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Wang X, Jiang W, Deng Y, Chen Z, Zheng Z, Sun Y, Xie Z, Lu X, Huang S, Lin Y, Huang Y, Chi P. Unraveling variations and enhancing prediction of successful sphincter-preserving resection for low rectal cancer: a post hoc analysis of the multicentre LASRE randomized clinical trial. Int J Surg 2024; 110:4031-4042. [PMID: 38652133 PMCID: PMC11254249 DOI: 10.1097/js9.0000000000001014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 12/11/2023] [Indexed: 04/25/2024]
Abstract
BACKGROUND Accurate prediction of successful sphincter-preserving resection (SSPR) for low rectal cancer enables peer institutions to scrutinize their own performance and potentially avoid unnecessary permanent colostomy. The aim of this study is to evaluate the variation in SSPR and present the first artificial intelligence (AI) models to predict SSPR in low rectal cancer patients. STUDY DESIGN This was a retrospective post hoc analysis of a multicenter, non-inferiority randomized clinical trial (LASRE, NCT01899547) conducted in 22 tertiary hospitals across China. A total of 604 patients who underwent neoadjuvant chemoradiotherapy (CRT) followed by radical resection of low rectal cancer were included as the study cohort, which was then split into a training set (67%) and a testing set (33%). The primary end point of this post hoc analysis was SSPR, which was defined as meeting all the following criteria: (1) sphincter-preserving resection; (2) complete or nearly complete TME, (3) a clear CRM (distance between margin and tumour of 1 mm or more), and (4) a clear DRM (distance between margin and tumour of 1 mm or more). Seven AI algorithms, namely, support vector machine (SVM), logistic regression (LR), extreme gradient boosting (XGB), light gradient boosting (LGB), decision tree classifier (DTC), random forest (RF) classifier, and multilayer perceptron (MLP), were employed to construct predictive models for SSPR. Evaluation of accuracy in the independent testing set included measures of discrimination, calibration, and clinical applicability. RESULTS The SSPR rate for the entire cohort was 71.9% (434/604 patients). Significant variation in the rate of SSPR, ranging from 37.7 to 94.4%, was observed among the hospitals. The optimal set of selected features included tumour distance from the anal verge before and after CRT, the occurrence of clinical T downstaging, post-CRT weight and clinical N stage measured by magnetic resonance imaging. The seven different AI algorithms were developed and applied to the independent testing set. The LR, LGB, MLP and XGB models showed excellent discrimination with area under the receiver operating characteristic (AUROC) values of 0.825, 0.819, 0.819 and 0.805, respectively. The DTC, RF and SVM models had acceptable discrimination with AUROC values of 0.797, 0.766 and 0.744, respectively. LR and LGB showed the best discrimination, and all seven AI models had superior overall net benefits within the range of 0.3-0.8 threshold probabilities. Finally, we developed an online calculator based on the LGB model to facilitate clinical use. CONCLUSIONS The rate of SSPR exhibits substantial variation, and the application of AI models has demonstrated the ability to predict SSPR for low rectal cancers with commendable accuracy.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Ying Huang
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, Fuzhou, People’s Republic of China
| | - Pan Chi
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, Fuzhou, People’s Republic of China
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Wu YJ, Huang ST, Chang YH, Lin SY, Lin WL, Chen YJ, Chien ST. SUMO-Activating Enzyme Subunit 1 Is Associated with Poor Prognosis, Tumor Progression, and Radio-Resistance in Colorectal Cancer. Curr Issues Mol Biol 2023; 45:8013-8026. [PMID: 37886949 PMCID: PMC10605852 DOI: 10.3390/cimb45100506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/28/2023] [Accepted: 09/29/2023] [Indexed: 10/28/2023] Open
Abstract
Concurrent chemoradiotherapy is an effective treatment option for patients with low-grade colorectal cancer (CRC) in the local disease stage. At present, the principle of the Taiwan Medical Center is to treat CRC patients with combination radiotherapy and chemotherapy (high-dose 5-FU) for a period of about five weeks prior to surgery. Radical resection of the tumor is performed at least six to eight weeks after concurrent chemoradiotherapy (CCRT). However, this approach fails to produce the desired therapeutic effect in approximately 20% to 30% of patients, and such patients are unnecessarily exposed to the risks of radiation and drug toxicity posed by this therapy. Therefore, it is crucial to explore new biomarkers to predict the prognosis of CRC. SUMO-activating enzyme subunit 1 (SAE1) plays an important role in SUMOylation, a post-translational modification involved in cellular functions, such as cell proliferation, cell cycle, and apoptosis. In our study, to explore the clinical-pathological role of SAE1 protein in CRC, we evaluated the clinical data and paraffin sections from CRC patients. The expression of SAE1 was evaluated using immunohistochemical analysis, and clinical parameters were analyzed using chi-square and Kaplan-Meier survival tests. The results of in vitro proliferation and radiosensitive assays were compared between control groups and SAE1 siRNA groups. Western blotting was also used to detect the expressions of the SAE1, PARP, cyclin D1, p-NF-κB, and NF-κB proteins. Flow cytometry and colony formation assays were used to detect the effect of SAE-1 on radiosensitivity. In vivo, we detected the growth curve in a mouse xenograft model. The results showed that SAE-1 was revealed to be an independent prognostic biomarker of CRC. SAE1 knockdown inhibited CRC proliferation in vitro and in vivo, and led to the cleavage of PARP, downregulation of cyclin D1 protein expression, and downregulation of p-NF-κB/NF-κB. Additionally, SAE1 knockdown promoted radiosensitivity in CRC cells. Therefore, it was inferred that SAE1 may be used as a potential therapeutic target in CRC treatment.
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Affiliation(s)
- Yueh-Jung Wu
- Division of Colorectal Surgery, Kaohsiung Armed Forces General Hospital, Kaohsiung 802, Taiwan
| | - Siang-Ting Huang
- Cancer Center, Kaohsiung Armed Forces General Hospital, Kaohsiung 802, Taiwan
| | - Ya-Hui Chang
- Cancer Center, Kaohsiung Armed Forces General Hospital, Kaohsiung 802, Taiwan
| | - Shih-Yi Lin
- Department of Pathology, Kaohsiung Armed Forces General Hospital, Kaohsiung 802, Taiwan
| | - Weng-Ling Lin
- Department of Pathology, Kaohsiung Armed Forces General Hospital, Kaohsiung 802, Taiwan
| | - Ying-Jung Chen
- Department of Fragrance and Cosmetic Science, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Shang-Tao Chien
- Department of Pathology, Kaohsiung Armed Forces General Hospital, Kaohsiung 802, Taiwan
- Department of Nursing, Fooyin University, Kaohsiung 831, Taiwan
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Evaluation of ctDNA in the Prediction of Response to Neoadjuvant Therapy and Prognosis in Locally Advanced Rectal Cancer Patients: A Prospective Study. Pharmaceuticals (Basel) 2023; 16:ph16030427. [PMID: 36986526 PMCID: PMC10057108 DOI: 10.3390/ph16030427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 02/28/2023] [Accepted: 03/03/2023] [Indexed: 03/18/2023] Open
Abstract
“Watch and wait” is becoming a common treatment option for patients with locally advanced rectal cancer (LARC) submitted to neoadjuvant treatment. However, currently, no clinical modality has an acceptable accuracy for predicting pathological complete response (pCR). The aim of this study was to assess the clinical utility of circulating tumor DNA (ctDNA) in predicting the response and prognosis in these patients. We prospectively enrolled a cohort of three Iberian centers between January 2020 and December 2021 and performed an analysis on the association of ctDNA with the main response outcomes and disease-free survival (DFS). The rate of pCR in the total sample was 15.3%. A total of 24 plasma samples from 18 patients were analyzed by next-generation sequencing. At baseline, mutations were detected in 38.9%, with the most common being TP53 and KRAS. Combination of either positive magnetic resonance imaging (MRI) extramural venous invasion (mrEMVI) and ctDNA increased the risk of poor response (p = 0.021). Also, patients with two mutations vs. those with fewer than two mutations had a worse DFS (p = 0.005). Although these results should be read carefully due to sample size, this study suggests that baseline ctDNA combined with mrEMVI could potentially help to predict the response and baseline ctDNA number of mutations might allow the discrimination of groups with different DFS. Further studies are needed to clarify the role of ctDNA as an independent tool in the selection and management of LARC patients.
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Nozawa H, Taira T, Sonoda H, Sasaki K, Murono K, Emoto S, Yokoyama Y, Nagai Y, Abe S, Ishihara S. Enhancement of radiation therapy by indoleamine 2,3 dioxygenase 1 inhibition through multimodal mechanisms. BMC Cancer 2023; 23:62. [PMID: 36653774 PMCID: PMC9847047 DOI: 10.1186/s12885-023-10539-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 01/11/2023] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Indoleamine 2,3-dioxygenase 1 (IDO1) is an enzyme that converts tryptophan to kynurenine. IDO1 expression is found not only in tumor cells but also in immune cells and is associated with tumor proliferation and immune responses. IDO1 inhibitors and radiation may cooperatively suppress tumor proliferation through the alterations in the Wnt/β-catenin pathway, cell cycle, and immune response. We investigated the antitumor effects of combination therapy of an IDO1 inhibitor, 1-methyl tryptophan (1-MT), and radiation on colorectal cancer. METHODS In vitro experiments were conducted using human and murine colon cancer cell lines (HCT116, HT-29, and Colon26). Cell growth inhibition was assessed using a MTS assay and Clonogenic assay. Cells were cultured for 48 h with or without 500 µM 1-MT after exposure to radiation (4 Gy). Cell cycle effects and modulation of Wnt/β-catenin pathway were evaluated using western blot analysis, flow cytometry, RT-PCR. Subcutaneous Colon26 tumors in BALB/c mice were treated by oral 1-MT (6 mg/mL) for 2 weeks and/or local radiation (10 Gy/10 fr). Bromodeoxyuridine (BrdU) incorporation in tumor cells and expression of differentiation markers of immune cells were evaluated using immunohistochemistry. RESULTS 1-MT and a small interfering RNA against IDO1 suppressed proliferation of all cell lines, which was rescued by kynurenine. Clonogenic assay showed that administration of 1-MT improved radiosensitivity by suppressing the Wnt/β-catenin pathway activated by radiation and enhancing cell cycle arrest induced by radiation. Combination therapy showed a further reduction in tumor burden compared with monotherapies or untreated control, inducing the highest numbers of intratumoral CD3 + and CD8 + T cells and the lowest numbers of Foxp3 + and BrdU-positive tumor cells. CONCLUSIONS The combination of 1-MT and radiation suppressed colon cancer cells in vitro and in vivo via multiple mechanisms.
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Affiliation(s)
- Hiroaki Nozawa
- grid.26999.3d0000 0001 2151 536XDepartment of Surgical Oncology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655 Japan
| | - Tetsuro Taira
- grid.26999.3d0000 0001 2151 536XDepartment of Surgical Oncology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655 Japan
| | - Hirofumi Sonoda
- grid.26999.3d0000 0001 2151 536XDepartment of Surgical Oncology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655 Japan
| | - Kazuhito Sasaki
- grid.26999.3d0000 0001 2151 536XDepartment of Surgical Oncology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655 Japan
| | - Koji Murono
- grid.26999.3d0000 0001 2151 536XDepartment of Surgical Oncology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655 Japan
| | - Shigenobu Emoto
- grid.26999.3d0000 0001 2151 536XDepartment of Surgical Oncology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655 Japan
| | - Yuichiro Yokoyama
- grid.26999.3d0000 0001 2151 536XDepartment of Surgical Oncology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655 Japan
| | - Yuzo Nagai
- grid.26999.3d0000 0001 2151 536XDepartment of Surgical Oncology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655 Japan
| | - Shinya Abe
- grid.26999.3d0000 0001 2151 536XDepartment of Surgical Oncology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655 Japan
| | - Soichiro Ishihara
- grid.26999.3d0000 0001 2151 536XDepartment of Surgical Oncology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655 Japan
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Shulman RM, Meyer JE. Current Trends in the Treatment of Locally Advanced Rectal Cancer: Where We Are and How We Got Here. CURRENT COLORECTAL CANCER REPORTS 2021. [DOI: 10.1007/s11888-021-00471-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Liao X, Li X, Cheng J, Zhang Y, Ding K, Li X. Extraperitoneal colostomy after laparoscopic abdominoperineal resection using a cannula for tunnel creation through a trocar port. Surg Endosc 2021; 36:3178-3182. [PMID: 34160698 DOI: 10.1007/s00464-021-08621-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 06/14/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Extraperitoneal colostomy (EPC) after laparoscopic abdominoperineal resection (APR) remains a challenge for surgeons. This study aims to summarize our laparoscopic EPC method and assess its effects versus a transperitoneal colostomy (TPC) for patients with rectal tumors. METHODS A total of 133 patients with rectal cancer treated with laparoscopic APR between May 2009 and May 2020 were retrospectively reviewed. The clinical data, including demographics, comorbidities, tumor stage, colostomy duration, and complications were compared between the EPC group and the TPC group. RESULTS The EPC group included 83 patients whose extraperitoneal tunnels were created using a cannula through a trocar port, and the TPC group included 50 patients whose stomata were formed traditionally. There were no differences in colostomy time [(23.1 ± 6) min vs. (21.4 ± 4) min, P = 0.078], number of parastomal dermatitis patients (5 vs. 2, P = 0.916), or number of stomal stenoses (1 vs. 1, P = 0.715) between the EPC and TPC groups. No cases of parastomal hernia developed in the EPC group, whereas 4 patients were diagnosed with a parastomal hernia; the difference between the two groups was statistically significant (P = 0.036). CONCLUSIONS Laparoscopic EPC have a lower incidence of parastomal hernia than TPC. It is easy and inexpensive to create an extraperitoneal tunnel using a cannula through a trocar port.
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Affiliation(s)
- Xiaofeng Liao
- Department of General Surgery, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, 441021, China
| | - Xiaoyun Li
- Department of General Surgery, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, 441021, China
| | - Jun Cheng
- Department of General Surgery, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, 441021, China
| | - Yongkang Zhang
- Department of General Surgery, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, 441021, China
| | - Ke Ding
- Department of General Surgery, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, 441021, China
| | - Xiaogang Li
- Department of General Surgery, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, 441021, China.
