1
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Wang G, Yao K, Yang Y, Chen H, Tang Z, Ye J, Fu M, Xue X, Shen Q, Tang H, Guo Y, Huang Y. Local resection versus radical resection after neoadjuvant chemoradiotherapy for patients with locally advanced rectal cancer: a propensity-score matched cohort analysis. BMC Gastroenterol 2023; 23:205. [PMID: 37312044 DOI: 10.1186/s12876-023-02809-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 05/09/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND We aimed to address the shortage of evidence regarding the safety of the local resection approach by comparing long-term oncological outcomes between patients managed by local resection and those who underwent radical resection. METHODS This was a propensity-score matched cohort analysis study that included patients of all ages diagnosed with locally advanced rectal cancer (LARC) who had received neoadjuvant chemoradiotherapy (nCRT) at the Fujian Medical University Union Hospital and Fujian Medical University Affiliated Zhangzhou Hospital, China, between Jan 10, 2011, to Dec 28, 2021. Partial patients with a significant downstage of the tumor were offered management with the local resection approach, and most of the rest were offered radical resection if eligible. FINDINGS One thousand six hundred ninety-three patients underwent radical resection after nCRT, and another 60 patients performed local resection. The median follow-up times were 44.0 months (interquartile range = 4-107 months). After propensity-core matching (PSM), in the Kaplan-Meier curves, local resection (n = 56) or radical resection (n = 211) was not significantly associated with 1-, 3-, and 5-year cumulative incidence of overall survival (OS) (HR = 1.103, 95% CI: 0.372 ~ 3.266), disease-free survival (DFS) ((HR = 0.972, 95% CI: 0.401 ~ 2.359), local recurrence (HR = 1.044, 95% CI: 0.225 ~ 4.847), and distant metastasis (HR = 0.818, 95% CI: 0.280 ~ 2.387) (all log-rank P > 0.05). Similarly, multivariate Cox regression analysis indicates that local excision still was not an independent risk factor for OS (HR = 0.863, 95% CI: 0.267 ~ 2.785, P = 0.805) and DFS (HR = 0.885, 95% CI: 0.353 ~ 2.215, p = 0.794). CONCLUSION Local resection can be a management option in selected patients with middle-low rectal cancer after nCRT for LARC and without loss of oncological safety at five years.
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Affiliation(s)
- Guancong Wang
- Department of Colorectal and Anal Surgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, 363000, China
| | - Kaiyuan Yao
- Department of Colorectal and Anal Surgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, 363000, China
| | - Yugang Yang
- Department of Colorectal and Anal Surgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, 363000, China
| | - Hongying Chen
- Department of Colorectal and Anal Surgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, 363000, China
| | - Zihan Tang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, China
| | - Jiahong Ye
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, China
| | - Muhai Fu
- Department of Colorectal and Anal Surgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, 363000, China
| | - Xiajuan Xue
- Department of Colorectal and Anal Surgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, 363000, China
| | - Qiyuan Shen
- Department of Colorectal and Anal Surgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, 363000, China
| | - Haiwen Tang
- Department of Colorectal and Anal Surgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, 363000, China
| | - Yincong Guo
- Department of Colorectal and Anal Surgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, 363000, China.
| | - Ying Huang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, China.
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2
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Kim S, Huh JW, Lee WY, Yun SH, Kim HC, Cho YB, Park Y, Shin JK. Correlation between T stage and lymph node metastasis in rectal cancer treated with preoperative chemoradiotherapy. Ther Adv Med Oncol 2022; 14:17588359221132620. [PMID: 36312818 PMCID: PMC9597009 DOI: 10.1177/17588359221132620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 09/27/2022] [Indexed: 11/07/2022] Open
Abstract
Background: Depth of tumor is a risk factor for lymph node metastasis in rectal cancer,
but impact of yield pathologic T (ypT) stage on lymph node involvement in
rectal cancer remains unclear. The aim of this study was to evaluate the
correlation between ypT stage and lymph node metastasis. Methods: From January 2010 to December 2015, 602 patients who were diagnosed with
rectal cancer and treated with neoadjuvant chemoradiotherapy (CRT) followed
by radical operation were reviewed retrospectively. The correlations between
ypT stage and lymph node status and survival were evaluated. Results: On pathology, 179 (29.7%) patients exhibited regional lymph node metastasis.
Lymph node metastasis was seen in 8.5% of ypT0 patients, 20% of ypT1, 18.4%
of ypT2, 47.5% of ypT3, and 27.3% of ypT4. Positive lymph node metastasis
was correlated with ypT stage. In addition, the difference of lymph node
metastasis in ypT stage subgroups was statistically significant
(p < 0.001). Five-year disease-free survival was
significantly different in the ypT stage subgroups (88.7%
versus 86.7% versus 82.6%
versus 64.7% versus 72.7%,
p < 0.001), as was 5-year overall survival (96.2%
versus 90.0% versus 95.8%
versus 80.0% versus 90.9%,
p < 0.001). Conclusion: YpT stage is associated with lymph node metastasis in rectal cancer treated
with neoadjuvant CRT and radical operation, and ypT0 patients exhibited an
8.5% lymph node metastasis rate. Therefore, the decision for local excision
or the watch-and-wait strategy for rectal cancer treated with neoadjuvant
CRT and predicted to show a pathologic complete response should be
considered with caution.
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Affiliation(s)
- Seijong Kim
- Department of Surgery, Samsung Medical Center,
Sungkyunkwan University School of Medicine, Seoul, Korea
| | | | - Woo Yong Lee
- Department of Surgery, Samsung Medical Center,
Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Hyeon Yun
- Department of Surgery, Samsung Medical Center,
Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Cheol Kim
- Department of Surgery, Samsung Medical Center,
Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Beom Cho
- Department of Surgery, Samsung Medical Center,
Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoonah Park
- Department of Surgery, Samsung Medical Center,
Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Kyong Shin
- Department of Surgery, Samsung Medical Center,
Sungkyunkwan University School of Medicine, Seoul, Korea
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3
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He L, Xiao J, Zheng P, Zhong L, Peng Q. Lymph node regression grading of locally advanced rectal cancer treated with neoadjuvant chemoradiotherapy. World J Gastrointest Oncol 2022; 14:1429-1445. [PMID: 36160739 PMCID: PMC9412927 DOI: 10.4251/wjgo.v14.i8.1429] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/30/2022] [Accepted: 07/06/2022] [Indexed: 02/05/2023] Open
Abstract
Neoadjuvant chemoradiotherapy (nCRT) and total rectal mesenteric excision are the main standards of treatment for locally advanced rectal cancer (LARC). Lymph node regression grade (LRG) is an indicator of prognosis and response to preoperative nCRT based on postsurgical metastatic lymph node pathology. Common histopathological findings in metastatic lymph nodes after nCRT include necrosis, hemorrhage, nodular fibrosis, foamy histiocytes, cystic cell reactions, areas of hyalinosis, residual cancer cells, and pools of mucin. A number of LRG systems designed to classify the amount of lymph node regression after nCRT is mainly concerned with the relationship between residual cancer cells and regressive fibrosis and with estimating the number of lymph nodes existing with residual cancer cells. LRG offers significant prognostic information, and in most cases, LRG after nCRT correlates with patient outcomes. In this review, we describe the systematic classification of LRG after nCRT, patient prognosis, the correlation with tumor regression grade, and the typical histopathological findings of lymph nodes. This work may serve as a reference to help predict the clinical complete response and determine lymph node regression in patients based on preservation strategies, allowing for the formulation of more accurate treatment strategies for LARC patients, which has important clinical significance and scientific value.
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Affiliation(s)
- Lei He
- School of Medicine, University of Electronic Science and Technology of China, Chengdu 611731, Sichuan Province, China
| | - Juan Xiao
- School of Medicine, University of Electronic Science and Technology of China, Chengdu 611731, Sichuan Province, China
| | - Ping Zheng
- Department of Pathology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610041, Sichuan Province, China
| | - Lei Zhong
- Personalized Drug Therapy Key Laboratory of Sichuan Province, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, Chengdu 610072, Sichuan Province, China
| | - Qian Peng
- Radiation Therapy Center, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610041, Sichuan Province, China
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4
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Collard MK, Rullier E, Panis Y, Manceau G, Benoist S, Tuech JJ, Alves A, Laforest A, Mege D, Cazelles A, Beyer-Berjot L, Christou N, Cotte E, Lakkis Z, O'Connell L, Parc Y, Piessen G, Lefevre JH. Nonmetastatic ypt0 rectal cancer after neoadjuvant treatment and total mesorectal excision: Lessons from a retrospective multicentric cohort of 383 patients. Surgery 2022; 171:1193-1199. [PMID: 35078629 DOI: 10.1016/j.surg.2021.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 10/04/2021] [Accepted: 10/04/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND A better understanding of pathological features and oncological survival in ypT0 rectal cancer after neoadjuvant chemoradiotherapy is required to improve patient selection criteria for rectal-preserving approach by local excision. Our aim was to define risk of lymph node metastasis and oncological outcomes in ypT0 rectal cancer after chemoradiotherapy and total mesorectal excision. METHODS All consecutive patients who underwent total mesorectal excision for a nonmetastatic rectal adenocarcinoma classified ypT0 after neoadjuvant chemoradiotherapy, with or without locoregional lymph node involvement (ypN+ or ypN-), in 14 French academic centers between 2002 and 2015 were included. Data were collected retrospectively. Overall and disease-free survival were explored. RESULTS Among the 383 ypT0 patients, 6% were ypN+ (23/283). Before chemoradiotherapy, 86% (327/380) were staged cT3-T4 and 41% (156/378) were staged cN+. The risk of ypN+ did not differ between cT3-T4 and cT1-T2 patients (P = .345) or between cN+ and cN- patients (P = .384). After a median follow-up of 61.1 months, we observed 95% confidence interval (92%-97%) of 5-year overall survival and 93% confidence interval (91%-96%) of 5-year disease-free survival. In Cox multivariate analysis, overall survival was altered by intra-abdominal septic complications (hazard ratio = 2.53, confidence interval [1.11-5.78], P = .028). Regarding disease-free survival, ypN+ status and administration of adjuvant chemotherapy were associated with a reduced disease-free survival (P = .001 for both). cT3/T4 staging and cN+ staging did not modify overall survival (P = .332 and P = .450) nor disease-free survival (P = .862 and P = .124). CONCLUSION The risk of lymph node metastasis and the oncological survival do not depend on the initial cT or cN staging in cases of ypT0 complete rectal tumor regression.
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Affiliation(s)
- Maxime K Collard
- Department of Digestive Surgery, Saint Antoine Hospital, Sorbonne University Paris, France
| | - Eric Rullier
- Department of Digestive Surgery, Saint André Hospital, Bordeaux, France
| | - Yves Panis
- Department of Colorectal Surgery, Beaujon Hospital, Clichy, France
| | - Gilles Manceau
- Department of General and Digestive Surgery, Université de Paris, Faculté de Médecine, Paris, France
| | - Stéphane Benoist
- Department of Digestive Surgery, Kremlin-Bicêtre Hospital, France
| | | | - Arnaud Alves
- Department of Digestive Surgery, Rouen Hospital, France
| | - Anais Laforest
- Department of Digestive Surgery, Montsouris Institut, Paris, France
| | - Diane Mege
- Department of Digestive Surgery, Aix Marseille Univ, APHM, Timone University Hospital, Marseille, France
| | | | | | - Niki Christou
- Department of Digestive Surgery, Limoges Hospital, Limoges, France
| | - Eddy Cotte
- Department of Digestive Surgery, Hopital Lyon Sud, Lyon, France
| | - Zaher Lakkis
- Department of Digestive Surgery, Jean Minoz Hospital, Besançon, France
| | - Lauren O'Connell
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Yann Parc
- Department of Digestive Surgery, Saint Antoine Hospital, Sorbonne University Paris, France
| | | | - Jérémie H Lefevre
- Department of Digestive Surgery, Saint Antoine Hospital, Sorbonne University Paris, France.
