Preoperative radiotherapy versus selective postoperative chemoradiotherapy in patients with rectal cancer (MRC CR07 and NCIC-CTG C016): a multicentre, randomised trial

Magnetic resonance imaging-detected lymph nodes close to the mesorectal fascia are rarely a cause of margin involvement after total mesorectal excision

BACKGROUND

In rectal cancer the management of suspicious magnetic resonance imaging (MRI)-detected lymph nodes lying close to the mesorectal fascia poses an ongoing dilemma. Key decisions in treatment planning are commonly based on the prediction of margin status. However, it is unclear whether a lymph node that appears to contain tumour close to the mesorectal fascia will result in a positive margin.

METHODS

Some 396 patients with rectal cancer were included. MRI assessment of mesorectal nodes, the pathologically involved circumferential resection margin (CRM) rate and causes of margin involvement were analysed to establish the clinical significance of MRI-detected suspicious lymph nodes at the resection margin.

RESULTS

Fifty (12.6 per cent) of 396 patients had a positive CRM on histopathological analysis, five (10 per cent) solely due to an involved lymph node. Four of the five malignant nodes were not predicted on MRI. Thirty-one of the 396 MRI studies had suspicious nodes 1 mm or less from the CRM. None of these patients had a positive CRM owing to nodal involvement.

CONCLUSION

Involvement of the CRM by lymph node metastases alone is uncommon.

Do all locally advanced rectal cancers require radiation? A review of literature in the modern era

Potentially curable rectal cancer is primarily treated with surgical resection. Adjuvant or neoadjuvant radiotherapy is often utilized for patients deemed to be at unacceptable risk for local recurrence. The purpose of this article is to review the pertinent literature and elucidate the role of radiotherapy in patients with an intermediate risk of local recurrence. The addition of chemoradiotherapy is recommended in the majority of patients with transmural or node positive rectal cancer. However, some patients with favorable characteristics may have only a small incremental benefit from the addition of radiotherapy. The decision to treat or not to treat should take into consideration the patient and physician tolerance of risk of recurrence and risk of treatment related toxicity. The primary factors identified for determining low risk patients are circumferential radial margin (CRM), location within the rectum, and nodal status. Patients at lowest risk have widely negative CRM (>2mm), proximal lesions (>10cm from the anal verge), and no nodal disease. Patients with all three low risk factors have an absolute reduction in local recurrence that is <5% and may be eligible to forego radiotherapy. Additional factors identified which may impact local recurrence risk are elevated serum CEA level, lymphovascular space invasion, pathologic grade, and extramural space invasion.

Clinical algorithms for the surgical management of locally recurrent rectal cancer

PURPOSE

Advances in surgical practice have helped expand the options for patients with locally recurrent rectal cancer through improvements in reconstructive options, management of operative complications, addition of intraoperative adjuvant therapies, and postoperative care. This review outlines the presentation and management of patients with locally recurrent rectal cancer, and it describes easy-to-apply clinical algorithms to aid management.

METHODS

The electronic literature was searched for studies reporting outcomes for locally recurrent rectal cancer limited to the English language.

RESULTS

Prospective and retrospective case series and single-center experiences were identified. A total of 106 articles were selected for full-text review of which 82 fulfilled the inclusion criteria. No randomized studies were identified. We found that multimodality treatment of locally recurrent rectal cancer can improve 5-year survival from 0% to over 40%, and selected patients may survive up to 10 years. A mixture of imaging modalities is used in patient selection for surgery. An R0 resection is consistently a favorable prognostic factor. R1 resection and surgery in the setting of oligometastases compare favorably with nonoperative palliation. Although mortality figures remain low, morbidity is significant and mostly wound related.

CONCLUSIONS

Improvements in radiological imaging modalities and technical improvements in surgical and reconstructive options have facilitated more accurate staging, better selection of patients for surgery, reduced morbidity and mortality, and higher R0 resections. Optimal management is in specialist units with a multidisciplinary approach with the use of multimodal therapy.

The cluster-randomized Quality Initiative in Rectal Cancer trial: evaluating a quality-improvement strategy in surgery

BACKGROUND

Following surgery for rectal cancer, two unfortunate outcomes for patients are permanent colostomy and local recurrence of cancer. We tested whether a quality-improvement strategy to change surgical practice would improve these outcomes.

METHODS

Sixteen hospitals were cluster-randomized to the intervention (Quality Initiative in Rectal Cancer strategy) or control (normal practice) arm. Consecutive patients with primary rectal cancer were accrued from May 2002 to December 2004. Surgeons at hospitals in the intervention arm could voluntarily participate by attending workshops, using opinion leaders, inviting a study team surgeon to demonstrate optimal techniques of total mesorectal excision, completing postoperative questionnaires, and receiving audits and feedback. Main outcome measures were hospital rates of permanent colostomy and local recurrence of cancer.

RESULTS

A total of 56 surgeons (n = 558 patients) participated in the intervention arm and 49 surgeons (n = 457 patients) in the control arm. The median follow-up of patients was 3.6 years. In the intervention arm, 70% of surgeons participated in workshops, 70% in intraoperative demonstrations and 71% in postoperative questionnaires. Surgeons who had an intraoperative demonstration provided care to 86% of the patients in the intervention arm. The rates of permanent colostomy were 39% in the intervention arm and 41% in the control arm (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.63-1.48). The rates of local recurrence were 7% in the intervention arm and 6% in the control arm (OR 1.06, 95% CI 0.68-1.64).

INTERPRETATION

Despite good participation by surgeons, the resource-intense quality-improvement strategy did not reduce hospital rates of permanent colostomy or local recurrence compared with usual practice.

