Resectable adenocarcinoma of the rectosigmoid and rectum. I. Patterns of failure and survival

Downstaging after preoperative chemoradiation for locally advanced rectal cancer is associated with better survival than pathologic stage 0-1 disease treated with upfront surgery

BACKGROUND AND OBJECTIVES

It is unknown how patients with locally advanced rectal cancer with significant response to preoperative radiotherapy/chemoradiotherapy fare relative to patients with true pathologic 0-1 disease undergoing upfront surgery. We aimed to determine whether survival is improved in locally advanced rectal cancer downstaged to pathologic stage 0-1 disease compared to true pathologic stage 0-1 tumors.

METHODS

A retrospective review of the National Cancer Database between 2004 and 2016 was conducted. Three groups were identified: (1) clinical stage 2-3 disease downstaged to pathologic stage 0-1 disease after radiotherapy, (2) clinical stage 2-3 disease not downstaged after radiotherapy, and (3) true pathologic 0-1 tumors undergoing upfront surgery. The primary endpoint was overall survival and was compared using Kaplan-Meier and multivariate Cox regression analyses.

RESULTS

The study population consisted of 59,884 patients. Of the 40,130 patients with locally advanced rectal cancer treated with preoperative radiation, 12,670 (31.5%) had significant downstaging (group 1), while 27,460 (68.4%) had no significant downstaging (group 2). A total of 19,754 had pathologic 0-1 disease treated with upfront resection (group 3). On Kaplan-Meier analysis, downstaged patients had significantly better overall survival compared to both non-downstaged and true pathologic stage 0-1 patients (median 156 vs. 99 and 136 months, respectively, p < 0.001). On multivariate analysis, downstaged patients had significantly better survival (HR 0.88, p < 0.001) compared to true pathologic 0-1 patients.

CONCLUSIONS

Locally advanced rectal cancer downstaged after preoperative radiotherapy has significantly better survival compared to true pathologic stage 0-1 disease treated with upfront surgery. Response to chemoradiotherapy likely identifies a subset of patients with a particularly good prognosis.

Radiologic Factors and Areas of Local Recurrence in Locally Advanced Lower Rectal Cancer After Lateral Pelvic Lymph Node Dissection

BACKGROUND

Identifying preoperative risk factors of local recurrence and patterns of treatment failure resulting after rectal cancer management is important for planning treatment strategies and improving the results of multidisciplinary care.

OBJECTIVE

The purpose of this study was to analyze the associations between the preoperative factors and local recurrence and to investigate the local recurrence areas in patients with locally advanced lower rectal cancer who underwent lateral pelvic lymph node dissection.

DESIGN

The study used a retrospective cohort design.

SETTINGS

It was conducted at a single institution.

PATIENTS

Overall 469 patients with locally advanced lower rectal adenocarcinoma located below the peritoneal reflex who received curative resection with lateral pelvic lymph node dissection during 2010 to 2018 were included.

MAIN OUTCOME MEASURES

Independent risk factors for local recurrence were assessed using multivariate Cox regression. Local recurrence was classified into 3 areas using follow-up images.

RESULTS

A total of 286 patients underwent upfront surgery, 132 patients received neoadjuvant chemotherapy followed by surgery, and 51 patients received preoperative chemoradiotherapy followed by surgery. Eighty-six patients (18.3%) were extramural venous invasion positive, and 113 patients (24.1%) were circumferential resection margin positive. The median follow-up period was 46 months. Local recurrence showed significant association with extramural venous invasion positive (HR = 2.596 (95% CI, 1.321-5.102); p = 0.006) or circumferential resection margin positive (HR = 2.298 (95% CI, 1.158-4.560); p = 0.017). The incidence of local recurrence was observed in 51 patients (10.8%), with the pelvic plexus and internal iliac area being the most frequent (6.6%), followed by the central pelvis area (3.8%), and was markedly low in the obturator area (0.4%).

LIMITATIONS

This was a retrospective, single-institution design.

CONCLUSIONS

Extramural venous invasion status and circumferential resection margin status were associated with a high local recurrence rate in patients who underwent lateral pelvic lymph node dissection. In addition, local recurrence in the obturator area was low compared with that in other areas. See Video Abstract at http://links.lww.com/DCR/B683.

FACTORES RADIOLGICOS Y REAS DE RECURRENCIA LOCAL EN EL CNCER DE RECTO INFERIOR LOCALMENTE AVANZADO DESPUS DE LA DISECCIN GANGLIONAR PLVICA LATERAL

ANTECEDENTES:El identificar los factores de riesgo preoperatorios para recurrencia local y los patrones de fracaso del tratamiento que resultan del manejo del cáncer de recto es importante para planificar las estrategias de tratamiento y mejorar los resultados de la atención multidisciplinaria.OBJETIVO:Analizar las asociaciones entre los factores preoperatorios y la recidiva local, e investigar las áreas de recidiva local en pacientes con cáncer de recto inferior localmente avanzado que se sometieron a disección de ganglios linfáticos pélvicos laterales.DISEÑO:Un diseño de cohorte retrospectivo.ENTORNO CLÍNICO:Una sola institución.PACIENTES:Un total de 469 pacientes con adenocarcinoma rectal inferior localmente avanzado ubicado debajo del reflejo peritoneal que recibieron resección curativa con disección de ganglios linfáticos pélvicos laterales durante 2010-2018.PRINCIPALES MEDIDAS DE RESULTADO:Los factores de riesgo independientes de recurrencia local se evaluaron mediante regresión de Cox multivariante. La recurrencia local se clasificó en 3 áreas utilizando imágenes de seguimiento.RESULTADOS:Doscientos ochenta y seis pacientes se sometieron a cirugía inicial, 132 pacientes recibieron quimioterapia neoadyuvante seguida de cirugía y 51 pacientes recibieron quimiorradioterapia preoperatoria seguida de cirugía. Ochenta y seis pacientes (18,3%) fueron positivos para invasión venosa extramural y 113 pacientes (24,1%) fueron positivos para el margen de resección circunferencial. La mediana del período de seguimiento fue de 46 meses. La recidiva local mostró una asociación significativa con la invasión venosa extramural positiva (cociente de riesgo: 2,596; intervalo de confianza del 95%: 1,321-5,102; p = 0,006) o el margen de resección circunferencial positivo (cociente de riesgo: 2,298; intervalo de confianza del 95%: 1,158-4,560; p = 0,017). La incidencia de recidiva local se observó en 51 pacientes (10,8%), siendo el plexo pélvico y el área ilíaca interna los más frecuentes (6,6%), seguidos del área pélvica central (3,8%), y fue marcadamente baja en el área del obtudador (0.4%).LIMITACIONES:Un diseño retrospectivo de una sola institución.CONCLUSIONES:El estado de invasión venosa extramural o el estado del margen de resección circunferencial se asociaron con una alta tasa de recurrencia local en pacientes que se sometieron a disección de ganglios linfáticos pélvicos laterales. Además, la recurrencia local en el área del obturador fue baja en comparación con la de otras áreas. Consulte Video Resumen en http://links.lww.com/DCR/B683.

Adequacy of Surgical Pathology Reports of Colorectal Carcinoma and Its Significance

Introduction Colorectal cancer is the fifth most common cancer in the world. For loco-regionally confined disease surgery is the definitive treatment. An adequate surgical pathology report is mandatory for the selection of adjuvant therapy. The objective of this study is to analyze whether adequate information is provided or not in the surgical pathology reports of colorectal carcinoma as according to College of American Pathologists (CAP) guidelines. Method This is a cross-sectional study carried out in the Department of Clinical Oncology, Jinnah Postgraduate Medical Center (JPMC) Karachi, tertiary care hospital in Pakistan. The duration of the study was from February 2020 to January 2021. A total of 153 surgical pathology reports issued by 11 different hospital-based laboratories after definitive surgery was assessed to look at its concordance rate with the checklist adapted from the CAP guidelines. Results Out of 153 surgical pathology reports, clinical information was provided in 72.5% of reports. Details of tumor extension were present in 88.2%, tumor margin in 75%, surgical procedure in 79%, and tumor deposits in 39.2% of reports. Macroscopic details including tumor perforation and evaluation of mesorectum were documented in 51.6% and 53.5% of the reports respectively. Details regarding perineural invasion along with lymphovascular invasion were present in 81.6% and 93% of the reports, respectively. The treatment effect was documented in only 25% of reports and regional lymph node status has been described in 85% of reports. Parameters described in all surgical pathology reports were: tumor site, tumor type, histologic type, and histologic grade. The pathological stage of the disease was documented in 91.5% of the reports. Conclusion This study concluded that surgical pathology reports of the majority of pathology laboratories were not fully adhered to the checklist provided by the CAP guidelines. This will affect post-operative management along with the prediction of disease prognosis.

Prognostic Value of Clinical vs Pathologic Stage in Rectal Cancer Patients Receiving Neoadjuvant Therapy

Background

Neoadjuvant chemoradiation is currently standard of care in stage II-III rectal cancer, resulting in tumor downstaging for patients with treatment-responsive disease. However, the prognosis of the downstaged patient remains controversial. This work critically analyzes the relative contribution of pre- and post-therapy staging to the anticipated survival of downstaged patients.

