1
|
Gao PF, Lu N, Liu W. MRI VS. FDG-PET for diagnosis of response to neoadjuvant therapy in patients with locally advanced rectal cancer. Front Oncol 2023; 13:1031581. [PMID: 36741013 PMCID: PMC9890074 DOI: 10.3389/fonc.2023.1031581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 01/02/2023] [Indexed: 01/19/2023] Open
Abstract
Aim In this study, we aimed to compare the diagnostic values of MRI and FDG-PET for the prediction of the response to neoadjuvant chemoradiotherapy (NACT) of patients with locally advanced Rectal cancer (RC). Methods Electronic databases, including PubMed, Embase, and the Cochrane library, were systematically searched through December 2021 for studies that investigated the diagnostic value of MRI and FDG-PET in the prediction of the response of patients with locally advanced RC to NACT. The quality of the included studies was assessed using QUADAS. The pooled sensitivity, specificity, positive and negative likelihood ratio (PLR and NLR), and the area under the ROC (AUC) of MRI and FDG-PET were calculated using a bivariate generalized linear mixed model, random-effects model, and hierarchical regression. Results A total number of 74 studies with recruited 4,105 locally advanced RC patients were included in this analysis. The pooled sensitivity, specificity, PLR, NLR, and AUC for MRI were 0.83 (95% CI: 0.77-0.88), 0.85 (95% CI: 0.79-0.89), 5.50 (95% CI: 4.11-7.35), 0.20 (95% CI: 0.14-0.27), and 0.91 (95% CI: 0.88-0.93), respectively. The summary sensitivity, specificity, PLR, NLR and AUC for FDG-PET were 0.81 (95% CI: 0.77-0.85), 0.75 (95% CI: 0.70-0.80), 3.29 (95% CI: 2.64-4.10), 0.25 (95% CI: 0.20-0.31), and 0.85 (95% CI: 0.82-0.88), respectively. Moreover, there were no significant differences between MRI and FDG-PET in sensitivity (P = 0.565), and NLR (P = 0.268), while the specificity (P = 0.006), PLR (P = 0.006), and AUC (P = 0.003) of MRI was higher than FDG-PET. Conclusions MRI might superior than FGD-PET for the prediction of the response of patients with locally advanced RC to NACT.
Collapse
Affiliation(s)
- Peng Fei Gao
- Department of Traditional Chinese medicine, Jinshan Hospital, Fudan University, Shanghai, China
| | - Na Lu
- Department of Radiology, Huashan Hospital North, Fudan University, Shanghai, China
| | - Wen Liu
- Department of Radiology, Jinshan Hospital, Fudan University, Shanghai, China,*Correspondence: Wen Liu,
| |
Collapse
|
2
|
Guido A, Cuicchi D, Castellucci P, Cellini F, Di Fabio F, Llimpe FLR, Strigari L, Buwenge M, Cilla S, Deodato F, Macchia G, Galietta E, Golfieri R, Ardizzoni A, Zagari RM, Fanti S, Poggioli G, Fuccio L, Morganti AG. Adaptive Individualized high-dose preoperAtive (AIDA) chemoradiation in high-risk rectal cancer: a phase II trial. Eur J Nucl Med Mol Imaging 2023; 50:572-580. [PMID: 36127416 PMCID: PMC9816267 DOI: 10.1007/s00259-022-05944-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 08/12/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE To evaluate the pathological complete response (pCR) rate of locally advanced rectal cancer (LARC) after adaptive high-dose neoadjuvant chemoradiation (CRT) based on 18 F-fluorodeoxyglucose positron emission tomography/computed tomography (18 F-FDG-PET/CT). METHODS The primary endpoint was the pCR rate. Secondary endpoints were the predictive value of 18 F-FDG-PET/CT on pathological response and acute and late toxicity. All patients performed 18 F-FDG-PET/CT at baseline (PET0) and after 2 weeks during CRT (PET1). The metabolic PET parameters were calculated both at the PET0 and PET1. The total CRT dose was 45 Gy to the pelvic lymph nodes and 50 Gy to the primary tumor, corresponding mesorectum, and to metastatic lymph nodes. Furthermore, a sequential boost was delivered to a biological target volume defined by PET1 with an additional dose of 5 Gy in 2 fractions. Capecitabine (825 mg/m2 twice daily orally) was prescribed for the entire treatment duration. RESULTS Eighteen patients (13 males, 5 females; median age 55 years [range, 41-77 years]) were enrolled in the trial. Patients underwent surgical resection at 8-9 weeks after the end of neoadjuvant CRT. No patient showed grade > 1 acute radiation-induced toxicity. Seven patients (38.8%) had TRG = 0 (complete regression), 5 (27.0%) showed TRG = 2, and 6 (33.0%) had TRG = 3. Based on the TRG results, patients were classified in two groups: TRG = 0 (pCR) and TRG = 1, 2, 3 (non pCR). Accepting p < 0.05 as the level of significance, at the Kruskal-Wallis test, the medians of baseline-MTV, interim-SUVmax, interim-SUVmean, interim-MTV, interim-TLG, and the MTV reduction were significantly different between the two groups. 18 F-FDG-PET/CT was able to predict the pCR in 77.8% of cases through compared evaluation of both baseline PET/CT and interim PET/CT. CONCLUSIONS Our results showed that a dose escalation on a reduced target in the final phase of CRT is well tolerated and able to provide a high pCR rate.
Collapse
Affiliation(s)
- Alessandra Guido
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Dajana Cuicchi
- Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Paolo Castellucci
- Nuclear Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesco Cellini
- Dipartimento di Diagnostica per Immagini Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, UOC di Radioterapia Oncologica, Roma, Italy.
- Università Cattolica del Sacro Cuore, Dipartimento Universitario Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Largo Agostino Gemelli 8, 00168, Roma, Italy.
| | - Francesca Di Fabio
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Lidia Strigari
- Department of Medical Physics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Milly Buwenge
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Savino Cilla
- Medical Physics, Gemelli Molise Hospital-Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Francesco Deodato
- Università Cattolica del Sacro Cuore, Dipartimento Universitario Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Largo Agostino Gemelli 8, 00168, Roma, Italy
- Radiation Oncology, Gemelli Molise Hospital-Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Gabriella Macchia
- Radiation Oncology, Gemelli Molise Hospital-Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Erika Galietta
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Rita Golfieri
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andrea Ardizzoni
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Rocco Maurizio Zagari
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Gastroenterology Unit, Department of Medical and Surgical Sciences, Gastroenterology Unit, University of Bologna, Bologna, Italy
| | - Stefano Fanti
- Nuclear Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Gilberto Poggioli
- Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Digestive Medicine and Surgery, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Lorenzo Fuccio
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Gastroenterology Unit, Department of Medical and Surgical Sciences, Gastroenterology Unit, University of Bologna, Bologna, Italy
| | - Alessio G Morganti
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum University of Bologna, Bologna, Italy
| |
Collapse
|
3
|
Kim CA, Ahmed S, Ahmed S, Brunet B, Chalchal H, Deobald R, Doll C, Dupre MP, Gordon V, Lee-Ying RM, Lim H, Liu D, Loree JM, McGhie JP, Mulder K, Park J, Yip B, Wong RP, Zaidi A. Report from the 19th annual Western Canadian Gastrointestinal Cancer Consensus Conference; Winnipeg, Manitoba; 29-30 September 2017. ACTA ACUST UNITED AC 2018; 25:275-284. [PMID: 30111968 DOI: 10.3747/co.25.4109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The 19th annual Western Canadian Gastrointestinal Cancer Consensus Conference (wcgccc) was held in Winnipeg, Manitoba, 29-30 September 2017. The wcgccc is an interactive multidisciplinary conference attended by health care professionals from across Western Canada (British Columbia, Alberta, Saskatchewan, and Manitoba) who are involved in the care of patients with gastrointestinal cancer. Surgical, medical, and radiation oncologists; pathologists; radiologists; and allied health care professionals participated in presentation and discussion sessions for the purpose of developing the recommendations presented here. This consensus statement addresses current issues in the management of colorectal cancer.