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Taira T, Nozawa H, Kawai K, Sasaki K, Murono K, Kaneko M, Emoto S, Iida Y, Ishii H, Yokoyama Y, Anzai H, Sonoda H, Ishihara S. Oncological Outcomes of Pathological T1 Lower Rectal Cancer Patients With or Without Preoperative Chemoradiotherapy. In Vivo 2021; 34:3559-3564. [PMID: 33144468 DOI: 10.21873/invivo.12199] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 09/12/2020] [Accepted: 09/13/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND/AIM It remains unclear whether rectal cancers down-staged by preoperative chemoradiotherapy (CRT) have similar prognoses to those of the same stage without preoperative CRT. We compared prognoses of pT1 rectal cancer patients stratified by preoperative CRT. PATIENTS AND METHODS We retrieved data of patients with pathological T1 rectal cancer between 2003 and 2020. Patients were divided into the "ypT1 group" who received preoperative CRT following surgery and the "pT1 group" who underwent surgery alone. Factors associated with relapse-free survival (RFS) were investigated. RESULTS Among 86 patients, ypT1 and pT1 groups comprised 18 and 68 patients, respectively. There was no significant difference in RFS between the groups (p=0.19). Tumor location within 5 cm from the anal verge was associated with recurrence (hazard ratio: 0.13, p=0.034). CONCLUSION The prognosis of patients with ypT1 rectal cancer was similar to that of patients with pT1. Low tumor location was a poor prognostic factor.
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Affiliation(s)
- Tetsuro Taira
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - Hiroaki Nozawa
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - Kazushige Kawai
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - Kazuhito Sasaki
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - Koji Murono
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - Manabu Kaneko
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - Shigenobu Emoto
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - Yuuki Iida
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - Hiroaki Ishii
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - Yuichiro Yokoyama
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Anzai
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - Hirofumi Sonoda
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - Soichiro Ishihara
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
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Can Pre-Treatment Inflammatory Parameters Predict the Probability of Sphincter-Preserving Surgery in Patients with Locally Advanced Low-Lying Rectal Cancer? Diagnostics (Basel) 2021; 11:diagnostics11060946. [PMID: 34070592 PMCID: PMC8226544 DOI: 10.3390/diagnostics11060946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/07/2021] [Accepted: 05/24/2021] [Indexed: 11/29/2022] Open
Abstract
There is evidence suggesting that pre-treatment clinical parameters can predict the probability of sphincter-preserving surgery in rectal cancer; however, to date, data on the predictive role of inflammatory parameters on the sphincter-preservation rate are not available. The aim of the present cohort study was to investigate the association between inflammation-based parameters and the sphincter-preserving surgery rate in patients with low-lying locally advanced rectal cancer (LARC). A total of 848 patients with LARC undergoing radiotherapy from 2004 to 2019 were retrospectively reviewed in order to identify patients with rectal cancer localized ≤6 cm from the anal verge, treated with neo-adjuvant radiochemotherapy (nRCT) and subsequent surgery. Univariable and multivariable analyses were used to investigate the role of pre-treatment inflammatory parameters, including the C-reactive protein (CRP), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) for the prediction of sphincter preservation. A total of 363 patients met the inclusion criteria; among them, 210 patients (57.9%) underwent sphincter-preserving surgery, and in 153 patients (42.1%), an abdominoperineal rectum resection was performed. Univariable analysis showed a significant association of the pre-treatment CRP value (OR = 2.548, 95% CI: 1.584–4.097, p < 0.001) with sphincter preservation, whereas the pre-treatment NLR (OR = 1.098, 95% CI: 0.976–1.235, p = 0.120) and PLR (OR = 1.002, 95% CI: 1.000–1.005, p = 0.062) were not significantly associated with the type of surgery. In multivariable analysis, the pre-treatment CRP value (OR = 2.544; 95% CI: 1.314–4.926; p = 0.006) was identified as an independent predictive factor for sphincter-preserving surgery. The findings of the present study suggest that the pre-treatment CRP value represents an independent parameter predicting the probability of sphincter-preserving surgery in patients with low-lying LARC.
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Harada Y, Kazama S, Morikawa T, Sonoda H, Ishi H, Emoto S, Murono K, Kaneko M, Sasaki K, Shuno Y, Nishikawa T, Tanaka T, Kawai K, Hata K, Nozawa H, Ushiku T, Tahara H, Ishihara S. Clinical significance of CD8 + and FoxP3 + tumor-infiltrating lymphocytes and MFG-E8 expression in lower rectal cancer with preoperative chemoradiotherapy. Mol Clin Oncol 2021; 14:87. [PMID: 33767856 DOI: 10.3892/mco.2021.2249] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 02/04/2021] [Indexed: 12/14/2022] Open
Abstract
Preoperative chemoradiotherapy (CRT) for rectal cancer contributes to tumor down-staging and decreases locoregional recurrence. However, each patient shows a significantly different response to CRT. Therefore, the identification of predictive factors to CRT response would be beneficial to avoid unnecessary treatment. Cancer immunity in patients has been suggested to play an important role in the eradication of the tumor by CRT. In the present study, the utility of CD8+ and forkhead box P3 (FoxP3)+ tumor-infiltrating lymphocytes (TILs) and the expression of a novel immuno-regulatory factor, lactadherin (MFG-E8), in predicting CRT effectiveness in patients with rectal cancer was examined. A total of 61 patients with rectal cancer, who underwent curative resection following CRT were included in the study. The numbers of CD8+ and FoxP3+ TILs in a biopsy taken before CRT and MFG-E8 expression level in the specimens obtained at the time of the surgery after CRT were examined using immunohistochemical staining, and their association with clinicopathological characteristics, including patient survival, was determined. The tumors with more CD8+ TILs in the biopsy samples before CRT showed a significantly more favorable CRT response. The patients with tumors and a higher number of CD8+ TILs before CRT also exhibited significantly longer disease-free and overall survival times. Higher MFG-E8 expression level in post-CRT specimens was significantly associated with favorable CRT response; however, no significant association was found with any other clinicopathological characteristics, including survival time. The number of CD8+ TILs before CRT was a valuable predictor for CRT response and was associated with favorable prognosis in patients with lower rectal cancer and who were treated with CRT. High MFG-E8 expression level after CRT was also associated with a favorable CRT response.
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Affiliation(s)
- Yuzo Harada
- Division of Surgical Oncology, Department of Surgery, Faculty of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Shinsuke Kazama
- Division of Surgical Oncology, Department of Surgery, Faculty of Medicine, The University of Tokyo, Tokyo 113-8655, Japan.,Department of Gastroenterological Surgery, Saitama Cancer Center, Saitama 362-0806, Japan
| | - Teppei Morikawa
- Department of Pathology, NTT Medical Center Tokyo, Tokyo 141-8625, Japan
| | - Hirofumi Sonoda
- Division of Surgical Oncology, Department of Surgery, Faculty of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Hiroaki Ishi
- Division of Surgical Oncology, Department of Surgery, Faculty of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Shigenobu Emoto
- Division of Surgical Oncology, Department of Surgery, Faculty of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Koji Murono
- Division of Surgical Oncology, Department of Surgery, Faculty of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Manabu Kaneko
- Division of Surgical Oncology, Department of Surgery, Faculty of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Kazuhito Sasaki
- Division of Surgical Oncology, Department of Surgery, Faculty of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Yasutaka Shuno
- Division of Surgical Oncology, Department of Surgery, Faculty of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Takeshi Nishikawa
- Division of Surgical Oncology, Department of Surgery, Faculty of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Toshiaki Tanaka
- Division of Surgical Oncology, Department of Surgery, Faculty of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Kazushige Kawai
- Division of Surgical Oncology, Department of Surgery, Faculty of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Keisuke Hata
- Division of Surgical Oncology, Department of Surgery, Faculty of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Hiroaki Nozawa
- Division of Surgical Oncology, Department of Surgery, Faculty of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Tetsuo Ushiku
- Department of Pathology, The University of Tokyo, Tokyo 113-8655, Japan
| | - Hideaki Tahara
- Project Division of Cancer Biomolecular Therapy, Institute of Medical Science, The University of Tokyo, Tokyo 108-8639, Japan.,Department of Cancer Drug Discovery and Development Project, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Soichiro Ishihara
- Division of Surgical Oncology, Department of Surgery, Faculty of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
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Calmels M, Collard MK, Cazelles A, Frontali A, Maggiori L, Panis Y. Local excision after neoadjuvant chemoradiotherapy versus total mesorectal excision: a case-matched study in 110 selected high-risk patients with rectal cancer. Colorectal Dis 2020; 22:1999-2007. [PMID: 32813899 DOI: 10.1111/codi.15323] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 08/10/2020] [Indexed: 02/08/2023]
Abstract
AIM The aim of this comparative study was to report a 10-year experience of an organ preservation strategy by local excision (LE) in selected high-risk patients (aged patients and/or patients with severe comorbidity and/or indication for abdominoperineal excision) versus total mesorectal excision (TME) after neoadjuvant radiochemotherapy (RCT) for patients with locally advanced (T3-T4 and/or N+) low and mid rectal cancer with suspicion of complete tumour response (CTR) or near-CTR. METHOD Thirty-nine patients with rectal cancer who underwent LE after RCT for suspicion of CTR were matched to 71 patients who underwent TME according to body mass index, gender, tumour location and ypTNM stage. Operative, oncological and functional results were compared between groups. RESULTS In the LE group, ypT0, ypTis or ypT1N0R0 were noted in 28/39 (72%). Overall morbidity was observed in 10/39 (26%) in LE vs 46/71 in the TME group (65%) (P = 0.001). Severe morbidity (Clavien-Dindo ≥ 3) was noted in 1/39 patients from the LE group (3%) vs 3/71 (4%) from the TME group (P = 1.000). After a mean follow-up of 63 ± 4 months (range 56-70 months), local recurrence was noted in 2/39 (5%) from the LE group vs 2/71 (3%) from the TME group (P = 0.601). Definitive stoma was noted in 2/39 (6%) from the LE group vs 8/71 (12%) from the TME group (P = 0.489). Major low anterior resection syndrome was noted in 5/23 (22%) from LE group vs 11/33 (33%) from the TME group (P = 0.042). CONCLUSION The accuracy of response prediction after RCT was 72% after LE. In high-risk patients, LE represents a safe alternative to TME with better functional results and the same long-term oncological outcome.
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Affiliation(s)
- M Calmels
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Denis Diderot (Paris VII), Clichy Cedex, France
| | - M K Collard
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Denis Diderot (Paris VII), Clichy Cedex, France
| | - A Cazelles
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Denis Diderot (Paris VII), Clichy Cedex, France
| | - A Frontali
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Denis Diderot (Paris VII), Clichy Cedex, France
| | - L Maggiori
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Denis Diderot (Paris VII), Clichy Cedex, France
| | - Y Panis
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Denis Diderot (Paris VII), Clichy Cedex, France
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11
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The Elevated Pre-Treatment C-Reactive Protein Predicts Poor Prognosis in Patients with Locally Advanced Rectal Cancer Treated with Neo-Adjuvant Radiochemotherapy. Diagnostics (Basel) 2020; 10:diagnostics10100780. [PMID: 33023215 PMCID: PMC7601888 DOI: 10.3390/diagnostics10100780] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/21/2020] [Accepted: 09/30/2020] [Indexed: 01/08/2023] Open
Abstract
The aim of the present study was to investigate the association of the pre-treatment C-reactive protein (CRP) plasma level with survival outcomes in a cohort of 423 consecutive patients with locally advanced rectal cancer treated with neo-adjuvant radiochemotherapy followed by surgical resection. To evaluate the prognostic value of the CRP level for clinical endpoints recurrence-free survival (RFS), local-regional control (LC), metastases-free survival (MFS), and overall survival (OS), uni- and multivariate Cox regression analyses were applied, and survival rates were calculated using Kaplan–Meier analysis. The median follow-up time was 73 months. In univariate analyses, the pre-treatment CRP level was a significant predictor of RFS (hazard ratio (HR) 1.015, 95% CI 1.006–1.023; p < 0.001), LC (HR 1.015, 95% CI 1.004–1.027; p = 0.009), MFS (HR 1.014, 95% CI 1.004–1.023; p = 0.004), and OS (HR 1.016, 95% CI 1.007–1.024; p < 0.001). Additionally, univariate analysis identified the MRI circumferential resection margin (mrCRM) and pre-treatment carcinoembryonic antigen (CEA) as significant predictor of RFS (HR 2.082, 95% CI 1.106–3.919; p = 0.023 and HR 1.005, 95% CI 1.002–1.008; p < 0.001). Univariate analysis also revealed a significant association of the mrCRM (HR 2.089, 95% CI 1.052–4.147; p = 0.035) and CEA (HR 1.006, 95% CI 1.003–1.008; p < 0.001) with MFS. Age and CEA were prognostic factors for OS (HR 1.039, 95% CI 1.013–1.066; p = 0.003 and HR 1.005, 95% CI 1.002–1.008; p < 0.001). In multivariate analysis that included parameters with a p-level < 0.20 in univariate analysis, the pre-treatment CRP remained a significant prognostic factor for RFS (HR 1.013, 95%CI 1.001–1.025; p = 0.036), LC (HR 1.014, 95% CI 1.001–1.027; p = 0.031), and MFS (HR 1.013, 95% CI 1.000–1.027; p = 0.046). The results support the hypothesis that an elevated pre-treatment CRP level is a predictor of poor outcome. If confirmed by additional studies, this easily measurable biomarker could contribute to the identification of patients who might be candidates for more aggressive local or systemic treatment approaches or the administration of anti-inflammatory drugs.
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12
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Partl R, Magyar M, Hassler E, Langsenlehner T, Kapp KS. Clinical parameters predictive for sphincter-preserving surgery and prognostic outcome in patients with locally advanced low rectal cancer. Radiat Oncol 2020; 15:99. [PMID: 32375894 PMCID: PMC7203844 DOI: 10.1186/s13014-020-01554-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 04/27/2020] [Indexed: 02/06/2023] Open
Abstract
Background Although controversial, there are data suggesting that clinical parameters can predict the probability of sphincter preserving procedures in rectal cancer. The purpose of this study was to investigate the association between clinical parameters and the sphincter-preserving surgery rate in patients who had undergone neoadjuvant combination therapy for advanced low rectal cancer. Methods In this single center study, the charts of 540 patients with locally advanced rectal cancer who had been treated with induction chemotherapy-and/or neoadjuvant concomitant radiochemotherapy (nRCT) over an 11-year period were reviewed in order to identify patients with rectal cancer ≤6 cm from the anal verge, who had received the prescribed nRCT only. Univariate and multivariate analyses were used to identify pretreatment patient- and tumor associated parameters correlating with sphincter preservation. Survival rates were calculated using Kaplan-Meier analyses. Results Two hundred eighty of the 540 patients met the selection criteria. Of the 280 patients included in the study, 158 (56.4%) underwent sphincter-preserving surgery. One hundred sixty-four of 280 patients (58.6%) had a downsizing of the primary tumor (ypT < cT) and 39 (23.8%) of these showed a complete histopathological response (ypT0 ypN0). In univariate analysis, age prior to treatment, Karnofsky performance status, clinical T-size, relative lymphocyte value, CRP value, and interval between nRCT and surgery, were significantly associated with sphincter-preserving surgery. In multivariate analysis, age (hazard ratio (HR) = 1.05, CI95%: 1.02–1.09, p = 0.003), relative lymphocyte value (HR = 0.94, CI95%: 0.89–0.99, p = 0.029), and interval between nRCT and surgery (HR = 2.39, CI95%: 1.17–4.88, p = 0.016) remained as independent predictive parameters. Conclusions These clinical parameters can be considered in the prognostication of sphincter-preserving surgery in case of low rectal adenocarcinoma. More future research is required in this area.
