Tumor downstaging and sphincter preservation with preoperative chemoradiation in locally advanced rectal cancer: the M. D. Anderson Cancer Center experience

Pathological prognostic factors in locally advanced rectal carcinoma after neoadjuvant radiochemotherapy: analysis of 113 cases

AIMS

Neoadjuvant radiochemotherapy (RCT) followed by surgical resection is the treatment for locally advanced mid-rectal or low rectal cancer. The aim of this study was to evaluate postoperative histological prognostic factors in a series of surgical specimens after neoadjuvant RCT.

METHODS AND RESULTS

One hundred and thirteen patients were included. Macroscopic and microscopic examinations were performed according to CAP recommendations, with additional criteria such as tumour budding, the presence of calcifications, and response to neoadjuvant therapy assessed according to Modified Rectal Cancer Regression Grade (m-RCRG). The 3-year disease-free survival (DFS) was 67.6%. In univariate analysis, ypTN stage, tumour budding, circumferential margin, invaded margin and vascular and perineural invasion were prognostic factors. In multivariate analysis, the presence of calcifications (P = 0.04) and an involved circumferential margin (P = 0.03) were the only independent factors for worse DFS. mRCRG was not correlated with DFS. Among the 50 m-RCRG1 tumours, DFS was better in ypT0 patients than in other ypT stages (P = 0.003).

CONCLUSIONS

The presence of calcifications in the tumour bed is described for the first time as a prognostic factor in rectal cancer. The prognostic value of budding was demonstrated in this study after neoadjuvant RCT. ypT stage appears to be a more reliable predictor of oncological outcome than histological tumour regression grade, which needs to be standardized for better reproducibility.

Tumor Regression Grading After Preoperative Chemoradiotherapy for Locally Advanced Rectal Carcinoma Revisited: Updated Results of the CAO/ARO/AIO-94 Trial

Purpose

We previously described the prognostic impact of tumor regression grading (TRG) on the outcome of patients with rectal carcinoma treated with preoperative chemoradiotherapy (CRT) in the CAO/ARO/AIO-94 trial. Here we report long-term results after a median follow-up of 132 months.

Patients and Methods

TRG after preoperative CRT was determined in 386 surgical specimens by the amount of viable tumor cells versus fibrosis, ranging from TRG 4 (no viable tumor cells) to TRG 0 (no signs of regression). Clinicopathologic parameters and TRG were correlated to the cumulative incidence of local recurrence, distant metastasis, and disease-free survival (DFS).

Results

Ten-year cumulative incidence of distant metastasis and DFS were 10.5% and 89.5% for patients with TRG 4 (complete regression), 29.3% and 73.6% for TRG 2 and 3 (intermediate regression), and 39.6% and 63% for TRG 0 and 1 (poor regression), respectively (P = .005 and P = .008, respectively). On multivariable analysis, residual lymph node metastasis (ypN+) and TRG were the only independent prognostic factors for cumulative incidence of distant metastasis (P < .001 and P = .035, respectively) and DFS (P < .001 and P = .039, respectively), whereas local recurrence was significantly affected by ypN status (P < .001) and lymphatic invasion (P = .026).

Conclusion

Complete and intermediate tumor regressions were associated with improved long-term outcome in patients with rectal carcinoma after preoperative CRT independent of clinicopathologic parameters. This classification system needs to be prospectively tested in multiple data sets to validate its reproducibility in a wider setting.

Multicenter Evaluation of Rectal cancer ReImaging pOst Neoadjuvant (MERRION) Therapy

OBJECTIVE

The aim of this study was to evaluate the utility of reimaging rectal cancer post-CRT (chemoradiotherapy) with magnetic resonance (MR) imaging of the pelvis for local staging and computed tomography of thorax, abdomen, and pelvis (CT TAP) to identify distant metastases.

BACKGROUND

The success of neoadjuvant CRT for locally advanced rectal cancer has changed an already complex management algorithm. There is no consensus whether patients should be restaged before surgery.

METHODS

Data from 5 institutions with prospectively maintained databases including patients who received neoadjuvant CRT for locally advanced rectal cancer were acquired. Only patients who had been staged pre- and post-CRT with MR imaging and CT TAP were included. MR findings were correlated with histopathological stage using weighted κ (kappa) statistics to test agreement, where a κ value of less than 0.5 was deemed unacceptable.

RESULTS

A total of 285 patients fulfilled the criteria for the study; 84% had American Joint Committee for Cancer stage 3 disease pre-CRT, and the remainder had stage 2 disease. Fourteen patients did not proceed to surgery post-CRT-2 were observed as "complete responders," and the remainder either had unresectable disease or were unfit for surgery. MR imaging could not predict T stage (κ = 0.212) or nodal involvement (κ = 0.336). Most pertinently, MR imaging was unable to detect a complete pathological response (κ = 0.021), nor could it discriminate T4 disease (κ = 0.445). CT TAP restaging altered management in 6.7% of patients, who had metastatic disease.

CONCLUSIONS

MR reimaging using standard protocols is of limited value in determining surgical approaches; a better modality of local restaging is required.

Laparoscopic total mesorectal excision for extraperitoneal rectal cancer: long-term results of a 18-year single-centre experience

BACKGROUND AND OBJECTIVES

The oncologic efficacy of laparoscopic total mesorectal excision (TME) for middle-low rectal cancer is still under discussion because of the few long-term data. This study reports the results arising from a single-institution experience during a 18-year period.

METHODS

Data about 132 consecutive laparoscopic TME performed between January 1994 and January 2012 were analysed with Kaplan-Meier method and a uni- and multi-variate analysis was conducted to define independent survival predictors.

RESULTS

A total of 116 sphincter-preserving operations and 16 abdominoperineal resections were performed. Postoperative mortality and morbidity were 0.8 and 18.2%, with a rate of anastomotic leakage of 13.8%. Average follow-up was 85.9 months (range 13-210). Actuarial local recurrence rate was 4.13% at 5 years (any pelvic recurrence developed after 3 years from surgery). Overall and disease-free survival was respectively 83 and 79.8% at 5 years, 71 and 73% at 10 years and then remained constant until 18 years. Survival was correlated only to tumour stage and the type of surgery.

CONCLUSIONS

Laparoscopic TME for extraperitoneal rectal cancer shows long-term oncologic outcomes similar to open rectal resections.

Oncological superiority of extralevator abdominoperineal resection over conventional abdominoperineal resection: a meta-analysis

PURPOSE

The oncological superiority, i.e., lower circumferential resection margin (CRM) involvement, lower intraoperative perforation (IOP), and local recurrence (LR) rates, of extralevator abdominoperineal resection (EAPR) over conventional abdominoperineal resection (APR) for rectal cancer is inconclusive. This meta-analysis systematically compared the rates of CRM involvement, IOP, and LR of rectal cancer patients treated by EAPR and APR, respectively.

METHODS

An electronic literature search of MEDLINE, EMBASE, and Cochrane Library through May 2013 was performed by two investigators independently to identify studies evaluating the CRM involvement, IOP, and LR rates of EAPR and APR, and search results were cross-checked to reach a consensus. Data was extracted accordingly. A Mantel-Haenszel random effects model was used to calculate the odds ratio (OR) with 95 % confidence intervals (95 % CI).

RESULTS

Six studies with a total of 881 patients were included. Meta-analysis of CRM involvement and IOP data from all six studies demonstrated significant lower CRM involvement (OR, 0.36; 95%CI, 0.23-0.58; P < 0.0001) and IOP (OR, 0.31; 95%CI, 0.12-0.80; P = 0.02) rates of EAPR. Data from four studies also showed that EAPR was associated with a lower LR rate than APR (OR, 0.27; 95%CI, 0.08-0.95; P = 0.04). No differences of between-study heterogeneity or publication bias were seen in any of the meta-analyses.

CONCLUSIONS

Extralevator abdominoperineal resection could achieve better CRM involvement outcome and lower IOP and LR rates, demonstrating an oncological superiority over conventional abdominoperineal resection.