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5
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Munk NE, Bondeven P, Pedersen BG. Diagnostic performance of MRI and endoscopy for assessing complete response in rectal cancer after neoadjuvant chemoradiotherapy: a systematic review of the literature. Acta Radiol 2021; 64:20-31. [PMID: 34928715 DOI: 10.1177/02841851211065925] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The diagnostic performance of magnetic resonance imaging (MRI) modalities and/or endoscopy for assessing complete response in rectal cancer after neoadjuvant chemoradiotherapy (nCRT) is unclear. PURPOSE To summarize existing evidence on the diagnostic performance of diffusion-weighted MRI, perfusion-weighted MRI, T2-weighted MR tumor regression grade, and/or endoscopy for assessing complete tumor response after nCRT. MATERIAL AND METHODS MEDLINE and Embase databases were searched. The PRISMA guidelines were followed. Sensitivity, specificity, negative predictive, and positive predictive values were retrieved from included studies. RESULTS In total, 81 studies were eligible for inclusion. Evidence suggests that combined use of MRI and endoscopy tends to improve the diagnostic performance compared to single imaging modality. The positive predictive value of a complete response varies substantially between studies. There is considerable heterogeneity between studies. CONCLUSION Combined re-staging tends to improve diagnostic performance compared to single imaging modality, but the vast majority of studies fail to offer true clinical value due to the study heterogeneity.
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Affiliation(s)
| | - Peter Bondeven
- Department of Surgery, Regional Hospital Randers, Randers, Denmark
| | - Bodil Ginnerup Pedersen
- Department of Radiology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
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6
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Marchegiani F, Palatucci V, Capelli G, Guerrieri M, Belluco C, Rega D, Morpurgo E, Coco C, Restivo A, De Franciscis S, Aschele C, Perin A, Bonomo M, Muratore A, Spinelli A, Ramuscello S, Bergamo F, Montesi G, Spolverato G, Del Bianco P, Gambacorta MA, Delrio P, Pucciarelli S. Rectal Sparing Approach After Neoadjuvant Therapy in Patients with Rectal Cancer: The Preliminary Results of the ReSARCh Trial. Ann Surg Oncol 2021; 29:1880-1889. [PMID: 34855063 DOI: 10.1245/s10434-021-11121-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 10/12/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Rectum-preservation for locally advanced rectal cancer has been proposed as an alternative to total mesorectal excision (TME) in patients with major (mCR) or complete clinical response (cCR) after neoadjuvant therapy. The purpose of this study was to report on the short-term outcomes of ReSARCh (Rectal Sparing Approach after preoperative Radio- and/or Chemotherapy) trial, which is a prospective, multicenter, observational trial that investigated the role of transanal local excision (LE) and watch-and-wait (WW) as integrated approaches after neoadjuvant therapy for rectal cancer. METHODS Patients with mid-low rectal cancer who achieved mCR or cCR after neoadjuvant therapy and were fit for major surgery were enrolled. Clinical response was evaluated at 8 and 12 weeks after completion of chemoradiotherapy. Treatment approach, incidence, and reasons for subsequent TME were recorded. RESULTS From 2016 to 2019, 160 patients were enrolled; mCR or cCR at 12 weeks was achieved in 64 and 96 of patients, respectively. Overall, 98 patients were managed with LE and 62 with WW. In the LE group, Clavien-Dindo 3+ complications occurred in three patients. The rate of cCR increased from 8- to 12-week restaging. Thirty-three (94.3%) of 35 patients with cCR had ypT0-1 tumor. At a median 24 months follow-up, a tumor regrowth was found in 15 (24.2%) patients undergoing WW. CONCLUSIONS LE for patients achieving cCR or mCR is safe. A 12-week interval from chemoradiotherapy completion to LE is correlated with an increased cCR rate. The risk of ypT > is reduced when LE is performed after cCR.
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Affiliation(s)
- Francesco Marchegiani
- Department of Surgical, Oncological and Gastroenterological Sciences, First Surgical Clinic, University of Padova, Padua, Italy
| | - Valeria Palatucci
- Department of Surgical, Oncological and Gastroenterological Sciences, First Surgical Clinic, University of Padova, Padua, Italy
| | - Giulia Capelli
- Department of Surgical, Oncological and Gastroenterological Sciences, First Surgical Clinic, University of Padova, Padua, Italy
| | - Mario Guerrieri
- Surgery Clinic, Marche Polytechnic University, Ancona, Italy
| | - Claudio Belluco
- Oncological Surgery Department, Centro di Riferimento Oncologico, National Cancer Institute, Aviano, Italy
| | - Daniela Rega
- National Cancer Institute, IRCCS Fondazione "G.Pascale", Naples, Italy
| | - Emilio Morpurgo
- Department of Surgery, Regional Center for Laparoscopic and Robotic Surgery, Camposampiero Hospital, Padua, Italy
| | - Claudio Coco
- Department of Surgical Sciences, Catholic University of Rome, Rome, Italy
| | - Angelo Restivo
- Department of Surgery, Colorectal Surgery Center, University of Cagliari, Cagliari, Italy
| | | | | | - Alessandro Perin
- Department of Surgical, Oncological and Gastroenterological Sciences, First Surgical Clinic, University of Padova, Padua, Italy
| | | | - Andrea Muratore
- Division of General Surgery, E. Agnelli Hospital, Pinerolo, Turin, Italy
| | - Antonino Spinelli
- Colon and Rectal Surgery Unit, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | | | | | - Giampaolo Montesi
- Radiation Oncology Unit, Santa Maria della Misericordia Hospital, Rovigo, Italy
| | - Gaya Spolverato
- Department of Surgical, Oncological and Gastroenterological Sciences, First Surgical Clinic, University of Padova, Padua, Italy.
| | | | | | - Paolo Delrio
- National Cancer Institute, IRCCS Fondazione "G.Pascale", Naples, Italy
| | - Salvatore Pucciarelli
- Department of Surgical, Oncological and Gastroenterological Sciences, First Surgical Clinic, University of Padova, Padua, Italy
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7
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Haak HE, Beets GL, Peeters K, Nelemans PJ, Valentini V, Rödel C, Kuo L, Calvo FA, Garcia-Aguilar J, Glynne-Jones R, Pucciarelli S, Suarez J, Theodoropoulos G, Biondo S, Lambregts DMJ, Beets-Tan RGH, Maas M. Prevalence of nodal involvement in rectal cancer after chemoradiotherapy. Br J Surg 2021; 108:1251-1258. [PMID: 34240110 DOI: 10.1093/bjs/znab194] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 04/28/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND The purpose of this study was to investigate the prevalence of ypN+ status according to ypT category in patients with locally advanced rectal cancer treated with chemoradiotherapy and total mesorectal excision, and to assess the impact of ypN+ on disease recurrence and survival by pooled analysis of individual-patient data. METHODS Individual-patient data from 10 studies of chemoradiotherapy for rectal cancer were included. Pooled rates of ypN+ disease were calculated with 95 per cent confidence interval for each ypT category. Kaplan-Meier and Cox regression analyses were undertaken to assess influence of ypN status on 5-year disease-free survival (DFS) and overall survival (OS). RESULTS Data on 1898 patients were included in the study. Median follow-up was 50 (range 0-219) months. The pooled rate of ypN+ disease was 7 per cent for ypT0, 12 per cent for ypT1, 17 per cent for ypT2, 40 per cent for ypT3, and 46 per cent for ypT4 tumours. Patients with ypN+ disease had lower 5-year DFS and OS (46.2 and 63.4 per cent respectively) than patients with ypN0 tumours (74.5 and 83.2 per cent) (P < 0.001). Cox regression analyses showed ypN+ status to be an independent predictor of recurrence and death. CONCLUSION Risk of nodal metastases (ypN+) after chemoradiotherapy increases with advancing ypT category and needs to be considered if an organ-preserving strategy is contemplated.
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Affiliation(s)
- H E Haak
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands.,GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
| | - G L Beets
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands.,GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
| | - K Peeters
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - P J Nelemans
- Department of Epidemiology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - V Valentini
- Department of Radiation Oncology, Universita Cattolica del Sacro Cuore, Rome, Italy
| | - C Rödel
- Department of Radiation Oncology, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - L Kuo
- Department of Colorectal Surgery, Taipei Medical University Hospital, Taipei, Taiwan
| | - F A Calvo
- Department of Oncology, General University Hospital Gregorio Marañón, Madrid, Spain
| | - J Garcia-Aguilar
- Department of Surgery, Memorial Sloan Kettering Cancer Centre, New York, USA
| | - R Glynne-Jones
- Department of Clinical Oncology, Mount Vernon Hospital, London, UK
| | - S Pucciarelli
- Department of Surgical, Oncological and Gastroenterological Sciences, First Surgical Clinic, University of Padua, Padua, Italy
| | - J Suarez
- Department of Surgery, Hospital de Navarra, Pamplona, Spain
| | - G Theodoropoulos
- First Department of Propaedeutic Surgery, Athens Medical School, Hippocration General Hospital, Athens, Greece
| | - S Biondo
- Department of Surgery, Bellvitge University Hospital, Barcelona, Spain.,IDIBELL, University of Barcelona, Barcelona, Spain
| | - D M J Lambregts
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - R G H Beets-Tan
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands.,Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - M Maas
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
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8
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Lymph Node Regression to Neoadjuvant Chemoradiotherapy in Patients with Locally Advanced Rectal Cancer: Prognostic Implication and a Predictive Model. J Gastrointest Surg 2021; 25:1019-1028. [PMID: 32219686 DOI: 10.1007/s11605-020-04566-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 03/01/2020] [Indexed: 01/31/2023]
Abstract
AIM Currently, few studies have focused on the prognostic impact of lymph node regression to neoadjuvant chemoradiotherapy (NCRT) in rectal cancer. This study aimed to explore the prognostic impact of lymph node regression grade (LRG) in patients with locally advanced rectal cancer (LARC) following NCRT and radical surgery and develop a predictive nomogram for disease-free survival (DFS). METHODS LARC patients undergoing NCRT and radical surgery between 2013 and 2014 were enrolled and divided into LRG low (≤ 2), middle (3-9), and high (≥ 10) groups. Clinicopathological characteristics and survival outcomes were compared. Predictors for DFS were identified by Cox regression analysis, and a nomogram was constructed. RESULTS A total of 257 LARC patients were eligible, including LRG low (n = 149), middle (n = 59), and high (n = 49) groups. Higher LRG score was associated with higher TRG, more advanced ypT and ypN stages, and poorer OS and DFS (all P < 0.001). Cox regression analysis demonstrated that tumor differentiation (poor and anaplastic, HR = 2.048, P = 0.048), ypTNM stage (HR = 2.389, P = 0.015), and LRG-sum (HR = 1.020, P = 0.029) were independent prognostic determinants for DFS after NCRT. A nomogram for DFS was developed with a C-index of 0.68 (95%CI 0.64-0.72). CONCLUSION LRG is an important prognostic indicator for DFS in LARC patients after NCRT. A predictive nomogram based on LRG was developed to guide more tailored adjuvant treatment and surveillance.
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9
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Calmels M, Collard MK, Cazelles A, Frontali A, Maggiori L, Panis Y. Local excision after neoadjuvant chemoradiotherapy versus total mesorectal excision: a case-matched study in 110 selected high-risk patients with rectal cancer. Colorectal Dis 2020; 22:1999-2007. [PMID: 32813899 DOI: 10.1111/codi.15323] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 08/10/2020] [Indexed: 02/08/2023]
Abstract
AIM The aim of this comparative study was to report a 10-year experience of an organ preservation strategy by local excision (LE) in selected high-risk patients (aged patients and/or patients with severe comorbidity and/or indication for abdominoperineal excision) versus total mesorectal excision (TME) after neoadjuvant radiochemotherapy (RCT) for patients with locally advanced (T3-T4 and/or N+) low and mid rectal cancer with suspicion of complete tumour response (CTR) or near-CTR. METHOD Thirty-nine patients with rectal cancer who underwent LE after RCT for suspicion of CTR were matched to 71 patients who underwent TME according to body mass index, gender, tumour location and ypTNM stage. Operative, oncological and functional results were compared between groups. RESULTS In the LE group, ypT0, ypTis or ypT1N0R0 were noted in 28/39 (72%). Overall morbidity was observed in 10/39 (26%) in LE vs 46/71 in the TME group (65%) (P = 0.001). Severe morbidity (Clavien-Dindo ≥ 3) was noted in 1/39 patients from the LE group (3%) vs 3/71 (4%) from the TME group (P = 1.000). After a mean follow-up of 63 ± 4 months (range 56-70 months), local recurrence was noted in 2/39 (5%) from the LE group vs 2/71 (3%) from the TME group (P = 0.601). Definitive stoma was noted in 2/39 (6%) from the LE group vs 8/71 (12%) from the TME group (P = 0.489). Major low anterior resection syndrome was noted in 5/23 (22%) from LE group vs 11/33 (33%) from the TME group (P = 0.042). CONCLUSION The accuracy of response prediction after RCT was 72% after LE. In high-risk patients, LE represents a safe alternative to TME with better functional results and the same long-term oncological outcome.
