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Barbaro B, Carafa MRPI, Minordi LM, Testa P, Tatulli G, Carano D, Fiorillo C, Chiloiro G, Romano A, Valentini V, Gambacorta MA. Magnetic resonance imaging for assessment of rectal cancer nodes after chemoradiotherapy: A single center experience. Radiother Oncol 2024; 193:110124. [PMID: 38309586 DOI: 10.1016/j.radonc.2024.110124] [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: 08/08/2023] [Revised: 01/14/2024] [Accepted: 01/30/2024] [Indexed: 02/05/2024]
Abstract
BACKGROUND Accurate nodal restaging is becoming clinically more important in patients with locally advanced rectal cancer (LARC) with the emergence of organ-preserving treatment after a good response to neoadjuvant chemoradiotherapy (nCRT). PURPOSE To evaluate the accuracy of MRI in identifying negative N status (ypN0 patients) in LARC after nCRT. MATERIAL AND METHODS 191 patients with LARC underwent MRI before and 6-8 weeks after nCRT and subsequent total mesorectal excision. Short-axis diameter of mesorectal lymph nodes was evaluated on the high resolution T2-weighted images to compare MRI restaging with histopathology.. RESULTS 146 and 45 patients had a negative N status (ypN0) and positive N status (ypN + ), respectively. On restaging MRI, the 70 % reduction in size of the largest node was associated with an area under the curve (AUC) of 0.818 to predict ypN0 stage, with a sensitivity of 93.3 % and a negative predictive value (NPV) of 95.4 %. No nodes were observed in 38 pts (37 pts ypN0 and 1 patient ypN + ), with sensitivity and NPV of nodes disappearance for ypN0 stage of 93.3 % and 92.5 % respectively. A 2.2 mm cut-off in short-axis diameter was associated with an AUC of 0.83 for the prediction of ypN0 nodal stage, with sensitivity and NPV of 79,5% and 91.1 % respectively. CONCLUSION A reduction in size of 70 % of the largest limph-node on MRI at rectal cancer restaging has high sensitivity and NPV for prediction of ypN0 stage after nCRT. The high NPV of node disappearance and of a ≤ 2.2 mm short-axis diameter is confirmed.
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Affiliation(s)
- Brunella Barbaro
- Department of Diagnostic Imaging, Oncological Radiotherapy, and Hematology. Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Maria Rachele PIa Carafa
- Department of Diagnostic Imaging, Oncological Radiotherapy, and Hematology. Università Cattolica del Sacro Cuore, Rome, Italy
| | - Laura Maria Minordi
- Department of Diagnostic Imaging, Oncological Radiotherapy, and Hematology. Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Priscilla Testa
- Department of Diagnostic Imaging, Oncological Radiotherapy, and Hematology. Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giulia Tatulli
- Department of Diagnostic Imaging, Oncological Radiotherapy, and Hematology. Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Davide Carano
- Department of Diagnostic Imaging, Oncological Radiotherapy, and Hematology. Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Claudio Fiorillo
- Digestive Surgery Unit, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Giuditta Chiloiro
- Department of Diagnostic Imaging, Oncological Radiotherapy, and Hematology. Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Angela Romano
- Department of Diagnostic Imaging, Oncological Radiotherapy, and Hematology. Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Vincenzo Valentini
- Department of Diagnostic Imaging, Oncological Radiotherapy, and Hematology. Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Maria Antonietta Gambacorta
- Department of Diagnostic Imaging, Oncological Radiotherapy, and Hematology. Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.
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Amintas S, Giraud N, Fernandez B, Dupin C, Denost Q, Garant A, Frulio N, Smith D, Rullier A, Rullier E, Vuong T, Dabernat S, Vendrely V. The Crying Need for a Better Response Assessment in Rectal Cancer. Curr Treat Options Oncol 2023; 24:1507-1523. [PMID: 37702885 PMCID: PMC10643426 DOI: 10.1007/s11864-023-01125-9] [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] [Accepted: 07/09/2023] [Indexed: 09/14/2023]
Abstract
OPINION STATEMENT Since total neoadjuvant treatment achieves almost 30% pathologic complete response, organ preservation has been increasingly debated for good responders after neoadjuvant treatment for patients diagnosed with rectal cancer. Two organ preservation strategies are available: a watch and wait strategy and a local excision strategy including patients with a near clinical complete response. A major issue is the selection of patients according to the initial tumor staging or the response assessment. Despite modern imaging improvement, identifying complete response remains challenging. A better selection could be possible by radiomics analyses, exploiting numerous image features to feed data characterization algorithms. The subsequent step is to include baseline and/or pre-therapeutic MRI, PET-CT, and CT radiomics added to the patients' clinicopathological data, inside machine learning (ML) prediction models, with predictive or prognostic purposes. These models could be further improved by the addition of new biomarkers such as circulating tumor biomarkers, molecular profiling, or pathological immune biomarkers.
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Affiliation(s)
- Samuel Amintas
- Tumor Biology and Tumor Bank Laboratory, CHU Bordeaux, F-33600, Pessac, France.
- BRIC (BoRdeaux Institute of onCology), UMR1312, INSERM, University of Bordeaux, F-33000, Bordeaux, France.
| | - Nicolas Giraud
- Department of Radiation Oncology, CHU Bordeaux, F-33000, Bordeaux, France
| | | | - Charles Dupin
- BRIC (BoRdeaux Institute of onCology), UMR1312, INSERM, University of Bordeaux, F-33000, Bordeaux, France
- Department of Radiation Oncology, CHU Bordeaux, F-33000, Bordeaux, France
| | - Quentin Denost
- Bordeaux Colorectal Institute, F-33000, Bordeaux, France
| | - Aurelie Garant
- UT Southwestern Department of Radiation Oncology, Dallas, USA
| | - Nora Frulio
- Radiology Department, CHU Bordeaux, F-33600, Pessac, France
| | - Denis Smith
- Department of Digestive Oncology, CHU Bordeaux, F-33600, Pessac, France
| | - Anne Rullier
- Histology Department, CHU Bordeaux, F-33000, Bordeaux, France
| | - Eric Rullier
- BRIC (BoRdeaux Institute of onCology), UMR1312, INSERM, University of Bordeaux, F-33000, Bordeaux, France
- Surgery Department, CHU Bordeaux, F-33600, Pessac, France
| | - Te Vuong
- Department of Radiation Oncology, McGill University, Jewish General Hospital, Montreal, Canada
| | - Sandrine Dabernat
- BRIC (BoRdeaux Institute of onCology), UMR1312, INSERM, University of Bordeaux, F-33000, Bordeaux, France
- Biochemistry Department, CHU Bordeaux, F-33000, Bordeaux, France
| | - Véronique Vendrely
- BRIC (BoRdeaux Institute of onCology), UMR1312, INSERM, University of Bordeaux, F-33000, Bordeaux, France
- Department of Radiation Oncology, CHU Bordeaux, F-33000, Bordeaux, France
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Cerdan-Santacruz C, São Julião GP, Vailati BB, Corbi L, Habr-Gama A, Perez RO. Watch and Wait Approach for Rectal Cancer. J Clin Med 2023; 12:jcm12082873. [PMID: 37109210 PMCID: PMC10143332 DOI: 10.3390/jcm12082873] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/10/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
The administration of neoadjuvant chemoradiotherapy (nCRT) followed by total mesorrectal excision (TME) and selective use of adjuvant chemotherapy can still be considered the standard of care in locally advanced rectal cancer (LARC). However, avoiding sequelae of TME and entering a narrow follow-up program of watch and wait (W&W), in select cases that achieve a comparable clinical complete response (cCR) to nCRT, is now very attractive to both patients and clinicians. Many advances based on well-designed studies and long-term data coming from big multicenter cohorts have drawn some important conclusions and warnings regarding this strategy. In order to safely implement W&W, it is important consider proper selection of cases, best treatment options, surveillance strategy and the attitudes towards near complete responses or even tumor regrowth. The present review offers a comprehensive overview of W&W strategy from its origins to the most current literature, from a practical point of view focused on daily clinical practice, without losing sight of the most important future prospects in this area.
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Affiliation(s)
- Carlos Cerdan-Santacruz
- Department of Coloproctology, Hospital Universitario de la Princesa, 28006 Madrid, Spain
- Department of Coloproctology, Clínica Santa Elena, 28003 Madrid, Spain
| | - Guilherme Pagin São Julião
- Angelita and Joaquim Gama Institute, São Paulo 01329-020, Brazil
- Department of Coloproctology, Hospital Alemão Oswaldo Cruz, São Paulo 01323-020, Brazil
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo 01323-001, Brazil
| | - Bruna Borba Vailati
- Angelita and Joaquim Gama Institute, São Paulo 01329-020, Brazil
- Department of Coloproctology, Hospital Alemão Oswaldo Cruz, São Paulo 01323-020, Brazil
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo 01323-001, Brazil
| | - Leonardo Corbi
- Angelita and Joaquim Gama Institute, São Paulo 01329-020, Brazil
- Department of Coloproctology, Hospital Alemão Oswaldo Cruz, São Paulo 01323-020, Brazil
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo 01323-001, Brazil
| | - Angelita Habr-Gama
- Angelita and Joaquim Gama Institute, São Paulo 01329-020, Brazil
- Department of Coloproctology, Hospital Alemão Oswaldo Cruz, São Paulo 01323-020, Brazil
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo 01323-001, Brazil
| | - Rodrigo Oliva Perez
- Angelita and Joaquim Gama Institute, São Paulo 01329-020, Brazil
- Department of Coloproctology, Hospital Alemão Oswaldo Cruz, São Paulo 01323-020, Brazil
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo 01323-001, Brazil
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Gao PF, Lu N, Liu W. MRI VS. FDG-PET for diagnosis of response to neoadjuvant therapy in patients with locally advanced rectal cancer. Front Oncol 2023; 13:1031581. [PMID: 36741013 PMCID: PMC9890074 DOI: 10.3389/fonc.2023.1031581] [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: 08/30/2022] [Accepted: 01/02/2023] [Indexed: 01/19/2023] Open
Abstract
Aim In this study, we aimed to compare the diagnostic values of MRI and FDG-PET for the prediction of the response to neoadjuvant chemoradiotherapy (NACT) of patients with locally advanced Rectal cancer (RC). Methods Electronic databases, including PubMed, Embase, and the Cochrane library, were systematically searched through December 2021 for studies that investigated the diagnostic value of MRI and FDG-PET in the prediction of the response of patients with locally advanced RC to NACT. The quality of the included studies was assessed using QUADAS. The pooled sensitivity, specificity, positive and negative likelihood ratio (PLR and NLR), and the area under the ROC (AUC) of MRI and FDG-PET were calculated using a bivariate generalized linear mixed model, random-effects model, and hierarchical regression. Results A total number of 74 studies with recruited 4,105 locally advanced RC patients were included in this analysis. The pooled sensitivity, specificity, PLR, NLR, and AUC for MRI were 0.83 (95% CI: 0.77-0.88), 0.85 (95% CI: 0.79-0.89), 5.50 (95% CI: 4.11-7.35), 0.20 (95% CI: 0.14-0.27), and 0.91 (95% CI: 0.88-0.93), respectively. The summary sensitivity, specificity, PLR, NLR and AUC for FDG-PET were 0.81 (95% CI: 0.77-0.85), 0.75 (95% CI: 0.70-0.80), 3.29 (95% CI: 2.64-4.10), 0.25 (95% CI: 0.20-0.31), and 0.85 (95% CI: 0.82-0.88), respectively. Moreover, there were no significant differences between MRI and FDG-PET in sensitivity (P = 0.565), and NLR (P = 0.268), while the specificity (P = 0.006), PLR (P = 0.006), and AUC (P = 0.003) of MRI was higher than FDG-PET. Conclusions MRI might superior than FGD-PET for the prediction of the response of patients with locally advanced RC to NACT.
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Affiliation(s)
- Peng Fei Gao
- Department of Traditional Chinese medicine, Jinshan Hospital, Fudan University, Shanghai, China
| | - Na Lu
- Department of Radiology, Huashan Hospital North, Fudan University, Shanghai, China
| | - Wen Liu
- Department of Radiology, Jinshan Hospital, Fudan University, Shanghai, China,*Correspondence: Wen Liu,
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Pham TT, Lim S, Lin M. Predicting neoadjuvant chemoradiotherapy response with functional imaging and liquid biomarkers in locally advanced rectal cancer. Expert Rev Anticancer Ther 2022; 22:1081-1098. [PMID: 35993178 DOI: 10.1080/14737140.2022.2114457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Non-invasive predictive quantitative biomarkers are required to guide treatment individualization in patients with locally advanced rectal cancer (LARC) in order to maximise therapeutic outcomes and minimise treatment toxicity. Magnetic resonance imaging (MRI), positron emission tomography (PET) and blood biomarkers have the potential to predict chemoradiotherapy (CRT) response in LARC. AREAS COVERED This review examines the value of functional imaging (MRI and PET) and liquid biomarkers (circulating tumor cells (CTCs) and circulating tumor nucleic acid (ctNA)) in the prediction of CRT response in LARC. Selected imaging and liquid biomarker studies are presented and the current status of the most promising imaging (apparent diffusion co-efficient (ADC), Ktrans, SUVmax, metabolic tumor volume (MTV) and total lesion glycolysis (TLG) and liquid biomarkers (circulating tumor cells (CTCs), circulating tumor nucleic acid (ctNA)) is discussed. The potential applications of imaging and liquid biomarkers for treatment stratification and a pathway to clinical translation are presented. EXPERT OPINION Functional imaging and liquid biomarkers provide novel ways of predicting CRT response. The clinical and technical validation of the most promising imaging and liquid biopsy biomarkers in multi-centre studies with harmonised acquisition techniques is required. This will enable clinical trials to investigate treatment escalation or de-escalation pathways in rectal cancer.