Methods

The National Cancer Database (NCDB) was queried for patients with rectal cancer treated with transabdominal resection between 2004 and 2014. Stage II-III patients downstaged with neoadjuvant radiation were compared with stage I patients treated with definitive resection alone. Patients with positive surgical margins were excluded. Overall survival was evaluated using both Kaplan-Meier analyses and Cox proportional hazards models. All statistical tests were two-sided.

Results

A total of 44 320 patients were eligible for analysis. Survival was equivalent for patients presenting with cT1N0 disease undergoing resection (mean survival = 113.0 months, 95% confidence interval [CI] = 110.8 to 115.3 months) compared with those downstaged to pT1N0 from both cT3N0 (mean survival = 114.9 months, 95% CI = 110.4 to 119.3 months, P = .12) and cT3N1 disease (mean survival = 115.4 months, 95% CI = 110.1 to 120.7 months, P = .22). Survival statistically significantly improved in patients downstaged to pT2N0 from cT3N0 disease (mean survival = 109.0 months, 95% CI = 106.7 to 111.2 months, P < .001) and cT3N1 (mean survival = 112.8 months, 95% CI = 110.0 to 115.7 months, P < .001), compared with cT2N0 patients undergoing resection alone (mean survival = 100.0 months, 95% CI = 97.5 to 102.5 months). Multiple survival analysis confirmed that final pathologic stage dictated long-term outcomes in patients undergoing neoadjuvant radiation (hazard ratio [HR] of pT2 = 1.24, 95% CI = 1.10 to 1.41; HR of pT3 = 1.81, 95% CI = 1.61 to 2.05; HR of pT4 = 2.72, 95% CI = 2.28 to 3.25, all P ≤ .001 vs pT1; HR of pN1 = 1.50, 95% CI = 1.41 to 1.59; HR of pN2 = 2.17, 95% CI = 2.00 to 2.35, both P < .001 vs pN0); while clinical stage at presentation had little to no predictive value (HR of cT2 = 0.81, 95% CI = 0.69 to 0.95, P = .008; HR of cT3 = 0.83, 95% CI = 0.72 to 0.96, P = .009; HR of cT4 = 1.02, 95% CI = 0.85 to 1.21, P = .87 vs cT1; HR of cN1 = 0.96, 95% CI = 0.91 to 1.02, P = .19; HR of cN2 = 0.96, 95% CI = 0.86 to 1.08, P = .48 vs cN0).

Conclusions

Survival in patients with rectal cancer undergoing neoadjuvant radiation is driven by post-therapy pathologic stage, regardless of pretherapy clinical stage. These data will further inform prognostic discussions with patients.

Raltitrexed and Radiotherapy as Adjuvant Treatment for Stage II-III Rectal Cancer: A Feasibility Study

Aims and Background

Adjuvant 5-FU chemotherapy plus radiotherapy represents the standard treatment for radically resected rectal cancer at high risk of relapse according to the NIH Consensus Conference. The therapeutic gain was obtained with a high rate of severe treatment-related toxicity and a sub-optimal patient compliance with this regimen. Raltitrexed is a specific thymidylate synthase inhibitor with a convenient administration schedule, acceptable toxicity and radiosensitizing properties, as the published phase I trials in combination with radiotherapy have shown. The aim of this prospective multicenter phase II study was to evaluate the feasibility, gastrointestinal and hematological acute toxicity of raltitrexed in combination with radiotherapy in rectal cancer patients.

Methods

From September 2000 to June 2004, 50 patients with radically resected stage II-III rectal adenocarcinoma were treated. All patients were evaluable for compliance and acute toxicity. Within 45-60 days of surgery, each patient underwent concomitant adjuvant radiochemotherapy. Radiotherapy was administered to the pelvis (plus perineum after abdominoperineal resection) with photon beam energy exceeding 5 MV, 3-4 fields, 45 Gy/25 fractions/5 weeks plus a boost delivered to the site of resected disease with 3-4 fields, 9 Gy/5 fractions/1 week to a total dose of 54 Gy. The boost dose was administered after complete exclusion of the small bowel from the treatment volumes; if this was not possible a total dose of 50.4 Gy was given. Raltitrexed was administered intravenously at a dose of 3 mg/m2 as a bolus injection on days 1 and 22 of radiotherapy one hour before treatment, for a total of two cycles. Each patient underwent weekly clinical evaluation and laboratory tests. Toxicity was assessed by the WHO scale.

Results

Forty-five (90%) patients completed the established treatment. Acute severe toxicity included grade III proctitis in 4/50 (8%), grade III-IV diarrhea in 4/50 (8%), grade III perineal dermatitis in 4/50 (8%) and grade III leukopenia in 2/50 (4%) patients; five patients (10%) experienced a transient grade III increase in their liver biochemistry values.

Conclusions

Our data related to acute toxicity and patient compliance proved the feasibility of this adjuvant radiochemotherapy treatment. A longer follow-up is necessary to evaluate the effectiveness of this new regimen in terms of disease-free and overall survival.

Risk factors for locoregional recurrence in patients with pathologic T3N0 rectal cancer with negative resection margin treated by surgery alone

Purpose

This study aimed to identify prognostic factors for locoregional recurrence (LRR) in pT3N0 rectal cancer patients who were treated with surgery alone and had negative resection margin including circumferential resection margin (CRM) for optimal indication of adjuvant radiotherapy.

Materials and Methods

We reviewed patients with pT3N0 rectal cancer who were treated via upfront surgery and had no other adjuvant treatment from January 2003 to December 2012. In total, 122 patients who had negative resection margin including negative CRM were included in the analysis.

Results

The median follow-up period after surgery was 60 months (range, 3 to 161 months). During this time, 6 patients (4.9%) experienced LRR at the anastomotic site (4 patients), and regional lymphatic area (2 patients). The estimated 5-year rates of overall survival, recurrence-free survival, and LRR-free survival were 96.7%, 84.6%, and 94.0%, respectively. Multivariate analysis showed that level of tumor ≤5 cm was a significant prognostic factor for LRR-free survival (LRRFS) (p = 0.04; hazard ratio = 7.08; 95% confidence interval, 1.06–47.30). Patients with level of tumor ≤5 cm had an estimated 5-year LRRFS of 66.8%, which was much higher than 2.3% in patients with level of tumor >5 cm. There was no significant factor for recurrence-free survival or overall survival.

Conclusion

In T3N0 rectal cancer, adjuvant chemoradiotherapy should be recommended in patients with level of tumor ≤5 cm for better local control. However, in patients with pT3N0 disease, negative resection margin, and level of tumor >5 cm, adjuvant chemoradiotherapy should be carefully suggested.

Adjuvant Radiochemotherapy in High-Risk Rectal Cancer Results of a Prospective Non-Randomized Study

Aims and Background

In 1990 the National Institutes of Health Consensus Conference recommended adjuvant combined therapy for patients with radically resected rectal cancer at high risk for relapse (ie, stage II-III). The purpose of our prospective non-randomized study was to verify the feasibility and effectiveness of postoperative radiochemotherapy in terms of improvement in disease-free and overall survival in this patient subgroup.

Study design

From January 1990 to October 1998, 191 consecutive patients with radically resected stage II-III rectal cancer were treated. A total of 159 patients with a 24-month follow-up were assessable for toxicity and survival. Anterior resection was performed in 129 (81%) and abdomino-perineal resection in 30 (19%) patients. Fifty-four (34%) stage II and 105 (66%) stage III patients entered the study. Within 45-60 days of surgery, all patients received 5-fluorouracil chemotherapy at the dose of 500 mg/m2 as an iv bolus on days 1-5, every 4 weeks, for 6 cycles. Chemotherapy cycles III and IV were administered at the same daily dose on radiotherapy days 1-3 and 29-31. Radiotherapy consisted of 45 Gy/25 fractions plus a boost dose of 5.4 Gy.

Results

After a median follow-up of 57 months (range, 25-123), overall recurrent disease was reported in 58 (36%) patients: local, systemic, and both local and systemic relapses in 12 (8%), 37 (23%) and 9 (6%) cases, respectively. According to local extension, recurrence rates were 15% and 48% in stage II and III, respectively. Five-year overall and disease-free survival were 71% and 66%, respectively. Overall survival was 87% in stage II and 62% in stage III patients, and disease-free survival was 84% and 56% in stage II and III disease, respectively. According to univariate and multivariate analyses, significant prognostic factors for better tumor control were: stage (II vs III, P <0.001), the number of involved nodes (≤3 vs >3, P <0.0001), and no extracapsular node invasion (P <0.0001). The recommended dose of the combined radiochemotherapy regimen was generally well tolerated. The incidence of any ≥ grade 3 acute toxicity (according to the WHO scale) was 13% diarrhea, 11% proctitis, 5% perineal dermatitis and 4% myelosuppression. Four (3%) patients had radiotherapy-related severe late toxicity which required surgery.

Conclusions

The study provided recurrence rates and survival similar to other adjuvant radiochemotherapy regimens published in the literature. However, in view of the low 5-year survival rate recorded in stage III patients, a different approach should be investigated.