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Affiliation(s)
- M Calmels
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Denis Diderot (Paris VII), Clichy Cedex, France
| | - M K Collard
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Denis Diderot (Paris VII), Clichy Cedex, France
| | - A Cazelles
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Denis Diderot (Paris VII), Clichy Cedex, France
| | - A Frontali
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Denis Diderot (Paris VII), Clichy Cedex, France
| | - L Maggiori
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Denis Diderot (Paris VII), Clichy Cedex, France
| | - Y Panis
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Denis Diderot (Paris VII), Clichy Cedex, France
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10
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Nahas SC, Nahas CSR, Cama GM, de Azambuja RL, Horvat N, Marques CFS, Menezes MR, Junior UR, Cecconello I. Diagnostic performance of magnetic resonance to assess treatment response after neoadjuvant therapy in patients with locally advanced rectal cancer. Abdom Radiol (NY) 2019; 44:3632-3640. [PMID: 30663025 DOI: 10.1007/s00261-019-01894-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE Our study aimed to evaluate the diagnostic performance of rectal magnetic resonance imaging (MRI) for local restaging in patients with non-metastatic locally advanced rectal cancer (LARC) after neoadjuvant chemoradiotherapy (CRT) using surgical histopathology of total mesorectal excision as the reference standard. METHODS Ninety-five patients with LARC who underwent rectal MRI after CRT between January 2014 and December 2016 were included. Accuracy, sensitivity, specificity, positive, and negative predictive value for local staging regarding T-stage, N-stage, circumferential resection margin, and MRI tumor regression grade (ymriTRG) were calculated, and inter-test agreements were assessed. RESULTS 22/95 (23.2%) patients had radiological complete response (rCR), whereas 20/95 (21.1%) had pathological complete response (pCR). Among the patients with pCR, 11/20 (55%) had rCR. Fair agreement was demonstrated between ymriTRG and pathological TRG (ypTRG) (κ = 0.255). The sensitivity and specificity for detection of pCR were 61.1% (95% CI 35.7-82.7) and 89.6% (95% CI 80.6-95.4). For the detection of ypTRG grades 1 and 2, the corresponding values were 67.2% (95% CI 54.3-78.4) and 51.6 (95% CI 33.1-69.8). The accuracy of ymriTRG was 24.2% (95% CI 15.6-32.8). Inter-test agreement in TRG between MRI and pathology was overall fair (κ = 0.255) and slight (κ = 0.179), if TRG 1 + 2. CONCLUSION Qualitative assessment on MRI for diagnosing pCR showed moderate sensitivity and high specificity, whereas the diagnosis of TRG had moderate sensitivity and low specificity with slight to fair inter-test agreement when compared with pathological specimens.
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11
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Delitto D, George TJ, Loftus TJ, Qiu P, Chang GJ, Allegra CJ, Hall WA, Hughes SJ, Tan SA, Shaw CM, Iqbal A. Prognostic Value of Clinical vs Pathologic Stage in Rectal Cancer Patients Receiving Neoadjuvant Therapy. J Natl Cancer Inst 2019; 110:460-466. [PMID: 29165692 DOI: 10.1093/jnci/djx228] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 09/28/2017] [Indexed: 12/15/2022] Open
Abstract
Background Neoadjuvant chemoradiation is currently standard of care in stage II-III rectal cancer, resulting in tumor downstaging for patients with treatment-responsive disease. However, the prognosis of the downstaged patient remains controversial. This work critically analyzes the relative contribution of pre- and post-therapy staging to the anticipated survival of downstaged patients. Methods The National Cancer Database (NCDB) was queried for patients with rectal cancer treated with transabdominal resection between 2004 and 2014. Stage II-III patients downstaged with neoadjuvant radiation were compared with stage I patients treated with definitive resection alone. Patients with positive surgical margins were excluded. Overall survival was evaluated using both Kaplan-Meier analyses and Cox proportional hazards models. All statistical tests were two-sided. Results A total of 44 320 patients were eligible for analysis. Survival was equivalent for patients presenting with cT1N0 disease undergoing resection (mean survival = 113.0 months, 95% confidence interval [CI] = 110.8 to 115.3 months) compared with those downstaged to pT1N0 from both cT3N0 (mean survival = 114.9 months, 95% CI = 110.4 to 119.3 months, P = .12) and cT3N1 disease (mean survival = 115.4 months, 95% CI = 110.1 to 120.7 months, P = .22). Survival statistically significantly improved in patients downstaged to pT2N0 from cT3N0 disease (mean survival = 109.0 months, 95% CI = 106.7 to 111.2 months, P < .001) and cT3N1 (mean survival = 112.8 months, 95% CI = 110.0 to 115.7 months, P < .001), compared with cT2N0 patients undergoing resection alone (mean survival = 100.0 months, 95% CI = 97.5 to 102.5 months). Multiple survival analysis confirmed that final pathologic stage dictated long-term outcomes in patients undergoing neoadjuvant radiation (hazard ratio [HR] of pT2 = 1.24, 95% CI = 1.10 to 1.41; HR of pT3 = 1.81, 95% CI = 1.61 to 2.05; HR of pT4 = 2.72, 95% CI = 2.28 to 3.25, all P ≤ .001 vs pT1; HR of pN1 = 1.50, 95% CI = 1.41 to 1.59; HR of pN2 = 2.17, 95% CI = 2.00 to 2.35, both P < .001 vs pN0); while clinical stage at presentation had little to no predictive value (HR of cT2 = 0.81, 95% CI = 0.69 to 0.95, P = .008; HR of cT3 = 0.83, 95% CI = 0.72 to 0.96, P = .009; HR of cT4 = 1.02, 95% CI = 0.85 to 1.21, P = .87 vs cT1; HR of cN1 = 0.96, 95% CI = 0.91 to 1.02, P = .19; HR of cN2 = 0.96, 95% CI = 0.86 to 1.08, P = .48 vs cN0). Conclusions Survival in patients with rectal cancer undergoing neoadjuvant radiation is driven by post-therapy pathologic stage, regardless of pretherapy clinical stage. These data will further inform prognostic discussions with patients.
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Affiliation(s)
- Daniel Delitto
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Thomas J George
- Division of Hematology and Oncology, Department of Medicine, University of Florida College of Medicine, Gainesville, FL
| | - Tyler J Loftus
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Peihua Qiu
- Department of Biostatistics, University of Florida College of Medicine, Gainesville, FL
| | - George J Chang
- Department of Surgical Oncology and Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Carmen J Allegra
- Division of Hematology and Oncology, Department of Medicine, University of Florida College of Medicine, Gainesville, FL
| | - William A Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Steven J Hughes
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Sanda A Tan
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Christiana M Shaw
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Atif Iqbal
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
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12
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Lee HG, Kim SJ, Park IJ, Hong SM, Lim SB, Lee JB, Yu CS, Kim JC. Effect of Responsiveness of Lymph Nodes to Preoperative Chemoradiotherapy in Patients With Rectal Cancer on Prognosis After Radical Resection. Clin Colorectal Cancer 2019; 18:e191-e199. [PMID: 31014994 DOI: 10.1016/j.clcc.2019.03.001] [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: 07/29/2018] [Revised: 03/05/2019] [Accepted: 03/25/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND The influence of lymph node (LN) response to preoperative chemoradiotherapy (PCRT) has not been well evaluated for prognosis and additional use of adjuvant treatment after PCRT in rectal cancer patients. The aim of this study was to evaluate the prognostic effect of LN regression grade (LRG) in rectal cancer after PCRT and radical resection. PATIENTS AND METHODS From 2008 to 2011, 389 patients with rectal cancer treated with PCRT followed by radical resection were identified. The pathologic LRG (pLRG) score was determined on the basis of the proportion of tumor cells and fibrosis. The sum of the pLRG of each evaluated LN was used as the final LRG score, LRG-sum. Cox regression analysis was used to evaluate the association of LRG-sum and recurrence-free survival (RFS). RESULTS The distribution of LRG-sum was significantly associated with tumor regression grade of the primary tumor (P < .001). LRG-sum showed different values even in patients with the same number of metastatic LNs. LRG-sum was confirmed as the most relevant associated factor among LN-related variables with RFS along with ypT stage in multivariate analysis. Patients were categorized according to the cutoff points of LRG-sum distribution: LRG1 (LRG-sum 0 to ≤3), LRG2 (LRG-sum 3 to ≤21), and LRG3 (LRG-sum >21). RFS showed a significant difference according to LRG group (P < .001) and showed more effective difference in RFS in the same ypN stage subgroup on the basis of the number of metastatic LNs. CONCLUSION LRG was a prognostic factor of oncologic outcomes of rectal cancer. LN response to PCRT might help in prognostication and determination of treatments after PCRT.
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Affiliation(s)
- Hyun Gu Lee
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sung Joo Kim
- Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - In Ja Park
- Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
| | - Seung Mo Hong
- Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Seok-Byung Lim
- Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jung Bok Lee
- Departments of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Chang Sik Yu
- Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jin Cheon Kim
- Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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13
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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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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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15
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Sposato LA, Lam Y, Karapetis C, Vatandoust S, Roy A, Hakendorf P, Dwyer A, de Fontgalland D, Hollington P, Wattchow D. Observation of "complete clinical response" in rectal cancer after neoadjuvant chemoradiation: The Flinders experience. Asia Pac J Clin Oncol 2018; 14:439-445. [PMID: 29932278 DOI: 10.1111/ajco.12993] [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: 11/04/2017] [Accepted: 04/29/2018] [Indexed: 01/17/2023]
Abstract
AIM Observation with close follow-up ("watch and wait") is a recognized treatment option in patients who achieve a complete clinical response to long course chemoradiotherapy. This review of a prospective database aims to evaluate the clinical outcomes among patients with a complete clinical response managed with observation. METHODS A prospective study of 32 patients who achieved a complete clinical response was undertaken. The primary outcomes measured were overall and recurrence-free survival, and rate of organ preservation in patients who deferred immediate surgery. RESULTS Seven patients developed local regrowth over a median follow-up period of 38 months (range, 9-91 months). Median time to detection was 12 months. All seven underwent salvage surgery with complete surgical clearance. One patient developed combined local and systemic recurrence following a low anterior resection. Organ preservation was possible in 25 (78%) patients who sustained a complete clinical response with no evidence of local regrowth or disease recurrence. Among the patients who sustained a complete response, two developed isolated systemic disease. Overall and recurrence-free survival was 95.7% and 87.0%, respectively. CONCLUSION The majority of patients with rectal cancer who achieved a complete clinical response after chemoradiotherapy and managed with a "watch and wait" approach preserved their rectum and did not develop cancer relapse. Salvage surgery was achieved in all patients who developed local regrowth. The study supports a period of observation in rectal cancer patients who achieve a complete clinical response.
