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

T-staging of rectal cancer: accuracy of 3.0 Tesla MRI compared with 1.5 Tesla

Objectives

Magnetic resonance imaging (MRI) is not accurate in discriminating T1-2 from borderline T3 rectal tumors. Higher resolution on 3 Tesla-(3T)-MRI could improve diagnostic performance for T-staging. The aim of this study was to determine whether 3T-MRI compared with 1.5 Tesla-(1.5T)-MRI improves the accuracy for the discrimination between T1-2 and borderline T3 rectal tumors and to evaluate reproducibility.

Methods

13 patients with non-locally advanced rectal cancer underwent imaging with both 1.5T and 3T-MRI. Three readers with different expertise evaluated the images and predicted T-stage with a confidence level score. Receiver operator characteristics curves with areas under the curve (AUC) and diagnostic parameters were calculated. Inter- and intra-observer agreements were calculated with quadratic kappa-weighting. Histology was the reference standard.

Results

Seven patients had pT1-2 tumors and six had pT3 tumors. AUCs ranged from 0.66 to 0.87 at 1.5T vs. 0.52–0.82 at 3T. Mean overstaging rate was 43% at 1.5T and 57% at 3T (P = 0.23). Inter-observer agreement was κ 0.50–0.71 at 1.5T vs. 0.15–0.68 at 3T. Intra-observer agreement was κ 0.71 at 1.5T and 0.76 at 3T.

Conclusions

This is the first study to compare 3T with 1.5T MRI for T-staging of rectal cancer within the same patients. Our results showed no difference between 3T and 1.5T-MRI for the distinction between T1-2 and borderline T3 tumors, regardless of expertise. The higher resolution at 3T-MRI did not aid in the distinction between desmoplasia in T1-2-tumors and tumor stranding in T3-tumors. Larger studies are needed to acknowledge these findings.

Ostomy function after abdominoperineal resection--a clinical and patient evaluation

PURPOSE

Abdominoperineal resection (APR) for rectal cancer results in a permanent colostomy. As a consequence of a recent change in operative technique from standard (S-APR) to extralevator resection (E-APR), the perineal part of the procedure is now performed with the patient in a prone jackknife position. The impact of this change on stoma function is unknown. The aim was to determine stoma-related complications and the individual patient experience of a stoma.

METHODS

Consecutive patients with rectal cancer operated on with APR in one institution in 2004 to 2009 were included. Recurrent cancer, palliative procedures, pre-existing stoma and patients not alive at the start of the study were excluded. Data were collected from hospital records and the national colorectal cancer registry. A questionnaire was sent out to patients. The median follow-up was 44 months (13-84) after primary surgery.

RESULTS

Ninety-six patients were alive in February 2011. Seventy seven agreed to participate. Sixty-nine patients (90 %) returned the questionnaire. Stoma necrosis was more common for E-APR, 34 % vs. 10 %, but bandaging problems and low stoma height were more common for S-APR. There were no differences in the patients' experience of stoma function. In all, 35 % of the patients felt dirty and unclean, but 90 % felt that they had a full life and could engage in leisure activities of their choice.

CONCLUSIONS

This exploratory study indicates no difference in stoma function after 1 year between S-APR and E-APR. Over 90 % of the patients accept their stoma, but our study indicates that more information and support for patients are warranted.

Outcome of extralevator abdominoperineal excision compared with standard surgery: results from a single centre

AIM

Extralevator abdominoperineal excision (APE) for low rectal tumours has been introduced to achieve improved local radicality. Fewer positive margins and intraoperative perforations have been reported compared with standard APE. The aim of this retrospective study was to compare short-term complications and results of the two techniques in our institution.

METHOD

Consecutive patients with rectal cancer undergoing APE between 2004 and 2009 were included. They were divided into two groups of 79 patients in extralevator APE and 79 in standard APE. Patients with recurrence and those having a palliative procedure were excluded. Data were collected from hospital records and the colorectal cancer registry. Main endpoints were wound infection, perineal wound revision, oncological data and length of hospital stay.

RESULTS

Circumferential resection margin positivity did not differ significantly between groups (17% extralevator APE; 20% standard APE). Intraoperative perforation (13%vs 10%) or local recurrence (seven in each group) were no different. Perineal wound infection was more common after extralevator APE (46%vs 28%, P<0.05) as was perineal wound revision (22%vs 8%, P<0.05). Hospital stay was longer after extralevator APE (median 12 vs 11days, P<0.05). Tumour height (median 4cm) and pTNM classification did not differ.

CONCLUSION

The results do not show any advantage for extralevator APE. The oncological data were no better and postoperative morbidity was increased. Further studies are needed before extralevator APE is widely adopted in clinical practice.

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.

T2 weighted signal intensity evolution may predict pathological complete response after treatment for rectal cancer

OBJECTIVES

To determine the diagnostic value of T2-weighted signal intensity evolution in the tumour for detection of complete response to neoadjuvant chemoradiotherapy in patients with rectal cancer.

METHODS

Thirty-nine patients diagnosed with locally advanced adenocarcinoma and treated with chemoradiotherapy (CRT), followed by surgery, underwent magnetic resonance imaging (MRI) before and after CRT on 1.5-T MRI using T2-weighted fast spin-echo (FSE) imaging. The relative T2-weighted signal intensity (rT2wSI) distribution in the tumour and post-CRT residual tissue was characterised by means of the descriptive statistical parameters, such as the mean, 95th percentile and standard deviation (SD). Receiver operating characteristic curves were used to determine the diagnostic potential of the CRT-induced alterations (Δ) in rT2wSI descriptives. The tumour regression grade (TRG) served as a histopathological reference standard.

RESULTS

CRT induced a significant decrease of approximately 50% in all rT2wSI descriptives in complete responders (TRG1). This drop was significantly larger than for incomplete response groups (TRG2-TRG4). The ΔrT2wSI descriptives produced a high diagnostic performance for identification of complete responders, e.g. Δ95th percentile, ΔSD and Δmean resulted in accuracy of 92%, 90% and 82%, respectively.

CONCLUSIONS

Quantitative assessment of the CRT-induced changes in the tumour T2-weighted signal intensity provides high diagnostic performance for selection of complete responders.

