) and two-year DFS (77.5 % vs 78.8 %, p = 0.87) between W&W patients and those who underwent surgery at 12 weeks after CRT. Two-year DMFS differed between W&W with local regrowth, W&W with sustained response and patients who had surgery (66.7 % vs 88.0 % vs 78.8 %; p = 0.04). At 6 and 12 months, W&W patients reported good QoL and bowel function. The model validation reached an AUC of 0.627. Conclusion Good functional outcome in patients with rectal cancer allocated to surveillance after CRT needs to be balanced against potentially worse DMFS in a subset of patients without sustained clinical complete response. Reliable prediction of patients eligible for surveillance programs needs further investigation.
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Transanal minimally invasive surgery (TAMIS) for rectal cancer. SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Ketelaers SHJ, Jacobs A, Verrijssen ASE, Cnossen JS, van Hellemond IEG, Creemers GJM, Schreuder RM, Scholten HJ, Tolenaar JL, Bloemen JG, Rutten HJT, Burger JWA. A Multidisciplinary Approach for the Personalised Non-Operative Management of Elderly and Frail Rectal Cancer Patients Unable to Undergo TME Surgery. Cancers (Basel) 2022; 14:2368. [PMID: 35625976 PMCID: PMC9139821 DOI: 10.3390/cancers14102368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/05/2022] [Accepted: 05/09/2022] [Indexed: 02/07/2023] Open
Abstract
Despite it being the optimal curative approach, elderly and frail rectal cancer patients may not be able to undergo a total mesorectal excision. Frequently, no treatment is offered at all and the natural course of the disease is allowed to unfold. These patients are at risk for developing debilitating symptoms that impair quality of life and require palliative treatment. Recent advancements in non-operative treatment modalities have enhanced the toolbox of alternative treatment strategies in patients unable to undergo surgery. Therefore, a proposed strategy is to aim for the maximal non-operative treatment, in an effort to avoid the onset of debilitating symptoms, improve quality of life, and prolong survival. The complexity of treating elderly and frail patients requires a patient-centred approach to personalise treatment. The main challenge is to optimise the balance between local control of disease, patient preferences, and the burden of treatment. A comprehensive geriatric assessment is a crucial element within the multidisciplinary dialogue. Since limited knowledge is available on the optimal non-operative treatment strategy, these patients should be treated by dedicated multidisciplinary rectal cancer experts with special interest in the elderly and frail. The aim of this narrative review was to discuss a multidisciplinary patient-centred treatment approach and provide a practical suggestion of a successfully implemented clinical care pathway.
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Affiliation(s)
- Stijn H. J. Ketelaers
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
| | - Anne Jacobs
- Department of Gerontology and Geriatrics, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands;
| | - An-Sofie E. Verrijssen
- Department of Radiation Oncology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (A.-S.E.V.); (J.S.C.)
| | - Jeltsje S. Cnossen
- Department of Radiation Oncology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (A.-S.E.V.); (J.S.C.)
| | - Irene E. G. van Hellemond
- Department of Medical Oncology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (I.E.G.v.H.); (G.-J.M.C.)
| | - Geert-Jan M. Creemers
- Department of Medical Oncology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (I.E.G.v.H.); (G.-J.M.C.)
| | - Ramon-Michel Schreuder
- Department of Gastroenterology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands;
| | - Harm J. Scholten
- Department of Anaesthesiology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands;
| | - Jip L. Tolenaar
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
| | - Johanne G. Bloemen
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
| | - Harm J. T. Rutten
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
- GROW, School for Oncology and Reproduction, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Jacobus W. A. Burger
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
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Chen X, Chen J, He X, Xu L, Liu W, Lin D, Luo Y, Feng Y, Lian L, Hu J, Lan P. Endoscopy-Based Deep Convolutional Neural Network Predicts Response to Neoadjuvant Treatment for Locally Advanced Rectal Cancer. Front Physiol 2022; 13:880981. [PMID: 35574447 PMCID: PMC9091815 DOI: 10.3389/fphys.2022.880981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 03/11/2022] [Indexed: 11/13/2022] Open
Abstract
Background and Aims: Although the wait and watch (W&W) strategy is a treatment choice for locally advanced rectal cancer (LARC) patients who achieve clinical complete response (cCR) after neoadjuvant therapy (NT), the issue on consistency between cCR and pathological CR (pCR) remains unsettled. Herein, we aimed to develop a deep convolutional neural network (DCNN) model using endoscopic images of LARC patients after NT to distinguish tumor regression grade (TRG) 0 from non-TRG0, thus providing strength in identifying surgery candidates. Methods: A total of 1000 LARC patients (6,939 endoscopic images) who underwent radical surgery after NT from April 2013 to April 2021 at the Sixth Affiliated Hospital, Sun Yat-sen University were retrospectively included in our study. Patients were divided into three cohorts in chronological order: the training set for constructing the model, the validation set, and the independent test set for validating its predictive capability. Besides, we compared the model's performance with that of three endoscopists on a class-balanced, randomly selected subset of 20 patients' LARC images (10 TRG0 patients with 70 images and 10 non-TRG0 patients with 72 images). The measures used to evaluate the efficacy for identifying TRG0 included overall accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the receiver operating characteristic curve (AUROC). Results: There were 219 (21.9%) cases of TRG0 in the included patients. The constructed DCNN model in the training set obtained an excellent performance with good accuracy of 94.21%, specificity of 94.39%, NPV of 98.11%, and AUROC of 0.94. The validation set showed accuracy, specificity, NPV, and AUROC of 92.13%, 93.04%, 96.69%, and 0.95, respectively; the corresponding values in the independent set were 87.14%, 92.98%, 91.37%, and 0.77, respectively. In the reader study, the model outperformed the three experienced endoscopists with an AUROC of 0.85. Conclusions: The proposed DCNN model achieved high specificity and NPV in detecting TRG0 LARC tumors after NT, with a better performance than experienced endoscopists. As a supplement to radiological images, this model may serve as a useful tool for identifying surgery candidates in LARC patients after NT.