Sexual function in females after radiotherapy for rectal cancer

BACKGROUND

Knowledge about female sexual problems after pre- or postoperative (chemo-)radiotherapy and radical resection of rectal cancer is limited. The aim of this study was to compare self-rated sexual functioning in women treated with or without radiotherapy (RT+ vs. RT-), at least two years after surgery for rectal cancer.

METHODS AND MATERIALS

Female patients diagnosed from 1993 to 2003 were identified from a national database, the Norwegian Rectal Cancer Registry. Eligible patients were without recurrence or metastases at the time of the study. The Sexual function and Vaginal Changes Questionnaire (SVQ) was used to measure sexual functioning.

RESULTS

Questionnaires were returned from 172 of 332 invited and eligible women (52%). The mean age was 65 years (range 42-79) and the time since surgery for rectal cancer was 4.5 years (range 2.6-12.4). Sexual interest was not significantly impaired in RT+ (n=62) compared to RT- (n=110) women. RT+ women reported more vaginal problems in terms of vaginal dryness (50% vs. 24%), dyspareunia (35% vs. 11%) and reduced vaginal dimension (35% vs. 6%) compared with RT- patients; however, they did not have significantly more worries about their sex life.

CONCLUSION

An increased risk of dyspareunia and vaginal dryness was observed in women following surgery combined with (chemo-)radiotherapy compared with women treated with surgery alone. Further research is required to determine the effect of adjuvant therapy on female sexual function.

Radiation, chemotherapy and biological therapy in the curative treatment of locally advanced rectal cancer

OBJECTIVE

To review the published evidence relating to the use of radiotherapy (RT), chemotherapy and biological therapy as adjuncts to surgery in the curative treatment of rectal cancer.

METHODS

Searches were carried out of the MEDLINE and CANCERLIT databases together with conference abstracts from key meetings including the American Society of Clinical Oncology Annual Meeting and Gastrointestinal Cancers Symposium and the ECCO/ESMO Multidisciplinary Congress.

RESULTS

RT reduces local pelvic recurrence when used as an adjunct to surgery, even when this is performed optimally by total mesorectal excision (TME). RT is usually given as short-course preoperative radiotherapy (SCPRT) followed by immediate surgery which produces no or very little downstaging or long-course concurrent chemoradiation (CRT) followed by a 6-8 week gap prior to surgery which produces significant downstaging. The prognostic importance of achieving a clear histological circumferential resection margin is now well recognised and pathological assessment of the quality of surgery can predict long-term outcomes. Internationally there is considerable heterogeneity in the staging modalities and criteria used in deciding which approach might be used, in the reporting of histological results and in RT parameters (time/dose/fractionation/volume). Attempts to increase the potency of CRT have included the addition of concurrent chemotherapeutic and biological agents to the standard fluoropyrimidine although there is little randomised data and none with regard to long-term survival outcomes. Neither SCPRT nor downstaging CRT have been shown to reduce the rate of subsequent distant metastatic relapse which remains a significant clinical problem. The potential additional benefit of neoadjuvant or adjuvant chemotherapy in addition to SCPRT or long-course CRT remains ill-defined. Late morbidity can include bowel and sexual dysfunction, pelvic fractures and second malignancies with considerably more being known in relation to SCPRT than long-course CRT.

CONCLUSIONS

Improvements in imaging, pathology and surgical technique combined with multimodality treatment using RT and chemotherapy are leading to continuing improvements in the long term outcome for patients with rectal cancer although much remains to be learnt regarding the optimum strategy for use of these in different clinical contexts and their relationship to long-term morbidity.

Risk factors for symptomatic anastomotic leakage after low anterior resection for rectal cancer with 30 Gy/10 f/2 w preoperative radiotherapy

OBJECTIVE

This retrospective study was designed to analyze the risk factors for symptomatic leakage after low anterior resection (LAR) for patients with rectal cancer who received 30 Gy/10 f/2 w preoperative radiotherapy.

METHODS

From April 2002 to December 2008, a total of 223 patients with mid-low rectal cancer received 30 Gy/10 f/2 w preoperative radiotherapy and underwent LAR. Six patients were excluded for positive air test, incomplete anastomotic rings, or other major adverse intraoperative events. In the 217 patients with satisfactory anastomoses, 15 probably factors relating to anastomotic leakage were recorded and statistically analyzed.

RESULTS

The median patient age was 57 years, and 48% were women. The median level of anastomosis was 6 cm, median operating time was 130 minutes, and intraoperative blood loss was 200 ml. The symptomatic leakage rate was 11.5% (25/217). Multivariable analysis demonstrated that male gender (odds ratio (OR) = 2.63; p = 0.0474), level of anastomosis < or =4 cm (OR = 8.80; p = 0.038), no defunctioning stoma (OR = 3.80; p = 0.038), and blood loss >200 ml (OR = 3.32; p = 0.080) were the independent risk factors for anastomotic leakage.

CONCLUSIONS

For patients with rectal cancer treated with preoperative radiotherapy and low anterior resection, the risk factors for anastomotic leakage are male gender, lack of defunctioning stoma, level of anastomosis < or =4 cm, and blood loss >200 ml. A defunctioning stoma can decrease the occurrence of symptomatic anastomotic leakage and should be routinely performed in all low anterior resections after 30 Gy/10 f/2 w preoperative radiotherapy.

Sphincter preservation in rectal cancer is associated with patients' socioeconomic status

Background

Decision making regarding the choice of surgical procedure in rectal cancer is complex. It was hypothesized that, in addition to clinical factors, several aspects of patients' socioeconomic background influence this process.

Methods

Individually attained data on civil status, education and income were linked to the Swedish Rectal Cancer Registry 1995–2005 (16 713 patients) and analysed by logistic regression.