Expression of vascular endothelial growth factor can predict distant metastasis and disease-free survival for clinical stage III rectal cancer following 30-Gy/10-f preoperative radiotherapy

PURPOSE

The purpose of this study was to analyze the prognostic value of vascular endothelial growth factor (VEGF) in patients with stage III rectal cancer treated with 30-Gy/10-fraction (f) preoperative radiotherapy and radical surgery.

METHODS

One hundred and sixteen patients with clinical stage III rectal cancer were studied. All patients underwent radical surgery after 30-Gy/10-f preoperative radiotherapy. Immunohistochemical examination of VEGF was performed on the resected tumor specimen. An immunohistochemical score established from the extension and intensity of the markers was used for analysis. The log-rank test and proportional hazards regression analysis were used to calculate the probability that this biomarker was associated with patient outcomes.

RESULTS

The expression of VEGF was identified among 74.1 % (86 of 116) of patients. We found an increased incidence of distant metastasis (19.8 vs. 3.3 %, p = 0.039) and a decreased 3-year disease-free survival rate (96.7 % vs. 72.7 %, p = 0.003) in patients with positive VEGF staining. In multivariate survival analysis, positive VEGF staining (hazard ratio (HR) = 9.364, 95 % confidence interval (CI) 1.298-71.519, p = 0.027) and ypN+ stage (HR = 2.714, 95 % CI 1.419-3.331, p = 0.000) were the independent prognostic factors for disease-free survival. Subgroup analyses showed that the expression of VEGF was significantly associated with increased distant metastasis rate and decreased DFS in patients with ypN+ stage.

CONCLUSIONS

VEGF expression may have potential value for predicting distant metastasis and disease-free survival in stage III rectal cancer after 30-Gy/10-f preoperative radiotherapy. Inhibition of VEGF in combination with radiotherapy may improve the patient outcomes.

Expression of vascular endothelial growth factor can predict distant metastasis and disease-free survival for clinical stage III rectal cancer following 30-Gy/10-f preoperative radiotherapy

PURPOSE

The purpose of this study was to analyze the prognostic value of vascular endothelial growth factor (VEGF) in patients with stage III rectal cancer treated with 30-Gy/10-fraction (f) preoperative radiotherapy and radical surgery.

METHODS

One hundred and sixteen patients with clinical stage III rectal cancer were studied. All patients underwent radical surgery after 30-Gy/10-f preoperative radiotherapy. Immunohistochemical examination of VEGF was performed on the resected tumor specimen. An immunohistochemical score established from the extension and intensity of the markers was used for analysis. The log-rank test and proportional hazards regression analysis were used to calculate the probability that this biomarker was associated with patient outcomes.

RESULTS

The expression of VEGF was identified among 74.1 % (86 of 116) of patients. We found an increased incidence of distant metastasis (19.8 vs. 3.3 %, p = 0.039) and a decreased 3-year disease-free survival rate (96.7 % vs. 72.7 %, p = 0.003) in patients with positive VEGF staining. In multivariate survival analysis, positive VEGF staining (hazard ratio (HR) = 9.364, 95 % confidence interval (CI) 1.298-71.519, p = 0.027) and ypN+ stage (HR = 2.714, 95 % CI 1.419-3.331, p = 0.000) were the independent prognostic factors for disease-free survival. Subgroup analyses showed that the expression of VEGF was significantly associated with increased distant metastasis rate and decreased DFS in patients with ypN+ stage.

CONCLUSIONS

VEGF expression may have potential value for predicting distant metastasis and disease-free survival in stage III rectal cancer after 30-Gy/10-f preoperative radiotherapy. Inhibition of VEGF in combination with radiotherapy may improve the patient outcomes.

International study group on rectal cancer regression grading: interobserver variability with commonly used regression grading systems

The aim of this study was to ascertain the level of concordance among gastrointestinal pathologists for regression grading in rectal cancers treated with neoadjuvant chemoradiation. Seventeen gastrointestinal pathologists participated using the Mandard, Dworak, and modified rectal cancer regression grading systems to grade 10 representative slides that were selected from 10 cases of rectal cancer treated with long-course neoadjuvant chemoradiation. The slides were scanned with a whole-slide scanner generating dynamic digitized images. The results showed very little concordance across the 3 grading systems, with κ values of 0.28, 0.35, and 0.38 for the Mandard, Dworak, and modified rectal cancer regression grading systems, respectively. In only 1 of 10 study cases was there unanimous grading concordance using the modified rectal cancer regression grading system. It was felt that these systems lacked precision and clarity for reproducible, accurate regression grading. The study concluded that there was a need for a simple, reproducible regression grading system with clear criteria, a cumulative or composite score taking into account all sections of the tumor bed that is sampled rather than the worst section (highest grade), and there should be a uniform method of sampling of these specimens.

Multidisciplinary treatment of patients with rectal cancer: Development during the past decades and plans for the future

In rectal cancer treatment, both the local primary and the regional and systemic tumour cell deposits must be taken care of in order to improve survival. The three main treatments, surgery, radiotherapy, and chemotherapy, each with their own advantages and limitations, must then be combined to improve results. Several large randomized trials have shown that combinations of the modalities have markedly reduced the loco-regional recurrences, but have not yet had any major influence on overall survival. The best integration of the weakest modality, to date the drugs (conventional cytotoxics and biologicals), is not known. A new generation of trials exploring the best sequence of treatments is required. Furthermore, treatment of rectal cancer is administered to populations of individuals, based upon clinical factors and imaging, and can presently not be further individualized. There is an urgent need to develop response predictors.

Management of local rectal cancer: evidence, controversies and future perspectives in radiotherapy

SUMMARY Rectal cancer comprises approximately 25% of all primary colorectal cancers. The optimal diagnostic and treatment approach for this heterogeneous malignancy is still contentious, and improvements in general multidisciplinary management are required. During recent years a number of randomized studies led by European investigators have shown optimization in preoperative staging, improvements in surgical technique and the histopathological assessment of the resected specimen, and the benefit of combined modality treatment. The main recommendations and the trends in research on radiotherapy and integrated treatments will be summarized with an overview on some relevant points about imaging and pathological staging.