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Affiliation(s)
- Xijie Chen
- Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Department of Gastrointestinal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Junguo Chen
- Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaosheng He
- Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Liang Xu
- Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Department of Pathology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wei Liu
- Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Dezheng Lin
- Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yuxuan Luo
- Tianjin Economic-Technological Development Area, Yujin Digestive Health Industry Research Institute, Tianjin, China
| | - Yue Feng
- Tianjin Economic-Technological Development Area, Yujin Digestive Health Industry Research Institute, Tianjin, China
| | - Lei Lian
- Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Department of Gastrointestinal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jiancong Hu
- Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Department of Network Management, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ping Lan
- Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Cerdán-Santacruz C, Vailati BB, São Julião GP, Habr-Gama A, Pérez RO. Watch and wait: Why, to whom and how. Surg Oncol 2022; 43:101774. [DOI: 10.1016/j.suronc.2022.101774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 04/12/2022] [Indexed: 12/26/2022]
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Cotti GC, Pandini RV, Braghiroli OFM, Nahas CSR, Bustamante-Lopez LA, Marques CFS, Imperiale AR, Ribeiro U, Salvajoli B, Hoff PM, Nahas SC. Outcomes of Patients With Local Regrowth After Nonoperative Management of Rectal Cancer After Neoadjuvant Chemoradiotherapy. Dis Colon Rectum 2022; 65:333-339. [PMID: 34775415 DOI: 10.1097/dcr.0000000000002197] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Clinical complete responders after chemoradiation for rectal cancer are increasingly being managed by a watch-and-wait strategy. Nonetheless, a significant proportion will experience a local regrowth, and the long-term oncological outcomes of these patients is not totally known. OBJECTIVE The purpose of this study was to analyze the outcomes of patients who submitted to a watch-and-wait strategy and developed a local regrowth, and to compare these results with sustained complete clinical responders. DESIGN This was a retrospective study. SETTING Single institution, tertiary cancer center involved in alternatives to organ preservation. PATIENTS Patients with a biopsy-proven rectal adenocarcinoma (stage II/III or low lying cT2N0M0 at risk for an abdominoperineal resection) treated with chemoradiation who were found at restage to have a clinical complete response. INTERVENTIONS Rectal cancer patients treated with chemoradiation who underwent a watch-and-wait strategy (without a full thickness local excision) and developed a local regrowth were compared to the remaining patients of the watch-and-wait strategy. MAIN OUTCOME MEASURES Overall survival between groups, incidence of regrowth' and results of salvage surgery. RESULTS There were 67 patients. Local regrowth occurred in 20 (29.9%) patients treated with a watch-and-wait strategy. Mean follow-up was 62.7 months. Regrowth occurred at mean 14.2 months after chemoradiation, half of them within the first 12 months. Patients presented with comparable initial staging, lateral pelvic lymph-node metastasis, and extramural venous invasion. The regrowth group had a statistically nonsignificant higher incidence of mesorectal fascia involvement (35.0% vs 13.3%, p = 0.089). All regrowths underwent salvage surgery, mostly (75%) a sphincter-sparing procedure. 5-year overall survival was 71.1% in patients with regrowth and 91.1% in patients with a sustained complete clinical response (p = 0.027). LIMITATIONS This study was limited by its retrospective evaluation of patient selection for a watch-and-wait strategy and outcomes, as well as its small sample size. CONCLUSIONS Local regrowth is a frequent event when following a watch-and-wait policy (29.9%); however, patients could undergo salvage surgical treatment with adequate pelvic control. In this series, overall survival showed a statistically significant difference from patients managed with a watch-and-wait strategy who experienced a local regrowth compared to those who did not. See Video Abstract at http://links.lww.com/DCR/B773.RESULTADOS DE LOS PACIENTES CON REBROTE LOCAL, DESPUÉS DEL MANEJO NO QUIRÚRGICO DEL CÁNCER DE RECTO, DESPUÉS DE LA QUIMIORRADIOTERAPIA NEOADYUVANTEANTECEDENTES:Los respondedores clínicos completos, después de la quimiorradiación para el cáncer de recto, se tratan cada vez más mediante una estrategia de observación y espera. No obstante, una proporción significativa experimentará un rebrote local y los resultados oncológicos a largo plazo de estos pacientes, no se conocen por completo.OBJETIVO:El propósito de este estudio, fue analizar los resultados de los pacientes sometidos a una estrategia de observación y espera, que desarrollaron un rebrote local, y comparar estos resultados con respondedores clínicos completos sostenidos.DISEÑO:Este fue un estudio retrospectivo.ENTORNO CLINICO.Institución única, centro oncológico terciario involucrado en alternativas a la preservación de órganos.PACIENTES:Pacientes con un adenocarcinoma de recto comprobado por biopsia (estadio II / III o posición baja cT2N0M0, en riesgo de resección abdominoperineal), tratados con quimiorradiación, y que durante un reestadiaje, presentaron una respuesta clínica completa.INTERVENCIONES:Los pacientes con cáncer de recto tratados con quimiorradiación, sometidos a una estrategia de observación y espera (sin una escisión local de espesor total) y que desarrollaron un rebrote local, se compararon con los pacientes restantes de la estrategia de observación y espera.PRINCIPALES MEDIDAS DE VALORACION:Supervivencia global entre los grupos, incidencia de rebrote y resultados de la cirugía de rescate.RESULTADOS:Fueron 67 pacientes. El rebrote local ocurrió en 20 (29,9%) pacientes tratados con una estrategia de observación y espera. El seguimiento medio fue de 62,7 meses. El rebrote se produjo a la media de 14,2 meses después de la quimiorradiación, la mitad de ellos dentro de los primeros 12 meses. Los pacientes se presentaron con una estadificación inicial comparable, metástasis en los ganglios linfáticos pélvicos laterales e invasión venosa extramural. El grupo de rebrote tuvo una mayor incidencia estadísticamente no significativa de afectación de la fascia mesorrectal (35,0 vs 13,3%, p = 0,089). Todos los rebrotes se sometieron a cirugía de rescate, en su mayoría (75%) con procedimiento de preservación del esfínter. La supervivencia global a 5 años fue del 71,1% en pacientes con rebrote y del 91,1% en pacientes con una respuesta clínica completa sostenida (p = 0,027).LIMITACIONES:Evaluación retrospectiva de la selección de pacientes para una estrategia y resultados de observar y esperar, tamaño de muestra pequeño.CONCLUSIONES:El rebrote local es un evento frecuente después de la política de observación y espera (29,9%), sin embargo los pacientes podrían someterse a un tratamiento quirúrgico de rescate con un adecuado control pélvico. En esta serie, la supervivencia global mostró una diferencia estadísticamente significativa de los pacientes manejados con una estrategia de observación y espera que experimentaron un rebrote local, en comparación con los que no lo hicieron. Consulte Video Resumen en http://links.lww.com/DCR/B773. (Traducción-Dr. Fidel Ruiz Healy).
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Affiliation(s)
- Guilherme Cutait Cotti
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
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Hedrick TL, Zaydfudim VM. Management of Synchronous Colorectal Cancer Metastases. Surg Oncol Clin N Am 2022; 31:265-278. [DOI: 10.1016/j.soc.2021.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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[Oncological surgery in the interdisciplinary context-On the way to personalized medicine]. Chirurg 2022; 93:234-241. [PMID: 35201386 DOI: 10.1007/s00104-022-01614-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2022] [Indexed: 11/03/2022]
Abstract
Oncological surgery is a discipline which closely interacts with other clinical partners and remains in many cases the cornerstone of a curative treatment of solid tumors. Due to the progress in the field of systemic tumor treatment as well as innovations in surgical techniques, the indications in oncological surgery are also changing, such as extended indications for patients with oligometastatic disease. Surgery of metastases has long been established for colorectal cancer and is being further tested for other entities, such as pancreatic and gastric cancer, within randomized controlled clinical trials (e.g. RENAISSANCE and METAPANC). A new challenge is the handling of a clinical complete remission after total neoadjuvant therapy, for example in locally advanced rectal cancer or in esophageal cancer. Here, organ and function preservation are increasingly propagated but should only be performed within clinical trials until stratification enables the identification of patients in whom this concept is oncologically safe. The personalized use of oncological surgery is dependent on the patient, the tumor and on the total multimodal concept.
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Zhang DK, Qiao J, Chen SX, Hou ZY, Jie JZ. Predictive value of serum alpha-fetoprotein for tumor regression after preoperative chemotherapy for rectal cancer. World J Gastrointest Oncol 2022; 14:525-532. [PMID: 35317314 PMCID: PMC8919007 DOI: 10.4251/wjgo.v14.i2.525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 11/20/2021] [Accepted: 01/20/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Preoperative therapy is widely used in locally advanced rectal cancer. It can improve local control of rectal cancer. However, there are few indicators that can predict the effect of preoperative chemotherapy accurately.
AIM To investigate whether the increase in serum α-fetoprotein (AFP) can predict better efficacy of preoperative chemotherapy.
METHODS This was a retrospective study. We analyzed 125 patients admitted between 2017 and 2019 with locally advanced rectal cancer. All patients received six cycles of preoperative chemotherapy (mFOLFOX6 every 2 wk). Serum AFP of 26 patients rose slightly after three or four cycles of chemotherapy, and fell to normal again within 2 mo. The other 99 patients had a normal level of serum AFP during chemotherapy. Patients were divided into two groups (AFP risen and AFP normal). According to postoperative pathology, we compared tumor regression and complete response rate between the two groups. The primary outcome measure was the tumor regression grade (TRG) after chemotherapy. The difference in pathological complete response between the two groups was also investigated.
RESULTS There were no tumor progression and distant metastasis in both groups during preoperative chemotherapy. Patients in the AFP risen group achieved better TRG 0/1 than those in the AFP normal group (61.5% vs 39.4%). The increase in AFP was a significant predictor for better tumor regression [χ2 = 4.144, odds ratio (OR) = 2.666, P = 0.04]. In the AFP risen group, the complete response rate was 30.8%, which was higher than in the AFP normal group (30.8% vs 12.1%, χ2 = 4.542, OR = 3.251, P = 0.03).
CONCLUSION Patients with a slight increase in serum AFP can achieve better tumor regression during preoperative chemotherapy, and are more likely to achieve pathological complete response.