Collapse
Affiliation(s)
- C A Kim
- Manitoba-Medical Oncology (Kim, Gordon, Wong) and Radiation Oncology (Shahida Ahmed), CancerCare Manitoba, University of Manitoba, Winnipeg; Surgery (Park, Yip) and Pathology (Dupre), University of Manitoba, Winnipeg
| | - S Ahmed
- Saskatchewan- Medical Oncology (Shahid Ahmed, Zaidi), Radiation Oncology (Brunet), and Surgery (Deobald), Saskatchewan Cancer Agency, University of Saskatchewan, Saskatoon; Medical Oncology (Chalchal), Allan Blair Cancer Centre, Regina
| | - S Ahmed
- Manitoba-Medical Oncology (Kim, Gordon, Wong) and Radiation Oncology (Shahida Ahmed), CancerCare Manitoba, University of Manitoba, Winnipeg; Surgery (Park, Yip) and Pathology (Dupre), University of Manitoba, Winnipeg
| | - B Brunet
- Saskatchewan- Medical Oncology (Shahid Ahmed, Zaidi), Radiation Oncology (Brunet), and Surgery (Deobald), Saskatchewan Cancer Agency, University of Saskatchewan, Saskatoon; Medical Oncology (Chalchal), Allan Blair Cancer Centre, Regina
| | - H Chalchal
- Saskatchewan- Medical Oncology (Shahid Ahmed, Zaidi), Radiation Oncology (Brunet), and Surgery (Deobald), Saskatchewan Cancer Agency, University of Saskatchewan, Saskatoon; Medical Oncology (Chalchal), Allan Blair Cancer Centre, Regina
| | - R Deobald
- Saskatchewan- Medical Oncology (Shahid Ahmed, Zaidi), Radiation Oncology (Brunet), and Surgery (Deobald), Saskatchewan Cancer Agency, University of Saskatchewan, Saskatoon; Medical Oncology (Chalchal), Allan Blair Cancer Centre, Regina
| | - C Doll
- Alberta-Medical Oncology (Mulder), Cross Cancer Institute, University of Alberta, Edmonton; Medical Oncology (Lee-Ying) and Radiation Oncology (Doll), Tom Baker Cancer Centre, University of Calgary, Calgary
| | - M P Dupre
- Manitoba-Medical Oncology (Kim, Gordon, Wong) and Radiation Oncology (Shahida Ahmed), CancerCare Manitoba, University of Manitoba, Winnipeg; Surgery (Park, Yip) and Pathology (Dupre), University of Manitoba, Winnipeg
| | - V Gordon
- Manitoba-Medical Oncology (Kim, Gordon, Wong) and Radiation Oncology (Shahida Ahmed), CancerCare Manitoba, University of Manitoba, Winnipeg; Surgery (Park, Yip) and Pathology (Dupre), University of Manitoba, Winnipeg
| | - R M Lee-Ying
- Alberta-Medical Oncology (Mulder), Cross Cancer Institute, University of Alberta, Edmonton; Medical Oncology (Lee-Ying) and Radiation Oncology (Doll), Tom Baker Cancer Centre, University of Calgary, Calgary
| | - H Lim
- British Columbia-Medical Oncology (Lim, Loree), BC Cancer, University of British Columbia, Vancouver; Medical Oncology (McGhie), BC Cancer, University of British Columbia, Victoria; Radiology (Liu), University of British Columbia, Vancouver
| | - D Liu
- British Columbia-Medical Oncology (Lim, Loree), BC Cancer, University of British Columbia, Vancouver; Medical Oncology (McGhie), BC Cancer, University of British Columbia, Victoria; Radiology (Liu), University of British Columbia, Vancouver
| | - J M Loree
- British Columbia-Medical Oncology (Lim, Loree), BC Cancer, University of British Columbia, Vancouver; Medical Oncology (McGhie), BC Cancer, University of British Columbia, Victoria; Radiology (Liu), University of British Columbia, Vancouver
| | - J P McGhie
- British Columbia-Medical Oncology (Lim, Loree), BC Cancer, University of British Columbia, Vancouver; Medical Oncology (McGhie), BC Cancer, University of British Columbia, Victoria; Radiology (Liu), University of British Columbia, Vancouver
| | - K Mulder
- Alberta-Medical Oncology (Mulder), Cross Cancer Institute, University of Alberta, Edmonton; Medical Oncology (Lee-Ying) and Radiation Oncology (Doll), Tom Baker Cancer Centre, University of Calgary, Calgary
| | - J Park
- Manitoba-Medical Oncology (Kim, Gordon, Wong) and Radiation Oncology (Shahida Ahmed), CancerCare Manitoba, University of Manitoba, Winnipeg; Surgery (Park, Yip) and Pathology (Dupre), University of Manitoba, Winnipeg
| | - B Yip
- Manitoba-Medical Oncology (Kim, Gordon, Wong) and Radiation Oncology (Shahida Ahmed), CancerCare Manitoba, University of Manitoba, Winnipeg; Surgery (Park, Yip) and Pathology (Dupre), University of Manitoba, Winnipeg
| | - R P Wong
- Manitoba-Medical Oncology (Kim, Gordon, Wong) and Radiation Oncology (Shahida Ahmed), CancerCare Manitoba, University of Manitoba, Winnipeg; Surgery (Park, Yip) and Pathology (Dupre), University of Manitoba, Winnipeg
| | - A Zaidi
- Saskatchewan- Medical Oncology (Shahid Ahmed, Zaidi), Radiation Oncology (Brunet), and Surgery (Deobald), Saskatchewan Cancer Agency, University of Saskatchewan, Saskatoon; Medical Oncology (Chalchal), Allan Blair Cancer Centre, Regina
| | | |
Collapse
|
4
|
Pretreatment identification of patients likely to have pathologic complete response after neoadjuvant chemoradiotherapy for rectal cancer. Int J Colorectal Dis 2018; 33:149-157. [PMID: 29247263 DOI: 10.1007/s00384-017-2939-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE In selected patients, a wait-and-see strategy after chemoradiotherapy for rectal cancer might be feasible provided that the probability of pathologic complete response (pCR) is high. This study aimed to identify clinical parameters associated with pCR. Furthermore, we attempted to identify subgroups with increased probability of pCR that might aid in clinical decision making. METHODS A total of 6444 patients that underwent surgical resection of a single primary carcinoma of the rectum after neoadjuvant chemoradiotherapy (nCRT) between January 2009 and December 2016 in the Netherlands were included in the study. Data on the outcome variable, pCR, and potential covariates were retrieved from a nationwide database. The variables included in the analysis were selected based on previous studies and were analyzed using univariate and multivariate logistic regression analyses. RESULTS pCR was observed in 1010 patients (15.7%). Pretreatment clinical tumor stage and signs of obstruction were independently associated with pCR. Nodal stage and presence of metastatic disease decreased chances of pCR significantly. The best response rate was observed in patients diagnosed with a non-obstructive, well-/moderately differentiated adenocarcinoma of the lower rectum with no clinical apparent nodal or distant metastatic disease (pCR ratio 18.8%). The percentage of patients demonstrating pCR decreased in case of symptoms of pretreatment obstruction or poorly differentiated tumors (pCR ratio of 11.8 and 6.7%, respectively). CONCLUSION This nationwide study confirms several of the previously reported clinical predictors of pCR.
Collapse
|
5
|
Habr-Gama A, São Julião GP, Vailati BB, Castro I, Raffaele D. Management of the Complete Clinical Response. Clin Colon Rectal Surg 2017; 30:387-394. [PMID: 29184475 DOI: 10.1055/s-0037-1606116] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Organ preservation is considered in the management of selected patients with rectal cancer. Complete clinical response observed after neoadjuvant chemoradiation for rectal cancer is one of these cases. Patients who present complete clinical response are candidates to the watch-and-wait approach, when radical surgery is not immediately performed and is offered only to patients in the event of a local relapse. These patients are included in a strict follow-up, and up of 70% of them will never be operated during the follow-up. This strategy is associated with similar oncological outcomes as patients operated on, and the advantage of avoiding the morbidity associated to the radical operation. In this article we will discuss in detail the best candidates for this approach, the protocol itself, and the long-term outcomes.
Collapse
Affiliation(s)
- Angelita Habr-Gama
- Angelita & Joaquim Gama Institute, Sao Paulo, SP, Brazil.,University of Sao Paulo School of Medicine, Sao Paulo, SP, Brazil
| | | | | | - Ivana Castro
- Angelita & Joaquim Gama Institute, Sao Paulo, SP, Brazil
| | | |
Collapse
|
6
|
Van Wickle JD, Paulson ES, Landry JC, Erickson BA, Hall WA. Adaptive radiation dose escalation in rectal adenocarcinoma: a review. J Gastrointest Oncol 2017; 8:902-914. [PMID: 29184696 DOI: 10.21037/jgo.2017.07.06] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Total mesorectal excision (TME) after neoadjuvant chemoradiotherapy (CRT) has offered superior control for patients with locally advanced rectal cancer, but can carry a quality of life cost. Fortunately, some patients achieve a complete response after CRT alone without the added morbidity caused by surgery. Efforts to increase fidelity of radiation treatment planning and delivery may allow for escalated doses of radiotherapy (RT) with limited off-target toxicity and elicit more pathological complete responses (pCR) to CRT thereby sparing more rectal cancer patients from surgery. In this review, methods of delivering escalated RT boost above 45-50.4 Gy are discussed including: 3D conformal, intensity-modulated radiotherapy (IMRT), and brachytherapy. Newly developed adaptive boost strategies and imaging modalities used in RT planning and response evaluation such as magnetic resonance imaging (MRI) and positron emission tomography (PET) are also discussed.
Collapse
Affiliation(s)
| | - Eric S Paulson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jerome C Landry
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - Beth A Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - William A Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| |
Collapse
|
7
|
Fusco R, Petrillo M, Granata V, Filice S, Sansone M, Catalano O, Petrillo A. Magnetic Resonance Imaging Evaluation in Neoadjuvant Therapy of Locally Advanced Rectal Cancer: A Systematic Review. Radiol Oncol 2017; 51:252-262. [PMID: 28959161 PMCID: PMC5611989 DOI: 10.1515/raon-2017-0032] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 06/21/2017] [Indexed: 02/07/2023] Open
Abstract
Background The aim of the study was to present an update concerning several imaging modalities in diagnosis, staging and pre-surgery treatment response assessment in locally advanced rectal cancer (LARC). Modalities include: traditional morphological magnetic resonance imaging (MRI), functional MRI such as dynamic contrast enhanced MRI (DCE-MRI) and diffusion weighted imaging (DWI). A systematic review about the diagnostic accuracy in neoadjuvant therapy response assessment of MRI, DCE-MRI, DWI and Positron Emission Tomography/Computed Tomography (PET/CT) has been also reported. Methods Several electronic databases were searched including PubMed, Scopus, Web of Science, and Google Scholar. All the studies included in this review reported findings about therapy response assessment in LARC by means of MRI, DCE-MRI, DWI and PET/CT with details about diagnostic accuracy, true and false negatives, true and false positives. Forest plot and receiver operating characteristic (ROC) curves analysis were performed. Risk of bias and the applicability at study level were calculated. Results Twenty-five papers were identified. ROC curves analysis demonstrated that multimodal imaging integrating morphological and functional MRI features had the best accuracy both in term of sensitivity and specificity to evaluate preoperative therapy response in LARC. DCE-MRI following to PET/CT showed high diagnostic accuracy and their results are also more reliable than conventional MRI and DWI alone. Conclusions Morphological MRI is the modality of choice for rectal cancer staging permitting a correct assessment of the disease extent, of the lymph node involvement, of the mesorectal fascia and of the sphincter complex for surgical planning. Multimodal imaging and functional DCE-MRI may also help in the assessment of treatment response allowing to guide the surgeon versus conservative strategies and/or tailored approach such as “wait and see” policy.