Initial results of a randomized controlled trial comparing clinical and pathological downstaging of rectal cancer after preoperative short-course radiotherapy or long-term chemoradiotherapy, both with delayed surgery

AIM

The aim of this study was to compare the downstaging achieved after long-course chemoradiotherapy (chRT) and short-term radiotherapy (sRT) followed by delayed surgery.

METHOD

A randomized controlled trial was carried out. Eighty-three patients with resectable stage II and III rectal adenocarcinoma were randomized to receive long-course chemoradiotherapy (46) and short-term radiotherapy (5×5 Gy) (37). Surgery was performed 6 weeks after preoperative treatment in both groups.

RESULTS

The R0 resection rate was 91.3% in the chRT and 86.5% in the sRT group (P=0.734). Sphincter preservation rates were 69.6%vs 70.3% (P=0.342) and postoperative complication rates were 26.1%vs 40.5% (P=0.221). There were more patients with early pT stage [pT0 (complete pathological response) pT1] in the chRT group [21.8%vs 2.7% (P=0.03)] and more patients with pT3 disease in the sRT group [75.7%vs 52.2% (P=0.036)]. There were no differences in pN stage and lymphatic or vascular invasion in either group. Pathological downstaging (stage 0 and I) was observed in eight (21.6%) patients in the sRT group and in 18 (39.1%) in the chRT group (P=0.07). Tumours were smaller after preoperative ChRT (2.5 cm vs 3.3 cm; P=0.04).

CONCLUSION

Long-course preoperative chemoradiation resulted in greater statistically significant tumour downsizing and downstaging compared with short-term radiation, but there was no difference in the R0 resection rates. Similar postoperative morbidity was observed in each group.

Characterisation of rectal motion during neo-adjuvant radiochemotherapy for rectal cancer with image-guided tomotherapy: implications for adaptive dose escalation strategies

BACKGROUND

Interest in boosting the dose to the tumour during neo-adjuvant radiochemotherapy for rectal cancer is ever increasing, especially within the frame of adaptive radiotherapy. Rectal motion remains a potentially important obstacle to the full exploitation of this approach and needs to be carefully investigated.

MATERIAL AND METHODS

The main purposes of this work were to: a) quantify rectal motion on all fractions of a treatment course; and b) assess margins for adaptive boosting in the second part of the treatment in order to benefit of tumour reduction during treatment. Ten consecutive patients treated with image-guided tomotherapy (41.4 Gy, 18 fractions) were selected. The cranial half of the rectum (subject to motion) was contoured by a single observer on daily MVCTs. The variations of rectal volume and of the envelope of rectum positions were investigated (169 MVCTs). The impact of applying different margins to the rectum in including all its possible positions was also investigated when considering the planning kVCT, the first fraction MVCT, the half-treatment MVCT or the median rectal contours of the whole or second half of treatment as reference volumes.

RESULTS

Rectal volume reduced during treatment in all patients, with a significant time-trend in 6/10 patients. The median values of the envelope volumes were 129 cm(3) and 87 cm(3) in the first and second half of the treatment, respectively. On average, 95% of the rectal envelope was included by an isotropic expansion of 12 mm and 5 mm of the median contours when considering the whole or the second half of the treatment, respectively.

CONCLUSION

A significant reduction of rectal volume was found in the second part of the treatment where rectal mobility was limited. As a consequence, relatively small margins may be used around the residual tumour volume when adaptive boost is delivered in the second half of the treatment.

The surgical significance of residual mucosal abnormalities in rectal cancer following neoadjuvant chemoradiotherapy

BACKGROUND

Local excision of rectal cancer after neoadjuvant chemoradiotherapy (CRT) has been proposed as an alternative to radical surgery in selected patients. However, little is known about the significance of the morphological and histological features of residual tumour.

METHODS

Patients who had undergone CRT at the authors' institution between 1997 and 2010 were identified. Multiple features were assessed as putative markers of pathological response. These included: gross residual disease, diameter of residual mucosal abnormalities, tumour differentiation, presence of lymphovascular/perineural invasion and lymph node ratio.

RESULTS

Data from 220 of 276 patients were suitable for analysis. Diameter of residual mucosal abnormalities correlated strongly with pathological tumour category after CRT (ypT) (P < 0·001). Forty of 42 tumours downstaged to ypT0/1 had residual mucosal abnormalities of 2·99 cm or less after CRT. Importantly, 19 of 31 patients with a complete pathological response had evidence of a residual mucosal abnormality consistent with an incomplete clinical response. The ypT category was associated with both pathological node status after CRT (P < 0·001) and lymph node ratio (P < 0·001). Positive nodes were found in only one of 42 patients downstaged to ypT0/1. The risk of nodal metastases was associated with poor differentiation (P = 0·027) and lymphovascular invasion (P < 0·001).

CONCLUSION

In this series, the majority of patients with a complete pathological response did not have a complete clinical response. In tumours downstaged to ypT0/1 after CRT, residual mucosal abnormalities were predominantly small and had a 2 per cent risk of positive nodes, thus potentially facilitating transanal excision. The presence of adverse histological characteristics risk stratified tumours for nodal metastases.

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.

Morphology and prognostic value of tumor budding in rectal cancer after neoadjuvant radiotherapy

Tumor budding is an acknowledged prognostic marker in colorectal cancer. This study was conducted to investigate the morphology and prognostic significance of budding in rectal cancer after neoadjuvant radiotherapy. Surgical specimens from 96 consecutive patients who underwent neoadjuvant radiotherapy and curative resection were retrieved to assess budding and other clinicopathologic factors. The morphology and prognostic significance of postirradiation tumor budding were closely associated with tumor regression grade. In the tumor regression grade 1 group, tumor budding presented as "false budding" and did not have a significant association with prognosis. In the tumor regression grade 2 and 3 groups, budding was observed surrounded by radiation-induced fibrosis and large populations of infiltrating inflammatory cells, and budding intensity was significantly associated with histologic differentiation, ypN stage, and lymphovascular invasion (P < .05). Moreover, the low-grade budding subgroup showed a significantly higher rate of 5-year disease-free survival than the high-grade budding subgroup (87.5% versus 55.6%, P < .0001). Multivariate analysis showed that pretreatment serum carcinoembyronic antigen, tumor regression grade, and tumor budding were the major independent factors affecting long-term disease-free survival. In conclusion, postirradiation budding has distinct morphology and prognostic significance in rectal cancer after neoadjuvant radiotherapy.

