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Aslanov K, Atici AE, Karaman D, Bozkurtlar E, Yegen ŞC. Optimal waiting period to surgical treatment after neoadjuvant chemoradiotherapy for locally advanced rectum cancer: a retrospective observational study. Langenbecks Arch Surg 2023; 408:210. [PMID: 37227524 DOI: 10.1007/s00423-023-02930-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 05/04/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND The optimal waiting period after neoadjuvant treatment in patients with locally advanced rectal cancers is still controversial. The literature has different results regarding the effect of waiting periods on clinical and oncological outcomes. We aimed to investigate the effects of these different waiting periods on clinical, pathological, and oncological outcomes. METHODS Between January 2014 and December 2018, a total of 139 consecutive patients with locally advanced rectal adenocarcinoma, who were treated in the Department of General Surgery at the Marmara University Pendik Training and Research Hospital, were enrolled in the study. The patients were split into three groups according to waiting time for surgery after neoadjuvant treatment: group 1 (n = 51) included patients that have 7 weeks and less (≤ 7 weeks) time interval, group 2 (n = 45) 8 to 10 weeks (8-10 weeks), group 3 (n = 43) 11 weeks and above (11 weeks ≤). Their database records, which were entered prospectively, were analyzed retrospectively. RESULTS There were 83 (59.7%) males and 56 (40.3%) females. The median age was 60 years, and there was no statistical difference between the groups regarding age, gender, BMI, ASA score, ECOG performance score, tumor location, and preoperative CEA values. Also, we found no significant differences regarding operation times, intraoperative bleeding, length of hospital stay, and postoperative complications. According to the Clavien-Dindo (CD) classification, severe early postoperative complications (CD 3 and above) were observed in 9 patients. The complete pathological response (pCR, ypT0N0) was observed in 21 (15.1%) patients. The groups had no significant difference regarding 3-year disease-free and 3-year overall survival (p = 0.3, p = 0.8, respectively). Local recurrence was observed in 12 of 139 (8.6%) patients and distant metastases occurred in 30 of 139 (21.5%) patients during the follow-up period. There was no significant difference between the groups in terms of both local recurrence and distant metastasis (p = 0.98, p = 0.43, respectively). CONCLUSION The optimal time for postoperative complications and sphincter-preserving surgery in patients with locally advanced rectal cancer is 8-10 weeks. The different waiting periods do not affect disease-free and overall survival. While long-term waiting time does not make a difference in pathological complete response rates, it negatively affects the TME quality rate.
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Affiliation(s)
- Khayal Aslanov
- Department of General Surgery, Pendik Education and Research Hospital, Faculty of Medicine, Marmara University, 34899, Pendik, Istanbul, Turkey
| | - Ali Emre Atici
- Department of General Surgery, Pendik Education and Research Hospital, Faculty of Medicine, Marmara University, 34899, Pendik, Istanbul, Turkey.
| | - Damlanur Karaman
- Department of Pathology, Pendik Education and Research Hospital, Faculty of Medicine, Marmara University, 34899, Pendik, Istanbul, Turkey
| | - Emine Bozkurtlar
- Department of Pathology, Pendik Education and Research Hospital, Faculty of Medicine, Marmara University, 34899, Pendik, Istanbul, Turkey
| | - Şevket Cumhur Yegen
- Department of General Surgery, Pendik Education and Research Hospital, Faculty of Medicine, Marmara University, 34899, Pendik, Istanbul, Turkey
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Meyer VM, Meuzelaar RR, Schoenaker IJH, de Groot JWB, Reerink O, de Vos Tot Nederveen Cappel WH, Beets GL, van Westreenen HL. Delayed TME Surgery in a Watch-and-Wait Strategy After Neoadjuvant Chemoradiotherapy for Rectal Cancer: An Analysis of Hospital Costs and Surgical and Oncological Outcomes. Dis Colon Rectum 2023; 66:671-680. [PMID: 34856587 DOI: 10.1097/dcr.0000000000002259] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND A watch-and-wait strategy for patients with rectal cancer with a clinical complete response after neoadjuvant chemoradiotherapy is a valuable alternative for rectal resection. However, there are patients who will have residual tumor or regrowth during watch and wait. OBJECTIVE The aim of this study was to investigate safety and costs for patients who underwent delayed surgery after neoadjuvant chemoradiotherapy. DESIGN This is a retrospective cohort study with prospectively collected data. SETTINGS The study was conducted at a large teaching hospital. PATIENTS Between January 2015 and May 2020, 622 new rectal cancer patients were seen, of whom 200 received neoadjuvant chemoradiotherapy. Ninety-four patients were included, 65 of whom underwent immediate surgery and 29 of whom required delayed surgery after an initial watch-and-wait approach. MAIN OUTCOME MEASURES Outcome measures included 30-day postoperative morbidity rate, hospital costs. 2-year overall and disease-free survival. RESULTS There was no difference in length of stay (9 vs 8; p = 0.83), readmissions (27.6% vs 10.0%; p = 0.10), surgical re-interventions (15.0% vs 3.4%; p = 0.16), or stoma-free rate (52.6% vs 31.0%; p = 0.09) between immediate and delayed surgery groups. Hospital costs were similar in the delayed group (€11,913 vs €13,769; p = 0.89). Two-year overall survival (93% vs 100%; p = 0.23) and disease-free survival (78% vs 81%; p = 0.47) rates were comparable. LIMITATIONS Limitations included small sample size, follow-up time and retrospective design. CONCLUSION Delayed surgery for regrowth in a watch-and-wait program or for persistent residual disease after a repeated assessment is not associated with an increased risk of postoperative morbidity or a significant rise in costs compared to immediate total mesorectal excision. There also appears to be no evident compromise in oncological outcome. Repeated response assessment in patients with a near complete clinical response after neoadjuvant chemoradiotherapy is a useful approach to identify more patients who can benefit from a watch-and-wait strategy. See Video Abstract at http://links.lww.com/DCR/B836 . CIRUGA DE TME RETRASADA EN UNA ESTRATEGIA DE WATCH AND WAIT DESPUS DE LA QUIMIORRADIOTERAPIA NEOADYUVANTE PARA CNCER DE RECTO UN ANLISIS DE COSTOS HOSPITALARIOS, Y DE RESULTADOS QUIRRGICOS Y ONCOLGICOS ANTECEDENTES: Una estrategia de Watch and Wait para pacientes con cáncer de recto con una respuesta clínica completa después de quimiorradioterapia neoadyuvante es una alternativa valiosa en vez de resección rectal. Sin embargo, hay pacientes que tendrán tumor residual o un recrecimiento durante el Watch and Wait .OBJETIVO: El objetivo fue investigar la seguridad y los costos para los pacientes que se sometieron a una cirugía diferida después de la quimiorradioterapia neoadyuvante.DISEÑO: Este es un estudio de cohorte retrospectivo con datos recolectados prospectivamente.AJUSTE: El estudio se llevó a cabo en un gran hospital universitario.PACIENTES: Entre enero de 2015 y mayo de 2020, se atendieron 622 nuevos pacientes con cáncer de recto, de los cuales 200 recibieron quimiorradioterapia neoadyuvante. Se incluyeron 94 pacientes, de los cuales 65 se sometieron a cirugía inmediata y 29 pacientes requirieron cirugía diferida después de un enfoque inicial de observación y espera.PRINCIPALES MEDIDAS DE RESULTADO: se incluyeron la tasa de morbilidad posoperatoria a 30 días, los costos hospitalarios y las sobrevidas general y libre de enfermedad a dos años.RESULTADOS: No hubo diferencia en la duración de la estancia (9 vs 8, p = 0,83), reingresos (27,6% vs 10,0%, p = 0,10), reintervenciones quirúrgicas (15,0% vs 3,4%, p = 0,16) y tasa libre de estoma (52,6% vs 31,0%, p = 0,09) entre los grupos de cirugía inmediata y tardía. Los costos hospitalarios fueron similares en el grupo retrasado (11913 € frente a 13769 €, p = 0,89). Las tasas de sobrevida general a dos años (93% frente a 100%, p = 0,23) y sobrevida libre de enfermedad (78% frente a 81%, p = 0,47) fueron comparables.LIMITACIONES: Tamaño de muestra pequeño, tiempo de seguimiento y diseño retrospectivo.CONCLUSIÓN: La cirugía tardía para el recrecimiento en un programa de Watch and Wait o para la enfermedad residual persistente después de una evaluación repetida no se asocia con un riesgo mayor de morbilidad posoperatoria ni con un aumento significativo en los costos, en comparación con la escisión total de mesorrecto inmediata. Tampoco parece haber un compromiso evidente en el resultado oncológico. La evaluación repetida de la respuesta en pacientes con una respuesta clínica casi completa después de la quimiorradioterapia neoadyuvante es un enfoque útil para identificar más pacientes que pueden beneficiarse de una estrategia de Watch and Wait . Consulte Video Resumen en http://links.lww.com/DCR/B836 . (Traducción-Dr. Juan Carlos Reyes ).
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Affiliation(s)
- Vincent M Meyer
- Department of Surgery, Isala Hospitals, Zwolle, The Netherlands
| | - Richtje R Meuzelaar
- Department of Surgery, Isala Hospitals, Zwolle, The Netherlands
- Department of Oncology, Isala Hospitals, Zwolle, The Netherlands
- Department of Radiotherapy, Isala Hospitals, Zwolle, The Netherlands
- Department of Gastroenterology, Isala Hospitals, Zwolle, The Netherlands
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, The Netherlands
- GROW School for Oncology and Developmental Biology, Maastricht University, The Netherlands
| | | | | | - Onne Reerink
- Department of Radiotherapy, Isala Hospitals, Zwolle, The Netherlands
| | | | - Geerard L Beets
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, The Netherlands
- GROW School for Oncology and Developmental Biology, Maastricht University, The Netherlands
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Khamzina S, Lee J, Ryoo SB, Kim MJ, Park JW, Kang HC, Chie EK, Lee DW, Han SW, Kim TY, Jeong SY, Park KJ. Standard versus longer interval of radical resection after neoadjuvant chemoradiotherapy in locally advanced rectal cancer: A 20-year single-center experience & propensity-score matching. J Surg Oncol 2022; 127:119-131. [PMID: 36169163 DOI: 10.1002/jso.27105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/22/2022] [Accepted: 09/15/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVES Despite the standard interval of 6-8 weeks between neoadjuvant chemoradiotherapy (nCRT) and surgery, it is debated whether an interval of >8 weeks increases the pathologic complete response (pCR) rate. We investigated the interval between nCRT and surgery, and its impact on oncological outcomes and postoperative complications in patients with locally advanced rectal cancer. METHODS We retrospectively reviewed patients with rectal cancer who underwent total mesorectal excision after long-course nCRT between 2000 and 2020. They were divided into two groups-those who underwent surgery at 6-8 and >8 weeks after nCRT. Surgical outcomes (stoma rate and postoperative complications), pCR, tumor regression grade (TRG), recurrence-free survival (RFS), and overall survival (OS) were compared. RESULTS We selected 770/1153 patients with rectal cancer, including 502 and 268 patients surgically treated at 6-8 and >8 weeks after nCRT, respectively. The pCR rates were similar between the two groups (14.7% vs. 15.3%, p = 0.836), while the TRG was significantly better in the >8 weeks group (p = 0.267). Additionally, the postoperative complications, recurrence, 5-year RFS, and OS rates were not significantly different between the two groups. CONCLUSIONS Although tumor regression increased in the >8 weeks group, the oncological benefits of surgery >8 weeks after nCRT remain uncertain.
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Affiliation(s)
- Saule Khamzina
- Department of Colorectal Surgery, Multidisciplinary City Hospital N1, Nur-Sultan, Kazakhstan.,Department of Surgery, National Research Oncology Center, Nur-Sultan, Kazakhstan
| | - Jongoh Lee
- Division of Colorectal Surgery, Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seung-Bum Ryoo
- Division of Colorectal Surgery, Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.,Colorectal Cancer Center, Seoul National University Cancer Hospital, Seoul, Korea.,Cancer Research Institute, Seoul National University, Seoul, Korea
| | - Min Jung Kim
- Division of Colorectal Surgery, Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.,Colorectal Cancer Center, Seoul National University Cancer Hospital, Seoul, Korea.,Cancer Research Institute, Seoul National University, Seoul, Korea
| | - Ji Won Park
- Division of Colorectal Surgery, Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.,Colorectal Cancer Center, Seoul National University Cancer Hospital, Seoul, Korea.,Cancer Research Institute, Seoul National University, Seoul, Korea
| | - Hyun-Cheol Kang
- Department of Radiation Oncology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Eui Kyu Chie
- Department of Radiation Oncology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Dae-Won Lee
- Division of Hematooncology, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sae-Won Han
- Division of Hematooncology, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Tae-You Kim
- Division of Hematooncology, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seung-Yong Jeong
- Division of Colorectal Surgery, Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.,Colorectal Cancer Center, Seoul National University Cancer Hospital, Seoul, Korea.,Cancer Research Institute, Seoul National University, Seoul, Korea
| | - Kyu Joo Park
- Division of Colorectal Surgery, Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.,Colorectal Cancer Center, Seoul National University Cancer Hospital, Seoul, Korea
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4
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Does a long interval between neoadjuvant chemoradiotherapy and surgery benefit the clinical outcomes of locally advanced rectal cancer? A systematic review and meta analyses. Int J Colorectal Dis 2022; 37:855-868. [PMID: 35279746 DOI: 10.1007/s00384-022-04122-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/02/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE The study aims to systematically evaluate the clinical efficacy after 8 weeks (long interval, LI) between neoadjuvant chemoradiotherapy and surgery for locally advanced rectal cancer. METHODS The PubMed database, EMBASE database, and the Cochrane Library (deadline: September 25, 2021) were searched to select clinical studies that compared two intervals between neoadjuvant chemoradiotherapy and surgery for locally advanced rectal cancer: after 8 weeks (long interval, LI) and within 8 weeks (short interval, SI). The included studies were screened and evaluated according to the inclusion and exclusion criteria, and meta-analysis was performed by RevMan 5.3 software. RESULTS Eighteen studies were included, with 9070 cases in the LI group and 14,207 cases in the SI group. The analysis results showed that the pathologic complete response (PCR) rate in the LI group was higher than that in the SI group (P < 0.00001). There was no significant difference in the R0 resection rate (P = 0.85), anal preservation rate (P = 0.89), morbidity rate (P = 0.60), anastomotic leakage rate (P = 0.06), operation time (P = 0.58), local recurrence rate (P = 0.56), distant metastasis rate (P = 0.32), or overall survival (OS) rate (P = 0.17) between the two groups. CONCLUSION A longer interval between neoadjuvant chemoradiotherapy and surgery can improve the PCR rate; however, it has no significant impact on the clinical efficacy or long-term prognosis. Due to some limitations in the number and quality of the studies, these findings still need to be further verified by multicenter, large-sample high-quality RCTs in the future.
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Qwaider YZ, Sell NM, Stafford CE, Kunitake H, Ricciardi R, Bordeianou LG, Goldstone RN, Cauley CE, Berger DL. The time Interval Between the End of Radiotherapy and Surgery Does Not Affect Outcomes in Rectal Cancer. Am Surg 2021:31348211047215. [PMID: 34633256 DOI: 10.1177/00031348211047215] [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: 11/17/2022]
Abstract
INTRODUCTION The ideal time interval between the completion of chemoradiotherapy and subsequent surgical resection of advanced stage rectal tumors is highly debated. Our aim is to study the effect of the time interval between the completion of chemoradiotherapy and surgical resection on postoperative and oncologic outcomes in rectal cancer. METHODS Patients who underwent neoadjuvant chemoradiotherapy for resected locally advanced rectal tumors between 2004 and 2015 were included in this analysis. The time interval was calculated from the date of radiation completion to date of surgery. Patients were split into 2 groups based on the time interval (<8 weeks and >8 weeks). Postoperative outcomes (anastomotic leak, pathologic complete response (pCR), and readmission) and survival were assessed with multivariable logistic regression and Cox regression models while adjusting for relevant confounders. RESULTS 200 patients (62% male) underwent resection with a median time interval of 8 weeks from completion of radiotherapy. On multivariable logistic regression, there was no significant increase in odds between time interval to surgery and anastomotic leak (aOR = .8 [.27-2.7], P = .8), pCR (aOR = 1.2[.58-2.6] P = .6), or readmission (aOR = 1.02, 95% CI:0.49-2.24, P = .9). Time interval to surgery was not an independent prognostic factor for overall (HR = 1.04 CI = .4-2.65, P = .9) and disease-free survival (HR = 1.2 CI = .5-2.9, P = .6). CONCLUSION The time interval between neoadjuvant radiotherapy completion and surgical resection does not affect anastomotic leak rate, achievement of pCR, or overall and disease-free survival in patients with rectal cancer. Extended periods of time to surgical resection are relatively safe.
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Affiliation(s)
- Yasmeen Z Qwaider
- Department of General and Gastrointestinal Surgery, 2348Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Naomi M Sell
- Department of General and Gastrointestinal Surgery, 2348Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Caitlin E Stafford
- Department of General and Gastrointestinal Surgery, 2348Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Hiroko Kunitake
- Department of General and Gastrointestinal Surgery, 2348Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Rocco Ricciardi
- Department of General and Gastrointestinal Surgery, 2348Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Liliana G Bordeianou
- Department of General and Gastrointestinal Surgery, 2348Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Robert N Goldstone
- Department of General and Gastrointestinal Surgery, 2348Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Christy E Cauley
- Department of General and Gastrointestinal Surgery, 2348Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - David L Berger
- Department of General and Gastrointestinal Surgery, 2348Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
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Koo K, Ward R, Smith RL, Ruben J, Carne PWG, Elsaleh H. Temporal determinants of tumour response to neoadjuvant rectal radiotherapy. PLoS One 2021; 16:e0254018. [PMID: 34191861 PMCID: PMC8244879 DOI: 10.1371/journal.pone.0254018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 06/17/2021] [Indexed: 02/01/2023] Open
Abstract
Introduction In locally advanced rectal cancer, longer delay to surgery after neoadjuvant radiotherapy increases the likelihood of histopathological tumour response. Chronomodulated radiotherapy in rectal cancer has recently been reported as a factor increasing tumour response to neoadjuvant treatment in patients having earlier surgery, with patients receiving a larger proportion of afternoon treatments showing improved response. This paper aims to replicate this work by exploring the impact of these two temporal factors, independently and in combination, on histopathological tumour response in rectal cancer patients. Methods A retrospective review of all patients with rectal adenocarcinoma who received long course (≥24 fractions) neoadjuvant radiotherapy with or without chemotherapy at a tertiary referral centre was conducted. Delay to surgery and radiotherapy treatment time were correlated to clinicopathologic characteristics with a particular focus on tumour regression grade. A review of the literature and meta-analysis were also conducted to ascertain the impact of time to surgery from preoperative radiotherapy on tumour regression. Results From a cohort of 367 patients, 197 patients met the inclusion criteria. Complete pathologic response (AJCC regression grade 0) was seen in 46 (23%) patients with a further 44 patients (22%) having at most small groups of residual cells (AJCC regression grade 1). Median time to surgery was 63 days, and no statistically significant difference was seen in tumour regression between patients having early or late surgery. There was a non-significant trend towards a larger proportion of morning treatments in patients with grade 0 or 1 regression (p = 0.077). There was no difference in tumour regression when composite groups of the two temporal variables were analysed. Visualisation of data from 39 reviewed papers (describing 27379 patients) demonstrated a plateau of response to neoadjuvant radiotherapy after approximately 60 days, and a meta-analysis found improved complete pathologic response in patients having later surgery. Conclusions There was no observed benefit of chronomodulated radiotherapy in our cohort of rectal cancer patients. Review of the literature and meta-analysis confirms the benefit of delayed surgery, with a plateau in complete response rates at approximately 60-days between completion of radiotherapy and surgery. In our cohort, time to surgery for the majority of our patients lay along this plateau and this may be a more dominant factor in determining response to neoadjuvant therapy, obscuring any effects of chronomodulation on tumour response. We would recommend surgery be performed between 8 and 11 weeks after completion of neoadjuvant radiotherapy in patients with locally advanced rectal cancer.