Collapse
Affiliation(s)
- Roberta Fusco
- Radiology Unit, Dipartimento di Supporto ai Percorsi Oncologici Area Diagnostica, Istituto Nazionale Tumori - IRCCS -Fondazione G. Pascale, Via Mariano Semmola, Naples, Italy
| | - Mario Petrillo
- Radiology Unit, Dipartimento di Supporto ai Percorsi Oncologici Area Diagnostica, Istituto Nazionale Tumori - IRCCS -Fondazione G. Pascale, Via Mariano Semmola, Naples, Italy
| | - Vincenza Granata
- Radiology Unit, Dipartimento di Supporto ai Percorsi Oncologici Area Diagnostica, Istituto Nazionale Tumori - IRCCS -Fondazione G. Pascale, Via Mariano Semmola, Naples, Italy
| | - Salvatore Filice
- Radiology Unit, Dipartimento di Supporto ai Percorsi Oncologici Area Diagnostica, Istituto Nazionale Tumori - IRCCS -Fondazione G. Pascale, Via Mariano Semmola, Naples, Italy
| | - Mario Sansone
- Department of Electrical Engineering and Information Technologies, Università degli Studi di Napoli Federico II, Via Claudio, Naples, Italy
| | - Orlando Catalano
- Radiology Unit, Dipartimento di Supporto ai Percorsi Oncologici Area Diagnostica, Istituto Nazionale Tumori - IRCCS -Fondazione G. Pascale, Via Mariano Semmola, Naples, Italy
| | - Antonella Petrillo
- Radiology Unit, Dipartimento di Supporto ai Percorsi Oncologici Area Diagnostica, Istituto Nazionale Tumori - IRCCS -Fondazione G. Pascale, Via Mariano Semmola, Naples, Italy
| |
Collapse
|
8
|
São Julião GP, Habr-Gama A, Vailati BB, Araujo SEA, Fernandez LM, Perez RO. New Strategies in Rectal Cancer. Surg Clin North Am 2017; 97:587-604. [PMID: 28501249 DOI: 10.1016/j.suc.2017.01.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In recent years, our understanding of rectal cancer has improved, including how locally advanced disease responds to chemotherapy and radiation. This has led to new innovations and advances in the treatment of rectal cancer, which includes organ-preserving strategies for responsive disease, and minimally invasive approaces for the performance of total mesorectal excision/protectomyh for persistently advanced disease. This article discusses new strategies for rectal cancer therapy, including Watch and Wait, local excision, minimally invasive proctectomy, and transanal total mesorectal excision particularly in the setting of preoperative multimodality treatment.
Collapse
Affiliation(s)
- Guilherme Pagin São Julião
- Department of Colorectal Surgery, Angelita & Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo 04001, Brazil
| | - Angelita Habr-Gama
- Department of Colorectal Surgery, Angelita & Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo 04001, Brazil
| | - Bruna Borba Vailati
- Department of Colorectal Surgery, Angelita & Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo 04001, Brazil
| | - Sergio Eduardo Alonso Araujo
- Department of Colorectal Surgery, Hospital Israelita Albert Einstein, Avenida Albert Einstein 627, Suite 219, São Paulo 05652, Brazil
| | - Laura Melina Fernandez
- Department of Colorectal Surgery, Angelita & Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo 04001, Brazil
| | - Rodrigo Oliva Perez
- Department of Colorectal Surgery, Angelita & Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo 04001, Brazil.
| |
Collapse
|
9
|
Travaini LL, Zampino MG, Colandrea M, Ferrari ME, Gilardi L, Leonardi MC, Santoro L, Orecchia R, Grana CM. PET/CT with Fluorodeoxyglucose During Neoadjuvant Chemoradiotherapy in Locally Advanced Rectal Cancer. Ecancermedicalscience 2016; 10:629. [PMID: 27110285 PMCID: PMC4817524 DOI: 10.3332/ecancer.2016.629] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Indexed: 12/18/2022] Open
Abstract
Objective The aim of the present study is to evaluate the accuracy of Positron Emission Tomography/Computed Tomography (PET/CT) with Fluorodeoxyglucose ([18F]FDG) to predict treatment response in patients with locally advanced rectal cancer (LARC) during neoadjuvant chemoradiotherapy. Patients and methods Forty-one LARC patients performed [18F]FDG-PET/CT at baseline (PET0). All patients received continuous capecitabine concomitant to radiotherapy on the pelvis, followed by intermittent capecitabine until two weeks before curative surgery. [18F]FDG-PET/CT was also carried out at 40 Gy-time (PET1) and at the end of neoadjuvant therapy (PET2). PET imaging was analysed semi-quantitatively through the measurement of maximal standardised uptake value (SUVmax) and the tumour volume (TV). Histology was expressed through pTNM and Dworak tumor regression grading. Patients were categorised into responder (downstaging or downsizing) and non-responder (stable or progressive disease by comparison pretreatment parameters with clinical/pathological characteristics posttreatment/after surgery). Logistic regression was used to evaluate SUVmax and TV absolute and percent reduction as predictors of response rate using gender, age, and CEA as covariates. Progression-free survival (PFS) and overall survival (OS) were estimated by the Kaplan-Meier method. Survivals were compared by the Log-Rank test. Results Twenty-three responders (9 ypCR, 14 with downstaged disease) and 18 non-responders showed differences in terms of both early and posttreatment SUVmax percent reduction (median comparison: responder = 63.2%, non-responder = 44.2%, p = 0.04 and responder = 76.9%, non-responder = 61.6%, p = 0.06 respectively). The best predictive cut-offs of treatment response for early and posttreatment SUVmax percent reduction were ≥57% and ≥66% from baseline (p = 0.02 and p = 0.01 respectively). Conclusions [18F]FDG-PET/CT is a reliable technique for evaluating therapy response during neoadjuvant treatment in LARC, through a categorical classification of the SUV max reduction during treatment.
Collapse
Affiliation(s)
- Laura L Travaini
- European Institute of Oncology, Via Ripamonti, 435 20141, Milan, Italy
| | - Maria G Zampino
- European Institute of Oncology, Via Ripamonti, 435 20141, Milan, Italy
| | - Marzia Colandrea
- European Institute of Oncology, Via Ripamonti, 435 20141, Milan, Italy
| | - Mahila E Ferrari
- European Institute of Oncology, Via Ripamonti, 435 20141, Milan, Italy
| | - Laura Gilardi
- European Institute of Oncology, Via Ripamonti, 435 20141, Milan, Italy
| | - Maria C Leonardi
- European Institute of Oncology, Via Ripamonti, 435 20141, Milan, Italy
| | - Luigi Santoro
- European Institute of Oncology, Via Ripamonti, 435 20141, Milan, Italy
| | - Roberto Orecchia
- European Institute of Oncology, Via Ripamonti, 435 20141, Milan, Italy
| | - Chiara M Grana
- European Institute of Oncology, Via Ripamonti, 435 20141, Milan, Italy
| |
Collapse
|
10
|
Habr-Gama A, Perez RO, São Julião GP, Proscurshim I, Fernandez LM, Figueiredo MN, Gama-Rodrigues J, Buchpiguel CA. Consolidation chemotherapy during neoadjuvant chemoradiation (CRT) for distal rectal cancer leads to sustained decrease in tumor metabolism when compared to standard CRT regimen. Radiat Oncol 2016; 11:24. [PMID: 26911200 PMCID: PMC4766749 DOI: 10.1186/s13014-016-0598-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 02/04/2016] [Indexed: 02/07/2023] Open
Abstract
Background Neoadjuvant CRT may lead to significant tumor regression in patients with rectal cancer. Different CRT regimens with consolidation chemotherapy may lead to increased rates of complete tumor regression. The purpose of this study was to understand tumor metabolic activity following two different neoadjuvant CRT regimens using sequential PET/CT imaging in two different intervals following RT. Methods Patients with cT2-4 N0-2 M0 rectal cancer treated by standard CRT (54Gy and 2 cycles of 5FU-based chemotherapy) or extended CRT (54Gy and 6 cycles of 5FU-based chemotherapy) underwent sequential PET/CT imaging at baseline, 6 weeks and 12 weeks from radiation completion. Results 99 patients undergoing standard CRT were compared to 12 patients undergoing CRT with consolidation chemotherapy. Patients treated with consolidation CRT had increased rates of complete clinical or pathological response (66 % vs. 23 %; p < 0.001). SUVmax variation between baseline and 6 weeks (88 % vs. 63 %; p < 0.001) and between baseline and 12 weeks (90 % vs. 57 %; p < 0.001) were significantly more pronounced among patients undergoing extended CRT with consolidation chemotherapy. An increase in SUVmax between 6 and 12 weeks was observed in 51 % of patients undergoing standard and 18 % of patients undergoing consolidation CRT (p = 0.04). Conclusions Most of the reduction in tumor metabolism after neoadjuvant CRT occurs within the first 6 weeks from RT completion. In patients undergoing CRT with consolidation chemotherapy, tumors are less likely to regain metabolic activity between 6 and 12 weeks. Therefore, assessment of tumor response may be safely postponed to 12 weeks in patients undergoing extended CRT with consolidation chemotherapy. Trial registration NCT00254683
Collapse
Affiliation(s)
- Angelita Habr-Gama
- Angelita & Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo, SP, Brazil. .,University of São Paulo School of Medicine, São Paulo, Brazil.
| | - Rodrigo O Perez
- Angelita & Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo, SP, Brazil. .,University of São Paulo School of Medicine Colorectal Surgery Division, São Paulo, Brazil. .,Ludwig Institute for Cancer Research São Paulo Branch, São Paulo, Brazil.