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Affiliation(s)
- Luigi A Sposato
- Department of Surgery, Flinders Medical Centre, Flinders University, Bedford Park, South Australia, Australia
| | - Yick Lam
- Department of Surgery, Flinders Medical Centre, Flinders University, Bedford Park, South Australia, Australia
| | - Chris Karapetis
- Department of Medical Oncology, Flinders Medical Centre, Flinders University, Bedford Park, South Australia, Australia
| | - Sina Vatandoust
- Department of Medical Oncology, Flinders Medical Centre, Flinders University, Bedford Park, South Australia, Australia
| | - Amitesh Roy
- Department of Medical Oncology, Flinders Medical Centre, Flinders University, Bedford Park, South Australia, Australia
| | - Paul Hakendorf
- Department of Epidemiology, Flinders Medical Centre, Flinders University, Bedford Park, South Australia, Australia
| | - Andrew Dwyer
- Department of Radiology, Flinders Medical Centre, Flinders University, Bedford Park, South Australia, Australia
| | - Dayan de Fontgalland
- Department of Surgery, Flinders Medical Centre, Flinders University, Bedford Park, South Australia, Australia
| | - Paul Hollington
- Department of Surgery, Flinders Medical Centre, Flinders University, Bedford Park, South Australia, Australia
| | - David Wattchow
- Department of Surgery, Flinders Medical Centre, Flinders University, Bedford Park, South Australia, Australia
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16
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Kim S, Han K, Seo N, Kim HJ, Kim MJ, Koom WS, Ahn JB, Lim JS. T2-weighted signal intensity-selected volumetry for prediction of pathological complete response after preoperative chemoradiotherapy in locally advanced rectal cancer. Eur Radiol 2018; 28:5231-5240. [PMID: 29858637 DOI: 10.1007/s00330-018-5520-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 04/22/2018] [Accepted: 04/27/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To evaluate the diagnostic value of signal intensity (SI)-selected volumetry findings in T2-weighted magnetic resonance imaging (MRI) as a potential biomarker for predicting pathological complete response (pCR) to preoperative chemoradiotherapy (CRT) in patients with rectal cancer. METHODS Forty consecutive patients with pCR after preoperative CRT were compared with 80 age- and sex-matched non-pCR patients in a case-control study. SI-selected tumor volume was measured on post-CRT T2-weighted MRI, which included voxels of the treated tumor exceeding the SI (obturator internus muscle SI + [ischiorectal fossa fat SI - obturator internus muscle SI] × 0.2). Three blinded readers independently rated five-point pCR confidence scores and compared the diagnostic outcome with SI-selected volumetry findings. The SI-selected volumetry protocol was validated in 30 additional rectal cancer patients. RESULTS The area under the receiver-operating characteristic curve (AUC) of SI-selected volumetry for pCR prediction was 0.831, with an optimal cutoff value of 649.6 mm3 (sensitivity 0.850, specificity 0.725). The AUC of the SI-selected tumor volume was significantly greater than the pooled AUC of readers (0.707, p < 0.001). At this cutoff, the validation trial yielded an accuracy of 0.87. CONCLUSION SI-selected volumetry in post-CRT T2-weighted MRI can help predict pCR after preoperative CRT in patients with rectal cancer. KEY POINTS • Fibrosis and viable tumor MRI signal intensities (SIs) are difficult to distinguish. • T2 SI-selected volumetry yields high diagnostic performance for assessing pathological complete response. • T2 SI-selected volumetry is significantly more accurate than readers and non-SI-selected volumetry. • Post-chemoradiation therapy T2-weighted MRI SI-selected volumetry facilitates prediction of pathological complete response.
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Affiliation(s)
- Sungwon Kim
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Shinchon-dong, Seodaemun-gu, Seoul, 120-752, Republic of Korea
| | - Kyunghwa Han
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Shinchon-dong, Seodaemun-gu, Seoul, 120-752, Republic of Korea
| | - Nieun Seo
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Shinchon-dong, Seodaemun-gu, Seoul, 120-752, Republic of Korea
| | - Hye Jin Kim
- Department of Radiology, Ajou University Hospital, Suwon, Republic of Korea
| | - Myeong-Jin Kim
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Shinchon-dong, Seodaemun-gu, Seoul, 120-752, Republic of Korea
| | - Woong Sub Koom
- Department of Radiation Oncology, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joong Bae Ahn
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joon Seok Lim
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Shinchon-dong, Seodaemun-gu, Seoul, 120-752, Republic of Korea.
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17
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Choi JP, Kim SJ, Park IJ, Hong SM, Lee JL, Yoon YS, Kim CW, Lim SB, Lee JB, Yu CS, Kim JC. Is the pathological regression level of metastatic lymph nodes associated with oncologic outcomes following preoperative chemoradiotherapy in rectal cancer? Oncotarget 2018; 8:10375-10384. [PMID: 28060748 PMCID: PMC5354665 DOI: 10.18632/oncotarget.14418] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 12/13/2016] [Indexed: 02/07/2023] Open
Abstract
Purpose The oncologic impact of the lymph node (LN) regression level after preoperative chemoradiotherapy (PCRT) has not been thoroughly evaluated. Hence, this study aimed to examine whether the regression level of metastatic LNs following PCRT is associated with oncologic outcomes in rectal cancer. Results The optimal number of cut points for LRG sum was determined to be three. The three LRG groups demonstrated different distributions according to the ypT and ypN stages (p < 0.001 for both). However, the distribution of the LRG groups was not associated with the TRG of the primary tumor (p = 0.527). The RFS significantly differed according to the LRG groups (p = 0.001). Moreover, the differences in RFS remained when the LRG groups were analyzed within each separate ypN stage. The LRG group was confirmed as a factor associated with RFS in the multivariate analysis (p=0.018), while the ypN stage was not (p=0.4). Patients and Methods We analyzed the outcomes of 142 rectal cancer patients diagnosed with ypN1 disease after PCRT followed by radical resection. The pathological responses of the primary tumor and LNs to PCRT were evaluated using the tumor regression grade (TRG) and LN regression grade (LRG), respectively. The impact of LRG on recurrence-free survival (RFS) was analyzed. The K-adaptive partitioning for survival data method was applied to determine the optimal number of cut points for the LRG-sum and the optimal number of subgroups. Conclusion The LRG as an indicator of response to PCRT should be considered as a prognostic determinant in rectal cancer patients. Future large-scale prospective studies are needed to confirm this finding.
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Affiliation(s)
- Jung Pil Choi
- Department of Surgery, Dong Kang Medical Center, Ulsan, Korea
| | - Sung Joo Kim
- Departments of Pathology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - In Ja Park
- Departments of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Seung Mo Hong
- Departments of Pathology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jong Lyul Lee
- Departments of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Yong Sik Yoon
- Departments of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Chan Wook Kim
- Departments of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Seok-Byung Lim
- Departments of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jung Bok Lee
- Departments of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Chang Sik Yu
- Departments of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jin Cheon Kim
- Departments of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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18
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Lynn PB, Strombom P, Garcia-Aguilar J. Organ-Preserving Strategies for the Management of Near-Complete Responses in Rectal Cancer after Neoadjuvant Chemoradiation. Clin Colon Rectal Surg 2017; 30:395-403. [PMID: 29184476 DOI: 10.1055/s-0037-1606117] [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: 02/07/2023]
Abstract
In recent years, organ preservation has been considered a feasible alternative to total mesorectal excision for patients with locally advanced rectal cancer with a clinical complete response to neoadjuvant therapy. However, the degree of tumor response to neoadjuvant therapy is variable. A fraction of the patients who did not achieve a complete response had grossly visible tumors. These patients, with clearly incomplete clinical response, need a total mesorectal excision. In addition, some patients with a significant tumor response still have some abnormalities in the bowel wall, such as superficial ulceration or tissue nodularity, which, while not conclusive for the presence of a tumor, are indicative of the possibility of a residual tumor in the bowel wall or in mesorectal lymph nodes. The management of patients with a so-called near-complete clinical response to neoadjuvant therapy is controversial. In this article, we will review the clinical and radiological criteria that define a clinical response to neoadjuvant therapy, possible treatment strategies, and follow-up protocols. We will also discuss patient and tumor characteristics that in our opinion can be useful in selecting the most appropriate treatment alternative. Although organ preservation and quality of life are important, the primary goal of treatment for these patients should be local tumor control and long-term survival.
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Affiliation(s)
- Patricio B Lynn
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Paul Strombom
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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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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20
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Park SH, Lim JS, Lee J, Kim HY, Koom WS, Hur H, Park MS, Kim MJ, Kim H. Rectal Mucinous Adenocarcinoma: MR Imaging Assessment of Response to Concurrent Chemotherapy and Radiation Therapy—A Hypothesis-generating Study. Radiology 2017; 285:124-133. [DOI: 10.1148/radiol.2017162657] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Seung Hyun Park
- From the Department of Radiology and Research Institute of Radiological Science (S.H.P., J.S.L., M.S.P., M.J.K., H.K.); Biostatistics Collaboration Unit (J.L., H.Y.K.); Department of Radiation Oncology (W.S.K.); and Department of Surgery, Division of Colon and Rectal Surgery (H.H.); Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Joon Seok Lim
- From the Department of Radiology and Research Institute of Radiological Science (S.H.P., J.S.L., M.S.P., M.J.K., H.K.); Biostatistics Collaboration Unit (J.L., H.Y.K.); Department of Radiation Oncology (W.S.K.); and Department of Surgery, Division of Colon and Rectal Surgery (H.H.); Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Jinae Lee
- From the Department of Radiology and Research Institute of Radiological Science (S.H.P., J.S.L., M.S.P., M.J.K., H.K.); Biostatistics Collaboration Unit (J.L., H.Y.K.); Department of Radiation Oncology (W.S.K.); and Department of Surgery, Division of Colon and Rectal Surgery (H.H.); Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Ha Yan Kim
- From the Department of Radiology and Research Institute of Radiological Science (S.H.P., J.S.L., M.S.P., M.J.K., H.K.); Biostatistics Collaboration Unit (J.L., H.Y.K.); Department of Radiation Oncology (W.S.K.); and Department of Surgery, Division of Colon and Rectal Surgery (H.H.); Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Woong Sub Koom
- From the Department of Radiology and Research Institute of Radiological Science (S.H.P., J.S.L., M.S.P., M.J.K., H.K.); Biostatistics Collaboration Unit (J.L., H.Y.K.); Department of Radiation Oncology (W.S.K.); and Department of Surgery, Division of Colon and Rectal Surgery (H.H.); Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Hyuk Hur
- From the Department of Radiology and Research Institute of Radiological Science (S.H.P., J.S.L., M.S.P., M.J.K., H.K.); Biostatistics Collaboration Unit (J.L., H.Y.K.); Department of Radiation Oncology (W.S.K.); and Department of Surgery, Division of Colon and Rectal Surgery (H.H.); Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Mi-Suk Park
- From the Department of Radiology and Research Institute of Radiological Science (S.H.P., J.S.L., M.S.P., M.J.K., H.K.); Biostatistics Collaboration Unit (J.L., H.Y.K.); Department of Radiation Oncology (W.S.K.); and Department of Surgery, Division of Colon and Rectal Surgery (H.H.); Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Myeong-Jin Kim
- From the Department of Radiology and Research Institute of Radiological Science (S.H.P., J.S.L., M.S.P., M.J.K., H.K.); Biostatistics Collaboration Unit (J.L., H.Y.K.); Department of Radiation Oncology (W.S.K.); and Department of Surgery, Division of Colon and Rectal Surgery (H.H.); Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Honsoul Kim
- From the Department of Radiology and Research Institute of Radiological Science (S.H.P., J.S.L., M.S.P., M.J.K., H.K.); Biostatistics Collaboration Unit (J.L., H.Y.K.); Department of Radiation Oncology (W.S.K.); and Department of Surgery, Division of Colon and Rectal Surgery (H.H.); Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
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Park IJ, An S, Kim SY, Lim HM, Hong SM, Kim MJ, Kim YJ, Yu CS. Prediction of radio-responsiveness with immune-profiling in patients with rectal cancer. Oncotarget 2017; 8:79793-79802. [PMID: 29108360 PMCID: PMC5668093 DOI: 10.18632/oncotarget.19558] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 07/14/2017] [Indexed: 12/18/2022] Open
Abstract
We evaluate whether the tumor immune infiltrate (TIL) could be used for prediction of responsiveness to preoperative chemoradiotherapy (PCRT) in rectal cancers. Using formalin-fixed paraffin-embedded slides of pretreatment biopsies, co-stain for CD4, CD8, CD274 (PD-L1), FOXP3, cytokeratin, and DAPI was performed with Opal multi staining kit (Perkin-Elmer, Waltham, MA). Multispectral imaging and digital analysis to visualize and quantify specific immune infiltrates were performed using the Vectra imaging system (Perkin-Elmer). The density (number of cells per mm2) and proportion of total TILs and specific cell types in the stroma were calculated by inForm™ 2.2.1 software (Perkin-Elmer). The density and proportion of total TILs and specific cell types in the stroma were calculated by inForm™ 2.2.1 software (Perkin-Elmer, Waltham, MA). Patients were classified as group with total regression (TR, n = 25) and group with residual disease (near total, moderate, and minimal regression, RD, n = 50). The mean density of T cell infiltration and CD274 (PD-L1)+ lymphocyte were significantly higher in TR (p = 0.005, p = 0.001). The proportion of CD4+ lymphocyte (p=0.042) and CD274 (PD-L1)+ lymphocyte (p = 0.002) were different between 2 groups. The TR group has lower CD4+ and higher CD274 (PD-L1)+ proportions than RD group. The ratio among CD4+, CD8+, CD274 (PD-L1)+, FOXP3+ T cell was different between groups. TR group showed lower CD4/ CD274 (PD-L1) (p = 0.007), CD8/ CD274 (PD-L1) (p = 0.02), and FOXP3/ CD274 (PD-L1) (p = 0.003) ratio than RD group. The determination of the immune infiltrate in biopsies before treatment could be a valuable information for the prediction of responsiveness to PCRT.