Gene expression profile is associated with chemoradiation resistance in rectal cancer

AIM

Patients with rectal cancer who achieve a complete pathological response after preoperative chemoradiation (CRT) have an improved oncological outcome. Identifying factors associated with a lack of response could help our understanding of the underlying biology of treatment resistance. This study aimed to develop a gene expression signature for CRT-resistant rectal cancer using high-throughput nucleotide microarrays.

METHOD

Pretreatment biopsies of rectal adenocarcinomas were prospectively collected and freshly frozen according to an institutional review board-approved protocol. Total tumour mRNA was extracted and gene expression levels were measured using microarrays. Patients underwent proctectomy after completing standard long-course CRT and the resected specimens were graded for treatment response. Gene expression profiles for nonresponders were compared with those of responders. Differentially expressed genes were analyzed for functional significance using the Ingenuity Pathway Analysis (IPA) software.

RESULTS

Thirty-three patients treated between 2006 and 2009 were included. We derived 812-gene and 183-gene signatures separating nonresponders from responders. The classifiers were able to identify nonresponders with a sensitivity and specificity of 100% using the 812-gene signature, and sensitivity and specificity of 33% and 100% using the 183-gene signature. IPA canonical pathway analysis revealed a significant ratio of differentially expressed genes in the 'DNA double-strand break repair by homologous recombination' pathway.

CONCLUSION

Certain rectal cancer gene profiles are associated with poor response to CRT. Alterations in the DNA double-strand break repair pathway could contribute to treatment resistance and provides an opportunity for further studies.

Restaging locally advanced rectal cancer by different imaging modalities after preoperative chemoradiation: a comparative study

Background

To compare the accuracy of different imaging modalities, alone and in combination in predicting findings at surgery after preoperative chemoradiation for locally advanced rectal cancer.

Methods

Following chemoradiation, tumors were reclassified on the basis of findings on pelvic computed tomography (CT) (94 patients), endorectal ultrasonography (EUS) (138 patients) alone or by both CT and EUS (80 patients). The ability of the imaging modalities, to predict the pathologic T status, N status, and TNM stage at surgery was evaluated and compared.

Results

Mean age of the patients was 64.5 years (range 28–88 years); 55% were male. CT and EUS combined had a positive predictive value of 20% for pathologic pT1 stage, 29% for pT1, 29% for pT2, and 58% for pT3. Predictive values for the operative TNM stage were 50% for stage I, 45% for stage II, and 31% for stage III. These values did not exceed those for each modality alone.

Conclusion

The performance of preoperative CT and EUS in predicting the T and TNM stage of rectal cancer at surgery is poor. Neither modality alone nor the two combined is sufficiently accurate to serve as the basis for decisions regarding treatment modification.

MRI predictive factors for tumor response in rectal cancer following neoadjuvant chemoradiation therapy--implications for induction chemotherapy?

PURPOSE

Clinical and magnetic resonance imaging (MRI) characteristics at baseline and following chemoradiation therapy (CRT) most strongly associated with histopathologic response were investigated and survival outcomes evaluated in accordance with imaging and pathological response.

METHODS AND MATERIALS

Responders were defined as mrT3c/d-4 downstaged to ypT0-2 on pathology or low at risk mrT2 downstaged to ypT1 or T0. Multivariate logistic regression of baseline and posttreatment MRI: T, N, extramural venous invasion (EMVI), circumferential resection margin, craniocaudal length <5 cm, and MRI tumor height ≤5 cm were used to identify independent predictor(s) for response. An association between induction chemotherapy and EMVI status was analyzed. Survival outcomes for pathologic and MRI responders and nonresponders were analyzed.

RESULTS

Two hundred eighty-one patients were eligible; 114 (41%) patients were pathology responders. Baseline MRI negative EMVI (odds ratio 2.94, P=.007), tumor height ≤5 cm (OR 1.96, P=.02), and mrEMVI status change (positive to negative) following CRT (OR 3.09, P<.001) were the only predictors for response. There was a strong association detected between induction chemotherapy and ymrEMVI status change after CRT (OR 9.0, P<.003). ymrT0-2 gave a positive predictive value of 80% and OR of 9.1 for ypT0-2. ymrN stage accuracy of ypN stage was 75%. Three-year disease-free survival for pathology and MRI responders were similar at 80% and 79% and significantly better than poor responders.

CONCLUSIONS

Tumor height and mrEMVI status are more important than baseline size and stage of the tumor as predictors of response to CRT. Both MRI- and pathologic-defined responders have significantly improved survival. "Good response" to CRT in locally advanced rectal cancer with ypT0-2 carries significantly better 3-year overall survival and disease-free survival. Use of induction chemotherapy for improving mrEMVI status and knowledge of MRI predictive factors could be taken into account in the pursuit of individualized neoadjuvant treatments for patients with rectal cancer.

Comparison between preoperative and postoperative concurrent chemoradiotherapy for rectal cancer: an institutional analysis

PURPOSE

To evaluate the treatment outcomes of preoperative versus postoperative concurrent chemoradiotherapy (CRT) on locally advanced rectal cancer.

MATERIALS AND METHODS

Medical data of 114 patients with locally advanced rectal cancer treated with CRT preoperatively (54 patients) or postoperatively (60 patients) from June 2003 to April 2011 was analyzed retrospectively. 5-Fluorouracil (5-FU) or a precursor of 5-FU-based concurrent CRT (median, 50.4 Gy) and total mesorectal excision were conducted for all patients. The median follow-up duration was 43 months (range, 16 to 118 months). The primary end point was disease-free survival (DFS). The secondary end points were overall survival (OS), locoregional control, toxicity, and sphincter preservation rate.

RESULTS

The 5-year DFS rate was 72.1% and 48.6% for the preoperative and postoperative CRT group, respectively (p = 0.05, the univariate analysis; p = 0.10, the multivariate analysis). The 5-year OS rate was not significantly different between the groups (76.2% vs. 69.0%, p = 0.23). The 5-year locoregional control rate was 85.2% and 84.7% for the preoperative and postoperative CRT groups (p = 0.98). The sphincter preservation rate of low-lying tumor showed significant difference between both groups (58.1% vs. 25.0%, p = 0.02). Pathologic tumor and nodal down-classification occurred after the preoperative CRT (53.7% and 77.8%, both p < 0.001). Acute and chronic toxicities were not significantly different between both groups (p = 0.10 and p = 0.62, respectively).

CONCLUSION

The results confirm that preoperative CRT can be advantageous for improving down-classification rate and the sphincter preservation rate of low-lying tumor in rectal cancer.

How reliable is current imaging in restaging rectal cancer after neoadjuvant therapy?

In patients with advanced rectal cancer, neoadjuvant chemo radiotherapy provides tumor downstaging and downsizing and complete pathological response in up to 30% of cases. After proctectomy complete pathological response is associated with low rates of local recurrence and excellent long term survival. Several authors claim a less invasive surgery or a non operative policy in patients with partial or clinical complete response respectively, however to identify patients with true complete pathological response before surgical resection remains a challenge. Current imaging techniques have been reported to be highly accurate in the primary staging of rectal cancer, however neoadjuvant therapy course produces deep modifications on cancer tissue and on surrounding structures such as overgrowth fibrosis, deep stroma alteration, wall thickness, muscle disarrangement, tumor necrosis, calcification, and inflammatory infiltration. As a result, the same imaging techniques, when used for restaging, are far less accurate. Local tumor extent may be overestimated or underestimated. The diagnostic accuracy of clinical examination, rectal ultrasound, computed tomography, magnetic resonance imaging, and positron emission tomography using 18F-fluoro-2’-deoxy-D-glucose ranges between 25% and 75% being less than 60% in most studies, both for rectal wall invasion and for lymph nodes involvement. In particular the ability to predict complete pathological response, in order to tailor the surgical approach, remains low. Due to the radio-induced tissue modifications, combined with imaging technical aspects, low rate accuracy is achieved, making modern imaging techniques still unreliable in restaging rectal cancer after chemo-radiotherapy.