Rectal cancer staging: is there an optimal method?

The staging process in a newly diagnosed rectal cancer is divided into three parts. One essential part is the local staging, in which both endorectal ultrasound and MRI are used to disclose the size of the tumor and its correlation to the perirectal fascia, and to identify lymph node deposits and vascular invasion. This local staging process will guide clinicians to decide upon not only the type of surgery (local excision or radical surgery) but also whether or not some type of neoadjuvant treatment, such as radiotherapy and/or chemotherapy, is indicated. The second part is to evaluate whether or not the tumor has already metastasized at diagnosis. The most important organs to evaluate are the liver and lungs, and imaging techniques such as ultrasound, CT-scan, or sometimes PET-CT, and MRI can be used. The third important part is to investigate the rest of the large bowel for synchronous adenomas or cancers. This will preferably be done with colonoscopy or CT-colonography and sometimes barium enema. This article discusses the imaging techniques used for local staging and distant metastases.

Concomitant boost radiotherapy and multidrug chemotherapy in the neoadjuvant treatment of locally advanced rectal cancer: results of a phase II study

BACKGROUND

An intensified multidrug chemotherapy regimen (raltitrexed plus oxaliplatin, Tom-Ox) plus concomitant boost radiotherapy, in the neoadjuvant treatment of locally advanced rectal cancer patients, was shown feasible in our previous study. The aim of this study was to evaluate the efficacy in terms of pathologic complete response to pre-operative therapy.

MATERIAL AND METHODS

A Phase II study was designed and clinical stage T3-T4 and/ or N ≥ 1 patients were treated with concomitant boost radiotherapy (55 Gy/5 weeks) plus concurrent chemotherapy (Tom-Ox). The primary endpoint was the assessment of efficacy in terms of clinical and pathologic response to pre-operative therapy. According to the Gehan's design study, 25 patients were enrolled. Toxicity was assessed according to the RTOG-EORTC and CTCAE v.3.0 criteria.

RESULTS

Twenty-five consecutive patients were treated. Twenty-two of the 25 (88%) patients had a partial clinical response at the time of pre-operative magnetic resonance imaging (MRI). Only one patient showed progressive systemic disease at pre-surgical revaluation and was subjected only to biopsy to evaluate pathological response. Twenty-four patients (96%) underwent surgery. Overall, pathologic complete response was observed in eight patients (32%; CI 0.95:12-55%) and only microscopic tumor foci (pTmic) in two patients (pT0-mic: 40%; CI 0.95:18-63%). Nineteen patients (76%) showed tumor down-staging. Proctitis and/or diarrhea were the most frequent acute side effects experienced. Eighteen patients had grade 1-2 toxicity (77%); whereas two patients experienced grade 3 toxicity (8%). Two-year Local control and actuarial Disease Free Survival were 100% and 91%, respectively. CONCLUSION. An intensified regimen of concomitant boost radiotherapy plus concurrent raltitrexed and oxaliplatin, can be safely administered in patients with locally advanced rectal cancer. This regimen produces high rates of pathological complete response. Based on available data, this type of treatment could be offered to patients with more advanced tumors (T4 or local recurrence).

[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.

Has the new TNM classification for colorectal cancer improved care?

In 2009, the Union for International Cancer Control issued the seventh edition of the well-used T (tumor), N (node), and M (metastasis) classification guidelines. There has been a continual refinement of the staging for colorectal cancer since this system for assessing tumor stage was initially adopted and it has been used to guide treatment decisions for over 50 years. However, the outcome after therapy for patients with colorectal cancer is very variable, even when patients are assigned to the same TNM category. This article assesses the changes that have been made since the sixth edition and discusses whether they are, in fact, informative improvements for a practicing clinician.

Use of primary radiotherapy for rectal cancer in the Netherlands between 1997 and 2008: a population-based study

AIMS

To describe variation in the utilisation rates of primary radiotherapy for patients with rectal cancer in the Netherlands, focusing on time trends and age effects.

MATERIALS AND METHODS

Data on primary non-metastatic rectal cancer were derived from the population-based cancer registries of four comprehensive cancer centres (regions) in the Netherlands (1997-2008, n=13,055).

RESULTS

An increase in the utilisation rate was noted for the four regions, from 37-46% in 1997 to 66-76% in 2008, for both genders. This increase was found predominately for preoperative radiotherapy (from 13-31% to 58-67%) and (unsurprisingly) was most pronounced for stage T2-3 patients (from 9-27% to 68-80%). The probability of receiving radiotherapy decreased with age: the odds of receiving preoperative radiotherapy was reduced in patients aged 65 years and older, as well as the odds of receiving postoperative radiotherapy in those aged 75 years and older, which remained significant after adjustment for stage, gender and region. Regional differences persisted in multivariable analyses, i.e. the odds of receiving preoperative radiotherapy was reduced in two regions: odds ratio: 0.4 (95% confidence interval: 0.4-0.5) and 0.7 (0.6-0.8). The odds of receiving postoperative radiotherapy was significantly increased in these regions [odds ratio: 2.6 (2.2-3.2) and 1.6 (1.3-1.9), respectively] and reduced in another [odds ratio 0.8 (0.6-0.96)].

CONCLUSIONS

The utilisation rate of radiotherapy for rectal cancer increased significantly over time, particularly for preoperative radiotherapy and was most pronounced for T2-3 patients. Due to national multidisciplinary treatment guidelines, regional differences became limited in recent years after adjustment for age and stage of the disease. A low utilisation rate of radiotherapy was seen in women and elderly patients.

EUS-FNA assessment of extramesenteric lymph node status in primary rectal cancer

BACKGROUND

Preoperative staging is an essential factor in the multidisciplinary management of rectal cancer. The accuracy of imaging alone with CT, magnetic resonance imaging, or rigid endorectal US is poor. The addition of EUS-FNA may enhance extramesenteric lymph node metastases detection (M1 disease) and overall staging accuracy.