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Affiliation(s)
- Kendrick Koo
- Radiation Oncology, Alfred Health, Melbourne, Victoria, Australia
| | - Rachel Ward
- Radiation Oncology, Alfred Health, Melbourne, Victoria, Australia
| | - Ryan L. Smith
- Radiation Oncology, Alfred Health, Melbourne, Victoria, Australia
| | - Jeremy Ruben
- Radiation Oncology, Alfred Health, Melbourne, Victoria, Australia
| | - Peter W. G. Carne
- Colorectal Surgery Unit, Alfred Health, Melbourne, Victoria, Australia
- Cabrini Monash University Department of Surgery, Melbourne, Victoria, Australia
| | - Hany Elsaleh
- Radiation Oncology, Alfred Health, Melbourne, Victoria, Australia
- * E-mail:
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Ocaña Jiménez J, Priego P, Cuadrado M, Blázquez LA, Sánchez Picot S, Pastor Peinado P, Longo F, López F, Caminoa-Lizarralde MA, Galindo J. Impact of interval timing to surgery on tumor response after neoadjuvant treatment for gastric cancer. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2021; 112:598-604. [PMID: 32496120 DOI: 10.17235/reed.2020.6763/2019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION neoadjuvant chemotherapy (NACT) followed by radical surgery is the optimal approach for locally advanced gastric cancer (GC). Interval timing to surgery after NACT in GC is controversial. The aim of this study was to evaluate the impact of NACT interval time on tumor response and overall survival. MATERIAL AND METHODS a retrospective analysis from a prospective database was performed at a single referral tertiary hospital, from January 2010 to October 2018. Patients were assigned to three groups according to the surgical interval time after NACT: < 4 weeks, 4-6 weeks and > 6 weeks. Univariate and multivariable analyses were performed in order to clarify the impact of NACT on post-neoadjuvant pathological complete response rate (ypCR), downstaging (DS) and overall survival (OS). RESULTS of the 60 patients analyzed, 18 patients (30 %) had an interval time to surgery < 4 weeks, 26 (43.3 %) between 4-6 weeks and 16 (26.7 %) > 6 weeks. Two patients (3 %) had achieved ypCR and 37 patients (62 %) had achieved DS. There were no differences in DS rates among the interval time groups (p: 0.66). According to the multivariate analysis, only poorly differentiated carcinoma was significantly related to lower DS rates (p: 0.04). Cox regression analysis showed that the NACT interval time had no impact on OS. According to the multivariate analysis, > 25 lymph node harvested (HR: 0.35) and female sex (HR: 5.67) were OS independent predictors. CONCLUSIONS the NACT interval time prior gastrectomy for locally advanced GC is not associated with ypCR or DS and has no impact on overall survival.
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Affiliation(s)
- Juan Ocaña Jiménez
- Cirugía General y Digestivo, Hospital Universitario Ramón y Cajal, España
| | - Pablo Priego
- Cirugía General y del Aparato Digestivo, Hospital Universitario Ramón y Cajal
| | - Marta Cuadrado
- Cirugía General y del Aparato Digestivo, Hospital Universitario Ramón y Cajal
| | | | | | - Paula Pastor Peinado
- Cirugía General y del Aparato Digestivo, Hospital Universitario Ramón y Cajal, España
| | | | - Fernando López
- Oncología Radioterápica, Hospital Universitario Ramón y Cajal
| | | | - Julio Galindo
- Cirugía General y del Aparato Digestivo, Hospital Universitario Ramón y Cajal
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Planellas Giné P, Cornejo Fernández L, Salvador Rosés H, Buxó Pujolras M, Farrés Coll R, Hernandez Yague X, Canals Subirats E, Gil Garcia J, Rodríguez Hermosa JI, Codina Cazador A. Delaying surgery by more than 10 weeks after long-course neoadjuvant radiotherapy in locally advanced rectal cancer patients improves pathologic complete response. Updates Surg 2020; 72:453-461. [PMID: 32232742 DOI: 10.1007/s13304-020-00747-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 03/17/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND We currently do not know the optimal time interval between the end of chemoradiotherapy and surgery. Longer intervals have been associated with a higher pathological response rate, worse pathological outcomes and more morbidity. The aim of this study was to evaluate the effect and safety of the current trend of increasing time interval between the end of chemoradiotherapy and surgery (< 10 weeks vs. ≥ 10 weeks) on postoperative morbidity and pathological outcomes. This study analyzed 232 consecutive patients with locally advanced rectal cancer treated with long-course neoadjuvant chemoradiotherapy from January 2012 to August 2018. 125 patients underwent surgery before 10 weeks from the end of chemoradiotherapy (Group 1) and 107 patients underwent surgery after 10 or more weeks after the end of chemoradiotherapy (Group 2). Results have shown that wait for ≥ 10 weeks did not compromise surgical safety. Pathological complete response and tumor stage was statistically significant among groups. The effect of wait for ≥ 10 weeks before surgery shown higher tumor regression than the first group (Group 1, 12.8% vs Group 2, 31.8%; p < 0.001). On multivariate analysis, wait for ≥ 10 weeks was associated with pathological compete response. Patients from the second group were four time more likely to achieve pathologic complete response than patients from the first group (OR, 4.27 95%CI 1.60-11.40; p = 0.004). Patients who undergo surgery after ≥ 10 weeks of the end of chemoradiotherapy are four time more likely to achieve complete tumor remission without compromise surgical safety or postoperative morbidity.
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Affiliation(s)
- Pere Planellas Giné
- Section of Colorectal Surgery, Department of General and Digestive Surgery, University Hospital of Girona, France Avenue s/n, 17007, Girona, Spain.
- Girona Biomedical Research Foundation (IdIBGI), Girona, Spain.
| | | | - Helena Salvador Rosés
- Section of Colorectal Surgery, Department of General and Digestive Surgery, University Hospital of Girona, France Avenue s/n, 17007, Girona, Spain
| | | | - Ramon Farrés Coll
- Section of Colorectal Surgery, Department of General and Digestive Surgery, University Hospital of Girona, France Avenue s/n, 17007, Girona, Spain
- Girona Biomedical Research Foundation (IdIBGI), Girona, Spain
| | - Xavier Hernandez Yague
- Section of Oncology, Institut Catala de Oncologia, "Doctor Josep Trueta", University Hospital, Girona, Spain
| | - Eugeni Canals Subirats
- Section of Radiotherapy, Institut Catala de Oncologia, "Doctor Josep Trueta", University Hospital, Girona, Spain
| | - Júlia Gil Garcia
- Section of Colorectal Surgery, Department of General and Digestive Surgery, University Hospital of Girona, France Avenue s/n, 17007, Girona, Spain
- Girona Biomedical Research Foundation (IdIBGI), Girona, Spain
| | - Jose Ignacio Rodríguez Hermosa
- Section of Colorectal Surgery, Department of General and Digestive Surgery, University Hospital of Girona, France Avenue s/n, 17007, Girona, Spain
- Girona Biomedical Research Foundation (IdIBGI), Girona, Spain
| | - Antoni Codina Cazador
- Section of Colorectal Surgery, Department of General and Digestive Surgery, University Hospital of Girona, France Avenue s/n, 17007, Girona, Spain
- Girona Biomedical Research Foundation (IdIBGI), Girona, Spain
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9
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Yang J, Chen Q, Li J, Song Z, Cheng Y. Short-Term Clinical and Oncological Outcome of Prolonging Operation Interval After Neoadjuvant Chemoradiotherapy for Locally Advanced Middle and Low Rectal Cancer. Cancer Manag Res 2020; 12:2315-2325. [PMID: 32273768 PMCID: PMC7108698 DOI: 10.2147/cmar.s245794] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 03/09/2020] [Indexed: 01/29/2023] Open
Abstract
Purpose The purpose of this study is to evaluate the short-term clinical and oncological outcome of prolonging operation interval to 11 weeks after the end of radiotherapy for locally advanced middle and low rectal cancer. Methods A total of 123 patients with stage II/III (cT3/T4 or N+) low and middle rectal cancer who had undergone operation after neoadjuvant chemoradiotherapy were selected. According to the interval time between the last radiotherapy and operation, they were assigned to a short-interval group (SG, <11 weeks, n=66) and long-interval group (LG, ≥11 weeks, n=57). The relations among interval time and short-term clinical outcome and oncological outcome were analyzed. Results The analysis found that basic information, clinical characteristics, and preoperative treatment between the two groups had no significant difference. There were no differences in operation time, estimated intraoperative blood loss and postoperative complications. The rate of sphincter preservation in the low and middle rectum was 66.7% in the short-interval group and 59.7% in the long-interval group (P=0.42). The incidence of anastomotic leak in the long-interval group was higher than that in the short-interval group (P=0.08). There was no significant difference in the recovery time of intestinal function and median duration of hospitalization between the two groups. The pathological complete remission rate was 17.07%. Multivariate analysis showed interval time had no influence on pathological complete remission. There was no significant difference in 3-year overall survival and 3-year disease-free survival between the two groups. The risk of recurrence and metastasis in patients with positive lymph nodes was higher than those with negative lymph nodes (P<0.05), HR=4.812 (95% CI 2.4–9.648). Conclusion Prolonging the interval time of operation to 11 weeks after neoadjuvant chemoradiotherapy for middle and low rectal cancer does not improve the pathologic complete remission, morbidity, and mortality. There was no significant effect on oncologic outcome after prolonging the operation interval. Therefore, it is safe to prolong the interval of operation to 11 weeks.
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Affiliation(s)
- Jianguo Yang
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Qingwei Chen
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Jindou Li
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Zhiyang Song
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Yong Cheng
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
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10
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Jin F, Luo H, Zhou J, Wu Y, Sun H, Liu H, Zheng X, Wang Y. Dose-time fractionation schedules of preoperative radiotherapy and timing to surgery for rectal cancer. Ther Adv Med Oncol 2020; 12:1758835920907537. [PMID: 32165928 PMCID: PMC7052459 DOI: 10.1177/1758835920907537] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 01/20/2020] [Indexed: 02/01/2023] Open
Abstract
Chemoradiotherapy (CRT) is extensively used prior to surgery for rectal cancer to provide significantly better local control, but the radiotherapy (RT), as the other component of CRT, has been subject to less interest than the drug component in recent years. With considerable developments in RT, the use of advanced techniques, such as intensity-modulated radiotherapy (IMRT) in rectal cancer, is garnering more attention nowadays. The radiation dose can be better conformed to the target volumes with possibilities for synchronous integrated boost without increased complications in normal tissue. Hopefully, both local recurrence and toxicities can be further reduced. Although those seem to be of interest, many issues remain unresolved. There is no international consensus regarding the radiation schedule for preoperative RT for rectal cancer. Moreover, an enormous disparity exists regarding the RT delivery. With the advent of IMRT, variations will likely increase. Moreover, time to surgery is also quite variable, as it depends upon the indication for RT/CRT in the clinical practices. In this review, we discuss the options and problems related to both the dose-time fractionation schedule and time to surgery; furthermore, it addresses the research questions that need answering in the future.
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Affiliation(s)
- Fu Jin
- Department of Radiation Oncology, Chongqing
University Cancer Hospital & Chongqing Cancer Institute & Chongqing
Cancer Hospital, Chongqing, People’s Republic of China
| | - Huanli Luo
- Department of Radiation Oncology, Chongqing
University Cancer Hospital & Chongqing Cancer Institute & Chongqing
Cancer Hospital, Chongqing, People’s Republic of China
| | - Juan Zhou
- Forensic Identification Center, Southwest
University of Political Science and Law, Chongqing, PR China
| | - Yongzhong Wu
- Department of Radiation Oncology, Chongqing
University Cancer Hospital & Chongqing Cancer Institute & Chongqing
Cancer Hospital, Chongqing, People’s Republic of China
| | - Hao Sun
- Department of Gynecologic Oncology, Chongqing
University Cancer Hospital & Chongqing Cancer Institute & Chongqing
Cancer Hospital, Chongqing, PR China
| | - Hongliang Liu
- Department of Anesthesiology, Chongqing
University Cancer Hospital & Chongqing Cancer Institute & Chongqing
Cancer Hospital, Chongqing, PR China
| | - Xiaodong Zheng
- Department of Science Education, Chongqing
University Cancer Hospital & Chongqing Cancer Institute & Chongqing
Cancer Hospital, Chongqing, PR China
| | - Ying Wang
- Department of Radiation Oncology, Chongqing
University Cancer Hospital & Chongqing Cancer Institute & Chongqing
Cancer Hospital, 181 Hanyu Road, Shapingba District, Chongqing 400030,
China
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11
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Gastrointestinal Malignancies and the COVID-19 Pandemic: Evidence-Based Triage to Surgery. J Gastrointest Surg 2020; 24:2357-2373. [PMID: 32607860 PMCID: PMC7325836 DOI: 10.1007/s11605-020-04712-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 06/22/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The COVID-19 pandemic has led to widespread cancelation of electively scheduled surgeries, including for colorectal, pancreatic, and gastric cancer. The American College of Surgeons and the Society of Surgical Oncology have released guidelines for triage of these procedures. We seek to synthesize available evidence on delayed resection and oncologic outcomes, while also providing a critical assessment of the released guidelines. METHODS A systematic review was conducted to identify literature between 2005 and 2020 investigating the impact of time to surgery on oncologic outcomes in colorectal, pancreatic, and gastric cancer. RESULTS For colorectal cancer, 1066 abstracts were screened and 43 papers were included. In primarily resected colon cancer, delay over 30 to 40 days is associated with lower survival. In rectal cancer, time to surgery over 7 to 8 weeks following neoadjuvant therapy is associated with decreased survival. Three hundred ninety-four abstracts were screened for pancreatic cancer and nine studies were included. Two studies demonstrate increased unexpected progression with delayed surgery over 30 days. Out of 633 abstracts screened for gastric cancer, six studies were included. No identified study demonstrated worse survival with increased time to surgery. CONCLUSION Moderate evidence suggests that delayed resection of colorectal cancer worsens survival; the impact of time to surgery on gastric and pancreatic cancer outcomes is uncertain. Early resection of gastrointestinal malignancies provides the best chance for curative therapy. During the COVID-19 pandemic, prioritization of procedures should account for available evidence on time to surgery and oncologic outcomes.
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12
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Monsellato I, Alongi F, Bertocchi E, Gori S, Ruffo G, Cassinotti E, Baldarti L, Boni L, Pernazza G, Pulighe F, De Nisco C, Perinotti R, Morpurgo E, Contardo T, Mammano E, Elmore U, Delpini R, Rosati R, Perna F, Coratti A, Menegatti B, Gentilli S, Baroffio P, Buccianti P, Balestri R, Ceccarelli C, Torri V, Cavaliere D, Solaini L, Ercolani G, Traverso E, Fusco V, Rossi M, Priora F, Numico G, Franzone P, Orecchia S. Standard (8 weeks) vs long (12 weeks) timing to minimally-invasive surgery after NeoAdjuvant Chemoradiotherapy for rectal cancer: a multicenter randomized controlled parallel group trial (TiMiSNAR). BMC Cancer 2019; 19:1215. [PMID: 31842784 PMCID: PMC6912945 DOI: 10.1186/s12885-019-6271-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 10/16/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The optimal timing of surgery in relation to chemoradiation is still controversial. Retrospective analysis has demonstrated in the recent decades that the regression of adenocarcinoma can be slow and not complete until after several months. More recently, increasing pathologic Complete Response rates have been demonstrated to be correlated with longer time interval. The purpose of the trial is to demonstrate if delayed timing of surgery after neoadjuvant chemoradiotherapy actually affects pathologic Complete Response and reflects on disease-free survival and overall survival rather than standard timing. METHODS The trial is a multicenter, prospective, randomized controlled, unblinded, parallel-group trial comparing standard and delayed surgery after neoadjuvant chemoradiotherapy for the curative treatment of rectal cancer. Three-hundred and forty patients will be randomized on an equal basis to either robotic-assisted/standard laparoscopic rectal cancer surgery after 8 weeks or robotic-assisted/standard laparoscopic rectal cancer surgery after 12 weeks. DISCUSSION To date, it is well-know that pathologic Complete Response is associated with excellent prognosis and an overall survival of 90%. In the Lyon trial the rate of pCR or near pathologic Complete Response increased from 10.3 to 26% and in retrospective studies the increase rate was about 23-30%. These results may be explained on the relationship between radiation therapy and tumor regression: DNA damage occurs during irradiation, but cellular lysis occurs within the next weeks. Study results, whether confirmed that performing surgery after 12 weeks from neoadjuvant treatment is advantageous from a technical and oncological point of view, may change the current pathway of the treatment in those patient suffering from rectal cancer. TRIAL REGISTRATION ClinicalTrials.gov NCT3465982.