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Affiliation(s)
- Trang Thanh Pham
- South West Sydney Clinical School, Faculty of Medicine and Health, University of New South Wales, Liverpool NSW Australia 2170.,Department of Radiation Oncology, Liverpool Cancer Therapy Centre, Liverpool Hospital, Liverpool NSW Australia 2170.,Ingham Institute for Applied Medical Research, Liverpool NSW Australia 2170
| | - Stephanie Lim
- Ingham Institute for Applied Medical Research, Liverpool NSW Australia 2170.,Department of Medical Oncology, Macarthur Cancer Therapy Centre, Campbelltown Hospital, Campbelltown Australia 2560.,School of Medicine, Western Sydney University, Campbelltown, Sydney 2560
| | - Michael Lin
- South West Sydney Clinical School, Faculty of Medicine and Health, University of New South Wales, Liverpool NSW Australia 2170.,School of Medicine, Western Sydney University, Campbelltown, Sydney 2560.,Department of Nuclear Medicine, Liverpool Hospital, Liverpool NSW Australia 2170
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Cerdán-Santacruz C, Vailati BB, São Julião GP, Habr-Gama A, Pérez RO. Watch and wait: Why, to whom and how. Surg Oncol 2022; 43:101774. [DOI: 10.1016/j.suronc.2022.101774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 04/12/2022] [Indexed: 12/26/2022]
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Kim JK, Thompson H, Jimenez-Rodriguez RM, Wu F, Sanchez-Vega F, Nash GM, Guillem JG, Paty PB, Wei IH, Pappou EP, Widmar M, Weiser MR, Smith JJ, Garcia-Aguilar J. Adoption of Organ Preservation and Surgeon Variability for Patients with Rectal Cancer Does Not Correlate with Worse Survival. Ann Surg Oncol 2022; 29:1172-1179. [PMID: 34601641 PMCID: PMC8727510 DOI: 10.1245/s10434-021-10877-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 09/04/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND OBJECTIVES Watch-and-wait is variably adopted by surgeons and the impact of this on outcomes is unknown. We compared the disease-free survival and organ preservation rates of locally advanced rectal cancer patients treated by expert colorectal surgeons at a comprehensive cancer center. METHODS This study included retrospective data on patients diagnosed with stage II/III rectal adenocarcinoma from January 2013 to June 2017 who initiated neoadjuvant therapy (either with chemoradiation, chemotherapy, or a combination of both) and were treated by an expert colorectal surgeon. RESULTS Overall, 444 locally advanced rectal cancer patients managed by five surgeons were included. Tumor distance from the anal verge, type of neoadjuvant therapy, and organ preservation rates varied by treating surgeon. There was no difference in disease-free survival after stratifying by the treating surgeon (p = 0.2). On multivariable analysis, neither the type of neoadjuvant therapy nor the treating surgeon was associated with disease-free survival. CONCLUSIONS While neoadjuvant therapy type and organ preservation rates varied among surgeons, there were no meaningful differences in disease-free survival. These data suggest that among expert colorectal surgeons, differing thresholds for selecting patients for watch-and-wait do not affect survival.
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Affiliation(s)
- Jin K. Kim
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Hannah Thompson
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | | | - Fan Wu
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Francisco Sanchez-Vega
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA,Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Garrett M. Nash
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Jose G. Guillem
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Philip B. Paty
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Iris H. Wei
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Emmanouil P. Pappou
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Maria Widmar
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Martin R. Weiser
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - J. Joshua Smith
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Julio Garcia-Aguilar
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, USA
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Vendrely V, Rullier E. [Rectal Cancer: Organ preservation and neoadjuvant treatment escalation]. Bull Cancer 2021; 108:1126-1131. [PMID: 34802716 DOI: 10.1016/j.bulcan.2021.09.007] [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: 09/02/2021] [Accepted: 09/17/2021] [Indexed: 11/15/2022]
Abstract
Standard treatment consisting of chemoradiotherapy followed by radical surgery with total mesorectal excision, results in good oncologic local control but high morbidity and poor functional results. Since chemoradiotherapy results in 15% pathological complete response, even reaching up to 30% in case of association with neoadjuvant chemotherapy, radical surgery has been recently debated for good responders. Therefore, a de-escalation strategy, by omitting radical surgery in good responders, has recently been developed with two different options: a watch and wait strategy, requiring an accurate clinical and radiological definition of complete response and a local excision strategy including patients with sub-complete response. Ongoing trials focus on response optimization by chemotherapy intensification or radiotherapy dose escalation. However, many questions are still to be answered regarding definition of complete response, follow-up strategy, morbidity of salvage surgery in case of recurrence as well as long-term oncological and functionnal results.
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Affiliation(s)
- Véronique Vendrely
- Hôpital Haut Lévêque, université de Bordeaux, service d'oncologie radiothérapie, avenue de Magellan, 33604 Pessac cédex, France.
| | - Eric Rullier
- Hôpital Haut Lévêque, université de Bordeaux, service de chirurgie centre Magellan, avenue de Magellan, 33604 Pessac cédex, France
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Kokaine L, Gardovskis A, Gardovskis J. Evaluation and Predictive Factors of Complete Response in Rectal Cancer after Neoadjuvant Chemoradiation Therapy. ACTA ACUST UNITED AC 2021; 57:medicina57101044. [PMID: 34684080 PMCID: PMC8537499 DOI: 10.3390/medicina57101044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/16/2021] [Accepted: 09/23/2021] [Indexed: 12/18/2022]
Abstract
The response to neoadjuvant chemoradiation therapy is an important prognostic factor for locally advanced rectal cancer. Although the majority of the patients after neoadjuvant therapy are referred to following surgery, the clinical data show that complete clinical or pathological response is found in a significant proportion of the patients. Diagnostic accuracy of confirming the complete response has a crucial role in further management of a rectal cancer patient. As the rate of clinical complete response, unfortunately, is not always consistent with pathological complete response, accurate diagnostic parameters and predictive markers of tumor response may help to guide more personalized treatment strategies and identify potential candidates for nonoperative management more safely. The management of complete response demands interdisciplinary collaboration including oncologists, radiotherapists, radiologists, pathologists, endoscopists and surgeons, because the absence of a multidisciplinary approach may compromise the oncological outcome. Prediction and improvement of rectal cancer response to neoadjuvant therapy is still an active and challenging field of further research. This literature review is summarizing the main, currently known clinical information about the complete response that could be useful in case if encountering such condition in rectal cancer patients after neoadjuvant chemoradiation therapy, using as a source PubMed publications from 2010–2021 matching the search terms “rectal cancer”, “neoadjuvant therapy” and “response”.
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Affiliation(s)
- Linda Kokaine
- Department of Surgery, Riga Stradins University, Dzirciema Street 16, LV-1007 Riga, Latvia; or
- Pauls Stradins Clinical University Hospital, Pilsoņu Street 13, LV-1002 Riga, Latvia
- Correspondence: (L.K.); (J.G.); Tel.: +371-2635-9472 (L.K.)
| | - Andris Gardovskis
- Department of Surgery, Riga Stradins University, Dzirciema Street 16, LV-1007 Riga, Latvia; or
- Pauls Stradins Clinical University Hospital, Pilsoņu Street 13, LV-1002 Riga, Latvia
| | - Jānis Gardovskis
- Department of Surgery, Riga Stradins University, Dzirciema Street 16, LV-1007 Riga, Latvia; or
- Pauls Stradins Clinical University Hospital, Pilsoņu Street 13, LV-1002 Riga, Latvia
- Correspondence: (L.K.); (J.G.); Tel.: +371-2635-9472 (L.K.)
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Kong JC, Ryan J, Akhurst T, Ngan SY, Michael M, Tie J, Warrier SK, Heriot AG. The predictive value of PET/CT for distant recurrences in locally advanced rectal cancer treated with neoadjuvant chemoradiotherapy. J Med Imaging Radiat Oncol 2021; 65:917-924. [PMID: 34435447 DOI: 10.1111/1754-9485.13315] [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: 07/26/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION It is well recognized that pathological complete response (pCR) for locally advanced rectal cancer after neoadjuvant chemoradiotherapy (CRT) confers a positive survival advantage. Despite this, a small proportion of patients can develop distant recurrence, and these are the patients that will likely benefit from adjuvant therapy. This study aims to investigate the role of PET/CT as a functional imaging to stratify patients according to their risk of distant recurrence. METHODS This is a retrospective analysis of a prospectively maintained database in a single quaternary teaching hospital from 2010 to 2019. All consecutive cases of locally advanced rectal cancer with restaging PET/CT were included. The primary outcome measure was 5-year OS and distant recurrence-free survival. RESULTS A pCR and complete metabolic response (CMR) were identified in 47 (18%) patients and 73 (27.4%) patients respectively. Of these, 26 patients had both pCR and CMR and these patients remained free of local and distant recurrence at their last censored date. Patients with both pCR and CMR achieved the highest 5-year overall survival of 96.2%, followed by those with pCR and incomplete CMR (iCMR) of 85.7%, non-pCR and CMR of 85.1% and non-pCR and iCMR of 83.1%. Independent predictors for 5-year distant recurrence-free survival were pathological and PET metabolic response, nodal staging and lymphovascular invasion (LVI). CONCLUSION In conclusion, a PET/CT has the potential to better stratify patients of their risk of distant metastasis. However, a larger validation cohort is required before these findings can be translated to clinical utility.
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Affiliation(s)
- Joseph C Kong
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Jennifer Ryan
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Timothy Akhurst
- Division of Nuclear Medicine, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Samuel Y Ngan
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Michael Michael
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,Division of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Jeanne Tie
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,Division of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Division of Personalised Oncology, Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australia
| | - Satish K Warrier
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Alexander G Heriot
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
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Lee W, Oh M, Kim JS, Park Y, Kwon JW, Jun E, Song KB, Lee JH, Hwang DW, Yoo C, Kim KP, Jeong JH, Chang HM, Ryoo BY, Park SY, Kim SC. Metabolic activity by FDG-PET/CT after neoadjuvant chemotherapy in borderline resectable and locally advanced pancreatic cancer and association with survival. Br J Surg 2021; 109:61-70. [PMID: 34378010 DOI: 10.1093/bjs/znab229] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 04/11/2021] [Accepted: 05/19/2021] [Indexed: 11/14/2022]
Abstract
BACKGROUND The optimal prognostic markers for neoadjuvant chemotherapy in patients with borderline resectable or locally advanced pancreatic cancer are not yet established. METHOD Patients who received neoadjuvant chemotherapy prior to surgery and underwent FDG-PET/CT between July 2012 and December 2017 were included. Metabolic parameters including standardised uptake value (SUV), metabolic tumour volume (MTV), and total lesion glycolysis (TLG) on PET/CT, and response evaluations using PERCIST criteria, were investigated for its impact on survival and recurrence. Cox proportional hazards model was performed. Differences in risk were expressed as hazard ratio [HR] with 95% confidence interval [c.i.]. RESULTS The patients with borderline resectable (N = 106) or locally advanced pancreatic cancer (N = 82) were identified. The median survival was 33.6 months. Decreased metabolic parameters of PET/CT after neoadjuvant chemotherapy were associated with positive impacts on survival and recurrence such as SUVmax (HR 1.16, 95% c.i. 1.01 to 1.32, P = 0.025), SUVpeak (HR 1.26, 95% c.i. 1.05 to 1.51, P = 0.011), and MTV (HR 1.15, 95% c.i. 1.04 to 1.26, P = 0.005). Large delta values were related to a positive impact on recurrence such as SUVmax (HR 1.21, 95% c.i. 1.06 to 1.38, P = 0.005). Post-neoadjuvant chemotherapy SUVmax ≥3 (HR 3.46, 95% c.i. 1.21 to 9.91; P = 0.036) was an independent prognostic factor for negative impact on survival. Patients with post-neoadjuvant chemotherapy SUVmax <3 showed more chemotherapy cycles (8.7 versus 6.2, P = 0.001), more frequent complete metabolic response (25 vs 2.2%, P = 0.002), smaller tumour size (2.1 vs 3.1 cm, P = 0.002), and less frequent lymphovascular invasion (23.7 vs 51.1%, P = 0.020) than patients with SUVmax ≥3. CONCLUSION Reduction in metabolic tumour parameters of FDG- PET/CT after neoadjuvant chemotherapy indicates improved overall survival and recurrence-free survival.
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Affiliation(s)
- Woohyung Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Minyoung Oh
- Department of Nuclear Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae Seung Kim
- Department of Nuclear Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yejong Park
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jae Woo Kwon
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Eunsung Jun
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Ki Byung Song
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jae Hoon Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Dae Wook Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Changhoon Yoo
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Kyu-Pyo Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jae Ho Jeong
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Heung-Moon Chang
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Baek-Yeol Ryoo
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Seo Young Park
- Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea.,Department of Statistics and Data Science, Korea National Open University, Seoul, Republic of Korea
| | - Song Cheol Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
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de Andrade V, Leal R, Fagundes J, Rodrigues Coy C, de Lourdes Setsuko Ayrizono M. Neoadjuvant Therapy and Surgery in Rectal Adenocarcinoma: Analysis of Patients with Complete Tumor Remission. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1016/j.jcol.2013.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Abstract
Introduction: the standard treatment for locally advanced extra-peritoneal rectal adenocarcinoma, consists of neoadjuvant treatment with radiotherapy and chemotherapy followed by total mesorectal excision.
Objective: evaluate, retrospectively, the patients submitted to neoadjuvant therapy and surgery that presents with total remission of the lesion in the anatomopathological examination.
Methods: between 2000 and 2010, 212 patients underwent surgery at the Coloproctology Unit at DMAD at FCM–UNICAMP. They were grouped as: rectosigmoidectomy and colorectal anastomosis (n = 54), rectosigmoidectomy with coloanal anastomosis (n = 41), 114 abdominoperineal resection of the rectum (n = 114) and other (n = 3).
Results: thirty (14.2%) patients (mean age 57.6 years; 60% males) showed complete remission of the rectal lesion. 4 (13.3%) had compromised lymph nodes and/or lymphatic invasionAt follow-up (mean 51.9 months), 4 (13.3%) presented with local recurrence (one patient) or distant metastases (two patients had liver metastasis, one had liver and lung, and one had bone metastasis). The mean survival was 86.7%.
Conclusion: patients with a complete tumor response show ed an increased survival rate, however, the same patients without evidence of residual tumors could develop local recurrence or distant metastases on a later follow-up.
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Affiliation(s)
- V.A. de Andrade
- School of Medical Sciences, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil
| | - R.F. Leal
- Service of Coloproctology, Departament of Surgery, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil
| | - J.J. Fagundes
- Service of Coloproctology, Departament of Surgery, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil
| | - C.S. Rodrigues Coy
- Service of Coloproctology, Departament of Surgery, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil
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14
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López-López V, Abrisqueta Carrión J, Luján J, B Lynn P, Frutos L, Ono A, Ortiz E, López-Espín JJ, Gil J, Parrilla P. Assessing tumor response to neoadjuvant chemoradiation in rectal cancer with rectoscopy and 18F-FDG PET/CT: results from a prospective series. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 113:307-312. [PMID: 33054291 DOI: 10.17235/reed.2020.6954/2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION rectoscopy and 18F-FDG PET/CT as a diagnostic algorithm for the assessment of tumor response in rectal cancer after neoadjuvant chemoradiation therapy (CRT) is very useful. MATERIAL AND METHODS this was a prospective longitudinal study in patients with locally advanced rectal cancer treated with neoadjuvant CRT. Patients were assessed after CRT completion with a digital rectal examination, proctoscopy and 18F-FDG PET/CT. Patients were subdivided as clinical (cCR) or radiologic (rCR) responders and non-responders according to tumor response. Clinical and radiological re-assessment was compared with the surgical specimen. Pathological tumor regression (pCR) grade was determined according to Mandard's classification. Of the 68 patients included, 15 (22 %) presented pCR in the surgical specimen and tumor persistence (non-PCR) was detected in the remaining 53 (78 %). Clinical assessment (DRE+ rectoscopy) identified 15 patients as cCR and 53 as non-cCR, two were false positives and two were false negatives. The overall accuracy was 94 %. 18F-FDG PET/CT identified 18 patients as rCR and 50 as non-rCR, one was a false positive and four were false negatives. The overall accuracy was 92 %. A combination of clinical findings and 18F-FDG PET/CT resulted in an accuracy of 96 %. The combination of clinical findings + 18F-FDG PET/CT was able to correctly identify all cases of pCR, with the exception of one case that presented a tumor regression of 80 %. In this series, 18F-PET-CT and clinical assessment had excellent accuracies in differentiating PCR from non-PCR after CRT completion. PET-CT combined with clinical assessment had a better accuracy than both modalities independently. 18F-FDG PET/CT is a valid tool that complements the clinical assessment of tumor response.