Ninety percent of the adverse outcomes occur in 10% of patients: can we identify the populations at high risk of developing peritoneal metastases after curative surgery for colorectal cancer?

BACKGROUND

Peritoneal metastases (PM) occur in 3.4-6.3% after curative surgery for non-metastatic colorectal cancer. Systematic "2nd look" surgery helps overcoming the diagnostic problem but can be only proposed to selected patients. The aim of this study was to update the knowledge on risk factors of developing PM after curative surgery for colorectal cancer.

METHODS

A systematic review of the literature published between 2011 and 2016 was made, searching for all clinical studies reporting the incidence of recurrent PM after curative surgery for colorectal cancer and factors associated with the primary tumour that were likely to influence this recurrence rate.

RESULTS

Seven new clinical studies were considered informative for risk factors and added to the 16 reviewed in 2013. Even if the level of evidence was low, data suggested rates of recurrent PM at 1 year between 54% and 71% after completely resected synchronous PM, between 62% and 71% after resection of isolated synchronous ovarian metastases, of 27% after surgery for a perforated primary tumour, of 16% after surgery for a pT4 tumour, and between 11% and 36% after surgery for a mucinous histological subtype. No new risk factor was identified.

CONCLUSIONS

Evidence regarding the incidence of recurrent PM after curative surgery for colorectal cancer is poor. Situations at higher risk of recurrent PM are synchronous PM, synchronous isolated ovarian metastases, perforated primary tumour with serosa invasion and mucinous histological subtype.

The potential predictive value of DEK expression for neoadjuvant chemoradiotherapy response in locally advanced rectal cancer

BACKGROUND

Limited data are available regarding the ability of biomarkers to predict complete pathological response to neoadjuvant chemoradiotherapy in locally advanced rectal cancer. Complete response translates to better patient survival. DEK is a transcription factor involved not only in development and progression of different types of cancer, but is also associated with treatment response. This study aims to analyze the role of DEK in complete pathological response following chemoradiotherapy for locally advanced rectal cancer.

METHODS

Pre-treated tumour samples from 74 locally advanced rectal-cancer patients who received chemoradiation therapy prior to total mesorectal excision were recruited for construction of a tissue microarray. DEK immunoreactivity from all samples was quantified by immunohistochemistry. Then, association between positive stained tumour cells and pathologic response to neoadjuvant treatment was measured to determine optimal predictive power.

RESULTS

DEK expression was limited to tumour cells located in the rectum. Interestingly, high percentage of tumour cells with DEK positiveness was statistically associated with complete pathological response to neoadjuvant treatment based on radiotherapy and fluoropyrimidine-based chemotherapy and a marked trend toward significance between DEK positiveness and absence of treatment toxicity. Further analysis revealed an association between DEK and the pro-apoptotic factor P38 in the pre-treated rectal cancer biopsies.

CONCLUSIONS

These data suggest DEK as a potential biomarker of complete pathological response to treatment in locally advanced rectal cancer.

Current Status and Perspectives Regarding LNA-Anti-miR Oligonucleotides and microRNA miR-21 Inhibitors as a Potential Therapeutic Option in Treatment of Colorectal Cancer

Colorectal cancer (CRC) is among the leading causes of cancer-related death, principally due to its metastatic spread and multifactorial chemoresistance. The therapeutic failure can also be explained by inter- or intra-tumor genetic heterogeneity and tumor stromal content. Thus, the identification of novel prognostic biomarkers and therapeutic options are warranted in the management of CRC patients. There are data showing that microRNA-21 is elevated in different types of cancer, particularly colon adenocarcinoma and that this is association with a poor prognosis. This suggests that microRNA-21 may be of value as a potential therapeutic target. Furthermore, locked nucleic acid (LNA)-modified oligonucleotides have recently emerged as a therapeutic option for targeting dysregulated miRNAs in cancer therapy, through antisense-based gene silencing. Further work is required to identify innovative anticancer drugs that improve the current therapy either through novel combinatorial approaches or with better efficacy than conventional drugs. We aimed to provide an overview of the preclinical and clinical studies targeting key dysregulated signaling pathways in CRC as well as the therapeutic application of LNA-modified oligonucleotides, and miR inhibitors in the treatment of CRC patients. J. Cell. Biochem. 118: 4129-4140, 2017. © 2017 Wiley Periodicals, Inc.

Colorectal multidisciplinary meeting audit to determine patient benefit

BACKGROUND

New Zealand tumour standards require discussion of all cases of colorectal cancer in a multidisciplinary meeting (MDM), but supporting evidence is lacking. The aim was to determine which patients benefit from MDM discussion.

METHODS

A retrospective and prospective audit was undertaken of all patients discussed in the Christchurch Hospital colorectal MDM over 12 months to November 2014, who were compared with contemporaneous patients not discussed and identified through Hospital discharge codes.

RESULTS

In total, 641 patients were identified, with 459 (70%) discussed in the MDM, on average 7 years younger than not discussed. The proportion discussed by location was 39.2% colon, 63% rectosigmoid, 98% rectal, 96.6% anal. Discussed patients were more likely to have magnetic resonance imaging (68% cf 9.3%), fluorodeoxyglucose positron emission tomography scan (18% versus 2%) and chest computerized tomography scan (50% versus 26%). For colon cancer, American Joint Committee on Cancer (AJCC) stage I and II, 91% of 68 non-discussed patients went straight to surgery compared with 48% of 27 discussed in the MDM; for AJCC stage III uptake of adjuvant chemotherapy was the same whether discussed or not. An R0 resection was achieved for 91% of discussed patients, and 96% of not discussed. A clear referrer's plan, prospectively recorded in 94 patients, was changed after the MDM in 23%. Clinical staging was changed in 20 patients (4%), none with colon cancers.

CONCLUSIONS

Discussion in the MDM influenced management, but was unlikely to change management for AJCC stage I/II colon cancer, who could be spared mandatory review in the MDM and be discussed selectively as treating clinicians decide.

Impact of anatomic location on locally recurrent rectal cancer: superior outcome for intraluminal tumour recurrence

BACKGROUND

Local recurrence of rectal cancer after curative surgery predicts patients' prognosis. The correlation between the exact anatomic location of tumour recurrence and patients' survival is still under debate. Thus, this study aimed to investigate the impact of the exact location of recurrent rectal cancer on post-operative morbidity and survival.

METHODS

This is a retrospective study including 90 patients with locally recurrent rectal cancer. The location of tumour recurrence was classified into intraluminal and extraluminal recurrence. Univariate and multivariable Cox regression analyses were used to determine the impact on post-operative morbidity and survival.

RESULTS

Patients' survival with intraluminal recurrence was significantly longer compared to patients with extraluminal recurrence (p = 0.027). Curative resection was associated with prolonged survival in univariate and multivariable analyses (p = 0.0001) and was more often achieved in patients with intraluminal recurrence (p = 0.024). Survival of curative resected patients with intraluminal recurrence was significantly longer compared to curatively resected patients with extraluminal recurrence (p = 0.0001). The rate of post-operative morbidity between intraluminal and extraluminal recurrence was not statistically different (p = 0.59).

CONCLUSION

Based on the present investigation, intraluminal recurrence is associated with superior outcome. Post-operative morbidity did not differ significantly between both groups.

Recurrence risk and prognostic parameters in stage I rectal cancers

BACKGROUND

The standard therapy for stage I rectum cancer is surgical resection. Currently, there is no strong evidence to suggest that any type of adjuvant therapy is beneficial. The risks of local relapse and distant metastasis are higher in rectal tumors. Therefore, while there is no clearly defined absolute indication for adjuvant therapy in lymph node negative colon cancers, rectum tumors that are T3N0 and higher require adjuvant treatment. Due to the more aggressive nature of rectal cancers, we explored the clinical and pathologic factors that could predict the risk of relapse in Stage I (T1-T2) disease and whether there was any progression-free survival benefit to adjuvant therapy.

MATERIALS AND METHODS

This multicenter study was carried out by the Anatolian Society of Medical Oncology. A total of 178 patients with rectal cancers who underwent curative surgery between January 1994 and August 2012 in 13 centers were included in the study. Patient demographics, including survival data and tumor characteristics were obtained from medical charts.

RESULTS

The median age was 58 years (range 26-85 years). Most tumors were well or moderately differentiated. For adjuvant treatment, 13 patients (7.3%) received radiotherapy alone, 12 patients (6.7%) received chemotherapy alone and 15 patients (8.4%) were given chemoradiotherapy. Median follow up was 29 months (3-225 months). Some 42 patients (23.6%) had relapse during follow up; 30 with local recurrence (71.4%) whereas 12 (28.6%) were distant metastases. Among the patients, 5-year DFS was 64% and OS was 82%. Mucinous histology and receiving adjuvant therapy were found to have statistically insignificant correlations with relapse and survival.

CONCLUSIONS

In our retrospective analysis, approximately one quarter of patients exhibited either local or systemic relapse. The rates of relapse were slightly higher in the patients who had no adjuvant therapy. There may thus be a role for adjuvant therapy in high-risk stage I rectal tumors.