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Affiliation(s)
- Igor Monsellato
- Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | | | | | | | | | - Elisa Cassinotti
- Department of Surgery, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Ludovica Baldarti
- Department of Surgery, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Luigi Boni
- Department of Surgery, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | | | | | | | | | - Emilio Morpurgo
- Ospedale Civile Pietro Cosma, Camposampiero/Ospedale Sant’Antonio, Padova, Italy
| | - Tania Contardo
- Ospedale Civile Pietro Cosma, Padova, Camposampiero Italy
| | - Enzo Mammano
- Ospedale Civile Pietro Cosma, Camposampiero/Ospedale Sant’Antonio, Padova, Italy
| | - Ugo Elmore
- Ospedale San raffaele IRCCS, Milan, Italy
| | | | | | - Federico Perna
- Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Andrea Coratti
- Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | | | - Sergio Gentilli
- Azienda Ospedaliero Universitaria Maggiore Della Carità, Novara, Italy
| | - Paolo Baroffio
- Azienda Ospedaliero Universitaria Maggiore Della Carità, Novara, Italy
| | | | | | | | - Valter Torri
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | | | | | | | - Elena Traverso
- Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Vittorio Fusco
- Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Maura Rossi
- Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Fabio Priora
- Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - G. Numico
- Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Paola Franzone
- Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Sara Orecchia
- Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
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13
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Maliske S, Chau J, Ginader T, Byrn J, Bhatia S, Bellizzi A, Berg DJ, Monga V. Timing of surgery following neoadjuvant chemoradiation in rectal cancer: a retrospective analysis from an academic medical center. J Gastrointest Oncol 2019; 10:597-604. [PMID: 31392039 DOI: 10.21037/jgo.2019.02.02] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background Neoadjuvant chemoradiotherapy (nCRT) has been shown to achieve decreased local recurrence (LR) with lower toxicity in rectal cancer patients, but data confirming the optimal timing of surgery following this therapy is less robust. Methods The University of Iowa Cancer Registry was queried to identify all patients with stages II-III rectal cancer who received nCRT and surgery from 2000 through 2012. Primary endpoints were time interval to surgery (TI), and overall survival (OS). Secondary endpoints included pathologic outcomes, perioperative morbidities and postoperative complications. Patient characteristics and treatment regimens were compared. Univariate Cox proportional hazard models were used to study the association between TI and OS. Associations of TI with secondary endpoints were tested using Chi-square tests of association. Results Eighty-seven patients presented with stages II-III rectal cancer. Mean TI was 9.92 weeks. There was no significant association between TI and OS when comparing <8 to ≥8 weeks (P=0.23) or when considering the interval as a continuous variable (P=0.85). Increased LOS [median 7.00 days, P=0.05, HR 1.03 (1.00-1.06)] did correlate with worse survival outcomes. Delaying surgery beyond 8 weeks was associated with increased risk for wound infection (P=0.05). Conclusions OS was not influenced by longer intervals between nCRT and surgery. Delaying surgery beyond 8 weeks was associated with increased risk for wound infection.
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Affiliation(s)
- Seth Maliske
- Division of Hematology, Oncology, and Blood & Marrow Transplantation, University of Iowa, University of Iowa, Iowa City, IA, USA
| | - Justin Chau
- Division of Hematology, Oncology, and Blood & Marrow Transplantation, University of Iowa, University of Iowa, Iowa City, IA, USA
| | - Timothy Ginader
- Holden Comprehensive Cancer Center, University of Iowa, University of Iowa, Iowa City, IA, USA
| | - John Byrn
- Division of General Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Sudershan Bhatia
- Division of Radiation Oncology, University of Iowa, Iowa City, IA, USA
| | - Andrew Bellizzi
- Division of Pathology, University of Iowa, Iowa City, IA, USA
| | - Daniel J Berg
- Division of Hematology, Oncology, and Blood & Marrow Transplantation, University of Iowa, University of Iowa, Iowa City, IA, USA
| | - Varun Monga
- Division of Hematology, Oncology, and Blood & Marrow Transplantation, University of Iowa, University of Iowa, Iowa City, IA, USA
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14
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Ryan ÉJ, O'Sullivan DP, Kelly ME, Syed AZ, Neary PC, O'Connell PR, Kavanagh DO, Winter DC, O'Riordan JM. Meta-analysis of the effect of extending the interval after long-course chemoradiotherapy before surgery in locally advanced rectal cancer. Br J Surg 2019; 106:1298-1310. [PMID: 31216064 DOI: 10.1002/bjs.11220] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 03/27/2019] [Accepted: 04/01/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND The current standard of care in locally advanced rectal cancer (LARC) is neoadjuvant long-course chemoradiotherapy (nCRT) followed by total mesorectal excision (TME). Surgery is conventionally performed approximately 6-8 weeks after nCRT. This study aimed to determine the effect on outcomes of extending this interval. METHODS A systematic search was performed for studies reporting oncological results that compared the classical interval (less than 8 weeks) from the end of nCRT to TME with a minimum 8-week interval in patients with LARC. The primary endpoint was the rate of pathological complete response (pCR). Secondary endpoints were recurrence-free survival, local recurrence and distant metastasis rates, R0 resection rates, completeness of TME, margin positivity, sphincter preservation, stoma formation, anastomotic leak and other complications. A meta-analysis was performed using the Mantel-Haenszel method. RESULTS Twenty-six publications, including four RCTs, with 25 445 patients were identified. A minimum 8-week interval was associated with increased odds of pCR (odds ratio (OR) 1·41, 95 per cent c.i. 1·30 to 1·52; P < 0·001) and tumour downstaging (OR 1·18, 1·05 to 1·32; P = 0·004). R0 resection rates, TME completeness, lymph node yield, sphincter preservation, stoma formation and complication rates were similar between the two groups. The increased rate of pCR translated to reduced distant metastasis (OR 0·71, 0·54 to 0·93; P = 0·01) and overall recurrence (OR 0·76, 0·58 to 0·98; P = 0·04), but not local recurrence (OR 0·83, 0·49 to 1·42; P = 0·50). CONCLUSION A minimum 8-week interval from the end of nCRT to TME increases pCR and downstaging rates, and improves recurrence-free survival without compromising surgical morbidity.
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Affiliation(s)
- É J Ryan
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - D P O'Sullivan
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
| | - M E Kelly
- Surgical Professorial Unit, St Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - A Z Syed
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
| | - P C Neary
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland.,School of Medicine, Trinity College Dublin, University of Dublin, Dublin, Ireland
| | - P R O'Connell
- Surgical Professorial Unit, St Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - D O Kavanagh
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland.,School of Medicine, Trinity College Dublin, University of Dublin, Dublin, Ireland
| | - D C Winter
- Surgical Professorial Unit, St Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - J M O'Riordan
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland.,School of Medicine, Trinity College Dublin, University of Dublin, Dublin, Ireland
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15
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Detering R, Borstlap WAA, Broeders L, Hermus L, Marijnen CAM, Beets-Tan RGH, Bemelman WA, van Westreenen HL, Tanis PJ. Cross-Sectional Study on MRI Restaging After Chemoradiotherapy and Interval to Surgery in Rectal Cancer: Influence on Short- and Long-Term Outcomes. Ann Surg Oncol 2018; 26:437-448. [PMID: 30547330 PMCID: PMC6341052 DOI: 10.1245/s10434-018-07097-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Indexed: 02/01/2023]
Abstract
Background The time interval between CRT and surgery in rectal cancer patients is still the subject of debate. The aim of this study was to first evaluate the nationwide use of restaging magnetic resonance imaging (MRI) and its impact on timing of surgery, and, second, to evaluate the impact of timing of surgery after chemoradiotherapy (CRT) on short- and long-term outcomes. Methods Patients were selected from a collaborative rectal cancer research project including 71 Dutch centres, and were subdivided into two groups according to time interval from the start of preoperative CRT to surgery (< 14 and ≥ 14 weeks). Results From 2095 registered patients, 475 patients received preoperative CRT. MRI restaging was performed in 79.4% of patients, with a median CRT–MRI interval of 10 weeks (interquartile range [IQR] 8–11) and a median MRI–surgery interval of 4 weeks (IQR 2–5). The CRT–surgery interval groups consisted of 224 (< 14 weeks) and 251 patients (≥ 14 weeks), and the long-interval group included a higher proportion of cT4 stage and multivisceral resection patients. Pathological complete response rate (n = 34 [15.2%] vs. n = 47 [18.7%], p = 0.305) and CRM involvement (9.7% vs. 15.9%, p = 0.145) did not significantly differ. Thirty-day surgical complications were similar (20.1% vs. 23.1%, p = 0.943), however no significant differences were found for local and distant recurrence rates, disease-free survival, and overall survival. Conclusions These real-life data, reflecting routine daily practice in The Netherlands, showed substantial variability in the use and timing of restaging MRI after preoperative CRT for rectal cancer, as well as time interval to surgery. Surgery before or after 14 weeks from the start of CRT resulted in similar short- and long-term outcomes. Electronic supplementary material The online version of this article (10.1245/s10434-018-07097-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Robin Detering
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Wernard A A Borstlap
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Lisa Broeders
- Scientific Bureau of the Dutch Institute of Clinical Auditing, Leiden, The Netherlands
| | - Linda Hermus
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Corrie A M Marijnen
- Department of Radiotherapy, Leiden University Medical Center, Leiden, The Netherlands
| | - Regina G H Beets-Tan
- Department of Radiology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Willem A Bemelman
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Pieter J Tanis
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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16
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Kim MJ, Cho JS, Kim EM, Ko WA, Oh JH. Optimal Time Interval for Surgery After Neoadjuvant Chemoradiotherapy in Patients With Locally Advanced Rectal Cancer: Analysis of Health Insurance Review and Assessment Service Data. Ann Coloproctol 2018; 34:241-247. [PMID: 30419721 PMCID: PMC6238805 DOI: 10.3393/ac.2018.01.01] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Accepted: 01/01/2018] [Indexed: 02/07/2023] Open
Abstract
Purpose Pathologic downstaging of rectal cancer has been suggested to be associated with the time interval from chemoradiotherapy (CRT) completion to surgery. We aimed to evaluate the effect of this time interval for patients with rectal cancer on the pathologic response. Methods All patients with rectal cancer undergoing neoadjuvant CRT with evaluable data were selected from among the Health Insurance Review and Assessment Service data. Patients were divided into groups according to the time between CRT and surgery. CRT responses were analyzed. Results Two hundred forty-nine patients were included, of whom 86 (34.5%) were in the 5- to 7-week interval, 113 (45.4%) in the 7- to 9-week interval, 38 (15.3%) in the 9- to 11-week interval, and 12 (4.8%) in the >11-week interval. The median time interval between CRT completion and surgery was 7.4 weeks (range: 5–22.7 weeks; interquartile range, 6.7–8.7 weeks). Surgery 9–11 weeks after CRT completion resulted in the highest, but not statistically significant, pathologic complete response (pCR) rate (3 patients, 8.6%; P = 0.886), no pCR was noted in the >11-week interval group. Results for downstaging in the 9- to 11-week interval group were as follows: T downstaging, 38.2% (P = 0.735); N downstaging, 50.0% (P = 0.439); and TN downstaging, 52.9% (P = 0.087). The 3-year overall survival rates for the 5- to 7-week, 7- to 9-week, 9- to 11-week, and >11-week interval groups were 93.0%, 85.0%, 81.6%, and 91.7%, respectively (P = 0.326). Conclusion Delaying surgery by 9 to 11 weeks may increase TN downstaging, but delaying for over 11 weeks may not increase additional tumor downstaging from long-course CRT.
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Affiliation(s)
- Min Jung Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Jin Suk Cho
- Health Insurance Review and Assessment Service, Seoul, Korea
| | - Eun Mi Kim
- Health Insurance Review and Assessment Service, Seoul, Korea
| | - Woo Ah Ko
- Health Insurance Review and Assessment Service, Seoul, Korea
| | - Jae Hwan Oh
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
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17
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Brix N, Tiefenthaller A, Anders H, Belka C, Lauber K. Abscopal, immunological effects of radiotherapy: Narrowing the gap between clinical and preclinical experiences. Immunol Rev 2018; 280:249-279. [PMID: 29027221 DOI: 10.1111/imr.12573] [Citation(s) in RCA: 133] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Radiotherapy-despite being a local therapy that meanwhile is characterized by an impressively high degree of spatial accuracy-can stimulate systemic phenomena which occasionally lead to regression and rejection of non-irradiated, distant tumor lesions. These abscopal effects of local irradiation have been observed in sporadic clinical case reports since the beginning of the 20th century, and extensive preclinical work has contributed to identify systemic anti-tumor immune responses as the underlying driving forces. Although abscopal tumor regression still remains a rare event in the radiotherapeutic routine, increasing numbers of cases are being reported, particularly since the clinical implementation of immune checkpoint inhibiting agents. Accordingly, interests to systematically exploit the therapeutic potential of radiotherapy-stimulated systemic responses are constantly growing. The present review briefly delineates the history of radiotherapy-induced abscopal effects and the activation of systemic anti-tumor immune responses by local irradiation. We discuss preclinical and clinical reports with specific focus on the corresponding controversies, and we propose issues that should be addressed in the future in order to narrow the gap between preclinical knowledge and clinical experiences.
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Affiliation(s)
- Nikko Brix
- Department of Radiation Oncology, University Hospital, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Anna Tiefenthaller
- Department of Radiation Oncology, University Hospital, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Heike Anders
- Department of Radiation Oncology, University Hospital, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, Ludwig-Maximilians-University of Munich, Munich, Germany.,Clinical Cooperation Group 'Personalized Radiotherapy in Head and Neck Cancer' Helmholtz Center Munich, German Research Center for Environmental Health GmbH, Neuherberg, Germany.,German Cancer Consortium Partner Site München, Munich, Germany
| | - Kirsten Lauber
- Department of Radiation Oncology, University Hospital, Ludwig-Maximilians-University of Munich, Munich, Germany.,Clinical Cooperation Group 'Personalized Radiotherapy in Head and Neck Cancer' Helmholtz Center Munich, German Research Center for Environmental Health GmbH, Neuherberg, Germany
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18
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Musio D, Raffetto N, Dionisi F, Iannacone E, Dipalma B, Caparrotti F, Meaglia I, Caiazzo R, Bangrazi C, Banelli E. Comparison between Intensified Neoadjuvant Treatment and Standard Preoperative Chemoradiation for Rectal Cancer. TUMORI JOURNAL 2018; 96:11-6. [DOI: 10.1177/030089161009600102] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Objectives The aim of the current study was to compare a neoadjuvant regimen containing oxaliplatin with standard preoperative treatment for rectal cancer. Methods From December 2006 to December 2007, 20 patients with rectal cancer were treated at our Institution with the weekly addition of oxaliplatin (50 mg/m2) to radiotherapy (50.4–54.0 Gy in 28–30 daily fractions) and continuous infusion of 5-fluorouracil (200 mg/m2). The results of the regimen were compared with a historical control group including 21 consecutive patients previously treated with standard 5-fluorouracil treatment from December 2004 to October 2006. Results Both the rate of sphincter preservation in low rectal cancer (91.7% vs 36.4%, P = 0.009) and the rate of downstaging (84.2% vs 47.6%, P = 0.023) were higher in the oxaliplatin group than in the control group. Pathological complete response was achieved in 8 patients (42.1%) in the oxaliplatin group and in 4 patients (19.0%) in the control group (P = 0.172). When ypT0-pT1 stages were analyzed together, the P value was 0.051. Acute toxicity was increased in the oxaliplatin group, with a higher incidence of G3 diarrhea and pelvic pain than in the control group (30.0% vs 14.3%, P = NS). Conclusions Our data seem to correlate the addition of oxaliplatin to the standard treatment for rectal cancer with higher rates of sphincter preservation, down-staging and complete response. Toxicity is increased and requires careful monitoring. However, our results refer to a retrospective comparison of a small series of patients and need to be validated by the large, phase III randomized trial currently ongoing.
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Affiliation(s)
- Daniela Musio
- Department of Radiation Oncology, University “Sapienza”, Rome, Italy
| | - Nicola Raffetto
- Department of Radiation Oncology, University “Sapienza”, Rome, Italy
| | - Francesco Dionisi
- Department of Radiation Oncology, University “Sapienza”, Rome, Italy
| | - Eva Iannacone
- Department of Radiation Oncology, University “Sapienza”, Rome, Italy
| | | | | | - Ilaria Meaglia
- Department of Radiation Oncology, University “Sapienza”, Rome, Italy
| | - Rossella Caiazzo
- Department of Radiation Oncology, University “Sapienza”, Rome, Italy
| | - Caterina Bangrazi
- Department of Radiation Oncology, University “Sapienza”, Rome, Italy
| | - Enzo Banelli
- Department of Radiation Oncology, University “Sapienza”, Rome, Italy
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Lefevre JH, Mineur L, Kotti S, Rullier E, Rouanet P, de Chaisemartin C, Meunier B, Mehrdad J, Cotte E, Desrame J, Karoui M, Benoist S, Kirzin S, Berger A, Panis Y, Piessen G, Saudemont A, Prudhomme M, Peschaud F, Dubois A, Loriau J, Tuech JJ, Meurette G, Lupinacci R, Goasgen N, Parc Y, Simon T, Tiret E. Effect of Interval (7 or 11 weeks) Between Neoadjuvant Radiochemotherapy and Surgery on Complete Pathologic Response in Rectal Cancer: A Multicenter, Randomized, Controlled Trial (GRECCAR-6). J Clin Oncol 2017; 34:3773-3780. [PMID: 27432930 DOI: 10.1200/jco.2016.67.6049] [Citation(s) in RCA: 299] [Impact Index Per Article: 42.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Purpose A pathologic complete response (pCR; ypT0N0) of a rectal tumor after neoadjuvant radiochemotherapy (RCT) is associated with an excellent prognosis. Several retrospective studies have investigated the effect of increasing the delay after RCT. The aim of this study was to evaluate the effect of increasing the interval between the end of RCT and surgery on the pCR rate. Methods GRECCAR6 was a phase III, multicenter, randomized, open-label, parallel-group controlled trial. Patients with cT3/T4 or Tx N+ tumors of the mid or lower rectum who had received RCT (45 to 50 Gy with fluorouracil or capecitabine) were included. Patients were randomly included in the 7-week or the 11-week (11w) group. Primary end point was the pCR rate defined as a ypT0N0 specimen (NCT01648894). Results A total of 265 patients from 24 centers were enrolled between October 2012 and February 2015. The majority of the tumors were cT3 (82%). After RCT, surgery was not performed in nine patients (3.4%) because of the occurrence of distant metastasis (n = 5) or other reasons. Two patients underwent local resection of the tumor scar. A total of 47 (18.6%) specimens were classified as ypT0 (four had invaded lymph nodes [8.5%]). The primary end point (ypT0N0) was not different (7 weeks: 20 of 133, 15.0% v 11w: 23 of 132, 17.4%; P = .5983). Morbidity was significantly increased in the 11w group (44.5% v 32%; P = .0404) as a result of increased medical complications (32.8% v 19.2%; P = .0137). The 11w group had a worse quality of mesorectal resection (complete mesorectum [I] 78.7% v 90%; P = .0156). Conclusion Waiting 11 weeks after RCT did not increase the rate of pCR after surgical resection. A longer waiting period may be associated with higher morbidity and more difficult surgical resection.