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Affiliation(s)
- Víctor López-López
- Cirugía General y del Aparato Digestivo, Hospital Clínico Universitario Virgen de la Arrixaca, España
| | - Jesús Abrisqueta Carrión
- Cirugía General y del Aparato Digestivo, Hospital Clínico Universitario Virgen de la Arrixaca, España
| | - Juan Luján
- Cirugía General y Aparato Digestivo, Hospital Clínico Universitario Virgen de la Arrixaca
| | | | - Laura Frutos
- Radiología Nuclear, Hospital Clínico Universitario Virgen de la Arrixaca
| | - Akiko Ono
- Digestivo/Endoscopias, Hospital Clínico Universitario Virgen de la Arrixaca
| | - Eduardo Ortiz
- Anatomía Patológica, Hospital Clínico Universitario Virgen de la Arrixaca
| | | | - José Gil
- Cirugía General y del Aparato Digestivo, Hospital Clínico Universitario Virgen de la Arrixaca
| | - Pascual Parrilla
- Cirugía General y del Aparato Digestivo, Hospital Clínico Universitario Virgen de la Arrixaca
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15
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Valkema MJ, van der Wilk BJ, Eyck BM, Wijnhoven BPL, Spaander MCW, Doukas M, Lagarde SM, Schreurs WMJ, Roef MJ, van Lanschot JJB, Valkema R. Surveillance of Clinically Complete Responders Using Serial 18F-FDG PET/CT Scans in Patients with Esophageal Cancer After Neoadjuvant Chemoradiotherapy. J Nucl Med 2020; 62:486-492. [PMID: 32887759 DOI: 10.2967/jnumed.120.247981] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 07/30/2020] [Indexed: 12/16/2022] Open
Abstract
Active surveillance for patients with esophageal cancer and a clinically complete response (cCR) after neoadjuvant chemoradiotherapy (nCRT) is being studied. Active surveillance requires accurate clinical response evaluations. 18F-FDG PET/CT might be able to detect local tumor recurrence after nCRT as soon as the esophagus recovers from radiation-induced esophagitis. The aims of this study were to assess the value of serial 18F-FDG PET/CT scans for detecting local recurrence in patients beyond 3 mo after nCRT and to determine when radiation-induced esophagitis has resolved. Methods: This retrospective multicenter study included patients who had cCR after nCRT, who initially declined surgery, and who subsequently underwent active surveillance. Clinical response evaluations included 18F-FDG PET/CT, endoscopic biopsies, and endoscopic ultrasound with fine-needle aspiration at regular intervals. SUVmax normalized for lean body mass (SULmax) was measured at the primary tumor site. The percentage change in SULmax (Δ%SULmax) between the last follow-up scan and the scan at 3 mo after nCRT was calculated. Tumor recurrence was defined as biopsy-proven vital tumor at the initial tumor site. Results: Of 41 eligible patients, 24 patients had recurrent disease at a median of 6.5 mo after nCRT and 17 patients remained cancer free during a median follow-up of 24 mo after nCRT. Five of 24 patients with tumor recurrence had sudden intense SULmax increases of greater than 180%. In 19 of 24 patients with tumor recurrence, SULmax gradually increased (median Δ%SULmax, +18%), whereas SULmax decreased (median Δ%SULmax, -12%) in patients with ongoing cCR (P < 0.001, independent-samples t test). In patients with ongoing cCR, SULmax was lowest at 11 mo after nCRT. Conclusion: Serial 18F-FDG PET/CT might be a useful tool for detecting tumor recurrence during active surveillance. In patients with ongoing cCR, the lowest SULmax was reached at 11 mo after nCRT, suggesting that radiation-induced esophagitis had mostly resolved by that time. These findings warrant further evaluation in a larger cohort.
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Affiliation(s)
- Maria J Valkema
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Berend J van der Wilk
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ben M Eyck
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Manon C W Spaander
- Department of Gastroenterology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Michail Doukas
- Department of Pathology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sjoerd M Lagarde
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Wendy M J Schreurs
- Department of Nuclear Medicine, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Mark J Roef
- Department of Nuclear Medicine, Catharina Hospital Eindhoven, Eindhoven, The Netherlands; and
| | - J Jan B van Lanschot
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Roelf Valkema
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
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16
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Dang Y, Gao H, Huang S, Qi T. Clinical complete regression after local radiotherapy combined with chemotherapy for stage IV rectal cancer: A case report. Mol Clin Oncol 2020; 13:186-190. [PMID: 32714544 DOI: 10.3892/mco.2020.2049] [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: 09/28/2019] [Accepted: 04/09/2020] [Indexed: 11/06/2022] Open
Abstract
Colorectal cancer is the fourth most common type of cancer worldwide with about 0.8 million new cases annually. Improving patient survival remains a challenge for clinicians. Observation waiting method provides improved quality of life compared with direct surgery. This case report suggested that colorectal cancer patients could choose active observation waiting method for treatment. A 59-year-old male patient, with rectal bleeding and an Eastern Cooperative Oncology Group (ECOG) performance status score of 0, was admitted to the hospital due to increased fecal blood volume. The electronic colonoscopy revealed multiple polyps in colon and rectum, whereas the pathological biopsy indicated poorly differentiated rectal adenocarcinoma. The clinical stage was defined as T3N2M1a according to the TNM classification of the American Joint Committee on Cancer (AJCC) staging manual (version 8). In addition, positron emission tomography/computed tomography (PET/CT) examination showed non-regional lymph node metastasis (subclavian). Subsequently, the expression of PD-L1 (-), NRAS (-), KRAS (-), HRAS (-), BRAF (-) (-, negative) and the microsatellite stability (MSS) were detected in the rectal cancer lesion using molecular pathological examination. Patients with primary rectal cancer and pelvic lymph node metastasis were treated with three-dimensional conformal radiotherapy (3D-CRT; dose, 60 Gy/30 Fr) and XELOX chemotherapy (200 mg oxaliplatin at day 1 plus 1.5 g capecitabine twice a day from day 1-14 for a total of 5 cycles). PET/CT scan revealed that the metabolism levels of the lesion returned to normal. In addition, the routine re-examination showed progressive improvement of tumor lesions. Until recently, the carcinoembryonic antigen (CEA) level of the male patient has been within normal range. The observation waiting method rather than the direct sequential surgical resection of the primary lesion in patients with advanced rectal cancer who achieved complete clinical remission (CCR) may provide a novel treatment method for rectal cancer. Thus, overall survival (OS) and quality of survival (QoS) differences between the two strategies need to be further verified by multicenter clinical trials.
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Affiliation(s)
- Yazheng Dang
- Department of Radiation Oncology, 986 Hospital of People's Liberation Army Air Force, Xi'an, Shaanxi 710054, P.R. China
| | - Hongxiang Gao
- Department of Oncology, Chang An Hospital, Xi'an, Shaanxi 710018, P.R. China
| | - Shigao Huang
- Cancer Center, Faculty of Health Sciences, University of Macau, Taipa, Macao SAR 999078, P.R. China.,Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Taipa, Macao SAR 999078, P.R. China
| | - Tao Qi
- Department of Radiation Oncology, 986 Hospital of People's Liberation Army Air Force, Xi'an, Shaanxi 710054, P.R. China
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17
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AlQudah M, Salmo E, Haboubi N. The effect of radiotherapy on rectal cancer: a histopathological appraisal and prognostic indicators. Radiat Oncol J 2020; 38:77-83. [PMID: 33012150 PMCID: PMC7533410 DOI: 10.3857/roj.2020.00010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 04/13/2020] [Indexed: 12/13/2022] Open
Abstract
The management of rectal cancer is a major undertaking. There are currently multiple treatment modalities with variable degrees of complications. Radiotherapy (RT) is one of the more frequently used modalities either on its own or more frequently with chemotherapy mostly before the definitive surgery. The outcome of RT is unpredictable. RT has its serious side effects and there are no guarantees of its usefulness in all patients. This article outlines the effect of RT on the tumor, reviews the various staging systems of responses to RT and present recent evidence of which case is less responsive to such treatments to avoid unnecessary complications.
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Affiliation(s)
- Mohammad AlQudah
- Department of Pathology and Microbiology, School of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Emil Salmo
- Department of Histopathology, The Pennine Acute Hospitals NHS Trust, The Royal Oldham Hospital, Oldham, UK
| | - Najib Haboubi
- Department of Histopathology, Spire Manchester Hospital, Manchester, UK
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18
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Pinto JC, Pereira AD, Pimenta A, Pedro C, Fernandez G, Marques I, Miguel I, Freire J, Maciel J, Venâncio J, D'Orey L, Mirones L, Limbert M, Labareda M, Chaves P, Fonseca R, Barroca R, Ferreira T, Marques T, Rosa I. Low rectal cancer treatment strategies: a cohort study assessing watch and wait. J Cancer Res Clin Oncol 2020; 146:2631-2638. [PMID: 32435893 DOI: 10.1007/s00432-020-03248-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 05/05/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Treatment strategies for low rectal cancer have been evolving toward achieving less treatment morbidity with the same oncological success-we aimed to assess the results of the new watch and wait (W&W) strategy in our cohort. METHODS A tertiary care cohort study was conducted. New patients with rectal adenocarcinoma up to 6 cm from the anal margin, cM0, locally staged higher than cT1N0, evaluated between November 2014 and October 2018, were included. All 93 patients received neoadjuvant radiotherapy ± chemotherapy. Re-evaluation was planned 8-12 weeks after the end of treatment. Patients showing clinical complete response (cCR) were given the choice of either to proceed to surgery or to enter W&W. RESULTS Of the 93 patients, 82.8% were re-evaluated and 20.8% had cCR. Patients in clinical stages II/III were significantly less likely to achieve cCR than those in stage I (p = 0.017). After a mean follow-up of 17.44 months, there were 4 regrowths in the 16 patients under W&W, all submitted to R0 surgery, ypN0; there were no deaths or local recurrences; one patient with regrowth had distant recurrence. Sixty patients underwent direct surgery after a mean follow-up of 16.23 months; 3 patients had local and distant recurrences; 7 others had only distant recurrences; there were 8 deaths. There were no statistically significant differences between patients under W&W and patients who underwent direct surgery regarding local or distant recurrences, or death (p > 0.9; p = 0.44; p = 0.19, respectively). CONCLUSION The W&W strategy for low rectal cancer achieved the same oncological outcomes as the traditional strategy while sparing some patients from surgery.
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Affiliation(s)
- João Cortez Pinto
- Gastroenterology Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Serviço de Gastrenterologia, Rua Prof. Lima Basto, 1099-023, Lisboa, Portugal
| | - António Dias Pereira
- Gastroenterology Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Serviço de Gastrenterologia, Rua Prof. Lima Basto, 1099-023, Lisboa, Portugal
| | - Ana Pimenta
- Radiotherapy Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Lisboa, Portugal
| | - Cátia Pedro
- Radiotherapy Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Lisboa, Portugal
| | - Gonçalo Fernandez
- Radiotherapy Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Lisboa, Portugal
| | - Inês Marques
- Gastroenterology Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Serviço de Gastrenterologia, Rua Prof. Lima Basto, 1099-023, Lisboa, Portugal
| | - Isália Miguel
- Oncology Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Lisboa, Portugal
| | - João Freire
- Oncology Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Lisboa, Portugal
| | - João Maciel
- Surgery Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Lisboa, Portugal
| | - José Venâncio
- Radiology Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Lisboa, Portugal
| | - Luís D'Orey
- Surgery Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Lisboa, Portugal
| | - Luísa Mirones
- Radiotherapy Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Lisboa, Portugal
| | - Manuel Limbert
- Surgery Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Lisboa, Portugal
| | - Miguel Labareda
- Radiotherapy Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Lisboa, Portugal
| | - Paula Chaves
- Pathology Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Lisboa, Portugal
| | - Ricardo Fonseca
- Pathology Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Lisboa, Portugal
| | - Rita Barroca
- Surgery Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Lisboa, Portugal
| | - Teresa Ferreira
- Nuclear Medicine Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Lisboa, Portugal
| | - Teresa Marques
- Oncology Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Lisboa, Portugal
| | - Isadora Rosa
- Gastroenterology Department, Instituto Português de Oncologia de Lisboa, Francisco Gentil, EPE, Serviço de Gastrenterologia, Rua Prof. Lima Basto, 1099-023, Lisboa, Portugal.
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19
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Rodríguez-Fraile M, Cózar-Santiago M, Sabaté-Llobera A, Caresia-Aróztegui A, Delgado-Bolton R, Orcajo-Rincon J, de Arcocha-Torres M, García-Velloso M, García-Talavera P. FDG PET/CT in colorectal cancer. Rev Esp Med Nucl Imagen Mol 2020. [DOI: 10.1016/j.remnie.2019.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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20
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Rodríguez-Fraile M, Cózar-Santiago MP, Sabaté-Llobera A, Caresia-Aróztegui AP, Delgado Bolton RC, Orcajo-Rincon J, de Arcocha-Torres M, García-Velloso MJ, García-Talavera P. FDG PET/CT in colorectal cancer. Rev Esp Med Nucl Imagen Mol 2019; 39:57-66. [PMID: 31776063 DOI: 10.1016/j.remn.2019.09.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 09/06/2019] [Accepted: 09/09/2019] [Indexed: 12/24/2022]
Abstract
Colorectal cancer is the third most frequent cancer worldwide. Although its incidence is increasing, mainly in those aged under50, mortality has decreased by 50% in the more developed countries, principally due to the adoption of new practices in prevention, diagnosis and treatment. In particular, the various diagnostic imaging modalities allow improved therapeutic decision-making, evaluation of the response and early detection of recurrence. The aim of this paper is to review the available scientific evidence on the value of positron emission tomography with 18F-FDG (18F-FDG PET/CT) in the colorectal cancer, with special emphasis on the indications of the guidelines and recommendations of the main international scientific associations regarding this imaging technique.