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Affiliation(s)
- Da-Kui Zhang
- Department of General Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Jun Qiao
- Department of General Surgery, Inner Mongolia International Mongolian Hospital, Hohhot 010020, Inner Mongolia Autonomous Region, China
| | - Shao-Xuan Chen
- Department of General Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Zhi-Yong Hou
- Department of General Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Jian-Zheng Jie
- Department of General Surgery, China-Japan Friendship Hospital, Beijing 100029, China
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Suzuki C, Halperin SK, Nilsson PJ, Martling A, Holm T. Initial magnetic resonance imaging tumour regression grade (mrTRG) as response evaluation after neoadjuvant treatment predicts sustained complete response in patients with rectal cancer. Eur J Surg Oncol 2022; 48:1643-1649. [DOI: 10.1016/j.ejso.2022.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/02/2022] [Accepted: 02/09/2022] [Indexed: 11/16/2022] Open
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Ryu HS, Lee JL, Kim CW, Yoon YS, Park IJ, Lim SB, Yu CS, Kim JH, Kim JC. Correlative significance of tumor regression grade and ypT category in patients undergoing preoperative chemoradiotherapy for locally advanced rectal cancer. Clin Colorectal Cancer 2022; 21:212-219. [DOI: 10.1016/j.clcc.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 01/28/2022] [Accepted: 02/07/2022] [Indexed: 11/03/2022]
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Kim JK, Thompson H, Jimenez-Rodriguez RM, Wu F, Sanchez-Vega F, Nash GM, Guillem JG, Paty PB, Wei IH, Pappou EP, Widmar M, Weiser MR, Smith JJ, Garcia-Aguilar J. Adoption of Organ Preservation and Surgeon Variability for Patients with Rectal Cancer Does Not Correlate with Worse Survival. Ann Surg Oncol 2022; 29:1172-1179. [PMID: 34601641 PMCID: PMC8727510 DOI: 10.1245/s10434-021-10877-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 09/04/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND OBJECTIVES Watch-and-wait is variably adopted by surgeons and the impact of this on outcomes is unknown. We compared the disease-free survival and organ preservation rates of locally advanced rectal cancer patients treated by expert colorectal surgeons at a comprehensive cancer center. METHODS This study included retrospective data on patients diagnosed with stage II/III rectal adenocarcinoma from January 2013 to June 2017 who initiated neoadjuvant therapy (either with chemoradiation, chemotherapy, or a combination of both) and were treated by an expert colorectal surgeon. RESULTS Overall, 444 locally advanced rectal cancer patients managed by five surgeons were included. Tumor distance from the anal verge, type of neoadjuvant therapy, and organ preservation rates varied by treating surgeon. There was no difference in disease-free survival after stratifying by the treating surgeon (p = 0.2). On multivariable analysis, neither the type of neoadjuvant therapy nor the treating surgeon was associated with disease-free survival. CONCLUSIONS While neoadjuvant therapy type and organ preservation rates varied among surgeons, there were no meaningful differences in disease-free survival. These data suggest that among expert colorectal surgeons, differing thresholds for selecting patients for watch-and-wait do not affect survival.
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Affiliation(s)
- Jin K. Kim
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Hannah Thompson
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | | | - Fan Wu
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Francisco Sanchez-Vega
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA,Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Garrett M. Nash
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Jose G. Guillem
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Philip B. Paty
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Iris H. Wei
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Emmanouil P. Pappou
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Maria Widmar
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Martin R. Weiser
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - J. Joshua Smith
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Julio Garcia-Aguilar
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
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Eng C, Jácome AA, Agarwal R, Hayat MH, Byndloss MX, Holowatyj AN, Bailey C, Lieu CH. A comprehensive framework for early-onset colorectal cancer research. Lancet Oncol 2022; 23:e116-e128. [PMID: 35090673 DOI: 10.1016/s1470-2045(21)00588-x] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 10/04/2021] [Accepted: 10/06/2021] [Indexed: 02/07/2023]
Abstract
Sporadic colorectal cancer has traditionally been viewed as a malignancy of older individuals. However, as the global prevalence of the disease diagnosed in younger individuals (<50 years) is expected to increase within the next decade, greater recognition is now being given to early-onset colorectal cancer. The cause of the predicted rise in prevalence is largely unknown and probably multifactorial. In this Series paper, we discuss the potential underlying causes of early-onset colorectal cancer, the role of energy balance, biological and genomic mechanisms (including microbiome aspects), and the treatment of early-onset colorectal cancer. We have specifically considered the psychosocial challenges of being diagnosed with colorectal cancer at younger age and the potential financial toxicity that might ensue. This Series paper brings a comprehensive review based on the existing data in the hopes of optimising the overall outcomes for patients with early-onset colorectal cancer.
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Horesh N, Freund MR, Garoufalia Z, Gefen R, Nagarajan A, Suarez E, Emile SH, Wexner SD. Total Neoadjuvant Therapy Is a Predictor for Complete Pathological Response in Patients Undergoing Surgery for Rectal Cancer. J Gastrointest Surg 2022; 26:2579-2584. [PMID: 36224480 PMCID: PMC9555694 DOI: 10.1007/s11605-022-05463-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 09/10/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Total neoadjuvant therapy (TNT) is a new therapeutic strategy in patients with rectal cancer. We examined the role of TNT, in addition to other pre-operative factors, as a predictor for pathologic complete response (pCR). METHODS A retrospective analysis of all rectal cancer patients who underwent surgery between 2016 and 2021 was conducted. Patients were classified into two groups-pCR group and residual tumor group. Patient data were reviewed and entered into univariate and multivariate analyses to determine predictors of pCR. RESULTS A total of 172 patients were treated with neoadjuvant therapy and underwent surgery during the study period. Sixty patients (34.9%) were treated with TNT while 112 (65.1%) were treated with traditional neoadjuvant chemoradiation. The overall pCR rate was 25.6% (44 patients), with 31.6% (19 patients) in patients who received TNT compared to 22.3% (25 patients) in patients who received neoadjuvant chemoradiation (NCRT). Univariate analysis of clinical and radiological factors correlated with pCR demonstrated no significant differences between the two groups in cT stage (p = 0.46), cN stage (p = 0.52), positive circumferential resection margin (CRM) (p = 0.72), tumor location (p = 0.35), symptomatic presentation (p = 0.09), and anal sphincter involvement (p = 0.68). Multivariate logistic analysis demonstrated that only pre-operative TNT (OR:2.35; 95% CI 1.06-5.25; p = 0.03) was predictive of pCR, while extramural vascular invasion (EMVI) was a predictor for lower rates of pCR (OR: 0.28; 95% CI 0.09-0.9; p = 0.03). CONCLUSION Rectal cancer patients undergoing TNT prior to surgery have a higher chance of developing a complete pathologic response. Evaluation of this therapy should be continued and extended to larger numbers of patients to see if the differences we observed are real.
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Affiliation(s)
- Nir Horesh
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331 USA ,Department of Surgery and Transplantations, Sheba Medical Center, Ramat Gan, Israel, affiliated with the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michael R. Freund
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331 USA ,Department of General Surgery, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Zoe Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331 USA
| | - Rachel Gefen
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331 USA
| | - Arun Nagarajan
- Department of Hematology/Oncology, Cleveland Clinic Florida, Weston, FL USA
| | - Eva Suarez
- Department of Radiation Oncology, Cleveland Clinic Florida, Weston, FL USA
| | - Sameh Hany Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331 USA ,Colorectal Surgery Unit, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Steven D. Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331 USA
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Predicting pathologic complete response in locally advanced rectal cancer patients after neoadjuvant therapy: a machine learning model using XGBoost. Int J Colorectal Dis 2022; 37:1621-1634. [PMID: 35704090 PMCID: PMC9262764 DOI: 10.1007/s00384-022-04157-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/17/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Watch and wait strategy is a safe and effective alternative to surgery in patients with locally advanced rectal cancer (LARC) who have achieved pathological complete response (pCR) after neoadjuvant therapy (NAT); present restaging methods do not meet clinical needs. This study aimed to construct a machine learning (ML) model to predict pCR preoperatively. METHODS LARC patients who received NAT were included to generate an extreme gradient boosting-based ML model to predict pCR. The group was divided into a training set and a tuning set at a 7:3 ratio. The SHapley Additive exPlanations value was used to quantify feature importance. The ML model was compared with a nomogram model developed using independent risk factors identified by conventional multivariate logistic regression analysis. RESULTS Compared with the nomogram model, our ML model improved the area under the receiver operating characteristics from 0.72 to 0.95, sensitivity from 43 to 82.2%, and specificity from 87.1 to 91.6% in the training set, the same trend applied to the tuning set. Neoadjuvant radiotherapy, preoperative carbohydrate antigen 125 (CA125), CA199, carcinoembryonic antigen level, and depth of tumor invasion were significant in predicting pCR in both models. CONCLUSION Our ML model is a potential alternative to the existing assessment tools to conduct triage treatment for patients and provides reference for clinicians in tailoring individual treatment: the watch and wait strategy is used to avoid surgical trauma in pCR patients, and non-pCR patients receive surgical treatment to avoid missing the optimal operation time window.