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Affiliation(s)
- Jérémie H Lefevre
- Jérémie H. Lefevre, Salma Kotti, Yann Parc, Tabassome Simon, and Emmanuel Tiret, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne Universités; Mehdi Karoui, Centre Hospitalier Universitaire (CHU) Pitié-Salpétrière; Anne Berger, CHU Hôpital Européen Georges-Pompidou; Jérome Loriau, Hôpital Saint-Joseph; Renato Lupinacci, Hôpital Croix Saint-Simon; Nicolas Goasgen, Hôpital des Diaconesses-Croix Saint-Simon, Paris; Laurent Mineur, Sainte-Camille Institut, Avignon; Eric Rullier, CHU Saint-André, Bordeaux; Philippe Rouanet, Val d'Aurelle Institut, Montpellier; Cécile de Chaisemartin, Paoli-Calmettes Institut, Marseille CHU, Marseille; Bernard Meunier, CHU Rennes, Rennes; Jafari Mehrdad, Oscar Lambret Center; Guillaume Piessen and Alain Saudemont, Centre Hospitalier Régional Universitaire, Lille; Eddy Cotte, CHU Lyon-Sud, Pierre-Bénite; Jérome Desrame, Jean Mermoz Institut, Lyon; Stéphane Benoist, CHU Bicètre, Le Kremlin-Bicêtre; Sylvain Kirzin, CHU Purpan, Toulouse; Yves Panis, Hôpital Beaujon, Université Paris VII, Clichy; Michel Prudhomme, CHU Carémeau, Nîmes; Frédérique Peschaud, CHU Ambroise-Paré, Boulogne-Billancourt; Anne Dubois, CHU Estaing, Clermont-Ferrand; Jean-Jacques Tuech, CHU, Rouen; and Guillaume Meurette, CHU Hôtel-Dieu, Nantes, France
| | - Laurent Mineur
- Jérémie H. Lefevre, Salma Kotti, Yann Parc, Tabassome Simon, and Emmanuel Tiret, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne Universités; Mehdi Karoui, Centre Hospitalier Universitaire (CHU) Pitié-Salpétrière; Anne Berger, CHU Hôpital Européen Georges-Pompidou; Jérome Loriau, Hôpital Saint-Joseph; Renato Lupinacci, Hôpital Croix Saint-Simon; Nicolas Goasgen, Hôpital des Diaconesses-Croix Saint-Simon, Paris; Laurent Mineur, Sainte-Camille Institut, Avignon; Eric Rullier, CHU Saint-André, Bordeaux; Philippe Rouanet, Val d'Aurelle Institut, Montpellier; Cécile de Chaisemartin, Paoli-Calmettes Institut, Marseille CHU, Marseille; Bernard Meunier, CHU Rennes, Rennes; Jafari Mehrdad, Oscar Lambret Center; Guillaume Piessen and Alain Saudemont, Centre Hospitalier Régional Universitaire, Lille; Eddy Cotte, CHU Lyon-Sud, Pierre-Bénite; Jérome Desrame, Jean Mermoz Institut, Lyon; Stéphane Benoist, CHU Bicètre, Le Kremlin-Bicêtre; Sylvain Kirzin, CHU Purpan, Toulouse; Yves Panis, Hôpital Beaujon, Université Paris VII, Clichy; Michel Prudhomme, CHU Carémeau, Nîmes; Frédérique Peschaud, CHU Ambroise-Paré, Boulogne-Billancourt; Anne Dubois, CHU Estaing, Clermont-Ferrand; Jean-Jacques Tuech, CHU, Rouen; and Guillaume Meurette, CHU Hôtel-Dieu, Nantes, France
| | - Salma Kotti
- Jérémie H. Lefevre, Salma Kotti, Yann Parc, Tabassome Simon, and Emmanuel Tiret, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne Universités; Mehdi Karoui, Centre Hospitalier Universitaire (CHU) Pitié-Salpétrière; Anne Berger, CHU Hôpital Européen Georges-Pompidou; Jérome Loriau, Hôpital Saint-Joseph; Renato Lupinacci, Hôpital Croix Saint-Simon; Nicolas Goasgen, Hôpital des Diaconesses-Croix Saint-Simon, Paris; Laurent Mineur, Sainte-Camille Institut, Avignon; Eric Rullier, CHU Saint-André, Bordeaux; Philippe Rouanet, Val d'Aurelle Institut, Montpellier; Cécile de Chaisemartin, Paoli-Calmettes Institut, Marseille CHU, Marseille; Bernard Meunier, CHU Rennes, Rennes; Jafari Mehrdad, Oscar Lambret Center; Guillaume Piessen and Alain Saudemont, Centre Hospitalier Régional Universitaire, Lille; Eddy Cotte, CHU Lyon-Sud, Pierre-Bénite; Jérome Desrame, Jean Mermoz Institut, Lyon; Stéphane Benoist, CHU Bicètre, Le Kremlin-Bicêtre; Sylvain Kirzin, CHU Purpan, Toulouse; Yves Panis, Hôpital Beaujon, Université Paris VII, Clichy; Michel Prudhomme, CHU Carémeau, Nîmes; Frédérique Peschaud, CHU Ambroise-Paré, Boulogne-Billancourt; Anne Dubois, CHU Estaing, Clermont-Ferrand; Jean-Jacques Tuech, CHU, Rouen; and Guillaume Meurette, CHU Hôtel-Dieu, Nantes, France
| | - Eric Rullier
- Jérémie H. Lefevre, Salma Kotti, Yann Parc, Tabassome Simon, and Emmanuel Tiret, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne Universités; Mehdi Karoui, Centre Hospitalier Universitaire (CHU) Pitié-Salpétrière; Anne Berger, CHU Hôpital Européen Georges-Pompidou; Jérome Loriau, Hôpital Saint-Joseph; Renato Lupinacci, Hôpital Croix Saint-Simon; Nicolas Goasgen, Hôpital des Diaconesses-Croix Saint-Simon, Paris; Laurent Mineur, Sainte-Camille Institut, Avignon; Eric Rullier, CHU Saint-André, Bordeaux; Philippe Rouanet, Val d'Aurelle Institut, Montpellier; Cécile de Chaisemartin, Paoli-Calmettes Institut, Marseille CHU, Marseille; Bernard Meunier, CHU Rennes, Rennes; Jafari Mehrdad, Oscar Lambret Center; Guillaume Piessen and Alain Saudemont, Centre Hospitalier Régional Universitaire, Lille; Eddy Cotte, CHU Lyon-Sud, Pierre-Bénite; Jérome Desrame, Jean Mermoz Institut, Lyon; Stéphane Benoist, CHU Bicètre, Le Kremlin-Bicêtre; Sylvain Kirzin, CHU Purpan, Toulouse; Yves Panis, Hôpital Beaujon, Université Paris VII, Clichy; Michel Prudhomme, CHU Carémeau, Nîmes; Frédérique Peschaud, CHU Ambroise-Paré, Boulogne-Billancourt; Anne Dubois, CHU Estaing, Clermont-Ferrand; Jean-Jacques Tuech, CHU, Rouen; and Guillaume Meurette, CHU Hôtel-Dieu, Nantes, France
| | - Philippe Rouanet
- Jérémie H. Lefevre, Salma Kotti, Yann Parc, Tabassome Simon, and Emmanuel Tiret, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne Universités; Mehdi Karoui, Centre Hospitalier Universitaire (CHU) Pitié-Salpétrière; Anne Berger, CHU Hôpital Européen Georges-Pompidou; Jérome Loriau, Hôpital Saint-Joseph; Renato Lupinacci, Hôpital Croix Saint-Simon; Nicolas Goasgen, Hôpital des Diaconesses-Croix Saint-Simon, Paris; Laurent Mineur, Sainte-Camille Institut, Avignon; Eric Rullier, CHU Saint-André, Bordeaux; Philippe Rouanet, Val d'Aurelle Institut, Montpellier; Cécile de Chaisemartin, Paoli-Calmettes Institut, Marseille CHU, Marseille; Bernard Meunier, CHU Rennes, Rennes; Jafari Mehrdad, Oscar Lambret Center; Guillaume Piessen and Alain Saudemont, Centre Hospitalier Régional Universitaire, Lille; Eddy Cotte, CHU Lyon-Sud, Pierre-Bénite; Jérome Desrame, Jean Mermoz Institut, Lyon; Stéphane Benoist, CHU Bicètre, Le Kremlin-Bicêtre; Sylvain Kirzin, CHU Purpan, Toulouse; Yves Panis, Hôpital Beaujon, Université Paris VII, Clichy; Michel Prudhomme, CHU Carémeau, Nîmes; Frédérique Peschaud, CHU Ambroise-Paré, Boulogne-Billancourt; Anne Dubois, CHU Estaing, Clermont-Ferrand; Jean-Jacques Tuech, CHU, Rouen; and Guillaume Meurette, CHU Hôtel-Dieu, Nantes, France
| | - Cécile de Chaisemartin
- Jérémie H. Lefevre, Salma Kotti, Yann Parc, Tabassome Simon, and Emmanuel Tiret, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne Universités; Mehdi Karoui, Centre Hospitalier Universitaire (CHU) Pitié-Salpétrière; Anne Berger, CHU Hôpital Européen Georges-Pompidou; Jérome Loriau, Hôpital Saint-Joseph; Renato Lupinacci, Hôpital Croix Saint-Simon; Nicolas Goasgen, Hôpital des Diaconesses-Croix Saint-Simon, Paris; Laurent Mineur, Sainte-Camille Institut, Avignon; Eric Rullier, CHU Saint-André, Bordeaux; Philippe Rouanet, Val d'Aurelle Institut, Montpellier; Cécile de Chaisemartin, Paoli-Calmettes Institut, Marseille CHU, Marseille; Bernard Meunier, CHU Rennes, Rennes; Jafari Mehrdad, Oscar Lambret Center; Guillaume Piessen and Alain Saudemont, Centre Hospitalier Régional Universitaire, Lille; Eddy Cotte, CHU Lyon-Sud, Pierre-Bénite; Jérome Desrame, Jean Mermoz Institut, Lyon; Stéphane Benoist, CHU Bicètre, Le Kremlin-Bicêtre; Sylvain Kirzin, CHU Purpan, Toulouse; Yves Panis, Hôpital Beaujon, Université Paris VII, Clichy; Michel Prudhomme, CHU Carémeau, Nîmes; Frédérique Peschaud, CHU Ambroise-Paré, Boulogne-Billancourt; Anne Dubois, CHU Estaing, Clermont-Ferrand; Jean-Jacques Tuech, CHU, Rouen; and Guillaume Meurette, CHU Hôtel-Dieu, Nantes, France
| | - Bernard Meunier
- Jérémie H. Lefevre, Salma Kotti, Yann Parc, Tabassome Simon, and Emmanuel Tiret, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne Universités; Mehdi Karoui, Centre Hospitalier Universitaire (CHU) Pitié-Salpétrière; Anne Berger, CHU Hôpital Européen Georges-Pompidou; Jérome Loriau, Hôpital Saint-Joseph; Renato Lupinacci, Hôpital Croix Saint-Simon; Nicolas Goasgen, Hôpital des Diaconesses-Croix Saint-Simon, Paris; Laurent Mineur, Sainte-Camille Institut, Avignon; Eric Rullier, CHU Saint-André, Bordeaux; Philippe Rouanet, Val d'Aurelle Institut, Montpellier; Cécile de Chaisemartin, Paoli-Calmettes Institut, Marseille CHU, Marseille; Bernard Meunier, CHU Rennes, Rennes; Jafari Mehrdad, Oscar Lambret Center; Guillaume Piessen and Alain Saudemont, Centre Hospitalier Régional Universitaire, Lille; Eddy Cotte, CHU Lyon-Sud, Pierre-Bénite; Jérome Desrame, Jean Mermoz Institut, Lyon; Stéphane Benoist, CHU Bicètre, Le Kremlin-Bicêtre; Sylvain Kirzin, CHU Purpan, Toulouse; Yves Panis, Hôpital Beaujon, Université Paris VII, Clichy; Michel Prudhomme, CHU Carémeau, Nîmes; Frédérique Peschaud, CHU Ambroise-Paré, Boulogne-Billancourt; Anne Dubois, CHU Estaing, Clermont-Ferrand; Jean-Jacques Tuech, CHU, Rouen; and Guillaume Meurette, CHU Hôtel-Dieu, Nantes, France
| | - Jafari Mehrdad
- Jérémie H. Lefevre, Salma Kotti, Yann Parc, Tabassome Simon, and Emmanuel Tiret, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne Universités; Mehdi Karoui, Centre Hospitalier Universitaire (CHU) Pitié-Salpétrière; Anne Berger, CHU Hôpital Européen Georges-Pompidou; Jérome Loriau, Hôpital Saint-Joseph; Renato Lupinacci, Hôpital Croix Saint-Simon; Nicolas Goasgen, Hôpital des Diaconesses-Croix Saint-Simon, Paris; Laurent Mineur, Sainte-Camille Institut, Avignon; Eric Rullier, CHU Saint-André, Bordeaux; Philippe Rouanet, Val d'Aurelle Institut, Montpellier; Cécile de Chaisemartin, Paoli-Calmettes Institut, Marseille CHU, Marseille; Bernard Meunier, CHU Rennes, Rennes; Jafari Mehrdad, Oscar Lambret Center; Guillaume Piessen and Alain Saudemont, Centre Hospitalier Régional Universitaire, Lille; Eddy Cotte, CHU Lyon-Sud, Pierre-Bénite; Jérome Desrame, Jean Mermoz Institut, Lyon; Stéphane Benoist, CHU Bicètre, Le Kremlin-Bicêtre; Sylvain Kirzin, CHU Purpan, Toulouse; Yves Panis, Hôpital Beaujon, Université Paris VII, Clichy; Michel Prudhomme, CHU Carémeau, Nîmes; Frédérique Peschaud, CHU Ambroise-Paré, Boulogne-Billancourt; Anne Dubois, CHU Estaing, Clermont-Ferrand; Jean-Jacques Tuech, CHU, Rouen; and Guillaume Meurette, CHU Hôtel-Dieu, Nantes, France
| | - Eddy Cotte
- Jérémie H. Lefevre, Salma Kotti, Yann Parc, Tabassome Simon, and Emmanuel Tiret, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne Universités; Mehdi Karoui, Centre Hospitalier Universitaire (CHU) Pitié-Salpétrière; Anne Berger, CHU Hôpital Européen Georges-Pompidou; Jérome Loriau, Hôpital Saint-Joseph; Renato Lupinacci, Hôpital Croix Saint-Simon; Nicolas Goasgen, Hôpital des Diaconesses-Croix Saint-Simon, Paris; Laurent Mineur, Sainte-Camille Institut, Avignon; Eric Rullier, CHU Saint-André, Bordeaux; Philippe Rouanet, Val d'Aurelle Institut, Montpellier; Cécile de Chaisemartin, Paoli-Calmettes Institut, Marseille CHU, Marseille; Bernard Meunier, CHU Rennes, Rennes; Jafari Mehrdad, Oscar Lambret Center; Guillaume Piessen and Alain Saudemont, Centre Hospitalier Régional Universitaire, Lille; Eddy Cotte, CHU Lyon-Sud, Pierre-Bénite; Jérome Desrame, Jean Mermoz Institut, Lyon; Stéphane Benoist, CHU Bicètre, Le Kremlin-Bicêtre; Sylvain Kirzin, CHU Purpan, Toulouse; Yves Panis, Hôpital Beaujon, Université Paris VII, Clichy; Michel Prudhomme, CHU Carémeau, Nîmes; Frédérique Peschaud, CHU Ambroise-Paré, Boulogne-Billancourt; Anne Dubois, CHU Estaing, Clermont-Ferrand; Jean-Jacques Tuech, CHU, Rouen; and Guillaume Meurette, CHU Hôtel-Dieu, Nantes, France
| | - Jérome Desrame
- Jérémie H. Lefevre, Salma Kotti, Yann Parc, Tabassome Simon, and Emmanuel Tiret, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne Universités; Mehdi Karoui, Centre Hospitalier Universitaire (CHU) Pitié-Salpétrière; Anne Berger, CHU Hôpital Européen Georges-Pompidou; Jérome Loriau, Hôpital Saint-Joseph; Renato Lupinacci, Hôpital Croix Saint-Simon; Nicolas Goasgen, Hôpital des Diaconesses-Croix Saint-Simon, Paris; Laurent Mineur, Sainte-Camille Institut, Avignon; Eric Rullier, CHU Saint-André, Bordeaux; Philippe Rouanet, Val d'Aurelle Institut, Montpellier; Cécile de Chaisemartin, Paoli-Calmettes Institut, Marseille CHU, Marseille; Bernard Meunier, CHU Rennes, Rennes; Jafari Mehrdad, Oscar Lambret Center; Guillaume Piessen and Alain Saudemont, Centre Hospitalier Régional Universitaire, Lille; Eddy Cotte, CHU Lyon-Sud, Pierre-Bénite; Jérome Desrame, Jean Mermoz Institut, Lyon; Stéphane Benoist, CHU Bicètre, Le Kremlin-Bicêtre; Sylvain Kirzin, CHU Purpan, Toulouse; Yves Panis, Hôpital Beaujon, Université Paris VII, Clichy; Michel Prudhomme, CHU Carémeau, Nîmes; Frédérique Peschaud, CHU Ambroise-Paré, Boulogne-Billancourt; Anne Dubois, CHU Estaing, Clermont-Ferrand; Jean-Jacques Tuech, CHU, Rouen; and Guillaume Meurette, CHU Hôtel-Dieu, Nantes, France
| | - Mehdi Karoui
- Jérémie H. Lefevre, Salma Kotti, Yann Parc, Tabassome Simon, and Emmanuel Tiret, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne Universités; Mehdi Karoui, Centre Hospitalier Universitaire (CHU) Pitié-Salpétrière; Anne Berger, CHU Hôpital Européen Georges-Pompidou; Jérome Loriau, Hôpital Saint-Joseph; Renato Lupinacci, Hôpital Croix Saint-Simon; Nicolas Goasgen, Hôpital des Diaconesses-Croix Saint-Simon, Paris; Laurent Mineur, Sainte-Camille Institut, Avignon; Eric Rullier, CHU Saint-André, Bordeaux; Philippe Rouanet, Val d'Aurelle Institut, Montpellier; Cécile de Chaisemartin, Paoli-Calmettes Institut, Marseille CHU, Marseille; Bernard Meunier, CHU Rennes, Rennes; Jafari Mehrdad, Oscar Lambret Center; Guillaume Piessen and Alain Saudemont, Centre Hospitalier Régional Universitaire, Lille; Eddy Cotte, CHU Lyon-Sud, Pierre-Bénite; Jérome Desrame, Jean Mermoz Institut, Lyon; Stéphane Benoist, CHU Bicètre, Le Kremlin-Bicêtre; Sylvain Kirzin, CHU Purpan, Toulouse; Yves Panis, Hôpital Beaujon, Université Paris VII, Clichy; Michel Prudhomme, CHU Carémeau, Nîmes; Frédérique Peschaud, CHU Ambroise-Paré, Boulogne-Billancourt; Anne Dubois, CHU Estaing, Clermont-Ferrand; Jean-Jacques Tuech, CHU, Rouen; and Guillaume Meurette, CHU Hôtel-Dieu, Nantes, France
| | - Stéphane Benoist
- Jérémie H. Lefevre, Salma Kotti, Yann Parc, Tabassome Simon, and Emmanuel Tiret, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne Universités; Mehdi Karoui, Centre Hospitalier Universitaire (CHU) Pitié-Salpétrière; Anne Berger, CHU Hôpital Européen Georges-Pompidou; Jérome Loriau, Hôpital Saint-Joseph; Renato Lupinacci, Hôpital Croix Saint-Simon; Nicolas Goasgen, Hôpital des Diaconesses-Croix Saint-Simon, Paris; Laurent Mineur, Sainte-Camille Institut, Avignon; Eric Rullier, CHU Saint-André, Bordeaux; Philippe Rouanet, Val d'Aurelle Institut, Montpellier; Cécile de Chaisemartin, Paoli-Calmettes Institut, Marseille CHU, Marseille; Bernard Meunier, CHU Rennes, Rennes; Jafari Mehrdad, Oscar Lambret Center; Guillaume Piessen and Alain Saudemont, Centre Hospitalier Régional Universitaire, Lille; Eddy Cotte, CHU Lyon-Sud, Pierre-Bénite; Jérome Desrame, Jean Mermoz Institut, Lyon; Stéphane Benoist, CHU Bicètre, Le Kremlin-Bicêtre; Sylvain Kirzin, CHU Purpan, Toulouse; Yves Panis, Hôpital Beaujon, Université Paris VII, Clichy; Michel Prudhomme, CHU Carémeau, Nîmes; Frédérique Peschaud, CHU Ambroise-Paré, Boulogne-Billancourt; Anne Dubois, CHU Estaing, Clermont-Ferrand; Jean-Jacques Tuech, CHU, Rouen; and Guillaume Meurette, CHU Hôtel-Dieu, Nantes, France