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Affiliation(s)
- M Rodríguez-Fraile
- Servicio de Medicina Nuclear, Clínica Universidad de Navarra, Pamplona, España; Grupo de Trabajo de Oncología de la Sociedad Española de Medicina Nuclear e Imagen Molecular.
| | - M P Cózar-Santiago
- Servicio de Medicina Nuclear, ERESA-Hospital General Universitario de Valencia, Valencia, España; Grupo de Trabajo de Oncología de la Sociedad Española de Medicina Nuclear e Imagen Molecular
| | - A Sabaté-Llobera
- Servicio de Medicina Nuclear-IDI, Hospital Universitario de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, España; Grupo de Trabajo de Oncología de la Sociedad Española de Medicina Nuclear e Imagen Molecular
| | - A P Caresia-Aróztegui
- Servicio de Medicina Nuclear, Parc Taulí Hospital Universitari, Corporació Sanitària Parc Taulí, Sabadell, Barcelona, España; Grupo de Trabajo de Oncología de la Sociedad Española de Medicina Nuclear e Imagen Molecular
| | - R C Delgado Bolton
- Departamento de Diagnóstico por la Imagen y Medicina Nuclear, Hospital San Pedro-Centro de Investigación Biomédica de La Rioja (CIBIR), Logroño, España; Grupo de Trabajo de Oncología de la Sociedad Española de Medicina Nuclear e Imagen Molecular
| | - J Orcajo-Rincon
- Servicio de Medicina Nuclear, Hospital General Universitario Gregorio Marañón, Madrid, España; Grupo de Trabajo de Oncología de la Sociedad Española de Medicina Nuclear e Imagen Molecular
| | - M de Arcocha-Torres
- Unidad de Radiofarmacia, Hospital Universitario Marqués de Valdecilla, Santander, España; Grupo de Trabajo de Oncología de la Sociedad Española de Medicina Nuclear e Imagen Molecular
| | - M J García-Velloso
- Servicio de Medicina Nuclear, Clínica Universidad de Navarra, Pamplona, España; Grupo de Trabajo de Oncología de la Sociedad Española de Medicina Nuclear e Imagen Molecular
| | - P García-Talavera
- Servicio de Medicina Nuclear, Hospital Universitario de Salamanca, Salamanca, España; Grupo de Trabajo de Oncología de la Sociedad Española de Medicina Nuclear e Imagen Molecular
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Oncological and Survival Outcomes in Watch and Wait Patients With a Clinical Complete Response After Neoadjuvant Chemoradiotherapy for Rectal Cancer: A Systematic Review and Pooled Analysis. Ann Surg 2019; 268:955-967. [PMID: 29746338 DOI: 10.1097/sla.0000000000002761] [Citation(s) in RCA: 164] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the oncological and survival outcomes of a Watch and Wait policy in rectal cancer after a clinical complete response (cCR) following neoadjuvant chemoradiotherapy. BACKGROUND The detection of a cCR after neoadjuvant treatment may facilitate a nonoperative approach in selected patients. However, the long-term safety of this strategy remains to be validated. METHOD This is a systematic review of the literature to determine the oncological outcomes in Watch and Wait patients. The primary outcome was the cumulative rate of local regrowth, success of salvage surgery, and incidence of metastases. We also evaluated survival outcomes. A pooled analysis of manually extracted summary statistics from individual studies was carried out using inverse variance weighting. RESULTS Seventeen studies comprising 692 patients were identified; incidence of cCR was 22.4% [95% confidence interval (CI),14.3-31.8]. There were 153 (22.1%) local regrowths, of which 96% (n = 147/153) manifested in the first 3 years of surveillance. The 3-year cumulative risk of local regrowth was 21.6% (95% CI, 16.0-27.8). Salvage surgery was performed in 88% of patients, of which 121 (93%) had a complete (R0) resection. Fifty-seven metastases (8.2%) were detected, and 35 (60%) were isolated without evidence of synchronous regrowths; 3-year incidence was 6.8% (95% CI, 4.1-10.2). The 3-year overall survival was 93.5% (95% CI, 90.2-96.2). CONCLUSION In rectal cancer patients with a cCR following neoadjuvant chemoradiotherapy, a Watch and Wait policy appears feasible and safe. Robust surveillance with early detection of regrowths allows a high rate of successful salvage surgery, without an increase in the risk of systemic disease, or adverse survival outcomes.
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Strode M, Shah R, Boland PM, Francescutti VA, Mangieri CW, Attwood K, Nurkin SJ. Nonoperative management after neoadjuvant therapy for rectal cancer: A single institution experience over 5 years. Surg Oncol 2019; 28:116-120. [DOI: 10.1016/j.suronc.2018.11.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 11/12/2018] [Indexed: 01/01/2023]
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Kong JCH, Guerra GR, Millen RM, Roth S, Xu H, Neeson PJ, Darcy PK, Kershaw MH, Sampurno S, Malaterre J, Liu DSH, Pham TD, Narasimhan V, Wang M, Huang YK, Visvanathan K, McCormick J, Lynch AC, Warrier S, Michael M, Desai J, Murray W, Mitchell C, Ngan S, Phillips WA, Heriot AG, Ramsay RG. Tumor-Infiltrating Lymphocyte Function Predicts Response to Neoadjuvant Chemoradiotherapy in Locally Advanced Rectal Cancer. JCO Precis Oncol 2018; 2:1-15. [DOI: 10.1200/po.18.00075] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Purpose The presence of tumor-infiltrating lymphocytes (TILs) in tumors is superior to conventional pathologic staging in predicting patient outcome. However, their presence does not define TIL functionality. Here we developed an assay that tests TIL cytotoxicity in patients with locally advanced rectal cancer before definitive treatment, identifying those who will obtain a pathologic complete response (pCR). We also used the assay to demonstrate the rescue of TIL function after checkpoint inhibition blockade (CIB). Patients and Methods Thirty-four consecutive patients were identified initially, with successful completion of the assay before surgery in those 17 patients who underwent full treatment. An in vitro cytotoxic assay of rectal cancer tumoroids cocultured with patient-matched TILs was established and validated. Newly diagnosed patients were recruited with pretreatment biopsy specimens processed within 1 month. Evaluation of TIL-mediated tumoroid lysis was performed by measuring the mean fluorescence intensity of cell death marker, propidium iodide. CIB (anti–programmed cell death protein 1 [anti–PD-1] antibody) response was also assessed in a subset of patient specimens. Results Six of the 17 patients achieved an objective pCR on final evaluation of the resected specimen after neoadjuvant chemoradiotherapy. Cytotoxic killing identified the pCR group with a higher mean fluorescence intensity (27,982 [95% CI, 25,340 to 30,625]) compared with the non-pCR cohort (12,428 [95% CI, 9,434 to 15,423]; p < .001). Assessment of the effectiveness of CIB revealed partial restoration of cytotoxicity in TILs with increased PD-1 expression with anti–PD-1 antibody exposure. Conclusion Evaluating TIL function can be undertaken within weeks of the diagnostic biopsy, affording the potential to alter patient management decisions and refine selection for a watch-and-wait protocol. This cytotoxic assay also has the potential to serve as a platform to assist in the additional development of CIB.
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Affiliation(s)
- Joseph Cherng Huei Kong
- Joseph Cherng Huei Kong, Glen Robert Guerra, Rosemary Magdalena Millen, Sara Roth, Huiling Xu, Paul Joseph Neeson, Phillip Kevin Darcy, Michael Henry Kershaw, Shienny Sampurno, Jordane Malaterre, David Shi Hao Liu, Toan Duc Pham, Vignesh Narasimhan, Minyu Wang, Yu-Kuan Huang, Jacob McCormick, Andrew Craig Lynch, Satish Warrier, Michael Michael, Jayesh Desai, William Murray, Catherine Mitchell, Samuel Ngan, Wayne Allen Phillips, Alexander Graham Heriot, and Robert George Ramsay, Peter MacCallum Cancer
| | - Glen Robert Guerra
- Joseph Cherng Huei Kong, Glen Robert Guerra, Rosemary Magdalena Millen, Sara Roth, Huiling Xu, Paul Joseph Neeson, Phillip Kevin Darcy, Michael Henry Kershaw, Shienny Sampurno, Jordane Malaterre, David Shi Hao Liu, Toan Duc Pham, Vignesh Narasimhan, Minyu Wang, Yu-Kuan Huang, Jacob McCormick, Andrew Craig Lynch, Satish Warrier, Michael Michael, Jayesh Desai, William Murray, Catherine Mitchell, Samuel Ngan, Wayne Allen Phillips, Alexander Graham Heriot, and Robert George Ramsay, Peter MacCallum Cancer
| | - Rosemary Magdalena Millen
- Joseph Cherng Huei Kong, Glen Robert Guerra, Rosemary Magdalena Millen, Sara Roth, Huiling Xu, Paul Joseph Neeson, Phillip Kevin Darcy, Michael Henry Kershaw, Shienny Sampurno, Jordane Malaterre, David Shi Hao Liu, Toan Duc Pham, Vignesh Narasimhan, Minyu Wang, Yu-Kuan Huang, Jacob McCormick, Andrew Craig Lynch, Satish Warrier, Michael Michael, Jayesh Desai, William Murray, Catherine Mitchell, Samuel Ngan, Wayne Allen Phillips, Alexander Graham Heriot, and Robert George Ramsay, Peter MacCallum Cancer
| | - Sara Roth
- Joseph Cherng Huei Kong, Glen Robert Guerra, Rosemary Magdalena Millen, Sara Roth, Huiling Xu, Paul Joseph Neeson, Phillip Kevin Darcy, Michael Henry Kershaw, Shienny Sampurno, Jordane Malaterre, David Shi Hao Liu, Toan Duc Pham, Vignesh Narasimhan, Minyu Wang, Yu-Kuan Huang, Jacob McCormick, Andrew Craig Lynch, Satish Warrier, Michael Michael, Jayesh Desai, William Murray, Catherine Mitchell, Samuel Ngan, Wayne Allen Phillips, Alexander Graham Heriot, and Robert George Ramsay, Peter MacCallum Cancer
| | - Huiling Xu
- Joseph Cherng Huei Kong, Glen Robert Guerra, Rosemary Magdalena Millen, Sara Roth, Huiling Xu, Paul Joseph Neeson, Phillip Kevin Darcy, Michael Henry Kershaw, Shienny Sampurno, Jordane Malaterre, David Shi Hao Liu, Toan Duc Pham, Vignesh Narasimhan, Minyu Wang, Yu-Kuan Huang, Jacob McCormick, Andrew Craig Lynch, Satish Warrier, Michael Michael, Jayesh Desai, William Murray, Catherine Mitchell, Samuel Ngan, Wayne Allen Phillips, Alexander Graham Heriot, and Robert George Ramsay, Peter MacCallum Cancer
| | - Paul Joseph Neeson
- Joseph Cherng Huei Kong, Glen Robert Guerra, Rosemary Magdalena Millen, Sara Roth, Huiling Xu, Paul Joseph Neeson, Phillip Kevin Darcy, Michael Henry Kershaw, Shienny Sampurno, Jordane Malaterre, David Shi Hao Liu, Toan Duc Pham, Vignesh Narasimhan, Minyu Wang, Yu-Kuan Huang, Jacob McCormick, Andrew Craig Lynch, Satish Warrier, Michael Michael, Jayesh Desai, William Murray, Catherine Mitchell, Samuel Ngan, Wayne Allen Phillips, Alexander Graham Heriot, and Robert George Ramsay, Peter MacCallum Cancer
| | - Phillip Kevin Darcy
- Joseph Cherng Huei Kong, Glen Robert Guerra, Rosemary Magdalena Millen, Sara Roth, Huiling Xu, Paul Joseph Neeson, Phillip Kevin Darcy, Michael Henry Kershaw, Shienny Sampurno, Jordane Malaterre, David Shi Hao Liu, Toan Duc Pham, Vignesh Narasimhan, Minyu Wang, Yu-Kuan Huang, Jacob McCormick, Andrew Craig Lynch, Satish Warrier, Michael Michael, Jayesh Desai, William Murray, Catherine Mitchell, Samuel Ngan, Wayne Allen Phillips, Alexander Graham Heriot, and Robert George Ramsay, Peter MacCallum Cancer
| | - Michael Henry Kershaw
- Joseph Cherng Huei Kong, Glen Robert Guerra, Rosemary Magdalena Millen, Sara Roth, Huiling Xu, Paul Joseph Neeson, Phillip Kevin Darcy, Michael Henry Kershaw, Shienny Sampurno, Jordane Malaterre, David Shi Hao Liu, Toan Duc Pham, Vignesh Narasimhan, Minyu Wang, Yu-Kuan Huang, Jacob McCormick, Andrew Craig Lynch, Satish Warrier, Michael Michael, Jayesh Desai, William Murray, Catherine Mitchell, Samuel Ngan, Wayne Allen Phillips, Alexander Graham Heriot, and Robert George Ramsay, Peter MacCallum Cancer
| | - Shienny Sampurno
- Joseph Cherng Huei Kong, Glen Robert Guerra, Rosemary Magdalena Millen, Sara Roth, Huiling Xu, Paul Joseph Neeson, Phillip Kevin Darcy, Michael Henry Kershaw, Shienny Sampurno, Jordane Malaterre, David Shi Hao Liu, Toan Duc Pham, Vignesh Narasimhan, Minyu Wang, Yu-Kuan Huang, Jacob McCormick, Andrew Craig Lynch, Satish Warrier, Michael Michael, Jayesh Desai, William Murray, Catherine Mitchell, Samuel Ngan, Wayne Allen Phillips, Alexander Graham Heriot, and Robert George Ramsay, Peter MacCallum Cancer
| | - Jordane Malaterre
- Joseph Cherng Huei Kong, Glen Robert Guerra, Rosemary Magdalena Millen, Sara Roth, Huiling Xu, Paul Joseph Neeson, Phillip Kevin Darcy, Michael Henry Kershaw, Shienny Sampurno, Jordane Malaterre, David Shi Hao Liu, Toan Duc Pham, Vignesh Narasimhan, Minyu Wang, Yu-Kuan Huang, Jacob McCormick, Andrew Craig Lynch, Satish Warrier, Michael Michael, Jayesh Desai, William Murray, Catherine Mitchell, Samuel Ngan, Wayne Allen Phillips, Alexander Graham Heriot, and Robert George Ramsay, Peter MacCallum Cancer