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83
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Kastner C, Petritsch B, Reibetanz J, Germer CT, Wiegering A. [Complete response after neoadjuvant therapy of rectal cancer: implications for surgery]. Chirurg 2021; 93:144-151. [PMID: 34878582 DOI: 10.1007/s00104-021-01540-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2021] [Indexed: 12/17/2022]
Abstract
For (locally advanced) rectal cancer, a multimodal therapy concept comprising neoadjuvant radiotherapy/chemoradiotherapy, radical surgical resection with partial/complete mesorectal excision and subsequent adjuvant chemotherapy represents the current international standard of care. Further developments in neoadjuvant therapy concepts, such as the principle of total neoadjuvant therapy, lead to an increasing number of patients who show a complete clinical response in restaging after neoadjuvant therapy without clinically detectable residual tumor. In view of the risk associated with radical surgical resection in terms of perioperative morbidity and a potentially non-continence-preserving procedure, the question of the oncological justifiability of an organ-preserving procedure in the case of a complete clinical response under neoadjuvant therapy is increasingly being raised. The therapeutic principle of watch and wait, defined by refraining from immediate radical surgical resection and inclusion in a close-meshed, structured follow-up program, currently appears to be oncologically justifiable based on the current study situation; however, for the initial evaluation of the extent of the clinical response and for the structuring of the close-meshed follow-up program, further optimization and standardization based on broadly designed studies appear necessary in order to be able to provide this concept to a clearly defined patient collective as an oncologically equivalent therapy principle also outside specialized centers.
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Affiliation(s)
- Carolin Kastner
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum für operative Medizin, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
- Institut für Biochemie und molekulare Biologie, Julius-Maximilians-Universität Würzburg, Würzburg, Deutschland
| | - Bernhard Petritsch
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Joachim Reibetanz
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum für operative Medizin, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Christoph-Thomas Germer
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum für operative Medizin, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
- Comprehensive Cancer Center Mainfranken, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Armin Wiegering
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Zentrum für operative Medizin, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland.
- Institut für Biochemie und molekulare Biologie, Julius-Maximilians-Universität Würzburg, Würzburg, Deutschland.
- Comprehensive Cancer Center Mainfranken, Universitätsklinikum Würzburg, Würzburg, Deutschland.
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Anker CJ, Lester-Coll NH, Akselrod D, Cataldo PA, Ades S. The Potential for Overtreatment With Total Neoadjuvant Therapy (TNT): Consider One Local Therapy Instead. Clin Colorectal Cancer 2021; 21:19-35. [DOI: 10.1016/j.clcc.2021.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/03/2021] [Accepted: 11/14/2021] [Indexed: 11/11/2022]
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Yu G, Lu W, Jiao Z, Qiao J, Ma S, Liu X. A meta-analysis of the watch-and-wait strategy versus total mesorectal excision for rectal cancer exhibiting complete clinical response after neoadjuvant chemoradiotherapy. World J Surg Oncol 2021; 19:305. [PMID: 34663341 PMCID: PMC8522111 DOI: 10.1186/s12957-021-02415-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 09/30/2021] [Indexed: 01/04/2023] Open
Abstract
Background Some clinical researchers have reported that patients with cCR (clinical complete response) status after neoadjuvant chemoradiotherapy (nCRT) could adopt the watch-and-wait (W&W) strategy. Compared with total mesorectal excision (TME) surgery, the W&W strategy could achieve a similar overall survival. Could the W&W strategy replace TME surgery as the main treatment option for the cCR patients? By using the meta-analysis method, we evaluated the safety and efficacy of the W&W strategy and TME surgery for rectal cancer exhibiting cCR after nCRT. Methods We evaluated two treatment strategies for rectal cancer with cCR after nCRT up to July 2021 by searching the Cochrane Library, PubMed, Wanfang, and China National Knowledge Infrastructure (CNKI) databases. Clinical data for primary outcomes (local recurrence, cancer-related death and distant metastasis), and secondary outcomes (disease-free survival (DFS) and overall survival (OS)) were collected to evaluate the efficacy and safety in the two groups. Results We included nine studies with 818 patients in the meta-analysis, and there were five moderate-quality studies and four high-quality studies. A total of 339 patients were in the W&W group and 479 patients were in the TME group. The local recurrence rate in the W&W group was greater than that in the TME group in the fixed-effects model (OR 8.54, 95% CI 3.52 to 20.71, P < 0.001). The results of other outcomes were similar in the two groups. Conclusion The local recurrence rate of the W&W group was greater than that in the TME group, but other results were similar in the two groups. With the help of physical examination and salvage therapy, the W&W strategy could achieve similar treatment effects with the TME approach. Trial registration Protocol registration number: CRD42021244032. Supplementary Information The online version contains supplementary material available at 10.1186/s12957-021-02415-y.
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Affiliation(s)
- Guilin Yu
- Department of General Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, No. 44 Xiaoheyan Road, Dadong District, Shenyang, 110042, Liaoning Province, People's Republic of China
| | - Wenqing Lu
- School of Life Sciences, Hebei University, Baoding, 071002, Hebei Province, People's Republic of China
| | - Zhouguang Jiao
- Institute of Process Engineering, Chinese Academy of Science, Beijing, 100190, People's Republic of China
| | - Jun Qiao
- Department of Colorectal Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, No. 44 Xiaoheyan Road, Dadong District, Shenyang, 110042, Liaoning Province, People's Republic of China
| | - Shiyang Ma
- Department of Colorectal Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, No. 44 Xiaoheyan Road, Dadong District, Shenyang, 110042, Liaoning Province, People's Republic of China
| | - Xin Liu
- Department of Colorectal Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, No. 44 Xiaoheyan Road, Dadong District, Shenyang, 110042, Liaoning Province, People's Republic of China.
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Chin RI, Roy A, Pedersen KS, Huang Y, Hunt SR, Glasgow SC, Tan BR, Wise PE, Silviera ML, Smith RK, Suresh R, Badiyan SN, Shetty AS, Henke LE, Mutch MG, Kim H. Clinical Complete Response in Patients With Rectal Adenocarcinoma Treated With Short-Course Radiation Therapy and Nonoperative Management. Int J Radiat Oncol Biol Phys 2021; 112:715-725. [PMID: 34653579 DOI: 10.1016/j.ijrobp.2021.10.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/11/2021] [Accepted: 10/05/2021] [Indexed: 01/04/2023]
Abstract
PURPOSE This study aimed to determine the clinical efficacy and safety of nonoperative management (NOM) for patients with rectal cancer with a clinical complete response (cCR) after short-course radiation therapy and consolidation chemotherapy. METHODS AND MATERIALS Patients with stage I-III rectal adenocarcinoma underwent short-course radiation therapy followed by consolidation chemotherapy between January 2018 and May 2019 (n = 90). Clinical response was assessed by digital rectal examination, pelvic magnetic resonance imaging, and endoscopy. Of the patients with an evaluable initial response, those with a cCR (n = 43) underwent NOM, and those with a non-cCR (n = 43) underwent surgery. The clinical endpoints included local regrowth-free survival, regional control, distant metastasis-free survival, disease-free survival, and overall survival. RESULTS Compared with patients with an initial cCR, patients with initial non-cCR had more advanced T and N stage (P = .05), larger primary tumors (P = .002), and more circumferential resection margin involvement on diagnostic magnetic resonance imaging (P < .001). With a median follow-up of 30.1 months, the persistent cCR rate was 79% (30 of 38 patients) in the NOM cohort. The 2-year local regrowth-free survival was 81% (95% confidence interval [CI], 70%-94%) in the initial cCR group, and all patients with local regrowth were successfully salvaged. Compared with those with a non-cCR, patients with a cCR had improved 2-year regional control (98% [95% CI, 93%-100%] vs 85% [95% CI, 74%-97%], P = .02), distant metastasis-free survival (100% [95% CI, 100%-100%] vs 80% [95% CI, 69%-94%], P < .01), disease-free survival (98% [95% CI, 93%-100%] vs 71% [95% CI, 59%-87%], P < .01), and overall survival (100% [95% CI, 100%-100%] vs 88% [95% CI, 79%-98%], P = .02). No late grade 3+ gastrointestinal or genitourinary toxicities were observed in the patients who underwent continued NOM. CONCLUSIONS Short-course radiation therapy followed by consolidation chemotherapy may be a feasible organ preservation strategy in rectal cancer. Additional prospective studies are necessary to evaluate the safety and efficacy of this approach.