FDG PET/CT in the management of colorectal and anal cancers

OBJECTIVE

CT remains the imaging modality of choice in the diagnosis of colorectal cancer (CRC) and anal cancer. However, advances in imaging have expanded the role of MRI and PET/CT. This article focuses on the evolving role of FDG PET/CT in the diagnosis, radiation therapy planning, therapy assessment, and posttherapy monitoring of CRC and anal cancer.

CONCLUSION

FDG PET/CT is a valuable imaging modality that impacts the clinical management of patients with CRC and those with anal cancer.

Multiplexed protein signal pathway mapping identifies patients with rectal cancer that responds to neoadjuvant treatment

BACKGROUND

Currently there is no reliable technique for predicting clinical or pathologic complete tumor response after radiochemotherapy (RCT) in patients with rectal cancer. We applied reverse phase protein microarray (RPMA) technology to find a signal pathway that may predict the response to preoperative treatment.

PATIENTS AND METHODS

Fifteen rectal cancer samples were collected during preoperative RCT. Seven patients had a good response to preoperative therapy (Mandard grade I-II) and 8 patients had a poor response (Mandard grade III-V). Using laser capture microdissection (LCM) and RPMA analysis, we measured the phosphorylation level of nearly 80 end points and analyzed the signaling pathways.

RESULTS

We identified 4 signaling proteins whose phosphorylation levels were significantly different (P < .05) between the good vs. poor responders; CHK2 and β-catenin were more highly phosphorylated in poor responders, whereas PDK1 and glycogen synthase kinase (GSK)-3α/β had lower phosphorylation levels in poor responders. Interestingly GSK-3α/β, β-catenin, and PDK1 are all present in the phosphatidylinositol-3-kinase (PI3K)-AKT signaling pathway.

CONCLUSIONS

Based on our results, we hypothesize that the activating state of the PI3K-AKT pathway can stratify patients who could benefit most from neoadjuvant treatment. Moreover, identification of theranostic targets has the potential to pinpoint new therapeutic strategies for the nonresponsive population.

T3N0 rectal cancer: radiation for all?

The optimal oncologic management for patients with T3N0 rectal cancer is currently controversial. Patients with pathologic T3N0 disease may have an "intermediate" risk of disease recurrence, suggesting that perhaps trimodality therapy may not be indicated for all patients. Adverse prognostic features, including a greater depth of perirectal fat invasion, poor tumor differentiation, the presence of lymphovascular invasion, abnormally elevated pretreatment carcinoembryonic antigen levels (>5 ng/mL), circumferential margin involvement, and a low-lying position may identify T3N0 patients at high risk for local recurrence who may benefit from the addition of radiation therapy. However, recent randomized data suggest an improvement in local control and disease-free survival with preoperative radiation therapy compared with selective postoperative radiation therapy in all patient subgroups, arguing in favor of routine preoperative therapy. Additionally, rates of clinical understaging may exceed 20%, representing the percentage of patients who would require the delivery of postoperative radiotherapy with its associated sequelae. Future prospective randomized studies of T3N0 patients with upfront stratification by known prognostic factors and studies evaluating the molecular profile of rectal cancers hold the promise of better classifying patients at high risk of local and systemic recurrence, and thus, in need of adjuvant radiation and chemotherapy.

A phase II study of neoadjuvant chemoradiotherapy with oxaliplatin and capecitabine for rectal cancer

PURPOSE

This study evaluated the efficacy and safety of neoadjuvant chemoradiotherapy with the XELOX regimen in rectal cancer patients.

PATIENTS AND METHODS

Twenty-five patients with histopathologically confirmed and locally advanced rectal cancer (T3/T4 or N+) were enrolled in the study. Radiotherapy of 5000 cGy was delivered in 25 fractions of 200 cGy five times per week for a total of 5 weeks. During the first, second, fourth and fifth weeks of radiotherapy, the patients also received the following chemotherapy: 50 mg/m2 oxaliplatin on day one and 850 mg/m2 capecitabine bid for 5 days. Surgery was scheduled 5-6 weeks after the completion of the preoperative chemoradiotherapy. Four weeks after the surgery, four more cycles of chemotherapy were administered every 3 weeks. The postoperative chemotherapy consisted of 130 mg/m2 oxaliplatin on day 1 and 1000 mg/m2 capecitabine bid from day 1 to day 14. The end points were the downstage rate, R0 resection rate, and sphincter preservation rate.

RESULTS

Twenty-five patients received the neoadjuvant chemoradiotherapy. The overall regression rate was 85%, with a Grade 3/4 regression rate of 30% and a pathological complete response rate of 12%. Among the 17 patients with lower rectal cancer, thirteen (76%) were originally indicated for abdominal-perineal resection (APR). However, after the neoadjuvant chemoradiotherapy, the anus could be preserved in nine patients (53%). The most frequent toxicities of the chemoradiotherapy were diarrhea (64%) and hematological toxicity (60%), followed by nausea and vomiting (48%), urinary tract irritation (28%), and anal pain (24%). Grade 3 or 4 adverse events were relatively infrequent and presented as diarrhea (12%), myelosuppression (8%), and elevated transaminase (4%). Six cases also experienced long-term anal exudates after surgery.

CONCLUSIONS

Neoadjuvant chemoradiotherapy using the XELOX regimen in rectal cancer patients obviously reduced the TNM staging and improved the pathological complete response rate. The therapy was well-tolerated and had mild adverse events and no serious perioperational complications.

Neoadjuvant bevacizumab, oxaliplatin, 5-fluorouracil, and radiation for rectal cancer

PURPOSE

To evaluate the feasibility and pathologic complete response rate of induction bevacizumab + modified infusional fluorouracil, leucovorin, and oxaliplatin (FOLFOX) 6 regimen followed by concurrent bevacizumab, oxaliplatin, continuous infusion 5-fluorouracil (5-FU), and radiation for patients with rectal cancer.

METHODS AND MATERIALS

Eligible patients received 1 month of induction bevacizumab and mFOLFOX6. Patients then received 50.4 Gy of radiation and concurrent bevacizumab (5 mg/kg on Days 1, 15, and 29), oxaliplatin (50 mg/m(2)/week for 6 weeks), and continuous infusion 5-FU (200 mg/m(2)/day). Because of gastrointestinal toxicity, the oxaliplatin dose was reduced to 40 mg/m(2)/week. Resection was performed 4-8 weeks after the completion of chemoradiation.

RESULTS

The trial was terminated early because of toxicity after 26 eligible patients were treated. Only 1 patient had significant toxicity (arrhythmia) during induction treatment and was removed from the study. During chemoradiation, Grade 3/4 toxicity was experienced by 19 of 25 patients (76%). The most common Grade 3/4 toxicities were diarrhea, neutropenia, and pain. Five of 25 patients (20%) had a complete pathologic response. Nine of 25 patients (36%) developed postoperative complications including infection (n = 4), delayed healing (n = 3), leak/abscess (n = 2), sterile fluid collection (n = 2), ischemic colonic reservoir (n = 1), and fistula (n = 1).

CONCLUSIONS

Concurrent oxaliplatin, bevacizumab, continuous infusion 5-FU, and radiation causes significant gastrointestinal toxicity. The pathologic complete response rate of this regimen was similar to other fluorouracil chemoradiation regimens. The high incidence of postoperative wound complications is concerning and consistent with other reports utilizing bevacizumab with chemoradiation before major surgical resections.

Can endoscopic ultrasound predict early rectal cancers that can be resected endoscopically? A meta-analysis and systematic review

BACKGROUND

Rectal cancers that are confined to the mucosa (T0) can be resected endoscopically. This can help the patient avoid transabdominal surgery. The published data on accuracy of endoscopic ultrasound (EUS) to predict T0 stage of rectal cancers has been varied.

AIM

To evaluate the accuracy of EUS in T0 staging of rectal cancers. METHOD (STUDY SELECTION CRITERIA): Only EUS studies confirmed by surgery were selected. T0 was defined as tumor confined to the mucosa. DATA COLLECTION AND EXTRACTION: Articles were searched in Medline, PubMed, and CENTRAL.

STATISTICAL METHOD

Pooling was conducted by both the fixed-effects model and random-effects model.

RESULTS

An initial search identified 3,360 reference articles. Of these, 339 relevant articles were selected and reviewed. Eleven studies (N = 1,791) which met the inclusion criteria were included in this analysis. Pooled sensitivity of EUS in diagnosing T0 was 97.3% (95% CI: 93.7-99.1). EUS had a pooled specificity of 96.3% (95% CI: 95.3-97.2). The positive likelihood ratio of EUS was 21.9 (95% CI: 16.3-29.7) and negative likelihood ratio was 0.08 (95% CI: 0.04-0.15). All the pooled estimates, calculated by fixed and random effect models, were similar. The P-value for Chi-squared heterogeneity for all the pooled accuracy estimates was >0.10.

CONCLUSIONS

EUS has excellent sensitivity and specificity, this helps accurately diagnose T0 stage of rectal cancers. Over the past two decades, the sensitivity and specificity of EUS to diagnose T0 stage of rectal cancers has remained high. This can help physicians offer endoscopic treatment to these patients, therefore EUS should be strongly considered for staging of early rectal cancers.