OBJECTIVE

To evaluate the frequency of extramesenteric lymph node visualization by EUS and the rate of extramesenteric lymph node metastases by FNA. Secondary goals were to evaluate the clinical, endoscopic, and sonographic features associated with extramesenteric lymph node metastases, disease progression, and overall mortality.

DESIGN

Retrospective cohort study.

SETTINGS

Tertiary referral center.

RESULTS

Forty-one of 316 patients (13%) with primary rectal cancer over a 6-year period had M1 disease by EUS-FNA. Significant clinical, endoscopic, and sonographic features associated with extramesenteric lymph node metastases included the serum carcinoembryonic antigen level, tumor length 4 cm and longer, annularity 50% or more, sessile morphology, and lymph node size. The sensitivity and specificity of CT for extramesenteric lymph node metastases were 44% and 89%, respectively. Twenty-three of 316 rectal cancer endosonographic procedures (7.3%) were up-staged by FNA, which established extramesenteric lymph node metastases. Over a 4-year follow-up, disease progression and overall mortality of patients with extramesenteric lymph node metastases was observed in 6 patients (14.6%) and 14 patients (34%), respectively.

CONCLUSIONS

Preoperative EUS-FNA identification of extramesenteric lymph node metastases outside of standard radiation fields or total mesorectal excision resection margins could affect medical and surgical planning.

Unique considerations in the patient with rectal cancer

In the past two decades, substantial progress has been made in the adjuvant management of colorectal cancer. Chemotherapy has improved overall survival in patients with node-positive (N+) disease. In contrast with colon cancer, which has a low incidence of local recurrence, patients with rectal cancer have a higher incidence requiring the addition of pelvic radiation therapy (chemoradiation). Patients with rectal cancer have a number of unique management considerations: for example, the role of short-course radiation, whether postoperative adjuvant chemotherapy is necessary for all patients, and if the type of surgery following chemoradiation should be based on the response rate. More accurate imaging techniques and/or molecular markers may help identify patients with positive pelvic nodes to reduce the chance of overtreatment with preoperative therapy. Will more effective systemic agents both improve the results of radiation as well as modify the need for pelvic radiation? This review will address these and other controversies specific to patients with rectal cancer.

Neoadjuvant treatment in rectal cancer: actual status

Neoadjuvant (preoperative) concomitant chemoradiotherapy (CRT) has become a standard treatment of locally advanced rectal adenocarcinomas. The clinical stages II (cT3-4, N0, M0) and III (cT1-4, N+, M0) according to International Union Against Cancer (IUCC) are concerned. It can reduce tumor volume and subsequently lead to an increase in complete resections (R0 resections), shows less toxicity, and improves local control rate. The aim of this review is to summarize actual approaches, main problems, and discrepancies in the treatment of locally advanced rectal adenocarcinomas.

Adverse features on rectal MRI identify a high-risk group that may benefit from more intensive preoperative staging and treatment

BACKGROUND

Magnetic resonance imaging (MRI) is highly accurate in local staging of rectal cancer. It can identify features known to be associated with increased risk of metastatic disease. We evaluated the incidence of synchronous metastatic disease on fludeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) and contrast-enhanced multiple-row detector computed tomography (ceMDCT) in MRI-stratified high- and low-risk rectal cancers. The aim was to determine the incidence of synchronous metastatic disease according to MRI risk features.

METHODS

A total of 236 patients with rectal cancer were recruited to a study evaluating FDG-PET/CT. All patients underwent MRI staging and were stratified into high and low risk (high risk: extramural venous invasion, extramural spread of >5 mm or T4, involved circumferential resection margin or intersphincteric plane involved for low rectal tumors). Confirmed metastases were those identified on FDG-PET/CT and ceMDCT.

RESULTS

Imaging data were available for 230 (97.5%) of 236 patients. Incidence of confirmed distant metastases was significantly greater in the MRI high-risk group, with 28 (20.7%) of 135 (95% confidence interval [CI] 14.8-28.3), versus the low-risk group, with 4 (4.2%) of 95 (95% CI 1.7-10.3) (odds ratio 6.0, 95% CI 2.0-17.6, P<0.001).

CONCLUSIONS

Adverse features found on rectal MRI identify patients at increased risk of synchronous metastatic disease. This group may benefit from additional preoperative investigation for synchronous metastases such as FDG-PET/CT or liver MRI and from alternative neoadjuvant chemotherapy regimens including induction chemotherapy.

Quality assessment of colorectal cancer care: an international online model

AIM

We present an alternative approach to quality assessment in colorectal cancer, enabling a direct comparison of improvement at the level of the care provider.

METHOD

In 2000, a quality assessment project in colorectal cancer in Germany was started. Data were provided for every patient treated for colorectal cancer. The enrolment questionnaire described patient data, risk factors, reason for hospitalization, diagnostics prior to surgery, surgical procedures, intraoperative complications, general and surgical complications in postoperative period, pathological report and discharge status.

RESULTS

From 2000 to 2007, there were 57 429 patients included in the study. The total number of 372 hospitals that took part in the project varied from 153 to 281 per year. The overall resection rate for colon cancer was 97.1% and 94.8% for rectal cancer. Although the localization of rectal tumours did not vary, the percentage of abdominoperineal excisions fell from 26.1% in 2000 to 21.3% in 2008 (P < 0.001). Hospital mortality for colon cancer varied between 3.2% and 4.2% (P Pearson chi-square 0.032, linear-by-linear 0.257) and for rectal cancer between 2.7% and 3.7% (P Pearson chi-square 0.233). Patient age was not related to in-hospital mortality.

CONCLUSION

The proposed model of quality assessment shows validity and results comparable to population-based studies. It does not require support from the health care system, making its implementation possible in every hospital worldwide.

Oncologic outcomes of primary and post-irradiated early stage rectal cancer: A retrospective cohort study

AIM: To evaluate the oncologic outcomes of primary and post-irradiated early stage rectal cancer and the effectiveness of adjuvant chemotherapy for rectal cancer patients.

METHODS: Eighty-four patients with stage I rectal cancer after radical surgery were studied retrospectively and divided into ypstage I group (n = 45) and pstage I group (n = 39), according to their preoperative radiation, and compared by univariate and multivariate analysis.