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Affiliation(s)
- Re-I Chin
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, Missouri
| | - Amit Roy
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, Missouri
| | - Katrina S Pedersen
- Division of Hematology and Oncology, Department of Internal Medicine, Washington University School of Medicine, Saint Louis, Missouri
| | - Yi Huang
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, Missouri
| | - Steven R Hunt
- Section of Colon and Rectal Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Sean C Glasgow
- Section of Colon and Rectal Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Benjamin R Tan
- Division of Hematology and Oncology, Department of Internal Medicine, Washington University School of Medicine, Saint Louis, Missouri
| | - Paul E Wise
- Section of Colon and Rectal Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Matthew L Silviera
- Section of Colon and Rectal Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Radhika K Smith
- Section of Colon and Rectal Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Rama Suresh
- Division of Hematology and Oncology, Department of Internal Medicine, Washington University School of Medicine, Saint Louis, Missouri
| | - Shahed N Badiyan
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, Missouri
| | - Anup S Shetty
- Section of Abdominal Imaging, Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri
| | - Lauren E Henke
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, Missouri
| | - Matthew G Mutch
- Section of Colon and Rectal Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Hyun Kim
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, Missouri.
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Kokaine L, Gardovskis A, Gardovskis J. Evaluation and Predictive Factors of Complete Response in Rectal Cancer after Neoadjuvant Chemoradiation Therapy. ACTA ACUST UNITED AC 2021; 57:medicina57101044. [PMID: 34684080 PMCID: PMC8537499 DOI: 10.3390/medicina57101044] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/16/2021] [Accepted: 09/23/2021] [Indexed: 12/18/2022]
Abstract
The response to neoadjuvant chemoradiation therapy is an important prognostic factor for locally advanced rectal cancer. Although the majority of the patients after neoadjuvant therapy are referred to following surgery, the clinical data show that complete clinical or pathological response is found in a significant proportion of the patients. Diagnostic accuracy of confirming the complete response has a crucial role in further management of a rectal cancer patient. As the rate of clinical complete response, unfortunately, is not always consistent with pathological complete response, accurate diagnostic parameters and predictive markers of tumor response may help to guide more personalized treatment strategies and identify potential candidates for nonoperative management more safely. The management of complete response demands interdisciplinary collaboration including oncologists, radiotherapists, radiologists, pathologists, endoscopists and surgeons, because the absence of a multidisciplinary approach may compromise the oncological outcome. Prediction and improvement of rectal cancer response to neoadjuvant therapy is still an active and challenging field of further research. This literature review is summarizing the main, currently known clinical information about the complete response that could be useful in case if encountering such condition in rectal cancer patients after neoadjuvant chemoradiation therapy, using as a source PubMed publications from 2010–2021 matching the search terms “rectal cancer”, “neoadjuvant therapy” and “response”.
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Affiliation(s)
- Linda Kokaine
- Department of Surgery, Riga Stradins University, Dzirciema Street 16, LV-1007 Riga, Latvia; or
- Pauls Stradins Clinical University Hospital, Pilsoņu Street 13, LV-1002 Riga, Latvia
- Correspondence: (L.K.); (J.G.); Tel.: +371-2635-9472 (L.K.)
| | - Andris Gardovskis
- Department of Surgery, Riga Stradins University, Dzirciema Street 16, LV-1007 Riga, Latvia; or
- Pauls Stradins Clinical University Hospital, Pilsoņu Street 13, LV-1002 Riga, Latvia
| | - Jānis Gardovskis
- Department of Surgery, Riga Stradins University, Dzirciema Street 16, LV-1007 Riga, Latvia; or
- Pauls Stradins Clinical University Hospital, Pilsoņu Street 13, LV-1002 Riga, Latvia
- Correspondence: (L.K.); (J.G.); Tel.: +371-2635-9472 (L.K.)
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Alvarez-Aguilera M, Jimenez-Rodriguez RM. Watch and wait in locally advance rectal cancer: Past, present and future. World J Meta-Anal 2021; 9:327-332. [DOI: 10.13105/wjma.v9.i4.327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 07/27/2021] [Accepted: 08/17/2021] [Indexed: 02/06/2023] Open
Abstract
In rectal cancer, a complete pathological response after neoadjuvant therapy means better rates survival and better rates of local recurrence. Nevertheless, these patients suffer from complications following surgery such as low anterior resection syndrome, sexual dysfunction or colostomy for the rest of their lives. Due to this, several groups are working in an organ preservation strategy when a clinical response is diagnosed. This strategy is known as watch and wait. In this editorial, we review the past, present and future perspectives for this conservative management.
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Kaul S, Rao C, Mane R, Tan KL, Khan AHA, Hussain MS, Shafi MA, Buettner F, Banerjee S, Boulton R, Bhargava A, Huang J, Hanson M, Raouf S, Ball S, Rajendran N. Is the Management of Rectal Cancer Using a Watch and Wait Approach Feasible, Safe and Effective in a Publicly Funded General Hospital? CLINICAL ONCOLOGY (ROYAL COLLEGE OF RADIOLOGISTS (GREAT BRITAIN)) 2021; 34:e25-e34. [PMID: 34454807 DOI: 10.1016/j.clon.2021.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 07/03/2021] [Accepted: 08/09/2021] [Indexed: 11/29/2022]
Abstract
AIMS Although there is emerging evidence to suggest equivalent oncological outcomes using a watch and wait approach compared with primary total mesorectal excision surgery, there is a paucity of evidence about the safety and efficacy of this approach in routine clinical practice. Here we report the long-term outcomes and quality of life from patients managed with watch and wait following a clinical complete response (cCR) to neoadjuvant therapy. MATERIALS AND METHODS Patients with adenocarcinoma of the rectum with cCR following neoadjuvant therapy managed using watch and wait were retrospectively identified. Demographic data, performance status, pretreatment staging information, oncological and surgical outcomes were obtained from routinely collected clinical data. Quality of life was measured by trained clinicians during telephone interviews. RESULTS Over a 7-year period, 506 patients were treated for rectal cancer, 276 had neoadjuvant therapy and 72 had a cCR (26.1%). Sixty-three were managed with watch and wait. Thirteen patients had mucosal regrowth. There was no significant difference in the incidence of metastatic disease between the surgical and watch and wait cohorts (P = 0.38). The 13 patients with mucosal regrowth underwent salvage surgery. Eleven of the patients who underwent surgical resection had R0 resections. There was also a statistically and clinically significant improvement in the Functional Assessment of Cancer Therapy - Colorectal (FACT-C) trial outcome index (P = 0.022). CONCLUSION This study shows that watch and wait is safe and effective outside of tertiary referral centres. It suggests that an opportunistic cCR is durable and when mucosal regrowth occurs it can be salvaged. Finally, we have shown that quality of life is probably improved if a watch and wait approach is adopted.
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Affiliation(s)
- S Kaul
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | - C Rao
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK; Department of Surgery and Cancer, Imperial College London, London, UK; North Cumbria Integrated Care NHS Foundation Trust, UK.
| | - R Mane
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | - K L Tan
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | - A H A Khan
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | - M S Hussain
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | - M A Shafi
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | - F Buettner
- German Cancer Consortium (DKTK), Heidelberg, Germany; German Cancer Research Centre (DKFZ), Heidelberg, Germany; Department of Medicine, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - S Banerjee
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | - R Boulton
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | - A Bhargava
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK; Institute of Health, Barts and London Medical School, Queen Mary University of London (QMUL), London, UK
| | - J Huang
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | - M Hanson
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | - S Raouf
- Barts Health NHS Trust, London, UK
| | - S Ball
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | - N Rajendran
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK.
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Watch and Wait Approach for Rectal Cancer Following Neoadjuvant Treatment: The Experience of a High Volume Cancer Center. Diagnostics (Basel) 2021; 11:diagnostics11081507. [PMID: 34441441 PMCID: PMC8394713 DOI: 10.3390/diagnostics11081507] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/07/2021] [Accepted: 08/08/2021] [Indexed: 11/17/2022] Open
Abstract
Multimodal treatments for rectal cancer, along with significant research on predictors to response to therapy, have led to more conservative surgical strategies. We describe our experience of the rectal sparing approach in rectal cancer patients with clinical complete response (cCR) after neoadjuvant treatment. We also specifically highlight our clinical and imaging criteria to select patients for the watch and wait strategy (w&w). Data came from 39 out of 670 patients treated for locally advanced rectal cancer between January 2016 until February 2020. The selection criteria were a clinical complete response after neoadjuvant chemotherapy managed with a watch and wait (w&w) strategy. A strict follow-up period was adopted in these selected patients and follow-ups were performed every three months during the first two years and every six months after that. The median follow-up time was 28 months. Six patients had a local recurrence (15.3%); all were salvageable by total mesorectal excision (TME). Five patients had a distant metastasis (12.8%). There was no local unsalvageable disease after w&w strategy. The rectal sparing approach in patients with clinical complete response after neoadjuvant treatment is the best possible treatment and is appropriate to analyze from this perspective. The watch and wait approach after neoadjuvant treatment for rectal cancer can be successfully explored after inflexible and strict patient selection.