| | - David Shi Hao Liu
- Joseph Cherng Huei Kong, Glen Robert Guerra, Rosemary Magdalena Millen, Sara Roth, Huiling Xu, Paul Joseph Neeson, Phillip Kevin Darcy, Michael Henry Kershaw, Shienny Sampurno, Jordane Malaterre, David Shi Hao Liu, Toan Duc Pham, Vignesh Narasimhan, Minyu Wang, Yu-Kuan Huang, Jacob McCormick, Andrew Craig Lynch, Satish Warrier, Michael Michael, Jayesh Desai, William Murray, Catherine Mitchell, Samuel Ngan, Wayne Allen Phillips, Alexander Graham Heriot, and Robert George Ramsay, Peter MacCallum Cancer
| | - Toan Duc Pham
- Joseph Cherng Huei Kong, Glen Robert Guerra, Rosemary Magdalena Millen, Sara Roth, Huiling Xu, Paul Joseph Neeson, Phillip Kevin Darcy, Michael Henry Kershaw, Shienny Sampurno, Jordane Malaterre, David Shi Hao Liu, Toan Duc Pham, Vignesh Narasimhan, Minyu Wang, Yu-Kuan Huang, Jacob McCormick, Andrew Craig Lynch, Satish Warrier, Michael Michael, Jayesh Desai, William Murray, Catherine Mitchell, Samuel Ngan, Wayne Allen Phillips, Alexander Graham Heriot, and Robert George Ramsay, Peter MacCallum Cancer
| | - Vignesh Narasimhan
- Joseph Cherng Huei Kong, Glen Robert Guerra, Rosemary Magdalena Millen, Sara Roth, Huiling Xu, Paul Joseph Neeson, Phillip Kevin Darcy, Michael Henry Kershaw, Shienny Sampurno, Jordane Malaterre, David Shi Hao Liu, Toan Duc Pham, Vignesh Narasimhan, Minyu Wang, Yu-Kuan Huang, Jacob McCormick, Andrew Craig Lynch, Satish Warrier, Michael Michael, Jayesh Desai, William Murray, Catherine Mitchell, Samuel Ngan, Wayne Allen Phillips, Alexander Graham Heriot, and Robert George Ramsay, Peter MacCallum Cancer
| | - Minyu Wang
- Joseph Cherng Huei Kong, Glen Robert Guerra, Rosemary Magdalena Millen, Sara Roth, Huiling Xu, Paul Joseph Neeson, Phillip Kevin Darcy, Michael Henry Kershaw, Shienny Sampurno, Jordane Malaterre, David Shi Hao Liu, Toan Duc Pham, Vignesh Narasimhan, Minyu Wang, Yu-Kuan Huang, Jacob McCormick, Andrew Craig Lynch, Satish Warrier, Michael Michael, Jayesh Desai, William Murray, Catherine Mitchell, Samuel Ngan, Wayne Allen Phillips, Alexander Graham Heriot, and Robert George Ramsay, Peter MacCallum Cancer
| | - Yu-Kuan Huang
- Joseph Cherng Huei Kong, Glen Robert Guerra, Rosemary Magdalena Millen, Sara Roth, Huiling Xu, Paul Joseph Neeson, Phillip Kevin Darcy, Michael Henry Kershaw, Shienny Sampurno, Jordane Malaterre, David Shi Hao Liu, Toan Duc Pham, Vignesh Narasimhan, Minyu Wang, Yu-Kuan Huang, Jacob McCormick, Andrew Craig Lynch, Satish Warrier, Michael Michael, Jayesh Desai, William Murray, Catherine Mitchell, Samuel Ngan, Wayne Allen Phillips, Alexander Graham Heriot, and Robert George Ramsay, Peter MacCallum Cancer
| | - Kumar Visvanathan
- Joseph Cherng Huei Kong, Glen Robert Guerra, Rosemary Magdalena Millen, Sara Roth, Huiling Xu, Paul Joseph Neeson, Phillip Kevin Darcy, Michael Henry Kershaw, Shienny Sampurno, Jordane Malaterre, David Shi Hao Liu, Toan Duc Pham, Vignesh Narasimhan, Minyu Wang, Yu-Kuan Huang, Jacob McCormick, Andrew Craig Lynch, Satish Warrier, Michael Michael, Jayesh Desai, William Murray, Catherine Mitchell, Samuel Ngan, Wayne Allen Phillips, Alexander Graham Heriot, and Robert George Ramsay, Peter MacCallum Cancer
| | - Jacob McCormick
- Joseph Cherng Huei Kong, Glen Robert Guerra, Rosemary Magdalena Millen, Sara Roth, Huiling Xu, Paul Joseph Neeson, Phillip Kevin Darcy, Michael Henry Kershaw, Shienny Sampurno, Jordane Malaterre, David Shi Hao Liu, Toan Duc Pham, Vignesh Narasimhan, Minyu Wang, Yu-Kuan Huang, Jacob McCormick, Andrew Craig Lynch, Satish Warrier, Michael Michael, Jayesh Desai, William Murray, Catherine Mitchell, Samuel Ngan, Wayne Allen Phillips, Alexander Graham Heriot, and Robert George Ramsay, Peter MacCallum Cancer
| | - Andrew Craig Lynch
- Joseph Cherng Huei Kong, Glen Robert Guerra, Rosemary Magdalena Millen, Sara Roth, Huiling Xu, Paul Joseph Neeson, Phillip Kevin Darcy, Michael Henry Kershaw, Shienny Sampurno, Jordane Malaterre, David Shi Hao Liu, Toan Duc Pham, Vignesh Narasimhan, Minyu Wang, Yu-Kuan Huang, Jacob McCormick, Andrew Craig Lynch, Satish Warrier, Michael Michael, Jayesh Desai, William Murray, Catherine Mitchell, Samuel Ngan, Wayne Allen Phillips, Alexander Graham Heriot, and Robert George Ramsay, Peter MacCallum Cancer
| | - Satish Warrier
- Joseph Cherng Huei Kong, Glen Robert Guerra, Rosemary Magdalena Millen, Sara Roth, Huiling Xu, Paul Joseph Neeson, Phillip Kevin Darcy, Michael Henry Kershaw, Shienny Sampurno, Jordane Malaterre, David Shi Hao Liu, Toan Duc Pham, Vignesh Narasimhan, Minyu Wang, Yu-Kuan Huang, Jacob McCormick, Andrew Craig Lynch, Satish Warrier, Michael Michael, Jayesh Desai, William Murray, Catherine Mitchell, Samuel Ngan, Wayne Allen Phillips, Alexander Graham Heriot, and Robert George Ramsay, Peter MacCallum Cancer
| | - Michael Michael
- Joseph Cherng Huei Kong, Glen Robert Guerra, Rosemary Magdalena Millen, Sara Roth, Huiling Xu, Paul Joseph Neeson, Phillip Kevin Darcy, Michael Henry Kershaw, Shienny Sampurno, Jordane Malaterre, David Shi Hao Liu, Toan Duc Pham, Vignesh Narasimhan, Minyu Wang, Yu-Kuan Huang, Jacob McCormick, Andrew Craig Lynch, Satish Warrier, Michael Michael, Jayesh Desai, William Murray, Catherine Mitchell, Samuel Ngan, Wayne Allen Phillips, Alexander Graham Heriot, and Robert George Ramsay, Peter MacCallum Cancer
| | - Jayesh Desai
- Joseph Cherng Huei Kong, Glen Robert Guerra, Rosemary Magdalena Millen, Sara Roth, Huiling Xu, Paul Joseph Neeson, Phillip Kevin Darcy, Michael Henry Kershaw, Shienny Sampurno, Jordane Malaterre, David Shi Hao Liu, Toan Duc Pham, Vignesh Narasimhan, Minyu Wang, Yu-Kuan Huang, Jacob McCormick, Andrew Craig Lynch, Satish Warrier, Michael Michael, Jayesh Desai, William Murray, Catherine Mitchell, Samuel Ngan, Wayne Allen Phillips, Alexander Graham Heriot, and Robert George Ramsay, Peter MacCallum Cancer
| | - William Murray
- Joseph Cherng Huei Kong, Glen Robert Guerra, Rosemary Magdalena Millen, Sara Roth, Huiling Xu, Paul Joseph Neeson, Phillip Kevin Darcy, Michael Henry Kershaw, Shienny Sampurno, Jordane Malaterre, David Shi Hao Liu, Toan Duc Pham, Vignesh Narasimhan, Minyu Wang, Yu-Kuan Huang, Jacob McCormick, Andrew Craig Lynch, Satish Warrier, Michael Michael, Jayesh Desai, William Murray, Catherine Mitchell, Samuel Ngan, Wayne Allen Phillips, Alexander Graham Heriot, and Robert George Ramsay, Peter MacCallum Cancer
| | - Catherine Mitchell
- Joseph Cherng Huei Kong, Glen Robert Guerra, Rosemary Magdalena Millen, Sara Roth, Huiling Xu, Paul Joseph Neeson, Phillip Kevin Darcy, Michael Henry Kershaw, Shienny Sampurno, Jordane Malaterre, David Shi Hao Liu, Toan Duc Pham, Vignesh Narasimhan, Minyu Wang, Yu-Kuan Huang, Jacob McCormick, Andrew Craig Lynch, Satish Warrier, Michael Michael, Jayesh Desai, William Murray, Catherine Mitchell, Samuel Ngan, Wayne Allen Phillips, Alexander Graham Heriot, and Robert George Ramsay, Peter MacCallum Cancer
| | - Samuel Ngan
- Joseph Cherng Huei Kong, Glen Robert Guerra, Rosemary Magdalena Millen, Sara Roth, Huiling Xu, Paul Joseph Neeson, Phillip Kevin Darcy, Michael Henry Kershaw, Shienny Sampurno, Jordane Malaterre, David Shi Hao Liu, Toan Duc Pham, Vignesh Narasimhan, Minyu Wang, Yu-Kuan Huang, Jacob McCormick, Andrew Craig Lynch, Satish Warrier, Michael Michael, Jayesh Desai, William Murray, Catherine Mitchell, Samuel Ngan, Wayne Allen Phillips, Alexander Graham Heriot, and Robert George Ramsay, Peter MacCallum Cancer
| | - Wayne Allen Phillips
- Joseph Cherng Huei Kong, Glen Robert Guerra, Rosemary Magdalena Millen, Sara Roth, Huiling Xu, Paul Joseph Neeson, Phillip Kevin Darcy, Michael Henry Kershaw, Shienny Sampurno, Jordane Malaterre, David Shi Hao Liu, Toan Duc Pham, Vignesh Narasimhan, Minyu Wang, Yu-Kuan Huang, Jacob McCormick, Andrew Craig Lynch, Satish Warrier, Michael Michael, Jayesh Desai, William Murray, Catherine Mitchell, Samuel Ngan, Wayne Allen Phillips, Alexander Graham Heriot, and Robert George Ramsay, Peter MacCallum Cancer
| | - Alexander Graham Heriot
- Joseph Cherng Huei Kong, Glen Robert Guerra, Rosemary Magdalena Millen, Sara Roth, Huiling Xu, Paul Joseph Neeson, Phillip Kevin Darcy, Michael Henry Kershaw, Shienny Sampurno, Jordane Malaterre, David Shi Hao Liu, Toan Duc Pham, Vignesh Narasimhan, Minyu Wang, Yu-Kuan Huang, Jacob McCormick, Andrew Craig Lynch, Satish Warrier, Michael Michael, Jayesh Desai, William Murray, Catherine Mitchell, Samuel Ngan, Wayne Allen Phillips, Alexander Graham Heriot, and Robert George Ramsay, Peter MacCallum Cancer
| | - Robert George Ramsay
- Joseph Cherng Huei Kong, Glen Robert Guerra, Rosemary Magdalena Millen, Sara Roth, Huiling Xu, Paul Joseph Neeson, Phillip Kevin Darcy, Michael Henry Kershaw, Shienny Sampurno, Jordane Malaterre, David Shi Hao Liu, Toan Duc Pham, Vignesh Narasimhan, Minyu Wang, Yu-Kuan Huang, Jacob McCormick, Andrew Craig Lynch, Satish Warrier, Michael Michael, Jayesh Desai, William Murray, Catherine Mitchell, Samuel Ngan, Wayne Allen Phillips, Alexander Graham Heriot, and Robert George Ramsay, Peter MacCallum Cancer
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MRI-Based Apparent Diffusion Coefficient for Predicting Pathologic Response of Rectal Cancer After Neoadjuvant Therapy: Systematic Review and Meta-Analysis. AJR Am J Roentgenol 2018; 211:W205-W216. [PMID: 30240291 DOI: 10.2214/ajr.17.19135] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The purpose of this study was to assess the use of apparent diffusion coefficient (ADC) during DWI for predicting complete pathologic response of rectal cancer after neoadjuvant therapy. MATERIALS AND METHODS A systematic review of available literature was conducted to retrieve studies focused on the identification of complete pathologic response of locally advanced rectal cancer after neoadjuvant chemoradiation, through the assessment of ADC evaluated before, after, or both before and after treatment, as well as in terms of the difference between pretreatment and posttreatment ADC. Pooled mean pretreatment ADC, posttreatment ADC, and Δ-ADC (calculated as posttreatment ADC minus pretreatment ADC divided by pretreatment ADC and multiplied by 100) in complete responders versus incomplete responders were calculated. For each parameter, we also pooled sensitivity and specificity and calculated the area under the summary ROC curve. RESULTS We found 10 prospective and eight retrospective studies. Overall, pathologic complete response was observed in 22.2% of patients. Pooled mean pretreatment ADC in complete responders was 0.84 × 10-3 mm2/s versus 0.89 × 10-3 mm2/s in incomplete responders (p = 0.33). Posttreatment ADC values were 1.51 × 10-3 mm2/s and 1.29 × 10-3 mm2/s, in complete and incomplete responders, respectively (p = 0.00001). The Δ-ADC percentages were also significantly higher in complete responders than in incomplete responders (59.7% vs 29.7%, respectively, p = 0.016). Pooled sensitivity, specificity, and AUC were 0.743, 0.755, and 0.841 for pretreatment ADC; 0.800, 0.737, and 0.782 for posttreatment ADC; and 0.832, 0.806, and 0.895 for Δ-ADC. CONCLUSION Use of ADC during DWI is a promising technique for assessment of results of neoadjuvant treatment of rectal cancer.
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Mullaney TG, Lightner AL, Johnston M, Keck J, Wattchow D. 'Watch and wait' after chemoradiotherapy for rectal cancer. ANZ J Surg 2018; 88:836-841. [PMID: 30047201 DOI: 10.1111/ans.14352] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 11/13/2017] [Accepted: 11/18/2017] [Indexed: 01/11/2023]
Abstract
Surgery remains the cornerstone of rectal cancer treatment. However, there is significant morbidity and mortality associated with pelvic surgery, and the past decade has illustrated that a cohort of rectal cancer patients sustain a remission of local disease with chemoradiation alone. Thus, questions remain regarding the optimal management for rectal cancer; namely, accurately identifying patients who have a complete pathologic response and determining the oncologic safety of the observational approach for this patient group. This review aims to summarize the current evidence to provide an overview to the 'watch and wait' approach in rectal cancer patients with a complete response to neoadjuvant chemoradiation therapy.