| | | | - Igor Proscurshim
- Angelita & Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo, SP, Brazil.
| | - Laura M Fernandez
- Angelita & Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo, SP, Brazil.
| | - Marleny N Figueiredo
- Angelita & Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo, SP, Brazil.
| | - Joaquim Gama-Rodrigues
- Angelita & Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo, SP, Brazil. .,University of São Paulo School of Medicine, São Paulo, Brazil.
| | - Carlos A Buchpiguel
- University of São Paulo School of Medicine Nuclear Imaging Division, São Paulo, Brazil.
| |
Collapse
|
11
|
Thavaneswaran S, Price TJ. Optimal therapy for resectable rectal cancer. Expert Rev Anticancer Ther 2015; 16:285-302. [PMID: 26652907 DOI: 10.1586/14737140.2016.1130627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A lot can be gained by improving our understanding of the optimal sequence of existing therapies in rectal cancer, with the more difficult task of balancing the morbidity of recurrence with the morbidity of prescribed therapies that are particularly toxic owing to tumour location. This review aims to highlight a recent shift in treatment strategies in the opposite direction, with a focus on earlier, more intense systemic treatments with reduced local therapies. Understanding the rationale for and evidence to support this shift will help identify gaps, shape future trials, and ultimately answer the question of whether this is indeed the right path to follow with regards to maintaining local control rates and long-term outcomes for patients, and improving distal disease control and local treatment-related morbidities without compromising quality of life.
Collapse
Affiliation(s)
| | - Timothy J Price
- b The Queen Elizabeth Hospital , University of Sydney and University of Adelaide , Woodville , SA , Australia
| |
Collapse
|
12
|
Can Surgery be Avoided After Preoperative Chemoradiation for Rectal Cancer in the Era of Organ Preservation? Current Review of Literature. Am J Clin Oncol 2015; 38:534-40. [DOI: 10.1097/coc.0000000000000122] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
13
|
Joye I, Deroose CM, Vandecaveye V, Haustermans K. The role of diffusion-weighted MRI and (18)F-FDG PET/CT in the prediction of pathologic complete response after radiochemotherapy for rectal cancer: a systematic review. Radiother Oncol 2015; 113:158-65. [PMID: 25483833 DOI: 10.1016/j.radonc.2014.11.026] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 11/13/2014] [Accepted: 11/13/2014] [Indexed: 02/07/2023]
Abstract
After neoadjuvant radiochemotherapy (RCT) for locally advanced rectal cancer, 15-27% of the patients experience a pathological complete response (pCR). This observation raises the question as to whether invasive surgery could be avoided in a selected cohort of patients who obtain a clinical complete response after preoperative RCT. In this respect, there has been growing interest in functional imaging techniques to improve clinical response assessment. This systematic review focuses on the role of diffusion-weighted imaging (DWI) and (18)F-fluorodeoxyglucose positron emission tomography/computed tomography ((18)F-FDG PET/CT) in the prediction of pCR after RCT for rectal cancer. A total of 14 publications on DWI and 25 on (18)F-FDG PET/CT were retrieved. Pooled analysis of individual patient data shows both imaging modalities have a low positive predictive value in the prediction of pCR (mean PPV of 54% and 39% for DWI- and (18)F-FDG PET/CT-based parameters respectively). Especially pre-RCT imaging is unable to predict pCR with overall accuracies of 68-72% for DWI and 44% for (18)F-FDG PET/CT. Qualitative DWI assessment 5-10weeks after the end of RCT may outperform apparent diffusion coefficient (ADC)-based DWI-parameters (overall accuracy of 87% vs. 74-78%). Although few data are available, early changes in FDG-uptake seem promising in the prediction of pCR and the role of (18)F-FDG PET/CT during RCT should be further investigated. Quantitative and qualitative (18)F-FDG PET/CT measurements are equally effective in the assessment of pCR after RCT. The major strength of DWI and (18)F-FDG PET/CT lies in the identification of non-responders who are not candidates for organ preservation. Up to now, DWI and (18)F-FDG PET/CT are not accurate enough to safely select patients for organ-sparing strategies. Future research must focus on the integration of functional imaging with clinical data and molecular biomarkers.
Collapse
Affiliation(s)
- Ines Joye
- Department of Radiation Oncology, University Hospitals Leuven, Belgium; Department of Oncology, KU Leuven, Belgium.
| | | | | | - Karin Haustermans
- Department of Radiation Oncology, University Hospitals Leuven, Belgium; Department of Oncology, KU Leuven, Belgium
| |
Collapse
|
14
|
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.
Collapse
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
| |
Collapse
|
15
|
Value of 18F-FDG PET for Predicting Response to Neoadjuvant Therapy in Rectal Cancer: Systematic Review and Meta-Analysis. AJR Am J Roentgenol 2015; 204:1261-8. [DOI: 10.2214/ajr.14.13210] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
16
|
Li YL, Wu LM, Chen XX, Delproposto Z, Hu JN, Xu JR. Is diffusion-weighted MRI superior to FDG-PET or FDG-PET/CT in evaluating and predicting pathological response to preoperative neoadjuvant therapy in patients with rectal cancer? J Dig Dis 2014; 15:525-37. [PMID: 25060294 DOI: 10.1111/1751-2980.12174] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE This meta-analysis aimed to compare the diagnostic accuracy of diffusion-weighted magnetic resonance imaging (DW-MRI) and fluorodeoxyglucose-positron emission tomography (FDG-PET) or FDG-PET/computed tomography (CT) in evaluating and predicting pathological response to preoperative neoadjuvant chemoradiotherapy (NCRT) in patients with rectal cancer. METHODS A comprehensive literature research was conducted to identify the relevant studies for this meta-analysis. Combined sensitivity, specificity, positive (PPV) and negative predictive values (NPV) were calculated. RESULTS A total of 33 studies including 1564 patients met the inclusion criteria. The pooled sensitivity (81% [95% CI 74-86%] vs 85% [95% CI 75-91%]) and NPV (80% [95% CI 68-89%] vs 91% [95% CI 80-95%]) for FDG-PET or FDG-PET/CT were significantly lower than those for DW-MRI (P < 0.05). No differences were observed in pooled specificity and PPV between DW-MRI and FDG-PET or FDG-PET/CT. Further subgroup analyses showed that DW-MRI had higher sensitivity on adenocarcinomas alone than on those including mucinous-type adenocarcinomas (92% [95% CI 83-99%] vs 76% [95% CI 63-90%], P = 0.00). CONCLUSIONS DW-MRI is superior to FDG-PET or FDG-PET/CT in predicting and evaluating pathological responses to preoperative NCRT in patients with rectal cancer. However, its relatively low specificity and PPV limit its application in clinic, making it currently inappropriate to monitor such patients, especially those with mucinous-type rectal adenocarcinomas.
Collapse
Affiliation(s)
- Yu Lai Li
- Department of Radiology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | | | | | | | | | | |
Collapse
|
17
|
Memon S, Lynch AC, Akhurst T, Ngan SY, Warrier SK, Michael M, Heriot AG. Systematic Review of FDG-PET Prediction of Complete Pathological Response and Survival in Rectal Cancer. Ann Surg Oncol 2014; 21:3598-607. [DOI: 10.1245/s10434-014-3753-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Indexed: 01/11/2023]
|
18
|
Li C, Lan X, Yuan H, Feng H, Xia X, Zhang Y. 18F-FDG PET predicts pathological response to preoperative chemoradiotherapy in patients with primary rectal cancer: a meta-analysis. Ann Nucl Med 2014; 28:436-46. [PMID: 24623152 DOI: 10.1007/s12149-014-0837-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 02/27/2014] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The aim of this study was to assess the performance of fluorine-18-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) in predicting pathological response to preoperative chemoradiotherapy (CRT) in patients with primary rectal cancer. METHODS Potentially relevant articles were searched in the databases of PubMed and Embase from January 1990 to September 2013. The Quality Assessment for Diagnostic Accuracy Studies criteria was employed to assess the quality of all of the included studies. The pooled sensitivity and specificity were calculated, and the area under the curve of the summary receiver operating characteristic curve was obtained. Subgroup analysis was conducted to explore the sources of heterogeneity. RESULTS Thirty-one eligible studies involving 1527 patients were ultimately included in the meta-analysis. Four main quantitative or qualitative parameters [response index (RI), post-treatment maximum standardized uptake value (SUVmax-post), visual response (VR) and the percentage change in total lesion glycolysis (TLG) before and after CRT (deltaTLG%)] related to PET or positron emission tomography/computed tomography (PET/CT) were assessed for the prediction of histopathological response. The pooled sensitivities of these four parameters were comparable and were 74, 74, 75 and 78%, respectively (P>0.05). The pooled specificity of deltaTLG% was higher than that of the other three parameters (RI, SUVmax-post and VR) and was 81, 66, 64 and 67%, respectively (P<0.05). The results from subgroup analysis showed that the RI and SUVmax-post had higher specificity in predicting tumor regression grade (TRG) than complete pathological response (pCR) [RI, 71 vs. 59% (P=0.0275); SUVmax-post, 72 vs. 61% (P=0.0178)].The diagnostic sensitivity and specificity of the RI and SUVmax-post when the post-treatment PET or PET/CT scan was performed at two different time points (during CRT and after the completion of CRT) were 82 vs. 72% (P=0.0630) and 78 vs. 63% (P=0.0059), respectively. CONCLUSIONS 18F-FDG PET could be a potentially powerful non-invasive tool for predicting pathological response; the related parameters RI and SUVmax-post may be more suitable for the prediction of TRG than pCR. The current data also suggested that the optimum post-treatment 18F-FDG PET scan could be carried out during CRT.