RESULTS: The median follow-up time of patients was 70 mo. No significant difference was observed in disease progression between the two groups. The 5-year disease-free survival rate was 84.4% and 92.3%, respectively (P = 0.327) and the 5-year overall survival rate was 88.9% and 92.3%, respectively, for the two groups (P = 0.692). The disease progression was not significantly associated with the pretreatment clinical stage in ypstage I group. The 5-year disease progression rate was 10.5% and 19.2%, respectively, for the patients who received adjuvant chemotherapy and for those who rejected chemotherapy in the ypstage I group (P = 0.681).

CONCLUSION: The oncologic outcomes of primary and post-irradiated early stage rectal cancer are similar. Patients with ypstage I rectal cancer may slightly benefit from adjuvant chemotherapy.

Nomograms for predicting local recurrence, distant metastases, and overall survival for patients with locally advanced rectal cancer on the basis of European randomized clinical trials

PURPOSE

The purpose of this study was to develop accurate models and nomograms to predict local recurrence, distant metastases, and survival for patients with locally advanced rectal cancer treated with long-course chemoradiotherapy (CRT) followed by surgery and to allow for a selection of patients who may benefit most from postoperative adjuvant chemotherapy and close follow-up.

PATIENTS AND METHODS

All data (N = 2,795) from five major European clinical trials for rectal cancer were pooled and used to perform an extensive survival analysis and to develop multivariate nomograms based on Cox regression. Data from one trial was used as an external validation set. The variables used in the analysis were sex, age, clinical tumor stage stage, tumor location, radiotherapy dose, concurrent and adjuvant chemotherapy, surgery procedure, and pTNM stage. Model performance was evaluated by the concordance index (c-index). Risk group stratification was proposed for the nomograms.

RESULTS

The nomograms are able to predict events with a c-index for external validation of local recurrence (LR; 0.68), distant metastases (DM; 0.73), and overall survival (OS; 0.70). Pathologic staging is essential for accurate prediction of long-term outcome. Both preoperative CRT and adjuvant chemotherapy have an added value when predicting LR, DM, and OS rates. The stratification in risk groups allows significant distinction between Kaplan-Meier curves for outcome.

CONCLUSION

The easy-to-use nomograms can predict LR, DM, and OS over a 5-year period after surgery. They may be used as decision support tools in future trials by using the three defined risk groups to select patients for postoperative chemotherapy and close follow-up (http://www.predictcancer.org).

Laparoscopic extraperitoneal rectal cancer surgery: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES)

BACKGROUND

The laparoscopic approach is increasingly applied in colorectal surgery. Although laparoscopic surgery in colon cancer has been proved to be safe and feasible with equivalent long-term oncological outcome compared to open surgery, safety and long-term oncological outcome of laparoscopic surgery for rectal cancer remain controversial. Laparoscopic rectal cancer surgery might be efficacious, but indications and limitations are not clearly defined. Therefore, the European Association for Endoscopic Surgery (EAES) has developed this clinical practice guideline.

METHODS

An international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. The expert panel constituted for a consensus development conference in May 2010. Thereafter, the recommendations were presented at the annual congress of the EAES in Geneva in June 2010 in a plenary session. A second consensus process (Delphi process) of the recommendations with the explanatory text was necessary due to the changes after the consensus conference.

RESULTS

Laparoscopic surgery for extraperitoneal (mid- and low-) rectal cancer is feasible and widely accepted. The laparoscopic approach must offer the same quality of surgical specimen as in open surgery. Short-term outcomes such as bowel function, surgical-site infections, pain and hospital stay are slightly improved with the laparoscopic approach. Laparoscopic resection of rectal cancer is not inferior to the open in terms of disease-free survival, overall survival or local recurrence. Laparoscopic pelvic dissection may impair genitourinary and sexual function after rectal resection, like in open surgery.

CONCLUSIONS

Laparoscopic surgery for mid- and low-rectal cancer can be recommended under optimal conditions. Still, most level 1 evidence is for colon cancer surgery rather than rectal cancer. Upcoming results from large randomised trials are awaited to strengthen the evidence for improved short-term results and equal long-term results in comparison with the open approach.

The effects of short-course preoperative irradiation on local recurrence rate and survival in rectal cancer: a population-based nationwide study

BACKGROUND

Preoperative irradiation with 5 × 5 Gy in randomized trials reduces local recurrence rate and may improve survival in patients with resectable rectal cancer.

OBJECTIVE

The aim of this study was to determine whether the same favorable effects could be observed in a population-based study.

DESIGN

This study was conducted via a retrospective analysis of prospectively collected data from the Swedish Rectal Cancer Registry.

SETTINGS

This study examined population-based data from Sweden.

PATIENTS

All newly diagnosed rectal cancers in Sweden are reported to the Swedish Rectal Cancer Registry.

INTERVENTIONS

Between 1995 and 2001, 6878 patients (stages I-III) were operated on with an anterior resection, an abdominoperineal resection, or a Hartmann's procedure. Short-course irradiation was given to 41% of patients preoperatively. To reduce bias, patients operated on with a Hartmann procedure or older than 75 years were excluded when 5-year survival was analyzed (n = 3466). Tumors were analyzed according to height (0-5 cm, 6-10 cm, 11-15 cm).

MAIN OUTCOME MEASURES

Five-year cumulative local recurrence and survival rates.

RESULTS

The 5-year cumulative local recurrence rate was 6.3% (95% CI 5.4-7.4) for patients receiving preoperative irradiation and 12.1% (95% CI 10.8-13.5) for patients not receiving preoperative irradiation. Multivariate analyses indicated the risk of local recurrence was 50% lower for patients receiving preoperative irradiation compared with patients not receiving irradiation (hazard ratio = 0.50; 95% CI 0.40-0.62). Among patients younger than 76 years and operated on with an anterior resection or abdominoperineal resection, the 5-year cumulative survival rate was 0.70 (95% CI 0.69-0.72). Disease-free and overall survivals were higher in irradiated patients, and the difference was statistically significant in low tumors.