| | - Sylvain Kirzin
- Jérémie H. Lefevre, Salma Kotti, Yann Parc, Tabassome Simon, and Emmanuel Tiret, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne Universités; Mehdi Karoui, Centre Hospitalier Universitaire (CHU) Pitié-Salpétrière; Anne Berger, CHU Hôpital Européen Georges-Pompidou; Jérome Loriau, Hôpital Saint-Joseph; Renato Lupinacci, Hôpital Croix Saint-Simon; Nicolas Goasgen, Hôpital des Diaconesses-Croix Saint-Simon, Paris; Laurent Mineur, Sainte-Camille Institut, Avignon; Eric Rullier, CHU Saint-André, Bordeaux; Philippe Rouanet, Val d'Aurelle Institut, Montpellier; Cécile de Chaisemartin, Paoli-Calmettes Institut, Marseille CHU, Marseille; Bernard Meunier, CHU Rennes, Rennes; Jafari Mehrdad, Oscar Lambret Center; Guillaume Piessen and Alain Saudemont, Centre Hospitalier Régional Universitaire, Lille; Eddy Cotte, CHU Lyon-Sud, Pierre-Bénite; Jérome Desrame, Jean Mermoz Institut, Lyon; Stéphane Benoist, CHU Bicètre, Le Kremlin-Bicêtre; Sylvain Kirzin, CHU Purpan, Toulouse; Yves Panis, Hôpital Beaujon, Université Paris VII, Clichy; Michel Prudhomme, CHU Carémeau, Nîmes; Frédérique Peschaud, CHU Ambroise-Paré, Boulogne-Billancourt; Anne Dubois, CHU Estaing, Clermont-Ferrand; Jean-Jacques Tuech, CHU, Rouen; and Guillaume Meurette, CHU Hôtel-Dieu, Nantes, France
| | - Anne Berger
- Jérémie H. Lefevre, Salma Kotti, Yann Parc, Tabassome Simon, and Emmanuel Tiret, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne Universités; Mehdi Karoui, Centre Hospitalier Universitaire (CHU) Pitié-Salpétrière; Anne Berger, CHU Hôpital Européen Georges-Pompidou; Jérome Loriau, Hôpital Saint-Joseph; Renato Lupinacci, Hôpital Croix Saint-Simon; Nicolas Goasgen, Hôpital des Diaconesses-Croix Saint-Simon, Paris; Laurent Mineur, Sainte-Camille Institut, Avignon; Eric Rullier, CHU Saint-André, Bordeaux; Philippe Rouanet, Val d'Aurelle Institut, Montpellier; Cécile de Chaisemartin, Paoli-Calmettes Institut, Marseille CHU, Marseille; Bernard Meunier, CHU Rennes, Rennes; Jafari Mehrdad, Oscar Lambret Center; Guillaume Piessen and Alain Saudemont, Centre Hospitalier Régional Universitaire, Lille; Eddy Cotte, CHU Lyon-Sud, Pierre-Bénite; Jérome Desrame, Jean Mermoz Institut, Lyon; Stéphane Benoist, CHU Bicètre, Le Kremlin-Bicêtre; Sylvain Kirzin, CHU Purpan, Toulouse; Yves Panis, Hôpital Beaujon, Université Paris VII, Clichy; Michel Prudhomme, CHU Carémeau, Nîmes; Frédérique Peschaud, CHU Ambroise-Paré, Boulogne-Billancourt; Anne Dubois, CHU Estaing, Clermont-Ferrand; Jean-Jacques Tuech, CHU, Rouen; and Guillaume Meurette, CHU Hôtel-Dieu, Nantes, France
| | - Yves Panis
- Jérémie H. Lefevre, Salma Kotti, Yann Parc, Tabassome Simon, and Emmanuel Tiret, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne Universités; Mehdi Karoui, Centre Hospitalier Universitaire (CHU) Pitié-Salpétrière; Anne Berger, CHU Hôpital Européen Georges-Pompidou; Jérome Loriau, Hôpital Saint-Joseph; Renato Lupinacci, Hôpital Croix Saint-Simon; Nicolas Goasgen, Hôpital des Diaconesses-Croix Saint-Simon, Paris; Laurent Mineur, Sainte-Camille Institut, Avignon; Eric Rullier, CHU Saint-André, Bordeaux; Philippe Rouanet, Val d'Aurelle Institut, Montpellier; Cécile de Chaisemartin, Paoli-Calmettes Institut, Marseille CHU, Marseille; Bernard Meunier, CHU Rennes, Rennes; Jafari Mehrdad, Oscar Lambret Center; Guillaume Piessen and Alain Saudemont, Centre Hospitalier Régional Universitaire, Lille; Eddy Cotte, CHU Lyon-Sud, Pierre-Bénite; Jérome Desrame, Jean Mermoz Institut, Lyon; Stéphane Benoist, CHU Bicètre, Le Kremlin-Bicêtre; Sylvain Kirzin, CHU Purpan, Toulouse; Yves Panis, Hôpital Beaujon, Université Paris VII, Clichy; Michel Prudhomme, CHU Carémeau, Nîmes; Frédérique Peschaud, CHU Ambroise-Paré, Boulogne-Billancourt; Anne Dubois, CHU Estaing, Clermont-Ferrand; Jean-Jacques Tuech, CHU, Rouen; and Guillaume Meurette, CHU Hôtel-Dieu, Nantes, France
| | - Guillaume Piessen
- Jérémie H. Lefevre, Salma Kotti, Yann Parc, Tabassome Simon, and Emmanuel Tiret, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne Universités; Mehdi Karoui, Centre Hospitalier Universitaire (CHU) Pitié-Salpétrière; Anne Berger, CHU Hôpital Européen Georges-Pompidou; Jérome Loriau, Hôpital Saint-Joseph; Renato Lupinacci, Hôpital Croix Saint-Simon; Nicolas Goasgen, Hôpital des Diaconesses-Croix Saint-Simon, Paris; Laurent Mineur, Sainte-Camille Institut, Avignon; Eric Rullier, CHU Saint-André, Bordeaux; Philippe Rouanet, Val d'Aurelle Institut, Montpellier; Cécile de Chaisemartin, Paoli-Calmettes Institut, Marseille CHU, Marseille; Bernard Meunier, CHU Rennes, Rennes; Jafari Mehrdad, Oscar Lambret Center; Guillaume Piessen and Alain Saudemont, Centre Hospitalier Régional Universitaire, Lille; Eddy Cotte, CHU Lyon-Sud, Pierre-Bénite; Jérome Desrame, Jean Mermoz Institut, Lyon; Stéphane Benoist, CHU Bicètre, Le Kremlin-Bicêtre; Sylvain Kirzin, CHU Purpan, Toulouse; Yves Panis, Hôpital Beaujon, Université Paris VII, Clichy; Michel Prudhomme, CHU Carémeau, Nîmes; Frédérique Peschaud, CHU Ambroise-Paré, Boulogne-Billancourt; Anne Dubois, CHU Estaing, Clermont-Ferrand; Jean-Jacques Tuech, CHU, Rouen; and Guillaume Meurette, CHU Hôtel-Dieu, Nantes, France
| | - Alain Saudemont
- Jérémie H. Lefevre, Salma Kotti, Yann Parc, Tabassome Simon, and Emmanuel Tiret, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne Universités; Mehdi Karoui, Centre Hospitalier Universitaire (CHU) Pitié-Salpétrière; Anne Berger, CHU Hôpital Européen Georges-Pompidou; Jérome Loriau, Hôpital Saint-Joseph; Renato Lupinacci, Hôpital Croix Saint-Simon; Nicolas Goasgen, Hôpital des Diaconesses-Croix Saint-Simon, Paris; Laurent Mineur, Sainte-Camille Institut, Avignon; Eric Rullier, CHU Saint-André, Bordeaux; Philippe Rouanet, Val d'Aurelle Institut, Montpellier; Cécile de Chaisemartin, Paoli-Calmettes Institut, Marseille CHU, Marseille; Bernard Meunier, CHU Rennes, Rennes; Jafari Mehrdad, Oscar Lambret Center; Guillaume Piessen and Alain Saudemont, Centre Hospitalier Régional Universitaire, Lille; Eddy Cotte, CHU Lyon-Sud, Pierre-Bénite; Jérome Desrame, Jean Mermoz Institut, Lyon; Stéphane Benoist, CHU Bicètre, Le Kremlin-Bicêtre; Sylvain Kirzin, CHU Purpan, Toulouse; Yves Panis, Hôpital Beaujon, Université Paris VII, Clichy; Michel Prudhomme, CHU Carémeau, Nîmes; Frédérique Peschaud, CHU Ambroise-Paré, Boulogne-Billancourt; Anne Dubois, CHU Estaing, Clermont-Ferrand; Jean-Jacques Tuech, CHU, Rouen; and Guillaume Meurette, CHU Hôtel-Dieu, Nantes, France
| | - Michel Prudhomme
- Jérémie H. Lefevre, Salma Kotti, Yann Parc, Tabassome Simon, and Emmanuel Tiret, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne Universités; Mehdi Karoui, Centre Hospitalier Universitaire (CHU) Pitié-Salpétrière; Anne Berger, CHU Hôpital Européen Georges-Pompidou; Jérome Loriau, Hôpital Saint-Joseph; Renato Lupinacci, Hôpital Croix Saint-Simon; Nicolas Goasgen, Hôpital des Diaconesses-Croix Saint-Simon, Paris; Laurent Mineur, Sainte-Camille Institut, Avignon; Eric Rullier, CHU Saint-André, Bordeaux; Philippe Rouanet, Val d'Aurelle Institut, Montpellier; Cécile de Chaisemartin, Paoli-Calmettes Institut, Marseille CHU, Marseille; Bernard Meunier, CHU Rennes, Rennes; Jafari Mehrdad, Oscar Lambret Center; Guillaume Piessen and Alain Saudemont, Centre Hospitalier Régional Universitaire, Lille; Eddy Cotte, CHU Lyon-Sud, Pierre-Bénite; Jérome Desrame, Jean Mermoz Institut, Lyon; Stéphane Benoist, CHU Bicètre, Le Kremlin-Bicêtre; Sylvain Kirzin, CHU Purpan, Toulouse; Yves Panis, Hôpital Beaujon, Université Paris VII, Clichy; Michel Prudhomme, CHU Carémeau, Nîmes; Frédérique Peschaud, CHU Ambroise-Paré, Boulogne-Billancourt; Anne Dubois, CHU Estaing, Clermont-Ferrand; Jean-Jacques Tuech, CHU, Rouen; and Guillaume Meurette, CHU Hôtel-Dieu, Nantes, France
| | - Frédérique Peschaud
- Jérémie H. Lefevre, Salma Kotti, Yann Parc, Tabassome Simon, and Emmanuel Tiret, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne Universités; Mehdi Karoui, Centre Hospitalier Universitaire (CHU) Pitié-Salpétrière; Anne Berger, CHU Hôpital Européen Georges-Pompidou; Jérome Loriau, Hôpital Saint-Joseph; Renato Lupinacci, Hôpital Croix Saint-Simon; Nicolas Goasgen, Hôpital des Diaconesses-Croix Saint-Simon, Paris; Laurent Mineur, Sainte-Camille Institut, Avignon; Eric Rullier, CHU Saint-André, Bordeaux; Philippe Rouanet, Val d'Aurelle Institut, Montpellier; Cécile de Chaisemartin, Paoli-Calmettes Institut, Marseille CHU, Marseille; Bernard Meunier, CHU Rennes, Rennes; Jafari Mehrdad, Oscar Lambret Center; Guillaume Piessen and Alain Saudemont, Centre Hospitalier Régional Universitaire, Lille; Eddy Cotte, CHU Lyon-Sud, Pierre-Bénite; Jérome Desrame, Jean Mermoz Institut, Lyon; Stéphane Benoist, CHU Bicètre, Le Kremlin-Bicêtre; Sylvain Kirzin, CHU Purpan, Toulouse; Yves Panis, Hôpital Beaujon, Université Paris VII, Clichy; Michel Prudhomme, CHU Carémeau, Nîmes; Frédérique Peschaud, CHU Ambroise-Paré, Boulogne-Billancourt; Anne Dubois, CHU Estaing, Clermont-Ferrand; Jean-Jacques Tuech, CHU, Rouen; and Guillaume Meurette, CHU Hôtel-Dieu, Nantes, France
| | - Anne Dubois
- Jérémie H. Lefevre, Salma Kotti, Yann Parc, Tabassome Simon, and Emmanuel Tiret, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne Universités; Mehdi Karoui, Centre Hospitalier Universitaire (CHU) Pitié-Salpétrière; Anne Berger, CHU Hôpital Européen Georges-Pompidou; Jérome Loriau, Hôpital Saint-Joseph; Renato Lupinacci, Hôpital Croix Saint-Simon; Nicolas Goasgen, Hôpital des Diaconesses-Croix Saint-Simon, Paris; Laurent Mineur, Sainte-Camille Institut, Avignon; Eric Rullier, CHU Saint-André, Bordeaux; Philippe Rouanet, Val d'Aurelle Institut, Montpellier; Cécile de Chaisemartin, Paoli-Calmettes Institut, Marseille CHU, Marseille; Bernard Meunier, CHU Rennes, Rennes; Jafari Mehrdad, Oscar Lambret Center; Guillaume Piessen and Alain Saudemont, Centre Hospitalier Régional Universitaire, Lille; Eddy Cotte, CHU Lyon-Sud, Pierre-Bénite; Jérome Desrame, Jean Mermoz Institut, Lyon; Stéphane Benoist, CHU Bicètre, Le Kremlin-Bicêtre; Sylvain Kirzin, CHU Purpan, Toulouse; Yves Panis, Hôpital Beaujon, Université Paris VII, Clichy; Michel Prudhomme, CHU Carémeau, Nîmes; Frédérique Peschaud, CHU Ambroise-Paré, Boulogne-Billancourt; Anne Dubois, CHU Estaing, Clermont-Ferrand; Jean-Jacques Tuech, CHU, Rouen; and Guillaume Meurette, CHU Hôtel-Dieu, Nantes, France
| | - Jérome Loriau
- Jérémie H. Lefevre, Salma Kotti, Yann Parc, Tabassome Simon, and Emmanuel Tiret, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne Universités; Mehdi Karoui, Centre Hospitalier Universitaire (CHU) Pitié-Salpétrière; Anne Berger, CHU Hôpital Européen Georges-Pompidou; Jérome Loriau, Hôpital Saint-Joseph; Renato Lupinacci, Hôpital Croix Saint-Simon; Nicolas Goasgen, Hôpital des Diaconesses-Croix Saint-Simon, Paris; Laurent Mineur, Sainte-Camille Institut, Avignon; Eric Rullier, CHU Saint-André, Bordeaux; Philippe Rouanet, Val d'Aurelle Institut, Montpellier; Cécile de Chaisemartin, Paoli-Calmettes Institut, Marseille CHU, Marseille; Bernard Meunier, CHU Rennes, Rennes; Jafari Mehrdad, Oscar Lambret Center; Guillaume Piessen and Alain Saudemont, Centre Hospitalier Régional Universitaire, Lille; Eddy Cotte, CHU Lyon-Sud, Pierre-Bénite; Jérome Desrame, Jean Mermoz Institut, Lyon; Stéphane Benoist, CHU Bicètre, Le Kremlin-Bicêtre; Sylvain Kirzin, CHU Purpan, Toulouse; Yves Panis, Hôpital Beaujon, Université Paris VII, Clichy; Michel Prudhomme, CHU Carémeau, Nîmes; Frédérique Peschaud, CHU Ambroise-Paré, Boulogne-Billancourt; Anne Dubois, CHU Estaing, Clermont-Ferrand; Jean-Jacques Tuech, CHU, Rouen; and Guillaume Meurette, CHU Hôtel-Dieu, Nantes, France
| | - Jean-Jacques Tuech
- Jérémie H. Lefevre, Salma Kotti, Yann Parc, Tabassome Simon, and Emmanuel Tiret, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne Universités; Mehdi Karoui, Centre Hospitalier Universitaire (CHU) Pitié-Salpétrière; Anne Berger, CHU Hôpital Européen Georges-Pompidou; Jérome Loriau, Hôpital Saint-Joseph; Renato Lupinacci, Hôpital Croix Saint-Simon; Nicolas Goasgen, Hôpital des Diaconesses-Croix Saint-Simon, Paris; Laurent Mineur, Sainte-Camille Institut, Avignon; Eric Rullier, CHU Saint-André, Bordeaux; Philippe Rouanet, Val d'Aurelle Institut, Montpellier; Cécile de Chaisemartin, Paoli-Calmettes Institut, Marseille CHU, Marseille; Bernard Meunier, CHU Rennes, Rennes; Jafari Mehrdad, Oscar Lambret Center; Guillaume Piessen and Alain Saudemont, Centre Hospitalier Régional Universitaire, Lille; Eddy Cotte, CHU Lyon-Sud, Pierre-Bénite; Jérome Desrame, Jean Mermoz Institut, Lyon; Stéphane Benoist, CHU Bicètre, Le Kremlin-Bicêtre; Sylvain Kirzin, CHU Purpan, Toulouse; Yves Panis, Hôpital Beaujon, Université Paris VII, Clichy; Michel Prudhomme, CHU Carémeau, Nîmes; Frédérique Peschaud, CHU Ambroise-Paré, Boulogne-Billancourt; Anne Dubois, CHU Estaing, Clermont-Ferrand; Jean-Jacques Tuech, CHU, Rouen; and Guillaume Meurette, CHU Hôtel-Dieu, Nantes, France
| | - Guillaume Meurette
- Jérémie H. Lefevre, Salma Kotti, Yann Parc, Tabassome Simon, and Emmanuel Tiret, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne Universités; Mehdi Karoui, Centre Hospitalier Universitaire (CHU) Pitié-Salpétrière; Anne Berger, CHU Hôpital Européen Georges-Pompidou; Jérome Loriau, Hôpital Saint-Joseph; Renato Lupinacci, Hôpital Croix Saint-Simon; Nicolas Goasgen, Hôpital des Diaconesses-Croix Saint-Simon, Paris; Laurent Mineur, Sainte-Camille Institut, Avignon; Eric Rullier, CHU Saint-André, Bordeaux; Philippe Rouanet, Val d'Aurelle Institut, Montpellier; Cécile de Chaisemartin, Paoli-Calmettes Institut, Marseille CHU, Marseille; Bernard Meunier, CHU Rennes, Rennes; Jafari Mehrdad, Oscar Lambret Center; Guillaume Piessen and Alain Saudemont, Centre Hospitalier Régional Universitaire, Lille; Eddy Cotte, CHU Lyon-Sud, Pierre-Bénite; Jérome Desrame, Jean Mermoz Institut, Lyon; Stéphane Benoist, CHU Bicètre, Le Kremlin-Bicêtre; Sylvain Kirzin, CHU Purpan, Toulouse; Yves Panis, Hôpital Beaujon, Université Paris VII, Clichy; Michel Prudhomme, CHU Carémeau, Nîmes; Frédérique Peschaud, CHU Ambroise-Paré, Boulogne-Billancourt; Anne Dubois, CHU Estaing, Clermont-Ferrand; Jean-Jacques Tuech, CHU, Rouen; and Guillaume Meurette, CHU Hôtel-Dieu, Nantes, France
| | - Renato Lupinacci