Results

Anterior resection (AR) was performed in 7433 patients (44·5 per cent), abdominoperineal resection (APR) in 3808 (22·8 per cent) and Hartmann's procedure in 1704 (10·2 per cent). Unmarried patients were least likely (odds ratio (OR) 0·76, 95 per cent confidence interval (c.i.) 0·64 to 0·88) and university-educated men were most likely (OR 1·30, 1·04 to 1·62) to have an AR. Patients with the highest income were more likely to undergo AR (OR 0·80, 0·85 and 0·86 respectively for first, second and third income quartiles). Socioeconomic differences in the use of AR were smallest among the youngest patients. Unmarried patients were more likely (OR 1·21, 95 per cent c.i. 1·00 to 1·48) and university-educated patients less likely (OR 0·78, 95 per cent c.i. 0·63 to 0·98) to have an APR.

Conclusion

The choice of surgical strategy in rectal cancer is not socioeconomically neutral. Confounding factors, such as co-morbidity or smoking, may explain some of the differences but inequality in treatment is also plausible.

Impact of short-course preoperative radiotherapy for rectal cancer on patients' quality of life: data from the Medical Research Council CR07/National Cancer Institute of Canada Clinical Trials Group C016 randomized clinical trial

PURPOSE

The Medical Research Council CR07/National Cancer Institute of Canada Clinical Trials Group C016 (MRC CR07/NCIC CTG C016) trial showed that, in patients with operable rectal cancer, short-course preoperative radiotherapy (PRE) reduced the rate of local recurrence compared with surgery followed by selective postoperative chemoradiotherapy for patients with a positive circumferential resection margin. However, the advantages of giving PRE to all patients needs to be balanced against any negative impact on patients' quality of life.

PATIENTS AND METHODS

All 1,350 patients were asked to complete the Medical Outcomes Study Short-Form 36-item (MOS SF-36) and the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Colorectal 38-item (EORTC QLQ-CR38) questionnaires. A priori hypotheses related to the impact of treatment on sexual, bowel, and physical function and general health.

RESULTS

Male sexual dysfunction was significantly increased following surgery (P < .001), although there was no difference between treatment arms. However, a treatment difference had emerged at 6 months (PRE patients reporting significantly greater dysfunction; P = .004), which persisted out to at least 2 years (an insufficient number of female patients completed the sexual dysfunction questions to draw firm conclusions). Both treatment groups reported similar levels of decreased physical function at 3 months, but thereafter it returned to baseline levels. There was no evidence of any major changes between treatments or time points in terms of general health or bowel function, but exploratory analysis indicated a significant (P = .006 at 2 years) increase in the level of fecal incontinence with PRE.

CONCLUSION

These results from a large randomized trial using validated patient-completed questionnaires show that, for males, the main adverse effect was sexual dysfunction, and the main cause of this was surgery, but that PRE also affected sexual and some aspects of bowel functioning.

Three-dimensional analysis of recurrence patterns in rectal cancer: the cranial border in hypofractionated preoperative radiotherapy can be lowered

PURPOSE

The aim of this study was to determine whether and where the radiotherapy (RT) clinical target volume (CTV) could be reduced in short-course preoperative treatment of rectal cancer patients.

METHODS AND MATERIALS

Patients treated in the Dutch total mesorectal excision trial, with a local recurrence were analyzed. For 94 (25 who underwent radiation therapy 69 who did not) of 114 patients with a local recurrence, the location of the recurrence was placed in a three-dimensionalthree (3D) model. The data in the 3D model were correlated to the clinical trial data to distinguish a group of patients eligible for CTV reduction. Effects of CTV reduction on dose to the small bowel was tested retrospectively in a dataset of 8 patients with three-field conformal plans and intensity-modulated RT (IMRT).

RESULTS

The use of preoperative RT mainly reduces anastomotic, lateral, and perineal recurrences. In patients without primary nodal involvement, no recurrences were found cranially of the S2-S3 interspace, irrespective of the delivery of RT. In patients without primary nodal involvement and a negative circumferential resection margin (CRM), only one recurrence was found cranial to the S2-S3 interspace. With a cranially reduced CTV to the S2-S3 interspace, over 60% reduction in absolute small bowel exposure at dose levels from 15 to 35 Gy could be achieved with three-field conventional RT, increasing to 80% when IMRT is also added.

CONCLUSIONS

The cranial border of the CTV can safely be lowered for patients without expected nodal or CRM involvement, yielding a significant reduction of dose to the small bowel. Therefore, a significant reduction of acute and late toxicity can be expected.

Identification of a quantitative MINT locus methylation profile predicting local regional recurrence of rectal cancer

PURPOSE

Risk assessment for locoregional disease recurrence would be highly valuable in preoperative treatment planning for patients undergoing primary rectal tumor resection. Epigenetic aberrations such as DNA methylation have been shown to be significant prognostic biomarkers of disease outcome. In this study, we evaluated the significance of a quantitative epigenetic multimarker panel analysis of primary tumors to predict local recurrence in rectal cancer patients from a retrospective multicenter clinical trial.

EXPERIMENTAL DESIGN

Primary tumors were studied from patients enrolled in the trial who underwent total mesorectal excision for rectal cancer (n=325). Methylation levels of seven methylated-in-tumor (MINT) loci were assessed by absolute quantitative assessment of methylated alleles. Unsupervised random forest clustering of quantitative MINT methylation data was used to show subclassification into groups with matching methylation profiles.

