Patterns and management of distant failure in locally advanced rectal cancer: a cohort study

Risk and location of distant metastases in patients with locally advanced rectal cancer after total neoadjuvant treatment or chemoradiotherapy in the RAPIDO trial

INTRODUCTION

Although optimising rectal cancer treatment has reduced local recurrence rates, many patients develop distant metastases (DM). The current study investigated whether a total neoadjuvant treatment strategy influences the development, location, and timing of metastases in patients diagnosed with high-risk locally advanced rectal cancer included in the Rectal cancer And Pre-operative Induction therapy followed by Dedicated Operation (RAPIDO) trial.

MATERIAL AND METHODS

Patients were randomly assigned to short-course radiotherapy followed by 18 weeks of CAPOX or FOLFOX4 before surgery (EXP), or long-course chemoradiotherapy with optional postoperative chemotherapy (SC-G). Assessments for metastatic disease were performed pre- and post-treatment, during surgery, and 6, 12, 24, 36, and 60 months postoperatively. From randomisation, differences in the occurrence of DM and first site of metastasis were evaluated.

RESULTS

In total, 462 patients were evaluated in the EXP and 450 patients in the SC-G groups. The cumulative probability of DM at 5 years after randomisation was 23% [95% CI 19-27] and 30% [95% CI 26-35] (HR 0.72 [95% CI 0.56-0.93]; P = 0.011) in the EXP and SC-G, respectively. The median time to DM was 1.4 (EXP) and 1.3 years (SC-G). After diagnosis of DM, median survival was 2.6 years [95% CI 2.0-3.1] in the EXP and 3.2 years [95% CI 2.3-4.1] in the SC-G groups (HR 1.39 [95% CI 1.01-1.92]; P = 0.04). First occurrence of DM was most often in the lungs (60/462 [13%] EXP and 55/450 [12%] SC-G) or the liver (40/462 [9%] EXP and 69/450 [15%] SC-G). A hospital policy of postoperative chemotherapy did not influence the development of DM.

CONCLUSIONS

Compared to long-course chemoradiotherapy, total neoadjuvant treatment with short-course radiotherapy and chemotherapy significantly decreased the occurrence of metastases, particularly liver metastases.

Impact of neoadjuvant chemoradiotherapy on the local recurrence and distant metastasis pattern of locally advanced rectal cancer: a propensity score-matched analysis

BACKGROUND

Previous studies have demonstrated different predominant sites of distant metastasis between patients with and without neoadjuvant chemoradiotherapy (NCRT). This study aimed to explore whether NCRT could influence the metastasis pattern of rectal cancer through a propensity score-matched analysis.

METHODS

In total, 1296 patients with NCRT or post-operative chemoradiotherapy (PCRT) were enrolled in this study between January 2008 and December 2015. Propensity score matching was used to correct for differences in baseline characteristics between the two groups. After propensity score matching, the metastasis pattern, including metastasis sites and timing, was compared and analyzed.

RESULTS

After propensity score matching, there were 408 patients in the PCRT group and 245 patients in the NCRT group. NCRT significantly reduced local recurrence (4.1% vs. 10.3%, P = 0.004), but not distant metastases (28.2% vs. 27.9%, P = 0.924) compared with PCRT. In both the NCRT and PCRT groups, the most common metastasis site was the lung, followed by the liver. The NCRT group developed local recurrence and distant metastases later than the PCRT group (median time: 29.2 [18.8, 52.0] months vs. 18.7 [13.3, 30.0] months, Z = -2.342, P = 0.019; and 21.2 [12.2, 33.8] vs. 16.4 [9.3, 27.9] months, Z = -1.765, P = 0.035, respectively). The distant metastases occurred mainly in the 2nd year after surgery in both the PCRT group (39/114, 34.2%) and NCRT group (21/69, 30.4%). However, 20.3% (14/69) of the distant metastases appeared in the 3rd year in the NCRT group, while this number was only 13.2% (15/114) in the PCRT group.

CONCLUSIONS

The predominant site of distant metastases was the lung, followed by the liver, for both the NCRT group and PCRT group. NCRT did not influence the predominant site of distant metastases, but the NCRT group developed local recurrence and distant metastases later than the PCRT group. The follow-up strategy for patients with NCRT should be adjusted and a longer intensive follow-up is needed.

Metastatic pattern and new primary tumours after neoadjuvant therapy and surgery in rectal cancer

AIM

Current follow-up guidelines for distant tumour recurrence after rectal cancer surgery are not defined or agreed. The aim was to elucidate the pattern of recurrence over time and provide information that could help direct a strategy for surveillance.

METHOD

In all, 378 patients with locally advanced rectal cancer were treated with preoperative chemoradiotherapy and surgery with curative intent. Patients were followed up with a standard protocol, and data were prospectively collected in a dedicated database. Disease-free survival and overall survival were calculated.

RESULTS

Within a median follow-up time of 75 months, rates of local and distant recurrence were 2.6% and 21.7%, respectively. Risk factors for recurrence were a baseline carcinoembryonic antigen > 5.0 ng/ml, a distance from the anal verge ≤ 5 cm, R1 resection margins, G3 grading, ypT staging > 2, positive lymph node status and a tumour regression grade of 3-5. Disease-free survival did not vary significantly between patients with lung and extra-pulmonary metastases (P = 0.59). The only factor associated with increased risk of lung metastases was a distance of the tumour from the anal verge of ≤ 5 cm (P = 0.01). Most recurrences occurred within the first 3 years after surgery (74.4%). The first site of recurrence was most frequently the lung (52.0%). The most frequent new primary malignancy was lung cancer (22.5%).