- Jérémie H. Lefevre, Salma Kotti, Yann Parc, Tabassome Simon, and Emmanuel Tiret, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne Universités; Mehdi Karoui, Centre Hospitalier Universitaire (CHU) Pitié-Salpétrière; Anne Berger, CHU Hôpital Européen Georges-Pompidou; Jérome Loriau, Hôpital Saint-Joseph; Renato Lupinacci, Hôpital Croix Saint-Simon; Nicolas Goasgen, Hôpital des Diaconesses-Croix Saint-Simon, Paris; Laurent Mineur, Sainte-Camille Institut, Avignon; Eric Rullier, CHU Saint-André, Bordeaux; Philippe Rouanet, Val d'Aurelle Institut, Montpellier; Cécile de Chaisemartin, Paoli-Calmettes Institut, Marseille CHU, Marseille; Bernard Meunier, CHU Rennes, Rennes; Jafari Mehrdad, Oscar Lambret Center; Guillaume Piessen and Alain Saudemont, Centre Hospitalier Régional Universitaire, Lille; Eddy Cotte, CHU Lyon-Sud, Pierre-Bénite; Jérome Desrame, Jean Mermoz Institut, Lyon; Stéphane Benoist, CHU Bicètre, Le Kremlin-Bicêtre; Sylvain Kirzin, CHU Purpan, Toulouse; Yves Panis, Hôpital Beaujon, Université Paris VII, Clichy; Michel Prudhomme, CHU Carémeau, Nîmes; Frédérique Peschaud, CHU Ambroise-Paré, Boulogne-Billancourt; Anne Dubois, CHU Estaing, Clermont-Ferrand; Jean-Jacques Tuech, CHU, Rouen; and Guillaume Meurette, CHU Hôtel-Dieu, Nantes, France
| | - Nicolas Goasgen
- Jérémie H. Lefevre, Salma Kotti, Yann Parc, Tabassome Simon, and Emmanuel Tiret, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne Universités; Mehdi Karoui, Centre Hospitalier Universitaire (CHU) Pitié-Salpétrière; Anne Berger, CHU Hôpital Européen Georges-Pompidou; Jérome Loriau, Hôpital Saint-Joseph; Renato Lupinacci, Hôpital Croix Saint-Simon; Nicolas Goasgen, Hôpital des Diaconesses-Croix Saint-Simon, Paris; Laurent Mineur, Sainte-Camille Institut, Avignon; Eric Rullier, CHU Saint-André, Bordeaux; Philippe Rouanet, Val d'Aurelle Institut, Montpellier; Cécile de Chaisemartin, Paoli-Calmettes Institut, Marseille CHU, Marseille; Bernard Meunier, CHU Rennes, Rennes; Jafari Mehrdad, Oscar Lambret Center; Guillaume Piessen and Alain Saudemont, Centre Hospitalier Régional Universitaire, Lille; Eddy Cotte, CHU Lyon-Sud, Pierre-Bénite; Jérome Desrame, Jean Mermoz Institut, Lyon; Stéphane Benoist, CHU Bicètre, Le Kremlin-Bicêtre; Sylvain Kirzin, CHU Purpan, Toulouse; Yves Panis, Hôpital Beaujon, Université Paris VII, Clichy; Michel Prudhomme, CHU Carémeau, Nîmes; Frédérique Peschaud, CHU Ambroise-Paré, Boulogne-Billancourt; Anne Dubois, CHU Estaing, Clermont-Ferrand; Jean-Jacques Tuech, CHU, Rouen; and Guillaume Meurette, CHU Hôtel-Dieu, Nantes, France
| | - Yann Parc
- Jérémie H. Lefevre, Salma Kotti, Yann Parc, Tabassome Simon, and Emmanuel Tiret, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne Universités; Mehdi Karoui, Centre Hospitalier Universitaire (CHU) Pitié-Salpétrière; Anne Berger, CHU Hôpital Européen Georges-Pompidou; Jérome Loriau, Hôpital Saint-Joseph; Renato Lupinacci, Hôpital Croix Saint-Simon; Nicolas Goasgen, Hôpital des Diaconesses-Croix Saint-Simon, Paris; Laurent Mineur, Sainte-Camille Institut, Avignon; Eric Rullier, CHU Saint-André, Bordeaux; Philippe Rouanet, Val d'Aurelle Institut, Montpellier; Cécile de Chaisemartin, Paoli-Calmettes Institut, Marseille CHU, Marseille; Bernard Meunier, CHU Rennes, Rennes; Jafari Mehrdad, Oscar Lambret Center; Guillaume Piessen and Alain Saudemont, Centre Hospitalier Régional Universitaire, Lille; Eddy Cotte, CHU Lyon-Sud, Pierre-Bénite; Jérome Desrame, Jean Mermoz Institut, Lyon; Stéphane Benoist, CHU Bicètre, Le Kremlin-Bicêtre; Sylvain Kirzin, CHU Purpan, Toulouse; Yves Panis, Hôpital Beaujon, Université Paris VII, Clichy; Michel Prudhomme, CHU Carémeau, Nîmes; Frédérique Peschaud, CHU Ambroise-Paré, Boulogne-Billancourt; Anne Dubois, CHU Estaing, Clermont-Ferrand; Jean-Jacques Tuech, CHU, Rouen; and Guillaume Meurette, CHU Hôtel-Dieu, Nantes, France
| | - Tabassome Simon
- Jérémie H. Lefevre, Salma Kotti, Yann Parc, Tabassome Simon, and Emmanuel Tiret, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne Universités; Mehdi Karoui, Centre Hospitalier Universitaire (CHU) Pitié-Salpétrière; Anne Berger, CHU Hôpital Européen Georges-Pompidou; Jérome Loriau, Hôpital Saint-Joseph; Renato Lupinacci, Hôpital Croix Saint-Simon; Nicolas Goasgen, Hôpital des Diaconesses-Croix Saint-Simon, Paris; Laurent Mineur, Sainte-Camille Institut, Avignon; Eric Rullier, CHU Saint-André, Bordeaux; Philippe Rouanet, Val d'Aurelle Institut, Montpellier; Cécile de Chaisemartin, Paoli-Calmettes Institut, Marseille CHU, Marseille; Bernard Meunier, CHU Rennes, Rennes; Jafari Mehrdad, Oscar Lambret Center; Guillaume Piessen and Alain Saudemont, Centre Hospitalier Régional Universitaire, Lille; Eddy Cotte, CHU Lyon-Sud, Pierre-Bénite; Jérome Desrame, Jean Mermoz Institut, Lyon; Stéphane Benoist, CHU Bicètre, Le Kremlin-Bicêtre; Sylvain Kirzin, CHU Purpan, Toulouse; Yves Panis, Hôpital Beaujon, Université Paris VII, Clichy; Michel Prudhomme, CHU Carémeau, Nîmes; Frédérique Peschaud, CHU Ambroise-Paré, Boulogne-Billancourt; Anne Dubois, CHU Estaing, Clermont-Ferrand; Jean-Jacques Tuech, CHU, Rouen; and Guillaume Meurette, CHU Hôtel-Dieu, Nantes, France
| | - Emmanuel Tiret
- Jérémie H. Lefevre, Salma Kotti, Yann Parc, Tabassome Simon, and Emmanuel Tiret, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne Universités; Mehdi Karoui, Centre Hospitalier Universitaire (CHU) Pitié-Salpétrière; Anne Berger, CHU Hôpital Européen Georges-Pompidou; Jérome Loriau, Hôpital Saint-Joseph; Renato Lupinacci, Hôpital Croix Saint-Simon; Nicolas Goasgen, Hôpital des Diaconesses-Croix Saint-Simon, Paris; Laurent Mineur, Sainte-Camille Institut, Avignon; Eric Rullier, CHU Saint-André, Bordeaux; Philippe Rouanet, Val d'Aurelle Institut, Montpellier; Cécile de Chaisemartin, Paoli-Calmettes Institut, Marseille CHU, Marseille; Bernard Meunier, CHU Rennes, Rennes; Jafari Mehrdad, Oscar Lambret Center; Guillaume Piessen and Alain Saudemont, Centre Hospitalier Régional Universitaire, Lille; Eddy Cotte, CHU Lyon-Sud, Pierre-Bénite; Jérome Desrame, Jean Mermoz Institut, Lyon; Stéphane Benoist, CHU Bicètre, Le Kremlin-Bicêtre; Sylvain Kirzin, CHU Purpan, Toulouse; Yves Panis, Hôpital Beaujon, Université Paris VII, Clichy; Michel Prudhomme, CHU Carémeau, Nîmes; Frédérique Peschaud, CHU Ambroise-Paré, Boulogne-Billancourt; Anne Dubois, CHU Estaing, Clermont-Ferrand; Jean-Jacques Tuech, CHU, Rouen; and Guillaume Meurette, CHU Hôtel-Dieu, Nantes, France
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Plastiras A, Sideris M, Gaya A, Haji A, Nunoo-Mensah J, Haq A, Papagrigoriadis S. Waiting Time following Neoadjuvant Chemoradiotherapy for Rectal Cancer: Does It Really Matter. Gastrointest Tumors 2017; 4:96-103. [PMID: 29594111 DOI: 10.1159/000484982] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 11/02/2017] [Indexed: 01/04/2023] Open
Abstract
Background Neoadjuvant chemoradiotherapy (CRT) is considered the standard approach before any surgical intervention for locally advanced rectal tumors and has been proven to significantly improve the local recurrence rates of rectal cancer. However, the optimal timing of surgical resection after neoadjuvant CRT remains debatable. Objective and Methods We conducted a retrospective review of 65 consecutive patients with locally advanced rectal cancer who underwent preoperative CRT followed by surgical resection in order to evaluate the optimal time for surgical treatment. We used two alternative groups for analysis: patients who underwent surgery up to 6 weeks after CRT (n = 28) and those who underwent surgery 6 weeks or more after CRT (n = 27). Also, we compared patients who were operated on within 3 months (n = 39) with those who underwent surgical resection after more than 3 months (n = 16). Nonresponders to CRT were excluded from the analysis. Results There was no statistically significant association between waiting period post CRT and radiological downstaging for any group (p > 0.05 for any association). Also, there was no association between recurrence of disease, cancer-related deaths, perineural invasion, or positive lymph node ratio and any waiting period up to 3 months (p > 0.05 for all associations). Conclusion In this small exploratory study there was no evident difference in outcome according to timing of surgery, which suggests that further research in larger cohorts is warranted.
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Affiliation(s)
- Aris Plastiras
- King's College Hospital, NHS Foundation Trust, London, United Kingdom
| | - Michail Sideris
- King's College Hospital, NHS Foundation Trust, London, United Kingdom
| | - Andy Gaya
- Guy's and St. Thomas' Hospital, NHS Foundation Trust, London, United Kingdom
| | - Amyn Haji
- King's College Hospital, NHS Foundation Trust, London, United Kingdom
| | | | - Asif Haq
- King's College Hospital, NHS Foundation Trust, London, United Kingdom
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Huang MJ, Wang XD, Hu YJ, Yang J, Li K. Short-course neoadjuvant chemoradiotherapy and surgery are beneficial in Chinese patients: A retrospective study. Medicine (Baltimore) 2017; 96:e9394. [PMID: 29390548 PMCID: PMC5758250 DOI: 10.1097/md.0000000000009394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Revised: 11/13/2017] [Accepted: 11/29/2017] [Indexed: 02/05/2023] Open
Abstract
Preoperative neoadjuvant chemoradiotherapy (NACR) is used to reduce tumor size for easier resection or improved resectability rates. Considering the difficulties regarding health insurance and health resources in China, an evidence-based short-course neoadjuvant chemoradiotherapy with surgery to cure patients was performed. This study compared the postoperative effects between short-course neoadjuvant chemoradiotherapy and surgery and surgery without neoadjuvant chemoradiotherapy.The current retrospective study was based on a rectal cancer database, including 274 patients diagnosed with rectal cancer between January 2014 and October 2016. Data were analyzed with respect to curative rate, postoperative recovery indicators (times to nasogastric tube, urinary catheter, and drainage tube removal and times to first oral feeding and passing of flatus postsurgery), chemoradiotherapy-related indicators [white blood cell count (WBC) and carcinoembryonic antigen (CEA) levels], and adverse effects indicators, evaluated according to Common Terminology Criteria for Adverse Events Version 4.0.There was no significant difference between the combined therapy and surgery groups (P > .05) in terms of radical resection rates and the times to urinary catheter removal and passing flatus (P > .05). Statistically significant differences (P < .05) in terms of earlier time for removal of the nasogastric and drainage tubes and time to first oral feeding were observed in the combined therapy group. The decreases in WBC and CEA levels in the combined therapy group were significantly greater than those in the surgery group 1 week after surgery (P < .05); after 1 month, the CEA decrease in the combined therapy group was significantly greater than that in the surgery group (P < .05). More patients in the combined therapy group experienced vomiting, indigestion, dehydration, oral mucositis, sensory neuritis, and alopecia compared with those in the surgery group 1 week after surgery (P < .05); after 1 month, only the incidence of alopecia was higher in the combined therapy group (P < .05).The combined therapy group demonstrated earlier postoperative recovery compared with the surgery group. Short-course neoadjuvant chemoradiotherapy with surgery may lead to postoperative treatment-related adverse effects of varying degrees; however, these adverse effects eventually improve with time.
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Affiliation(s)
| | | | - Yan Jie Hu
- Department of Hepatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jie Yang
- Department of Gastrointestinal Surgery
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Du D, Su Z, Wang D, Liu W, Wei Z. Optimal Interval to Surgery After Neoadjuvant Chemoradiotherapy in Rectal Cancer: A Systematic Review and Meta-analysis. Clin Colorectal Cancer 2017; 17:13-24. [PMID: 29153429 DOI: 10.1016/j.clcc.2017.10.012] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 10/10/2017] [Accepted: 10/14/2017] [Indexed: 12/16/2022]
Abstract
This study aimed to evaluate the influence of a waiting interval of ≥ 8 weeks between the end of preoperative neoadjuvant chemoradiotherapy (nCRT) and surgery on the outcomes of patients with locally advanced rectal cancer. We conducted a comprehensive literature review of retrospective and prospective studies from PubMed, Embase, and Cochrane Library databases to investigate the length of the preoperative nCRT-surgery waiting interval and outcomes in patients with locally advanced rectal cancer. The primary outcome measure was pathologic complete response (pCR) rate. Secondary outcome measures included overall survival, disease-free survival, operative time, and the incidence of local recurrence, postoperative complications, anastomotic leakage, and sphincter-preserving surgery. Standardized mean differences and risk ratios were calculated. Thirteen studies involving 19,652 patients were included. The meta-analysis demonstrated that pCR was significantly increased in patients with locally advanced rectal cancer and a waiting interval of ≥ 8 weeks between preoperative nCRT and surgery compared to a waiting interval of < 8 weeks, or a waiting interval of > 8 weeks compared to ≤ 8 weeks (risk ratio = 1.25; 95% confidence interval, 1.16-1.35; P < .0001). There were no significant differences in overall survival, disease-free survival, operative time, or incidence of local recurrence, postoperative complications, or sphincter-preserving surgery. This study revealed that performing surgery after a waiting interval of ≥ 8 weeks after the end of preoperative nCRT is safe and efficacious for patients with locally advanced rectal cancer, significantly improving pCR without increasing operative time or incidence of postoperative complications, compared to a waiting interval of ≤ 8 weeks.
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Affiliation(s)
- Donglin Du
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhourong Su
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Dan Wang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wenwen Liu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhengqiang Wei
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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Macchia G, Gambacorta MA, Masciocchi C, Chiloiro G, Mantello G, di Benedetto M, Lupattelli M, Palazzari E, Belgioia L, Bacigalupo A, Sainato A, Montrone S, Turri L, Caroli A, De Paoli A, Matrone F, Capirci C, Montesi G, Niespolo RM, Osti MF, Caravatta L, Galardi A, Genovesi D, Rosetto ME, Boso C, Sciacero P, Giaccherini L, Parisi S, Fontana A, Filippone FR, Picardi V, Morganti AG, Valentini V. Time to surgery and pathologic complete response after neoadjuvant chemoradiation in rectal cancer: A population study on 2094 patients. Clin Transl Radiat Oncol 2017; 4:8-14. [PMID: 29594202 PMCID: PMC5833913 DOI: 10.1016/j.ctro.2017.04.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 03/22/2017] [Accepted: 04/20/2017] [Indexed: 01/27/2023] Open
Abstract
A large population based analysis to evaluate pathologic response according to time of surgery. LARC patients were treated with modern techniques of radiotherapy and surgery. The rate of pCR increased according to time interval from 12.6% to 31.1%. The pCR increasing was 1.5% (about 0.2%/die) per each week of waiting. Lengthening the interval (>13 weeks) significantly improved the pathological response.