RESULTS

Variable importance parameters [Gini-Index (GI)] of the clustering algorithm indicated MINT3 and MINT17 (GI, 20.2 and 20.7, respectively) to be informative for patient grouping compared with the other MINT loci (highest GI, 12.2). When using this two-biomarker panel, four different patient clusters were identified. One cluster containing 73% (184 of 251) of the patients was at significantly increased risk of local recurrence (hazard ratio, 10.23; 95% confidence interval, 1.38-75.91) in multivariate analysis, corrected for standard prognostic factors of rectal cancer. This group showed a significantly higher local recurrence probability than patients receiving preoperative radiation (P<0.0001).

CONCLUSION

Quantitative epigenetic subclassification of rectal cancers has clinical utility in distinguishing tumors with increased risk for local recurrence and may help tailor treatment regimens for locoregional control.

Surgery for recurrent rectal cancer: technical notes and management of complications

Local recurrence following surgery for rectal cancer remains a significant clinical problem and poses major therapeutic challenges. Radical surgical salvage is the only option with potential for curative treatment and is indicated in carefully selected patients. Surgery also provides acceptable palliation in certain cases. Nevertheless, such surgery is challenging, not commonly used, and historically associated with considerable morbidity and mortality. In more recent times, improvements in surgical techniques, reconstruction methods and management of perioperative complications have helped expand the options available for patients with recurrent rectal cancer. This review article highlights the techniques employed at our institution for the management of locally recurrent rectal cancer with particular emphasis on the surgical approaches, the methods used for reconstruction and the avoidance of complications.

Prospective assessment of imaging after preoperative chemoradiotherapy for rectal cancer

BACKGROUND

The aim of the study was to assess the accuracy of imaging techniques in predicting pathologic tumor (ypT), node (ypN) stages and the circumferential resection margin (ypCRM) status of rectal cancers after preoperative chemoradiotherapy (CRT).

METHODS

Using pelvic computed tomography (CT), magnetic resonance imaging (MRI), and endorectal ultrasound (ERUS), 90 consecutive patients with locally advanced mid-to-low rectal cancer were prospectively assessed. Postirradiation T and N stages and infiltration of the CRM, as assessed by CT, MRI and ERUS, were compared with histopathologic findings.

RESULTS

The accuracy of ypT staging was low, whatever the imaging technique used (37% by CT, 34% by MRI, and 27% by ERUS), the most frequent inaccuracy being overstaging. Imaging showed a good specificity and good negative predictive values (NPV) when mural staging was grouped into ypT ≤ 3 and ypT4 categories; in particular, ERUS achieved a 92% specificity and 95% NPV. CRM involvement was correctly predicted in 71% of patients by CT (74% specificity; 93% NPV) and in 85% by MRI (88% specificity; 95% NPV). The accuracy for nodal staging was 62%, 68%, and 65% by CT, MRI and ERUS, respectively; the corresponding NPV were 88%, 78%, and 76%.

CONCLUSION

Current imaging techniques are inaccurate in restaging rectal cancer after CRT but are useful in predicting T ≤ 3 tumors, cases with negative nodes and tumor-free CRM. These findings may be of clinical relevance for planning less invasive surgery.

Does a rectal cancer of the upper third behave more like a colon or a rectal cancer?

PURPOSE

This study aimed to evaluate whether cancers in the upper third of the rectum should be treated according to colon or rectal cancer guidelines.

METHODS

We evaluated 499 patients with tumors located in the sigmoid colon (299 patients, 60%), the upper third of the rectum (95 patients, 19%), or the middle third of the rectum (105 patients, 21%), International Union against Cancer tumor stage II or III, no preoperative radiochemotherapy, and primary curative tumor resection between 1990 and 2006. Patients' surgical, histopathological, and prognostic parameters were compared. The median follow-up time was 80 months.

RESULTS

Patients with sigmoid cancer showed a trend of significantly better estimated cause-specific survival (5-y value +/- 95% CI: 83.6 +/- 4.7%) compared with patients with rectal cancers of the upper third of the rectum (5-y value +/- 95% CI: 74.3 +/- 9.6%) or the middle third of the rectum (5-y value +/- 95% CI: 73.4 +/- 9.2%) (P = .063). Tumor location was an independent prognostic parameter (P = .036), with an increased risk of cause-specific death for rectal cancers of the upper third (hazard ratio, 1.87; P = .007) and of the middle third (hazard ratio, 1.43; P = .022) compared with sigmoid cancers. Stratification of upper third rectal cancers according to tumor grade, tumor infiltration depth (pT), and lymph node status (pN) identified a high-risk group.

CONCLUSIONS

Cancers of the upper third of the rectum have more similarities with rectal cancers of the middle third of the rectum than with sigmoid cancers. A subgroup of patients with upper third rectal cancer can be identified who may require a more aggressive therapy than only primary resection followed by adjuvant therapy.

[Rectal cancer: which patients benefit from radiotherapy?]

The prognosis of patients with rectal cancer has improved in recent years, particularly as regards the lower probability of local recurrence. These positive results are obtained through correct preoperative staging and an adequate surgical resection of the affected lesion, as well as a multidisciplinary therapeutic approach. Based on the available scientific evidence, our aim is to clarify the framework in which options for the right therapy can be taken, especially in relation to the preoperative staging and its limitations, with regards to radiotherapy and its indications. We also emphasize the need of a tailor-made approach for each case.

Phase I study of preoperative short-course chemoradiation with proton beam therapy and capecitabine for resectable pancreatic ductal adenocarcinoma of the head

PURPOSE

To evaluate the safety of 1 week of chemoradiation with proton beam therapy and capecitabine followed by early surgery.