Improved patient and regimen selection in locally advanced rectal cancer: who, how, and what next?

Before the advent of neoadjuvant chemoradiation therapy (NCRT) for locally advanced rectal cancer, local failure represented half of treatment failures. The German Rectal Cancer Study Group trial demonstrated that NCRT along with total mesorectal excision can improve local control and the rate of sphincter-preserving surgery. Thus, the National Comprehensive Cancer Network now recommends NCRT as the standard of care for stage III and IV rectal cancer. Recent trials and analysis have questioned accepted wisdom regarding patient selection for NCRT and methods of administration. EORTC 22921 demonstrated that the addition of chemotherapy to radiation therapy, regardless of timing, improved local control but not overall survival, and subgroup analysis from this study generated the hypothesis that the subgroup of patients with good pathologic response to NCRT would benefit the most from additional chemotherapy following surgery. The prognosis of rectal cancer is stage dependent, and 2 major analyses question whether T1/2 N1 and T3 N0 patients benefit from NCRT. Application of the results from these studies is hindered by imperfections in staging. Future improvement in patient selection might result from biologic analysis of tumor sensitivity. NCRT might be improved with the use of oral fluoropyrimidines and perhaps the addition of a second agent such as oxaliplatin, irinotecan, or cetuximab. Improvements in radiation, such as the use of more conformal techniques, might decrease the toxicity of therapy. Given the success of NCRT in improving local control, distant metastasis now predominates as the cause of treatment failure, and larger gains will likely be made from improvements in adjuvant chemotherapy.

Accuracy of endoscopic ultrasound to diagnose nodal invasion by rectal cancers: a meta-analysis and systematic review

BACKGROUND

Nodal staging in patients with rectal cancer predicts prognosis and directs therapy. Published data on the accuracy of endoscopic ultrasound (EUS) for diagnosing nodal invasion in patients with rectal cancer has been inconsistent.

AIM

To evaluate the accuracy of EUS in diagnosing nodal metastasis of rectal cancers.

METHOD

Study Selection Criteria: Only EUS studies confirmed by surgical histology were selected. Data Collection and Extraction: Articles were searched in Medline, Pubmed, and CENTRAL.

STATISTICAL METHOD

Pooling was conducted by both fixed-effects model and random-effects model.

RESULTS

The initial search identified 3610 reference articles in which 352 relevant articles were selected and reviewed. Data were extracted from 35 studies (N = 2732) that met the inclusion criteria. Pooled sensitivity of EUS in diagnosing nodal involvement by rectal cancers was 73.2% (95% confidence interval [95% CI] 70.6-75.6). EUS had a pooled specificity of 75.8% (95% CI 73.5-78.0). The positive likelihood ratio of EUS was 2.84 (95% CI 2.16-3.72), and negative likelihood ratio was 0.42 (95% CI 0.33-0.52). All the pooled estimates, calculated by fixed- and random-effect models, were similar. SROC curves showed an area under the curve of 0.79. The P for chi-squared heterogeneity for all the pooled accuracy estimates was >.10.

CONCLUSIONS

EUS is an important and accurate diagnostic tool for evaluating nodal metastasis of rectal cancers. This meta-analysis shows that the sensitivity and specificity of EUS is moderate. Further refinement in EUS technologies and diagnostic criteria are needed to improve the diagnostic accuracy.

How good is endoscopic ultrasound in differentiating various T stages of rectal cancer? Meta-analysis and systematic review

Published data on accuracy of endoscopic ultrasound (EUS) in differentiating T stages of rectal cancers is varied. Study selection criteria were to select only EUS studies confirmed with results of surgical pathology. Articles were searched in Medline and Pubmed. Pooling was conducted by both fixed and random effects models. Initial search identified 3,630 reference articles, of which 42 studies (N = 5,039) met the inclusion criteria and were included in this analysis. The pooled sensitivity and specificity of EUS to determine T1 stage was 87.8% [95% confidence interval (CI) 85.3-90.0%] and 98.3% (95% CI 97.8-98.7%), respectively. For T2 stage, EUS had a pooled sensitivity and specificity of 80.5% (95% CI 77.9-82.9%) and 95.6% (95% CI 94.9-96.3%), respectively. To stage T3 stage, EUS had a pooled sensitivity and specificity of 96.4% (95% CI 95.4-97.2%) and 90.6% (95% CI 89.5-91.7%), respectively. In determining the T4 stage, EUS had a pooled sensitivity of 95.4% (95% CI 92.4-97.5%) and specificity of 98.3% (95% CI 97.8-98.7%). The p value for chi-squared heterogeneity for all the pooled accuracy estimates was > 0.10. We conclude that, as a result of the demonstrated sensitivity and specificity, EUS should be the investigation of choice to T stage rectal cancers. The sensitivity of EUS is higher for advanced disease than for early disease. EUS should be strongly considered for T staging of rectal cancers.

Postoperative radiotherapy for stage IIIA rectal cancer: is it justified?

PURPOSE

Adjuvant radiotherapy is currently recommended for all node-positive rectal cancers to reduce local recurrence. This study evaluated if an adequate mesorectal excision can obviate the need for radiotherapy in early node-positive cancer.

METHODS

Stage IIIA rectal cancer patients were identified in a prospectively maintained database. Patients who received postoperative radiotherapy (radiotherapy) and those who did not (no radiotherapy) were compared for recurrence, survival, bowel function, and quality of life. Quality of life was assessed using the Short Form-36 Medical Outcomes Survey.

RESULTS

Eighty-six patients underwent proctectomy for T1-T2,N1 rectal cancers from 1978 to 2004. Patients receiving radiotherapy (n = 34) were younger and had a higher percentage of T1 tumors than patients who did not receive radiotherapy (n = 52). Other tumor characteristics, type of surgery, and number of involved lymph nodes were comparable. Estimated 5-year local recurrence was radiotherapy 3.4 percent and no radiotherapy 4.7 percent; distant recurrence was radiotherapy 13.5 percent and no radiotherapy 16.5 percent; and disease-specific mortality rates were similar 13.5 vs. 11.3 percent, for radiotherapy and no radiotherapy (all P > .05). Patients receiving radiotherapy had higher frequency of daytime bowel movements, urgency, and usage of pads and antidiarrheal medications. Age adjusted quality of life parameters were comparable between treatments.

CONCLUSION

Postoperative radiotherapy did not reduce recurrence or mortality. Function but not quality of life was adversely affected. Routine postoperative radiotherapy for Stage IIIA rectal cancer should be reconsidered.

Patterns of recurrence following liver resection for colorectal metastases: effect of primary rectal tumor site

HYPOTHESIS

Patients with rectal adenocarcinoma are at increased risk of locoregional recurrence compared with patients with colon cancer. This may affect the pattern of recurrence and survival rates following hepatic resection of liver metastases from rectal adenocarcinoma.

DESIGN

Retrospective review of a prospectively collected cancer center database.

PATIENT AND METHODS

From April 1, 1984, to December 31, 2005, 582 patients with liver metastases from a primary colorectal adenocarcinoma underwent hepatic resection. Clinical and pathological factors were analyzed using Cox regression analyses and log-rank tests.

RESULTS

Of 582 patients, 141 (24.2%) had liver metastases from a primary rectal tumor site. Treatment of the primary rectal tumor most frequently included chemoradiation therapy (59.6%) and low anterior resection (63.1%). Most rectal tumors were pathological stage T3/T4 (85.8%) and N1 (68.1%). Treatment directed at the hepatic metastases included resection only (81.5%), resection plus radiofrequency ablation (17.8%), or radiofrequency ablation only (0.7%). With a median follow-up time of 30.7 months, 80 of 141 patients (56.7%) developed recurrence; 23 patients (16.3%) developed recurrence in the pelvis. Of 23 patients with pelvic recurrence, 56.5% also developed recurrence in the liver. The 3- and 5-year survival rates for all patients were 62.4% and 36.4%, respectively. Of 80 patients who had a recurrence following hepatic metastectomy, 23 (28.8%) underwent another operation. Following repeat metastectomy, 3- and 5-year survival rates were 76.7% and 38.6%, respectively.

CONCLUSIONS

Following resection of hepatic rectal metastases, pelvic recurrence is relatively common, and most patients with pelvic recurrence will also develop recurrence in the liver. Surgery for recurrent disease following hepatic resection of rectal metastases is warranted among well-selected patients.

Adjuvant and neoadjuvant chemoradiation or radiotherapy in rectal cancer--a review focusing on open questions

BACKGROUND

The therapy of rectal cancer has been a matter of debate since decades, especially with regard to the benefits of neoadjuvant or adjuvant therapies. Principles of additional therapies have been established nearly two decades ago and are questioned nowadays on the basis of more recently modified operative techniques. Benefits and sequelae of therapies have to be balanced against each other, and it seems somewhat likely that a more differentiated strategy than simply stating that every patient with stage II and III rectal cancer needs chemoradiation or radiotherapy will, in long term, be recommended.

CONCLUSION

It should be kept in mind that results of centers of excellence and of phase-III studies with their positively selected patient populations are not representative for all the patients with rectal cancer and physicians treating them.