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Affiliation(s)
- Richard Partl
- Department of Therapeutic Radiology and Oncology, Medical University of Graz, Comprehensive Cancer Center Graz (CCC), Auenbruggerplatz 32, 8036, Graz, Austria.
| | - Marton Magyar
- Division of Neuroradiology, Vascular and Interventional Radiology, Medical University of Graz, Comprehensive Cancer Center Graz (CCC), Auenbruggerplatz 9, 8036, Graz, Austria
| | - Eva Hassler
- Division of Neuroradiology, Vascular and Interventional Radiology, Medical University of Graz, Comprehensive Cancer Center Graz (CCC), Auenbruggerplatz 9, 8036, Graz, Austria
| | - Tanja Langsenlehner
- Department of Therapeutic Radiology and Oncology, Medical University of Graz, Comprehensive Cancer Center Graz (CCC), Auenbruggerplatz 32, 8036, Graz, Austria
| | - Karin Sigrid Kapp
- Department of Therapeutic Radiology and Oncology, Medical University of Graz, Comprehensive Cancer Center Graz (CCC), Auenbruggerplatz 32, 8036, Graz, Austria
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13
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Cosimelli M, Ursi P, Mancini R, Pattaro G, Perri P, Parrino C, De Peppo V, Diodoro MG, Balla A, Grazi GL. Organ-saving surgery for rectal cancer after neoadjuvant chemoradiation: Analysis of failures and long-term results. J Surg Oncol 2020; 121:375-381. [PMID: 31788805 DOI: 10.1002/jso.25794] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 11/25/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND To analyze long-term results and risk of relapse in the clinical TNM stages II and III, mid-low rectal cancer patients (RC pts), treated with transanal local excision (LE) after major response to neoadjuvant chemoradiation (n-CRT). METHODS Thirty-two out of 345 extraperitoneal cT3-4 or N+ RC pts (9.3%) underwent LE. INCLUSION CRITERIA extraperitoneal RC, adenocarcinoma, ECOG Performance Status ≤2. Pts with distant metastases were excluded. RESULTS All pts showed histologically clear margins of resection and 81.2% were restaged ypT0/mic/1. Nine out of 32 (28.1%) pts relapsed: 7 (21.8%) showed a local recurrence, of which 5 (15.6%) at the endorectal suture, 1 (3.1%) pelvic and 1 (3.1%) mesorectal. Two pts (6.2%) relapsed distantly. Among the pT0/1, 11.5% relapsed vs 100% of the pT2 and pT4 ones. The six pts relapsing locally or in the mesorectal fat underwent a salvage total mesorectal excision surgery. The old patient with pelvic recurrence relapsed after 108 months and underwent a re-irradiation; the two pts with distant metastases were treated with chemotherapy followed by radical surgery. CONCLUSIONS Presently combined approach seems a valid option in major responders, confirming its potential curative impact in the ypT0/mic/1 pts. A strict selection of pts is basic to obtain favourable results.
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Affiliation(s)
- Maurizio Cosimelli
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Pietro Ursi
- Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Rome, Italy
| | - Raffaello Mancini
- Robotic General Surgery Unit, San Giovanni Addolorata Hospital, Rome, Italy
| | - Giada Pattaro
- Department of General Surgery, S.M. Goretti Hospital, Latina, Italy
| | - Pasquale Perri
- Division of General and HepatoPancreatoBiliary Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Chiara Parrino
- Division of General and HepatoPancreatoBiliary Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Valerio De Peppo
- Division of General and HepatoPancreatoBiliary Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Maria Grazia Diodoro
- Department of Pathology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Andrea Balla
- Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Rome, Italy
| | - Gian Luca Grazi
- Division of General and HepatoPancreatoBiliary Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy
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14
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Peacock O, Chang GJ. "Watch and Wait" for complete clinical response after neoadjuvant chemoradiotherapy for rectal cancer. MINERVA CHIR 2019; 74:481-495. [PMID: 31580047 DOI: 10.23736/s0026-4733.19.08184-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The management of rectal cancer has evolved substantially over recent decades, becoming increasingly complex. This was once a disease associated with high mortality and limited treatment options that typically necessitated a permanent colostomy, has now become a model for multidisciplinary evaluation, treatment and surgical advancement. Despite advances in the rates of total mesorectal excision, decreased local recurrence and increased 5-year survival rates, the multimodal treatment of rectal cancer is associated with a significant impact on long-term functional and quality of life outcomes including risks of bowel, bladder and sexual dysfunction, and potential need for a permanent stoma. There is great interest in strategies to decrease the toxicity of treatment, including selective use of radiation, chemotherapy or even surgery. The modern concept of selective use of surgery for patients with rectal cancer are based on the observed pathological complete response in approximately 10-20% of patients following long-course chemoradiation therapy. While definitive surgical resection remains the standard of care for all patients with non-metastatic rectal cancer, a growing number of studies are providing supportive evidence for a watch-and-wait, organ preserving approach in highly selected patients with rectal cancer. However, questions regarding the heterogeneity of patient selection, optimal method for inducing pathological complete response, methods and intervals for assessing treatment response and adequacy of follow-up remain unanswered. The aim of this review is to provide an up-to-date summary of the current evidence for the watch-and-wait management of rectal cancer following a complete clinical response after neoadjuvant chemoradiation.
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Affiliation(s)
- Oliver Peacock
- Colorectal Surgical Oncology, University of Texas MD Anderson Cancer Centre, Houston, TX, USA
| | - George J Chang
- Colorectal Surgical Oncology, University of Texas MD Anderson Cancer Centre, Houston, TX, USA -
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15
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Kim JY, Park SG, Kim KS, Choi YH, Kim NK. The Krüppel-like factor (KLF5) as a predictive biomarker in preoperative chemoradiation therapy for rectal cancer. Ann Surg Treat Res 2019; 97:83-92. [PMID: 31388510 PMCID: PMC6669127 DOI: 10.4174/astr.2019.97.2.83] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 05/17/2019] [Accepted: 06/07/2019] [Indexed: 02/06/2023] Open
Abstract
Purpose Preoperative chemoradiation therapy (CRT) has become the standard treatment for patients with locally advanced rectal cancer, 15%–30% of patients still progress while being treated with CRT. The aim of this study was to identify as important biomarker of poor response and evaluate the mechanism associated with CRT resistance. Methods This study included 60 human colon tumour pre-irradiation specimens. Expressions of epidermal growth factor receptor (EGFR), p53, Krüppel-like factor 5 (KLF5), C-ern, Ki67 were assessed and correlated with tumor regression grades and complete remission. We added in vitro study with biomarker which has been identified as important biomarker of poor response to evaluate the mechanism associated with CRT resistance. Results Pathologic complete remission (pCR) was achieved by 9 patients (18%). EGFR and KLF5 were significantly associated with pCR (P = 0.048, P = 0.023, respectfully). And multivariate analysis showed high KLF5 intensity was worse factor for pCR (P = 0.012). In vitro study, radiation or chemotherapy therapy stabilized KLF5 protein levels in a time- and dose-depended manner in HCT116 and Caco-2 cells. KLF5 overexpression in HCT116 stable cell line showed significantly better cell viability by increasing cyclinD1 and b-catenin compared to control cells in MTT (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide) assay, suggesting that KLF5 mediates cell survival. Conclusion KLF5 was significantly associated with the presence of KRAS mutations, and KLF5 was an independent poor response predictor of CRT in rectal cancer. Our study is pilot study and more research will be needed in the future.
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Affiliation(s)
- Jeong Yeon Kim
- Department of Surgery, Colorectal Cancer Special Clinic, University Health System, Yonsei University College of Medicine, Seoul, Korea.,Department of Surgery, Dongtan Sacred Heart Hospital, Hallym University Medical Center, Hwasung, Korea
| | - Sung Gil Park
- Department of Surgery, Dongtan Sacred Heart Hospital, Hallym University Medical Center, Hwasung, Korea
| | - Kyung-Sub Kim
- Department of Biochemistry, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Hee Choi
- Department of Pathology, Hangang Sacred Heart Hospital, Hallym University Medical Center, Seoul, Korea
| | - Nam Kyu Kim
- Department of Surgery, Colorectal Cancer Special Clinic, University Health System, Yonsei University College of Medicine, Seoul, Korea
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16
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Ryan ÉJ, O'Sullivan DP, Kelly ME, Syed AZ, Neary PC, O'Connell PR, Kavanagh DO, Winter DC, O'Riordan JM. Meta-analysis of the effect of extending the interval after long-course chemoradiotherapy before surgery in locally advanced rectal cancer. Br J Surg 2019; 106:1298-1310. [PMID: 31216064 DOI: 10.1002/bjs.11220] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 03/27/2019] [Accepted: 04/01/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND The current standard of care in locally advanced rectal cancer (LARC) is neoadjuvant long-course chemoradiotherapy (nCRT) followed by total mesorectal excision (TME). Surgery is conventionally performed approximately 6-8 weeks after nCRT. This study aimed to determine the effect on outcomes of extending this interval. METHODS A systematic search was performed for studies reporting oncological results that compared the classical interval (less than 8 weeks) from the end of nCRT to TME with a minimum 8-week interval in patients with LARC. The primary endpoint was the rate of pathological complete response (pCR). Secondary endpoints were recurrence-free survival, local recurrence and distant metastasis rates, R0 resection rates, completeness of TME, margin positivity, sphincter preservation, stoma formation, anastomotic leak and other complications. A meta-analysis was performed using the Mantel-Haenszel method. RESULTS Twenty-six publications, including four RCTs, with 25 445 patients were identified. A minimum 8-week interval was associated with increased odds of pCR (odds ratio (OR) 1·41, 95 per cent c.i. 1·30 to 1·52; P < 0·001) and tumour downstaging (OR 1·18, 1·05 to 1·32; P = 0·004). R0 resection rates, TME completeness, lymph node yield, sphincter preservation, stoma formation and complication rates were similar between the two groups. The increased rate of pCR translated to reduced distant metastasis (OR 0·71, 0·54 to 0·93; P = 0·01) and overall recurrence (OR 0·76, 0·58 to 0·98; P = 0·04), but not local recurrence (OR 0·83, 0·49 to 1·42; P = 0·50). CONCLUSION A minimum 8-week interval from the end of nCRT to TME increases pCR and downstaging rates, and improves recurrence-free survival without compromising surgical morbidity.
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Affiliation(s)
- É J Ryan
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - D P O'Sullivan
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
| | - M E Kelly
- Surgical Professorial Unit, St Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - A Z Syed
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
| | - P C Neary
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland.,School of Medicine, Trinity College Dublin, University of Dublin, Dublin, Ireland
| | - P R O'Connell
- Surgical Professorial Unit, St Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - D O Kavanagh
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland.,School of Medicine, Trinity College Dublin, University of Dublin, Dublin, Ireland
| | - D C Winter
- Surgical Professorial Unit, St Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - J M O'Riordan
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland.,School of Medicine, Trinity College Dublin, University of Dublin, Dublin, Ireland
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17
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Yang Y, Liu Q, Jia B, Du X, Dai G, Liu H, Chen J, Zeng M, Wen K, Zhu Y, Wang Y, Feng L. Preoperative Volumetric Modulated Arc Therapy With Simultaneous Integrated Boost for Locally Advanced Distal Rectal Cancer. Technol Cancer Res Treat 2019; 18:1533033818824367. [PMID: 30803368 PMCID: PMC6373990 DOI: 10.1177/1533033818824367] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The aim of this study was to evaluate the safety and clinical efficacy of a combined preoperative regimen consisting of volumetric modulated arc therapy–simultaneous integrated boost and capecitabine chemotherapy for distal rectal cancer. A total of 26 patients with locally advanced distal rectal cancer were enrolled from March 2015 to May 2016. The radiation dose fractionation was 58.75 Gy/25 fractions (2.35 Gy/fraction) for rectal tumor and pelvic lymph node metastasis and 50 Gy/25 fractions for pelvic lymph node stations, accompanied with simultaneous capecitabine chemotherapy. Completion of the simultaneous chemotherapy was ensued by 1 week of rest and then another cycle of induction chemotherapy with capecitabine. A radical rectal cancer surgery was performed 6 to 8 weeks after the simultaneous chemoradiotherapy. The primary end points were the complete pathological response rate and the postoperative sphincter preservation rate. All 26 patients completed the neoadjuvant chemoradiotherapy, among which 25 received surgical treatment. The postoperative complete pathological response rate was as high as 32% (8/25), while the sphincter preservation rate was 60% (15/25), the overall tumor/node (T/N) downstaging rate was 92% (23/25), and the R0 resection rate was 100%. During the chemoradiation, the most common adverse events were grade 1 and 2; grade 3 radiodermatitis occurred in 2 cases but no occurrence of acute adverse events occurred that were grade 4 and above. After the surgery, there was one case of ureteral injury and one case of intestinal obstruction, but no perioperative deaths occurred. In conclusion, the chemoradiation regimen of preoperative volumetric modulated arc therapy-simultaneous integrated boost (VMAT-SIB58.75Gy) and a single cycle of induction chemotherapy with capecitabine for patients with distal rectal cancer is safe and feasible with a satisfactory complete pathological response rate, sphincter preservation rate, and R0 resection rate.