METHODS AND MATERIALS

Fifteen patients with localized resectable, pancreatic adenocarcinoma of the head were enrolled from May 2006 to September 2008. Patients received radiation with proton beam. In dose level 1, patients received 3 GyE × 10 (Week 1, Monday-Friday; Week 2, Monday-Friday). Patients in Dose Levels 2 to 4 received 5 GyE × 5 in progressively shortened schedules: level 2 (Week 1, Monday, Wednesday, and Friday; Week 2, Tuesday and Thursday), Level 3 (Week 1, Monday, Tuesday, Thursday, and Friday; Week 2, Monday), Level 4 (Week 1, Monday through Friday). Capecitabine was given as 825 mg/m(2) b.i.d. Weeks 1 and 2 Monday through Friday for a total of 10 days in all dose levels. Surgery was performed 4 to 6 weeks after completion of chemotherapy for Dose Levels 1 to 3 and then after 1 to 3 weeks for Dose Level 4.

RESULTS

Three patients were treated at Dose Levels 1 to 3 and 6 patients at Dose Level 4, which was selected as the MTD. No dose limiting toxicities were observed. Grade 3 toxicity was noted in 4 patients (pain in 1; stent obstruction or infection in 3). Eleven patients underwent resection. Reasons for no resection were metastatic disease (3 patients) and unresectable tumor (1 patient). Mean postsurgical length of stay was 6 days (range, 5-10 days). No unexpected 30-day postoperative complications, including leak or obstruction, were found.

CONCLUSIONS

Preoperative chemoradiation with 1 week of proton beam therapy and capecitabine followed by early surgery is feasible. A Phase II study is underway.

Self assessment questions in general surgery

The advent of Modernising Medical Careers has meant that many more junior doctors are coming into contact with general surgical patients either as part of Foundation Year 2 or Core Training rotation or during the course of cross covering other specialities due to the hours constraints of the European Working Time Directive. These scenarios are all common general surgical cases that such a junior doctor may be expected to manage.

Impact of neoadjuvant treatment on total mesorectal excision for ultra-low rectal cancers

Background

This study reviewed the impact of pre-operative chemoradiotherapy or post-operative chemotherapy and/or radiotherapy on total mesorectal excision (TME) for ultralow rectal cancers that required either low anterior resection with peranal coloanal anastomosis or abdomino-perineal resection (APR). We examined surgical complications, local recurrence and survival.

Methods

Of the 1270 patients who underwent radical resection for rectal cancer from 1994 till 2007, 180 with tumors within 4 cm with either peranal coloanal anastomosis or APR were analyzed. Patients were compared in groups that had surgery only (Group A), pre-operative chemoradiotherapy (Group B), and post-operative therapy (Group C).

Results

There were 115 males and the mean age was 65.43 years (range 30-89). APR was performed in 134 patients while 46 had a sphincter-preserving resection with peranal coloanal anastomosis. The mean follow-up period was 52.98 months (range: 0.57 to 178.9). There were 69, 58 and 53 patients in Groups A, B, and C, respectively. Nine patients in Group B could go on to have sphincter-saving rectal resection. The overall peri-operative complication rate was 43.4% in Group A vs. 29.3% in Group B vs. 39.6% in Group C, respectively. The local recurrence rate was significantly lower in Group B (8.6.9% vs. 21.7% in Group A vs. 33.9% in Group C) p < 0.05. The 5-year cancer-specific survival rates for Group A was 49.3%, Group B was 69.9% and Group C was 38.8% (p = 0.14).

Conclusion

Pre-operative chemoradiation in low rectal cancer is not associated with a higher incidence of peri-operative complications and its benefits may include reduction local recurrence.

Can chemotherapy concomitantly delivered with radiotherapy improve survival of patients with resectable rectal cancer? A meta-analysis of literature data

BACKGROUND

There is clear evidence from two systematic reviews that radiotherapy (RT) reduces the risk of local recurrence in patients with resectable rectal cancer, though the data on survival are still equivocal.

OBJECTIVE

To assess the effects of chemotherapy combined concomitantly with radiotherapy (CRT) on the increase of overall survival, and on the prevention of local recurrence and distant metastases.

DATA SOURCES

Computerized bibliographic searches of MEDLINE and CANCERLIT (1970-2008) were supplemented with hand searches of reference lists.

STUDY SELECTION

Studies were included if they were randomized controlled trials (RCTs) comparing preoperative or postoperative CRT to preoperative or postoperative RT alone, and if they included patients with resectable, histologically-proven, rectal adenocarcinoma without metastases. Thirteen RCTs, seven of preoperative CRT vs. preoperative RT (2787 patients), four of postoperative CRT vs. postoperative RT (726 patients) and two of postoperative CRT vs. preoperative RT (1400 patients), were analyzed.

DATA EXTRACTION

Data on population, intervention, and outcomes were extracted from each RCT, in accordance with the intention-to-treat method, by three independent observers, and combined using the DerSimonian method and Laird method.

RESULTS

Preoperative CRT compared to preoperative RT alone significantly reduces the 5-year local recurrence rate (RR 1.05; 95%CI 1.01-1.10). No increase was observed in 5-year overall survival rate (RR 0.94; 95%CI 0.94-1.09), and in the occurrence of distant metastases (RR 0.97; 95%CI 0.93-1.02). Instead, postoperative CRT did not reduce local recurrence (RR 0.96; 95%CI 0.80-1.16), distant metastases (RR 1.11; 95%CI 0.94-1.31) and overall mortality (RR 1.09; 95%CI 0.83-1.41). By pooling data on postoperative CRT vs. preoperative RT a significant reduction of local recurrence was found for the preoperative approach (RR 0.93; 95%CI 0.90-0.96), though no difference was found in distant metastases rates and overall survival. Finally, the risk of mortality related to toxic events was significantly higher when adding chemotherapy to radiotherapy (RR 2.86; 95%CI 0.99-8.26).