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Affiliation(s)
- Tamara G Mullaney
- Department of Colorectal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Amy L Lightner
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael Johnston
- Department of Colorectal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - James Keck
- Department of Colorectal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - David Wattchow
- Department of Colorectal Surgery, Flinders Medical Centre, Flinders Private Hospital, Flinders University, Adelaide, South Australia, Australia
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Kong JC, Guerra GR, Warrier SK, Lynch AC, Michael M, Ngan SY, Phillips W, Ramsay G, Heriot AG. Prognostic value of tumour regression grade in locally advanced rectal cancer: a systematic review and meta-analysis. Colorectal Dis 2018; 20:574-585. [PMID: 29582537 DOI: 10.1111/codi.14106] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 03/01/2018] [Indexed: 02/08/2023]
Abstract
AIM The current standard of care for locally advanced rectal cancer involves neoadjuvant chemoradiotherapy (CRT) followed by total mesorectal excision. There is a spectrum of response to neoadjuvant therapy; however, the prognostic value of tumour regression grade (TRG) in predicting disease-free survival (DFS) or overall survival (OS) is inconsistent in the literature. METHOD This study was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic search was undertaken using Ovid MEDLINE, Embase and Google Scholar. Inclusion criteria were Stage II and III locally advanced rectal cancer treated with long-course CRT followed by radical surgery. The aim of the meta-analysis was to assess the prognostic implication of each TRG for rectal cancer following neoadjuvant CRT. Long-term prognosis was assessed. The main outcome measures were DFS and OS. A random effects model was performed to pool the hazard ratio (HR) from all included studies. RESULTS There were 4875 patients from 17 studies, with 775 (15.9%) attaining a pathological complete response (pCR) and 719 (29.9%) with no response. A significant association with OS was identified from a pooled-estimated HR for pCR (HR = 0.47, P = 0.002) and nonresponding tumours (HR = 2.97; P < 0.001). Previously known tumour characteristics, such as ypN, lymphovascular invasion and perineural invasion, were also significantly associated with DFS and OS, with estimated pooled HRs of 2.2, 1.4 and 2.3, respectively. CONCLUSION In conclusion, the degree of TRG was of prognostic value in predicting long-term outcomes. The current challenge is the development of a high-validity tests to predict pCR.
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Affiliation(s)
- J C Kong
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - G R Guerra
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - S K Warrier
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - A Craig Lynch
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - M Michael
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia.,Division of Cancer Medicine, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - S Y Ngan
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia.,Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - W Phillips
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - G Ramsay
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - A G Heriot
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
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27
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Loftås P, Sturludóttir M, Hallböök O, Almlöv K, Arbman G, Blomqvist L. Assessment of remaining tumour involved lymph nodes with MRI in patients with complete luminal response after neoadjuvant treatment of rectal cancer. Br J Radiol 2018; 91:20170938. [PMID: 29668301 DOI: 10.1259/bjr.20170938] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE To assess the accuracy of MRI to predict remaining lymph node metastases in patients with complete pathological luminal response (ypT0) after neoadjuvant therapy. METHODS Data from a national registry were used. 19 patients with histopathologically remaining lymph node metastases (ypT0N+) were identified. Another 19 patients without lymph node metastases (ypT0N0) were used as matched controls. Two radiologists blinded to all patient information evaluated staging and restaging MRI that was compared to histopathological findings of the resected specimen. RESULTS The average size of the largest lymph node on restaging MRI was significantly larger (4.5 mm) in the ypT0N+ group than in the ypT0N0 group (2.6 mm) (p = 0.04). Presence of ypN+ was correctly predicted by MRI in 7 of 19 patients. In patients without lymph node metastases (ypT0N0), these were correctly classified by MRI in 16 of 19 patients. All patients who had MR-identified lymph nodes larger than 8 mm at restaging were ypTN+. The sensitivity, specificity, positive predictive value and negative for prediction of remaining lymph node metastasis with MRI were 37, 84, 70 and 57%. CONCLUSION In patients with ypT0 in rectal cancer after neoadjuvant treatment, remaining regional lymph node metastases cannot safely be predicted by restaging MRI alone using presently known criteria. Presence of a lymph node over 8 mm on restaging MRI strongly indicates yPN+. Advances in knowledge: This is one of the first studies on MRI lymph node assessment after chemo-radiotherapy (CRT) in luminal complete response.
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Affiliation(s)
- Per Loftås
- 1 Department of Surgery, Institution for clinical and experimental medicine, Linköping University , Linköping , Sweden
| | - Margrét Sturludóttir
- 2 Department of Diagnostic Radiology, Karolinska University hospital , Stockholm , Sweden.,3 Department of Molecular Medicine and Surgery, Karolinska Institutet , Stockholm , Sweden
| | - Olof Hallböök
- 1 Department of Surgery, Institution for clinical and experimental medicine, Linköping University , Linköping , Sweden
| | - Karin Almlöv
- 4 Department of Surgery, Institution for clinical and experimental medicine, Linköping University , Norrköping , Sweden
| | - Gunnar Arbman
- 4 Department of Surgery, Institution for clinical and experimental medicine, Linköping University , Norrköping , Sweden
| | - Lennart Blomqvist
- 2 Department of Diagnostic Radiology, Karolinska University hospital , Stockholm , Sweden.,3 Department of Molecular Medicine and Surgery, Karolinska Institutet , Stockholm , Sweden
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Perez RO, Habr-Gama A. Putting down the scalpel in rectal cancer management - a historical perspective. Colorectal Dis 2018; 20 Suppl 1:12-15. [PMID: 29878677 DOI: 10.1111/codi.14070] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The surgical management of rectal cancer has evolved from a disease without any possibility of cure in the early 1700s where surgical management consisted of the palliative drainage of disease related abscesses to the present day where surgical cure is not only possible but also possible with sphincter or even organ preservation. Prof Habr-Gama's lecture describes the evolution of the surgical management of rectal cancer and the current focus on organ preservation.
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Affiliation(s)
- R O Perez
- Angelita and Joaquim Gama Institute, São Paulo, Brazil.,Colorectal Surgery Division, School of Medicine, University of São Paulo, São Paulo, Brazil.,Ludwig Institute for Cancer Research, São Paulo, Brazil.,Gastrointestinal Surgical Oncology Division, Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | - A Habr-Gama
- Angelita and Joaquim Gama Institute, São Paulo, Brazil.,Colorectal Surgery Division, School of Medicine, University of São Paulo, São Paulo, Brazil
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Abstract
Purpose of Review Pathological complete response is seen in approximately one fifth of rectal cancer patients following neoadjuvant chemoradiation. Since these patients have excellent oncological outcomes, there has been a rapidly growing interest in organ preservation for those who develop a clinical complete response. We review the watch-and-wait strategy and focus on all aspects of this hot topic, including who should be considered for this approach, how should we identify treatment response and what are the expected outcomes. Recent Findings The major challenges in interpreting the data on watch-and-wait are the significant heterogeneity of patients selected for this approach and of methods employed to identify them. The evidence available comes mostly from retrospective cohort studies, but has shown good oncological outcomes, including the rate of successful salvage surgery, locoregional control and overall survival. Summary There is currently not enough and not robust enough evidence to support watch-and-wait as a standard approach, outside a clinical trial, for patients achieving clinical complete response following neoadjuvant chemoradiation. Furthermore, there is a lack of data on long-term outcomes. However, the results we have so far are promising, and there is therefore an urgent need for randomised control studies such as the TRIGGER trial to confirm the safety of this strategy.
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30
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Taveras LR, Cunningham HB, Imran JB. Can We Reliably Predict a Clinical Complete Response in Rectal Cancer? Current Trends and Future Strategies. CURRENT COLORECTAL CANCER REPORTS 2018. [DOI: 10.1007/s11888-018-0401-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Predictive value of APAF-1 and COX-2 expression in pathologic complete response to neoadjuvant chemoradiotherapy for patients with locally advanced rectal adenocarcinoma. Oncotarget 2018; 7:35233-40. [PMID: 27153549 PMCID: PMC5085224 DOI: 10.18632/oncotarget.9125] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 03/28/2016] [Indexed: 01/27/2023] Open
Abstract
Purpose To investigate predictive value of APAF-1 and COX-2 expression in pathologic complete response (pCR) for patients with rectal adenocarcinoma (RAC) who were treated with neoadjuvant chemoradiotherapy (neo-CRT) followed by total mesorectal excision (TME). Materials and Methods Immunohistochemistry assay was used to detect expression of APAF-1 and COX-2 in paraffin-wax embedded tissues obtained before neo-CRT for patients with RAC. A 5-point tumor-regression grade (TRG) based on the ratio of residual tumor to fibrosis according to Dworak's scoring system was used to assess neo-CRT response. The relationship between expression of APAF-1 and COX-2 genes and pCR was explored. Results pCR (TRG4) was observed in 23 patients (28.0%). pCR were more likely to be achieved for those with APAF-1 over-expression or lower expression of COX-2. pCR rate in patients with combination of high APAF-1 and low COX-2 expression was 56.0%, significantly higher than those with other combination of APAF1 and COX-2 expression. Multivariate analysis showed that over-expression of APAF-1 and suppressed expression of COX-2 were independent predictive factors for pCR. Conclusion Immunohistochemical evaluation of APAF-1 and COX-2 expression on pretreatment specimen may be used to predict pCR to neo-CRT in patients with RAC. The potential of the markers in monitoring pCR patient merits further investigation.
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32
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Li J, Li L, Yang L, Yuan J, Lv B, Yao Y, Xing S. Wait-and-see treatment strategies for rectal cancer patients with clinical complete response after neoadjuvant chemoradiotherapy: a systematic review and meta-analysis. Oncotarget 2018; 7:44857-44870. [PMID: 27070085 PMCID: PMC5190140 DOI: 10.18632/oncotarget.8622] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 03/28/2016] [Indexed: 12/16/2022] Open
Abstract
Wait-and-see treatment strategies may benefit rectal cancer patients who achieve a clinical complete response (cCR) after neoadjuvant chemoradiotherapy (NCRT). In this study, we analyzed data from 9 eligible trials to compare the oncologic outcomes of 251 rectal cancer patients achieving a cCR through nonsurgical management approaches with the outcomes of 344 patients achieving a pathologic complete response (pCR) through radical surgery. The two patient groups did not differ in distant metastasis rates or disease-free and overall survival, but the nonsurgical group had a higher risk of 1, 2, 3, and 5-year local recurrence. Hence, we concluded that for rectal cancer patients achieving a cCR after NCRT, a wait-and-see strategy with strict selection criteria, an appropriate follow-up schedule, and salvage treatments achieved outcomes at least as good as radical surgery. Long-term randomized and controlled trials with more uniform inclusion criteria and standardized follow-up schedules will help clarify the risks and benefits of wait-and-see treatment strategies for these patients.
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Affiliation(s)
- Jun Li
- General Surgery Department and Central Laboratory, Affiliated Hospital/Clinical Medical College of Chengdu University, Chengdu, People's Republic of China
| | - Lunjin Li
- Pharmacy Department, Affiliated Hospital/Clinical Medical College of Chengdu University, Chengdu, People's Republic of China
| | - Lin Yang
- Department of Pathology, Cancer Hospital, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Jiatian Yuan
- General Surgery Department and Central Laboratory, Affiliated Hospital/Clinical Medical College of Chengdu University, Chengdu, People's Republic of China
| | - Bo Lv
- General Surgery Department and Central Laboratory, Affiliated Hospital/Clinical Medical College of Chengdu University, Chengdu, People's Republic of China
| | - Yanan Yao
- Department of General Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Shasha Xing
- Central Laboratory, Affiliated Hospital/Clinical Medical College of Chengdu University, Chengdu, People's Republic of China
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33
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Song JH, Park YH, Seo SH, Lee A, Kim KH, An MS, Bae KB, Hong KH, Hwang JW, Kim JH, Jung HS, Ahn KJ. Difference in Tumor Area as a Predictor of a Pathological Complete Response for Patients With Locally Advanced Rectal Cancer. Ann Coloproctol 2017; 33:219-226. [PMID: 29354604 PMCID: PMC5768476 DOI: 10.3393/ac.2017.33.6.219] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 10/02/2017] [Indexed: 12/11/2022] Open
Abstract
Purpose This study was conducted to discover the clinical factors that can predict pathologically complete remission (pCR) after neoadjuvant chemoradiotherapy (CRT), so that those factors may help in deciding on a treatment program for patients with locally advanced rectal cancer. Methods A total of 137 patients with locally advanced rectal cancer were retrospectively enrolled in this study, and data were collected retrospectively. The patients had undergone a total mesorectal excision after neoadjuvant CRT. Histologic response was categorized as pCR vs. non-pCR. The tumor area was defined as (tumor length) × (maximum tumor depth). The difference in tumor area was defined as pre-CRT tumor area - post-CRT tumor area. Univariate and multivariate logistic regression analyses were conducted to find the factors affecting pCR. A P-value < 0.05 was considered significant. Results Twenty-three patients (16.8%) achieved pCR. On the univariate analysis, endoscopic tumor circumferential rate <50%, low pre-CRT T & N stage, low post-CRT T & N stage, small pretreatment tumor area, and large difference in tumor area before and after neoadjuvant CRT were predictive factors of pCR. A multivariate analysis found that only the difference in tumor area before and after neoadjuvant CRT was an independent predictor of pCR (P < 0.001). Conclusion The difference in tumor area, as determined using radiologic tools, before and after neoadjuvant CRT may be important predictor of pCR. This clinical factor may help surgeons to determine which patients who received neoadjuvant CRT for locally advanced rectal cancer should undergo surgery.