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91
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Lee JK, Cho JR, Song KS, Oh JH, Jeong SY, Kim MJ, Lee J, Kim MH, Oh HK, Kim DW, Kang SB. Oncologic comparison between nonradical management and total mesorectal excision in good responders after chemoradiotherapy in patients with mid-to-low rectal cancer. Ann Surg Treat Res 2021; 101:93-101. [PMID: 34386458 PMCID: PMC8331553 DOI: 10.4174/astr.2021.101.2.93] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/06/2021] [Accepted: 06/16/2021] [Indexed: 01/04/2023] Open
Abstract
Purpose This study was performed to compare the oncologic outcomes between nonradical management and total mesorectal excision in good responders after chemoradiotherapy. Methods We analyzed 75 patients, who underwent 14 watch-and-wait, 30 local excision, and 31 total mesorectal excision, in ycT0-1N0M0 based on magnetic resonance imaging after chemoradiotherapy for advanced mid-to-low rectal cancer in 3 referral hospitals. The nonradical management group underwent surveillance with additional sigmoidoscopy and rectal magnetic resonance imaging every 3-6 months within the first 2 years. Results Nonradical management group had more low-lying tumors (P < 0.001) and less lymph node metastasis based on magnetic resonance imaging (P = 0.004). However, cT stage, ycT, and ycN stage were not different between the 2 groups. With a median follow-up period of 64.7 months, the 5-year locoregional failure rate was higher in the nonradical management group than in the total mesorectal excision group (16.7% vs. 0%, P = 0.013). However, the 5-year overall survival and disease-free survival rates of the nonradical management and total mesorectal excision groups were not different (95.2% vs. 93.5%, P = 0.467; 76.4% vs. 83.6%, P = 0.665; respectively). Conclusion This study shows that nonradical management for ycT0-1N0 mid-to-low rectal cancer may be an alternative treatment to total mesorectal excision under proper surveillance and management for oncologic events.
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Affiliation(s)
- Ja Kyung Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jung Rae Cho
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Kwang-Seop Song
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Jae Hwan Oh
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Seung-Yong Jeong
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Min Jung Kim
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jeehye Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Min Hyun Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Heung-Kwon Oh
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Duck-Woo Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Sung-Bum Kang
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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92
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Zhang S, Zhang R, Li RZ, Wang QX, Chang H, Ding PR, Li LR, Wu XJ, Chen G, Zeng ZF, Xiao WW, Gao YH. Beneficiaries of radical surgery among clinical complete responders to neoadjuvant chemoradiotherapy in rectal cancer. Cancer Sci 2021; 112:3607-3615. [PMID: 34146368 PMCID: PMC8409289 DOI: 10.1111/cas.15039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 06/05/2021] [Accepted: 06/15/2021] [Indexed: 12/24/2022] Open
Abstract
This study aimed to identify patients who benefit from radical surgery among those with rectal cancer who achieved clinical complete response (cCR). Patients with locally advanced rectal cancer (LARC; stage II/III) who achieved cCR after neoadjuvant chemoradiotherapy (nCRT) were included (n = 212). Univariate/multivariate Cox analysis was performed to validate predictors for distant metastasis‐free survival (DMFS). A decision tree was generated using recursive partitioning analysis (RPA) to categorize patients into different risk stratifications. Total mesorectal excision (TME) was compared with the watch‐and‐wait (W&W) strategy in each risk group. Two molecular predicators of CEA and CA19‐9 were selected to establish the RPA‐based risk stratification, categorizing LARC patients into low‐risk (n = 139; CA19‐9 < 35 U/mL and CEA < 5 ng/mL) and high‐risk (n = 73; CA19‐9 ≥ 35 U/mL or CEA ≥5 ng/mL) groups. Superior 5‐y DMFS was observed in the low‐risk group vs. the high‐risk group (92.9% vs. 76.2%, P = .002). Low‐risk LARC patients who underwent TME had significantly improved 5‐y DMFS compared with their counterparts receiving the W&W strategy (95.9% vs. 84.3%; P = .028). No significant survival difference was observed in high‐risk patients receiving the 2 treatment modalities (77.9% vs. 94.1%; P = .143). LARC patients with cCR who had both baseline CA19‐9 < 35 U/mL and CEA < 5 ng/mL may benefit from radical surgery.
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Affiliation(s)
- Shu Zhang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangzhou, China.,Department of Radiation Oncology, The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Rong Zhang
- Department of Endoscopy, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangzhou, China
| | - Rong-Zhen Li
- Department of Radiation Oncology, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangzhou, China
| | - Qiao-Xuan Wang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangzhou, China
| | - Hui Chang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangzhou, China
| | - Pei-Rong Ding
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangzhou, China
| | - Li-Ren Li
- Department of Endoscopy, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangzhou, China
| | - Xiao-Jun Wu
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangzhou, China
| | - Gong Chen
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangzhou, China
| | - Zhi-Fan Zeng
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangzhou, China
| | - Wei-Wei Xiao
- Department of Radiation Oncology, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangzhou, China
| | - Yuan-Hong Gao
- Department of Radiation Oncology, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangzhou, China
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93
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Cho E, Jung SW, Park IJ, Jang JK, Park SH, Hong SM, Lee JL, Kim CW, Yoon YS, Lim SB, Yu CS, Kim JC. Improvement in the Assessment of Response to Preoperative Chemoradiotherapy for Rectal Cancer Using Magnetic Resonance Imaging and a Multigene Biomarker. Cancers (Basel) 2021; 13:cancers13143480. [PMID: 34298695 PMCID: PMC8305437 DOI: 10.3390/cancers13143480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 07/09/2021] [Accepted: 07/09/2021] [Indexed: 11/16/2022] Open
Abstract
The response to preoperative chemoradiotherapy (PCRT) is correlated with oncologic outcomes in patients with locally advanced rectal cancer. Accurate prediction of PCRT response before surgery can provide crucial information to aid clinicians in further treatment planning. This study aimed to develop an evaluation tool incorporating a genetic biomarker and magnetic resonance imaging (MRI) to improve the assessment of response in post-CRT patients with locally advanced rectal cancer. A total of 198 patients who underwent PCRT followed by surgical resection for locally advanced rectal cancer between 2010 and 2016 were included in this study. Each patient's response prediction index (RPI) score, a multigene biomarker developed in our previous study, and magnetic resonance tumor regression grade (mrTRG) score were added to create a new predictive value for pathologic response after PCRT, called the combined radiation prediction value (cRPV). Based on the new value, 121 and 77 patients were predicted to be good and poor responders, respectively, showing significantly different cRPV values (p = 0.001). With an overall predictive accuracy of 84.8%, cRPV was superior to mrTRG and RPI for the prediction of pathologic chemoradiotherapy response (mrTRG, 69.2%; RPI, 77.3%). In multivariate analysis, cRPV was found to be the sole predictor of tumor response (odds ratio, 32.211; 95% confidence interval, 14.408-72.011; p = 0.001). With its good predictive value for final pathologic regression, cRPV may be a valuable tool for assessing the response to PCRT before surgery.
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Affiliation(s)
- Eunhae Cho
- Asan Medical Center, Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Seoul 05505, Korea; (E.C.); (J.L.L.); (C.W.K.); (Y.S.Y.); (S.-B.L.); (C.S.Y.); (J.C.K.)
| | - Sung Woo Jung
- Department of General Surgery, Good Morning Hospital, Pyeongtaek-si 17874, Korea;
| | - In Ja Park
- Asan Medical Center, Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Seoul 05505, Korea; (E.C.); (J.L.L.); (C.W.K.); (Y.S.Y.); (S.-B.L.); (C.S.Y.); (J.C.K.)