Microarray profiling of mononuclear peripheral blood cells identifies novel candidate genes related to chemoradiation response in rectal cancer

Preoperative chemoradiation significantly improves oncological outcome in locally advanced rectal cancer. However there is no effective method of predicting tumor response to chemoradiation in these patients. Peripheral blood mononuclear cells have emerged recently as pathology markers of cancer and other diseases, making possible their use as therapy predictors. Furthermore, the importance of the immune response in radiosensivity of solid organs led us to hypothesized that microarray gene expression profiling of peripheral blood mononuclear cells could identify patients with response to chemoradiation in rectal cancer. Thirty five 35 patients with locally advanced rectal cancer were recruited initially to perform the study. Peripheral blood samples were obtained before neaodjuvant treatment. RNA was extracted and purified to obtain cDNA and cRNA for hybridization of microarrays included in Human WG CodeLink bioarrays. Quantitative real time PCR was used to validate microarray experiment data. Results were correlated with pathological response, according to Mandard´s criteria and final UICC Stage (patients with tumor regression grade 1-2 and downstaging being defined as responders and patients with grade 3-5 and no downstaging as non-responders). Twenty seven out of 35 patients were finally included in the study. We performed a multiple t-test using Significance Analysis of Microarrays, to find those genes differing significantly in expression, between responders (n = 11) and non-responders (n = 16) to CRT. The differently expressed genes were: BC 035656.1, CIR, PRDM2, CAPG, FALZ, HLA-DPB2, NUPL2, and ZFP36. The measurement of FALZ (p = 0.029) gene expression level determined by qRT-PCR, showed statistically significant differences between the two groups. Gene expression profiling reveals novel genes in peripheral blood samples of mononuclear cells that could predict responders and non-responders to chemoradiation in patients with locally advanced rectal cancer. Moreover, our investigation added further evidence to the importance of mononuclear cells' mediated response in the neoadjuvant treatment of rectal cancer.

Molecular markers for targeted neoadjuvant rectal cancer therapy

SUMMARY Neoadjuvant chemoradiotherapy is the standard of care for locally advanced rectal cancer. While neoadjuvant chemoradiation has been demonstrated to improve oncological outcomes, there is a wide spectrum of responses to therapy. The ability to predict who will respond favorably or unfavorably to neoadjuvant therapy could prevent unnecessary morbidity and potentially lead to novel therapeutic targets. A number of individual biomarkers and multigene signatures have been investigated as potential means of predicting response to neoadjuvant chemoradiation. While promising, none of these predictive biomarkers have yet been introduced clinically. This review summarizes both individual and multigene biomarkers for rectal cancer response to neoadjuvant chemoradiation.

Non-operative management for locally advanced rectal cancer: critical review and future perspective

SUMMARY Over the last few decades we have observed important advances in diagnostic imaging, surgery, pathology and multimodal treatments for rectal cancer, as well as increased efforts to reduce treatment-related toxicities and preserve quality of life for curatively treated patients. Neoadjuvant short-course radiotherapy and long-course chemoradiotherapy followed by total mesorectal excision remain widely accepted as the standard of care for patients with locally advanced rectal cancer. However, a carefully selected group of patients achieving a complete response to neoadjuvant chemoradiotherapy may be spared the effects of surgery and achieve satisfactory oncologic outcomes with a ‘wait-and-see’ strategy. Although supported by the results of previous studies, this intriguing paradigm shift needs prospective evaluation within a clinical trial setting and a more accurate prediction and assessment of response by means of tumor biomarkers and diagnostic imaging.

CEA - a predictor for pathologic complete response after neoadjuvant therapy for rectal cancer

BACKGROUND

Preoperative chemoradiation therapy in patients with rectal cancer results in pathologic complete response in approximately 10% to 30% of patients. Accurate predictive factors for obtaining pathologic complete response would likely influence the selection of patients best treated by chemoradiation therapy as the primary treatment without radical surgery.

OBJECTIVE

The aim of this study was to evaluate the impact of tumor size, stage, location, circumferential extent, patient characteristics, and pretreatment CEA levels on the development of pathologic complete response after chemoradiation therapy.

DESIGN

This study is a retrospective review.

SETTINGS AND PATIENTS

Five hundred thirty patients treated with preoperative chemoradiation therapy and radical surgery for rectal adenocarcinoma between 1998 and 2011 were identified. A total of 469 patients remained after excluding patients with a history of pelvic radiation (n = 2), previous transanal endoscopic microsurgery or polypectomy of the primary lesion (n = 15), concurrent malignant tumor (n = 14), and no information about pre- or posttreatment T stage in the chart (n = 30). Preoperative CEA levels were available for 267 patients (57%).

INTERVENTIONS

Preoperative chemoradiation therapy and total mesorectal excision were performed in patients with rectal cancer.

MAIN OUTCOME

The primary outcome measured was pathologic complete response.

RESULTS

: Ninety-six patients (20%) were found to have a pathologic complete response in the operative specimen. Low pretreatment CEA (3.4 vs 9.6 ng/mL; p = 0.008) and smaller mean tumor size (4.2 vs 4.7 cm; p = 0.02) were significantly associated with pathologic complete response. Low CEA levels and interruption in chemoradiation therapy were significant predictors of pathologic complete response in the multivariate analysis. When stratifying for smoking status, low CEA level was significantly associated with pathologic complete response only in the group of nonsmokers (p = 0.02).

LIMITATIONS

This study was limited by its retrospective design, missing CEA values, and lack of tumor regression grade assessment.

CONCLUSIONS

We demonstrated an association between low pretreatment CEA levels, interruption in chemoradiation therapy, and pathologic complete response in patients treated with neoadjuvant chemoradiation therapy for locally advanced rectal cancer. The predictive value of CEA in smokers can be limited, and further studies are needed to evaluate the impact of smoking on the predictive value of CEA levels for pathologic complete response in rectal cancer.

Locally advanced rectal cancer: diffusion-weighted MR tumour volumetry and the apparent diffusion coefficient for evaluating complete remission after preoperative chemoradiation therapy

OBJECTIVE

To evaluate DW MR tumour volumetry and post-CRT ADC in rectal cancer as predicting factors of CR using high b values to eliminate perfusion effects.

METHODS

One hundred rectal cancer patients who underwent 1.5-T rectal MR and DW imaging using three b factors (0, 150, and 1,000 s/mm(2)) were enrolled. The tumour volumes of T2-weighted MR and DW images and pre- and post-CRT ADC150-1000 were measured. The diagnostic accuracy of post-CRT ADC, T2-weighted MR, and DW tumour volumetry was compared using ROC analysis.

RESULTS

DW MR tumour volumetry was superior to T2-weighted MR volumetry comparing the CR and non-CR groups (P < 0.001). Post-CRT ADC showed a significant difference between the CR and non-CR groups (P = 0.001). The accuracy of DW tumour volumetry (Az = 0.910) was superior to that of T2-weighed MR tumour volumetry (Az = 0.792) and post-CRT ADC (Az = 0.705) in determining CR (P = 0.015). Using a cutoff value for the tumour volume reduction rate of more than 86.8 % on DW MR images, the sensitivity and specificity for predicting CR were 91.4 % and 80 %, respectively.

CONCLUSION

DW MR tumour volumetry after CRT showed significant superiority in predicting CR compared with T2-weighted MR images and post-CRT ADC.

hPEBP4 as a predictive marker for the pathological response of rectal cancer to preoperative radiotherapy

PURPOSE

The ability to predict tumor sensitivity toward radiotherapy is important in the personalized application of preoperative radiotherapy for patients with rectal cancer. The aim of the present study was to test the human phosphatidylethanolamine-binding protein 4 (hPEBP4) as a predictive marker of tumor response to preoperative radiotherapy in patients with rectal cancer.

METHOD

A retrospective analysis was conducted, consisting of 86 patients with locally advanced rectal cancer who underwent short-course preoperative radiotherapy (20 Gy in five fractions for 1 week) followed by a radical resection. Both pretreatment biopsy specimens and resected primary tumor tissue were collected. Immunohistochemistry and tumor regression grading system were used to evaluate the expression of hPEBP4 in the pretreatment biopsy specimens and the response of rectal cancer to radiotherapy, respectively. Expression of hPEBP4 was correlated with tumor regression in the resected specimen and the clinical outcome of the patients as well.