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Affiliation(s)
- In Ja Park
- Department of Colon and Rectal Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | - Soyeon An
- Department of Pathology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Sang-Yeob Kim
- Department of Convergence Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea.,Asan Institute for life sciences, Asan Medical Center, Seoul, Korea
| | - Hye Min Lim
- Asan Institute for life sciences, Asan Medical Center, Seoul, Korea
| | - Seung-Mo Hong
- Department of Pathology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | - Mi-Ju Kim
- Asan Institute for life sciences, Asan Medical Center, Seoul, Korea
| | - Yun Jae Kim
- Asan Institute for life sciences, Asan Medical Center, Seoul, Korea
| | - Chang Sik Yu
- Department of Colon and Rectal Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
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Huang SH, Chi P, Lin HM, Lu XR, Huang YW, Xu ZB, Sun YW, Ye DX, Wang XJ, Wang X. Selecting stage ypT0-1N0 for locally advanced rectal cancer following preoperative chemoradiotherapy: implications for potential candidates of organ-sparing management. Colorectal Dis 2016; 18:989-996. [PMID: 26880193 DOI: 10.1111/codi.13297] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Accepted: 12/01/2015] [Indexed: 12/11/2022]
Abstract
AIM Local excision or a wait-and-see policy may offer the possibility of organ preservation for locally advanced rectal cancer (LARC) after preoperative chemoradiotherapy (CRT). Identifying associated factors of good responders (GR) with stage ypT0-1N0 would probably influence the selection of potential candidates who were theoretically eligible for organ-sparing management. This study was to establish a scoring system to select stage ypT0-1N0 for LARC following preoperative CRT. METHOD Between 2009 and 2014, 262 patients with middle and low LARC were treated with CRT and radical surgery. Clinicopathological data which were found to be significantly associated with GR were incorporated into a scoring system. RESULTS Fifty-seven (21.8%) patients were GR with stage ypT0-1N0 in the operative specimen. Multivariate analyses indicated that a low level of pretreatment carcinoembryonic antigen (CEA) and post-treatment CEA <2.55 ng/ml (P = 0.008 and P = 0.009 respectively) and long-axis diameter of residual tumours (P = 0.006) were independently associated with stage ypT0-1N0. The three factors were incorporated into a scoring system. Using receiver operating characteristic curve analysis, we determined a cutoff value of -0.3 for scores, at which the system's sensitivity was 71.9% and specificity 73.1%. When applied to testing samples, the sensitivity was 74.1% and specificity 76.2%. CONCLUSION We demonstrated that low levels of pretreatment and post-treatment CEA and the long-axis diameter of residual tumours were associated with stage ypT0-1N0 for LARC after CRT. Therefore, the three-factor scoring system may be used to select potential candidates for organ-sparing management.
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Affiliation(s)
- S H Huang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - P Chi
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China.
| | - H M Lin
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - X R Lu
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Y W Huang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Z B Xu
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Y W Sun
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - D X Ye
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - X J Wang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - X Wang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China
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Vallam KC, Engineer R, Desouza A, Patil P, Saklani A. High nodal positivity rates even in good clinical responders after chemoradiation of rectal cancer: is organ preservation feasible? Colorectal Dis 2016; 18:976-982. [PMID: 26362820 DOI: 10.1111/codi.13114] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Accepted: 07/06/2015] [Indexed: 02/05/2023]
Abstract
AIM Local excision (LE) is emerging as a treatment option for rectal cancer responding well to chemoradiation. However, it does not address the mesorectal nodal burden. We aimed to identify the factors influencing nodal positivity and subsequently defined a low-risk group by including only patients at low risk. METHOD A single-centre, retrospective database analysis was carried out of patients with radically resected rectal cancer after neoadjuvant chemoradiation. RESULTS This study included 524 patients with predominantly low rectal tumours. Nodal positivity among ypT0, T1 and T2 groups was 14.7%, 28% and 30%, respectively. Multivariate analysis with stepwise logistic regression identified the following low-risk features: age ≥ 40 years, nonsignet ring cell carcinoma (SRCC) histology and pathological complete response (pCR). Sixty-nine patients fulfilling all three criteria were analysed and the nodal positivity was found to be 10.1%, which implies that, if these patients had been selected for LE, one in 10 would have had positive mesorectal nodes. CONCLUSION Even in patients with low-risk criteria (pCR, non-SRCC histology and age ≥ 40 years), the residual positive nodal disease burden is 10%. Whether this high incidence of residual nodal disease translates into a similar risk of locoregional recurrence if an organ-preservation strategy is adopted is unclear.
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Affiliation(s)
- K C Vallam
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India
| | - R Engineer
- Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India
| | - A Desouza
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India
| | - P Patil
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Centre, Mumbai, India
| | - A Saklani
- Department of GI Oncology, Tata Memorial Centre, Mumbai, India.
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A Systematic Review of Local Excision After Neoadjuvant Therapy for Rectal Cancer: Are ypT0 Tumors the Limit? Dis Colon Rectum 2016; 59:984-97. [PMID: 27602930 DOI: 10.1097/dcr.0000000000000613] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Neoadjuvant therapy reduces local recurrence after radical surgery for rectal cancer with complete pathological response in 15% to 25% of patients. Radical surgery is associated with significant morbidity that may be avoided by local excision in selected cases. OBJECTIVE This systematic review aimed to determine the oncological outcomes and morbidity of local excision after neoadjuvant therapy. DATA SOURCES Data sources included MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials databases. STUDY SELECTION A systematic search of the databases using validated terms for rectal cancer, neoadjuvant therapy, and local excision was conducted. INTERVENTIONS Neoadjuvant therapy and local excision were the included interventions. MAIN OUTCOME MEASURES Pooled local recurrence, median survival, and pooled morbidity were measured. RESULTS Twenty unique studies were included (14 cohort, 5 comparative cohort, and 1 randomized controlled trial), describing 1068 patients. Patient choice, prohibitive comorbidity, good clinical response, and early stage disease were the most frequent indications for local excision. Pretreatment T2 and T3 tumors accounted for 46.4% and 30.7% of cases. Long-course treatment was administered in all of the studies, except to a cohort of 64 patients who received short-course radiotherapy. Pooled complete clinical response was 45.8% (95% CI, 31.4%-60.5%), and pooled complete pathological response was 44.2% (95% CI, 36.4%-52.0%). Median follow-up was 54 months (range, 12-81 months). ypT0 tumors had a pooled local recurrence rate of 4.0% (95% CI, 1.9%-6.9%) and a median disease-free survival rate of 95.0% (95% CI, 87.4%-100%). Pooled local recurrence and median disease-free survival rates for ypT1 tumors or higher were 21.9% (95% CI, 15.9%-28.5%) and 68.0% (58.3%-69.0%). Pooled incidence of complications was 23.2% (95% CI, 15.7%-31.7%), with suture-line dehiscence reported in 9.9% (95% CI, 4.8%-16.7%). LIMITATIONS Limitations included study quality, high risk of selection bias and detection bias in study designs, and limited sample sizes. CONCLUSIONS Local excision after neoadjuvant therapy should only be considered a curative treatment if complete pathological response is obtained. Given the high rate of local recurrence among incomplete responders, future studies should focus on predicting patients who will achieve complete pathological response.
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Jung SM, Yu CS, Park IJ, Kim TW, Kim JH, Yoon YS, Lim SB, Kim JC. Oncologic Safety of Local Excision Compared With Total Mesorectal Excision for ypT0-T1 Rectal Cancer: A Propensity Score Analysis. Medicine (Baltimore) 2016; 95:e3718. [PMID: 27196490 PMCID: PMC4902432 DOI: 10.1097/md.0000000000003718] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Good oncologic outcomes, demonstrated by a complete pathologic response after preoperative chemoradiotherapy (PCRT), have led to local excision (LE) in selected patients with rectal cancer. We evaluated the oncologic safety of LE compared with total mesorectal excision (TME) in patients with ypT0-T1 rectal cancer.A retrospective review of 304 patients who underwent PCRT, followed by LE or TME, for ypT0-T1 rectal cancer was performed. Propensity scores were computed and used to match groups (LE:TME = 1:1), and analysis of disease-free survival (DFS) and overall survival (OS) was made by comparing patients who underwent LE or TME. Prognostic factors of relapse were analyzed for all patients.Tumor categories were ypT0 in 25 (61.9%) cases, ypTis in 6 (14.3%) cases, and ypT1 in 11 (26.2%) cases for the LE group, and ypT0 in 28 (66.7%) cases, ypTis in 4 (9.5%) cases, and ypT1 in 10 (23.8%) cases for the matched TME patients. There was no significant difference between the matched LE and TME groups in relapse (4.8% and 7.14%, respectively; P = 0.646), 5-year DFS (95.2% vs 91.6%; P = 0.33) and 5-year OS (96.6% vs 88.0%; P = 0.238). In the multivariate Cox regression analysis, tumor distance from the anal verge (hazard ratio [HR] = 0.78; 95% confidence interval (CI) = 0.616-0.992) and the tumor grade (HR = 4.29; 95% CI = 1.430-12.886) were significantly associated with the recurrence risk.LE results in oncologic outcomes that are comparable to those achieved by TME in selected patients with ypT0-T1 rectal cancer after PCRT.
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Affiliation(s)
- Sung Min Jung
- From the Department of Colon and Rectal Surgery (SMJ, CSY, IJP, YSY, SBL, JCK), Department of Oncology (TWK), and Department of Radiation Oncology (JHK), University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
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Local excision of low rectal cancer treated by chemoradiotherapy: is it safe for all patients with suspicion of complete tumor response? Int J Colorectal Dis 2016; 31:853-60. [PMID: 26951185 DOI: 10.1007/s00384-016-2546-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/25/2016] [Indexed: 02/07/2023]
Abstract
PURPOSE The purpose of this study is to assess if local excision (LE) could be proposed if suspicion of complete tumor response (CR) after neoadjuvant chemoradiotherapy (CRT) for low rectal cancer (LRC) and this despite a potential risk of nodes (N+) or other tumor deposits (OTD) left in place. The aim was to assess in patients with LRC treated by CRT: (a) pathologic results of LE and total mesorectal excision (TME) in case of preoperative suspicion of CR and (b) the risk of N+ or OTD on TME if ypT0-Tis-T1 tumor. PATIENTS Among 202 patients with LRC after CRT, 33 (16 %) with suspicion of CR underwent LE (n = 20) because of comorbidities and/or indication of definitive stoma or TME (n = 13). Pathologic examination of LE and TME specimens and oncological outcomes were assessed. Furthermore, 40/202 patients with pathologic CR on TME specimen (ypT0-Tis-T1) were assessed for possible N+ or OTD. RESULTS In the 33 patients with suspicion of CR: (a) after LE, tumor was ypT0-Tis-T1 in only 15/20 cases (75 %); (b) after TME, tumor was ypT0-Tis-T1 in only 7/13 cases (54 %). Among 40 patients with ypT0-Tis-T1 tumor on TME specimen, 4 (10 %) presented N+ and/or OTD. CONCLUSION In LRC with suspicion of CR after CRT, LE deserves a word of caution: 25 % of patients have in fact ypT2-T3 tumors. Furthermore, in patients with ypT0-Tis or T1 on TME specimen, a 10 % risk of N+ and/or ODT is observed. Thus, patient with suspicion of CR after CRT and treated by LE is exposed to a possible incomplete oncologic treatment.