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Affiliation(s)
- Yongqiang Yang
- 1 Department of Radiotherapy & Oncology, the Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Qiteng Liu
- 2 Department of Radiation Oncology, Beijing Luhe Hospital, Affiliated to Capital Medical University, Beijing, China
| | - Baoqing Jia
- 3 Department of Surgical Oncology, Chinese PLA General Hospital, Beijing, China
| | - Xiaohui Du
- 4 Department of General Surgery, Chinese PLA General Hospital, Beijing, China
| | - Guanghai Dai
- 5 Department of Medical Oncology, Chinese PLA General Hospital, Beijing, China
| | - Hongyi Liu
- 3 Department of Surgical Oncology, Chinese PLA General Hospital, Beijing, China
| | - Jing Chen
- 6 Department of Radiation Oncology, Chinese PLA General Hospital, Beijing, China
| | - Mingyue Zeng
- 6 Department of Radiation Oncology, Chinese PLA General Hospital, Beijing, China
| | - Ke Wen
- 7 Department of Radiation Oncology, Chinese PLA 302 Hospital, Beijing, China
| | - Yaqun Zhu
- 1 Department of Radiotherapy & Oncology, the Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Yunlai Wang
- 6 Department of Radiation Oncology, Chinese PLA General Hospital, Beijing, China
| | - Linchun Feng
- 6 Department of Radiation Oncology, Chinese PLA General Hospital, Beijing, China
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18
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Cattapan K, Chulroek T, Wancharoenrung D, Kordbacheh H, Harisinghani M. Can MR imaging be useful in differentiating low rectal cancer from anal cancer? Abdom Radiol (NY) 2019; 44:438-445. [PMID: 30171293 DOI: 10.1007/s00261-018-1759-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE To evaluate the role of pelvic MR imaging in differentiating between low rectal and anal cancers using the pathological results as the gold standard. MATERIALS AND METHODS In this study, retrospective analysis of 100 patients with a history of low rectal (n = 50) or anal (n = 50) cancers who underwent staging pelvic MR imaging before treatment was performed. The following parameters were analyzed: distance from the anal verge to the tumor, percentage of tumor above puborectalis muscle, tumor size, T2W signal intensity, sphincter/levator muscles invasion, organ invasion, and MRI diagnosis. Multivariable logistic regression was performed to determine factors associated with low rectal and anal cancers. Distances from the anal verge to the tumor were compared using receiver-operating characteristic (ROC) curves. RESULTS From the ROC curves, the cut-off value for the distance from the anal verge to the tumor in differentiating between low rectal and anal cancers was 2.1 cm and the area under the ROC curve was 0.90 (95% CI 0.84-0.97). Multivariate logistic regression revealed three significant factors in differentiating between low rectal and anal cancers, including T2 mixed hyper- and hyposignal intensity (OR 66.00, 95% CI 4.66-934.81), distance cut-off value (OR 34.72, 95% CI 5.73-210.27), and absence of sphincter invasion (OR 18.75, 95% CI 1.91-183.96), with sensitivity, specificity, PPV, and NPV of 98%, 88%, 89%, and 97%, respectively, and diagnostic accuracy increased from 79% (reader 1) and 82% (reader 2) to 93%. CONCLUSION MR imaging can be useful to differentiating between low rectal and anal cancers which benefits staging and treatment planning.
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Affiliation(s)
- Kamonwon Cattapan
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, White 270, Boston, MA, 02114, USA
- Department of Radiology, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Thitinan Chulroek
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, White 270, Boston, MA, 02114, USA
- Department of Diagnostic Radiology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Dearada Wancharoenrung
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, White 270, Boston, MA, 02114, USA
- Department of Diagnostic Radiology, Faculty of Medicine, Vajira Hospital, Nawamindradhiraj University, Bangkok, Thailand
| | - Hamed Kordbacheh
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, White 270, Boston, MA, 02114, USA
| | - Mukesh Harisinghani
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, White 270, Boston, MA, 02114, USA.
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19
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Harada Y, Kazama S, Morikawa T, Emoto S, Murono K, Kaneko M, Sasaki K, Otani K, Nishikawa T, Tanaka T, Kiyomatsu T, Kawai K, Hata K, Nozawa H, Ishihara S, Watanabe T. Prognostic impact of doublecortin-like kinase 1 expression in locally advanced rectal cancer treated with preoperative chemoradiotherapy. APMIS 2018; 126:486-493. [DOI: 10.1111/apm.12852] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 04/30/2018] [Indexed: 12/16/2022]
Affiliation(s)
- Yuzo Harada
- Division of Surgical Oncology; Department of Surgery; Faculty of Medicine; The University of Tokyo; Tokyo Japan
| | - Shinsuke Kazama
- Division of Surgical Oncology; Department of Surgery; Faculty of Medicine; The University of Tokyo; Tokyo Japan
- Department of Gastroenterological Surgery; Saitama Cancer Center; Saitama Japan
| | - Teppei Morikawa
- Department of Pathology; The University of Tokyo; Tokyo Japan
| | - Shigenobu Emoto
- Division of Surgical Oncology; Department of Surgery; Faculty of Medicine; The University of Tokyo; Tokyo Japan
| | - Koji Murono
- Division of Surgical Oncology; Department of Surgery; Faculty of Medicine; The University of Tokyo; Tokyo Japan
| | - Manabu Kaneko
- Division of Surgical Oncology; Department of Surgery; Faculty of Medicine; The University of Tokyo; Tokyo Japan
| | - Kazuhito Sasaki
- Division of Surgical Oncology; Department of Surgery; Faculty of Medicine; The University of Tokyo; Tokyo Japan
| | - Kensuke Otani
- Division of Surgical Oncology; Department of Surgery; Faculty of Medicine; The University of Tokyo; Tokyo Japan
| | - Takeshi Nishikawa
- Division of Surgical Oncology; Department of Surgery; Faculty of Medicine; The University of Tokyo; Tokyo Japan
| | - Toshiaki Tanaka
- Division of Surgical Oncology; Department of Surgery; Faculty of Medicine; The University of Tokyo; Tokyo Japan
| | - Tomomichi Kiyomatsu
- Division of Surgical Oncology; Department of Surgery; Faculty of Medicine; The University of Tokyo; Tokyo Japan
| | - Kazushige Kawai
- Division of Surgical Oncology; Department of Surgery; Faculty of Medicine; The University of Tokyo; Tokyo Japan
| | - Keisuke Hata
- Division of Surgical Oncology; Department of Surgery; Faculty of Medicine; The University of Tokyo; Tokyo Japan
| | - Hiroaki Nozawa
- Division of Surgical Oncology; Department of Surgery; Faculty of Medicine; The University of Tokyo; Tokyo Japan
| | - Soichiro Ishihara
- Division of Surgical Oncology; Department of Surgery; Faculty of Medicine; The University of Tokyo; Tokyo Japan
- Surgery Department; Sanno Hospital; International University of Health and Welfare; Tokyo Japan
| | - Toshiaki Watanabe
- Division of Surgical Oncology; Department of Surgery; Faculty of Medicine; The University of Tokyo; Tokyo Japan
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20
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Model predicting the ypN0 status after good response to chemoradiotherapy in rectal cancer. Am J Surg 2018; 216:438-443. [PMID: 29656991 DOI: 10.1016/j.amjsurg.2018.03.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 03/14/2018] [Accepted: 03/29/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND The purpose of this study was to identify the predictive factors for ypN0 status in tumors with good pathologic response to chemoradiotherapy (CRT). METHODS A retrospective chart review was conducted on patients at two tertiary cancer center who underwent rectal resection after good response to CRT between 2000 and 2013. RESULTS No preoperative treatment (oxaliplatin use, radiotherapy boost of 5,4 Gy, delay CRT-surgery) impacted on the ypN status. In the multivariate analysis, only a ypT<3 (HR 7.5 [2,9-19.5]) was significant and no lymphovascular invasion (HR 8,9 [1.6-49.8]) was limited to significance.The best model predicting the ypN0 status used only the ypT status<3. The major part (92.2%) of patients with ypT0-2 tumors had no LN invasion. CONCLUSION The risk of lymph node involvement metastases was only 7.8% for the patients with an ypT0-2 status. A fullthickness transanal resection coud be the futur treatment of these patients.
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Lin JZ, Peng JH, Qdaisat A, Lu ZH, Wu XJ, Chen G, Ding PR, Li LR, Gao YH, Zeng ZF, Wan DS, Pan ZZ. Preoperative chemoradiotherapy creates an opportunity to perform sphincter preserving resection for low-lying locally advanced rectal cancer based on an oncologic outcome study. Oncotarget 2018; 7:57317-57326. [PMID: 27374175 PMCID: PMC5302992 DOI: 10.18632/oncotarget.10303] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 06/02/2016] [Indexed: 11/25/2022] Open
Abstract
Low-lying locally advanced rectal cancer (LARC) after preoperative chemoradiotherapy (CRT) can be surgically removed by either abdominperineal resection (APR) or sphincter preserving resection (SPR). This retrospective cohort study of 251 consecutive patients with low lying LARC who underwent CRT followed by radical surgery in a single institute, between March 2003 and November 2012, aimed to compare the oncological benefits between the two groups. 3-year disease free survival (DFS), overall survival (OS), cumulative incidence of recurrence and postoperative complications were compared between the two approaches. With median follow-up of 48.6 months, SPR group had higher 3-year DFS rate (86.4% vs 73.6%, P=0.023) and lower incidence of distant recurrence (12.0% vs 23.7%, P=0.026). The postoperative complications, incidence of local recurrence and the 3-year OS were comparable between the two groups. Pathologic T and N stage were the independent predictors for 3-year DFS (P=0.020 and P<0.001). In conclusion, our study suggest that low-lying LARC patients with a significant response to preoperative CRT can benefit from the advantage of SPR in preserving the anal sphincter function without compromising their oncologic outcome.
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Affiliation(s)
- Jun-Zhong Lin
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, P.R. China
| | - Jian-Hong Peng
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, P.R. China
| | - Aiham Qdaisat
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Zhen-Hai Lu
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, P.R. China
| | - Xiao-Jun Wu
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, P.R. China
| | - Gong Chen
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, P.R. China
| | - Pei-Rong Ding
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, P.R. China
| | - Li-Ren Li
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, P.R. China
| | - Yuan-Hong Gao
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, P.R. China
| | - Zhi-Fan Zeng
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, P.R. China
| | - De-Sen Wan
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, P.R. China
| | - Zhi-Zhong Pan
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, P.R. China
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Gambacorta MA, Valentini V, Coco C, Manno A, Doglietto GB, Ratto C, Cosimelli M, Miccichè F, Maurizi F, Tagliaferri L, Mantini G, Balducci M, La Torre G, Barbaro B, Picciocchi A. Sphincter Preservation in Four Consecutive Phase II Studies of Preoperative Chemoradiation: Analysis of 247 T3 Rectal Cancer Patients. TUMORI JOURNAL 2018; 93:160-9. [PMID: 17557563 DOI: 10.1177/030089160709300209] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims and Background To evaluate the impact of preoperative chemoradiation on sphincter preservation in patients with low- medium locally advanced resectable rectal cancer treated by four chemoradiation schedules. Materials and Methods Between 1990 and 2002, 247 patients were treated according to four schedules of chemoradiotherapy: FUMIR (5-fluorouracil, mitomycin, external beam radiotherapy 37.8 Gy), PLAFUR (cisplatinum, 5-fluorouracil, external beam radiotherapy 50.4 Gy), TOMRT (raltitrexed, external beam radiotherapy 50.4 Gy), and TOMOXRT (raltitrexed, oxaliplatin, external beam radiotherapy 50.4 Gy). Four to five weeks after chemoradiation, patients were restaged and surgery was performed 2-3 weeks later. Results Overall, the sphincter-saving surgery was performed in 82.5% of patients. In patients candidate to an abdominoperineal resection before chemoradiaton (distance tumor-anorectal ring, <30 mm) a sphincter-saving surgery was possible in 58% of cases: 44% (FUMIR), 52% (PLAFUR), 63% (TOMRT), 76% (TOMOXRT) (P <0.017). The involved surgeons kept the same surgical criteria in performing sphincter-saving surgery. After chemoradiation, patients with tumor location still between 0 and 30 mm received sphincter-saving surgery according to the protocols: 33% (FUMIR), 42% (PLAFUR), 50% (TOMRT), 64% (TOMOXRT) (P = 0.066) Conclusions Even though the surgeons’ skill in performing sphincter-saving surgery could be improved with time, the high rate of this procedure in the latest schedules suggests an impact of the new drugs in promoting tumor downsizing and therefore sphincter-saving surgery.
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Cunningham HB, Weis JJ, Taveras LR. Current Trends in the Rate of Rectal Cancer Restorative Operations in the Era of Neoadjuvant Chemoradiation. CURRENT COLORECTAL CANCER REPORTS 2018. [DOI: 10.1007/s11888-018-0400-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Du D, Su Z, Wang D, Liu W, Wei Z. Optimal Interval to Surgery After Neoadjuvant Chemoradiotherapy in Rectal Cancer: A Systematic Review and Meta-analysis. Clin Colorectal Cancer 2017; 17:13-24. [PMID: 29153429 DOI: 10.1016/j.clcc.2017.10.012] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 10/10/2017] [Accepted: 10/14/2017] [Indexed: 12/16/2022]
Abstract
This study aimed to evaluate the influence of a waiting interval of ≥ 8 weeks between the end of preoperative neoadjuvant chemoradiotherapy (nCRT) and surgery on the outcomes of patients with locally advanced rectal cancer. We conducted a comprehensive literature review of retrospective and prospective studies from PubMed, Embase, and Cochrane Library databases to investigate the length of the preoperative nCRT-surgery waiting interval and outcomes in patients with locally advanced rectal cancer. The primary outcome measure was pathologic complete response (pCR) rate. Secondary outcome measures included overall survival, disease-free survival, operative time, and the incidence of local recurrence, postoperative complications, anastomotic leakage, and sphincter-preserving surgery. Standardized mean differences and risk ratios were calculated. Thirteen studies involving 19,652 patients were included. The meta-analysis demonstrated that pCR was significantly increased in patients with locally advanced rectal cancer and a waiting interval of ≥ 8 weeks between preoperative nCRT and surgery compared to a waiting interval of < 8 weeks, or a waiting interval of > 8 weeks compared to ≤ 8 weeks (risk ratio = 1.25; 95% confidence interval, 1.16-1.35; P < .0001). There were no significant differences in overall survival, disease-free survival, operative time, or incidence of local recurrence, postoperative complications, or sphincter-preserving surgery. This study revealed that performing surgery after a waiting interval of ≥ 8 weeks after the end of preoperative nCRT is safe and efficacious for patients with locally advanced rectal cancer, significantly improving pCR without increasing operative time or incidence of postoperative complications, compared to a waiting interval of ≤ 8 weeks.