RESULTS

We found that high expression of hPEBP4 was associated with radioresistance in both univariate and multivariate analyses, and patients with a high hPEBP4 expression had a poorer progression-free survival than those with low hPEBP4 expression.

CONCLUSION

Our study revealed the independent predictive values of hPEBP4 in response of rectal cancer to preoperative radiotherapy, which suggests that upregulating hPEBP4 might be a potential mechanism by which rectal cancer cells avoid the destructive effects of radiotherapy.

The Factors Effecting Lymphovascular Invasion in Adenocarcinoma of the Colon and Rectum

Adenocarcinomas of the colon and rectum are the most common gastrointestinal malignancy, and lymph node metastases are established as a prognostic factor. Lymphovascular invasion has been recognized as an indication of lymph node metastases. This prompted us to investigate the features of primary tumor that may serve as a risk factor for lymphovascular invasion in colorectal carcinoma. Clinical and pathologic tissue data of colorectal carcinoma treated in our hospital were retrieved from the computer files at Haydarpasa Numune Education and Research Hospital, from June 1998 to December 2010, retrospectively. We excluded all patients who have two-thirds distal rectal carcinoma to rule out neoadjuvant treatment bias. Tissues from the specimens were stained with standard hematoxylin and eosin. Clinical data including age and sex of patient, location and diameter of tumor, perineural invasion, peritumoral lymphocytic infiltration, tumor grade, lymphovascular invasion, Pathologic T level (pT), and lymph node metastasis were recorded. Lymphovascular invasion was present only in 43 patients out of 108. Only pT and lymph node metastases were found to be statistically significant related to lymphovascular invasion (p = 0.04 and p < 0.001). Perineural invasion, pT, and peritumoral lymphocytic infiltration are the factors with p < 0.2 in the univariate analysis that were investigated with multivariate analysis, but no factor was found as an independent prognostic factor for lymphovascular invasion. Lymphovascular invasion is significantly related to lymph node metastases. Only pT is found as a factor that increases the lymphovascular invasion.

Is the standardized uptake value of FDG-PET/CT predictive of pathological complete response in locally advanced rectal cancer treated with capecitabine-based neoadjuvant chemoradiation?

OBJECTIVES

Our aim was to assess FDG-PET/CT as a surrogate biomarker of the pathological complete response in locally advanced rectal cancer treated with neoadjuvant chemoradiation.

METHODS

T3-4 and/or N+ rectal cancer patients were treated prospectively with capecitabine-based chemoradiation and total mesorectal excision 7-8 weeks later. FDG-PET/CT uptake was obtained at baseline, after 2 weeks, and 6 weeks following treatment completion, calculating the maximum standardized uptake value (SUV) and percentage difference to identify the early and late metabolic 'response index'.

RESULTS

Thirty-one patients were treated from January 2009 to January 2012 at the Istituto Nazionale dei Tumori of Milan. One patient was excluded due to surgery refusal. The pathological complete response rate was 30%. Early FDG-PET/CT was performed in 24 consenting patients and failed to show predictive utility. On the contrary, significant differences in late SUV value and response index were observed between complete and noncomplete pathological responders (p = 0.0006 and 0.03). In multivariate analysis including most relevant SUV parameters, none of them was independently associated with a pathological complete response. With receiver operating characteristic curve analysis, a late SUV threshold <5.4 had 81% sensitivity and 100% specificity, with 90% overall accuracy.

CONCLUSIONS

We evidenced a possible predictive role of late FDG-PET/CT for the assessment of pathological response in locally advanced rectal cancer following neoadjuvant chemoradiation.

Organ-preserving therapy for rectal cancer

SUMMARY Total mesorectal excision has resulted in low local recurrence rates in rectal cancer patients; however, it is associated with a significant impairment in quality of life. The operation may be disfiguring and cause permanent effects on gastrointestinal, genitourinary and sexual function. Recently, researchers have identified subgroups of rectal cancer patients who may be able to forgo total mesorectal excision without compromising their oncological outcomes. Two groups of patients are candidates for organ preservation: those with early-stage disease that may be adequately addressed by a more limited resection, and those with locally advanced disease that has responded completely to neoadjuvant therapy. Additionally, radiation alone may be curative in both early and locally advanced disease. This article reviews the data regarding these approaches.

What is the incidence of metastatic lymph node involvement after significant pathologic response of primary tumor following neoadjuvant treatment for locally advanced rectal cancer?

BACKGROUND

In locally advanced rectal cancer (LARC) patients, major response to neoadjuvant radiotherapy (NR) has been associated with favorable long-term outcomes. Positive pathologic nodal status was recently proven to be associated with poor prognosis even after total regression of primary tumor (ypT0). The aim of this study was to evaluate the rate of lymph node (LN) involvement in patients with complete (ypT0) or major (TRG1: very few viable tumor cells) response.

METHODS

Included were patients with complete or major response after radiotherapy followed by surgery and histological examination of the whole specimen.

RESULTS

From 1996 to 2010, 245 patients with LARC were treated by NR. We collected clinical data for 53 patients (21.6 %) with ypT0 (n = 26, 49 %) or TRG1 (n = 27, 51 %) response. Sphincter-preserving surgery was performed in 40 patients (75 %). Overall, nine patients (16.9 %) presented LN involvement: 2 (7.7 %) in the ypT0 group and 7 (25.9 %) in the TRG1 group (NS). Patients with ypT3 tumors had significantly more invaded LN than patients with ypT1-T2 tumors (6 of 13 [46 %] vs 1 of 14 [7 %], p = .032). After median follow-up of 30 months (range, 1-160 months), 5-year disease-free and overall survivals were 88.2 and 89.0 %, respectively.

CONCLUSIONS

There was a clear cutoff between patients with ypT0-T2 (3 of 40, 7.5 %) and ypT3 (6 of 13, 46 %) concerning the incidence of metastatic LN in patients achieving pathologic complete or major response after NR. In patients with good clinical response, local full-thickness resection of the residual tumor could be a first step, followed by standard rectal resection in cases of ypT3.

Oncologic outcome after preoperative chemoradiotherapy in patients with pathologic T0 (ypT0) rectal cancer

BACKGROUND

Little is known about the oncologic outcomes of patients with ypT0 rectal cancer after preoperative chemoradiotherapy.

OBJECTIVE

To evaluate the clinicopathologic characteristics and oncologic outcomes of patients with ypT0 rectal cancer after preoperative chemoradiotherapy and curative radical surgery.

DESIGN AND SETTINGS

This was a retrospective review of factors influencing outcome of patients treated with preoperative chemoradiotherapy for rectal cancer at a tertiary care university medical center in Seoul, Korea between 2000 and 2008.

PATIENTS

A total of 830 rectal cancer patients underwent surgery after preoperative chemoradiotherapy. Patients were included in the study if they had a pretreatment clinical classification of T3-4 or N+ (or T2N0 and preoperative chemoradiotherapy for sphincter preservation) and if they were classified on pathologic examination as ypT0 after preoperative CRT and curative radical surgery. Patients were classified as.

MAIN OUTCOME MEASURES

Overall survival and disease-free survival were evaluated in relation to ypT0N0 or ypT0N1-2 status and other factors that might influence outcome.

RESULTS

Of 91 patients included in the study, 54 (59.3%) were men; the mean patient age was 55 (SD, 11) years, and mean follow-up duration was 44 (SD, 23) months. Surgical procedures included low anterior resection in 68 patients, abdominoperineal resection in 21, and intersphincteric resection in 2. Mean tumor distance from the anal verge was 4.7 (SD, 1.8) cm. Of the 91 patients, 85 were classified as ypT0N0 and 6 as ypT0N1-2. No patient experienced local recurrence. A total of 11 patients (12.1%) had distant metastases, after a mean 11.1 months, including 7 (8.2%) with ypT0N0 and 4 (66.7%) with ypT0N1-2 tumors. One patient with ypT0N0 and 2 patients with ypT0N1-2 tumors died of metastasis. In patients classified as ypT0N0, the 5-year disease free survival and overall survival rates were 82.3% and 89.2%, respectively. Multivariate analysis showed that ypN1-2 status (p = 0.001) was a significant independent risk factor for recurrence (decreased 5-year disease-free survival), but no factor was associated with 5-year overall survival.