Patterns of locoregional recurrence after surgery and radiotherapy or chemoradiation for rectal cancer

PURPOSE

To identify patterns of locoregional recurrence in patients treated with surgery and preoperative or postoperative radiotherapy or chemoradiation for rectal cancer.

METHODS AND MATERIALS

Between November 1989 and October 2001, 554 patients with rectal cancer were treated with surgery and preoperative (85%) or postoperative (15%) radiotherapy, with 95% receiving concurrent chemotherapy. Among these patients, 46 had locoregional recurrence as the first site of failure. Computed tomography images showing the site of recurrence and radiotherapy simulation films were available for 36 of the 46 patients. Computed tomography images were used to identify the sites of recurrence and correlate the sites to radiotherapy fields in these 36 patients.

RESULTS

The estimated 5-year locoregional control rate was 91%. The 36 patients in the study had locoregional recurrences at 43 sites. There were 28 (65%) in-field, 7 (16%) marginal, and 8 (19%) out-of-field recurrences. Among the in-field recurrences, 15 (56%) occurred in the low pelvis, 6 (22%) in the presacral region, 4 (15%) in the mid-pelvis, and 2 (7%) in the high pelvis. Clinical T stage, pathologic T stage, and pathologic N stage were significantly associated with the risk of in-field locoregional recurrence. The median survival after locoregional recurrence was 24.6 months.

CONCLUSIONS

Patients treated with surgery and radiotherapy or chemoradiation for rectal cancer had a low risk of locoregional recurrence, with the majority of recurrences occurring within the radiation field. Because 78% of in-field recurrences occur in the low pelvic and presacral regions, consideration should be given to including the low pelvic and presacral regions in the radiotherapy boost field, especially in patients at high risk of recurrence.

Surgical outcomes after total mesorectal excision for rectal cancer

BACKGROUND AND OBJECTIVES

This study reviewed the results of surgery for distal rectal cancer following the introduction of total mesorectal excision (TME) for rectal cancer.

METHODS

Two hundred sixty-four patients who had undergone elective curative surgical resection of rectal cancer within 12 cm of the anal verge were included. Comparisons were made between patients who had different surgical procedures.

RESULTS

The overall operative mortality rate was nil, and the morbidity 39.4%. With a mean follow-up of 34 months (range 5-105 months), local recurrence occurred in 21 of the patients. The 3- and 5-year actuarial local recurrence rates were 9% and 12%, respectively for the whole group. Abdominoperineal resection (APR) was necessary in 65 of 264 (24.6%) of the patients, with a very low local recurrence rate in this subgroup (5% at 3 years). On multivariate analysis, only stage was a significant prognosticator of overall survival (P = 0.012).

CONCLUSIONS

With the practice of TME, APR was still necessary in 25% of patients with rectal cancer within 12 cm of the anal verge. Type of surgery and tumor distance from the anal verge influenced local recurrence rates, but only initial tumor stage was associated with long-term survival.

Chemotherapy with preoperative radiotherapy in rectal cancer

BACKGROUND

Preoperative radiotherapy is recommended for selected patients with rectal cancer. We evaluated the addition of chemotherapy to preoperative radiotherapy and the use of postoperative chemotherapy in the treatment of rectal cancer.

METHODS

We randomly assigned patients with clinical stage T3 or T4 resectable rectal cancer to receive preoperative radiotherapy, preoperative chemoradiotherapy, preoperative radiotherapy and postoperative chemotherapy, or preoperative chemoradiotherapy and postoperative chemotherapy. Radiotherapy consisted of 45 Gy delivered over a period of 5 weeks. One course of chemotherapy consisted of 350 mg of fluorouracil per square meter of body-surface area per day and 20 mg of leucovorin per square meter per day, both given for 5 days. Two courses were combined with preoperative radiotherapy in the group receiving preoperative chemoradiotherapy and the group receiving preoperative chemoradiotherapy and postoperative chemotherapy; four courses were planned postoperatively in the group receiving preoperative radiotherapy and postoperative chemotherapy and the group receiving preoperative chemoradiotherapy and postoperative chemotherapy. The primary end point was overall survival.

RESULTS

We enrolled 1011 patients in the trial. There was no significant difference in overall survival between the groups that received chemotherapy preoperatively (P=0.84) and those that received it postoperatively (P=0.12). The combined 5-year overall survival rate for all four groups was 65.2%. The 5-year cumulative incidence rates for local recurrences were 8.7%, 9.6%, and 7.6% in the groups that received chemotherapy preoperatively, postoperatively, or both, respectively, and 17.1% in the group that did not receive chemotherapy (P=0.002). The rate of adherence to preoperative chemotherapy was 82.0%, and to postoperative chemotherapy was 42.9%.

CONCLUSIONS

In patients with rectal cancer who receive preoperative radiotherapy, adding fluorouracil-based chemotherapy preoperatively or postoperatively has no significant effect on survival. Chemotherapy, regardless of whether it is administered before or after surgery, confers a significant benefit with respect to local control. (ClinicalTrials.gov number, NCT00002523 [ClinicalTrials.gov].).

Gene expression in tumor-adjacent normal tissue is associated with recurrence in patients with rectal cancer treated with adjuvant chemoradiation

Recurrence is a significant clinical problem for patients with rectal cancer treated with adjuvant chemoradiation. Previous studies have suggested that determining intratumoral gene expression of key genes may be helpful in predicting clinical outcome of patients with gastrointestinal malignancies undergoing chemotherapy. The role of molecular predictors for prediction of recurrence in the setting of adjuvant chemoradiotherapy is not well established. The present study was designed to identify a genetic profile that would be associated with recurrence in patients with rectal cancer treated with adjuvant chemoradiation therapy. A retrospective study with a longitudinal cohort and a cross-sectional cohort of 67 patients with locally advanced rectal cancer who underwent cancer resection, followed by 5-fluorouracil (5-FU) plus pelvic radiation was conducted. Total RNA was extracted from formalin-fixed, paraffin-embedded, laser-captured-microdissected tissue. We determined mRNA levels of genes involved in the 5-FU pathway (thymidylate synthase, dihydropyrimidine dehydrogenase), DNA-repair (excision-repair cross-complementing factor 1, Rad51), angiogenesis/radiation sensitivity [vascular endothelial growth factor (VEGF)] and radio-sensitivity [epidermal growth factor receptor (EGFR)] in tumor tissue and tumor-adjacent normal tissue by quantitative reverse transcriptase-polymerase chain reaction. In univariate analysis, only intratumoral gene expression level of VEGF (P = 0.055) was associated with recurrence, whereas elevated mRNA expression levels of thymidylate synthase (P = 0.008), VEGF (P = 0.023) and EGFR (P = 0.004) in tumor-adjacent normal tissue were significantly associated with recurrence. Multivariate analysis using recursive partitioning indicated that distinct groups of recurrence could be defined by elevated mRNA expression levels of VEGF, EGFR in tumor-adjacent normal tissue, and Rad51 in tumor tissue. These data suggest that the genetic profile of the tumor-adjacent normal tissue may be associated with treatment failure, indicating that tumor microenvironment may be more important in the development of recurrence of rectal tumors than formerly expected.

Surgical adjuvant therapy for colorectal cancer: current approaches and future directions

Colon cancer is the fourth most common cancer worldwide. The role of systemic adjuvant chemotherapy in colorectal cancer patients with lymph node involvement has been established in a large number of clinical trials. However, its role in stage II colorectal cancer is less well established. 5-Fluorouracil has been the mainstay of therapy for the last four decades. With the development of novel chemotherapy and biological agents, we have entered into a new era for the treatment of colorectal cancer. The combination of adjuvant 5-fluorouracil, leucovorin, and oxaliplatin has been shown to significantly improve disease-free survival and is now considered the standard of care for completely resected colon cancer in healthy patients. For rectal cancer patients with locally advanced tumors, neoadjuvant chemoradiation followed by adjuvant chemotherapy after surgery is the mainstay of treatment. The availability of oral chemotherapy agents has helped with the ease of administration and avoidance of indwelling catheters. A number of national clinical trials are under way to determine the role of targeted agents in combination with chemotherapy. The goal is to develop a regimen that would improve survival without excessive toxicity while maintaining quality of life. Patients should be encouraged to participate in clinical trials whenever feasible. Despite the advances, many patients will develop recurrent disease. It is of utmost importance to develop molecular markers that could predict which patients are at high risk for disease recurrence. Clinical trials are under way to address this issue. Thus, it will be advantageous to be able to tailor therapy individually, according to the risk of recurrence.

Advances in chemotherapy for colorectal cancer

Gastroenterologists have a primary role in the management of colorectal cancer patients in that they frequently establish the diagnosis, direct or perform tumor staging evaluations, and initiate referrals for oncologic treatment. Several important advances have been made in the adjuvant treatment of colon and rectal cancers and in therapy of metastatic disease. These advances include the development of more effective combination chemotherapy regimens and molecularly targeted antibodies. These antibodies are directed against regulators of angiogenesis (vascular endothelial growth factor) and tumor cell growth (epidermal growth factor receptor) and have been shown to enhance the efficacy of cytotoxic chemotherapy. In the treatment of localized rectal cancer, the integration of chemotherapy and radiation with surgery has resulted in neoadjuvant approaches that achieve improved tumor control, sphincter preservation, and reduce treatment-related toxicities. This review presents an update of the current approach to colon and rectal cancer treatment, highlighting recent chemotherapeutic advances in the management of these highly prevalent malignancies.