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Affiliation(s)
- Donglin Du
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhourong Su
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Dan Wang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wenwen Liu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhengqiang Wei
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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Lee YY, Wei YC, Tian YF, Sun DP, Sheu MJ, Yang CC, Lin LC, Lin CY, Hsing CH, Li WS, Li CF, Hsieh PL, Lin CY. Overexpression of Transcobalamin 1 is an Independent Negative Prognosticator in Rectal Cancers Receiving Concurrent Chemoradiotherapy. J Cancer 2017; 8:1330-1337. [PMID: 28638446 PMCID: PMC5479237 DOI: 10.7150/jca.18274] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 03/06/2017] [Indexed: 12/27/2022] Open
Abstract
Objective: Neoadjuvant concurrent chemoradiotherapy (CCRT) is an increasingly common therapeutic strategy for locally advanced rectal cancer, but stratification of risk and final outcomes remain a major challenge. Transcobalamin 1 (TCN1), a vitamin B12 (cobalamin)-binding protein, regulates cobalamin homeostasis. High expression of TCN1 have been reported in neoplasms such as breast cancer and hepatocellular carcinoma. However, little is known about the relevance of TCN1 to rectal cancer receiving CCRT. This study examined the predictive and prognostic impact of TCN1 expression in patients with rectal cancer following neoadjuvant CCRT. Methods: Through data mining from a published transcriptome of rectal cancers (GSE35452), we identified upregulation of TCN1 gene as the most significantly predicted poor response to CCRT among ion transport-related genes (GO:0006811). We evaluated TCN1 immunohistochemistry and performed an H-score analysis on endoscopic biopsy specimens from 172 rectal cancer patients receiving neoadjuvant CCRT followed by curative surgery. Expression levels of TCN1 were further correlated with clinicopathologic features, therapeutic response, tumor regression grade (TRG) and survivals including metastasis-free survival (MeFS), disease-specific survival (DSS) and recurrent-free survival (LRFS). Results: TCN1 overexpression was significantly related to advanced post-treatment tumor (T3, T4; p<0.001) and nodal status (N1, N2; p<0.001), vascular invasion (p=0.003) and inferior tumor regression grade (p < 0.001). In survival analyses, TCN1 overexpression was significantly associated with shorter DSS (p<0.0001), MeFS (p=0.0002) and LRFS (p=0.0001). Furthermore, it remained an independent prognosticator of worse DSS (p=0.002, hazard ratio=3.344), MeFS (p=0.021, hazard ratio=3.015) and LRFS (p=0.037, hazard ratio=3.037) in the multivariate comparison. Conclusion: Overexpression of TCN1 is associated with poor therapeutic response and adverse outcomes in rectal cancer patients receiving CCRT, justifying the potential prognostic value of TCN1 in rectal cancer receiving CCRT.
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Affiliation(s)
- Yi-Ying Lee
- Department of Pathology, Chi Mei Medical Center, Liouying, Tainan, Taiwan
- Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Yu-Ching Wei
- Department of Pathology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
| | - Yu-Feng Tian
- Division of General Surgery, Department of Surgery, Chi Mei Medical Center, Tainan, Taiwan
- Department of Health & Nutrition, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Ding-Ping Sun
- Division of General Surgery, Department of Surgery, Chi Mei Medical Center, Tainan, Taiwan
- Department of Pharmacy, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Ming-Jen Sheu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Ching-Chieh Yang
- Department of Radiation Oncology, Chi Mei Medical Center, Tainan, Taiwan
| | - Li-Ching Lin
- Department of Radiation Oncology, Chi Mei Medical Center, Tainan, Taiwan
| | - Chen-Yi Lin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Chung-Hsi Hsing
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
| | - Wan-Shan Li
- Department of Pathology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chien-Feng Li
- Department of Pathology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Pathology, Chi Mei Medical Center, Tainan, Taiwan
- National Institute of Cancer Research, National Health Research Institutes, Tainan, Taiwan
- Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Pei-Ling Hsieh
- Department of Medical Image, Chi Mei Medical Center, Tainan, Taiwan
| | - Ching-Yih Lin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
- Department of Leisure, Recreation, and Tourism Management, Southern Taiwan
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Kang DW, Kwak HD, Sung NS, Yang IS, Baek SJ, Kwak JM, Kim J, Kim SH. Oncologic outcomes in rectal cancer patients with a ≤1-cm distal resection margin. Int J Colorectal Dis 2017; 32:325-332. [PMID: 27900522 DOI: 10.1007/s00384-016-2708-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/18/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE Recently, common application of sphincter-saving resection in rectal cancer has led to acceptance of a 1-cm distal resection margin (DRM). The aim of this study was to evaluate oncologic outcomes of a DRM ≤1 cm in sphincter-saving resection for rectal cancer. The outcomes of a DRM ≤0.5 cm was also evaluated. METHODS We reviewed prospectively collected data from 415 patients who underwent sphincter-saving resection for mid and low rectal cancer between September 2006 and December 2012 at Korea University Anam Hospital. Patients were divided into two groups according to DRM measured in a formalin fixed specimen: ≤1 cm (n = 132) and >1 cm (n = 283). The DRM ≤1 cm group was divided into two subgroups: ≤0.5 cm (n = 45) and >0.5, ≤1 cm (n = 87). RESULTS Median follow-up periods were 47.2 months. The 5-year local recurrence rate was 8.8% in the DRM ≤1 cm group and 8.5% in the DRM >1 cm group (p = 0.630). The 5-year disease-free survival rate was 75.1 and 76.3% (p = 0.895), and the 5-year overall survival rate was 82.6 and 85.9% (p = 0.401), respectively. In subanalysis of the DRM ≤1 cm group, there was also no significant difference in the local recurrence and survival. CONCLUSIONS There was no significant difference in local recurrence and survival based on DRM length. We found that DRM length less than 1 cm was not a prognostic factor for local recurrence or survival.
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Affiliation(s)
- Dong Woo Kang
- Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, Seoul, 136-705, South Korea
| | - Han Deok Kwak
- Division of Colorectal Surgery, Department of Surgery, Chonnam National University Hospital, Chonnam National University College of Medicine, Gwangju, South Korea
| | - Nak Song Sung
- Division of Colorectal Surgery, Department of Surgery, Konyang University Hospital, Konyang University College of Medicine, Daejeon, South Korea
| | - In Soo Yang
- Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, Seoul, 136-705, South Korea
| | - Se Jin Baek
- Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, Seoul, 136-705, South Korea
| | - Jung Myun Kwak
- Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, Seoul, 136-705, South Korea
| | - Jin Kim
- Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, Seoul, 136-705, South Korea
| | - Seon Hahn Kim
- Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, Seoul, 136-705, South Korea.
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Cebrián A, Gómez Del Pulgar T, Fernández-Aceñero MJ, Borrero-Palacios A, Del Puerto-Nevado L, Martínez-Useros J, Marín-Arango JP, Caramés C, Vega-Bravo R, Rodríguez-Remírez M, Manzarbeitia F, García-Foncillas J. Decreased PLK1 expression denotes therapy resistance and unfavourable disease-free survival in rectal cancer patients receiving neoadjuvant chemoradiotherapy. Pathol Res Pract 2016; 212:1133-1137. [PMID: 27712975 DOI: 10.1016/j.prp.2016.09.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 05/02/2016] [Accepted: 09/19/2016] [Indexed: 12/12/2022]
Abstract
AIM Polo-like kinase 1 (Plk1) plays a key role in mitotic cell division and DNA damage repair. It has been observed that either up-regulated or down-regulated Plk1 could induce mitotic defects that results in aneuploidy and tumorigenesis, probably depending on the context. Few previous reports have associated Plk1 expression with prognosis and response to radiotherapy in rectal carcinomas. The aim of this study is to investigate the prognostic impact of Plk1 expression and its role in predicting response to neoadjuvant cheomoradiotherapy in rectal cancer. METHODS AND RESULTS Immunohistochemical analysis of Plk1 expression was performed in the pre-treatment tumour specimens from 75 rectal cancer patients. We analysed the assocation between Plk1 expression and clinicopathological parameters, pathologic response and outcome. Opposed to previous reports on this issue, low expression of Plk1 was significantly associated with a high grade of differentiation (P=0.0007) and higher rate of distant metastasis (P=0.014). More importantly, decreased levels of Plk1 were associated with absence of response after neoadjuvant therapy (P=0.049). Moreover, low Plk1 expression emerged as an unfavourable prognostic factor for disease-free survival in the non-responder group of patients (P=0.037). CONCLUSIONS Decreased Plk1 expression was associated with poor pathologic response and worse disease-free survival in rectal cancer patients receiving neoadjuvant chemoradiotherapy, suggesting Plk1 as a clinically relevant marker to predict chemoradiotherapy response and outcome.
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Affiliation(s)
- Arancha Cebrián
- Translational Oncology Division, Oncohealth Institute, Health Research Institute FJD-UAM, University Hospital "Fundacion Jimenez Diaz", 28040 Madrid Spain.
| | - Teresa Gómez Del Pulgar
- Translational Oncology Division, Oncohealth Institute, Health Research Institute FJD-UAM, University Hospital "Fundacion Jimenez Diaz", 28040 Madrid Spain
| | - Maria Jesús Fernández-Aceñero
- Pathology Department, Oncohealth Institute, Health Research Institute FJD-UAM, University Hospital "Fundacion Jimenez Diaz", 28040 Madrid Spain
| | - Aurea Borrero-Palacios
- Translational Oncology Division, Oncohealth Institute, Health Research Institute FJD-UAM, University Hospital "Fundacion Jimenez Diaz", 28040 Madrid Spain
| | - Laura Del Puerto-Nevado
- Translational Oncology Division, Oncohealth Institute, Health Research Institute FJD-UAM, University Hospital "Fundacion Jimenez Diaz", 28040 Madrid Spain
| | - Javier Martínez-Useros
- Translational Oncology Division, Oncohealth Institute, Health Research Institute FJD-UAM, University Hospital "Fundacion Jimenez Diaz", 28040 Madrid Spain
| | - Juan Pablo Marín-Arango
- Translational Oncology Division, Oncohealth Institute, Health Research Institute FJD-UAM, University Hospital "Fundacion Jimenez Diaz", 28040 Madrid Spain
| | - Cristina Caramés
- Translational Oncology Division, Oncohealth Institute, Health Research Institute FJD-UAM, University Hospital "Fundacion Jimenez Diaz", 28040 Madrid Spain
| | - Ricardo Vega-Bravo
- Pathology Department, Oncohealth Institute, Health Research Institute FJD-UAM, University Hospital "Fundacion Jimenez Diaz", 28040 Madrid Spain
| | - María Rodríguez-Remírez
- Translational Oncology Division, Oncohealth Institute, Health Research Institute FJD-UAM, University Hospital "Fundacion Jimenez Diaz", 28040 Madrid Spain
| | - Felix Manzarbeitia
- Pathology Department, Oncohealth Institute, Health Research Institute FJD-UAM, University Hospital "Fundacion Jimenez Diaz", 28040 Madrid Spain
| | - Jesús García-Foncillas
- Translational Oncology Division, Oncohealth Institute, Health Research Institute FJD-UAM, University Hospital "Fundacion Jimenez Diaz", 28040 Madrid Spain
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Baral J, Schön MR, Ruppert R, Ptok H, Strassburg J, Brosi P, Kreis ME, Lewin A, Sauer J, Sawicki S, Schiffmann L, Winde G, Junginger T, Merkel S, Hermanek P. [Spincter preservation after selective chemoradiotherapy of rectal cancer. Interim results of the OCUM study]. Chirurg 2016; 86:1138-44. [PMID: 26347011 DOI: 10.1007/s00104-015-0083-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND In a prospective multicenter observational study (OCUM) neoadjuvant chemoradiotherapy (nRCT) was selectively administered depending on the risk of local recurrence and based on the distance between tumor and mesorectal fascia in pretherapeutic high-resolution magnetic resonance imaging (MRI). OBJECTIVE Frequency and quality of abdominoperineal excision (APE) and sphincter preserving operations. PATIENTS AND METHODS Of 642 patients treated in 13 hospitals 389 received surgery alone and 253 nRCT followed by surgery. By univariate and multivariate analysis risk factors for APE were determined. Quality parameters were the quality grade of mesorectal excision, the pathohistological involvement of the circumferential resection margin and intraoperative local dissemination of tumor cells. RESULTS AND DISCUSSION In 12.8 % of the patients APE was performed. Independent risk factors for APE were tumor location in the lower third of the rectum and the individual hospitals, where APE varied between 0 and 32 %. This variation was chiefly caused by the different case mix. Hospitals with a high APE rate (> 30 %) treated significantly more patients with very low lying carcinomas (< 3 cm above the anal verge) and more advanced tumors. The median height of the tumor in cases of APE was nearly equal in all participating hospitals. Independent on the number of cases the quality of rectal surgery was high. Within the patient groups of primary surgery and nRCT the oncological quality parameter did not significantly differ between sphincter preservation and APE. As far as sphincter preservation is concerned the results justify a selective application of nRCT in patients with rectal carcinoma. The long-term results still have to be awaited.
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Affiliation(s)
- J Baral
- Chirurgische Klinik, Städtisches Klinikum, Karlsruhe, Deutschland
| | - M R Schön
- Chirurgische Klinik, Städtisches Klinikum, Karlsruhe, Deutschland
| | - R Ruppert
- Klinik Neuperlach, Klinik für Allgemein- und Viszeralchirurgie, Endokrine Chirurgie und Coloproktologie, Städtische Kliniken München, München, Deutschland
| | - H Ptok
- Klinik für Chirurgie, Carl-Thiem-Klinik, Cottbus, Deutschland
| | - J Strassburg
- Abteilung für Allgemein- und Viszeralchirurgie, Vivantes-Klinik im Friedrichshain, Berlin, Deutschland
| | - P Brosi
- Chirurgische Klinik, Kantonspital Liestal, Liestal, Schweiz
| | - M E Kreis
- Chirurgische Klinik I, Charité Campus Benjamin Franklin, Berlin, Deutschland
| | - A Lewin
- Allgemein- und Viszeralchirurgie, Sanaklinikum Berlin Lichtenberg, Berlin, Deutschland
| | - J Sauer
- Klinik für Allgemein-, Viszeral- und Minimalinvasive Chirurgie, Klinikum Arnsberg, Arnsberg, Deutschland
| | - S Sawicki
- Franziskus Hospital Bielefeld, Bielefeld, Deutschland
| | - L Schiffmann
- Klinik für Allgemein-, Unfall- Viszeral- und Plastische Chirurgie, Ev. Krankenhaus Lippstadt, Lippstadt, Deutschland
| | - G Winde
- Klinik für Allgemein- und Viszeralchirurgie, Thoraxchirurgie und Proktologie, Klinikum Herford, Herford, Deutschland
| | - T Junginger
- Klinik für Allgemein- und Abdominalchirurgie, Universitätsmedizin Mainz, Langenbeckstr.1, 55131, Mainz, Deutschland.