- Correspondence: ; Tel.: +82-2-3010-3937
| | - Jong Keon Jang
- Asan Medical Center, Department of Radiology, University of Ulsan College of Medicine, Seoul 05505, Korea; (J.K.J.); (S.H.P.)
| | - Seong Ho Park
- Asan Medical Center, Department of Radiology, University of Ulsan College of Medicine, Seoul 05505, Korea; (J.K.J.); (S.H.P.)
| | - Seung-Mo Hong
- Asan Medical Center, Department of Pathology, University of Ulsan College of Medicine, Seoul 05505, Korea;
| | - Jong Lyul Lee
- Asan Medical Center, Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Seoul 05505, Korea; (E.C.); (J.L.L.); (C.W.K.); (Y.S.Y.); (S.-B.L.); (C.S.Y.); (J.C.K.)
| | - Chan Wook Kim
- Asan Medical Center, Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Seoul 05505, Korea; (E.C.); (J.L.L.); (C.W.K.); (Y.S.Y.); (S.-B.L.); (C.S.Y.); (J.C.K.)
| | - Yong Sik Yoon
- Asan Medical Center, Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Seoul 05505, Korea; (E.C.); (J.L.L.); (C.W.K.); (Y.S.Y.); (S.-B.L.); (C.S.Y.); (J.C.K.)
| | - Seok-Byung Lim
- Asan Medical Center, Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Seoul 05505, Korea; (E.C.); (J.L.L.); (C.W.K.); (Y.S.Y.); (S.-B.L.); (C.S.Y.); (J.C.K.)
| | - Chang Sik Yu
- Asan Medical Center, Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Seoul 05505, Korea; (E.C.); (J.L.L.); (C.W.K.); (Y.S.Y.); (S.-B.L.); (C.S.Y.); (J.C.K.)
| | - Jin Cheon Kim
- Asan Medical Center, Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Seoul 05505, Korea; (E.C.); (J.L.L.); (C.W.K.); (Y.S.Y.); (S.-B.L.); (C.S.Y.); (J.C.K.)
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94
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Haak HE, Beets GL, Peeters K, Nelemans PJ, Valentini V, Rödel C, Kuo L, Calvo FA, Garcia-Aguilar J, Glynne-Jones R, Pucciarelli S, Suarez J, Theodoropoulos G, Biondo S, Lambregts DMJ, Beets-Tan RGH, Maas M. Prevalence of nodal involvement in rectal cancer after chemoradiotherapy. Br J Surg 2021; 108:1251-1258. [PMID: 34240110 DOI: 10.1093/bjs/znab194] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 04/28/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND The purpose of this study was to investigate the prevalence of ypN+ status according to ypT category in patients with locally advanced rectal cancer treated with chemoradiotherapy and total mesorectal excision, and to assess the impact of ypN+ on disease recurrence and survival by pooled analysis of individual-patient data. METHODS Individual-patient data from 10 studies of chemoradiotherapy for rectal cancer were included. Pooled rates of ypN+ disease were calculated with 95 per cent confidence interval for each ypT category. Kaplan-Meier and Cox regression analyses were undertaken to assess influence of ypN status on 5-year disease-free survival (DFS) and overall survival (OS). RESULTS Data on 1898 patients were included in the study. Median follow-up was 50 (range 0-219) months. The pooled rate of ypN+ disease was 7 per cent for ypT0, 12 per cent for ypT1, 17 per cent for ypT2, 40 per cent for ypT3, and 46 per cent for ypT4 tumours. Patients with ypN+ disease had lower 5-year DFS and OS (46.2 and 63.4 per cent respectively) than patients with ypN0 tumours (74.5 and 83.2 per cent) (P < 0.001). Cox regression analyses showed ypN+ status to be an independent predictor of recurrence and death. CONCLUSION Risk of nodal metastases (ypN+) after chemoradiotherapy increases with advancing ypT category and needs to be considered if an organ-preserving strategy is contemplated.
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Affiliation(s)
- H E Haak
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands.,GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
| | - G L Beets
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands.,GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
| | - K Peeters
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - P J Nelemans
- Department of Epidemiology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - V Valentini
- Department of Radiation Oncology, Universita Cattolica del Sacro Cuore, Rome, Italy
| | - C Rödel
- Department of Radiation Oncology, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - L Kuo
- Department of Colorectal Surgery, Taipei Medical University Hospital, Taipei, Taiwan
| | - F A Calvo
- Department of Oncology, General University Hospital Gregorio Marañón, Madrid, Spain
| | - J Garcia-Aguilar
- Department of Surgery, Memorial Sloan Kettering Cancer Centre, New York, USA
| | - R Glynne-Jones
- Department of Clinical Oncology, Mount Vernon Hospital, London, UK
| | - S Pucciarelli
- Department of Surgical, Oncological and Gastroenterological Sciences, First Surgical Clinic, University of Padua, Padua, Italy
| | - J Suarez
- Department of Surgery, Hospital de Navarra, Pamplona, Spain
| | - G Theodoropoulos
- First Department of Propaedeutic Surgery, Athens Medical School, Hippocration General Hospital, Athens, Greece
| | - S Biondo
- Department of Surgery, Bellvitge University Hospital, Barcelona, Spain.,IDIBELL, University of Barcelona, Barcelona, Spain
| | - D M J Lambregts
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - R G H Beets-Tan
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands.,Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - M Maas
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
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95
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Nishi M, Shimada M, Tokunaga T, Higashijima J, Yoshikawa K, Kashihara H, Takasu C, Ishikawa D, Wada Y, Eto S, Yoshimoto T. Lymphocyte to C-reactive protein ratio predicts long-term outcomes for patients with lower rectal cancer. World J Surg Oncol 2021; 19:201. [PMID: 34229704 PMCID: PMC8262012 DOI: 10.1186/s12957-021-02319-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/25/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUNDS The lymphocyte to C-reactive protein (CRP) ratio (LCR) is an indicator of systemic inflammation and host-tumor cell interactions. The aim of this study was to investigate the prognostic significance of LCR in lower rectal cancer patients who received preoperative chemo-radiotherapy (CRT). METHODS Forty-eight patients with lower rectal cancer who underwent CRT followed by curative surgery were enrolled in this study. Routine blood examinations were performed before and after CRT were used to calculate pre-CRT LCR and post-CRT LCR. The median LCR was used to stratify patients into low and high LCR groups for analysis. The correlation between pre- and post-CRT LCR and clinical outcomes was retrospectively investigated. RESULTS The pre-CRT LCR was significantly higher than the post-CRT LCR (11,765 and 6780, respectively, P < 0.05). The 5-year overall survival rate was significantly higher for patients with high post-CRT LCR compared with low post-CRT LCR (90.6% and 65.5%, respectively, P < 0.05). In univariate analysis, post-CRT LCR, post-CRT neutrophil to lymphocyte ratio, and fStage were significant prognostic factors for overall survival. In multivariate analysis, post-CRT LCR, but not other clinicopathological factors or prognostic indexes, was a significant prognostic factor for overall survival (P < 0.05). CONCLUSIONS Post-CRT LCR could be a prognostic biomarker for patients with lower rectal cancer.
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Affiliation(s)
- Masaaki Nishi
- Department of Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan.
| | - Mistuo Shimada
- Department of Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan
| | - Takuya Tokunaga
- Department of Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan
| | - Jun Higashijima
- Department of Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan
| | - Kozo Yoshikawa
- Department of Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan
| | - Hideya Kashihara
- Department of Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan
| | - Chie Takasu
- Department of Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan
| | - Daichi Ishikawa
- Department of Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan
| | - Yuma Wada
- Department of Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan
| | - Shohei Eto
- Department of Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan
| | - Toshiaki Yoshimoto
- Department of Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan
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96
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Santiago I, Barata MJ, Figueiredo N, Parés O, Matos C. Early conformational changes at tumour bed and long term response after neoadjuvant therapy in locally-advanced rectal cancer. Eur J Radiol 2021; 140:109742. [PMID: 33971571 DOI: 10.1016/j.ejrad.2021.109742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 03/24/2021] [Accepted: 04/23/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To evaluate how changes in tumour scar depth angle and thickness in the post-neoadjuvant period relate to long-term response in locally-advanced rectal cancer patients. METHODS Informed consent was obtained from all patients and institutional review board approved this retrospective study. Sixty-nine consecutive locally-advanced rectal cancer patients who underwent neoadjuvant therapy and were selected for "Watch-and-Wait" were enrolled. Two radiologists, O1 and O2, blindly and independently reviewed the 1st and 2nd post-neoadjuvant therapy pelvic MRI T2-weighted images and recorded depth angle and thickness of the tumour scar. Value changes were calculated by simple subtraction (2nd-1st). Mann-Whitney U test was employed to assess for significant differences between sustained clinical complete responders (SCR), defined as patients with pathologic complete response or clinical complete response with a minimum follow-up of 1 year; and non-sustained complete responders (non-SCR). Interobserver agreement was estimated using intraclass correlation coefficient (ICC). Data on mrTRG, DWI and endoscopy at 1st and 2nd timepoints were retrieved for comparison. RESULTS In SCR, depth angle change between 1st (med = 10 weeks after end of radiotherapy) and 2nd (med = 23 weeks after end of radiotherapy) timepoints was significantly different (O1:p = 0.004; O2:p = 0.010): the SCR group showed a depth angle reduction (O1:med=-4.45; O2:med=-2.35), whereas non-SCRs showed a depth angle increase (O1:med=+2.60; O2:med=+7.40). Also, at 2nd timepoint, SCR scars were significantly thinner both for O1 (p = 0.003; SCR:med = 7.05 mm; non-SCR:med = 9.4 mm) and O2 (p = 0.006; SCR:med = 6.45 mm; non-SCR:med = 8.2 mm). A depth angle increase >21º between 1st and 2nd timepoints and a scar thickness >10 mm at 2nd timepoint were not sensitive but were highly specific for a non-SCR (91/94 %) for both observers. Interobserver agreement was good for scar depth angle change (ICC = 0.65) and excellent for scar thickness at 2nd timepoint (ICC = 0.84). Of the retrieved data, only DWI at 2nd timepoint was discriminative (p = 0.043) providing a similar sensitivity (33 %) and a slightly lower specificity (87.5 %). CONCLUSION Tumour scar expansion >21° between 1st and 2nd post-neoadjuvancy MRI and a scar thickness >10 mm at 2nd post-neoadjuvancy MRI may consistently indicate a non-SCR with high specificity in locally-advanced rectal cancer patients.