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Affiliation(s)
- Ji Hyeong Song
- Department of Surgery, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Yo-Han Park
- Department of Surgery, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Sang Hyuk Seo
- Department of Surgery, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Anbok Lee
- Department of Surgery, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Kwang Hee Kim
- Department of Surgery, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Min Sung An
- Department of Surgery, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Ki Beom Bae
- Department of Surgery, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Kwan Hee Hong
- Department of Surgery, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Jin Won Hwang
- Department of Internal Medicine, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Ji Hyun Kim
- Department of Internal Medicine, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Hyun Seok Jung
- Department of Radiology, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Ki Jung Ahn
- Department of Radiation Oncology, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
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34
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Fernandez LM, Perez RO. Organ-preservation strategies in rectal cancer: advances and challenges. COLORECTAL CANCER 2017. [DOI: 10.2217/crc-2017-0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Laura Melina Fernandez
- Department of Colorectal Surgery, Angelita & Joaquim Gama Institute, São Paulo 04001, Brazil
| | - Rodrigo Oliva Perez
- Department of Colorectal Surgery, Angelita & Joaquim Gama Institute, São Paulo 04001, Brazil
- Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo 04001, Brazil
- Department of Molecular Oncology, Ludwig Institute for Cancer Research, São Paulo Branch, São Paulo 01308, Brazil
- Department of Surgical Oncology, Digestive Surgical Oncology Division, BP- A Beneficência Portuguesa de São Paulo, São Paulo 01323-900, Brazil
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35
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Habr-Gama A, São Julião GP, Vailati BB, Castro I, Raffaele D. Management of the Complete Clinical Response. Clin Colon Rectal Surg 2017; 30:387-394. [PMID: 29184475 DOI: 10.1055/s-0037-1606116] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Organ preservation is considered in the management of selected patients with rectal cancer. Complete clinical response observed after neoadjuvant chemoradiation for rectal cancer is one of these cases. Patients who present complete clinical response are candidates to the watch-and-wait approach, when radical surgery is not immediately performed and is offered only to patients in the event of a local relapse. These patients are included in a strict follow-up, and up of 70% of them will never be operated during the follow-up. This strategy is associated with similar oncological outcomes as patients operated on, and the advantage of avoiding the morbidity associated to the radical operation. In this article we will discuss in detail the best candidates for this approach, the protocol itself, and the long-term outcomes.
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Affiliation(s)
- Angelita Habr-Gama
- Angelita & Joaquim Gama Institute, Sao Paulo, SP, Brazil.,University of Sao Paulo School of Medicine, Sao Paulo, SP, Brazil
| | | | | | - Ivana Castro
- Angelita & Joaquim Gama Institute, Sao Paulo, SP, Brazil
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36
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São Julião GP, Celentano JP, Alexandre FA, Vailati BB. Local Excision and Endoscopic Resections for Early Rectal Cancer. Clin Colon Rectal Surg 2017; 30:313-323. [PMID: 29184466 DOI: 10.1055/s-0037-1606108] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Radical surgery is considered as the standard treatment for rectal cancer. Transanal local excision has been considered an interesting alternative for the management of selected patients with rectal cancers for many decades. Different approaches had been considered for local excision, from endoscopic submucosal dissection to resections using platforms, such as transanal endoscopic microsurgery or transanal minimally invasive surgery. Identifying the ideal candidate for this approach is crucial, as a local failure after local excision is associated with poor outcomes, even for an initial early rectal tumor. In this article, the diagnostic tools and criteria to select patients for local excision, the different modalities used, and the outcomes are discussed.
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37
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São Julião GP, Habr-Gama A, Vailati BB, Araujo SEA, Fernandez LM, Perez RO. New Strategies in Rectal Cancer. Surg Clin North Am 2017; 97:587-604. [PMID: 28501249 DOI: 10.1016/j.suc.2017.01.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In recent years, our understanding of rectal cancer has improved, including how locally advanced disease responds to chemotherapy and radiation. This has led to new innovations and advances in the treatment of rectal cancer, which includes organ-preserving strategies for responsive disease, and minimally invasive approaces for the performance of total mesorectal excision/protectomyh for persistently advanced disease. This article discusses new strategies for rectal cancer therapy, including Watch and Wait, local excision, minimally invasive proctectomy, and transanal total mesorectal excision particularly in the setting of preoperative multimodality treatment.
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Affiliation(s)
- Guilherme Pagin São Julião
- Department of Colorectal Surgery, Angelita & Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo 04001, Brazil
| | - Angelita Habr-Gama
- Department of Colorectal Surgery, Angelita & Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo 04001, Brazil
| | - Bruna Borba Vailati
- Department of Colorectal Surgery, Angelita & Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo 04001, Brazil
| | - Sergio Eduardo Alonso Araujo
- Department of Colorectal Surgery, Hospital Israelita Albert Einstein, Avenida Albert Einstein 627, Suite 219, São Paulo 05652, Brazil
| | - Laura Melina Fernandez
- Department of Colorectal Surgery, Angelita & Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo 04001, Brazil
| | - Rodrigo Oliva Perez
- Department of Colorectal Surgery, Angelita & Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo 04001, Brazil.
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38
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Al-Najami I, Drue HC, Steele R, Baatrup G. Dual energy CT - a possible new method to assess regression of rectal cancers after neoadjuvant treatment. J Surg Oncol 2017; 116:984-988. [PMID: 28703886 DOI: 10.1002/jso.24761] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 06/17/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND AND OBJECTIVES The measurement of tumor regression after neoadjuvant oncological treatment has gained increasing interest because it has a prognostic value and because it may influence the method of treatment in rectal cancer. The assessment of tumor regression remains difficult and inaccurate with existing methods. Dual Energy Computed Tomography (DECT) enables qualitative tissue differentiation by simultaneous scanning with different levels of energy. We aimed to assess the feasibility of DECT in quantifying tumor response to neoadjuvant therapy in loco-advanced rectal cancer. METHODS We enrolled 11 patients with histological and MRI verified loco-advanced rectal adenocarcinoma and followed up on them prospectively. All patients had one DECT scanning before neoadjuvant treatment and one 12 weeks after using the spectral imaging scan mode. DECT analyzing tools were used to determine the average quantitative parameters; effective-Z, water- and iodine-concentration, Dual Energy Index (DEI), and Dual Energy Ratio (DER). These parameters were compared to the regression in the resection specimen as measured by the pathologist. RESULTS Changes in the quantitative parameters differed significantly after treatment in comparison with pre-treatment, and the results were different in patients with different CRT response rates. CONCLUSION DECT might be helpful in the assessment of rectal cancer regression grade after neoadjuvant treatment.
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Affiliation(s)
- Issam Al-Najami
- Department of Surgery, Odense University Hospital, Svendborg, Denmark.,Department of Clinical Research, University of Southern Denmark, Denmark
| | - Henrik C Drue
- Department of Radiology, Odense University Hospital, Svendborg, Denmark
| | - Robert Steele
- Centre for Research Into Cancer Prevention and Screening, Cancer Division, Medical Research Institute, Ninewells Medical School, Dundee, United Kingdom
| | - Gunnar Baatrup
- Department of Surgery, Odense University Hospital, Svendborg, Denmark.,Department of Clinical Research, University of Southern Denmark, Denmark
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39
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Quantitative imaging outperforms molecular markers when predicting response to chemoradiotherapy for rectal cancer. Radiother Oncol 2017. [PMID: 28647399 DOI: 10.1016/j.radonc.2017.06.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND PURPOSE To explore the integration of imaging and molecular data for response prediction to chemoradiotherapy (CRT) for rectal cancer. MATERIAL AND METHODS Eighty-five rectal cancer patients underwent preoperative CRT. 18F-FDG PET/CT and diffusion-weighted imaging (DWI) were acquired before (TP1) and during CRT (TP2) and prior to surgery (TP3). Inflammatory cytokines and gene expression were analysed. Tumour response was defined as ypT0-1N0. Multivariate models were built combining the obtained parameters. Final models were calculated on the data combination with the highest AUC. RESULTS Twenty-two patients (26%) achieved ypT0-1N0 response. 18F-FDG PET/CT had worse predictive performance than DWI and T2-volumetry (AUC 0.61±0.04, 0.72±0.03, and 0.72±0.02, respectively). Combining all imaging parameters increased the AUC to 0.81±0.03. Adding cytokines or gene expression did not improve the AUC (AUC of 0.72±0.06 and 0.79±0.04 respectively). Final models combining 18F-FDG PET/CT, DWI, and T2-weighted volumetry at all TPs and using only TP1 and TP3, allowed ypT0-1N0 prediction with a 75% sensitivity, 94% specificity and PPV of 80%. CONCLUSIONS Combining 18F-FDG PET/CT, DWI, and T2-weighted MRI volumetry obtained before CRT and prior to surgery may help physicians in selecting rectal cancer patients for organ-preservation.
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40
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Vojtíšek R, Korčáková E, Mařan J, Šorejs O, Fínek J. Neoadjuvant chemoradiotherapy of the rectal carcinoma - The correlation between the findings on the restaging multiparametric 3T MRI scanning and the surgical findings. Rep Pract Oncol Radiother 2017; 22:265-276. [PMID: 28507455 DOI: 10.1016/j.rpor.2017.02.004] [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: 11/14/2016] [Revised: 01/05/2017] [Accepted: 02/25/2017] [Indexed: 12/18/2022] Open
Abstract
AIM To figure out how to correlate the findings on functional MRI and carried out after neoadjuvant CRT of rectal carcinoma with final histology after surgery. BACKGROUND Neoadjuvant CRT is the standard treatment of locally advanced rectal carcinoma. Its use leads to the downstaging of the disease and in 15-42% of patients even to the detection of pCR after TME. The use of functional MRI improves the sensitivity and specificity of pCR detection up to 52-64% and 89-98%, respectively. MATERIALS AND METHODS Between January 2013 and June 2016, 67 patients suffering from histologically proven locally advanced rectal cancer underwent neoadjuvant RT or CRT. We selected for further investigation only patients (33 patients) who underwent pelvic staging and restaging using multiparametric imaging on 3T MRI scanner. We compared the findings on functional MRI after neoadjuvant CRT with final histology after surgery. RESULTS In 15 patients pathologic staging of primary tumor differed from expected staging assessed according to preoperative MRI. In 5 patients pathologic complete remission was achieved. In none of these 5 patients pCR was predicted using preoperative MRI. Sensitivity and specificity of MRI in predicting pCR were 0% and 96%. Accuracy of MRI in predicting pT and pN was 79% and 74%. CONCLUSIONS We have verified that the use of neoadjuvant CRT in the treatment of locally advanced rectal carcinoma leads to a possible achievement of pCR. But in our group of patients this was not predictable nor was it with the use of multiparametric 3T MRI.
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Affiliation(s)
- Radovan Vojtíšek
- Department of Oncology and Radiotherapy, University Hospital in Pilsen, alej Svobody 80, 304 60 Pilsen, Czech Republic
| | - Eva Korčáková
- Department of Imaging Methods, University Hospital in Pilsen, alej Svobody 80, 304 60 Pilsen, Czech Republic
| | - Jan Mařan
- Department of Oncology and Radiotherapy, University Hospital in Pilsen, alej Svobody 80, 304 60 Pilsen, Czech Republic
| | - Ondřej Šorejs
- Department of Oncology and Radiotherapy, University Hospital in Pilsen, alej Svobody 80, 304 60 Pilsen, Czech Republic
| | - Jindřich Fínek
- Department of Oncology and Radiotherapy, University Hospital in Pilsen, alej Svobody 80, 304 60 Pilsen, Czech Republic
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41
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Dossa F, Chesney TR, Acuna SA, Baxter NN. A watch-and-wait approach for locally advanced rectal cancer after a clinical complete response following neoadjuvant chemoradiation: a systematic review and meta-analysis. Lancet Gastroenterol Hepatol 2017; 2:501-513. [PMID: 28479372 DOI: 10.1016/s2468-1253(17)30074-2] [Citation(s) in RCA: 343] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 02/28/2017] [Accepted: 02/28/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND A watch-and-wait approach for patients with clinical complete response to neoadjuvant chemoradiation could avoid the morbidity of conventional surgery for rectal cancer. However, the safety of this approach is unclear. We synthesised the evidence for watch-and-wait as a treatment for rectal cancer. METHODS We systematically searched MEDLINE, Embase, and the grey literature (up to June 28, 2016) for studies of patients with rectal adenocarcinoma managed by watch-and-wait after complete clinical response to neoadjuvant chemoradiation. We determined the proportion of 2-year local regrowth after watch-and-wait. We assessed non-regrowth recurrence, cancer-specific mortality, disease-free survival, and overall survival from studies comparing patients who had watch-and-wait versus those who had radical surgery after detection of clinical complete response or versus patients with pathological complete response. FINDINGS We identified 23 studies including 867 patients with median follow-up of 12-68 months. Pooled 2-year local regrowth was 15·7% (95% CI 11·8-20·1); 95·4% (95% CI 89·6-99·3) of patients with regrowth had salvage therapies. There was no significant difference between patients managed with watch-and-wait after a clinical complete response and patients with pathological complete response identified at resection with respect to non-regrowth recurrence (risk ratio [RR] 1·46, 95% CI 0·70-3·05) or cancer-specific mortality (RR 0·87, 95% CI 0·38-1·99). Although there was no significant difference in overall survival between groups (hazard ratio [HR] 0·73, 95% CI 0·35-1·51), disease-free survival was better in the surgery group (HR 0·47, 95% CI 0·28-0·78). We found no significant difference between patients managed with watch-and-wait and patients with clinical complete response treated with surgery in terms of non-regrowth recurrence (RR 0·58, 95% CI 0·18-1·90), cancer-specific mortality (RR 0·58, 95% CI 0·06-5·84), disease-free survival (HR 0·56, 95% CI 0·20-1·60), or overall survival (HR 3·91, 95% CI 0·57-26·72). INTERPRETATION Most patients treated by watch-and-wait avoid radical surgery and of those who have regrowth almost all have salvage therapy. Although we detected no significant differences in non-regrowth cancer recurrence or overall survival in patients treated with watch-and-wait versus surgery, few patients have been studied and more prospective studies are needed to confirm long-term safety. FUNDING None.
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Affiliation(s)
- Fahima Dossa
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada; Department of Surgery, St Michael's Hospital, Toronto, ON, Canada
| | - Tyler R Chesney
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Sergio A Acuna
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada; Department of Surgery, St Michael's Hospital, Toronto, ON, Canada
| | - Nancy N Baxter
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada; Department of Surgery, St Michael's Hospital, Toronto, ON, Canada.
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FDG-PET predicts treatment efficacy and surgical outcome of pre-operative chemoradiation therapy for resectable and borderline resectable pancreatic cancer. Eur J Surg Oncol 2017; 43:1061-1067. [PMID: 28389044 DOI: 10.1016/j.ejso.2017.03.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Revised: 03/07/2017] [Accepted: 03/15/2017] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The efficacy of neoadjuvant chemoradiotherapy (NACRT) for resectable and borderline resectable pancreatic cancer is important for predicting outcomes after radical surgery, but few clinical indicators predict outcome before resection. This study examined the utility of FDG-PET in predicting the efficacy of NACRT and outcome after radical surgery. METHODS Eighty-three pancreatic cancer patients who underwent FDG-PET before and after NACRT and had positive standard uptake values (SUVs) before NACRT were enrolled in this study. Peri-operative clinical factors, including FDG-PET findings, were examined to predict the efficacy of NACRT and outcome after surgery. RESULTS Evans grade I, IIA, IIB, III, and IV was determined in 11, 31, 27, 11, and 3 patients, respectively. The maximum SUVs after NACRT (post SUV-max) and tumor size were significantly decreased compared to pretreatment values (p < 0.001 and p = 0.007, respectively). The post SUV-max and regression index were significantly related to grade III/IV (p = 0.04 and p < 0.001, respectively), but only the regression index predicted NACRT efficacy (p = 0.002). The AUC of the regression index for the detection of grade III/IV was 0.822, and 13 of 14 grade III/IV patients were picked up using 50% as the threshold (p < 0.001). Patients with a regression index >50% had a significantly better prognosis after radical resection than patients with <50% (p = 0.032). Regression index as well as pathological lymph node status and resectability status were independent prognostic factors in multivariate analysis (exp 2.086, p = 0.043). CONCLUSION The regression index is potentially a good indicator of the efficacy of NACRT and outcome after radical resection for pancreatic cancer.