| | - S Merkel
- Chirurgische Klinik, Friedrich-Alexander-Universität, Erlangen-Nürnberg, Deutschland
| | - P Hermanek
- Chirurgische Klinik, Friedrich-Alexander-Universität, Erlangen-Nürnberg, Deutschland
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29
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Kaneko K, Kawai K, Kazama S, Murono K, Sasaki K, Yasuda K, Ohtani K, Nishikawa T, Tanaka T, Kiyomatsu T, Hata K, Nozawa H, Ishihara S, Morikawa T, Fukayama M, Watanabe T. Clinical significance of mucinous components in rectal cancer after preoperative chemoradiotherapy. Surg Today 2016; 47:697-704. [DOI: 10.1007/s00595-016-1419-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Accepted: 09/01/2016] [Indexed: 12/20/2022]
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30
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Park IJ, Yu CS, Lim SB, Lee JL, Kim CW, Yoon YS, Park SH, Kim JC. Is Preoperative Chemoradiotherapy Beneficial for Sphincter Preservation in Low-Lying Rectal Cancer Patients? Medicine (Baltimore) 2016; 95:e3463. [PMID: 27149445 PMCID: PMC4863762 DOI: 10.1097/md.0000000000003463] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The present study explored the benefit of preoperative chemoradiotherapy (PCRT) for sphincter preservation in locally advanced low-lying rectal cancer patients who underwent stapled anastomosis, especially in those with deep and narrow pelvises determined by magnetic resonance imaging.Patients with locally advanced low-lying rectal cancer (≤5 cm from the anal verge) who underwent stapled anastomosis were included. Patients were categorized into two groups (PCRT+ vs. PCRT-) according to PCRT application. Patients in the PCRT+ group were matched to those in the PCRT- group according to potential confounding factors (age, gender, clinical stage, and body mass index) for sphincter preservation. Sphincter preservation, permanent stoma, and anastomosis-related complications were compared between the groups. Pelvic magnetic resonance imaging was used to measure 12 dimensions representing pelvic cavity depth and width with which deep and narrow pelvis was defined. The impact of PCRT on sphincter preservation and permanent stoma in pelvic dimensions defined as deep and narrow pelvis was evaluated, and factors associated with sphincter preservation and permanent stoma were analyzed.One hundred sixty-six patients were one-to-one matched between the PCRT+ and PCRT- groups. Overall, sphincter-saving surgery was performed in 66.3% and the rates were not different between the 2 groups. Anastomotic complications and permanent stoma occurred nonsignificantly more frequently in the PCRT+ group. PCRT was not associated with higher rate of sphincter preservation in all pelvic dimensions defined as deep and narrow pelvis, while PCRT was related to higher rate of permanent stoma in shorter transverse diameter and interspinous distance. On logistic regression analysis, PCRT was not shown to influence both sphincter preservation and permanent stoma, while longer transverse diameter and interspinous distance were associated with lower rate of permanent stoma.PCRT had no beneficial effect on sphincter preservation in patients with locally advanced low-lying rectal cancer who had undergone stapled anastomosis. In patients with deep and narrow pelvis, PCRT had no impact on sphincter preservation but was associated with higher rate of permanent stoma.
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Affiliation(s)
- In Ja Park
- From the Department of Colon and Rectal Surgery (IJP, CSY, S-BL, JLL, CWK, YSY, JCK); and Department of Radiology (SHP), University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
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Travaini LL, Zampino MG, Colandrea M, Ferrari ME, Gilardi L, Leonardi MC, Santoro L, Orecchia R, Grana CM. PET/CT with Fluorodeoxyglucose During Neoadjuvant Chemoradiotherapy in Locally Advanced Rectal Cancer. Ecancermedicalscience 2016; 10:629. [PMID: 27110285 PMCID: PMC4817524 DOI: 10.3332/ecancer.2016.629] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Indexed: 12/18/2022] Open
Abstract
Objective The aim of the present study is to evaluate the accuracy of Positron Emission Tomography/Computed Tomography (PET/CT) with Fluorodeoxyglucose ([18F]FDG) to predict treatment response in patients with locally advanced rectal cancer (LARC) during neoadjuvant chemoradiotherapy. Patients and methods Forty-one LARC patients performed [18F]FDG-PET/CT at baseline (PET0). All patients received continuous capecitabine concomitant to radiotherapy on the pelvis, followed by intermittent capecitabine until two weeks before curative surgery. [18F]FDG-PET/CT was also carried out at 40 Gy-time (PET1) and at the end of neoadjuvant therapy (PET2). PET imaging was analysed semi-quantitatively through the measurement of maximal standardised uptake value (SUVmax) and the tumour volume (TV). Histology was expressed through pTNM and Dworak tumor regression grading. Patients were categorised into responder (downstaging or downsizing) and non-responder (stable or progressive disease by comparison pretreatment parameters with clinical/pathological characteristics posttreatment/after surgery). Logistic regression was used to evaluate SUVmax and TV absolute and percent reduction as predictors of response rate using gender, age, and CEA as covariates. Progression-free survival (PFS) and overall survival (OS) were estimated by the Kaplan-Meier method. Survivals were compared by the Log-Rank test. Results Twenty-three responders (9 ypCR, 14 with downstaged disease) and 18 non-responders showed differences in terms of both early and posttreatment SUVmax percent reduction (median comparison: responder = 63.2%, non-responder = 44.2%, p = 0.04 and responder = 76.9%, non-responder = 61.6%, p = 0.06 respectively). The best predictive cut-offs of treatment response for early and posttreatment SUVmax percent reduction were ≥57% and ≥66% from baseline (p = 0.02 and p = 0.01 respectively). Conclusions [18F]FDG-PET/CT is a reliable technique for evaluating therapy response during neoadjuvant treatment in LARC, through a categorical classification of the SUV max reduction during treatment.
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Affiliation(s)
- Laura L Travaini
- European Institute of Oncology, Via Ripamonti, 435 20141, Milan, Italy
| | - Maria G Zampino
- European Institute of Oncology, Via Ripamonti, 435 20141, Milan, Italy
| | - Marzia Colandrea
- European Institute of Oncology, Via Ripamonti, 435 20141, Milan, Italy
| | - Mahila E Ferrari
- European Institute of Oncology, Via Ripamonti, 435 20141, Milan, Italy
| | - Laura Gilardi
- European Institute of Oncology, Via Ripamonti, 435 20141, Milan, Italy
| | - Maria C Leonardi
- European Institute of Oncology, Via Ripamonti, 435 20141, Milan, Italy
| | - Luigi Santoro
- European Institute of Oncology, Via Ripamonti, 435 20141, Milan, Italy
| | - Roberto Orecchia
- European Institute of Oncology, Via Ripamonti, 435 20141, Milan, Italy
| | - Chiara M Grana
- European Institute of Oncology, Via Ripamonti, 435 20141, Milan, Italy
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Lopez-Lopez V, Abrisqueta J, Lujan J, Hernández Q, Ono A, Parrilla P. Utility of rectoscopy in the assessment of response to neoadjuvant treatment for locally advanced rectal cancer. Saudi J Gastroenterol 2016; 22:148-53. [PMID: 26997222 PMCID: PMC4817299 DOI: 10.4103/1319-3767.178526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 09/05/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND/AIMS The management of locally advanced rectal cancer has changed substantially over the last few decades with neoadjuvant chemoradiotherapy. The aim of the present study is to compare the results between neoadjuvant post-treatment rectoscopy and the anatomopathological findings of the surgical specimen. PATIENTS AND METHODS We conducted a prospective study of 67 patients with locally advanced adenocarcinoma of the rectum (stages II and III). Two groups were established: One with complete clinical response (cCR) and one without (non-cCR), based on the findings at rectoscopy. Assessment of tumor regression grade in the surgical specimen was determined using Mandard's tumor regression scale. RESULTS Seventeen patients showed a cCR. Thirty-five biopsies were negative and 32 were positive for malignancy. All the cCR patients had a negative biopsy (P < 0.0001). All 32 positive biopsies revealed the presence of adenocarcinoma, and of the 35 negative biopsies, 18 had no malignancy and 17 were diagnosed with adenocarcinoma (P < 0.0001). Sixteen of the 17 cCR patients showed a complete pathological response and one patient showed the presence of adenocarcinoma. Of the 50 non-cCR patients 48 revealed the presence of adenocarcinoma and two had absence of malignancy. According to the Mandard classification, 16 of the 17 cCR patients were grade I and 1 grade II; 2 non-cCR patients were grade I, 7 grade II, 13 grade III, 19 grade IV, and 9 grade V. CONCLUSIONS Endoscopic and histological findings could be determinants in the assessment of response to neoadjuvant treatment.
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Affiliation(s)
- Victor Lopez-Lopez
- Department of General Surgery, Colorectal Unit, Virgen de la Arrixaca University Clinical Hospital, University of Murcia, Murcia, Spain
| | - Jesús Abrisqueta
- Department of General Surgery, Colorectal Unit, Virgen de la Arrixaca University Clinical Hospital, University of Murcia, Murcia, Spain
| | - Juán Lujan
- Department of General Surgery, Colorectal Unit, Virgen de la Arrixaca University Clinical Hospital, University of Murcia, Murcia, Spain
| | - Quiteria Hernández
- Department of General Surgery, Colorectal Unit, Virgen de la Arrixaca University Clinical Hospital, University of Murcia, Murcia, Spain
| | - Akiko Ono
- Division of Gastroenterology, Virgen de la Arrixaca University Clinical Hospital, University of Murcia, Murcia, Spain
| | - Pascual Parrilla
- Department of General Surgery, Colorectal Unit, Virgen de la Arrixaca University Clinical Hospital, University of Murcia, Murcia, Spain
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Park IJ, Lee JL, Yoon YS, Kim CW, Lim SB, Lee JS, Park SH, Park JH, Kim JH, Yu CS, Kim JC. Influence of Preoperative Chemoradiotherapy on the Surgical Strategy According to the Clinical T Stage of Patients With Rectal Cancer. Medicine (Baltimore) 2015; 94:e2377. [PMID: 26717384 PMCID: PMC5291625 DOI: 10.1097/md.0000000000002377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The aim of this study was to evaluate the pathologic responses and changes to surgical strategies following preoperative chemoradiotherapy (PCRT) in rectal cancer patients according to their clinical T stage (cT).The use of PCRT has recently been extended to less advanced disease.The authors enrolled 650 patients with cT2 to 4 mid and low rectal cancer who received both PCRT and surgical resection. The rate of total regression and the proportion of local excision were compared according to the cT category. The 3-year recurrence-free survival (RFS) rate was compared using the log-rank test according to patient cT category, pathologic stage, and type of surgical treatment.Patients with cT2 were older (P = 0.001), predominately female (P = 0.028), and had low-lying rectal cancer (P = 0.008). Pathologic total regression was achieved most frequently in cT2 patients (54% of cT2 versus 17.6% of cT3 versus 8.2% of cT4; P < 0.001). Local excision was performed on 42 cT2 (42%) and 24 cT3 (5.2%) patients (P < 0.001). The 3-year RFS rates differed according to both cT (P < 0.001) and ypT stage (P < 0.001). Among patients with ypT0 to 1 disease, the 3-year RFS did not differ according to the type of surgical treatment received (P = 0.5).Total regression of the primary tumor and a change in the surgical strategy after PCRT are most commonly seen in cT2 disease. Although PCRT is not generally indicated for cT2 rectal cancer, optimal surgical treatment may be achieved with the tailored use of PCRT.
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Affiliation(s)
- In Ja Park
- From the Department of Colon and Rectal Surgery (IJP, JLL, YSY, CWK, S-BL, JCK); Department of Radiology (JSL, SHP); and Department of Radiation Oncology (JHP, JHK), University of Ulsan College of Medicine and Asan Medical Center, Seoul, South Korea
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Abstract
Abdominoperineal resection (APR) and sphincter-preserving resection (SPR) are the two primary surgical options for rectal cancer. Retrospectively we collected rectal cancer patients for SPR and APR observation between 2005 and 2007. The patient-related, tumor-related, and surgery-related variables of the SPR and APR groups were analyzed by using logistic regression techniques. The mean distance from the anal verge (DAV) of cancer is significantly higher in SPR than that in APR (P<0.001). In cancers with DAV<40 mm (SPR, 40 versus APR, 110), multivariate analysis shows that surgeon procedure volume (odds ratio [OR]=0.244; 95% confidence interval [CI]: 0.077-0.772; P=0.016) and neoadjuvant radiotherapy (OR=0.031; 95% CI: 0.002-0.396; P=0.008) are factors influencing SPR. In cancers with DAV ranging from 40 mm to 59 mm (SPR 190 versus APR 50), analysis shows that patient age (OR=2.139; 95% CI: 1.124-4.069; P=0.021), diabetes (OR=2.657; 95% CI: 0.872-8.095; P=0.086), and colorectal surgeon (OR=0.122, 95% CI: 0.020-0.758; P=0.024), are influencing factors for SPR. The local recurrence and disease-free survival reveal no significant difference. A significant difference exists in DAV, surgeon specialization, procedure volume, age, diabetes, and neoadjuvant radiotherapy between SPR and APR.
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Kleiman A, Al-Khamis A, Farsi A, Kezouh A, Vuong T, Gordon PH, Vasilevsky CA, Morin N, Faria J, Ghitulescu G, Boutros M. Normalization of CEA Levels Post-Neoadjuvant Therapy is a Strong Predictor of Pathologic Complete Response in Rectal Cancer. J Gastrointest Surg 2015; 19:1106-12. [PMID: 25859755 DOI: 10.1007/s11605-015-2814-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Accepted: 03/25/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Recent attention has been focused on the relationship between carcinoembryonic antigen (CEA) and pathological complete response (pCR), without consensus regarding its predictive value. This study aims to examine the association between CEA and pCR. METHODS We conducted a retrospective review of a prospectively maintained database of all patients who underwent primary rectal cancer resection after neo-adjuvant chemoradiotherapy (nCRT). Patients were divided into two groups, pCR or no-pCR, based on final pathology. CEA levels were measured at the initial visit with the surgeon/oncologist and post-completion of nCRT. RESULTS One hundred and forty-one patients underwent primary rectal cancer resections after nCRT. Nineteen patients (13.5 %) achieved pCR, while 122 (86.5 %) had no-pCR. Pre-nCRT CEA levels were not significantly different between groups (2.75 vs 4.5 μg/L, p = 0.65). However, post-nCRT CEA levels were significantly lower in patients with pCR (1.7 vs 2.4 μg/L, p < 0.01). On multivariate logistic regression analyses, low post-nCRT CEA level was an independent predictor of pCR (OR 1.74, CI 1.06, 3.81) and normalization of CEA from an initially elevated level was a highly significant predictor of pCR (OR 64.8, CI 2.53, 18,371). CONCLUSION Low post-nCRT CEA is an independent predictor of pCR, and normalization of CEA post-nCRT is a strong predictor of pCR.