CONCLUSIONS

In patients with resectable rectal cancer, CRT does not increase overall survival, despite the fact that preoperative CRT significantly reduces the risk of the local recurrence. No reduction in the distant metastases rate was found. Toxicity-related mortality is significantly increased by the concomitant approach, emphasizing the need for safer treatment combinations.

Colorectal cancer

Substantial progress has been made in colorectal cancer in the past decade. Screening, used to identify individuals at an early stage, has improved outcome. There is greater understanding of the genetic basis of inherited colorectal cancer and identification of patients at risk. Optimisation of surgery for patients with localised disease has had a major effect on survival at 5 years and 10 years. For rectal cancer, identification of patients at greatest risk of local failure is important in the selection of patients for preoperative chemoradiation, a strategy proven to improve outcomes in these patients. Stringent postoperative follow-up helps the early identification of potentially radically treatable oligometastatic disease and improves long-term survival. Treatment with adjuvant fluoropyrimidine for colon and rectal cancers further improves survival, more so in stage III than in stage II disease, and oxaliplatin-based combination chemotherapy is now routinely used for stage III disease, although efficacy must be carefully balanced against toxicity. In stage II disease, molecular markers such as microsatellite instability might help select patients for treatment. The integration of targeted treatments with conventional cytotoxic drugs has expanded the treatment of metastatic disease resulting in incremental survival gains. However, biomarker development is essential to aid selection of patients likely to respond to therapy, thereby rationalising treatments and improving outcomes.

Comparison of two neoadjuvant chemoradiotherapy regimens for locally advanced rectal cancer: results of the phase III trial ACCORD 12/0405-Prodige 2

PURPOSE

Neoadjuvant chemoradiotherapy is considered a standard approach for T3-4 M0 rectal cancer. In this situation, we compared neoadjuvant radiotherapy plus capecitabine with dose-intensified radiotherapy plus capecitabine and oxaliplatin.

PATIENTS AND METHODS

We randomly assigned patients to receive 5 weeks of treatment with radiotherapy 45 Gy/25 fractions with concurrent capecitabine 800 mg/m(2) twice daily 5 days per week (Cap 45) or radiotherapy 50 Gy/25 fractions with capecitabine 800 mg/m(2) twice daily 5 days per week and oxaliplatin 50 mg/m(2) once weekly (Capox 50). The primary end point was complete sterilization of the operative specimen (ypCR).

RESULTS

Five hundred ninety-eight patients were randomly assigned to receive Cap 45 (n = 299) or Capox 50 (n = 299). More preoperative grade 3 to 4 toxicity occurred in the Capox 50 group (25 v 1%; P < .001). Surgery was performed in 98% of patients in both groups. There were no differences between groups in the rate of conservative surgery (75%) or postoperative deaths at 60 days (0.3%). The ypCR rate was 13.9% with Cap 45 and 19.2% with Capox 50 (P = .09). When ypCR was combined with yp few residual cells, the rate was respectively 28.9% with Cap 45 and 39.4% with Capox 50 (P = .008). The rate of positive circumferential rectal margins (between 0 and 2 mm) was 19.3% with Cap 45 and 9.9% with Capox 50 (P = .02).

CONCLUSION

The benefit of oxaliplatin was not demonstrated and this drug should not be used with concurrent irradiation. Cap 50 merits investigation for T3-4 rectal cancers.

Locally advanced rectal carcinoma treated with preoperative chemotherapy and radiation therapy: preliminary analysis of diffusion-weighted MR imaging for early detection of tumor histopathologic downstaging

PURPOSE

To determine whether changes in apparent diffusion coefficients (ADCs) of rectal carcinoma obtained 1 week after the beginning of chemotherapy and radiation therapy (CRT) correlate with tumor histopathologic downstaging after preoperative CRT.

MATERIALS AND METHODS

This prospective study was approved by an institutional review board; informed consent was obtained from all patients. Thirty-seven patients (mean age, 54.7 years; 13 women, 24 men) with primary rectal carcinoma who were undergoing preoperative CRT were recruited for the study. Diffusion-weighted (DW) magnetic resonance (MR) imaging was performed with a 1.5-T MR imager in all patients before therapy, at the end of the 1st and 2nd week of therapy, and before surgery. Tumor ADCs were calculated. Linear mixed-effects modeling was applied to analyze change in ADCs and volumes following treatment.

RESULTS

Patients were assigned to the tumor downstaged group (n = 17) or the tumor nondownstaged group (n = 20) on the basis of histopathologic examination results following surgery. Before CRT, the mean tumor ADC in the downstaged group was lower than that in the nondownstaged group (1.07 x 10(-3) mm(2)/sec +/- 0.13 [standard deviation] vs 1.19 x 10(-3) mm(2)/sec +/- 0.15, F = 6.91, P = .013). At the end of the 1st week of CRT, the mean tumor ADC increased significantly from 1.07 x 10(-3) mm(2)/sec +/- 0.13 to 1.32 x 10(-3) mm(2)/sec +/- 0.16 (F = 37.63, P <.001) in the downstaged group, but there was no significant ADC increase in the nondownstaged group (F = 1.18, P = .291). The mean percentage of tumor ADC change in the downstaged group was significantly higher than that in the nondownstaged group at each time point (F = 18.39, P < .001).

CONCLUSION

Early increase of mean tumor ADC and low pretherapy mean ADC in rectal carcinoma correlate with good response to CRT. DW MR imaging is a promising noninvasive technique for helping predict and monitor early therapeutic response in patients with rectal carcinoma who are undergoing CRT.