Collapse
Affiliation(s)
- Chongjiao Li
- Department of Nuclear Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Hubei Province Key Laboratory of Molecular Imaging, No. 1277, Jiefang Ave., Wuhan, Hubei, People's Republic of China
| | | | | | | | | | | |
Collapse
|
19
|
McKeown E, Nelson DW, Johnson EK, Maykel JA, Stojadinovic A, Nissan A, Avital I, Brücher BL, Steele SR. Current approaches and challenges for monitoring treatment response in colon and rectal cancer. J Cancer 2014; 5:31-43. [PMID: 24396496 PMCID: PMC3881219 DOI: 10.7150/jca.7987] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 11/25/2013] [Indexed: 12/18/2022] Open
Abstract
Introduction: With the advent of multidisciplinary and multimodality approaches to the management of colorectal cancer patients, there is an increasing need to define how we monitor response to novel therapies in these patients. Several factors ranging from the type of therapy used to the intrinsic biology of the tumor play a role in tumor response. All of these can aid in determining the ideal course of treatment, and may fluctuate over time, pending down-staging or progression of disease. Therefore, monitoring how disease responds to therapy requires standardization in order to ultimately optimize patient outcomes. Unfortunately, how best to do this remains a topic of debate among oncologists, pathologists, and colorectal surgeons. There may not be one single best approach. The goal of the present article is to shed some light on current approaches and challenges to monitoring treatment response for colorectal cancer. Methods: A literature search was conducted utilizing PubMed and the OVID library. Key-word combinations included colorectal cancer metastases, neoadjuvant therapy, rectal cancer, imaging modalities, CEA, down-staging, tumor response, and biomarkers. Directed searches of the embedded references from the primary articles were also performed in selected circumstances. Results: Pathologic examination of the post-treatment surgical specimen is the gold standard for monitoring response to therapy. Endoscopy is useful for evaluating local recurrence, but not in assessing tumor response outside of the limited information gained by direct examination of intra-lumenal lesions. Imaging is used to monitor tumors throughout the body for response, with CT, PET, and MRI employed in different circumstances. Overall, each has been validated in the monitoring of patients with colorectal cancer and residual tumors. Conclusion: Although there is no imaging or serum test to precisely correlate with a tumor's response to chemo- or radiation therapy, these modalities, when used in combination, can aid in allowing clinicians to adjust medical therapy, pursue operative intervention, or (in select cases) identify complete responders. Improvements are needed, however, as advances across multiple modalities could allow appropriate selection of patients for a close surveillance regimen in the absence of operative intervention.
Collapse
Affiliation(s)
| | - Daniel W Nelson
- 2. Department of Surgery, Madigan Army Center, Tacoma, WA, USA
| | - Eric K Johnson
- 2. Department of Surgery, Madigan Army Center, Tacoma, WA, USA
| | - Justin A Maykel
- 3. Division of Colorectal Surgery, UMass Medical Center, Worcester, MA, USA
| | - Alexander Stojadinovic
- 4. Department of Surgery, Division of Surgical Oncology, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Aviram Nissan
- 5. Department of Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | | | | | - Scott R Steele
- 2. Department of Surgery, Madigan Army Center, Tacoma, WA, USA
| |
Collapse
|
20
|
Neither FDG-PET Nor CT can distinguish between a pathological complete response and an incomplete response after neoadjuvant chemoradiation in locally advanced rectal cancer: a prospective study. Ann Surg 2013. [PMID: 23187748 DOI: 10.1097/sla.0b013e318277b625] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To prospectively compare the ability of flourodeoxyglucose-positron emission tomography (FDG-PET) and computed tomography (CT) to identify a pathological complete response (pCR) in patients with rectal cancer treated by chemoradiation. BACKGROUND A major obstacle in pursuing nonoperative management in patients with rectal cancer after chemoradiation is the inability to identify a pCR preoperatively. METHODS A total of 121 patients with rectal cancer were prospectively enrolled. FDG-PET scans and helical CT scans were obtained before and after neoadjuvant chemoradiation. Consensus readings of PET and CT scans were used to classify certainty of disease (5-point confidence rating scale). The ability of PET and CT scans to accurately distinguish a pCR (ypT0) from an incomplete response (ypT1-4) was estimated using the area under the receiver operating characteristic curve (AUC). RESULTS Of the 121 patients, 26 (21%) had a pCR. PET and CT scans were equally inadequate at distinguishing a pCR from an incomplete response (AUC = 0.64 for both, P = 0.97). Among the 26 patients with a pCR, 14 (54%) and 5 (19%) were classified as complete responders on PET and CT scans, respectively. Among the 95 patients with an incomplete pathological response, 63 (66%) and 90 (95%) were classified as incomplete responders on PET and CT scans, respectively. None of the individual PET parameters, including visual response score, mean standard uptake value (SUVmean), maximum SUV (SUVmax), and total lesion glycolysis, accurately distinguished a pCR (AUCs = 0.57-0.73). CONCLUSIONS Neither PET nor CT scans have adequate predictive value to be clinically useful in distinguishing a pCR from an incomplete response and, therefore, should not be obtained for the purpose of attempting to predict a pCR after neoadjuvant chemoradiation for rectal cancer.
Collapse
|
21
|
Maffione AM, Ferretti A, Grassetto G, Bellan E, Capirci C, Chondrogiannis S, Gava M, Marzola MC, Rampin L, Bondesan C, Colletti PM, Rubello D. Fifteen different 18F-FDG PET/CT qualitative and quantitative parameters investigated as pathological response predictors of locally advanced rectal cancer treated by neoadjuvant chemoradiation therapy. Eur J Nucl Med Mol Imaging 2013; 40:853-64. [PMID: 23417501 DOI: 10.1007/s00259-013-2357-3] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Accepted: 01/24/2013] [Indexed: 01/11/2023]
Abstract
PURPOSE The aim of this study was to correlate qualitative visual response and various PET quantification factors with the tumour regression grade (TRG) classification of pathological response to neoadjuvant chemoradiotherapy (CRT) proposed by Mandard. METHODS Included in this retrospective study were 69 consecutive patients with locally advanced rectal cancer (LARC). FDG PET/CT scans were performed at staging and after CRT (mean 6.7 weeks). Tumour SUVmax and its related arithmetic and percentage decrease (response index, RI) were calculated. Qualitative analysis was performed by visual response assessment (VRA), PERCIST 1.0 and response cut-off classification based on a new definition of residual disease. Metabolic tumour volume (MTV) was calculated using a 40 % SUVmax threshold, and the total lesion glycolysis (TLG) both before and after CRT and their arithmetic and percentage change were also calculated. We split the patients into responders (TRG 1 or 2) and nonresponders (TRG 3-5). RESULTS SUVmax MTV and TLG after CRT, RI, ΔMTV% and ΔTLG% parameters were significantly correlated with pathological treatment response (p < 0.01) with a ROC curve cut-off values of 5.1, 2.1 cm(3), 23.4 cm(3), 61.8 %, 81.4 % and 94.2 %, respectively. SUVmax after CRT had the highest ROC AUC (0.846), with a sensitivity of 86 % and a specificity of 80 %. VRA and response cut-off classification were also significantly predictive of TRG response (VRA with the best accuracy: sensitivity 86 % and specificity 55 %). In contrast, assessment using PERCIST was not significantly correlated with TRG. CONCLUSION FDG PET/CT can accurately stratify patients with LARC preoperatively, independently of the method chosen to interpret the images. Among many PET parameters, some of which are not immediately obtainable, the most commonly used in clinical practice (SUVmax after CRT and VRA) showed the best accuracy in predicting TRG.
Collapse
|
22
|
Kim AY. Imaging Diagnosis of Locally Advanced Rectal Cancer: Tumor Staging before and after Preoperative Chemoradiotherapy. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2013; 61:3-8. [DOI: 10.4166/kjg.2013.61.1.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Ah Young Kim
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| |
Collapse
|
23
|
Murcia Duréndez MJ, Frutos Esteban L, Luján J, Frutos MD, Valero G, Navarro Fernández JL, Mohamed Salem L, Ruiz Merino G, Claver Valderas MA. The value of 18F-FDG PET/CT for assessing the response to neoadjuvant therapy in locally advanced rectal cancer. Eur J Nucl Med Mol Imaging 2012; 40:91-7. [DOI: 10.1007/s00259-012-2257-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Accepted: 09/17/2012] [Indexed: 01/11/2023]
|
24
|
Ceelen WP. Progress in rectal cancer treatment. ISRN GASTROENTEROLOGY 2012; 2012:648183. [PMID: 22970381 PMCID: PMC3437282 DOI: 10.5402/2012/648183] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/24/2012] [Accepted: 08/08/2012] [Indexed: 12/17/2022]
Abstract
The dramatic improvement in local control of rectal cancer observed during the last decades is to be attributed to attention to surgical technique and to the introduction of neoadjuvant therapy regimens. Nevertheless, systemic relapse remains frequent and is currently insufficiently addressed. Intensification of neoadjuvant therapy by incorporating chemotherapy with or without targeted agents before the start of (chemo)radiation or during the waiting period to surgery may present an opportunity to improve overall survival. An increasing number of patients can nowadays undergo sphincter preserving surgery. In selected patients, local excision or even a "wait and see" approach may be feasible following active neoadjuvant therapy. Molecular and genetic biomarkers as well as innovative imaging techniques may in the future allow better selection of patients for this treatment option. Controversy persists concerning the selection of patients for adjuvant chemotherapy and/or targeted therapy after neoadjuvant regimens. The currently available evidence suggests that in complete pathological responders long-term outcome is excellent and adjuvant therapy may be omitted. The results of ongoing trials will help to establish the ideal tailored approach in resectable rectal cancer.