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Nodal involvement in luminal complete response after neoadjuvant treatment for rectal cancer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2016; 42:801-7. [PMID: 27146960 DOI: 10.1016/j.ejso.2016.03.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 03/10/2016] [Accepted: 03/16/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND Pathological complete response (pCR) after neoadjuvant therapy in rectal cancer is correlated with improved survival. There is limited knowledge on the incidence of pCR at a national level with uniform guidelines. The aim of this prospective register-based study was to investigate the incidence and outcome of pCR in relation to neoadjuvant therapy in a national cohort. METHOD All patients abdominally operated for rectal cancer between 2007 and 2012 (n = 7885) were selected from The Swedish Colo-rectal Cancer Register. Twenty-six per cent (n = 2063) had neoadjuvant therapy with either long or short course radiotherapy with >4 weeks delay with the potential to achieve pCR. The primary endpoints were pCR and survival in relation to neoadjuvant therapy. RESULTS Complete eradication of the luminal tumor, ypT0 was found in 161 patients (8%). In 83% of the ypT0 the regional lymph nodes were tumor negative (ypT0N0), 12% had 1-3 positive lymph nodes (ypT0N1) and 4% had more than three positive lymph nodes (ypT0N2). There was significantly greater survival with ypT0 compared to ypT+ (hazard ratio 0.38 (C.I 0.25-0.58)) and survival was significantly greater in patients with ypT0N0 compared to ypT0N1-2 (hazard ratio 0.36 (C.I 0.15-0.86)). In ypT0, cT3-4 tumors had the greater risk of node-positivity. The added use of chemotherapy resulted in 10% ypT0 compared to 5.1% in the group without chemotherapy (p < 0.00004). CONCLUSION Luminal pathological complete response occurred in 8%, 16% of them had tumor positive nodes. The survival benefit of luminal complete response is dependent upon nodal involvement status.
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Kim H, Kim H, Koom W, Kim N, Kim MJ, Kim H, Hur H, Lim J. Profiling of rectal cancers MRI in pathological complete remission states after neoadjuvant concurrent chemoradiation therapy. Clin Radiol 2016; 71:250-7. [DOI: 10.1016/j.crad.2015.11.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 10/12/2015] [Accepted: 11/17/2015] [Indexed: 02/07/2023]
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Guedj N, Maggiori L, Poté N, Norkowski E, Cros J, Bedossa P, Panis Y. Distal intramural and tumor spread in the mesorectum after neoadjuvant radiochemotherapy in rectal cancer: about 124 consecutive patients. Hum Pathol 2016; 52:164-72. [PMID: 27210028 DOI: 10.1016/j.humpath.2016.01.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 01/15/2016] [Accepted: 01/24/2016] [Indexed: 02/07/2023]
Abstract
This observational prospective study aimed to assess the distribution of intramural and mesorectal tumor spread in mid/low rectal cancer after neoadjuvant radiochemotherapy. Distribution of mesorectal metastatic lymph nodes (MLNs) and mesorectal extranodal cancer tissue (EX), according to the tumor location, were analyzed. Distal intramural tumor spread was also performed. A total of 1676 LNs, 135 MLNs, and 69 EX were detected on 124 consecutive surgical specimens. Forty-two patients (34%) had MLNs. Six patients (4.8%) were classified as ypN1c. Distal viable cancer spread was observed in 3 patients (2.4%), all with mid rectal carcinoma. Two patients (1.6%) presented distal direct intramural extension less than 1 cm; and 1 (0.8%), with EX localized no more than 2 cm from the lower edge of the tumor. MLNs (76%) and EX (94%) were preferentially localized in the peritumoral area and in the first 3 cm just above the tumor. No viable distal intramural or mesorectal spread was observed in low rectal carcinoma. Distal intramural and mesorectal cancer spread is a rare event after neoadjuvant RCT. These results suggest that the 1-cm distal margin recommended in patients with low rectal carcinoma could be reduced with insurance to obtain a negative distal margin. The knowledge of preferential localization of MLNs and EX would help the pathologist to improve patient's lymph node staging.
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Affiliation(s)
- Nathalie Guedj
- Department of Pathology, Beaujon Hospital, 92110 Clichy, France.
| | - Léon Maggiori
- Department of Colo-rectal Surgery, Beaujon Hospital, 92110 Clichy, France
| | - Nicolas Poté
- Department of Pathology, Beaujon Hospital, 92110 Clichy, France
| | - Emma Norkowski
- Department of Pathology, Beaujon Hospital, 92110 Clichy, France
| | - Jérôme Cros
- Department of Pathology, Beaujon Hospital, 92110 Clichy, France
| | - Pierre Bedossa
- Department of Pathology, Beaujon Hospital, 92110 Clichy, France
| | - Yves Panis
- Department of Colo-rectal Surgery, Beaujon Hospital, 92110 Clichy, France
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Kim H, Myoung S, Koom WS, Kim NK, Kim MJ, Ahn JB, Hur H, Lim JS. MRI Risk Stratification for Tumor Relapse in Rectal Cancer Achieving Pathological Complete Remission after Neoadjuvant Chemoradiation Therapy and Curative Resection. PLoS One 2016; 11:e0146235. [PMID: 26730717 PMCID: PMC4701470 DOI: 10.1371/journal.pone.0146235] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 12/15/2015] [Indexed: 12/27/2022] Open
Abstract
Purpose Rectal cancer patients achieving pCR are known to have an excellent prognosis, yet no widely accepted consensus on risk stratification and post-operative management (e.g., adjuvant therapy) has been established. This study aimed to identify magnetic resonance imaging (MRI) high-risk factors for tumor relapse in pathological complete remission (pCR) achieved by rectal cancer patients who have undergone neoadjuvant concurrent chemoradiation therapy (CRT) and curative resection. Materials and Methods We analyzed 88 (male/female = 55/33, median age, 59.5 years [range 34–78]) pCR-proven rectal cancer patients who had undergone pre-CRT MRI, CRT, post-CRT MRI and curative surgery between July 2005 and December 2012. Patients were observed for post-operative tumor relapse. We analyzed the pre/post-CRT MRIs for parameters including mrT stage, mesorectal fascia (mrMRF) status, tumor volume, tumor regression grade (mrTRG), nodal status (mrN), and extramural vessel invasion (mrEMVI). We performed univariate analysis and Kaplan-Meier survival analysis. Results Post-operative tumor relapse occurred in seven patients (8.0%, n = 7/88) between 5.7 and 50.7 (median 16.8) months. No significant relevance was observed between tumor volume, volume reduction rate, mrTRG, mrT, or mrN status. Meanwhile, positive mrMRF (Ppre-CRT = 0.018, Ppre/post-CRT = 0.006) and mrEMVI (Ppre-CRT = 0.026, Ppre-/post-CRT = 0.008) were associated with higher incidence of post-operative tumor relapse. Kaplan-Meier survival analysis revealed a higher risk of tumor relapse in patients with positive mrMRF (Ppre-CRT = 0.029, Ppre-/post-CRT = 0.009) or mrEMVI (Ppre-CRT = 0.024, Ppre-/post-CRT = 0.003). Conclusion Positive mrMRF and mrEMVI status was associated with a higher risk of post-operative tumor relapse of pCR achieved by rectal cancer patients, and therefore, can be applied for risk stratification and to individualize treatment plans.
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Affiliation(s)
- Honsoul Kim
- Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, 120–752, Republic of Korea
| | - Sungmin Myoung
- Department of Medical Information, Jungwon University, Goesan, 367–805, Republic of Korea
| | - Woong Sub Koom
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, 120–752, Republic of Korea
| | - Nam Kyu Kim
- Department of Surgery, Division of Colon and Rectal Surgery, Yonsei University College of Medicine, Seoul, 120–752, Republic of Korea
| | - Myeong-Jin Kim
- Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, 120–752, Republic of Korea
| | - Joong Bae Ahn
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, 120–752, Republic of Korea
| | - Hyuk Hur
- Department of Surgery, Division of Colon and Rectal Surgery, Yonsei University College of Medicine, Seoul, 120–752, Republic of Korea
- * E-mail: (HH); (JSL)
| | - Joon Seok Lim
- Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, 120–752, Republic of Korea
- * E-mail: (HH); (JSL)
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Nodal staging in rectal cancer: why is restaging after chemoradiation more accurate than primary nodal staging? Int J Colorectal Dis 2016; 31:1157-62. [PMID: 27055660 PMCID: PMC4867151 DOI: 10.1007/s00384-016-2576-8] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/22/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE This study aims to explore the influence of chemoradiation treatment (CRT) on rectal cancer nodes and to generate hypotheses why nodal restaging post-CRT is more accurate than at primary staging. METHODS Thirty-nine patients with locally advanced rectal cancer underwent MRI pre- and post-CRT. All visible mesorectal nodes were measured on a 3D T1-weighted gradient echo (3D T1W GRE) sequence with 1-mm(3) voxels and matched between pre- and post-CRT-MRI and with histology by lesion-by-lesion matching. Change in number and size of nodes was compared between pre- and post-CRT-MRI. ROC curves were constructed to assess diagnostic performance of size. RESULTS Eight hundred ninety-five nodes were found pre-CRT: 44 % disappeared and 40 % became smaller post-CRT. Disappearing nodes were initially significantly smaller than nodes that remained visible post-CRT: 2.9 mm vs. 3.8 mm. cN+ stage was predicted in 97 % pre-CRT and 36 % of patients had ypN+ post-CRT. ypN+ patients had significantly larger nodes than ypN0 patients both pre- and post-CRT. Optimal size cutoff for post-CRT ypN stage prediction was 2.5 mm (area under the curve (AUC) of 0.78) at MRI. CONCLUSIONS After CRT, most lymph nodes become smaller, and many disappear. Size predicts disappearance and node positivity. Together with a low prevalence of ypN+, this can explain the higher accuracy of nodal staging after CRT than in a primary staging setting, possibly of use when considering organ-preserving strategies after CRT.
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Hav M, Libbrecht L, Ferdinande L, Geboes K, Pattyn P, Cuvelier CA. Pathologic Assessment of Rectal Carcinoma after Neoadjuvant Radio(chemo)therapy: Prognostic Implications. BIOMED RESEARCH INTERNATIONAL 2015; 2015:574540. [PMID: 26509160 PMCID: PMC4609786 DOI: 10.1155/2015/574540] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Accepted: 06/14/2015] [Indexed: 12/21/2022]
Abstract
Neoadjuvant radio(chemo)therapy is increasingly used in rectal cancer and induces a number of morphologic changes that affect prognostication after curative surgery, thereby creating new challenges for surgical pathologists, particularly in evaluating morphologic changes and tumour response to preoperative treatment. Surgical pathologists play an important role in determining the many facets of rectal carcinoma patient care after neoadjuvant treatment. These range from proper handling of macroscopic specimens to accurate microscopic evaluation of pathological features associated with patients' prognosis. This review presents the well-established pathological prognostic indicators and discusses challenging features in order to provide both surgical pathologists and treating physicians with a checklist that is useful in a neoadjuvant setting.