Prospective phase II study of preoperative short-course radiotherapy for rectal cancer with twice daily fractions of 2.9 Gy to a total dose of 29 Gy--long-term results

Background

To evaluate clinical outcome after preoperative short-course radiotherapy for rectal cancer with twice daily fractions of 2.9 Gy to a total dose of 29 Gy and adjuvant chemotherapy for pathological stage UICC ≥ II.

Methods

118 patients (median age 64 years; male : female ratio 2.5 : 1) with pathological proven rectal cancer (clinical stage II 50%, III 41.5%, IV 8.5%) were treated preoperatively with twice daily radiotherapy of 2.9 Gy single fraction dose to a total dose of 29 Gy; surgery was performed immediately in the following week with total mesorectal excision (TME). Adjuvant 5-FU based chemotherapy was planned for pathological stage UICC ≥ II.

Results

After low anterior resection (70%) and abdominoperineal resection (30%), pathology showed stage UICC I (27.1%), II (25.4%), III (37.3%) and IV (9.3%). Perioperative mortality was 3.4% and perioperative complications were observed in 22.8% of the patients. Adjuvant chemotherapy was given in 75.3% of patients with pathological stage UICC ≥ II. After median follow-up of 46 months, five-year overall survival was 67%, cancer-specific survival 76%, local control 92% and freedom from systemic progression 75%. Late toxicity > grade II was observed in 11% of the patients.

Conclusions

Preoperative short-course radiotherapy, total mesorectal excision and adjuvant chemotherapy for pathological stage UICC ≥ II achieved excellent local control and favorable survival.

Anemia response and safety to epoetin-beta treatment in patients with neoadjuvant therapy prior to primary digestive tract tumor surgery

PURPOSE

Anemia is common during anticancer treatment. This study aimed to evaluate the response and safety of treatment with epoetin-beta (EB) in patients with neoadjuvant therapy prior to primary digestive tract tumor surgery.

PATIENTS AND METHODS

In this open-label, single-arm study, patients (n = 22) with hemoglobin (Hb) levels below 11 g/dl who received epoetin-beta 450 IU/kg (30,000 IU) weekly until the hemoglobin level reached 12 g/dl.

RESULTS

After treatment with EB, a mean absolute increment of 2.6 g/dl was attained. The mean hemoglobin values during the study were pretreatment 10.1 g/dl, half-way through treatment 12.3 g/dl, 4 weeks after concomitant radiochemotherapy 12.7 g/dl, the week prior to surgery 12.5 g/dl, and after surgery 10.9 g/dl. No patient required transfusion before or after surgery. The probability or risk of postoperative complications was 27.3%, and included one rectovaginal fistula, one parastomal hernia, one case of ileus and two surgical wound infections. In this series, downstaging was observed in 81.8% of patients, and downsizing in 90.9%. Most interestingly, histopathological complete response rate was achieved by 18.2%.

CONCLUSIONS

Epoetin-beta (EB) treatment in our series of patients with digestive malignancies subjected to neoadjuvant radiochemotherapy proved effective and safe, avoiding the need for transfusion during surgery.

Clinically-staged T3N0 rectal cancer: is preoperative chemoradiotherapy the optimal treatment?

BACKGROUND

Preoperative chemoradiotherapy has been widely adopted as the standard of care for stage II-III rectal cancers. However, patients with T3N0 lesions had been shown to have a better prognosis than other categories of locally advanced tumor. Thus, neoadjuvant chemoradiation is likely to be overtreatment in this subgroup of patients. Nevertheless, the low accuracy rate of preoperative staging techniques for detection of node-negative tumors does not allow to check this hypothesis. We analyzed a group of patients with cT3N0 low rectal cancer who underwent neoadjuvant chemoradiotherapy with the purpose of evaluating the incidence of metastatic nodes in the resected specimens.

METHODS

Between January 2002 and February 2008, 100 patients with low rectal cancer underwent clinical staging by means of endorectal ultrasound, computed tomography, positron emission tomography, and magnetic resonance imaging. All patients received preoperative 5-fluorouracil-based chemoradiotherapy and surgical resection with curative aim.

RESULTS

Of 100 patients with locally advanced rectal cancer, 32 were clinically staged as T3N0M0. Pathological analysis showed the presence of lymph node metastases in nine patients (28%) (node-positive group). In the remaining 23 cases, clinical N stage was confirmed at pathology (node-negative group). Node-positive and node-negative groups differ only in the number of ypT3 tumors (P < .01).

CONCLUSIONS

Our results indicate that immediate surgery for patients with cT3N0 rectal cancer represents an undertreatment risk in at least 28% of cases, making necessary the use of postoperative chemoradiotherapy. Preoperative chemoradiotherapy should be the therapy of choice on the grounds of the principle that overtreatment is less hazardous than undertreatment for cT3N0 rectal cancers.

Multidisciplinary treatment of locally advanced rectal cancer: a literature review. Part 1

In Western countries, colorectal cancer is the third most common cancer in terms of incidence and mortality. The management of rectal cancer has undergone and continues to undergo significant evolutions. In the last two decades, new multimodality strategies have been developed. Multimodality treatments have improved the prognosis of locally advanced rectal cancer with local recurrences decreasing from 40% to < 10% and overall survival increasing from 50% to 75% in the last 40 years. This review discusses the role of neoadjuvant chemoradiotherapy regimens used in the standard combined modality treatment programs for rectal cancer and focuses on the ongoing research to improve these regimens.

Clinical outcome in 520 consecutive Danish rectal cancer patients treated with short course preoperative radiotherapy

AIM

The purpose of this study was to analyse the results of preoperative short course radiotherapy in a consecutive, national cohort of patients with rectal cancer.