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Outcome and Salvage Surgery Following "Watch and Wait" for Rectal Cancer after Neoadjuvant Therapy: A Systematic Review. Dis Colon Rectum 2017; 60:335-345. [PMID: 28177997 DOI: 10.1097/dcr.0000000000000754] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Currently there is no reliable test to predict pathological complete response following neoadjuvant chemoradiotherapy for rectal cancer. However, there is increasing interest in using clinical complete response as a surrogate marker, allowing a subset of patients with locally advanced rectal cancer to be allocated into a "watch and wait" pathway. Little is known about the oncological safety of the "watch and wait" approach or the rate of salvage surgery in cases of tumor regrowth. This information is critical for the implementation of this approach. OBJECTIVE The aim of this study is to assess the rate of salvage surgery and associated oncological outcomes for patients who develop a tumor regrowth with the "watch and wait" approach. DATA SOURCES Relevant studies were identified through PubMed, Embase, and Google Scholar search. STUDY SELECTION A systematic review was undertaken of studies assessing patients selected for the "watch and wait" approach according to PRISMA guidelines. MAIN OUTCOME MEASURES The associated tumor regrowth, salvage surgery, and disease-free and overall survival rates were assessed. RESULTS Five retrospective and 4 prospective observational studies were included into the analysis, with a total of 370 patients in the "watch and wait" group, of which 256 (69.2%) had persistent clinical complete response. Of those who had tumor regrowth, salvage surgery was possible in 83.8%. There was no difference in overall survival and disease-free survival between patients who received immediate surgery and the "watch and wait" group. LIMITATIONS The limitations of this study include its retrospective nature and small sample size. Furthermore, there is significant heterogeneity between study protocols, including the short median follow-up, given that tumor regrowth and distant metastasis may manifest at a later time point. CONCLUSION The majority of patients with tumor regrowth can be salvaged with definite surgery after "watch and wait." However, there is insufficient evidence to draw firm conclusions on the oncological safety of this approach; therefore, it is currently not the standard of care for locally advanced rectal cancer.
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Alongi F, Fersino S, Mazzola R, Fiorentino A, Giaj-Levra N, Ricchetti F, Ruggieri R, Di Paola G, Cirillo M, Gori S, Salgarello M, Zamboni G, Ruffo G. Radiation dose intensification in pre-operative chemo-radiotherapy for locally advanced rectal cancer. Clin Transl Oncol 2017; 19:189-196. [PMID: 27271749 DOI: 10.1007/s12094-016-1522-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 05/28/2016] [Indexed: 01/11/2023]
Abstract
BACKGROUND To assess the role of radiation dose intensification with simultaneous integrated boost guided by 18-FDG-PET/CT in pre-operative chemo-radiotherapy (ChT-RT) for locally advanced rectal cancer. METHODS A prospective study was approved by the Internal Review Board. Inclusion criteria were: age >18 years old, World Health Organization performance status of 0-1, locally advanced histologically proven adenocarcinoma of the rectum within 10 cm of the anal verge, signed specific informed consent. High-dose volumes were defined including the hyper-metabolic areas of 18-FDG-PET/CT of primary tumor and the corresponding mesorectum and/or pelvic nodes with at least a standardized uptake values (SUV) of 5. A dose of 60 Gy/30 fractions was delivered. A total dose of 54 Gy/30 fractions was delivered to prophylactic areas. Capecitabine was administered concomitantly with RT for a dose of 825 mg/mq twice daily for 5 days/every week. RESULTS Between September 2011 and July 2015 fortypatients were recruited. At the time of the analysis, median follow up was 20 months (range 5-51). The median interval from the end of ChT-RT to surgery was 9 weeks (range 8-12). Thirty-seven patients (92.5 %) were submitted to sphincter preservation. Tumor Regression Grade (Mandard scale) was recorded as follows: grade 1 in 7 (17.5 %), grade 2 in 17 (42.5 %), grade 3 in 15 (37.5 %) and grade 4 in 1 (2.5 %). Post-surgical circumferential resection margin was negative in all patients. A tumor downstaging was reported in 62.5 % (95 % CI: 0.78-0.47). A nodes downstaging was registered in 85 % (95 % CI: 0.55-0.25). 18-FDG-PET/CT was not able to predict pCR. No correlation was found between pre-treatment SUV-max values and pCR. A metabolic tumor volume >127 cc was related to ypT ≥2 (p 0.01). Patients with TRG >2 had higher tumor lesion glycolysis values (p 0.05). CONCLUSION Preliminary results did not confirm some advantages in terms of primary tumor downstaging/downsizing compared to conventional schedules reported in historical series. The role of 18-FDG-PET/CT in neoadjuvant rectal cancer management needs to be confirmed in further investigations. Long terms results are necessary.
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Affiliation(s)
- F Alongi
- Radiation Oncology Division, Sacro Cuore Don Calabria Cancer Care Center, Negrar, Verona, Italy
| | - S Fersino
- Radiation Oncology Division, Sacro Cuore Don Calabria Cancer Care Center, Negrar, Verona, Italy
| | - R Mazzola
- Radiation Oncology Division, Sacro Cuore Don Calabria Cancer Care Center, Negrar, Verona, Italy.
| | - A Fiorentino
- Radiation Oncology Division, Sacro Cuore Don Calabria Cancer Care Center, Negrar, Verona, Italy
| | - N Giaj-Levra
- Radiation Oncology Division, Sacro Cuore Don Calabria Cancer Care Center, Negrar, Verona, Italy
| | - F Ricchetti
- Radiation Oncology Division, Sacro Cuore Don Calabria Cancer Care Center, Negrar, Verona, Italy
| | - R Ruggieri
- Radiation Oncology Division, Sacro Cuore Don Calabria Cancer Care Center, Negrar, Verona, Italy
| | - G Di Paola
- Statistic Science Faculty, University of Palermo, Palermo, Italy
| | - M Cirillo
- Medical Oncology Division, Sacro Cuore Don Calabria Cancer Care Center, Negrar, Verona, Italy
| | - S Gori
- Medical Oncology Division, Sacro Cuore Don Calabria Cancer Care Center, Negrar, Verona, Italy
| | - M Salgarello
- Nuclear Medicine Division, Sacro Cuore Don Calabria Cancer Care Center, Negrar, Verona, Italy
| | - G Zamboni
- Pathology Division, Sacro Cuore Don Calabria Cancer Care Center, Negrar, Verona, Italy
| | - G Ruffo
- Surgery Division, Sacro Cuore Don Calabria Cancer Care Center, Negrar, Verona, Italy
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Semiquantitative Volumetry by Sequential PET/CT May Improve Prediction of Complete Response to Neoadjuvant Chemoradiation in Patients With Distal Rectal Cancer. Dis Colon Rectum 2016; 59:805-12. [PMID: 27505108 DOI: 10.1097/dcr.0000000000000655] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Previous studies using PET/CT imaging have failed to accurately identify complete responders to neoadjuvant chemoradiation among patients with rectal cancer. The use of metabolic parameters alone or imprecise delineation of baseline and residual tumor volumes may have contributed for these disappointing findings. OBJECTIVE The purpose of this study was to determine the accuracy of complete response identification in rectal cancer after neoadjuvant chemoradiation by sequential PET/CT imaging with a decrease in tumor metabolism and volume using optimal tumor volume delineation. DESIGN This was a retrospective comparison of prospectively collected data from a clinical trial (National Clinical Trial 00254683). SETTINGS The study was conducted at a single research center. PATIENTS Ninety patients with cT2-4N0-2M0 distal rectal cancer underwent sequential PET/CT at baseline and 12 weeks after neoadjuvant chemoradiation. Quantitative metabolic analysis (median and maximal standard uptake values), volumetric estimates (metabolic tumor volume), and composite estimates incorporating volume and quantitative data (total lesion glycolysis) were compared for the assessment of response to neoadjuvant chemoradiation using receiver operating characteristic curves. Individual standard uptake value thresholds were used according to response to neoadjuvant chemoradiation to match metabolic activity and optimize volume delineation. MAIN OUTCOME MEASURES The accuracy of complete response identification by multiple volumetric and metabolic parameters using sequential PET/CT imaging was measured. RESULTS Variation in total lesion glycolysis between baseline and 12-week PET/CT scans was associated with the best area under the curve (area under the curve = 0.81 (95% CI, 0.69-0.92)) when compared with standard uptake value or metabolic tumor volume for the identification of a complete responder. Patients with a ≥92% decrease in total lesion glycolysis between baseline and 12-week PET/CT scan had a 90% chance to harbor complete response. LIMITATIONS This study was limited by its lack of interobserver agreement analysis. CONCLUSIONS PET/CT scan using volume and metabolic estimates with individual standard uptake value thresholds for volume determination may provide a useful tool to predict response to neoadjuvant chemoradiation in distal rectal cancer.
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dos Anjos DA, Habr-Gama A, Vailati BB, Rossi CB, Coturel AE, Perez RO, São Julião GP, de Sousa JB, Buchpiguel CA. 18F-FDG uptake by rectal cancer is similar in mucinous and nonmucinous histological subtypes. Ann Nucl Med 2016; 30:513-7. [DOI: 10.1007/s12149-016-1089-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 05/22/2016] [Indexed: 12/17/2022]
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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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Meng X, Li H, Kong L, Zhao X, Huang Z, Zhao H, Zhu W, Li X, Yu J, Xing L. MRI In rectal cancer: Correlations between MRI features and molecular markers Ki-67, HIF-1α, and VEGF. J Magn Reson Imaging 2016; 44:594-600. [PMID: 26919464 DOI: 10.1002/jmri.25195] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 01/31/2016] [Accepted: 02/02/2016] [Indexed: 01/26/2023] Open
Affiliation(s)
- Xiangjiao Meng
- Department of Radiation Oncology of Shandong Cancer Hospital and Institute; Jinan Shandong China
| | - Huijuan Li
- Department of Radiation Oncology of Shandong Cancer Hospital and Institute; Jinan Shandong China
| | - Lingling Kong
- Department of Radiation Oncology of Shandong Cancer Hospital and Institute; Jinan Shandong China
| | - Xianguang Zhao
- Department of Radiation Oncology of Shandong Cancer Hospital and Institute; Jinan Shandong China
| | - Zhaoqin Huang
- Department of Radiology; Provincial Hospital Affiliated to Shandong University; Jinan Shandong China
| | - Hanxi Zhao
- Department of Radiation Oncology of Shandong Cancer Hospital and Institute; Jinan Shandong China
| | - Wanqi Zhu
- Department of Radiation Oncology of Shandong Cancer Hospital and Institute; Jinan Shandong China
| | - Xiaolin Li
- Department of Radiation Oncology of Shandong Cancer Hospital and Institute; Jinan Shandong China
| | - Jinming Yu
- Department of Radiation Oncology of Shandong Cancer Hospital and Institute; Jinan Shandong China
| | - Ligang Xing
- Department of Radiation Oncology of Shandong Cancer Hospital and Institute; Jinan Shandong China
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Habr-Gama A, Perez RO, São Julião GP, Proscurshim I, Fernandez LM, Figueiredo MN, Gama-Rodrigues J, Buchpiguel CA. Consolidation chemotherapy during neoadjuvant chemoradiation (CRT) for distal rectal cancer leads to sustained decrease in tumor metabolism when compared to standard CRT regimen. Radiat Oncol 2016; 11:24. [PMID: 26911200 PMCID: PMC4766749 DOI: 10.1186/s13014-016-0598-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 02/04/2016] [Indexed: 02/07/2023] Open
Abstract
Background Neoadjuvant CRT may lead to significant tumor regression in patients with rectal cancer. Different CRT regimens with consolidation chemotherapy may lead to increased rates of complete tumor regression. The purpose of this study was to understand tumor metabolic activity following two different neoadjuvant CRT regimens using sequential PET/CT imaging in two different intervals following RT. Methods Patients with cT2-4 N0-2 M0 rectal cancer treated by standard CRT (54Gy and 2 cycles of 5FU-based chemotherapy) or extended CRT (54Gy and 6 cycles of 5FU-based chemotherapy) underwent sequential PET/CT imaging at baseline, 6 weeks and 12 weeks from radiation completion. Results 99 patients undergoing standard CRT were compared to 12 patients undergoing CRT with consolidation chemotherapy. Patients treated with consolidation CRT had increased rates of complete clinical or pathological response (66 % vs. 23 %; p < 0.001). SUVmax variation between baseline and 6 weeks (88 % vs. 63 %; p < 0.001) and between baseline and 12 weeks (90 % vs. 57 %; p < 0.001) were significantly more pronounced among patients undergoing extended CRT with consolidation chemotherapy. An increase in SUVmax between 6 and 12 weeks was observed in 51 % of patients undergoing standard and 18 % of patients undergoing consolidation CRT (p = 0.04). Conclusions Most of the reduction in tumor metabolism after neoadjuvant CRT occurs within the first 6 weeks from RT completion. In patients undergoing CRT with consolidation chemotherapy, tumors are less likely to regain metabolic activity between 6 and 12 weeks. Therefore, assessment of tumor response may be safely postponed to 12 weeks in patients undergoing extended CRT with consolidation chemotherapy. Trial registration NCT00254683
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Affiliation(s)
- Angelita Habr-Gama
- Angelita & Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo, SP, Brazil. .,University of São Paulo School of Medicine, São Paulo, Brazil.
| | - Rodrigo O Perez
- Angelita & Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo, SP, Brazil. .,University of São Paulo School of Medicine Colorectal Surgery Division, São Paulo, Brazil. .,Ludwig Institute for Cancer Research São Paulo Branch, São Paulo, Brazil.
| | | | - Igor Proscurshim
- Angelita & Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo, SP, Brazil.
| | - Laura M Fernandez
- Angelita & Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo, SP, Brazil.
| | - Marleny N Figueiredo
- Angelita & Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo, SP, Brazil.
| | - Joaquim Gama-Rodrigues
- Angelita & Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo, SP, Brazil. .,University of São Paulo School of Medicine, São Paulo, Brazil.
| | - Carlos A Buchpiguel
- University of São Paulo School of Medicine Nuclear Imaging Division, São Paulo, Brazil.
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