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Affiliation(s)
- Monirath Hav
- Department of Pathology, Calmette Hospital, No. 3, Monivong Boulevard (93), Phnom Penh 12201, Cambodia ; Department of Pathology, Ghent University Hospital, 9000 Gent, Belgium
| | - Louis Libbrecht
- Department of Pathology, Calmette Hospital, No. 3, Monivong Boulevard (93), Phnom Penh 12201, Cambodia
| | - Liesbeth Ferdinande
- Department of Pathology, Calmette Hospital, No. 3, Monivong Boulevard (93), Phnom Penh 12201, Cambodia
| | - Karen Geboes
- Department of Gastrointestinal Oncology, Ghent University Hospital, 9000 Gent, Belgium
| | - Piet Pattyn
- Department of Gastrointestinal Surgery, Ghent University Hospital, 9000 Gent, Belgium
| | - Claude A Cuvelier
- Department of Pathology, Calmette Hospital, No. 3, Monivong Boulevard (93), Phnom Penh 12201, Cambodia
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Clinical Complete Response After Neoadjuvant Therapy in Rectal Cancer: Is Surgery Needed? CURRENT COLORECTAL CANCER REPORTS 2015. [DOI: 10.1007/s11888-015-0299-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Ryan JE, Warrier SK, Lynch AC, Heriot AG. Assessing pathological complete response to neoadjuvant chemoradiotherapy in locally advanced rectal cancer: a systematic review. Colorectal Dis 2015; 17:849-61. [PMID: 26260213 DOI: 10.1111/codi.13081] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 05/11/2015] [Indexed: 12/13/2022]
Abstract
AIM Pathological complete response to neoadjuvant chemoradiotherapy is found in 20% of patients with rectal cancer undergoing long-course chemoradiotherapy. Some authors have suggested that these patients do not need to undergo surgery and can be managed with careful follow-up, with surgery only used in the event of clinical failure. Widespread adoption of this regimen is limited by the accuracy of methods to confirm a pathological complete response (pCR). METHOD A systematic search of PubMed, Medline and Cochrane databases was conducted to identify clinical, histological and radiological features in those patients with rectal cancer who achieved a pCR following chemoradiotherapy. Searches were conducted with the following keywords and MeSH search terms: 'rectal neoplasm', 'response', 'neoadjuvant', 'preoperative chemoradiation' and 'tumour response'. After review of title and abstracts, 89 articles addressing the assessment of pCR were identified. RESULTS Histology and clinical assessment are the most effective methods of assessment of pCR, with histology considered the gold standard. Clinical assessment is limited to low rectal tumours and is open to significant inter-rater variability, while histological examination requires a surgical specimen. Diffusion-weighted MRI and (18) F-fluorodeoxyglucose positron emission tomography/CT demonstrate the greatest potential for the assessment of pCR, but both modalities have limited accuracy. CONCLUSION Determination of a pCR is crucial if a nonoperative approach is to be undertaken proactively. Various methods are available, but currently they lack sufficient sensitivity and specificity to define management. This is likely to be an area of further research in the future.
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Affiliation(s)
- J E Ryan
- Department of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Epworth Healthcare, Melbourne, Victoria, Australia.,Austin Academic Centre, University of Melbourne, Melbourne, Victoria, Australia
| | - S K Warrier
- Department of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - A C Lynch
- Department of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - A G Heriot
- Department of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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García-Flórez LJ, Gómez-Álvarez G, Frunza AM, Barneo-Serra L, Fresno-Forcelledo MF. Response to chemoradiotherapy and lymph node involvement in locally advanced rectal cancer. World J Gastrointest Surg 2015; 7:196-202. [PMID: 26425268 PMCID: PMC4582237 DOI: 10.4240/wjgs.v7.i9.196] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 07/15/2015] [Accepted: 08/11/2015] [Indexed: 02/07/2023] Open
Abstract
AIM: To establish the association between lymph node involvement and the response to neoadjuvant therapy in locally advanced rectal cancer.
METHODS: Data of 130 patients with mid and low locally advanced rectal adenocarcinoma treated with neoadjuvant chemoradiation followed by radical surgery over a 5-year period were reviewed. Tumor staging was done by endorectal ultrasound and/or magnetic resonance imaging. Tumor response to neoadjuvant therapy was determined by T-downstaging and tumor regression grading (TRG). Pathologic complete response (pCR) is defined as the absence of tumor cells in the surgical specimen (ypT0N0). The varying degrees TRG were classified according to Mandard’s scoring system. The evaluation of the response is based on the comparison between previous clinico-radiological staging and the results of pathological evaluation. χ2 and Spearman’s correlation tests were used for the comparison of variables.
RESULTS: Pathologic complete response (pCR, ypT0N0, TRG1) was observed in 19 cases (14.6%), and other 18 (13.8%) had only very few residual malignant cells in the rectal wall (TRG2). T-downstaging was found in 63 (48.5%). Mean lymph node retrieval was 9.4 (range 0-38). In 37 cases (28.5%) more than 12 nodes were identified in the surgical specimen. Preoperative lymph node involvement was seen in 77 patients (59.2%), 71 N1 and 6 N2. Postoperative lymph node involvement was observed in 41 patients (31.5%), 29 N1 and 12 N2, while the remaining 89 were N0 (68.5%). In relation to ypT stage, we found nodal involvement of 9.4% in ypT0-1, 22.2% in ypT2 and 43.7% in ypT3-4. Of the 37 patients considered “responders” to neoadjuvant therapy (TRG1 and 2), there were only 4 N+ (10.8%) and the remainder N0 (89.2%). In the “non responders” group (TRG 3, 4 and 5), 37 cases were N+ (39.8%) and 56 (60.2%) were N0 (P < 0.001).
CONCLUSION: Response to neoadjuvant chemoradiation in rectal cancer is associated with lymph node involvement.
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Habr-Gama A, São Julião GP, Perez RO. Nonoperative management of rectal cancer: identifying the ideal patients. Hematol Oncol Clin North Am 2015; 29:135-51. [PMID: 25475576 DOI: 10.1016/j.hoc.2014.09.004] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Neoadjuvant chemoradiation (CRT) is considered one of the preferred treatment strategies for patients with locally advanced rectal cancer. This strategy may lead to significant tumor regression, ultimately leading to a complete pathologic response in up to 42% of patients. Assessment of tumor response following CRT and before radical surgery may identify patients with a complete clinical response who could possibly be managed nonoperatively with strict follow-up (watch-and-wait strategy). The present article deals with critical issues regarding appropriate selection of patients for this approach.
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Affiliation(s)
- Angelita Habr-Gama
- Angelita and Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, Paraiso, São Paulo 04001-005, Brazil; University of São Paulo School of Medicine, Rua Manoel da Nóbrega 1564, Paraiso, São Paulo 04001-005, Brazil.
| | | | - Rodrigo O Perez
- Angelita and Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, Paraiso, São Paulo 04001-005, Brazil; Colorectal Surgery Division, Department of Gastroenterology, University of São Paulo School of Medicine, Rua Manoel da Nóbrega 1564, Paraiso, São Paulo 04001-005, Brazil
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Habr-Gama A, São Julião GP, Perez RO. Pitfalls of transanal endoscopic microsurgery for rectal cancer following neoadjuvant chemoradiation therapy. MINIM INVASIV THER 2014; 23:63-9. [PMID: 24635719 DOI: 10.3109/13645706.2014.893891] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Transanal endoscopic microsurgery has become a very useful surgical tool for the management of selected cases of rectal cancer. However, the considerably high local recurrence rates led to the introduction of neoadjuvant therapies including radiation with or without chemotherapy. This treatment strategy may result in significant rates of tumor regression allowing the procedure to be offered to a significant proportion of cases. On the other hand, neoadjuvant chemoradiation (CRT) may also determine wound-healing difficulties with significant postoperative pain. In addition, salvage total mesorectal excision in the case of local recurrence may also be a challenging task. Finally, accurate selection criteria for this minimally invasive approach are still lacking and may be influenced by baseline staging, post-treatment staging and final pathology information. Ultimately, selection of patients for this treatment modality remains a significant challenge for the colorectal surgeon who should be aware of the pitfalls of this procedure in the setting of neoadjuvant CRT.
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Affiliation(s)
- Angelita Habr-Gama
- Angelita & Joaquim Gama Institute/Hospital Alemão Oswaldo Cruz , São Paulo , Brazil
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Vignali A, Nardi PD. Multidisciplinary treatment of rectal cancer in 2014: Where are we going? World J Gastroenterol 2014; 20:11249-11261. [PMID: 25170209 PMCID: PMC4145763 DOI: 10.3748/wjg.v20.i32.11249] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2014] [Revised: 05/08/2014] [Accepted: 05/26/2014] [Indexed: 02/06/2023] Open
Abstract
In the present review we discuss the recent developments and future directions in the multimodal treatment of locally advanced rectal cancer, with respect to staging and re-staging modalities, to the current role of neoadjuvant chemo-radiation and to the conservative and more limited surgical approaches based on tumour response after neoadjuvant combined therapy. When initial tumor staging is considered a high accuracy has been reported for T pre-treatment staging, while preoperative lymph node mapping is still suboptimal. With respect to tumour re-staging, all the current available modalities still present a limited accuracy, in particular in defining a complete response. The role of short vs long-course radiotherapy regimens as well as the optimal time of surgery are still unclear and under investigation by means of ongoing randomized trials. Observational management or local excision following tumour complete response are promising alternatives to total mesorectal excision, but need further evaluation, and their use outside of a clinical trial is not recommended. The preoperative selection of patients who will benefit from neoadjuvant radiotherapy or not, as well as the proper identification of a clinical complete tumour response after combined treatment modalities,will influence the future directions in the treatment of locally advanced rectal cancer.
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Desenlaces del manejo no quirúrgico posterior a neoadyuvancia del cáncer localmente avanzado de recto. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.rccan.2014.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Simpson GS, Eardley N, McNicol F, Healey P, Hughes M, Rooney PS. Circumferential resection margin (CRM) positivity after MRI assessment and adjuvant treatment in 189 patients undergoing rectal cancer resection. Int J Colorectal Dis 2014; 29:585-90. [PMID: 24651956 DOI: 10.1007/s00384-014-1846-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/07/2014] [Indexed: 02/04/2023]
Abstract
PURPOSE The management of rectal cancer relies on accurate MRI staging. Multi-modal treatments can downstage rectal cancer prior to surgery and may have an effect on MRI accuracy. We aim to correlate the findings of MRI staging of rectal cancer with histological analysis, the effect of neoadjuvant therapy on this and the implications of circumferential resection margin (CRM) positivity following neoadjuvant therapy. METHODS An analysis of histological data and radiological staging of all cases of rectal cancer in a single centre between 2006 and 2011 were conducted. RESULTS Two hundred forty-one patients had histologically proved rectal cancer during the study period. One hundred eighty-two patients underwent resection. Median age was 66.6 years, and male to female ratio was 13:5. R1 resection rate was 11.1%. MRI assessments of the circumferential resection margin in patients without neoadjuvant radiotherapy were 93.6 and 88.1% in patients who underwent neoadjuvant radiotherapy. Eighteen patients had predicted positive margins following chemoradiotherapy, of which 38.9% had an involved CRM on histological analysis. CONCLUSIONS MRI assessment of the circumferential resection margin in rectal cancer is associated with high accuracy. Neoadjuvant chemoradiotherapy has a detrimental effect on this accuracy, although accuracy remains high. In the presence of persistently predicted positive margins, complete resection remains achievable but may necessitate a more radical approach to resection.
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Affiliation(s)
- G S Simpson
- Department of General Surgery, Royal Liverpool University Hospital, Liverpool, England, UK,
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Leibold T, Hui VW, Shia J, Ruby JA, Riedel ER, Guillem JG. p27 expression in post-treatment rectal cancer: a potential novel approach for predicting residual nodal disease. Am J Surg 2014; 208:228-34. [PMID: 24814310 DOI: 10.1016/j.amjsurg.2014.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 01/14/2014] [Accepted: 02/06/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Expression profiles of p21, p27, p53, Ki-67, and thymidylate synthase may be associated with response to neoadjuvant chemoradiation. The relationship between post-treatment protein expression and regional lymph node involvement has not been fully explored. METHODS Tumor cores from 126 rectal cancer patients underwent immunohistochemical analysis for the aforementioned proteins. Staining indices (SIs) using percentage of stained cells and staining intensity were calculated for 10 tumor cores per patient. SI for each marker was compared between node negative and node positive patients. RESULTS Twenty-six (20.6%) cancer patients had a pathologic complete response and 37 had inadequate tissue or cancer cells, leaving 63 for analysis. Thirty-seven (58.7%) cancer patients were node negative and 26 (41.3%) were node positive. There was an association between increased p27 SI and nodal positivity (P = .04). CONCLUSION Increased p27 expression in post-treatment rectal cancer is associated with nodal positivity and may determine which patients are suitable for local excision.