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Affiliation(s)
- Ariella Kleiman
- Division of Colorectal Surgery, Jewish General Hospital, Montreal, QC, Canada
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Anderson BJ, Hill EG, Sweeney RE, Wahlquist AE, Marshall DT, O'Carroll KFS, Cole DJ, Camp ER. The Impact of Surgical Diversion Before Neoadjuvant Therapy for Rectal Cancer. Am Surg 2015. [DOI: 10.1177/000313481508100522] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Up-front fecal diversion can palliate emergent symptoms related to locally advanced rectal cancer (LARC) allowing patients to receive neoadjuvant chemoradiation therapy (nCRT). We analyzed outcomes of pretreatment-diverted LARC patients relative to nondiverted patients to define the impact of this management strategy. We retrospectively collected data on 103 LARC patients treated with nCRTand surgery. Medical records were reviewed for patient characteristics, staging, treatment plan, and outcomes. Thirteen LARC patients underwent pretreatment diversion for urgent symptoms and 90 LARC patients proceeded directly to nCRT. In all, 50 per cent of diverted patients presented with T4 tumor compared with 14 per cent in the nondiverted patients ( P = 0.003). Diverted patients experienced a delay in time-to-treatment initiation of 12 days, although this difference was not statistically significant. Similar rates of chemoradiation and surgical toxicities were observed. Even though diverted patients demonstrated less pathologic response to nCRT compared with nondiverted patients ( P = 0.04), there was no significant difference in overall survival. In conclusion, our study demonstrates the effectiveness of up-front fecal diversion at managing emergent obstructive symptoms related to advanced rectal cancer without additional complications, allowing patients to proceed with nCRT followed by radical surgery.
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Affiliation(s)
| | - Elizabeth G. Hill
- Department of Public Health Sciences, Medical University of South Carolina
- Hollings Cancer Center, Medical University of South Carolina
| | - Robert E. Sweeney
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Amy E. Wahlquist
- Department of Public Health Sciences, Medical University of South Carolina
- Hollings Cancer Center, Medical University of South Carolina
| | - David T. Marshall
- Department of Radiation Oncology, Medical University of South Carolina
| | - Kevin F. Staveley O'Carroll
- Department of Surgery, Medical University of South Carolina
- Department of Public Health Sciences, Medical University of South Carolina
- Hollings Cancer Center, Medical University of South Carolina
| | - David J. Cole
- Department of Surgery, Medical University of South Carolina
- Hollings Cancer Center, Medical University of South Carolina
| | - Ernest Ramsay Camp
- Department of Surgery, Medical University of South Carolina
- Hollings Cancer Center, Medical University of South Carolina
- the Ralph H. Johnson VA Medical Center, Charleston, South Carolina
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Clinical complete response (cCR) after neoadjuvant chemoradiotherapy and conservative treatment in rectal cancer. Findings from the ACCORD 12/PRODIGE 2 randomized trial. Radiother Oncol 2015; 115:246-52. [PMID: 25921382 DOI: 10.1016/j.radonc.2015.04.003] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Revised: 04/09/2015] [Accepted: 04/09/2015] [Indexed: 01/22/2023]
Abstract
BACKGROUND During the ACCORD 12 randomized trial, an evaluation of the clinical tumor response was prospectively performed after neoadjuvant chemoradiotherapy. The correlations between clinical complete response and patient characteristics and treatment outcomes are reported. MATERIAL AND METHODS Between 2005 and 2008 the Accord 12 trial accrued 598 patients with locally advanced rectal cancer and compared two different neoadjuvant chemoradiotherapies (Capox 50: capecitabine+oxaliplatin+50Gy vs Cap 45: capecitabine+45Gy). An evaluation of the clinical tumor response with rectoscopy and digital rectal examination was planned before surgery. A score to classify tumor response was used adapted from the RECIST definition: complete response: no visible or palpable tumor; partial response, stable and progressive disease. RESULTS The clinical tumor response was evaluable in 201 patients. Score was: complete response: 8% (16 patients); partial response: 68% (137 patients); stable: 21%; progression: 3%. There was a trend toward more complete response in the Capox 50 group (9.3% vs 6.7% with Cap 45). In the whole cohort of 201 pts complete response was significantly more frequent in T2 tumors (28%; p=0.025); tumors <4cm in diameter (14%; p=0.017), less than half rectal circumference and with a normal CEA level. Clinical complete response observed in 16 patients was associated with more conservative treatment (p=0.008): 2 patients required an abdomino-perineal resection, 11 an anterior resection and 3 patients benefited from organ preservation (2 local excision, 1 "watch and wait". A complete response was associated with more ypT0 (73%; p<0.001); ypNO (92%); R0 circumferential margin (100%). CONCLUSION These data support the hypothesis that a clinical complete response assessed using rectoscopy and digital rectal examination after neoadjuvant therapy may increase the chance of a sphincter or organ preservation in selected rectal cancers.
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Kinoshita O, Nakanishi M, Murayama Y, Kuriu Y, Kokuba Y, Otsuji E. Flattened tumor requires a more careful attention for residual distal cancer spread in locally advanced lower rectal carcinoma after chemoradiotherapy. Dig Surg 2015; 32:159-65. [PMID: 25833218 DOI: 10.1159/000371586] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 12/15/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND/AIMS Limited data are available on distal resection margin (DRM) for lower rectal cancer (LRC) after preoperative chemoradiotherapy (pre-CRT); thus, we aimed to establish the criteria for DRMs as estimated by the macroscopic tumor appearance. METHODS This was a pathological study using whole-mount sections that included the entire circumference of tumor. Residual cancer spread located most distally from the macroscopic tumor border was mainly evaluated. RESULTS A retrospective cohort of 42 consecutive patients with locally advanced LRC after pre-CRT was enrolled, and 38 patients were eligible for this study. According to the macroscopic tumor appearance, 18 patients had raised-type and 20 had flattened-type tumors. Patients with flattened-type tumors were closely associated with histopathological regression grade. Residual distal cancer spread (RDCS) was located ≤4.0 mm (median, 0.1 mm) in the raised-type tumors and ≤17.1 mm (median, 4.2 mm) in the flattened-type tumors. RDCS in flattened-type tumors was distributed diffusely and distally from the tumor border (p = 0.022). CONCLUSION Even in patients evaluated as pre-CRT responders, flattened tumors often accompanied distally located residual cancer that had spread from the tumor border and require more careful attention in order to ensure cancer clearance.
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Affiliation(s)
- Osamu Kinoshita
- Department of Surgery, Division of Digestive Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Overexpression of DNAJC12 predicts poor response to neoadjuvant concurrent chemoradiotherapy in patients with rectal cancer. Exp Mol Pathol 2015; 98:338-45. [PMID: 25805104 DOI: 10.1016/j.yexmp.2015.03.029] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 03/20/2015] [Indexed: 12/16/2022]
Abstract
Genes associated with protein folding have been found to have certain prognostic significance in a subset of cancers. The aim of this study is to evaluate the clinical impact of DNAJC12 expression in patients with rectal cancers receiving neoadjuvant concurrent chemoradiotherapy (CCRT) followed by surgery. Through data mining from a public transcriptomic dataset of rectal cancer focusing on genes associated with protein folding, we found that DNAJC12, a member of the HSP40/DNAJ family, was the most significant such gene correlated with the CCRT response. We further evaluated the expression of DNAJC12 by immunohistochemistry in the pre-treatment tumor specimens from 172 patients with rectal cancers. From this set, we statistically analyzed the association of DNAJC12 expression with various clinicopathological factors, tumor regression grade, overall survival (OS), disease-free survival (DFS) and local recurrence-free survival (LRFS). High expression of DNAJC12 was significantly associated with advanced pre- and post-treatment tumor status (P<0.001), advanced pre- and post-treatment nodal status (P<0.001), increased vascular invasion (P=0.015), increased perineural invasion (P=0.023) and lower tumor regression grade (P=0.009). More importantly, high expression of DNAJC12 was found to be correlated with poor prognosis for OS (P=0.0012), DFS (P<0.0001) and LRFS (P=0.0001). In multivariate analysis, DNAJC12 overexpression still emerged as an independent prognosticator for shorter OS (P=0.040), DFS (P<0.001) and LRFS (P=0.016). The data indicate that DNAJC12 overexpression acts as a negative predictive factor for the response to neoadjuvant CCRT and was significantly associated with shorter survival in patients with rectal cancers receiving neoadjuvant CCRT followed by surgery.
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Deorukhkar A, Ahuja N, Mercado AL, Diagaradjane P, Raju U, Patel N, Mohindra P, Diep N, Guha S, Krishnan S. Zerumbone increases oxidative stress in a thiol-dependent ROS-independent manner to increase DNA damage and sensitize colorectal cancer cells to radiation. Cancer Med 2015; 4:278-92. [PMID: 25450478 PMCID: PMC4329011 DOI: 10.1002/cam4.367] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 09/26/2014] [Accepted: 09/29/2014] [Indexed: 12/14/2022] Open
Abstract
Locally advanced rectal cancers are treated with neoadjuvant chemoradiation therapy followed by surgery. In a minority (~20%) of patients, no tumor is present at the time of surgery; these patients with a complete pathologic response (pathCR) to neoadjuvant therapy have better treatment outcomes. Unfortunately, the inherent radioresistance of colorectal cancer (CRC) cells dictates that the majority of patients do not achieve a pathCR. Efforts to improve these odds have fueled the search for novel, relatively less-toxic radiosensitizers with distinct molecular mechanism(s) and broad-spectrum anticancer activities. Here, we use zerumbone, a sesquiterpene from the edible ginger (Zingiber zerumbet Smith), to enhance radiosensitivity of CRC cells. Short exposure to zerumbone (7 h) profoundly sensitized CRC cells, independent of their p53 or k-RAS status. Zerumbone enhanced radiation-induced cell cycle arrest (G2/M), increased radiation-induced apoptosis, but induced little apoptosis by itself. Zerumbone significantly enhanced radiation-induced DNA damage, as evident by delayed resolution of post-irradiation nuclear γH2AX foci, whereas zerumbone treatment alone did not induce γH2AX foci formation. Zerumbone pretreatment inhibited radiation-induced nuclear expression of DNA repair proteins ataxia-telangiectasia mutated (ATM) and DNA-PKcs. Interestingly, zerumbone-mediated radiosensitization did not involve reactive oxygen species (ROS), but was mediated through depletion of cellular glutathione (GSH). Ability of only thiol-based antioxidants to abrogate zerumbone-mediated radiosensitization further corroborated this hypothesis. The α,β-unsaturated carbonyl group in zerumbone was found to be essential for its bioactivity as zerumbone analog α-Humulene that lacks this functional group, could neither radiosensitize CRC cells, nor deplete cellular GSH. Our studies elucidate novel mechanism(s) of zerumbone's ability to enhance CRC radiosensitivity.
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Affiliation(s)
- Amit Deorukhkar
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer CenterHouston, Texas, 77030
| | - Niharika Ahuja
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer CenterHouston, Texas, 77030
| | - Armando-Lopez Mercado
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer CenterHouston, Texas, 77030
| | - Parmeswaran Diagaradjane
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer CenterHouston, Texas, 77030
| | - Uma Raju
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer CenterHouston, Texas, 77030
| | - Nalini Patel
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer CenterHouston, Texas, 77030
| | - Pranshu Mohindra
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer CenterHouston, Texas, 77030
| | - Nga Diep
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer CenterHouston, Texas, 77030
| | - Sushovan Guha
- Division of Gastroenterology, Hepatology, and Nutrition, The UT Medical School and Health Science Center at Houston6431 Fannin Street, MSB 4.234, Houston, Texas, 77030
| | - Sunil Krishnan
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer CenterHouston, Texas, 77030
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He HL, Lee YE, Shiue YL, Lee SW, Lin LC, Chen TJ, Wu TF, Li CF. PLA2G2A overexpression is associated with poor therapeutic response and inferior outcome in rectal cancer patients receiving neoadjuvant concurrent chemoradiotherapy. Histopathology 2015; 66:991-1002. [DOI: 10.1111/his.12613] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 11/09/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Hong-Lin He
- Department of Pathology; E-DA Hospital; I-Shou University; Kaohsiung Taiwan
- Institute of Biomedical Science; National Sun Yat-sen University; Kaohsiung Taiwan
| | - Ying-En Lee
- Department of Anesthesiology; Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine; Kaohsiung Taiwan
| | - Yow-Ling Shiue
- Institute of Biomedical Science; National Sun Yat-sen University; Kaohsiung Taiwan
| | - Sung-Wei Lee
- Department of Radiation Oncology; Chi-Mei Medical Center; Liouying Tainan Taiwan
| | - Li-Ching Lin
- Department of Radiation Oncology; Chi-Mei Medical Center; Tainan Taiwan
| | - Tzu-Ju Chen
- Department of Pathology; Chi Mei Medical Center; Tainan Taiwan
| | - Ting-Feng Wu
- Department of Biotechnology; Southern Taiwan University of Science and Technology; Tainan Taiwan
| | - Chien-Feng Li
- Department of Pathology; Chi Mei Medical Center; Tainan Taiwan
- Department of Biotechnology; Southern Taiwan University of Science and Technology; Tainan Taiwan
- Graduate Institute of Clinical Medicine; College of Medicine; Kaohsiung Medical University; Kaohsiung Taiwan
- National Institute of Cancer Research; National Health Research Institutes; Tainan Taiwan
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Changing Operative Strategy from Abdominoperineal Resection to Sphincter Preservation in T3 Low Rectal Cancer after Downstaging by Neoadjuvant Chemoradiation: A Preliminary Report. World J Surg 2015; 39:1248-56. [DOI: 10.1007/s00268-014-2930-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Ihn MH, Kim YH, Kim DW, Oh HK, Lee SY, Park JT, Son IT, Park JH, Lee YJ, Kim JW, Lee KW, Kim JH, Shin E, Lee HS, Ahn S, Kang SB. Effects of Preoperative Chemoradiotherapy on the Likelihood of Sphincter Preservation Surgery in Locally Advanced Distal Rectal Cancer: A Longitudinal Study Based on Pelvic Magnetic Resonance Imaging. Ann Surg Oncol 2014; 22:2159-67. [PMID: 25503346 DOI: 10.1245/s10434-014-4286-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Indexed: 12/29/2022]
Abstract
BACKGROUND It is unclear whether preoperative chemoradiotherapy (pCRT) increases the rate of sphincter-preserving surgery (SPS), avoiding abdominoperineal resection (APR), for the treatment of distal rectal cancer. We examined whether pCRT increases the likelihood of SPS based on changes in tumor height using pelvic magnetic resonance imaging (MRI). METHODS Between January 2009 and December 2013, 105 patients underwent long-course pCRT for locally advanced distal rectal cancer (≤5 cm from the anal verge) and were included in this study. The surgical procedures were analyzed in terms of radiologic findings, including the distance from the inferior margin of tumor to the superior margin of the anorectal ring (tumor height) measured by pelvic MRI before and after pCRT. RESULTS Eighty-six (81.9 %) patients underwent SPS. Overall clinical downstaging occurred in 48 (45.7 %) patients. Tumor height increased significantly after pCRT (from 15.0 ± 15.3 to 18.1 ± 16.9 mm, change 3.1 ± 9.7 mm, p = 0.01). The mean change in tumor height was not significantly different between patients who underwent SPS or APR (mean change 3.3 ± 9.6 vs. 2.3 ± 10.5 mm, p = 0.68). The mean change was significantly greater in the double-stapled anastomosis group than in the handsewn anastomosis group (mean change 5.6 ± 9.9 vs. -0.6 ± 8.6 mm, p = 0.02). CONCLUSIONS This was the first MRI-based longitudinal study to show that pCRT does not appear to increase the likelihood of SPS in locally advanced distal rectal cancer, although it could improve the potential of double-stapled anastomoses.