METHODS

Through a validated, prospective national database we identified 520 Danish patients who presented with high-risk mobile tumours in the lower two thirds of the rectum and were referred for preoperative radiotherapy with 5 x 5 Gy. The inclusion period was 56 months. Radiotherapy data was retrospectively collected.

RESULTS

Of the 520 patients, 514 completed radiotherapy and 506 had surgery. Surgery was considered curative in 439 patients. The 3-year local recurrence rate was 4.0% (95% CI 2.5-6.5%) and the distant recurrence rate at 3 years was 18.7% (95% CI 15.4-22.5%). The 5-year disease free survival rate was 40.2% (95% CI 27.0-53.1%) and overall survival 50.4% (95% CI 36.1-63.1%). Most tumours (61%) were classified as T3 or T4 and 41% of the local recurrences occurred in patients with a fixed tumour at surgery.

CONCLUSION

This study confirms data from randomised studies that the short course 5 x 5 Gy regime is a feasible treatment for locally advanced rectal cancer even when applied in a population outside clinical trials.

Multidisciplinary Rectal Cancer Management: 2nd European Rectal Cancer Consensus Conference (EURECA-CC2)

BACKGROUND AND PURPOSE

During the first decade of the 21st century a number of important European randomized studies were published. In order to help shape clinical practice based on best scientific evidence from the literature, the International Conference on 'Multidisciplinary Rectal Cancer Treatment: Looking for an European Consensus' (EURECA-CC2) was organized in Italy under the endorsement of European Society of Medical Oncology (ESMO), European Society of Surgical Oncology (ESSO), and European Society of Therapeutic Radiation Oncology (ESTRO).

METHODS

Consensus was achieved using the Delphi method. The document was available to all Committee members as a web-based document customized for the consensus process. Eight chapters were identified: epidemiology, diagnostics, pathology, surgery, radiotherapy and chemotherapy, treatment toxicity and quality of life, follow-up, and research questions. Each chapter was subdivided by a topic, and a series of statements were developed. Each member commented and voted, sentence by sentence thrice. Sentences upon which an agreement was not reached after voting round # 2 were openly debated during a Consensus Conference in Perugia (Italy) from 11 December to 13 December 2008. A hand-held televoting system collected the opinions of both the Committee members and the audience after each debate. The Executive Committee scored percentage consensus based on three categories: "large consensus", "moderate consensus", and "minimum consensus".

RESULTS

The total number of the voted sentences was 207. Of the 207, 86% achieved large consensus, 13% achieved moderate consensus, and only 3 (1%) resulted in minimum consensus. No statement was disagreed by more than 50% of the members. All chapters were voted on by at least 75% of the members, and the majority was voted on by >85%.

CONCLUSIONS

This Consensus Conference represents an expertise opinion process that may help shape future programs, investigational protocols, and guidelines for staging and treatment of rectal cancer throughout Europe.

Preoperative staging of rectal cancer

Preoperative staging is now an essential factor in the multidisciplinary management of rectal cancer because tumor stage is the strongest predictive factor for recurrence. Preoperative staging of rectal cancer can be divided into either local or distant staging. Local staging incorporates the assessment of mural wall invasion, circumferential resection margin involvement, as well as the nodal status for metastasis. Distant staging assesses for evidence of metastatic disease. The aim of this review is to consider the indications and limitations of the current preoperative imaging modalities for rectal cancer staging including clinical examination, endorectal ultrasound, magnetic resonance imaging, computed tomography and positron emission tomography–computed tomography, with respect to local and distant disease.

Extended lymphadenectomy versus conventional surgery for rectal cancer: a meta-analysis

BACKGROUND

Lateral pelvic lymph-node metastases occur in 10-25% of patients with rectal cancer, and are associated with higher local recurrence and reduced survival rates. A meta-analysis was undertaken to assess the value of extended lateral pelvic lymphadenectomy in the operative management of rectal cancer.

METHODS

We searched Medline, Embase, Ovid, Cochrane Library, and Google Scholar for studies published between 1965 and 2009 that compared extended lymphadenectomy (EL) with standard rectal resection. 20 studies, which included 5502 patients from one randomised, three prospective non-randomised, and 14 retrospective case-control studies published between 1984 and 2009, met our search criteria and were assessed. 2577 patients underwent EL and 2925 underwent non-EL for rectal cancer. Random and fixed-effects meta-analytical models were used where indicated, and between-study heterogeneity was assessed. End-points evaluated included peri-operative outcomes, 5-year survival and recurrence rates.

FINDINGS

Operating time was significantly longer in the EL group by 76.7 min (95% CI 18.77-134.68; p=0.0096). Intra-operative blood loss was greater in the EL group by 536.5 mL (95% CI 353.7-719.2; p<0.0001). Peri-operative mortality (OR 0.81, 95% CI 0.34-1.93; p=0.63) and morbidity (OR 1.45, 95% CI 0.89-2.35; p=0.13) were similar between the two groups. Data from individual studies showed that male sexual dysfunction and urinary dysfunction (three studies: OR 3.70, 95% CI 1.66-8.23; p=0.0012) were more prevalent in the EL group. There were no significant differences in 5-year survival (hazard ratio [HR] 1.09, 95% CI 0.78-1.50; p=0.62), 5-year disease-free survival (HR 1.23, 95% CI 0.75-2.03, p=0.41), and local (OR 0.83, 95% CI 0.61-1.13; p=0.23) or distant recurrence (OR 0.93, 95% CI 0.72-1.21; p=0.60).

INTERPRETATION

Extended lymphadenectomy does not seem to confer a significant overall cancer-specific advantage, but does seem to be associated with increased urinary and sexual dysfunction.