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Affiliation(s)
- Inês Santiago
- Radiology Department, Champalimaud Foundation, Avenida Brasília, Lisbon, 1400-038, Portugal; Nova Medical School, Campo Mártires da Pátria 130, Lisbon, 1169-056, Portugal.
| | - Maria-João Barata
- Radiology Department, Champalimaud Foundation, Avenida Brasília, Lisbon, 1400-038, Portugal
| | - Nuno Figueiredo
- Colorectal Surgery, Digestive Unit, Champalimaud Foundation, Avenida Brasília, Lisbon, 1400-038, Portugal
| | - Oriol Parés
- Radiation Oncology Department, Champalimaud Foundation, Avenida Brasília, Lisbon, 1400-038, Portugal
| | - Celso Matos
- Radiology Department, Champalimaud Foundation, Avenida Brasília, Lisbon, 1400-038, Portugal
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97
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Haak HE, Žmuc J, Lambregts DMJ, Beets-Tan RGH, Melenhorst J, Beets GL, Maas M. The evaluation of follow-up strategies of watch-and-wait patients with a complete response after neoadjuvant therapy in rectal cancer. Colorectal Dis 2021; 23:1785-1792. [PMID: 33725387 DOI: 10.1111/codi.15636] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/19/2021] [Accepted: 03/05/2021] [Indexed: 12/25/2022]
Abstract
AIM Many of the current follow-up schedules in a watch-and-wait approach include very frequent MRI and endoscopy examinations to ensure early detection of local regrowth (LR). The aim of this study was to analyse the occurrence and detection of LR in a watch-and-wait cohort and to suggest a more efficient follow-up schedule. METHOD Rectal cancer patients with a clinical complete response after neoadjuvant therapy were prospectively and retrospectively included in a multicentre watch-and-wait registry between 2004 and 2018, with the current follow-up schedule with 3-monthly endoscopy and MRI in the first year and 6 monthly thereafter. A theoretical comparison was constructed for the detection of LR in the current follow-up schedule against four other hypothetical schedules. RESULTS In all, 50/304 (16%) of patients developed a LR. The majority (98%) were detected at ≤2 years, located in the lumen (94%) and were visible on endoscopy (88%). The theoretical comparison of the different hypothetical schedules suggests that the optimal follow-up schedule should focus on the first 2 years with 3-monthly endoscopy and 3-6 monthly MRI. Longer intervals in the first 2 years will cause delays in diagnosis of LR ranging from 0 to 5 months. After 2 years, increasing the interval from 6 to 12 months did not cause important delays. CONCLUSION The optimal follow-up schedule for a watch-and-wait policy in patients with a clinical complete response after chemoradiation for rectal cancer should include frequent endoscopy and to a lesser degree MRI in the first 2 years. Longer intervals, up to 12 months, can be considered after 2 years.
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Affiliation(s)
- Hester E Haak
- Department of Surgery, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands.,GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Jan Žmuc
- Department of Surgical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Doenja M J Lambregts
- Department of Radiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Regina G H Beets-Tan
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands.,Department of Radiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Jarno Melenhorst
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Geerard L Beets
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands.,Department of Radiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Monique Maas
- Department of Radiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
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98
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Liu LL, Sun JD, Xiang ZL. A nomogram to predict the prognosis of patients with unresected rectal adenocarcinoma undergoing chemoradiotherapy: a population-based study. J Cancer 2021; 12:4745-4761. [PMID: 34234846 PMCID: PMC8247370 DOI: 10.7150/jca.61642] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 05/29/2021] [Indexed: 02/02/2023] Open
Abstract
Background: Chemotherapy combined with radiotherapy is the main treatment strategy for unresectable rectal cancer. However, the prognostic factors of patients with unresectable rectal cancer treated with radiotherapy and chemotherapy have not been systematically studied. Therefore, this study investigated the prognostic factors and prognosis based on surveillance, epidemiology and final results of the SEER medical insurance database. Methods: Primary rectum patients were selected from the SEER database. The independent prognostic factors associated with overall survival (OS), cancer-specific survival (CSS) and noncancer-related death were evaluated using the Kaplan-Meier method and log-rank test, a competing risk model, and the Cox proportional hazards regression model. Two nomograms were established for predicting the 1- and 3-year OS and CSS of patients. Results: A total of 3,998 rectal adenocarcinoma cancer patients who received chemoradiotherapy but had not undergone surgery were included in this study and divided into training (n = 3559) and validation cohorts (n = 439). Patients in the training cohort had a 1-year OS rate of 65.7±0.8%, a 3-year OS rate of 26.6±0.8%, a 5-year OS rate of 1.6±0.8%, and a median survival rate of 20.0 months (range, 19.22-20.8 months). The following factors were significant prognostic factors of OS: age (p< 0.001); tumour grade (p< 0.001); T stage (p< 0.001); M stage (p< 0.001); bone metastasis (p<0.001); brain metastases (p<0.001); liver metastases (p<0.001); lung metastases (p<0.001); marital status (p<0.001) and insurance status (p=0.005). Age (p< 0.001), tumour grade (p< 0.001), T stage (p< 0.001), M stage (p< 0.001), bone metastasis (p<0.001), brain metastases (p<0.001), liver metastases (p<0.001), lung metastases (p<0.001) and race (p=0.034) were independent prognostic factors of CSS. Age (p< 0.001), T stage (p< 0.001), N stage (p=0.007), M stage (p<0.001), liver metastases (p<0.001), lung metastases (p<0.001), marital status (p<0.001) and insurance status (p=0.019) were independently associated with noncancer-related death. Conclusion: Age, tumour grade, T and M stage, bone, brain, liver and lung metastases, marital status and insurance status are independent risk factors for the OS of rectal adenocarcinoma patients who have undergone chemoradiotherapy but have not undergone surgery. Age, tumour grade, T stage, M stage, bone, brain, liver, lung metastases and race were independent prognostic factors of CSS. Age, T, N and M stage, liver and lung metastases, marital status and insurance status, were independently associated with noncancer-related death. Interestingly, the earlier the T stage was, the higher the rate of noncancer-related death. Two nomograms were developed to predict OS and CSS, and the C-indexes were 0.6776 and 0.6744, respectively. Rectal cancer screening is strongly recommended for patients under the age of 50.
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Affiliation(s)
- Lin-Lin Liu
- Department of Radiation Oncology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200120, China
| | - Jun-Die Sun
- Department of Radiation Oncology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200120, China
| | - Zuo-Lin Xiang
- Department of Radiation Oncology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200120, China
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99
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Rektumkarzinom. COLOPROCTOLOGY 2021. [DOI: 10.1007/s00053-021-00541-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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100
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Jiménez-Rodríguez R, García-Aguilar J. Non Surgical Treatment in Patients With Advanced Rectal Cancer. Cir Esp 2021; 99:401-403. [PMID: 34052165 DOI: 10.1016/j.cireng.2020.06.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 06/07/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Rosa Jiménez-Rodríguez
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, United States
| | - Julio García-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, United States.
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