Peritoneal carcinomatosis of colorectal origin: incidence and current treatment strategies

OBJECTIVE

To review the literature with regard to the incidence and prognostic significance of peritoneal seeding during surgery for primary colorectal cancer (CRC), the incidence of intraperitoneal recurrence of CRC, and the current treatment strategies of established PC of colorectal origin, with special focus on cytoreductive surgery and intraperitoneal chemotherapy (IPEC).

SUMMARY BACKGROUND DATA

Although hematogenous dissemination forms the greatest threat to patients with CRC, peritoneal carcinomatosis (PC), presumably arising from intraperitoneal seeding of cancer cells, is a relatively frequent event in patients with recurrent CRC.

METHODS

The PubMed and Medline literature databases were searched for pertinent publications regarding the incidence and prognostic significance of exfoliated tumor cells in the peritoneal cavity during curative surgery for primary CRC, the incidence of intraperitoneal recurrence of CRC, and the therapeutic results of systemic chemotherapy or cytoreductive surgery followed by IPEC.

RESULTS

The incidence of peritoneal seeding during potentially curative surgery for primary CRC, as reported in 12 patient series, varied widely, from 3% to 28%, which may be explained by differences in methods to detect tumor cells. PC is encountered in approximately 7% of patients at primary surgery, in approximately 4% to 19% of patients during follow-up after curative surgery, in up to 44% of patients with recurrent CRC who require relaparotomy, and in 40% to 80% of patients who succumb to CRC. The reported median survival after systemic 5-fluorouracil-based chemotherapy for PC varies from 5.2 to 12.6 months. Median survival after aggressive cytoreductive surgery followed by (hyperthermic) IPEC in selected patients, as reported in 16 patient series, tends to be better and varies from 12 to 32 months at the cost of morbidity and mortality rates of 14% to 55% and 0% to 19%, respectively. One randomized controlled trial has been published confirming the superiority of aggressive surgical cytoreduction and intraperitoneal chemotherapy over strictly palliative treatment.

CONCLUSIONS

Peritoneal seeding of cancer cells possibly leading to PC is a rather common phenomenon in patients with CRC. Cytoreductive surgery and adjuvant (hyperthermic) IPEC have been shown to be efficacious in selected patients and should therefore be considered in patients with resectable PC of colorectal origin.

The management of rectal cancer in the elderly

INTRODUCTION

The majority of patients with rectal cancer are elderly. Due to the increasingly aging population the number of people with colorectal cancer is increasing. As medical advances in the areas of local therapy, radiation therapy, and surgical technique, such as, laparoscopy are made more elderly patients are offered various types of treatment for rectal cancer. As the number of treatment options increase, the debate on how to treat elderly patients' with rectal cancer intensifies.

METHODS

A Medline search using "rectal cancer," "elderly," "local therapy," "radical surgery," and "radiation therapy" as key words was performed for English-language articles. Further references were obtained through cross-referencing the bibliography cited in each work.

DISCUSSION

Numerous treatment options exists for elderly patients with rectal cancer. These range from transanal local excision to radical surgery. The best treatment option for a certain elderly patient is multifactorial and includes tumor stage, operative curability, preoperative functioning of the patient, patient comorbidities, quality of life goals, and patient preference.

CONCLUSION

Age, taken as an independent variable, is not a contraindication to any specific type of therapy, including radical surgery with primary anastomsis. Patients' who meet the criteria for local resection should undergo this procedure. However, for tumors which are not amenable to local resection, these patients should be considered for radical surgery if this provides the best chance for cure. Elderly patients who can tolerate a major operation, and have good preoperative sphincter function should undergo a resection with primary anastomosis.

Results of treatment of distal rectal carcinoma since the introduction of total mesorectal excision: a single unit experience, 1994-2003

BACKGROUND AND AIMS

This study reviewed the results of surgery for distal rectal cancer (where the tumour was within 6 cm of the anal verge) following the introduction of total mesorectal excision for rectal cancer in one institution.

PATIENTS AND METHODS

One hundred and fifty-three patients who had undergone elective curative surgical resection of rectal cancer within 6 cm of the anal verge were included. The demographic, operative and follow-up data were collected retrospectively. Comparisons were made between patients who had different surgical procedures.

RESULTS

The overall operative mortality rate was nil, and the morbidity 41%. With a mean follow-up of 37 months (range 5-100 months), local recurrence occurred in 18 of the patients. The 5-year actuarial local recurrence rates for double-stapled anastomosis, low-strength anastomosis and abdominoperineal resection (APR) were 39, 17 and 11% respectively. The local recurrence rate was significantly higher for double-stapled low anterior resection than for the other types of operation (P=0.007). On multivariate analysis type of surgery (P=0.025) and tumour stage (P=0.043), were associated with local recurrence, but only stage was a significant prognosticator of overall survival (P=0.0006).

CONCLUSION

With the practice of total mesorectal excision, APR was still necessary in 40% of patients with rectal cancer within 6 cm of the anal verge. The local recurrence rate was lower in patients treated with APR than in those with double-stapled low anterior resection; however, survival rates were similar in these two groups.

Statistical comparison of random allocation methods in cancer clinical trials

The selection of a trial design is an important issue in the planning of clinical trials. One of the most important considerations in trial design is the method of treatment allocation and appropriate analysis plan corresponding to the design. In this article, we conducted computer simulations using the actual data from 2158 rectal cancer patients enrolled in the surgery-alone group from seven randomized controlled trials in Japan to compare the performance of allocation methods, simple randomization, stratified randomization and minimization in relatively small-scale trials (total number of two groups are 50, 100, 150 or 200 patients). The degree of imbalance in prognostic factors between groups was evaluated by changing the allocation probability of minimization from 1.00 to 0.70 by 0.05. The simulation demonstrated that minimization provides the best performance to ensure balance in the number of patients between groups and prognostic factors. Moreover, to achieve the 1 percentile for the p-value of chi-square test around 0.50 with respect to balance in prognostic factors, the allocation probability of minimization was required to be set to 0.95 for 50, 0.80 for 100, 0.75 for 150 and 0.70 for 200 patients. When the sample size was larger, sufficient balance could be achieved even if reducing allocation probability. The simulation using actual data demonstrated that unadjusted tests for the allocation factors resulted in conservative type I errors when dynamic allocation, such as minimization, was used. In contrast, adjusted tests for allocation factors as covariates improved type I errors closer to the nominal significance level and they provided slightly higher power. In conclusion, both the statistical and clinical validity of minimization was demonstrated in our study.

Outcome of anterior resection for stage II rectal cancer without radiation: the role of adjuvant chemotherapy

BACKGROUND

This study aimed to evaluate the oncological outcome of patients who had Stage II rectal cancer and underwent curative nonsphincter-ablation surgery without adjuvant radiation.

PATIENTS AND METHODS

During the study period from August 1993 to December 2002, 224 patients (141 men) with Stage II cancer underwent curative anterior resection or Hartmann's procedure without adjuvant radiation. Data were collected prospectively. The oncologic outcomes of these patients were studied and the risk factors for recurrence and survival were analyzed.

RESULTS

The median age of the patients was 69 (range, 27-89) years and the median level of the tumor from the anal verge was 8 (range, 3-20) cm. Four patients (1.8 percent) died in the postoperative period and postoperative complications occurred in 74 patients (33 percent). The median follow-up time of the surviving patients was 43.6 months. The actuarial five-year recurrence rate was 25.4 percent, whereas the five-year actuarial local and systemic recurrence rates were 6.1 percent and 20 percent, respectively. On multivariate analysis, independent factors associated with a higher recurrence rate included lymphovascular invasion, perineural invasion, and absence of chemotherapy. The overall and cancer-specific survival rates of the patients were 71.1 percent and 81.1 percent, respectively. On multivariate analysis, only adjuvant chemotherapy (P = 0.024; hazard ratio = 6.04; 95 percent confidence interval, 1.27-28.74) and the absence of lymphovascular invasion (P = 0.002; hazard ratio = 3.77; 95 percent confidence interval, 1.63-8.77) were independent factors associated with significantly better cancer-specific survival.

CONCLUSION

A low local recurrence rate can be achieved in patients with Stage II rectal cancer treated with nonsphincter-ablation surgery without adjuvant radiation. Postoperative chemotherapy is associated with a lower recurrence rate and higher survival rates. Further study is warranted to define the role of adjuvant chemotherapy in patients with rectal cancer.

Impact of Preoperative Staging and Chemoradiation Versus Postoperative Chemoradiation on Outcome in Patients With Rectal Cancer: A Decision Analysis

BACKGROUND

Although radical resection and postoperative chemoradiation have been the standard therapy for patients with rectal cancer, preoperative staging by local imaging and chemoradiation are widely used. We used a decision analysis to compare the two strategies for rectal cancer management.