Background To retrospectively evaluate the difference in terms of pathologic complete response (pCR) according to time elapsed between chemoradiation (CRT) and total mesorectal excision (TME) on a large unselected real-life dataset of locally advanced rectal cancer (LARC) patients. Methods A multicentre retrospective cohort study of LARC patients from 21 Italian Radiotherapy Institutions was performed. Patients were stratified into 3 different time intervals from CRT. The 1st group included 300 patients who underwent TME within 6 weeks, the 2nd 1598 patients (TME within 7–12 weeks) and the 3rd 196 patients (TME within 13 or more weeks after CRT), respectively. Results Data on 2094 LARC patients treated between 1997 and 2016 were considered suitable for analysis. Overall, 578 patients had stage II while 1516 had stage III histological proven invasive rectal adenocarcinoma. A CRT schedule of one agent (N = 1585) or 2-drugs (N = 509) was administered. Overall, pCR was 22.3% (N = 468 patients). The proportion of patients achieving pCR with respect to time interval was, as follows: 12.6% (1st group), 23% (2nd group) and 31.1% (3rd group) (p < 0.001), respectively. The pCR relative risk comparison of 2nd to 1st group was 1.8, while 3rd to 2nd group was 1.3. Moreover, between the 3rd and 1st group, a pCR relative risk of 2.4 (p < 0.01) was noted. At univariate analysis, clinical stage III (p < 0.001), radiotherapy dose >5040 cGy (p = 0.002) and longer interval (p < 0.001) were significantly correlated to pCR. The positive impact of interval (p < 0.001) was confirmed at multivariate analysis as the only correlated factor. Conclusion We confirmed on a population-level that lengthening the interval (>13 weeks) from CRT to surgery improves the pathological response (pCR and pathologic partial response; pPR) in comparison to historic data. Furthermore, radiotherapy dose >5040 cGy and two drugs chemotherapy correlated with pPR rate.
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Affiliation(s)
- Gabriella Macchia
- Radiotherapy Unit, Fondazione di Ricerca e Cura "Giovanni Paolo II", Università Cattolica S. Cuore, Campobasso, Italy
| | | | - Carlotta Masciocchi
- Department of Radiotherapy, Fondazione "Policlinico Gemelli", Università Cattolica S. Cuore, Roma, Italy
| | - Giuditta Chiloiro
- Department of Radiotherapy, Fondazione "Policlinico Gemelli", Università Cattolica S. Cuore, Roma, Italy
| | - Giovanna Mantello
- Radiotherapy Unit, Azienda Ospedaliero Universitaria, Ospedali Riuniti Ancona, Italy
| | - Maika di Benedetto
- Radiotherapy Unit, Azienda Ospedaliero Universitaria, Ospedali Riuniti Ancona, Italy
| | - Marco Lupattelli
- Radiotherapy Unit, 'S. Maria della Misericordia' Hospital, Perugia, Italy
| | - Elisa Palazzari
- Radiotherapy Unit, 'S. Maria della Misericordia' Hospital, Perugia, Italy
| | - Liliana Belgioia
- Radiotherapy Unit, AOU IRCCS San Martino, IST National Cancer Research Institute, Genova, Italy
| | - Almalina Bacigalupo
- Radiotherapy Unit, AOU IRCCS San Martino, IST National Cancer Research Institute, Genova, Italy
| | - Aldo Sainato
- Radiotherapy Unit, University Hospital, Pisa, Italy
| | | | - Lucia Turri
- Radiotherapy Unit, 'Maggiore della Carità' Hospital, Novara, Italy
| | - Angela Caroli
- Radiotherapy Unit, 'Maggiore della Carità' Hospital, Novara, Italy
| | - Antonino De Paoli
- Radiation Oncology Department, Oncological Referral Center, Aviano, Italy
| | - Fabio Matrone
- Radiation Oncology Department, Oncological Referral Center, Aviano, Italy
| | | | | | | | - Mattia Falchetto Osti
- Department of Radiation Oncology, Facoltà di Medicina e Psicologia, Università Sapienza, Roma, Italy
| | - Luciana Caravatta
- Radiation Oncology Department, 'A. Businco' Regional Oncological Hospital, Cagliari, Italy
| | | | - Domenico Genovesi
- Radiotherapy Unit, 'SS Annunziata' Hospital, 'G.D'Annunzio' University, Chieti, Italy
| | | | - Caterina Boso
- Radiotherapy and Nuclear Medicine Unit, Veneto Institute of Oncology-IRCCS, Padova, Italy
| | - Piera Sciacero
- Radiotherapy Unit, ASL TO4, General Hospital, Ivrea, Italy
| | - Lucia Giaccherini
- Radiation Oncology Center, Department of Experimental, Diagnostic and Speciality Medicine-DIMES-University of Bologna, S. Orsola-Malpighi Hospital, Italy
| | - Salvatore Parisi
- Radiotherapy Unit, Casa Sollievo della Sofferenza, IRCCS-CSS San Giovanni Rotondo, Italy
| | | | | | - Vincenzo Picardi
- Radiotherapy Unit, Fondazione di Ricerca e Cura "Giovanni Paolo II", Università Cattolica S. Cuore, Campobasso, Italy
| | - Alessio Giuseppe Morganti
- Radiation Oncology Center, Department of Experimental, Diagnostic and Speciality Medicine-DIMES-University of Bologna, S. Orsola-Malpighi Hospital, Italy
| | - Vincenzo Valentini
- Department of Radiotherapy, Fondazione "Policlinico Gemelli", Università Cattolica S. Cuore, Roma, Italy
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García-Cabezas S, Rodríguez-Liñán M, Otero-Romero AM, Bueno-Serrano CM, Gómez-Barbadillo J, Palacios-Eito A. Respuesta al tratamiento e intervalo de tiempo hasta la cirugía con radioterapia preoperatoria de curso corto en el cáncer de recto. Cir Esp 2016; 94:460-6. [DOI: 10.1016/j.ciresp.2016.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 05/10/2016] [Accepted: 06/05/2016] [Indexed: 01/13/2023]
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Does Extending the Waiting Time of Low-Rectal Cancer Surgery after Neoadjuvant Chemoradiation Increase the Perioperative Complications? Gastroenterol Res Pract 2016; 2016:7870815. [PMID: 27738430 PMCID: PMC5055975 DOI: 10.1155/2016/7870815] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 09/01/2016] [Indexed: 12/22/2022] Open
Abstract
Background. Traditionally, rectal cancer surgery is recommended 6 to 8 weeks after completing neoadjuvant chemoradiation. Extending the waiting time may increase the tumor response rate. However, the perioperative complication rate may increase. The purpose of this study was to determine the association between extending the waiting time of surgery after neoadjuvant chemoradiation and perioperative outcomes. Methods. Sixty patients with locally advanced rectal cancer who underwent neoadjuvant chemoradiation followed by radical resection at Siriraj hospital between June 2012 and January 2015 were retrospectively analyzed. Demographic data and perioperative outcomes were compared between the two groups. Results. The two groups were comparable in term of demographic parameters. The mean time interval from neoadjuvant chemoradiation to surgery was 6.4 weeks in Group A and 11.7 weeks in Group B. The perioperative outcomes were not significantly different between Groups A and B. Pathologic examination showed a significantly higher rate of circumferential margin positivity in Group A than in Group B (30% versus 9.3%, resp.; P = 0.04). Conclusions. Extending the waiting to >8 weeks from neoadjuvant chemoradiation to surgery did not increase perioperative complications, whereas the rate of circumferential margin positivity decreased.
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Wei D. Surgical treatment of low rectal cancer: Current status and future prospects. Shijie Huaren Xiaohua Zazhi 2016; 24:3238-3247. [DOI: 10.11569/wcjd.v24.i21.3238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Rectal cancer is a common type of malignant tumor in China, and its incidence rate is rising year by year. Middle and low rectal cancer accounts for 70%-80% of all rectal cancer cases. The treatment concept requires not only radical resection of tumor, but also preservation of the anal and urogenital function, in order to improve the quality of life. Improved surgical technique requires laparoscopic minimally invasive surgery, to reduce trauma and shorten hospital stay. To improve the 5-year disease-free survival rate, correct treatment of distant metastases, especially liver metastases, is required. By improving the accuracy of preoperative staging of rectal cancer, applying neoadjuvant therapy, and following the principle of total mesorectal excision, patients can benefit in terms of increased resection rate, decreased operation complication incidence, increased sphincter preservation, decreased local recurrence and increased overall survival rate. With the development of medical technology, minimally invasive surgery for low rectal cancer has been developed rapidly. Surgical resection is the only curative method in the therapy of rectal cancer and liver metastases. However, there are still some doubts concerning what to resect first in cases of synchronous rectal cancer and liver metastases in order to achieve the best results. In this paper, we discuss new progress in the surgical treatment of low rectal cancer and rectal cancer liver metastases.
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Increasing the Interval Between Neoadjuvant Chemoradiotherapy and Surgery in Rectal Cancer: A Meta-analysis of Published Studies. Ann Surg 2016; 263:458-64. [PMID: 24263329 DOI: 10.1097/sla.0000000000000368] [Citation(s) in RCA: 173] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE The aim of this meta-analysis was to demonstrate whether a longer interval between the end of neoadjuvant chemoradiotherapy (CRT) and surgery is associated with a better rate of pathological complete response (pCR) in rectal cancer. BACKGROUND The standard of care in locally advanced rectal cancer is preoperative, long course (5-fluorouracil-based) CRT. After this neoadjuvant CRT, surgical exploration is undertaken 6 to 8 weeks later. METHODS PubMed, EMBASE, the ISI Web of Science, and The Cochrane Library (CENTRAL) were searched systematically for prospective or retrospective studies reporting oncological results for intervals longer or shorter than 6 to 8 weeks between the end of CRT and surgery, in rectal cancer. The primary endpoint, reported as relative risk (RR), was the rate of pCR. Secondary endpoints were overall survival (OS), disease-free survival (DFS), R0 resection rates, sphincter preservations, and wound/anastomotic complications. A meta-analysis was performed, using the fixed- or random-effects model, with Review Manager 5.1. RESULTS Thirteen trials, including 3584 patients, were identified, and overall, an interval longer than 6 to 8 weeks from the end of neoadjuvant CRT and surgery significantly improved the pCR (RR = 1.42, 95% confidence interval: 1.19-1.68; P < 0.0001). Pathological complete responses increased from 13.7% to 19.5% in the longer interval group, and the OS, DFS, R0 resection rates, sphincter preservation, and complication rates were similar in the 2 groups. CONCLUSIONS A longer waiting interval (more than the classical 6-8 weeks) from the end of preoperative CRT increases the rate of pCR by 6% in rectal cancer, with similar outcomes and complication rates. These results should be validated prospectively in a randomized trial.
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Wang XJ, Zheng ZR, Chi P, Lin HM, Lu XR, Huang Y. Effect of Interval between Neoadjuvant Chemoradiotherapy and Surgery on Oncological Outcome for Rectal Cancer: A Systematic Review and Meta-Analysis. Gastroenterol Res Pract 2016; 2016:6756859. [PMID: 27190505 PMCID: PMC4829714 DOI: 10.1155/2016/6756859] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 11/09/2015] [Accepted: 11/10/2015] [Indexed: 12/18/2022] Open
Abstract
Aim. To evaluate the influence of interval between neoadjuvant chemoradiotherapy (NCRT) and surgery on oncological outcome. Methods. A systematic search was conducted in PubMed, the Cochrane Library, and Embase databases for publications reporting oncological outcomes of patients following rectal cancer surgery performed at different NCRT-surgery intervals. Relative risk (RR) of pathological complete response (pCR) among different intervals was pooled. Results. Fifteen retrospective cohort studies representing 4431 patients met the inclusion criteria. There was a significantly increased rate of pCR in patients treated with surgery followed 7 or 8 weeks later (RR, 1.45; 95% CI, 1.18-1.78; and P < 0.01 and RR, 1.49; 95% CI, 1.15-1.92; and P = 0.002, resp.). There is no consistent evidence of improved local control or overall survival with longer or shorter intervals. Conclusion. Performing surgery 7-8 weeks after the end of NCRT results in the highest chance of achieving pCR. For candidates of abdominoperineal resection before NCRT, these data support implementation of prolonging the interval after NCRT to optimize the chances of pCR and perhaps add to the possibility of ultimate organ preservation.
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Affiliation(s)
- Xiao-Jie Wang
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian 350001, China
| | - Zheng-Rong Zheng
- Oncology Department, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian 360000, China
| | - Pan Chi
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian 350001, China
| | - Hui-Ming Lin
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian 350001, China
| | - Xing-Rong Lu
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian 350001, China
| | - Ying Huang
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian 350001, China
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Akbar A, Bhatti ABH, Niazi SK, Syed AA, Khattak S, Raza SH, Kazmi AS. Impact of Time Interval Between Chemoradiation and Surgery on Pathological Complete Response and Survival in Rectal Cancer. Asian Pac J Cancer Prev 2016; 17:89-93. [PMID: 26838260 DOI: 10.7314/apjcp.2016.17.1.89] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Ali Akbar
- Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital Research Centre, Lahore, Pakistan E-mail :
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Increasing the Interval Between Neoadjuvant Chemoradiotherapy and Surgery in Rectal Cancer. Ann Surg 2015; 262:e116. [DOI: 10.1097/sla.0000000000000771] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Sirohi B, Barreto SG, Patkar S, Gupta A, DeSouza A, Talole S, Deodhar K, Shetty N, Engineer R, Goel M, Shrikhande SV. Down-staging following neoadjuvant chemo-radiotherapy for locally advanced rectal cancer: Does timing of surgery really matter? Indian J Med Paediatr Oncol 2014; 35:263-6. [PMID: 25538402 PMCID: PMC4264271 DOI: 10.4103/0971-5851.144986] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background: Neoadjuvant chemoradiotherapy (NACTRT) improves local recurrence rate in locally advanced (LA) rectal cancer with no survival benefit. Pathological complete response (pCR) post-NACTRT is associated with improved outcome. Debate is ongoing as to when would be the opportune time to operate. Aim: To determine if greater down-staging can be achieved by a longer time interval from NACTRT to surgery (tumor regression score [TRS]) and whether this would impact sphincter saving surgery rates and early relapse rates. Materials and Methods: A retrospective analysis of a prospectively maintained database of patients with LA rectal adenocarcinoma treated from January 2012 to August 2013 was carried out. One hundred and ten patients who completed NACTRT (50 Gy/25 fractions with capecitabine 825 mg/m2 twice daily) followed by surgical resection were included. For response evaluation patients were divided into two groups, Group 1 (TRS ≤60 days, n = 42) and 2 (TRS >60 days, n = 68). Tumor down-staging, pCR rate, tumor regression grade (TRG) post-NACTRT and relapse rates were correlated with TRS. Results: Of 110 patients (median age: 49 years (21-73), 71% males; 18 (16.5%) with signet ring histology) 96% patients underwent an R0 resection. Post-NACTRT, CR was attained in 5 (4.5%), partial response in 98 (89%) and stable disease in 7 (6.4%) patients. Median time from completion of NACTRT to surgery was 64.5 days (6-474). Median lymph nodes harvested were 10 (1-50). Overall, 22 (20%) patients achieved pCR. 26 (62%) patients in Group 1 compared to 36 (53%) in Group 2 underwent sphincter sparing surgery (SSS) (P = 0.357). Six patients (14%) in Group 1 and 16 (24%) in Group 2 achieved pCR (P = 0.24). Median TRG in both groups was three. Conclusion: Timing of surgery following NACTRT for LA rectal cancer does not influence pathological response, ability to perform SSS or disease-free survival. There is no incremental benefit of delaying the surgery though this needs to be confirmed in a prospective randomized trial.
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Affiliation(s)
- Bhawna Sirohi
- Department of Medical Oncology, Tata Memorial Centre, Parel, Mumbai, Maharashtra, India
| | - Savio George Barreto
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Centre, Parel, Mumbai, Maharashtra, India
| | - Shraddha Patkar
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Centre, Parel, Mumbai, Maharashtra, India
| | - Alok Gupta
- Department of Medical Oncology, Tata Memorial Centre, Parel, Mumbai, Maharashtra, India
| | - Ashwin DeSouza
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Centre, Parel, Mumbai, Maharashtra, India
| | - Sanjay Talole
- Department of Biostatistics, Tata Memorial Centre, Parel, Mumbai, Maharashtra, India
| | - Kedar Deodhar
- Department of Pathology, Tata Memorial Centre, Parel, Mumbai, Maharashtra, India
| | - Nitin Shetty
- Department of Radiodiagnosis, Tata Memorial Centre, Parel, Mumbai, Maharashtra, India
| | - Reena Engineer
- Department of Radiation Oncology, Tata Memorial Centre, Parel, Mumbai, Maharashtra, India
| | - Mahesh Goel
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Centre, Parel, Mumbai, Maharashtra, India
| | - Shailesh V Shrikhande
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Centre, Parel, Mumbai, Maharashtra, India
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Patrlj L, Kopljar M, Kliček R, Patrlj MH, Kolovrat M, Rakić M, Đuzel A. The surgical treatment of patients with colorectal cancer and liver metastases in the setting of the "liver first" approach. Hepatobiliary Surg Nutr 2014; 3:324-9. [PMID: 25392845 PMCID: PMC4207835 DOI: 10.3978/j.issn.2304-3881.2014.09.12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 09/16/2014] [Indexed: 02/05/2023]
Abstract
A surgical resection is the only curative method in the therapy of colorectal carcinoma and liver metastases. Along with the development of interventional radiological techniques the indications for surgery widen. The number of metastases and patients age should not present a contraindication for surgical resection. However, there are still some doubts concerns what to resect first in cases of synchronous colorectal carcinoma and liver metastases and how to ensure the proper remnant liver volume in order to avoid postoperative liver failure and achieve the best results. Through this review the surgical therapy of colorectal carcinoma and liver metastases was revised in the setting of "liver-first" approach and the problem of ensuring of remnant liver volume.
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Tian HH, Wang HF, Zhang JR, Ayiguli·Hare, Yisikandaer·Abulimiti. Impact of interval between preoperative chemotherapy and surgery on therapeutic effects in patients with stage ⅢA and ⅢB rectal cancer. Shijie Huaren Xiaohua Zazhi 2014; 22:3918-3924. [DOI: 10.11569/wcjd.v22.i26.3918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess whether the time interval between neoadjuvant chemoradiotherapy and surgery affects the pathologic complete response (pCR) rate, disease-free survival (DFS), disease recurrence and overall survival (OS) in patients with stage ⅢA and ⅢB rectal cancer.
METHODS: We retrospectively studied 93 patients diagnosed with stage ⅢA and ⅢB rectal cancer by pathological examination who underwent neoadjuvant therapy followed by total mesorectal excision (TME) between March 2009 and March 2011 at our hospital. They were divided into two groups according to the interval between neoadjuvant therapy and surgery: A (≤7 wk, n = 49) and B (>7 wk, n = 44). The primary endpoints were reported as pCR rate, DFS, disease recurrence and OS. Secondary endpoints were type of surgery, postoperative complications, operative time and length of hospital stay.