CONCLUSIONS

Patients undergoing curative therapy for rectal cancer often experience distant recurrence; the majority of recurrences occur within the first 3 years after surgery and lung metastases are the most common. A predictive factor for pulmonary recurrence is a tumour in the lower rectum.

Nomogram Predicting Survival After Recurrence in Patients With Stage I to III Colon Cancer: A Nationwide Multicenter Study

BACKGROUND

Although a number of studies have been conducted to investigate factors affecting colon cancer recurrence and patient overall survival after surgical treatment, no prognostic risk models have been proposed for predicting survival specifically after postsurgical recurrence.

OBJECTIVE

We aimed to identify factors affecting the survival of the patients with recurrent colon cancer and to construct a nomogram for predicting their survival.

DESIGN

This was a retrospective study.

SETTINGS

This study used the Japanese Study Group for Postoperative Follow-Up of Colorectal Cancer database, which contains retrospectively collected data of all consecutive patients with stage I to III colorectal cancer who underwent surgical curative resection between 1997 and 2008 at 23 referral institutions.

PATIENTS

A total of 2563 patients with stage I to III colon cancer who experienced recurrence after surgery were included in the present study.

MAIN OUTCOME MEASURES

A nomogram predicting survival was constructed using a training cohort composed of patients from 15 hospitals (n = 1721) using a Cox regression hazard model analysis. The clinical applicability of this nomogram was validated in patients from the 8 remaining hospitals (the validation cohort; n = 842).

RESULTS

Eight factors (age, location of the primary tumor, histopathological type, positive lymph node status, presence of peritoneal metastasis, number of organs involved in the first recurrence, treatment for recurrence, and the interval between initial surgery and recurrence) were identified as nomogram variables. Our nomogram showed good calibration, with concordance indexes of 0.744 in the training cohort and 0.730 in the validation cohort. The survival curves stratified by the risk score calculated by the nomogram were almost identical for the training and validation cohorts.

LIMITATIONS

The study was conducted using the data until 2008, and more advanced chemotherapeutic agents and multidisciplinary therapies that might have improved the outcomes predicted by our nomogram were not available. In addition, treatment strategies for recurrence might differ between countries.

CONCLUSIONS

Our nomogram, which is based on a nationwide multicenter study, is the first statistical model predicting survival after recurrence in patients with stage I to III colon cancer. It promises to be of use in postoperative colon cancer surveillance. See Video Abstract at http://links.lww.com/DCR/A687.

Are We Predicting Disease Progress of the Rectal Cancer Patients without Surgery after Neoadjuvant Chemoradiotherapy?

Purpose

There are patients who do not undergo surgery, regardless of tumor response for neoadjuvant chemoradiotherapy (nCRT) in rectal cancer. However, there have been few reports focused on how oncologic outcomes are worse in these patients. We sought to investigate oncologic outcomes for these non-operated patients with rectal cancer after nCRT.

Materials and Methods

A total of 1,063 records of patients with rectal cancer who were treated with nCRT from January 2002 to December 2013 were retrospectively reviewed. We categorized patients into the non-operated group (n=77), transanal local excision (TLE) group (n=54), ortotal mesorectal excision (TME) group (n=932) and compared each group using propensity score matching.

Results

In the non-operated group, the most common reason for no surgery was patient refusal (n=64). Eleven patients were considered to have achieve clinical complete response (cCR), which was an independent prognostic factor of progression-free survival (p=0.045). In patients with disease progression in the non-operated group, the overall survival did not improved according to salvage treatments (p=0.451). The non-operated group showed worse survivals compared to the TLE or TME group before and after matching (p < 0.001). This finding was also noted in the analysis of survival only in patients with cCR.

Conclusion

In this study, non-operated patients did not secure oncologic safety regardless of cCR after nCRT. Our results suggest that a non-operative management must be carefully considered even if cCR is achieved.

Impact of Recurrence and Salvage Surgery on Survival After Multidisciplinary Treatment of Rectal Cancer

Purpose After preoperative chemoradiotherapy followed by total mesorectal excision for locally advanced rectal cancer, patients who experience local or systemic relapse of disease may be eligible for curative salvage surgery, but the benefit of this surgery has not been fully investigated. The purpose of this study was to characterize recurrence patterns and investigate the impact of salvage surgery on survival in patients with rectal cancer after receiving multidisciplinary treatment. Patients and Methods Patients with locally advanced (cT3-4 or cN+) rectal cancer who were treated with preoperative chemoradiotherapy followed by total mesorectal excision at our institution during 1993 to 2008 were identified. We examined patterns of recurrence location, time to recurrence, treatment factors, and survival. Results A total of 735 patients were included. Tumors were mostly midrectal to lower rectal cancer, with a median distance from the anal verge of 5.0 cm. The most common recurrence site was the lung followed by the liver. Median time to recurrence was shorter in liver-only recurrence (11.2 months) than in lung-only recurrence (18.2 months) or locoregional-only recurrence (24.7 months; P = .001). Salvage surgery was performed in 57% of patients with single-site recurrence and was associated with longer survival after recurrence in patients with lung-only and liver-only recurrence ( P < .001) but not in those with locoregional-only recurrence ( P = .353). Conclusion We found a predilection for lung recurrence in patients with rectal cancer after multidisciplinary treatment. Salvage surgery was associated with prolonged survival in patients with lung-only and liver-only recurrence, but not in those with locoregional recurrence, which demonstrates a need for careful consideration of the indications for resection.