LIMITATIONS

The study is limited by its retrospective nature.

CONCLUSION

Oncologic outcomes in patients with ypT0N0 rectal cancer were excellent. The presence of residual cancer cells in mesorectal lymph nodes represents a risk factor for distant metastasis.

Neoadjuvant oral vs. infusional chemoradiotherapy on locally advanced rectal cancer: Prognostic factors

AIM

To evaluate the prognostic factors and impact on survival of neoadjuvant oral and infusional chemoradiotherapy in patients with locally advanced rectal cancer.

BACKGROUND

There is still no definitive consensus about the prognostic factors and the impact of neoadjuvant chemoradiotherapy on survival. Some studies have pointed to an improvement in overall survival (OS) and progression-free survival (PFS) in patients with tumor downstaging (TD) and nodal downstaging (ND).

MATERIALS AND METHODS

A set of 159 patients with LARC were treated preoperatively. Group A - 112 patients underwent concomitant oral chemoradiotherapy: capecitabine or UFT + folinic acid. Group B - 47 patients submitted to concomitant chemoradiation with 5-FU in continuous infusion. 63.6% of patients were submitted to adjuvant chemotherapy.

RESULTS

GROUP A

pathologic complete response (pCR) - 18.7%; TD - 55.1%; ND - 76%; loco-regional response - 74.8%. Group B: pCR - 11.4%; TD - 50%; ND - 55.8%; LRR - 54.5%. The loco-regional control was 95.6%. There was no difference in survival between both groups. Those with loco-regional response had better PFS.

CONCLUSIONS

Tumor and nodal downstaging, loco-regional response and a normal CEA level turned out to be important prognostic factors in locally advanced rectal cancer. Nodal downstaging and loco-regional response were higher in Group A. Those with tumor downstaging and loco-regional response from Group A had better OS. Adjuvant chemotherapy had no impact on survival except in those patients with loco-regional response who achieved a higher PFS.

Comparison of neoadjuvant oral chemotherapy with UFT plus Folinic acid or Capecitabine concomitant with radiotherapy on locally advanced rectal cancer

AIM

To evaluate the differences in treatment response and the impact on survival with both oral agents (UFT and Capecitabine) as neoadjuvant chemotherapy administered concomitantly with radiotherapy.

BACKGROUND

There are still no studies comparing the use of neoadjuvant oral chemotherapy either with UFT plus Folinic acid or Capecitabine concomitant with radiotherapy in locally advanced rectal cancer (LARC).

MATERIALS AND METHODS

A set of 112 patients with LARC were treated preoperatively. GROUP 1 - 61 patients underwent concomitant oral chemotherapy with Capecitabine (825 mg/m(2) twice daily). GROUP 2 - 51 patients submitted to concomitant oral chemotherapy with UFT (300 mg/m(2)/d) + Folinic acid (90 mg/d) and radiotherapy. 57.1% of patients were submitted to adjuvant chemotherapy.

RESULTS

GROUP 1: acute toxicity - 80.3%; pathological complete response (pCR) - 10.5%; tumor downstaging (TD) - 49.1%; nodal downstaging (ND) - 76.5%; loco-regional response (LRR) - 71.9%; toxicity to adjuvant chemotherapy - 75%. GROUP 2: acute toxicity - 80.4%; pCR - 28%; TD - 62%; ND - 75.6%; LRR - 78%; toxicity to adjuvant chemotherapy - 56%. There was no difference in survival nor loco-regional control between the groups.

CONCLUSIONS

Patients treated with neoadjuvant oral UFT + Folinic acid had a higher rate of pathologic complete response than patients treated with Capecitabine concomitant with radiotherapy. There were no differences in downstaging, LRR, toxicity, survival or loco-regional control between both groups. There was a trend to a higher rate of toxicity to adjuvant chemotherapy in the Capecitabine group.

Failure patterns correlate with the tumor response after preoperative chemoradiotherapy for locally advanced rectal cancer

BACKGROUND AND OBJECTIVES

To determine whether the patterns of failure are correlated with the degree of response to preoperative chemoradiotherapy (CRT) and to evaluate outcomes after recurrence in rectal cancer patients who underwent CRT followed by resection.

METHODS

Response to CRT was evaluated according to tumor regression grade (TRG), with 581 patients categorized into two groups, a good response (GR, TRG 3/4, n = 224) and a poor response (PR, TRG 1/2, n = 357) group.

RESULTS

At a mean follow-up of 61 months, the 5-year overall (88.2% vs. 71.3%, P < 0.001) and disease-free (86.7% vs. 63.6%, P < 0.001) survival rates were higher in the GR group. In patients with recurrence, time to recurrence was shorter (13.5 months vs. 18.7 months, P = 0.01), and the cumulative 2-year recurrence rates (92.9% vs. 73.4%, P = 0.024) was higher in the GR group. Rates of local (1.3% vs. 9.5% P < 0.001) and systemic (11.6% vs. 27.2%, P < 0.001) recurrence were significantly lower in the GR group, as were rates of pulmonary (3.6% vs. 15.1%, P < 0.001) and systemic lymph node (1.3% vs. 5.9%, P = 0.009) recurrences. The 5-year overall survival rates after recurrence were similar (GR: 23.7% vs. PR: 16.0%, P = 0.911).

CONCLUSIONS

More than one-third of patients with locally advanced rectal cancer showed good response to CRT, with improved local and systemic recurrence rates, especially low rates of pulmonary and systemic lymph node recurrence. Recurrence occurred earlier in the GR than the PR group, and oncologic outcomes after recurrence did not differ between the two groups.

Complete pathologic response after combined modality treatment for rectal cancer and long-term survival: a meta-analysis

BACKGROUND

Complete pathologic response (CPR) after neoadjuvant chemoradiotherapy (combined modality treatment, CMT) for rectal cancer seems associated with improved survival compared to partial or no response (NPR). However, previous reports have been limited by small sample size and single-institution design.

METHODS

A systematic literature review was conducted to detect studies comparing long-term results of patients with CPR and NPR after CMT for rectal cancer. Variables were pooled only if evaluated by 3 or more studies. Study end points included rates of CPR, local recurrence (LR), distant recurrence (DR), 5-year overall survival (OS), and disease-free survival (DFS).

RESULTS

Twelve studies (1,913 patients) with rectal cancer treated with CMT were included. CPR was observed in 300 patients (15.6%). CPR and NPR patient groups were similar with respect to age, sex, tumor size, distance of tumor from the anus, and stage of disease before treatment. Median follow-up ranged from 23 to 46 months. CPR patients had lower rates of LR [0.7% vs. 2.6%; odds ratio (OR) 0.45, 95% confidence interval (CI) 0.22-0.90, P = 0.03], DR (5.3% vs. 24.1%; OR 0.15, 95% CI 0.07-0.31, P = 0.0001), and simultaneous LR + DR (0.7% vs. 4.8%; OR 0.32, 95% CI 0.13-0.79, P = 0.01). OS was 92.9% for CPR versus 73.4% for NPR (OR 3.6, 95% CI 1.84-7.22, P = 0.002), and DFS was 86.9% versus 63.9% (OR 3.53, 95% CI 1.62-7.72, P = 0.002).

CONCLUSIONS

CPR after CMT for rectal cancer is associated with improved local and distal control as well as better OS and DFS.