Collapse
Affiliation(s)
- Wim P Ceelen
- Department of Surgery, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium
| |
Collapse
|
25
|
Positron Emission Tomography for Predicting Pathologic Response After Neoadjuvant Chemoradiotherapy for Locally Advanced Rectal Cancer. Am J Clin Oncol 2012; 35:334-9. [DOI: 10.1097/coc.0b013e3182118d12] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
|
26
|
Zhang C, Tong J, Sun X, Liu J, Wang Y, Huang G. 18F-FDG-PET evaluation of treatment response to neo-adjuvant therapy in patients with locally advanced rectal cancer: a meta-analysis. Int J Cancer 2012; 131:2604-11. [PMID: 22447461 DOI: 10.1002/ijc.27557] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Revised: 03/16/2012] [Accepted: 03/19/2012] [Indexed: 12/16/2022]
Abstract
The purpose of this meta-analysis was to evaluate the utility of positron emission tomography (PET) using fluor-18-deoxyglucose (FDG) to predict the response of rectal cancer to neo-adjuvant therapy. All previously published studies on the role of FDG-PET in predicting the response of rectal cancer to neo-adjuvant therapy were collected. Pooled sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated using statistical software. A total of 28 studies, comprising 1,204 patients with rectal cancer, were included in the meta-analysis. Pooled sensitivity, specificity, PPV and NPV for FDG-PET predicting the response to therapy was 78% [95% confidence interval (CI): 75-82%], 66% (95% CI: 62-69%), 70% (95% CI; 66-73%) and 75% (95% CI: 71-0.79%), respectively. The included studies were of a relatively high methodological quality according to the QUADAS (quality assessment of studies of diagnostic accuracy included in systematic reviews) criteria. Based on the subgroup analyses, there was no significant difference between the response index, the standardized uptake value and the visual response score in predicting the therapy response. However, the accuracy of the group that underwent PET scanning during therapy showed significantly higher values (sensitivity 86% and specificity 80%) than the group that was scanned after completion of the therapy. Therefore, FDG-PET is valuable for predicting the response of rectal carcinoma to neo-adjuvant therapy, and early evaluation of response during the therapy may be more promising. However, additional studies using prospective clinical trials will be required to assess the clinical benefit of this strategy.
Collapse
Affiliation(s)
- Chenpeng Zhang
- Department of Nuclear Medicine, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | | | | | | | | | | |
Collapse
|
27
|
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.
Collapse
Affiliation(s)
- R O Perez
- Colorectal Surgery Division, University of São Paulo, School of Medicine Angelita & Joaquim Gama Institute, São Paulo, Brazil.
| | | | | | | | | | | | | | | |
Collapse
|
28
|
Perez RO, Habr-Gama A, São Julião GP, Gama-Rodrigues J, Sousa AHS, Campos FG, Imperiale AR, Lynn PB, Proscurshim I, Nahas SC, Ono CR, Buchpiguel CA. Optimal timing for assessment of tumor response to neoadjuvant chemoradiation in patients with rectal cancer: do all patients benefit from waiting longer than 6 weeks? Int J Radiat Oncol Biol Phys 2012; 84:1159-65. [PMID: 22580120 DOI: 10.1016/j.ijrobp.2012.01.096] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Revised: 01/30/2012] [Accepted: 01/31/2012] [Indexed: 12/17/2022]
Abstract
PURPOSE To estimate the metabolic activity of rectal cancers at 6 and 12 weeks after completion of chemoradiation therapy (CRT) by 2-[fluorine-18] fluoro-2-deoxy-d-glucose-labeled positron emission tomography/computed tomography ([(18)FDG]PET/CT) imaging and correlate with response to CRT. METHODS AND MATERIALS Patients with cT2-4N0-2M0 distal rectal adenocarcinoma treated with long-course neoadjuvant CRT (54 Gy, 5-fluouracil-based) were prospectively studied (ClinicalTrials.org identifier NCT00254683). All patients underwent 3 PET/CT studies (at baseline and 6 and 12 weeks from CRT completion). Clinical assessment was at 12 weeks. Maximal standard uptake value (SUVmax) of the primary tumor was measured and recorded at each PET/CT study after 1 h (early) and 3 h (late) from (18)FDG injection. Patients with an increase in early SUVmax between 6 and 12 weeks were considered "bad" responders and the others as "good" responders. RESULTS Ninety-one patients were included; 46 patients (51%) were "bad" responders, whereas 45 (49%) patients were "good" responders. "Bad" responders were less likely to develop complete clinical response (6.5% vs. 37.8%, respectively; P=.001), less likely to develop significant histological tumor regression (complete or near-complete pathological response; 16% vs. 45%, respectively; P=.008) and exhibited greater final tumor dimension (4.3 cm vs. 3.3 cm; P=.03). Decrease between early (1 h) and late (3 h) SUVmax at 6-week PET/CT was a significant predictor of "good" response (accuracy of 67%). CONCLUSIONS Patients who developed an increase in SUVmax after 6 weeks were less likely to develop significant tumor downstaging. Early-late SUVmax variation at 6-week PET/CT may help identify these patients and allow tailored selection of CRT-surgery intervals for individual patients.
Collapse
Affiliation(s)
- Rodrigo O Perez
- Department of Gastroenterology, Colorectal Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Kosinski L, Habr-Gama A, Ludwig K, Perez R. Shifting concepts in rectal cancer management: a review of contemporary primary rectal cancer treatment strategies. CA Cancer J Clin 2012; 62:173-202. [PMID: 22488575 DOI: 10.3322/caac.21138] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The management of rectal cancer has transformed over the last 3 decades and continues to evolve. Some of these changes parallel progress made with other cancers: refinement of surgical technique to improve organ preservation, selective use of neoadjuvant (and adjuvant) therapy, and emergence of criteria suggesting a role for individually tailored therapy. Other changes are driven by fairly unique issues including functional considerations, rectal anatomic features, and surgical technical issues. Further complexity is due to the variety of staging modalities (each with its own limitations), neoadjuvant treatment alternatives, and competing strategies for sequencing multimodal treatment even for nonmetastatic disease. Importantly, observations of tumor response made in the era of neoadjuvant therapy are reshaping some traditionally held concepts about tumor behavior. Frameworks for prioritizing and integrating complex data can help to formulate treatment plans for patients.
Collapse
Affiliation(s)
- Lauren Kosinski
- Division of Colorectal Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA.
| | | | | | | |
Collapse
|
30
|
Evidence-based Guideline Recommendations on the use of Positron Emission Tomography Imaging in Colorectal Cancer. Clin Oncol (R Coll Radiol) 2012; 24:232-49. [DOI: 10.1016/j.clon.2011.11.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2011] [Revised: 10/17/2011] [Accepted: 11/23/2011] [Indexed: 01/11/2023]
|
31
|
Shanmugan S, Arrangoiz R, Nitzkorski JR, Yu JQ, Li T, Cooper H, Konski A, Farma JM, Sigurdson ER. Predicting pathological response to neoadjuvant chemoradiotherapy in locally advanced rectal cancer using 18FDG-PET/CT. Ann Surg Oncol 2012; 19:2178-85. [PMID: 22395978 DOI: 10.1245/s10434-012-2248-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Indexed: 12/16/2022]
Abstract
BACKGROUND Pathologic complete response (pCR) after neoadjuvant chemoradiation (CRT) has been observed in 15-30% of patients with locally advanced rectal cancer (LARC). The objective of this study was to determine whether PET/CT can predict pCR and disease-free survival in patients receiving CRT with LARC. METHODS This is a retrospective review of patients with EUS-staged T3-T4, N+rectal tumors treated with CRT, who underwent pre/post-treatment PET/CT from 2002-2009. All patients were treated with CRT and surgical resection. Standardized uptake value (SUV) of each tumor was recorded. Logistic regression was used to analyze the association of pre-CRT SUV, post-CRT SUV, %SUV change, and time between CRT and surgery, compared with pCR. Kaplan-Meier estimation evaluated significant predictors of survival. RESULTS Seventy patients (age 62 years; 42M:28F) with preoperative stage T3 (n=61) and T4 (n=9) underwent pre- and post-CRT PET/CT followed by surgery. The pCR rate was 26%. Median pre-CRT SUV was 10.8, whereas the median post-CRT SUV was 4 (P=0.001). Patients with pCR had a lower median post-CRT SUV compared with those without (2.7 vs. 4.5, P=0.01). Median SUV decrease was 63% (7.5-95.5%) and predicted pCR (P=0.002). Patients with a pCR had a greater time interval between CRT and surgery (median, 58 vs. 50 days) than those without (P=0.02). Patients with post-CRT SUV<4 had a lower recurrence compared with those without (P=0.03). Patients with SUV decrease≥63% had improved overall survival at median follow-up of 40 months than those without (P=0.006). CONCLUSIONS PET/CT can predict response to CRT in patients with LARC. Posttreatment SUV, %SUV decrease, and greater time from CRT to surgery correlate with pCR. Post-CRT, SUV<4, and SUV decrease≥63% were predictive of recurrence-free and overall survival.