CONCLUSIONS

In this population-based analysis, the favorable effect of preoperative short-course irradiation on local recurrence rates, seen in randomized trials, was confirmed for the entire Swedish population irrespective of tumor height and stage. Data also suggested an effect on 5-year survival, especially in patients with low tumors (0-5 cm).

Assessing the effectiveness of a guideline recommendation for pre-operative radiochemotherapy in rectal cancer

AIM

To ascertain the degree of adherence to the guideline recommendation on pre-operative RT/ChT for stage-II and -III patients in Catalonian public hospitals, and its impact on local recurrence among rectal cancer patients.

METHODS

Data were derived from a multicentre retrospective cohort study of patients who underwent curative-intent surgery for primary rectal cancer at Catalonian public hospitals in 2005 and 2007.

RESULTS

The study covered 1229 patients with TNM stage-II or -III primary rectal cancer. Of these patients, 54.5% underwent pre-operative RT/ChT; 14.9% underwent post-operative RT (± chemotherapy); and 30.6% did not undergo any RT. The crude local recurrence rate at 2years was 4.1% and the crude distant recurrence rate at 2years was 6.5%. The results of the univariate analyses showed a local-recurrence hazard ratio of 1.84 for the group of patients that received no RT versus the group that received pre-operative RT/ChT (p<0.01).

CONCLUSIONS

This is the first population-based study in Catalonia to support the use of pre-operative RT/ChT in rectal cancer patients because, in line with the results of population-based studies reported from other countries, its application, compared to non-application of RT, was found to lead to a clear reduction in the probability of local recurrence.

International trends in surgical treatment of rectal cancer

BACKGROUND

Surgical technique might influence rectal cancer survival, yet international practices for surgical treatment of rectal cancer are poorly described.

METHODS

We performed a cross-sectional survey in a cohort of experienced colorectal surgeons representing 123 centers.

RESULTS

Seventy-one percent responded, 70% are from departments performing more than 50 proctectomies annually. More than 50% defined the rectum as "15 cm from the verge." Seventy-two percent perform laparoscopic proctectomy, 80% use oral bowel preparation, 69% perform high ligation of the inferior mesenteric artery, 76% divert stomas as routine for colo-anal anastomosis, and 63% use enhanced recovery protocols. Different practices exist between US and non-US surgeons: 15 cm from the verge to define the rectum (34% vs 59%; P = .03), personally perform laparoscopic resection (82% vs 66%; P = .05), rectal stump washout (36% vs 73%; P = .0001), always drain after surgery (23% vs 42%; P = .03), transanal endoscopic microsurgery for T2N0 in medically unfit patients (39% vs 61%; P = .0001).

CONCLUSIONS

Wide international variations in rectal cancer management make outcome comparisons challenging, and consensus development should be encouraged.

Clinical significance of magnetic resonance imaging findings in rectal cancer

Staging of rectal cancer is essential to help guide clinicians to decide upon the correct type of surgery and determine whether or not neoadjuvant therapy is indicated. Magnetic resonance imaging (MRI) is currently one of the most accurate modalities on which to base treatment decisions for patients with rectal cancer. MRI can accurately detect the mesorectal fascia, assess the invasion of the mesorectum or surrounding organs and predict the circumferential resection margin. Although nodal disease remains a difficult radiological diagnosis, new lymphographic agents and diffusion weighted imaging may allow identification of metastatic nodes by criteria other then size. In light of this, we have reviewed the literature on the accuracy of specific MRI findings for staging the local extent of primary rectal cancer. The aim of this review is to establish a correlation between MRI findings, prognosis, and available treatment options.

Can radiotherapy alone be effective for treating anastomotic recurrence of rectal cancer? When the patient decides?

Among pelvic recurrences of rectal cancer following surgical resection, anastomotic recurrences are relatively rare; the literature reports an incidence between 2.4% and 12% of all patients who underwent colorectal anastomosis. The authors report the case of a patient already treated for an early rectal cancer who 1 year after surgery developed a 2 cm recurrence at the colorectal anastomosis. As he refused reoperation, he underwent radiation therapy only (54 Gy) with complete remission. After 8 years of follow-up, the patient is free of any further distant or local recurrence. The authors did not find, to the best of their knowledge, in the literature any similar case of a patient with anastomotic rectal recurrence who has been positively treated by radiotherapy only. The authors focus on its diagnostic and therapeutic problems: although surgical reresection is undoubtedly the best therapeutic option, in the case reported here, radiotherapy alone proved effective.

Effect of multidisciplinary team treatment on outcomes of patients with gastrointestinal malignancy

AIM: To evaluate the effect of multidisciplinary team (MDT) treatment modality on outcomes of patients with gastrointestinal malignancy in China.

METHODS: Data about patients with gastric and colorectal cancer treated in our center during the past 10 years were collected and divided into two parts. Part 1 consisted of the data collected from 516 consecutive complicated cases discussed at MDT meetings in Peking University School of Oncology (PKUSO) from December 2005 to July 2009. Part 2 consisted of the data collected from 263 consecutive cases of resectable locally advanced rectal cancer from January 2001 to January 2005. These 263 patients were divided into neoadjuvant therapy (NT) group and control group. Patients in NT group received MDT treatment, namely neoadjuvant therapy + surgery + postoperative adjuvant therapy. Patients in control group underwent direct surgery + postoperative adjuvant therapy. The outcomes in two groups were compared.

RESULTS: The treatment strategy was altered after discussed at MDT meeting in 76.81% of gastric cancer patients and in 58.33% of colorectal cancer patients before operation. The sphincter-preservation and local control of tumor were better in NT group than in control group. The 5-year overall survival rate was also higher in NT group than in control group (77.23% vs 69.75%, P = 0.049).

CONCLUSION: MDT treatment modality can significantly improve the outcomes of patients with gastrointestinal malignancy in China.

What is the most accurate whole-body imaging modality for assessment of local and distant recurrent disease in colorectal cancer? A meta-analysis : imaging for recurrent colorectal cancer

PURPOSE

The objective of this study was to compare the diagnostic performance of positron emission tomography (PET), PET/CT, CT and MRI as whole-body imaging modalities for the detection of local and/or distant recurrent disease in colorectal cancer (CRC) patients who have a (high) suspicion of recurrent disease, based on clinical findings or rise in carcinoembryonic antigen (CEA).