Primary staging and response assessment postchemoradiotherapy in rectal cancer

SUMMARY Initial assessment of newly diagnosed patients with rectal cancer includes clinical examination, colonoscopy, pelvic MRI and CT scan of the thorax, abdomen and pelvis. Radiological staging can objectively evaluate both surgical and biological prognostic features of rectal cancer. MRI has emerged to be the most useful preoperative prognostic staging tool and it can predict the risk of tumor involvement of surgical circumferential resection margin. An agreed definition of favorable tumor response to chemoradiotherapy is controversial. The importance of detecting and assessing good versus poor responders to chemoradiotherapy is of increasing relevance. MRI has been found to be useful in assessing tumor response postchemoradiotherapy, especially the assessment of potential circumferential resection margin and magnetic resonance tumor regression grade. These imaging markers predict survival outcomes for good and poor responders and provide an opportunity for clinicians to offer additional neoadjuvant and adjuvant treatments to reduce local or distance failure for the poor responders.

A multi-centre pathologist survey on pathological processing and regression grading of colorectal cancer resection specimens treated by neoadjuvant chemoradiation

To ascertain the approach and degree of consensus of pathologists in the handling and regression grading of colorectal cancer resection specimens treated with neoadjuvant chemoradiation, a ten-part questionnaire was circulated to 18 gastrointestinal pathologists in eight countries. The questions were specific and addressed pertinent issues related to colorectal cancer with neoadjuvant chemoradiation. There is a lack of consensus on how to handle the specimen, number of sections taken, correlation with pre- and post-operative radiological imaging, and especially, regression grading schema employed. Consensus in the form of guidelines is required so that the pathological assessment of these specimens will provide clinically relevant information for patient management, irrespective of location.

Perineal reconstruction after abdominoperineal excision using inferior gluteal artery perforator flaps2

Background

Perineal wound complications following abdominoperineal excision (APE) for low rectal tumours remain an important cause of morbidity and prolonged hospital stay, particularly after chemoradiotherapy. The aim was to assess outcomes after using inferior gluteal artery perforator (IGAP) flaps for immediate perineal reconstruction, and to compare these with the authors' previous experience and published literature on myocutaneous flaps.

Methods

A series of patients who underwent immediate IGAP flap reconstruction after APE between April 2008 and December 2010 were examined retrospectively to determine patient demographics, length of operation, complications (perineal wound and general) and length of hospital stay.

Results

Forty patients with rectal adenocarcinoma (33 primary and 7 recurrent disease) underwent immediate IGAP flap reconstruction following APE. Median follow-up was 9 months. Neoadjuvant chemoradiotherapy was received by 98 per cent of the patients. Thirty-two patients underwent APE plus IGAP flaps (25 open, 7 laparoscopic), with a median operating time of 402 min, and eight patients had multivisceral resection (MVR) plus IGAP flaps (7 total pelvic exenteration (TPE), 1 abdominosacral resection), with a median duration of surgery of 561 min. There was one death (fatal stroke) and four major flap complications (10 per cent) (1 enteroperineal fistula, and 3 deep wound infections). Median length of hospital stay was 13 days after APE plus IGAP flaps and 27 days following MVR plus IGAP flaps. Late complications occurred in two patients who had vaginal reconstruction and developed perineal hernias requiring revisional surgery.

Conclusion

Although operating times are long, the IGAP flap is robust, with no flap necrosis observed in this series.

The CARTS study: Chemoradiation therapy for rectal cancer in the distal rectum followed by organ-sparing transanal endoscopic microsurgery

Background

The CARTS study is a multicenter feasibility study, investigating the role of rectum saving surgery for distal rectal cancer.

Methods/Design

Patients with a clinical T1-3 N0 M0 rectal adenocarcinoma below 10 cm from the anal verge will receive neoadjuvant chemoradiation therapy (25 fractions of 2 Gy with concurrent capecitabine). Transanal Endoscopic Microsurgery (TEM) will be performed 8 - 10 weeks after the end of the preoperative treatment depending on the clinical response.

Primary objective is to determine the number of patients with a (near) complete pathological response after chemoradiation therapy and TEM. Secondary objectives are the local recurrence rate and quality of life after this combined therapeutic modality. A three-step analysis will be performed after 20, 33 and 55 patients to ensure the feasibility of this treatment protocol.

Discussion

The CARTS-study is one of the first prospective multicentre trials to investigate the role of a rectum saving treatment modality using chemoradiation therapy and local excision. The CARTS study is registered at clinicaltrials.gov (NCT01273051)

Criteria for three-dimensional anorectal ultrasound assessment of response to chemoradiotherapy in rectal cancer patients

AIM

The aim of this study was to identify criteria for three-dimensional anorectal ultrasonography (3D-AUS) to assess the response of rectal cancer to chemoradiotherapy; the 3D-AUS results were compared with the histopathological findings of the resected specimen.

METHOD

Thirty-five patients underwent 3D-AUS and were grouped according to the presence (GI; n = 19) or absence (GII; n = 16) of anal canal invasion. All patients received chemoradiotherapy, then underwent a second 3D-AUS. The response (complete, partial or insignificant and lymph node metastasis) was evaluated. Tumour length (cm) and volume (cm(3) ), length and volume regression percentage (%), distal length regression, and distance between the distal tumour edge and the proximal border of the internal anal sphincter were measured before and after chemoradiotherapy. All patients underwent surgery, and the 3D-AUS image was compared with the histopathological findings.

RESULTS

Before chemoradiotherapy, the average tumour length was similar in G1 and GII, but the volume differed significantly (P = 0.0408). The response was insignificant in seven (37%) patients, partial in 10 (53%) patients and complete in two (10%) patients in GI. The corresponding figures for GII were one (6%) patient, 12 (75%) patients and three (19%) patients (P = 0.0318). The agreement between pathological and post-chemoratherapy 3D-AUS findings was almost identical for the identification of residual tumour or complete response (κ = 1.0) and substantial for lymph node metastases (κ = 0.74). The mean distance to the internal anal sphincter was greater in GII. A sphincter-saving resection was performed in 2/19 patients in GI and in 14/16 patients in GII (P < 0.0001). The histopathological examination revealed a free distal margin.

CONCLUSION

3D-AUS was shown to evaluate accurately the response to chemoradiotherapy, helping in the selection of patients for a sphincter-saving resection. The distance between the tumour and the internal anal sphincter was the most important parameter in this respect.

Total mesorectal excision of initially unresectable locally advanced rectal cancer infiltrating the pelvic wall after treatment with FOLFOX4 plus bevacizumab and preoperative chemoradiation: report of a case

A 60-year-old man underwent sigmoid loop colostomy for obstructive rectal cancer. Computed tomography (CT) showed a circumferential thickening of the lower rectal wall caused by a tumor invading the posterior and side pelvic wall. As we considered R0 resection too difficult, we gave the patient bevacizumab plus FOLFOX4 (oxaliplatin, leucovorin, and 5-fluorouracil). After eight courses, CT showed improvement in the rectal wall thickening but linear thickening of the mesorectal fascia remained. We therefore gave the patient chemoradiotherapy (CRT), and then 10 weeks later performed Hartmann's operation laparoscopically. Microscopic examination revealed that the tumor had been almost replaced by fibrous tissue, with only a few cancer cells left in the subserosa. The circumferential resection margin was free of cancer cells. The patient is doing well after 27 months of follow-up. This case suggests that systemic chemotherapy with FOLFOX4 plus bevacizumab prior to conventional preoperative CRT is a promising strategy for patients with initially unresectable locally advanced rectal cancer.

[Prognostic factors and functional imaging in rectal cancer]

The outcome of treatment for rectal cancer in recent years has been improved by diverse advances in the field of surgery and in neoadjuvant oncologic therapies. Heald's introduction of the concept of the mesorectum as an anatomical unit (total mesorectal excision) in 1982 and the generalization of preoperative radiochemotherapy have improved the prognosis in a significant number of patients. Owing to these advances, it has become necessary for imaging studies to define a series of prognostic factors for tumors, both before and after neoadjuvant treatment, to make it possible to tailor treatment for individual patients with rectal tumors. On the other hand, the advent of functional and molecular imaging techniques has provided a way to study a series of distinctive tumor characteristics in vivo, including the angiogenesis, metabolism, or cellularity of rectal tumors, and these techniques are making a growing contribution to the prognosis, staging, treatment planning, and evaluation of the response to therapy in patients with rectal cancer.