METHODS

We developed a decision model to compare survival outcomes after postoperative chemoradiation versus preoperative staging and chemoradiation in patients aged 70 years with resectable rectal cancer. In the postoperative chemoradiation strategy, patients undergo radical resection and receive postoperative chemoradiation. In the preoperative staging and chemoradiation strategy, patients with locally advanced cancer receive preoperative chemoradiation and radical resection, whereas those with amenable localized tumors undergo local excision. The cohorts of patients were entered into a Markov model incorporating age-adjusted and disease-specific mortality. Outcomes were evaluated by modeling 5-year disease-specific survival for preoperative chemoradiation as less than, equal to, or greater than that of postoperative chemoradiation. Base-case probabilities were derived from published data; the Surveillance, Epidemiology, and End Results (SEER) Program database; and U.S. Life Tables. One-way and two-way sensitivity analyses were performed. The outcome measures were life expectancy and quality-adjusted life expectancy.

RESULTS

Life expectancy and quality-adjusted life expectancy were 9.72 and 8.72 years, respectively, in the postoperative chemoradiation strategy. In the preoperative staging and chemoradiation strategy, life expectancy was 9.36, 9.72, and 10.09 years and quality-adjusted life expectancy was 8.71, 9.04, and 9.37 years when 5-year disease-specific survival was less than, equal to, or greater than that of postoperative chemoradiation, respectively. The decision model was sensitive to differences in the long-term toxicity of pre- and postoperative chemoradiation. When the 5-year disease-specific survival for patients after pre- or postoperative chemoradiation was equal, the decision model was sensitive to surgical mortality and to the probability of residual lymph node disease after local excision.

CONCLUSION

If efficacy and toxicity after preoperative chemoradiation are equal to or better than that after postoperative chemoradiation in patients with locally advanced rectal cancer, then preoperative staging to select patients appropriate for preoperative chemoradiation is beneficial.

Clinical and sociodemographic factors associated with colon surveillance among patients with a history of colorectal cancer

BACKGROUND

Substantial variability in the use of colon surveillance among colorectal cancer survivors has been reported. This study sought to examine trends in the use of colon surveillance among patients who have had colorectal cancer and to investigate factors associated with utilization.

METHODS

Health maintenance organization enrollees with a diagnosis of local or regional colon or rectal cancer between January 1993 and December 1999 were studied. Receipt of a colon examination by colonoscopy or by flexible sigmoidoscopy, together with barium contrast radiography of the colon was determined from automated clinical records, and rates of colon surveillance were estimated by using survival analysis.

RESULTS

A total of 1002 patients with a diagnosis of colorectal cancer met inclusion criteria for the study. Colon examinations were performed in 61% of patients within 18 months of diagnosis and in 80% of patients within 5 years of diagnosis. The median time from diagnosis to first colon surveillance examination (14 months) was unchanged over the study period, but the interval between first and second surveillance examinations increased by 17 months (p<0.001). Patients over 80 years of age (relative risk=0.32; 95% CI[0.22, 0.45]) and those with rectal cancer (relative risk=0.80; 95% CI[0.66, 0.97]) were less likely to undergo surveillance. Higher socioeconomic status (relative risk=1.29; 95% CI[1.03, 1.61]) and being married (relative risk=1.27; 95% CI[1.05, 1.53]) were associated with greater utilization. There was lower utilization among African American patients (relative risk=0.70; p=0.14) and increased utilization among other minorities (relative risk=1.47; p=0.06).

CONCLUSIONS

There is substantial variability in the use of colon examination for surveillance in patients with a history of colorectal cancer, and clinical and sociodemographic factors appear to influence the likelihood of surveillance.

Follow-up strategies after curative resection of colorectal cancer

Consensus is lacking as to the best strategy for following patients who have undergone definitive surgical medical treatment for colon cancer. The goal of any surveillance program should be detection of recurrent disease at a sufficiently early time to allow subsequent curative therapy. Although periodic clinical examinations, laboratory tests, radiographic imaging, and carcinoembryonic antigen (CEA) testing have been utilized as a form of surveillance, such aggressive and costly intervention has not been validated through clinical studies. Four of the five randomized trials comparing such an intensive surveillance strategy to less frequent testing have not demonstrated the intensive approach to lead to an improvement in overall survival. Furthermore, intensive testing is both costly and has been shown not to improve quality of life. Further research designing appropriate postoperative testing is needed to guide physicians and patients after the curative resection of a colorectal cancer.

Importance of tumor regression assessment in predicting the outcome in patients with locally advanced rectal carcinoma who are treated with preoperative radiotherapy

BACKGROUND

Locally advanced rectal carcinoma has a poor prognosis. However, since the introduction of preoperative radiotherapy, the outcome of patients with rectal carcinoma has been reported to have improved. Nevertheless, to the authors' knowledge few data are available regarding the histopathologic response to radiotherapy as assessed on surgical specimens as a potential predictive factor for outcome.

METHODS

To estimate the effect of radiotherapy on rectal carcinoma, the authors retrospectively reviewed the surgical specimens of 102 patients with T3-4, N0 or > or = N1 rectal carcinoma and 1 patient with T2 but N1 rectal carcinoma. All patients were treated preoperatively with a hyperfractionated accelerated radiotherapy schedule in a prospective protocol (Trial 93-01). Using a standardized approach, tumor regression was graded using a system that varies from Grade 1 (tumor regression Grade [TRG] 1) when complete tumor regression is observed to Grade 5 (TRG5) when no tumor regression is observed.

RESULTS

Radiotherapy resulted in tumor downstaging in 43% of the patients. There were 2 pT1 tumors (2%), 21 pT2 tumors (20%), 66 pT3 tumors (64%), and 14 pT4 tumors (14%) after treatment. Regional lymph nodes were involved in 55 patients (53%). None of the patients demonstrated a complete tumor regression after radiotherapy, but in 79% of the specimens a partial tumor regression was observed (TRG1: 0%; TRG2: 20%; TRG3: 39%; TRG4: 20%; and TRG5: 21%). The median actuarial overall survival (OS) and disease-free survival (DFS) were 52 months. Actuarial local recurrence rates at 2 years and 5 years were 6.4% and 7.6%, respectively. Univariate analysis showed the actuarial DFS to be significantly lower in patients with lymph node metastases (P = 0.0004) and advanced pT stages (pT3-4) (P = 0.03). A favorable outcome for OS, DFS, and local control was observed in patients with TRG2-4 (i.e., responders) compared with patients with TRG5 (i.e., nonresponders), but also in patients with low residual tumor cell density (TRG2, 3, and 4). On multivariate analysis, TRG remained an independent prognostic indicator for local tumor control.

CONCLUSIONS

Tumor regression as well as residual tumor cell density were found to be predictive factors of survival in rectal carcinoma patients after preoperative radiotherapy. Even after preoperative radiotherapy, the pathologic stage of the surgical specimen remained a prognostic factor. The use of a standardized approach for pathologic evaluation must be implemented to allow comparison between the results of various treatment approaches.

Randomized trial of postoperative adjuvant therapy in stage II and III rectal cancer to define the optimal sequence of chemotherapy and radiotherapy: a preliminary report

PURPOSE

We conducted a prospective randomized trial to define the optimal sequence of chemotherapy and radiotherapy of postoperative adjuvant treatment in stage II and III rectal cancer.

PATIENTS AND METHODS

Three hundred eight patients were enrolled onto the study. We randomly assigned 155 to arm I (early radiotherapy group) and 153 to arm II (late radiotherapy group). Treatment included eight cycles of chemotherapy at 4-week intervals and pelvic radiotherapy of 45 Gy in 25 fractions. Radiotherapy started on day 1 of the first chemotherapy cycle in arm I and on day 1 of the third chemotherapy cycle in arm II. The chemotherapy regimen consisted of fluorouracil 375 mg/m(2)/d and leucovorin 20 mg/m(2)/d. Chemotherapy was administered for 3 days per cycle in two cycles during the period of radiotherapy and for 5 days per cycle in the remaining six cycles.

RESULTS

Twenty patients in arm I and 14 in arm II were not eligible. We included 274 patients in the analysis. With a median follow-up of 37 months for surviving patients, disease-free survival was significantly prolonged in arm I compared with arm II (81% v. 70% at 4 years; P =.043). Twenty-three recurrences occurred in arm I and 38 in arm II (P =.047). Overall survival was not significantly different between arms I and II (84% v. 82% at 4 years; P =.387).

CONCLUSION

Early radiotherapy with concurrent chemotherapy after resection of stage II and III rectal cancer demonstrated a statistically significant advantage for disease-free survival compared with late radiotherapy with chemotherapy.

Radiation plus chemotherapy as adjuvant therapy for rectal cancer

The most common neo-adjuvant therapy for rectal cancer is chemotherapy and concurrent radiation therapy. In general, it is delivered pre-operatively for patients with clinical evidence of T(3-4) disease or post-operatively in patients who have undergone surgery and have T(3) and/or N(1-2) disease. This chapter reviews the rationale and results for neo-adjuvant therapy, the selection process for pre-operative versus post-operative treatment, and new approaches and controversies.