Collapse
|
32
|
Fischkoff KN, Ruby JA, Guillem JG. Nonoperative Approach to Locally Advanced Rectal Cancer After Neoadjuvant Combined Modality Therapy: Challenges and Opportunities From a Surgical Perspective. Clin Colorectal Cancer 2011; 10:291-7. [DOI: 10.1016/j.clcc.2011.06.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2010] [Revised: 12/16/2010] [Accepted: 12/21/2010] [Indexed: 12/22/2022]
|
33
|
Minsky BD. Progress in the Treatment of Locally Advanced Clinically Resectable Rectal Cancer. Clin Colorectal Cancer 2011; 10:227-37. [DOI: 10.1016/j.clcc.2011.06.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Accepted: 06/21/2011] [Indexed: 12/11/2022]
|
34
|
Perez RO, Habr-Gama A, Gama-Rodrigues J, Proscurshim I, Julião GPS, Lynn P, Ono CR, Campos FG, Silva e Sousa AH, Imperiale AR, Nahas SC, Buchpiguel CA. Accuracy of positron emission tomography/computed tomography and clinical assessment in the detection of complete rectal tumor regression after neoadjuvant chemoradiation: long-term results of a prospective trial (National Clinical Trial 00254683). Cancer 2011; 118:3501-11. [PMID: 22086847 DOI: 10.1002/cncr.26644] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2011] [Revised: 09/14/2011] [Accepted: 09/26/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND Neoadjuvant chemoradiation (CRT) therapy may result in significant tumor regression in patients with rectal cancer. Patients who develop complete tumor regression have been managed by treatment strategies that are alternatives to standard total mesorectal excision. Therefore, assessment of tumor response with positron emission tomography/computed tomography (PET/CT) after neoadjuvant treatment may offer relevant information for the selection of patients to receive alternative treatment strategies. METHODS Patients with clinical T2 (cT2) through cT4NxM0 rectal adenocarcinoma were included prospectively. Neoadjuvant therapy consisted of 54 grays of radiation and 5-fluorouracil-based chemotherapy. Baseline PET/CT studies were obtained before CRT followed by PET/CT studies at 6 weeks and 12 weeks after the completion of CRT. Clinical assessment was performed at 12 weeks after CRT completion. PET/CT results were compared with clinical and pathologic data. RESULTS In total, 99 patients were included in the study. Twenty-three patients were complete responders (16 had a complete clinical response, and 7 had a complete pathologic response). The PET/CT response evaluation at 12 weeks indicated that 18 patients had a complete response, and 81 patients had an incomplete response. There were 5 false-negative and 10 false-positive PET/CT results. PET/CT for the detection of residual cancer had 93% sensitivity, 53% specificity, a 73% negative predictive value, an 87% positive predictive value, and 85% accuracy. Clinical assessment alone resulted in an accuracy of 91%. PET/CT information may have detected misdiagnoses made by clinical assessment alone, improving overall accuracy to 96%. CONCLUSIONS Assessment of tumor response at 12 weeks after CRT completion with PET/CT imaging may provide a useful additional tool with good overall accuracy for the selection of patients who may avoid unnecessary radical resection after achieving a complete clinical response. Cancer 2012;3501-3511. © 2011 American Cancer Society.
Collapse
|
35
|
Abstract
Rectal excision is the standard in rectal cancer treatment. The morbidity of rectal excision, together with the low rate of positive lymph nodes in patients with a good response after radiochemotherapy, raises the challenging concept of organ preservation. Patients with a complete response can benefit from a nonoperative strategy based on a strict follow up. Those with a complete or subcomplete response can be treated by local excision. Limitations in accurately assessing a complete response by conventional and modern imaging modalities suggest that local excision is more appropriate for the majority of patients when organ preservation is being considered. The encouraging results of retrospective series of local excision in downstaged clinical T2/T3 low rectal cancer after radiochemotherapy, however, need to be confirmed by the ongoing multicentre phase II United States and phase III French trials before routinely proposing organ preservation in patients with a good response.
Collapse
Affiliation(s)
- E Rullier
- Department of Surgery, Saint-Andre Hospital, Victor Segalen University of Bordeaux, Bordeaux, France.
| | | |
Collapse
|
36
|
Georgiou PA, Tekkis PP, Brown G. Pelvic colorectal recurrence: crucial role of radiologists in oncologic and surgical treatment options. Cancer Imaging 2011; 11 Spec No A:S103-11. [PMID: 22186112 PMCID: PMC3266566 DOI: 10.1102/1470-7330.2011.9025] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Radical resection is the only potential cure for patients with locally advanced primary and recurrent rectal cancer and is considered curative only when the histologic margins are clear of tumour. Early diagnosis of the disease is essential as it increases the likelihood of a potentially curative resection and prevention of dissemination. Clinical examination, tumour markers and radiologic modalities such as ultrasonography, computed tomography, magnetic resonance imaging and positron emission tomography are routinely used in an effort to accurately stage these patients and provide useful information for the selection of patients for further treatment/management. This review describes the methods of staging patients with locally advanced primary and recurrent rectal cancer prior to surgery emphasizing the role that radiologists have in this process.
Collapse
Affiliation(s)
- P A Georgiou
- Department of Colorectal Surgery, The Royal Marsden Hospital, Fulham Road, London, UK
| | | | | |
Collapse
|
37
|
Abstract
In the past two decades, substantial progress has been made in the adjuvant management of colorectal cancer. Chemotherapy has improved overall survival in patients with node-positive (N+) disease. In contrast with colon cancer, which has a low incidence of local recurrence, patients with rectal cancer have a higher incidence requiring the addition of pelvic radiation therapy (chemoradiation). Patients with rectal cancer have a number of unique management considerations: for example, the role of short-course radiation, whether postoperative adjuvant chemotherapy is necessary for all patients, and if the type of surgery following chemoradiation should be based on the response rate. More accurate imaging techniques and/or molecular markers may help identify patients with positive pelvic nodes to reduce the chance of overtreatment with preoperative therapy. Will more effective systemic agents both improve the results of radiation as well as modify the need for pelvic radiation? This review will address these and other controversies specific to patients with rectal cancer.
Collapse
Affiliation(s)
- Bruce D Minsky
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, IL 60637, USA.
| |
Collapse
|
38
|
Minsky BD. Counterpoint: Long-Course Chemoradiation Is Preferable in the Neoadjuvant Treatment of Rectal Cancer. Semin Radiat Oncol 2011; 21:228-33. [DOI: 10.1016/j.semradonc.2011.02.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
|
39
|
Abstract
AIM to evaluate the treatment response in patients with recurrent colorectal cancer (CRC) using FDG PET/CT. MATERIALS AND METHODS a total of 32 recurrent CRC patients (21 males, 11 females; mean age, 52.8 years) were included in this retrospective study. All patients underwent a baseline and follow-up FDG PET/CT scans after chemotherapy. Of 32 patients, 23 patients had follow-up carcinoembryonic antigen (CEA) levels. RESULTS on qualitative analysis of baseline and follow-up FDG PET/CT studies, there were 20 nonresponders and 12 were responders. On quantitative analysis, there were 19 nonresponders and 13 were responders. In responders, baseline and follow-up mean SUV(max) were 11.8 ± 10.1 and 3.7 ± 4.1, respectively (significant decrease, P = 0.001). Among nonresponders, baseline and follow-up mean SUV(max) were 8.1 ± 5.2 and 14.1 ± 9.0, respectively (significant increase, P = 0.003). There was no association between response and different factors like age, sex, diagnosis, extent of the lesions, and number of lesions. CONCLUSION FDG PET/CT appears to be useful modality in evaluating chemotherapy response and can differentiate responders from nonresponders in recurrent CRC patients.
Collapse
|
40
|
Yasuda K, Sunami E, Kawai K, Nagawa H, Kitayama J. Laboratory Blood Data Have a Significant Impact on Tumor Response and Outcome in Preoperative Chemoradiotherapy for Advanced Rectal Cancer. J Gastrointest Cancer 2011; 43:236-43. [DOI: 10.1007/s12029-011-9268-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
|
41
|
Lambregts DMJ, Vandecaveye V, Barbaro B, Bakers FCH, Lambrecht M, Maas M, Haustermans K, Valentini V, Beets GL, Beets-Tan RGH. Diffusion-weighted MRI for selection of complete responders after chemoradiation for locally advanced rectal cancer: a multicenter study. Ann Surg Oncol 2011; 18:2224-31. [PMID: 21347783 PMCID: PMC3136702 DOI: 10.1245/s10434-011-1607-5] [Citation(s) in RCA: 276] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2010] [Indexed: 11/18/2022]
Abstract
PURPOSE In 10-24% of patients with rectal cancer who are treated with neoadjuvant chemoradiation, no residual tumor is found after surgery (ypT0). When accurately selected, these complete responders might be considered for less invasive treatments instead of standard surgery. So far, no imaging method has proven reliable. This study was designed to assess the accuracy of diffusion-weighted MRI (DWI) in addition to standard rectal MRI for selection of complete responders after chemoradiation. METHODS A total of 120 patients with locally advanced rectal cancer from three university hospitals underwent chemoradiation followed by a restaging MRI (1.5T), consisting of standard T2W-MRI and DWI (b0-1000). Three independent readers first scored the standard MRI only for the likelihood of a complete response using a 5-point confidence score, after which the DWI images were added and the scoring was repeated. Histology (ypT0 vs. ypT1-4) was the standard reference. Diagnostic performance for selection of complete responders and interobserver agreement were compared for the two readings. RESULTS Twenty-five of 120 patients had a complete response (ypT0). Areas under the ROC-curve for the three readers improved from 0.76, 0.68, and 0.58, using only standard MRI, to 0.8, 0.8, and 0.78 after addition of DWI (P = 0.39, 0.02, and 0.002). Sensitivity for selection of complete responders ranged from 0-40% on standard MRI versus 52-64% after addition of DWI. Specificity was equally high (89-98%) for both reading sessions. Interobserver agreement improved from κ 0.2-0.32 on standard MRI to 0.51-0.55 after addition of DWI. CONCLUSIONS Addition of DWI to standard rectal MRI improves the selection of complete responders after chemoradiation.