METHODS

A meta-analysis was undertaken. PubMed and Embase were searched for studies on the accuracy of whole-body imaging for patients with suspected local and/or distant recurrence of their CRC. Additionally, studies had to have included at least 20 patients with CRC and 2 × 2 contingency tables had to be provided or derivable. Articles evaluating only local recurrence or liver metastasis were excluded. Summary receiver-operating characteristic (ROC) curves were constructed from the data on sensitivity and specificity of individual studies and pooled estimates of diagnostic odds ratios (DORs) and areas under the ROC curve (AUCs) were calculated. To test for heterogeneity the Cochran Q test was used.

RESULTS

Fourteen observational studies were included which evaluated PET, PET/CT, CT and/or MRI. Study results were available in 12 studies for PET, in 5 studies for CT, in 5 studies for PET/CT and in 1 study for MRI. AUCs for PET, PET/CT and CT were 0.94 (0.90-0.97), 0.94 (0.87-0.98) and 0.83 (0.72-0.90), respectively. In patient based analyses PET/CT had a higher diagnostic performance than PET with an AUC of 0.95 (0.89-0.97) for PET/CT vs 0.92 (0.86-0.96) for PET.

CONCLUSION

Both whole-body PET and PET/CT are very accurate for the detection of local and/or distant recurrent disease in CRC patients with a (high) suspicion of recurrent disease. CT has the lowest diagnostic performance. This difference is probably mainly due to the lower accuracy of CT for detection of extrahepatic metastases (including local recurrence). For clinical practice PET/CT might be the modality of choice when evaluating patients with a (high) suspicion of recurrent disease, because of its best performance in patient based analyses and confident prediction of disease status.

Efficacy and safety of intraoperative radiotherapy in colorectal cancer: a systematic review

Intraoperative radiotherapy (IORT) has been proposed as an encouraging treatment for colorectal cancer. The aim of this study is to assess the efficacy and safety of IORT for this cancer through a systematic review. Studies located in electronic databases were selected according to established criteria, read and analysed and the results extracted by two independent reviewers. Fifteen studies met the selection criteria. Five-to-six-year local control (LC) was over 80% and 5-year overall survival (OS) was close to 65%. For recurrences, the 5-year overall survival was 30%. The main acute complications were gastrointestinal. Adding IORT to conventional treatment reduces the incidence of local recurrences within the radiation area over 10%. IORT is a safe technique as it does not increase toxicity associated with conventional treatment.

Neoadjuvant vs adjuvant pelvic radiotherapy for locally advanced rectal cancer: Which is superior?

The treatment of locally advanced rectal cancer including timing and dosage of radiotherapy, degree of sphincter preservation with neoadjuvant radiotherapy, and short and long term effects of radiotherapy are controversial topics. The MEDLINE, Cochrane Library databases, and meeting proceedings from the American Society of Clinical Oncology, were searched for reports of randomized controlled trials and meta-analyses comparing neoadjuvant and adjuvant radiotherapy with surgery to surgery alone for rectal cancer. Neoadjuvant radiotherapy shows superior results in terms of local control compared to adjuvant radiotherapy. Neither adjuvant or neoadjuvant radiotherapy impacts overall survival. Short course versus long course neoadjuvant radiotherapy remains controversial. There is insufficient data to conclude that neoadjuvant therapy improves rates of sphincter preserving surgery. Radiation significantly impacts anorectal and sexual function and includes both acute and long term toxicity. Data demonstrate that neoadjuvant radiation causes less toxicity compared to adjuvant radiotherapy, and specifically short course neoadjuvant radiation results in less toxicity than long course neoadjuvant radiation. Neoadjuvant radiotherapy is the preferred modality for administering radiation in locally advanced rectal cancer. There are significant side effects from radiation, including anorectal and sexual dysfunction, which may be less with short course neoadjuvant radiation.

Chemoradiation for rectal cancer: rationale, approaches, and controversies

The standard adjuvant treatment of cT3 and/or N+ rectal cancer is preoperative chemoradiation. However, there are many controversies regarding this approach. These controversies include the role of short course radiation, whether postoperative adjuvant chemotherapy is necessary for all patients, and if the type of surgery following chemoradiation should be based on the response rate. More accurate imaging techniques and/or molecular markers may help identify patients with positive pelvic nodes to reduce the chance of overtreatment with preoperative therapy. Will more effective systemic agents both improve the results of radiation, as well as modify the need for pelvic radiation? These questions and others remain active areas of clinical investigation.

Changes in colorectal cancer incidence and mortality trends in Spain

BACKGROUND

Some years ago, Spain registered a much lower colorectal cancer (CRC) incidence and mortality rate than did other European countries but the rates have since converged. This study sought to compare time trends for CRC incidence and mortality, identify change-points in these trends and thereby update available information in Spain.

METHODS

Incidence data were drawn from all population-based cancer registries in Spain which participated in the European Network of Cancer Registries and had been collecting data for at least 10 consecutive years during the period 1975-2004. Colorectal cancer corresponded to codes 153, 154 and 159.0 of the International Classification of Diseases ninth revision (ICD-9) and codes C18-C21 and C26.0 of the ICD-10. In all, the 13 registries included in this study cover approximately 26% of the total Spanish population. We evaluated the time trends in incidence and mortality using transition change-point and age-period-cohort models.

RESULTS

Our results revealed an important increase in CRC incidence in Spain, which held constant across the entire study period but became slightly attenuated in both sexes around 1995, when a change-point was detected. The annual increase in incidence, which had been 4.3% per annum in men up to this point, declined to 2.5% thereafter. In women, the increase in incidence, albeit also of considerable magnitude, was more moderate. The incidence trend contrasted sharply with that for mortality, inasmuch as the latter changed in 1997-98, after which point mortality rates in both sexes began to decline.

CONCLUSIONS

The divergence between incidence (upward trend) and mortality rates (downward trend from the mid-1990s onwards) would suggest that possible explanations may lie in improved accessibility to endoscopy increased early detection with a corresponding shift to an earlier disease stage and improvements in therapy. This trend is having important consequences insofar as disease prevalence and burden of care are concerned.