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Affiliation(s)
- Myong Hoon Ihn
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
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Abstract
The two goals of surgery for lower rectal cancer surgery are to obtain clear "curative" margins and to limit post-surgical functional disorders. The question of whether or not to preserve the anal sphincter lies at the center of the therapeutic choice. Histologically, tumor-free distal and circumferential margins of>1mm allow a favorable oncologic outcome. Whether such margins can be obtained depends of TNM staging, tumor location, response to chemoradiotherapy and type of surgical procedure. The technique of intersphincteric resection relies on these narrow margins to spare the sphincter. This procedure provides satisfactory oncologic outcome with a rate of circumferential margin involvement ranging from 5% to 11%, while good continence is maintained in half of the patients. The extralevator abdominoperineal resection provides good oncologic results, however this procedure requires a permanent colostomy. A permanent colostomy alters several domains of quality of life when located at the classical abdominal site but not when brought out at the perineal site as a perineal colostomy.
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Affiliation(s)
- F Dumont
- Départment de chirurgie oncologique, institut Gustave-Roussy, 114, rue Edouard-Vaillant, 94805 Villejuif cedex, France.
| | - A Mariani
- Départment de chirurgie oncologique, institut Gustave-Roussy, 114, rue Edouard-Vaillant, 94805 Villejuif cedex, France
| | - D Elias
- Départment de chirurgie oncologique, institut Gustave-Roussy, 114, rue Edouard-Vaillant, 94805 Villejuif cedex, France
| | - D Goéré
- Départment de chirurgie oncologique, institut Gustave-Roussy, 114, rue Edouard-Vaillant, 94805 Villejuif cedex, France
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Wasserberg N, Kundel Y, Purim O, Keidar A, Kashtan H, Sadot E, Fenig E, Brenner B. Sphincter preservation in distal CT2N0 rectal cancer after preoperative chemoradiotherapy. Radiat Oncol 2014; 9:233. [PMID: 25338839 PMCID: PMC4215010 DOI: 10.1186/s13014-014-0233-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 10/08/2014] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Preoperative chemoradiotherapy is usually not indicated for cT2N0 rectal cancer. Abdominoperineal resection is the standard treatment for distal rectal tumors. The aim of the study was to evaluate the actual sphincter-preservation rate in patients with distal cT2N0 rectal cancer given neoadjuvant chemoradiotherapy. METHODS Data were retrospectively collected for all patients who were diagnosed with distal cT2N0 rectal cancer at a tertiary medical center in 2000-2008 and received chemoradiotherapy followed by surgery (5-7 weeks later). RESULTS Thirty-three patients (22 male) of median age 65 years (range, 32-88) were identified. Tumor distance from the anal verge ranged from 0 to 5 cm. R0 resection with sphincter preservation was accomplished in 22 patients (66%), with a 22% pathological complete response rate. Median follow-up time was 62 months (range 7-120). There were no local failures. Crude disease-free and overall survival were 82% and 86%, respectively. Factors associated with sphincter preservation were tumor location (OR=0.58, p=0.02, 95% CI=0.37-0.91) and pathological downstaging (OR=7.8, p=0.02, 95% CI=1.35-45.85). Chemoradiotherapy was well tolerated. CONCLUSION High rates of sphincter preservation can be achieved after preoperative chemoradiotherapy for distal cT2N0 rectal cancer, with tolerable toxicity, without compromising oncological outcome.
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Affiliation(s)
| | - Yulia Kundel
- Davidoff Cancer Center, Rabin Medical Center, Beilinson Campus, Petach Tikva, 49100, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 69978, Israel.
| | - Ofer Purim
- Davidoff Cancer Center, Rabin Medical Center, Beilinson Campus, Petach Tikva, 49100, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 69978, Israel.
| | - Andrei Keidar
- Department of Surgery B, Petach Tikva, 49100, Israel.
| | | | - Eran Sadot
- Department of Surgery B, Petach Tikva, 49100, Israel.
| | - Eyal Fenig
- Davidoff Cancer Center, Rabin Medical Center, Beilinson Campus, Petach Tikva, 49100, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 69978, Israel.
| | - Baruch Brenner
- Davidoff Cancer Center, Rabin Medical Center, Beilinson Campus, Petach Tikva, 49100, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 69978, Israel.
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He HL, Lee YE, Shiue YL, Lee SW, Lin LC, Chen TJ, Wu TF, Hsing CH, Huang HY, Wang JY, Li CF. Overexpression of REG4 confers an independent negative prognosticator in rectal cancers receiving concurrent chemoradiotherapy. J Surg Oncol 2014; 110:1002-10. [PMID: 25155043 DOI: 10.1002/jso.23764] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 07/19/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Neoadjuvant concurrent chemoradiotherapy (CCRT) followed by surgery is the standard treatment for locally advanced rectal cancer. Through data mining from published transcriptomic database, we identified Regenerating Gene Type IV (REG4) as the most significantly associated gene with resistance to CCRT. This study examined the prognostic impact of REG4 expression in patients with rectal cancer receiving neoadjuvant CCRT. METHODS REG4 immunohistochemistry was retrospectively assessed for pre-treatment biopsy specimens from 172 rectal cancer patients who received neoadjuvant CCRT followed by surgery without initial distant metastasis. The results were correlated with the clinicopathological variables, disease-specific survival (DSS), local recurrence-free survival (LRFS), and distant metastasis-free survival (DMFS), as well as γ-H2AX expression in post-treatment tumor samples. RESULTS High expression of REG4 was associated with advanced pre-treatment nodal status (P = 0.026), advanced post-treatment tumor status (P = 0.006), advanced post-treatment nodal status (P = 0.001), advanced post-treatment tumor stage (P < 0.001), and inferior tumor regression grade (P = 0.001). Of note, high expression of REG4 emerged as an adverse prognosticator for DSS (P = 0.0004), LRFS (P = 0.0009), and MeFS (P = 0.0254). After multivariate comparisons, it remained independently prognostic for worse DSS (hazard ratio [HR] = 2.731; P = 0.025) and LRFS (HR = 2.676; P = 0.029). High expression of REG4 was also negatively associated with γ-H2AX expression (P < 0.0001, r = -0.708). CONCLUSIONS High expression of REG4 is associated with poor therapeutic response, adverse outcome and an aggressive phenotype in rectal cancer patients treated with neoadjuvant CCRT, justifying REG4 is a surrogate marker to predict CCRT resistance.
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Affiliation(s)
- Hong-Lin He
- Department of Pathology, E-DA Hospital, I-Shou University, Kaohsiung, Taiwan; Institute of Biomedical Science, National Sun Yat-sen University, Kaohsiung, Taiwan
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Lee YY, Li CF, Lin CY, Lee SW, Sheu MJ, Lin LC, Chen TJ, Wu TF, Hsing CH. Overexpression of CPS1 is an independent negative prognosticator in rectal cancers receiving concurrent chemoradiotherapy. Tumour Biol 2014; 35:11097-105. [PMID: 25099619 DOI: 10.1007/s13277-014-2425-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 07/29/2014] [Indexed: 12/13/2022] Open
Abstract
Locally advanced rectal cancers are currently treated with neoadjuvant concurrent chemoradiotherapy (CCRT) followed by surgery, but stratification of risk and final outcomes remain suboptimal. In view of the fact that glutamine metabolism is usually altered in cancer, we profiled and validated the significance of genes involved in this pathway in rectal cancers treated with CCRT. From a published transcriptome of rectal cancers (GSE35452), we focused on glutamine metabolic process-related genes (GO:0006541) and found upregulation of carbamoyl phosphate synthetase 1 (CPS1) gene most significantly predicted poor response to CCRT. We evaluated the expression levels of CPS1 using immunohistochemistry to analyze tumor specimens obtained during colonoscopy from 172 rectal cancer patients. Expression levels of CPS1 were further correlated with major clinicopathological features and survivals in this validation cohort. To further confirm CPS1 expression levels, Western blotting was performed for human colon epithelial primary cell (HCoEpiC) and four human colon cancer cells, including HT29, SW480, LoVo, and SW620. CPS1 overexpression was significantly related to advanced posttreatment tumor (T3, T4; P = 0.006) and nodal status (N1, N2; P < 0.001), and inferior tumor regression grade (P = 0.004). In survival analyses, CPS1 overexpression was significantly associated with shorter disease-specific survival (DSS) and metastasis-free survival (MeFS). Furthermore, using multivariate analysis, it was also independently predictive of worse DSS (P = 0.021, hazard ratio = 2.762) and MeFS (P = 0.004, hazard ratio = 3.897). CPS1 protein expression, as detected by Western blotting, is more abundant in colon cancer cells than nonneoplastic HCoEpiC. Overexpression of CPS1 is associated with poor therapeutic response and adverse outcomes among rectal cancer patients receiving CCRT, justifying the potential theranostic value of CPS1 for such patients.
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Affiliation(s)
- Yi-Ying Lee
- Department of Pathology, Chi Mei Medical Center, Tainan, Taiwan
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Can a biomarker-based scoring system predict pathologic complete response after preoperative chemoradiotherapy for rectal cancer? Dis Colon Rectum 2014; 57:592-601. [PMID: 24819099 DOI: 10.1097/dcr.0000000000000109] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Numerous molecular markers have been investigated as potential predictors of tumor responses to preoperative chemoradiotherapy (preCRT) for rectal cancer. OBJECTIVE To develop a system in which biomarkers are used to predict the likelihood of a pathologic complete response (pCR) to preCRT. DESIGN & SETTING This is a retrospective analysis of tumor specimens collected prior to preCRT from 81 patients who underwent curative resection for primary rectal adenocarcinoma between June 2008 and February 2012. MAIN OUTCOME MEASURES Using tissue microarrays and immunohistochemistry, expression levels of twelve candidate biomarkers (p53, p21, Bcl2, Bax, EGFR, Cox-2, MLH-1, MSH-2, Ku70, VEGF, TS, Ki-67) were evaluated in paraffin-embedded tumor samples collected before preCRT. The correlation between biomarker expression levels and the pathologic response to preCRT was assessed based on histopathological staging (pTNM) and tumor regression grade (TRG). RESULTS Expression levels of 4 biomarkers (p53, VEGF, p21, Ki67) correlated with pCR. Patients showing low expression of p53 and/or high expression of VEGF, p21, and Ki67 exhibited a significantly greater pCR rate. A scoring system devised so that one point was given for each biomarker whose expression level correlated with pCR (score range: 0-4) showed that 1 of 26 patients with scores of 0 to 1 achieved pCR, whereas 26 of 55 patients with scores of 2 to 4 achieved pCR (3.8% vs. 47.3%, p < 0.001). For prediction of pCR, the scoring system showed 96.3% sensitivity, 46.3% specificity, a 47.3% positive predictive value, and a 96.2% negative predictive value. LIMITATIONS Immunohistochemistry has limitations related to reproducibility and the ability to provide quantitative information. In addition, this study lacks test and validation sets. CONCLUSIONS Expression levels of 4 biomarkers correlated with pCR after preCRT for rectal cancer. A scoring system based on levels of biomarker expression showed good sensitivity and negative predictive value for pCR.
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Deficiency in asparagine synthetase expression in rectal cancers receiving concurrent chemoradiotherapy: negative prognostic impact and therapeutic relevance. Tumour Biol 2014; 35:6823-30. [DOI: 10.1007/s13277-014-1895-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 03/25/2014] [Indexed: 01/10/2023] Open
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50
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Gerard JP, Benezery K, Doyen J, Francois E. Aims of combined modality therapy in rectal cancer (M0). Recent Results Cancer Res 2014; 203:153-69. [PMID: 25103004 DOI: 10.1007/978-3-319-08060-4_11] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
UNLABELLED OPTIMIZING THE COST/BENEFIT RATIO OF TREATMENT: Evidence Based The aim of a cancer treatment is always to achieve the maximum of cure rate with a minimum of toxicity and best quality of life at an acceptable cost for the society. It is always a multifactorial challenge depending on the patient, the tumor, the doctor, and the society cultural and financial backgrounds. The goal is to find the best cost/benefit ratio between all possible strategies in agreement with a well-informed patient. In rectal cancer (M0) surgery is the cornerstone of treatment. Combined modality therapies aim at optimizing the cost/benefit ratio of possible strategies and only randomized trials can bring strong evidence regarding their results and recommendations. LESSONS FROM RANDOMIZED TRIALS: quite modest During the past decades many phase III trials have shown that: (1) neoadjuvant treatment even with "TME" surgery was better than adjuvant, (2) chemoradiotherapy (CRT) was better than RT alone, (3) long course CRT was probably more efficient (in terms of ypCR) than short course (25/5), and (4) capecitabine was as efficient as 5 FU but oxaliplatin was not adding benefit. Overall, the gains of nCRT remain modest and it is mainly a reduction in local relapse not exceeding 5 %, but no benefit in survival and neither in sphincter saving surgery has been proven. The way forwards organ preservation in case of CCR. Local control: can probably be improved for T4 tumors by RT dose escalation. Survival: can be increased by innovative medical treatment either before or after surgery. TOXICITY may be reduced by a less aggressive treatment in elderly. Conservative treatment: A new field of clinical research is to achieve "organ preservation" (and not only sphincter saving). To modify the surgical approach and preserve the whole rectum, neoadjuvant treatment must achieve safely a clinical complete response. As rectal adenocarcinoma is a relatively radioresistant tumor endocavitary irradiation (contact X-Ray) is a promising safe approach and this hypothesis will be addressed by the OPERA randomized trial.
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Affiliation(s)
- J P Gerard
- Departement of Radiation Oncology, Centre Antoine-Lacassagne, 33 Avenue de Valombrose, 01689, Nice Cedex 2, France,
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