Collapse
Affiliation(s)
- Doenja M J Lambregts
- Department of Radiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | | | | | | | | | | | | | | | | |
Collapse
|
42
|
Habr-Gama A, Perez R, Proscurshim I, Gama-Rodrigues J. Complete clinical response after neoadjuvant chemoradiation for distal rectal cancer. Surg Oncol Clin N Am 2011; 19:829-45. [PMID: 20883957 DOI: 10.1016/j.soc.2010.08.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Multimodality treatment of rectal cancer, with the combination of radiation therapy, chemotherapy, and surgery has become the preferred approach to locally advanced rectal cancer. The use of neoadjuvant chemoradiation therapy (CRT) has resulted in reduced toxicity rates, significant tumor downsizing and downstaging, better chance of sphincter preservation, and improved functional results. A proportion of patients treated with neoadjuvant CRT may ultimately develop complete clinical response. Management of these patients with complete clinical response remains controversial and approaches including radical resection, transanal local excision, and observation alone without immediate surgery have been proposed. The use of strict selection criteria of patients after neoadjuvant CRT has resulted in excellent long-term results with no oncological compromise after observation alone in patients with complete clinical response. Recurrences are detectable by clinical assessment and frequently amenable to salvage procedures.
Collapse
Affiliation(s)
- Angelita Habr-Gama
- Angelita & Joaquim Gama Institute, and University of Sao Paulo, Av. Dr Enéas de Carvalho Aguiar 255, Sao Paulo, SP, Brazil.
| | | | | | | |
Collapse
|
43
|
Minsky BD. Chemoradiation for rectal cancer: rationale, approaches, and controversies. Surg Oncol Clin N Am 2011; 19:803-18. [PMID: 20883955 DOI: 10.1016/j.soc.2010.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The standard adjuvant treatment of cT3 and/or N+ rectal cancer is preoperative chemoradiation. However, there are many controversies regarding this approach. These controversies include the role of short course radiation, whether postoperative adjuvant chemotherapy is necessary for all patients, and if the type of surgery following chemoradiation should be based on the response rate. More accurate imaging techniques and/or molecular markers may help identify patients with positive pelvic nodes to reduce the chance of overtreatment with preoperative therapy. Will more effective systemic agents both improve the results of radiation, as well as modify the need for pelvic radiation? These questions and others remain active areas of clinical investigation.
Collapse
Affiliation(s)
- Bruce D Minsky
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, 5841 South Maryland Avenue, Chicago, IL 60637, USA.
| |
Collapse
|
44
|
Palma P, Conde-Muíño R, Rodríguez-Fernández A, Segura-Jiménez I, Sánchez-Sánchez R, Martín-Cano J, Gómez-Río M, Ferrón JA, Llamas-Elvira JM. The value of metabolic imaging to predict tumour response after chemoradiation in locally advanced rectal cancer. Radiat Oncol 2010; 5:119. [PMID: 21159200 PMCID: PMC3012041 DOI: 10.1186/1748-717x-5-119] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2010] [Accepted: 12/15/2010] [Indexed: 01/11/2023] Open
Abstract
Background We aim to investigate the possibility of using 18F-positron emission tomography/computer tomography (PET-CT) to predict the histopathologic response in locally advanced rectal cancer (LARC) treated with preoperative chemoradiation (CRT). Methods The study included 50 patients with LARC treated with preoperative CRT. All patients were evaluated by PET-CT before and after CRT, and results were compared to histopathologic response quantified by tumour regression grade (patients with TRG 1-2 being defined as responders and patients with grade 3-5 as non-responders). Furthermore, the predictive value of metabolic imaging for pathologic complete response (ypCR) was investigated. Results Responders and non-responders showed statistically significant differences according to Mandard's criteria for maximum standardized uptake value (SUVmax) before and after CRT with a specificity of 76,6% and a positive predictive value of 66,7%. Furthermore, SUVmax values after CRT were able to differentiate patients with ypCR with a sensitivity of 63% and a specificity of 74,4% (positive predictive value 41,2% and negative predictive value 87,9%); This rather low sensitivity and specificity determined that PET-CT was only able to distinguish 7 cases of ypCR from a total of 11 patients. Conclusions We conclude that 18-F PET-CT performed five to seven weeks after the end of CRT can visualise functional tumour response in LARC. In contrast, metabolic imaging with 18-F PET-CT is not able to predict patients with ypCR accurately.
Collapse
Affiliation(s)
- Pablo Palma
- Division of Colon &Rectal Surgery - Department of Surgery, HUVN Granada, Spain.
| | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Abstract
The standard adjuvant treatment for cT3 and/or N+ rectal cancer is preoperative chemoradiation. However, there are many controversies regarding this approach. These include the role of short course radiation, whether postoperative adjuvant chemotherapy necessary for all patients and whether the type of surgery after chemoradiation should be based on the response rate. More accurate imaging techniques and/or molecular markers may help identify patients with positive pelvic nodes to reduce the chance of overtreatment with preoperative therapy. Will more effective systemic agents both improve the results of radiation as well as modify the need for pelvic radiation? These questions and others remain active areas of clinical investigation.
Collapse
|
46
|
Mak D, Joon DL, Chao M, Wada M, Joon ML, See A, Feigen M, Jenkins P, Mercuri A, McNamara J, Poon A, Khoo V. The use of PET in assessing tumor response after neoadjuvant chemoradiation for rectal cancer. Radiother Oncol 2010; 97:205-11. [PMID: 20598390 DOI: 10.1016/j.radonc.2010.05.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2009] [Revised: 05/24/2010] [Accepted: 05/31/2010] [Indexed: 01/08/2023]
Abstract
PURPOSE To assess the correlation of 18F-FDG-PET (PET) response to pathological response after neoadjuvant chemoradiation (CRT) for locally advanced rectal cancer. METHODS AND MATERIALS Twenty patients with locally advanced rectal cancer were identified between 2001 and 2005. The median age was 57 years (range 37-72) with 14 males and 6 females. All patients were staged with endorectal ultrasound and/or MRI, CT, and PET. The clinical staging was T3N0M0 (16), T3N1M0 (2), and T3N0M1 (2). Restaging PET was performed after CRT, and prior to definitive surgery. The response on PET and pathology was assessed and correlated. Patient outcome according to PET response was also assessed. RESULTS Following CRT, a complete PET response occurred in 7 patients, incomplete response in 10, and no response in 3 patients. At surgery, complete pathological response was recorded in 7 patients, incomplete response in 10 and no response in 3. There was a good correlation of PET and pathological responses in complete responders (5/7 cases) and non-responders (3/3 cases). After a median follow-up of 62 months (range 7-73), twelve patients were alive with no evidence of disease. All patients achieving complete metabolic response were alive with no evidence of disease, while as those who had no metabolic response, all died as a result of metastatic disease. CONCLUSIONS PET is a promising complementary assessment tool for assessing tumor response after CRT if there is a complete or no response. PET response may also predict for outcome.
Collapse
Affiliation(s)
- Daisy Mak
- Radiation Oncology Centre, Austin Health, Heidelberg West, Australia
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
47
|
Hopkins S, Fakih M, Yang GY. Positron emission tomography as predictor of rectal cancer response during or following neoadjuvant chemoradiation. World J Gastrointest Oncol 2010; 2:213-7. [PMID: 21160619 PMCID: PMC2998836 DOI: 10.4251/wjgo.v2.i5.213] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2009] [Revised: 01/27/2010] [Accepted: 02/02/2010] [Indexed: 02/05/2023] Open
Abstract
Positron emission tomography (PET) shows great promise as a tool to evaluate the effectiveness of rectal cancer neoadjuvant therapy as it has demonstrated high predictive value in several studies. Creating a standardized method of using PET has the potential to reduce ineffective treatments. However, relevant studies have been heterogenous in approach, making any unified standard difficult to establish. PET related parameters used to assess treatment response include magnitude and change of standard uptake value, total lesion glycolysis, and visual response. Finding the best evaluation interval and parameters to use for interpreting PET results in the neo-adjuvant treatment of rectal cancer needs additional study.
Collapse
Affiliation(s)
- Shane Hopkins
- Shane Hopkins, Gary Y Yang, Department of Radiation Medicine, Roswell Park Cancer Institute, Buffalo, NY 14263, United States
| | | | | |
Collapse
|
48
|
Higgins KA, Willett CG, Czito BG. Nonoperative Management of Rectal Cancer: Current Perspectives. Clin Colorectal Cancer 2010; 9:83-8. [DOI: 10.3816/ccc.2010.n.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
|
49
|
Imaging for staging and response assessment in rectal cancer. CURRENT COLORECTAL CANCER REPORTS 2009. [DOI: 10.1007/s11888-009-0031-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
50
|
de Geus-Oei LF, Vriens D, van Laarhoven HWM, van der Graaf WTA, Oyen WJG. Monitoring and predicting response to therapy with 18F-FDG PET in colorectal cancer: a systematic review. J Nucl Med 2009; 50 Suppl 1:43S-54S. [PMID: 19403879 DOI: 10.2967/jnumed.108.057224] [Citation(s) in RCA: 178] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Molecular imaging with (18)F-FDG PET has been proven useful in the management of colorectal cancer. (18)F-FDG PET plays a pivotal role in staging before surgical resection of recurrent colorectal cancer and metastases, in the localization of recurrence in patients with an unexplained rise in serum carcinoembryonic antigen levels, and in the assessment of residual masses after treatment. Currently, there is increasing interest in the role of (18)F-FDG PET beyond staging. The technique appears to have significant potential for the characterization of tumors and for the prediction of prognosis in the context of treatment stratification and early assessment of tumor response to therapy. This systematic review provides an overview of the literature on the value of (18)F-FDG PET for monitoring and predicting the response to therapy in colorectal cancer. The review covers chemotherapy response monitoring in advanced colorectal cancer, monitoring of the effects of local ablative therapies, and preoperative radiotherapy and multimodality treatment response evaluation in primary rectal cancer. Given the added value of (18)F-FDG PET for these indications, implementation in clinical practice and systematic inclusion in therapeutic trials to exploit the potential of (18)F-FDG PET are warranted.
Collapse
Affiliation(s)
- Lioe-Fee de Geus-Oei
- Department of Nuclear Medicine, Radboud University, Nijmegen Medical Centre, Nijmegen, The Netherlands.
| | | | | | | | | |
Collapse
|