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Affiliation(s)
- Tobias Leibold
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Vanessa W Hui
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Jinru Shia
- Department of Pathology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Jeannine A Ruby
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Elyn R Riedel
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - José G Guillem
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
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Habr-Gama A, Gama-Rodrigues J, São Julião GP, Proscurshim I, Sabbagh C, Lynn PB, Perez RO. Local Recurrence After Complete Clinical Response and Watch and Wait in Rectal Cancer After Neoadjuvant Chemoradiation: Impact of Salvage Therapy on Local Disease Control. Int J Radiat Oncol Biol Phys 2014; 88:822-8. [DOI: 10.1016/j.ijrobp.2013.12.012] [Citation(s) in RCA: 306] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 11/29/2013] [Accepted: 12/10/2013] [Indexed: 12/19/2022]
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Sclafani F, Cunningham D. Non-operative management for locally advanced rectal cancer: critical review and future perspective. COLORECTAL CANCER 2013. [DOI: 10.2217/crc.13.33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
SUMMARY Over the last few decades we have observed important advances in diagnostic imaging, surgery, pathology and multimodal treatments for rectal cancer, as well as increased efforts to reduce treatment-related toxicities and preserve quality of life for curatively treated patients. Neoadjuvant short-course radiotherapy and long-course chemoradiotherapy followed by total mesorectal excision remain widely accepted as the standard of care for patients with locally advanced rectal cancer. However, a carefully selected group of patients achieving a complete response to neoadjuvant chemoradiotherapy may be spared the effects of surgery and achieve satisfactory oncologic outcomes with a ‘wait-and-see’ strategy. Although supported by the results of previous studies, this intriguing paradigm shift needs prospective evaluation within a clinical trial setting and a more accurate prediction and assessment of response by means of tumor biomarkers and diagnostic imaging.
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Affiliation(s)
- Francesco Sclafani
- Department of Medicine, The Royal Marsden NHS Foundation Trust, Sutton, Surrey, SM2 5PT, UK
| | - David Cunningham
- Department of Medicine, The Royal Marsden NHS Foundation Trust, Sutton, Surrey, SM2 5PT, UK
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de Campos-Lobato LF, Stocchi L, de Sousa JB, Buta M, Lavery IC, Fazio VW, Dietz DW, Kalady MF. Less than 12 nodes in the surgical specimen after total mesorectal excision following neoadjuvant chemoradiation: it means more than you think! Ann Surg Oncol 2013; 20:3398-406. [PMID: 23812804 DOI: 10.1245/s10434-013-3010-x] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND A minimum of 12 examined lymph nodes (LN) is recommended to ensure adequate staging and oncologic resection of patients undergoing proctectomy for rectal adenocarcinoma. However, a decreased number of LN is not unusual in patients receiving neoadjuvant chemoradiation. PURPOSE We hypothesized that a decreased number of LN in the proctectomy specimen of these patients may be an indicator of tumor response and be associated with improved prognosis. METHODS A single-center colorectal cancer database was queried for c-stage II-III rectal cancer patients undergoing neoadjuvant chemoradiation followed by proctectomy between 1997 and 2007. Patients were categorized into two groups according to the number of LN retrieved from the proctectomy specimen: <12 LN versus ≥12 LN. Groups were compared with respect to demographics, tumor and treatment characteristics, and the following oncologic outcomes: overall-survival (OS), cancer-specific-mortality (CSM), cancer-free-survival (CFS), distant (DR), and local recurrences (LR). RESULTS The query returned 237 patients. There were 173 (73 %) males, and the median age was 57 years [interquartile range (IQR) 49-66 years]. The median number of LN retrieved was 15 (IQR 10-23) and 70 (30 %) patients had less than 12 nodes examined. The <12 nodes group was older [60 (IQR 51-71 years) vs. 55 (IQR 48-65 years), p = 0.009] and had more pathologic complete responders (36 vs. 19 %, p = 0.01). No <12 nodes patient experienced a LR, whereas the 5-year LR rate was 11 % in the ≥12 nodes group (p = 0.004). Other oncologic outcomes were not significantly different. CONCLUSIONS Retrieval of less than 12 nodes in the proctectomy specimen of rectal cancer patients treated with neoadjuvant chemoradiation does not affect OS, CSM, CFS, or DR and may be a marker of higher tumor response and, consequently, decreased LR rate.
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Allaix ME, Fichera A. Modern rectal cancer multidisciplinary treatment: the role of radiation and surgery. Ann Surg Oncol 2013; 20:2921-8. [PMID: 23604783 DOI: 10.1245/s10434-013-2966-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Treatment of rectal cancer has evolved during the last few decades due to more in-depth knowledge of rectal cancer biology and major advances in the field of preoperative staging, medical management and surgical techniques. Consequently, treatment strategies are shifting moving towards a more personalized approach based on the response to treatment. Currently topics of controversy are centered around the indication for neoadjuvant radiation therapy in locally advanced rectal cancer and the role of surgery in patients with complete clinical response after neoadjuvant combined modality therapy. This manuscript aims to critically evaluate the evolution of treatment of rectal cancer during the last three decades and future directions. METHODS A review of the literature has been performed in PubMed/Medline electronic databases. RESULTS Treatment modalities are moving towards a tailored approach to rectal cancer patients based on the response to chemoradiation. A "wait-and-see" approach and local excision by Transanal Endoscopic Microsurgery (TEM) are strategies recently proposed in case of complete clinical response. CONCLUSIONS The standard of care still requires that locally advanced rectal cancer should be treated by neoadjuvant chemoradiation therapy followed by total mesorectal excision, including patients with a clinical complete response. Further evidence is needed to endorse a "wait-and-see" strategy and to define the role of TEM.
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Affiliation(s)
- Marco E Allaix
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
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Abstract
Thanks to major advances in the field of surgical techniques and neoadjuvant chemoradiation therapy, along with more accurate pre-operative staging tools and the widespread introduction of population-based screening programs, treatment of rectal cancer has been evolving over the past few decades, moving towards a more tailored approach. This has brought a shift in the treatment algorithm of benign rectal lesions and selected early rectal cancers, for which today transanal endoscopic microsurgery (TEM) is accepted as an effective alternative to abdominal surgery. In 2013, topics of controversy are the role of TEM in the treatment of more advanced rectal cancers, in cases of complete pathological response after chemoradiation therapy and the role of TEM as a platform for single-port surgery and NOTES. This article reviews the current indications for TEM and the future perspectives of this approach in the treatment of rectal tumors.
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Affiliation(s)
- Mario Morino
- Digestive, Colorectal, Oncologic and Minimally Invasive Surgery, Department of Surgical Sciences, University of Turin, Italy
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Issa N, Murninkas A, Powsner E, Dreznick Z. Long-term outcome of local excision after complete pathological response to neoadjuvant chemoradiation therapy for rectal cancer. World J Surg 2013; 36:2481-7. [PMID: 22736345 DOI: 10.1007/s00268-012-1697-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Neoadjuvant chemoradiotion therapy (CRT) for advanced rectal cancer has improved local disease. Complete rectal wall tumor regression may be associated with the absence of viable cancer cells in the mesorectum, and thus local excision (LE) of such lesions as an alternative to radical surgery has recently gained interest. We report the long-term outcome of LE in patients with a mural pathological complete response (ypT0) after CRT. METHODS A retrospective review of patients with rectal cancer treated by CRT and followed by LE with pathological complete response in the specimen between 1998 and 2009 was performed. RESULTS A total of 174 patients had neoadjuvant CRT, and 68 (39 %) showed complete clinical response (cCR). Thirty-one of the cCR patients underwent LE; 23 of them resulted in ypT0 and 8 had residual disease. The ypT0 group included 12 men and 11 women with a median age of 66. The pretreatment stage was T3N1 in 4 (17 %) patients, T3N0 in 11 (48 %), T2N1 in 3 (13 %), and T2N0 in 5 (22 %). The median tumor distance from the anal verge was 6 cm. Sixteen patients (70 %) underwent transanal excision, and 7 (30 %) were treated by transanal-endoscopic microsurgery. Three patients died: one of pneumonia, one of melanoma of the rectum, and one of lung carcinoma. No local or distant recurrences were detected in the remaining 20 patients. The median follow-up was 87 months. CONCLUSIONS Although radical rectal resection is the treatment of choice, LE of complete rectal tumor regression could be a safe alternative with an acceptable result in selected patients.
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Affiliation(s)
- Nidal Issa
- Department of Surgery, Hasharon Hospital, Rabin Medical Center, 7 Keren-Kayemet St, 49100, Petah Tikva, Israel.
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Baker B, Salameh H, Al-Salman M, Daoud F. How does preoperative radiotherapy affect the rate of sphincter-sparing surgery in rectal cancer? Surg Oncol 2012; 21:e103-9. [DOI: 10.1016/j.suronc.2012.03.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Revised: 03/27/2012] [Accepted: 03/28/2012] [Indexed: 01/03/2023]
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Perez RO, Habr-Gama A, Pereira GV, Lynn PB, Alves PA, Proscurshim I, Rawet V, Gama-Rodrigues J. Role of biopsies in patients with residual rectal cancer following neoadjuvant chemoradiation after downsizing: can they rule out persisting cancer? Colorectal Dis 2012; 14:714-20. [PMID: 22568644 DOI: 10.1111/j.1463-1318.2011.02761.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM The study aimed to determine the value of postchemoradiation biopsies, performed after significant tumour downsizing following neoadjuvant therapy, in predicting complete tumour regression in patients with distal rectal cancer. METHOD A retrospective comparative study was performed in patients with rectal cancer who achieved an incomplete clinical response after neoadjuvant chemoradiotherapy. Patients with significant tumour downsizing (> 30% of the initial tumour size) were compared with controls (< 30% reduction of the initial tumour size). During flexible proctoscopy carried out postchemoradiation, biopsies were performed using 3-mm biopsy forceps. The biopsy results were compared with the histopathological findings of the resected specimen. UICC (Union for International Cancer Control) ypTNM classification, tumour differentiation and regression grade were evaluated. The main outcome measures were sensitivity and specificity, negative and positive predictive values, and accuracy of a simple forceps biopsy for predicting pathological response after neoadjuvant chemoradiotherapy. RESULTS Of the 172 patients, 112 were considered to have had an incomplete clinical response and were included in the study. Thirty-nine patients achieved significant tumour downsizing and underwent postchemoradiation biopsies. Overall, 53 biopsies were carried out. Of the 39 patients who achieved significant tumour downsizing, the biopsy result was positive in 25 and negative in 14. Only three of the patients with a negative biopsy result were found to have had a complete pathological response (giving a negative predictive value of 21%). Considering all biopsies performed, only three of 28 negative biopsies were true negatives, giving a negative predictive value of 11%. CONCLUSION In patients with distal rectal cancer undergoing neoadjuvant chemoradiation, post-treatment biopsies are of limited clinical value in ruling out persisting cancer. A negative biopsy result after a near-complete clinical response should not be considered sufficient for avoiding a radical resection.
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Affiliation(s)
- R O Perez
- Colorectal Surgery Division, University of São Paulo, School of Medicine Angelita & Joaquim Gama Institute, São Paulo, Brazil.
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Kennelly RP, Heeney A, White A, Fennelly D, Sheahan K, Hyland JMP, O'Connell PR, Winter DC. A prospective analysis of patient outcome following treatment of T3 rectal cancer with neo-adjuvant chemoradiotherapy and transanal excision. Int J Colorectal Dis 2012; 27:759-64. [PMID: 22173716 DOI: 10.1007/s00384-011-1388-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/01/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Local excision is an alternative to anterior or abdomino-perineal resection in patients with early rectal cancer. In more advanced disease, neo-adjuvant therapy (CRXT) can result in significant disease regression such that local excision may be considered. The primary aim was to assess oncological outcome in patients with T3 rectal cancer treated with CRXT and local excision due to unsuitability for or aversion to anterior resection and stoma. The secondary aim was to examine oncological outcomes in patients treated in a similar way in the published literature. METHODS Between July 2006 and July 2009, patients with rectal cancer staged T3, N0/N1, M0 who were deemed unfit for or who refused anterior resection were offered long-course CRXT. Patients were restaged 8 weeks following completion. If there was a good response (regression grade 2 or 3 clinically and radiologically), full thickness transanal excision was performed. All patients were followed regularly (monthly CT abdomen/pelvis and annual endoscopy) to assess for recurrence of disease. A literature search of PubMed was performed to identify all prospective data available of T3 rectal cancers managed with CRXT and local excision. RESULTS Ten patients were treated over 3 years. Six patients had complete pathological response, while four patients had a partial response. The resection margins following local excision were clear in all. There was no local recurrence (median follow-up 24 months, range 9-42 months). CONCLUSION Neo-adjuvant chemoradiotherapy and local excision is an option in patients unfit for or averse to major surgical resection if there is a good response to CRXT.
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Affiliation(s)
- Rory P Kennelly
- Department of Surgery, St. Vincent's University Hospital and School of Medicine and Medical Sciences, University College Dublin, Dublin 4, Ireland.
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