Surgical Complications and Pathologic Complete Response after Neoadjuvant Chemoradiation in Locally Advanced Rectal Cancer

Pathologic complete response (pCR) to neoadjuvant chemoradiation (CRT) in patients with rectal cancer is associated with improved prognosis, whereas postoperative surgical complications have been linked with poor oncologic outcomes. Our objective was to examine the association between postoperative complications and pCR. We analyzed 127 patients enrolled in a prospective multicenter study investigating rectal cancer response to CRT. Surgical complications were scored according to the Clavien-Dindo scale (Grade 1 to 4). Among the 127 patients analyzed, 28 (22%) patients had a pCR. In the pCR group, six surgical Grade 3+ complications occurred in five (18%) patients, including anastomotic leak (n = 2), ureteral injury (n = 2), pelvic abscess (n = 1), and pneumonia (n = 1). In the non-pCR group, there were 10 Grade 3+ complications in eight (8%) patients, including severe obstruction (n = 1), postoperative hemorrhage (n = 1), leak (n = 2), pelvic abscess (n = 2), ureteral injury (n = 1), and severe morbidity (stroke, n = 1; acute respiratory distress, n = 1; and cardiac event, n = 1). There was no significant difference in the frequency of total surgical complications between pCR and non-pCR patients; and no association was observed between pCR and major postoperative complications. In conclusion, postoperative complication rates do not differ between pCR and non-pCR groups. The occurrence of major postoperative complications is not associated with response to neoadjuvant CRT.

Who performs proctectomy for rectal cancer in the United States?

BACKGROUND

There is wide variation in surgical care for rectal cancer in the United States.

OBJECTIVE

This study aimed to assess the differences in individual surgeon procedural profiles that might explain variations in the rates of restorative vs nonrestorative proctectomy for rectal cancer.

DESIGN

This study was a retrospective examination of a cohort derived from trackable state hospital discharge data from 11 states.

PATIENTS

We identified all patients with rectal cancer that underwent restorative proctectomy (sphincter-sparing surgery) vs nonrestorative proctectomy (colostomy formation) over a 24-month study period (January 1, 2003 through December 31, 2004).

INTERVENTION

We developed an inpatient procedural profile of each treating surgeon's practice across general surgery procedure codes and summed the number of restorative vs nonrestorative proctectomies for rectal cancer by surgeon.

MAIN OUTCOME MEASURES

The primary outcome measures were nonrestorative proctectomy, mortality, and length of stay.

RESULTS

A total of 7519 proctectomies were performed for rectal cancer by 2588 surgeons. During the 24-month study period, 1003 (38.8%) surgeons performed only nonrestorative procedures for rectal cancer. On multivariate analysis, the likelihood that a surgeon performed only nonrestorative procedures was increased if that surgeon performed more integumentary procedures and decreased if the surgeon performed at least one ileoanal pouch procedure or more anorectal procedures. Patients who underwent proctectomy by surgeons who performed only nonrestorative procedures had significantly higher mortality (2.5 ± 0.7%) and longer length of stay (11.3 ± 8.8 days) in comparison with those patients treated by surgeons who performed both restorative and nonrestorative procedures (1.3 ± 0.3% mortality and 9.2 ± 6.9 days, P < .001 for both analyses). The volume of proctectomy performed significantly affected all analyses.

LIMITATIONS

: The retrospective design introduces potential selection bias.

CONCLUSIONS

Over a 24-month period, 38.8% of surgeons performed only nonrestorative procedures for rectal cancer. These surgeons did not regularly perform anorectal or ileoanal pouch procedures, suggesting that they may not have a focus on colorectal disease in their practice; they had significantly higher mortality and length of stay for their patients who underwent proctectomy for rectal cancer.

Preoperative radiotherapy combined with capecitabine chemotherapy in Chinese patients with locally advanced rectal cancer

BACKGROUND

This phase II study is performed to evaluate the efficacy and safety of capecitabine combined with preoperative radiotherapy (RT) in Chinese patients with locally advanced rectal cancer (LARC).

METHODS

Between February 2007 and December 2008, 62 patients with LARC were treated with capecitabine (825 mg/m(2), twice daily) and concurrent RT (50.4 Gy/28 fractions). Patients underwent surgery after 6-8 weeks of combined therapy, followed by 4 cycles of adjuvant capecitabine (1,250 mg/m(2), twice daily on days 1-14, every 3 weeks). The primary endpoint was the rate of pathologic complete response (pCR).

RESULTS

Fifty-eight patients (93.5%) completed the preoperative chemoradiation course as initially planned. The most severe hematologic adverse event was leucopenia, which occurred with grade 2 intensity in 12 (19.7%) patients and grade 3 in 2 (3.3%) patients. Grade 3 diarrhea and hand-foot syndrome (HFS) were observed in one (1.6%) and two (3.3%) patients, respectively. However, no grade 4 toxicity was observed. There were no treatment-related deaths during this study. Of the 59 patients treated with surgery, all had radial margins (R0 resections). Among the 29 patients with the primary tumor ≤5 cm from the anal verge, 18 (62.1%) underwent sphincter-preserving surgical resections. pCR was found in eight patients (13.6%). The pathologic stage was lower than the initial clinical stage in 57.6% (34/59), 63.4% (26/41), and 81.4% (48/59) of the resected tumors for the primary tumor (T), lymph node (N), and combined TN categories, respectively. The estimate of disease-free survival and overall survival at 24 months were 80.6% (95% CI, 70.8-90.4%) and 92.5% (95% CI, 85.9-99.1%), respectively.

CONCLUSION

Preoperative chemoradiotherapy with capecitabine and RT appears to be a safe, well-tolerated, and effective neoadjuvant treatment modality for LARC.

Pretreatment CD133 and cyclooxygenase-2 expression as the predictive markers of the pathological effect of chemoradiotherapy in rectal cancer patients

BACKGROUND

CD133 confers chemoradioresistance properties to cells and has recently been used to identify cancer-initiating cells.

OBJECTIVE

We investigated whether the overexpression of CD133 and cyclooxygenase-2 can be used as predictive markers of tumor response to preoperative chemoradiotherapy in patients with rectal cancer.

SETTING

The study was conducted at the National Defense Medical College Hospital in Japan.

PATIENTS

We recruited 96 patients who underwent a single regimen of preoperative short-term chemoradiotherapy (20 Gy in 5 fractions with 400 mg/day Tegafur/Uracil for 1 week) and radical resection.

DESIGN

This was a retrospective study. We obtained pretreatment biopsy specimens of these patients and immunostained these specimens with antibodies for CD133, cyclooxygenase-2, p53, p27, p21, and epidermal growth factor receptor. The resected primary tumor was evaluated according to 2 different tumor regression grading systems that were based on the degrees of fibrosis and cytological alterations.

RESULTS

Positivity for CD133 or cyclooxygenase-2 expression was associated with chemoradioresistance, which was determined by the degree of fibrosis, in both univariate (P = .02 and P = .0003) and multivariate (P = .03 and P = .001) analyses. Univariate and multivariate analyses of the degree of cytological alterations also revealed a significant association between chemoradioresistance and the expression of CD133 (P = .005 and P = .003) and cyclooxygenase-2 (P = .005 and P = .03), whereas other markers failed to associate.

LIMITATIONS

The information on patients' outcome was not available.

CONCLUSIONS

Our study revealed the independent predictive values of CD133 and cyclooxygenase-2 expressions in histological tumor regression after preoperative chemoradiotherapy.

Clinicopathologic variables predicting tumor response to neoadjuvant chemotherapy in patients with locally advanced gastric cancer

BACKGROUND AND OBJECTIVES

To identify clinicopathologic variables that could predict pathologic tumor response to neoadjuvant chemotherapy for patients with locally advanced gastric cancer.

METHODS

The study enrolled 108 patients who underwent neoadjuvant chemotherapy followed by surgery between July 2004 and December 2010. Tumor responses to neoadjuvant chemotherapy were assessed in terms of tumor regression. Statistical analyses were performed to identify factors associated with pathologic tumor response.

RESULTS

Tumor regression was found in 22.2% (24/108) patients, patients with tumor regression observed better overall survival as compared to that of patients without tumor regression. Univariate and multivariate analyses observed that both tumor differentiation and tumor size were independent predictors of tumor regression.

CONCLUSIONS

This study suggests that both tumor differentiation and tumor size is the most important clinical predicator of pathologic tumor response, it may be of benefit in the selection of treatment options in locally advanced gastric cancer.

A phase II trial of neoadjuvant chemoradiation and local excision for T2N0 rectal cancer: preliminary results of the ACOSOG Z6041 trial

PURPOSE

We designed American College of Surgeons Oncology Group (ACOSOG) Z6041, a prospective, multicenter, single-arm, phase II trial to assess the efficacy and safety of neoadjuvant chemoradiation (CRT) and local excision (LE) for T2N0 rectal cancer. Here, we report tumor response, CRT-related toxicity, and perioperative complications (PCs).

METHODS

Clinically staged T2N0 rectal cancer patients were treated with capecitabine and oxaliplatin during radiation followed by LE. Because of toxicity, capecitabine and radiation doses were reduced. LE was performed 6 weeks after CRT. Patients were evaluated for clinical and pathologic response. CRT-related complications and PCs were recorded.

RESULTS

Ninety patients were accrued; 6 received nonprotocol treatment. The remaining 84 were 65% male; median age 63 years; 83% Eastern Cooperative Oncology Group performance score 0; 92% white; mean tumor size 2.9 cm; and average distance from anal verge 5.1 cm. Five patients were considered ineligible. Therapy was completed per protocol in 79 patients, but two patients did not undergo LE. Among 77 eligible patients who underwent LE, 34 patients achieved a pathologic complete response (44%) and 49 (64%) tumors were downstaged (ypT0-1), but 4 patients (5%) had ypT3 tumors. Five LE specimens contained lymph nodes; one T3 tumor had a positive node. All but one patient had negative margins. Thirty-three (39%) of 84 patients developed CRT-related grade ≥3 complications. Rectal pain was the most common PC.

CONCLUSIONS

CRT before LE for T2N0 tumors results in a high pathologic complete response rate and negative resection margins. However, complications during CRT and after LE are high. The true efficacy of this approach will ultimately be assessed by the long-term oncologic outcomes.

Molecular diagnosis of response to neoadjuvant chemoradiation therapy in patients with locally advanced rectal cancer

BACKGROUND

Pathologic complete response (pCR) to neoadjuvant chemoradiation (CRT) is an important prognostic factor in locally advanced rectal cancer. However, it is uncertain if histopathological techniques accurately detect pCR. We tested a novel molecular approach for detecting pCR and compared it with current histopathological approaches.

STUDY DESIGN

Pretreatment tumor biopsies and surgical specimens were collected from 96 patients with locally advanced rectal cancer treated with neoadjuvant CRT and surgery. Tumor response was categorized by tumor regression grade. Tumor DNA from pre-CRT tumor biopsies was screened for K-ras and p53 mutations. DNA from paired surgical specimens was then screened for the same mutations using highly sensitive polymerase chain reaction-based techniques.

RESULTS

Sixty-eight of 96 (71%) pretreatment biopsies harbored K-ras and/or p53 mutation; 36 (38%) had K-ras mutations, 52 (54%) had p53 mutations, and 20 (21%) carried both mutations. Of 70 patients with tumor regression grades 1 to 3, sixty-six (94%) had a concordant K-ras and p53 mutation profile in pre- and post-treatment tissues. Of 26 patients with tumor regression grade 0 (pCR), 12 had K-ras or p53 mutations in pretreatment biopsies. Of these, 2 (17%) patients had the same K-ras (n = 1) or p53 (n = 1) mutation detected in post-treatment tissue.

CONCLUSIONS

Sensitive molecular techniques detect K-ras and p53 mutations in post-CRT surgical specimens in some patients with a pCR. This suggests histopathological techniques might not be completely accurate, and some patients diagnosed with a pCR to CRT might have occult cancers cells in their surgical specimens.

Pharmacogenetic study in rectal cancer patients treated with preoperative chemoradiotherapy: polymorphisms in thymidylate synthase, epidermal growth factor receptor, GSTP1, and DNA repair genes

PURPOSE

Several studies have been performed to evaluate the usefulness of neoadjuvant treatment using oxaliplatin and fluoropyrimidines for locally advanced rectal cancer. However, preoperative biomarkers of outcome are lacking. We studied the polymorphisms in thymidylate synthase, epidermal growth factor receptor, glutathione S-transferase pi 1 (GSTP1), and several DNA repair genes to evaluate their usefulness as pharmacogenetic markers in a cohort of 128 rectal cancer patients treated with preoperative chemoradiotherapy.

METHODS AND MATERIALS

Blood samples were obtained from 128 patients with Stage II-III rectal cancer. DNA was extracted from the peripheral blood nucleated cells, and the genotypes were analyzed by polymerase chain reaction amplification and automated sequencing techniques or using a 48.48 dynamic array on the BioMark system. The germline polymorphisms studied were thymidylate synthase, (VNTR/5'UTR, 2R G>C single nucleotide polymorphism [SNP], 3R G>C SNP), epidermal growth factor receptor (Arg497Lys), GSTP1 (Ile105val), excision repair cross-complementing 1 (Asn118Asn, 8092C>A, 19716G>C), X-ray repair cross-complementing group 1 (XRCC1) (Arg194Trp, Arg280His, Arg399Gln), and xeroderma pigmentosum group D (Lys751Gln). The pathologic response, pathologic regression, progression-free survival, and overall survival were evaluated according to each genotype.

RESULTS

The ∗3/∗3 thymidylate synthase genotype was associated with a greater response rate (pathologic complete remission and microfoci residual tumor, 59% in ∗3/∗3 vs. 35% in ∗2/∗2 and ∗2/∗3; p=.013). For the thymidylate synthase genotype, the median progression-free survival was 103 months for the ∗3/∗3 patients and 84 months for the ∗2/∗2 and ∗2/∗3 patients (p=.039). For XRCC1 Arg399Gln SNP, the median progression-free survival was 101 months for the G/G, 78 months for the G/A, and 31 months for the A/A patients (p=.048).

CONCLUSIONS

The thymidylate synthase genotype and XRCC1 Arg399Gln polymorphism might help to identify Stage II-III rectal cancer patients with a better outcome after preoperative concomitant chemoradiotherapy.

Laparoscopic total mesorectal excision following long course chemoradiotherapy for locally advanced rectal cancer

PURPOSE

Laparoscopic total mesorectal excision (TME) of locally advanced rectal cancer after long-course chemoradiotherapy (LCRT) is surgically and oncologically challenging. We have assessed the feasibility, timing, and short-term oncological outcome of laparoscopic TME after LCRT.

METHODS

Between 2004 and 2006, 30 patients were selected for LCRT based on clinical examination and MRI. Patients received 3/4 field radiotherapy, 45-50.4 Gy in 25-28 fractions during 5 weeks with either 5-fluorouracil or Uftoral. Clinical assessments were made 4 weeks after completion of radiotherapy and then 2 weekly with sequential 4 weekly MRI, to individualize the timing of surgery at maximal response. Laparoscopic TME was performed using a standard technique.

RESULTS

Thirty patients received LCRT and 26 patients (21 men; median age, 63 years) underwent laparoscopic TME at 11 weeks (median) after LCRT. Median operating time was 270 min. Sixteen patients had LAR and ten had APR. There were three conversions. Three patients developed anastomotic leak (18.7%): one was managed conservatively and one patient died of septicemia. Morbidity was seen in 19% of patients. There were 25 (96%) R0 resections with a complete response in 5 (19%) cases and microscopic tumor in lakes of mucin (Tmic) in another 6 (23%). Two patients (7.6%) developed local recurrence (median follow up, 34 months). The median time interval between radiotherapy and surgery was 11 (range, 7-13) weeks, which was based on serial MRI scans after LCRT.

CONCLUSIONS

Laparoscopic TME after LCRT is feasible and safe both oncologically and surgically. Serial MRI helps to determine the optimum timing of surgery.