RESULTS: The overall pCR rate was 10.75% (pCR: group A vs group B, 8.2% vs 13.6%; P = 0.027), and the overall 3-year DFS was 39.8% (DFS: group A vs group B, 28.6% vs 52.3%; P = 0.013). Disease recurrence was 20.4% in group A vs 4.5% in group B (P = 0.023). There were no significant differences in OS, type of surgery, postoperative complications, operative time or length of hospital stay between the two groups.
CONCLUSION: A neoadjuvant-surgery interval > 7 wk increases the rates of pCR and DFS and decreases disease recurrence in patients with stage ⅢA and ⅢB rectal cancer, with no effect on type of surgery, postoperative complications, operative time, length of hospital stay or oncologic outcome.
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Prognostic factors for postoperative morbidity and tumour response after neoadjuvant chemoradiation followed by resection for rectal cancer. J Gastrointest Surg 2014; 18:1648-57. [PMID: 24939597 DOI: 10.1007/s11605-014-2559-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2014] [Accepted: 05/27/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND PURPOSE In patients with locally advanced rectal cancer treated with neoadjuvant chemoradiation followed by rectal resection, postoperative morbidity is a significant clinical problem. Pathologic complete tumour response seems to give the best prognosis in the long term. Little is known about the factors that are associated with postoperative complications and pathologic complete response. The aim of this retrospective study was to identify and describe these factors. METHODS Ninety-nine consecutive patients with locally advanced rectal cancer who underwent neoadjuvant chemoradiation (50 Gy and capecitabine) followed by surgery at our institute between January 2007 and May 2012 were identified. Postoperative complications were graded according to the Clavien-Dindo classification. Pathologic tumour response was categorized as complete response or no/partial response. RESULTS Postoperative complications occurred in 68 patients (69%) and grade 3-5 complications in 25 patients (25%). The 30-day and 90-day mortality were 1% (n = 1) and 2% (n = 2), respectively. A young age (p = 0.021) and a preoperative or postoperative blood transfusion (p = 0.015) independently predicted complications. Intraoperative or postoperative blood transfusion (p = 0.007) and ypT0-1 stage (p = 0.037) were independent predictors for grade 3-5 complications. Complete response rate was 22% (n = 22); 4% (n = 4) of patients showed no response. No independent factors predicting complete response were found. CONCLUSIONS Neoadjuvant chemoradiation followed by rectal resection is associated with significant postoperative morbidity but minimal postoperative mortality. A complete response rate of 22% was achieved.
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Reply to Letter: "Increasing the Interval Between Neoadjuvant Chemoradiotherapy and Surgery in Rectal Cancer: A Meta-analysis of Published Studies". Ann Surg 2014; 262:e116-7. [PMID: 24887979 DOI: 10.1097/sla.0000000000000772] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Calvo FA, Morillo V, Santos M, Serrano J, Gomez-Espí M, Rodriguez M, Del Vale E, Gracia-Sabrido JL, Ferrer C, Sole C. Interval between neoadjuvant treatment and definitive surgery in locally advanced rectal cancer: impact on response and oncologic outcomes. J Cancer Res Clin Oncol 2014; 140:1651-60. [PMID: 24880919 DOI: 10.1007/s00432-014-1718-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Accepted: 05/18/2014] [Indexed: 02/01/2023]
Abstract
PURPOSE The optimal waiting period between neoadjuvant treatment completion and surgery in locally advanced rectal cancer (LARC) is controversial. The specific purpose of this study was to evaluate the effect of prolonging this interval on the pathologic response, postoperative morbidity, and long-term oncologic outcomes. METHODS Retrospective data analysis is reported from LARC patients who had been treated with chemoradiation followed by surgery and intra-operative radiotherapy, between February 1995 and December 2012. In total, two groups were studied, according to the time elapsed between neoadjuvant treatment and surgery: conventional interval (CI; <6 weeks) and delayed interval (DI; ≥6 weeks). Clinicopathological data related to tumor response, postoperative morbidity, and oncologic outcomes were compared. RESULTS This study included 335 consecutive LARC patients. There was a higher proportion of patients with clinical staging nodal involvement (cN+) in the DI group (76.6 vs. 64.1 %; p = 0.01). The pathologic complete response (pCR) was not significantly different among groups (8.8 vs. 12.1 %; p = 0.34). Longer intervals did not affect complication incidence or severity or hospital admission length. Certain postneoadjuvant tumor effect parameters were significantly increased in the DI group, including N-downstaging and T-downsizing. After a median follow-up of 71 months, patients in the DI group presented with superior 5-year overall survival (OS) (55.9 vs. 70.4 %, p = 0.014); however, no statistically significant differences were observed in 5-year disease-free survival (DFS) or 5-year local control (LC) (69.9 vs. 74.9 %, p = 0.223; 90.4 vs. 94.5 %, p = 0.123, respectively). CONCLUSIONS A modest surgical interval delay (≥6 weeks) did not increase postoperative complications and was identified as a favorable prognostic factor for OS, although no differences were observed in pCR, LC, or DFS. Innovative multidisciplinary strategies incorporating further time extension of the surgical interval can be safely explored.
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Affiliation(s)
- Felipe A Calvo
- Hospital General Universitário Gregório Marañón, Madrid, Spain
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Zeng WG, Zhou ZX, Liang JW, Wang Z, Hou HR, Zhou HT, Zhang XM, Hu JJ. Impact of interval between neoadjuvant chemoradiotherapy and surgery for rectal cancer on surgical and oncologic outcome. J Surg Oncol 2014; 110:463-7. [PMID: 24889826 DOI: 10.1002/jso.23665] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 05/06/2014] [Indexed: 12/25/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the effect of a longer interval between long-course neoadjuvant chemoradiotherapy and surgery on surgical and oncologic outcome. METHODS A total of 233 consecutive patients with clinical stage II and III rectal cancer were divided into 2 groups according to the neoadjuvant-surgery interval: short-interval group (≤ 7 weeks, n = 111), and long-interval group (>7 weeks, n = 122). Data on neoadjuvant-surgery interval, operative time, perioperative complications, final pathology, disease recurrence, and mortality were prospectively collected and analyzed. RESULTS The two groups were comparable in terms of demographics, tumor, and treatment characteristics. Operative time and perioperative complications were not influenced by a longer interval. Patients in the long-interval group had a significantly higher pathologic complete response (pCR) rate (27.1% vs. 15.3%, P = 0.029), and a decreased rate of circumferential resection margin involvement (1.6% vs. 8.1%, P = 0.020). After a median follow-up of 42 months (range 6-90 months), the 3-year local recurrence rate was 12.9% in the short-interval group versus 4.8% in the long-interval group (P = 0.025). CONCLUSIONS A neoadjuvant-surgery interval >7 weeks is safe and is associated with a higher rate of pCR and R0 resection, and decreased local recurrence.
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Affiliation(s)
- Wei-Gen Zeng
- Department of Colorectal Surgery, Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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Wasserberg N. Interval to surgery after neoadjuvant treatment for colorectal cancer. World J Gastroenterol 2014; 20:4256-62. [PMID: 24764663 PMCID: PMC3989961 DOI: 10.3748/wjg.v20.i15.4256] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Revised: 11/11/2013] [Accepted: 01/14/2014] [Indexed: 02/06/2023] Open
Abstract
The current standard treatment of low-lying locally advanced rectal cancer consists of chemoradiation followed by radical surgery. The interval between chemoradiation and surgery varied for many years until the 1999 Lyon R90-01 trial which compared the effects of a short (2-wk) and long (6-wk) interval. Results showed a better clinical tumor response (71.7% vs 53.1%) and higher rate of positive and pathologic tumor regression (26% vs 10.3%) after the longer interval. Accordingly, a 6-wk interval between chemoradiation and surgery was set to balance the oncological results with the surgical complexity. However, several recent retrospective studies reported that prolonging the interval beyond 8 or even 12 wk may lead to significantly higher rates of tumor downstaging and pathologic complete response. This in turn, according to some reports, may improve overall and disease-free survival, without increasing the surgical difficulty or complications. This work reviews the data on the effect of different intervals, derived mostly from retrospective analyses using a wide variation of treatment protocols. Prospective randomized trials are currently ongoing.
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Laparoscopic surgery decreases the surgical risks associated with hyperlipidemia in rectal cancer: a retrospective analysis of 495 patients. Surg Laparosc Endosc Percutan Tech 2014; 24:e162-6. [PMID: 24710264 DOI: 10.1097/sle.0000000000000000] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Epidemiologic studies provide evidence for a link between disorders of lipid metabolism and the risk for colorectal cancer, hyperlipidemia is a common feature of rectal cancer patients. However, information about the effects of hyperlipidemia on rectal cancer surgery is scarce. OBJECTIVE The aim of this study was to investigate whether hyperlipidemia affected short-term outcomes of rectal cancer surgery, and determine the preferable surgery method based on the comparison of laparoscopic surgery and open surgery. METHODS Clinical data of 495 rectal cancer patients who received traditional open or laparoscopic radical resection between March 2006 and December 2010 were retrospectively reviewed. RESULTS Compared with normal blood lipid group (n=232), hyperlipidemia group (n=263) showed increased intraoperative bleeding (P<0.001), prolonged time for resuming food intake (P<0.001), peritoneal drainage (P<0.001), and hospital stay (P=0.019). However, there was no difference in operation time. Compared with those receiving open surgery, patients receiving laparoscopic surgery exhibited less intraoperative bleeding (P<0.001), less time for resuming food intake (P<0.001), peritoneal drainage (P<0.001), and hospital stay (P<0.001), whereas more operation time was needed (P<0.001). Among patients receiving laparoscopic surgery, no differences were shown on hospital stay, time for resuming food intake, and peritoneal drainage between hyperlipidemia group and normal blood lipid group, although more intraoperative bleeding was still presented in the hyperlipidemia group (P<0.001). CONCLUSION Hyperlipidemia has adverse effects on rectal cancer surgery. Laparoscopic surgery can eliminate postoperative recovery retardation caused by hyperlipidemia.
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Saglam S, Bugra D, Saglam EK, Asoglu O, Balik E, Yamaner S, Basaran M, Oral EN, Kizir A, Kapran Y, Gulluoglu M, Sakar B, Bulut T. Fourth versus eighth week surgery after neoadjuvant radiochemotherapy in T3-4/N0+ rectal cancer: Istanbul R-01 study. J Gastrointest Oncol 2014; 5:9-17. [PMID: 24490038 DOI: 10.3978/j.issn.2078-6891.2013.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Accepted: 04/17/2013] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND AND PURPOSE The optimum duration between neoadjuvant radiochemotherapy and transmesorectal excision in locally advanced rectal cancer has not been defined yet. This randomized study was designed to compare the efficacy of four-week versus eight-week delay before surgery. METHODS One-hundred and fifty-three patients with locally advanced low- or mid-rectum rectal adenocarcinoma were included in this single center prospective randomized trial. Patients were assigned to receive surgical treatment after either four weeks or eight weeks of delay after chemoradiotherapy. Patients were followed for local recurrence and survival, and surgical specimens were examined for pathological staging and circumferential margin positivity. RESULTS 4-week and 8-week groups did not differ with regard to lateral surgical margin positivity (9.2% vs. 5.1%, P=0.33, respectively), pathological tumor regression rate (P=0.90), overall survival (5-year, 76.5% vs. 74.2%, P=0.60) and local recurrence rate (11.8% vs. 10.3%, 0.77). Overall survival was better in patients with negative surgical margins (78.8% vs. 53.0%, P=0.04). Local recurrence rate was significantly higher among patients with positive surgical margin (28.5% vs. 9.3%, P=0.02). CONCLUSIONS Intentional prolongation of the chemoradiotherapy-surgery interval does not seem to improve clinical outcomes of patients with locally advanced rectal cancer. Surgical margin positivity seems to be more important with this regard.
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Affiliation(s)
- Sezer Saglam
- Istanbul Bilim University Medical Faculty, Department of Medical Oncology, Turkey
| | - Dursun Bugra
- Koc University, School of Medicine, Department of General Surgery, Turkey
| | - Esra K Saglam
- Istanbul University, Istanbul Medical Faculty, Department of Radiation Oncology, Turkey
| | - Oktar Asoglu
- Istanbul University, Istanbul Medical Faculty, Department of General Surgery, Turkey
| | - Emre Balik
- Istanbul University, Istanbul Medical Faculty, Department of General Surgery, Turkey
| | - Sumer Yamaner
- Istanbul University, Istanbul Medical Faculty, Department of General Surgery, Turkey
| | - Mert Basaran
- Istanbul University Oncology Institute, Department of Medical Oncology, Turkey
| | - Ethem N Oral
- Istanbul University, Istanbul Medical Faculty, Department of Radiation Oncology, Turkey
| | - Ahmet Kizir
- Istanbul University, Istanbul Medical Faculty, Department of Radiation Oncology, Turkey
| | - Yersu Kapran
- Istanbul University, Istanbul Medical Faculty, Department of Pathology, Turkey
| | - Mine Gulluoglu
- Istanbul University, Istanbul Medical Faculty, Department of Pathology, Turkey
| | - Burak Sakar
- Istanbul Bilim University Medical Faculty, Department of Medical Oncology, Turkey
| | - Turker Bulut
- Istanbul University, Istanbul Medical Faculty, Department of General Surgery, Turkey
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Maggiori L, Bretagnol F, Aslam MI, Guedj N, Zappa M, Ferron M, Panis Y. Does pathologic response of rectal cancer influence postoperative morbidity after neoadjuvant radiochemotherapy and total mesorectal excision? Surgery 2013; 155:468-75. [PMID: 24439750 DOI: 10.1016/j.surg.2013.10.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 10/17/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND A pathologic complete response (pCR) can be observed in up to 25% of patients after preoperative chemoradiotherapy for rectal cancer and is associated with an improved long-term prognosis. However, few data are available regarding the effect of pCR on postoperative morbidity. This study aimed to assess the impact of the pCR on postoperative outcomes after laparoscopic total mesorectal excision (TME). METHODS A prospectively maintained database (2006-2011) was reviewed for all consecutive patients (n = 143) undergoing laparoscopic TME for mid or low rectal cancer after neoadjuvant chemoradiotherapy. Postoperative data were compared for pCR-group and non-pCR-group. A pCR was defined as the absence of gross and microscopic tumor in the specimen, irrespective of the nodal status (ypT0). RESULTS Thirty-three patients (23%) had a pCR. Median operating time was greatly shorter in the pCR-group (230 minutes, 180-360), compared with the non-pCR-group (240 minutes, 130-420, P = .02). Lymph node involvement was noted for 12% of the patients in the pCR-group and 33% of the patients in the non-pCR-group (P = .91). Clavien Dindo grade 3 and 4 complications (6% vs 22%, P = .04), infection related morbidity (47% vs 76%, P = .04), and clinical anastomotic leakage rates (9% vs 29%, P = .02) were lesser in the pCR group compared with the non-pCR group. Mean duration of hospital stay was lesser in the pCR-group (9 vs 12 days, P = .01). CONCLUSION This study showed that Clavien Dindo grade 3 and 4 complications, including anastomosis leakage, and infection related complications rates were lesser in patients with pathologic complete response after RCT and laparoscopic TME for rectal cancer.
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Affiliation(s)
- Léon Maggiori
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital (AP-HP), 100 boulevard du Général Leclerc, 92118 Clichy, France
| | - Frédéric Bretagnol
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital (AP-HP), 100 boulevard du Général Leclerc, 92118 Clichy, France
| | - Muhammad I Aslam
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital (AP-HP), 100 boulevard du Général Leclerc, 92118 Clichy, France; Department of Cancer Studies and Molecular Medicine, University of Leicester, University Hospitals of Leicester NHS Trust, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, Leicester, UK
| | - Nathalie Guedj
- Department of Pathology, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital (AP-HP), 100 boulevard du Général Leclerc, 92118 Clichy, France
| | - Magaly Zappa
- Department of Radiology, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital (AP-HP), 100 boulevard du Général Leclerc, 92118 Clichy, France
| | - Marianne Ferron
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital (AP-HP), 100 boulevard du Général Leclerc, 92118 Clichy, France
| | - Yves Panis
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital (AP-HP), 100 boulevard du Général Leclerc, 92118 Clichy, France.
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Timing of surgery after long-course neoadjuvant chemoradiotherapy for rectal cancer: a systematic review of the literature. Dis Colon Rectum 2013; 56:921-30. [PMID: 23739201 DOI: 10.1097/dcr.0b013e31828aedcb] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Neoadjuvant long-course chemoradiotherapy is commonly used to improve the local control and resectability of locally advanced rectal cancer, with surgery performed after an interval of a number of weeks. OBJECTIVE We report an evidence-based systematic review of published data supporting the optimal time to perform surgical resection after long-course neoadjuvant therapy. DATA SOURCES A systematic literature search was undertaken of the MEDLINE and Embase electronic databases from 1995 to 2012. STUDY SELECTION English language articles were included that compared outcomes following rectal cancer surgery performed at different times after a long course of neoadjuvant radiation-based therapy. INTERVENTIONS : Patients received a long course of neoadjuvant therapy followed by radical surgical resection after an interval period. MAIN OUTCOME MEASURES The rates of tumor response, R0 resection, sphincter preservation, surgical complications, and disease recurrence were the primary outcomes measured. RESULTS Fifteen studies were identified: 1 randomized controlled trial, 1 prospective nonrandomized interventional study, and 13 observational studies. Studies compared time intervals that varied between <5 days and >12 weeks, with a large degree of variation in what the standard interval length was considered to be. Four of the 7 studies that reported rates of pathological complete response identified significantly higher rates with an extended interval between chemoradiotherapy and surgery; 3 of 8 studies demonstrated increased primary tumor downstaging with a longer interval. No significant differences have been consistently demonstrated in rates of surgical complications, sphincter preservation, or long-term recurrence and survival. LIMITATIONS Neoadjuvant regimes, indications for neoadjuvant therapy, and time intervals after chemoradiotherapy were heterogeneous between studies; consequently, meta-analysis could not be performed. CONCLUSIONS There is limited evidence to support decisions regarding when to resect rectal cancer following chemoradiotherapy. There may be benefits in prolonging the interval between chemoradiotherapy and surgery beyond the 6 to 8 weeks that is commonly practiced. However, outcomes need to be studied further in robust randomized studies.
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Jeong DH, Lee HB, Hur H, Min BS, Baik SH, Kim NK. Optimal timing of surgery after neoadjuvant chemoradiation therapy in locally advanced rectal cancer. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2013; 84:338-45. [PMID: 23741691 PMCID: PMC3671002 DOI: 10.4174/jkss.2013.84.6.338] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Revised: 01/10/2013] [Accepted: 02/12/2013] [Indexed: 01/04/2023]
Abstract
PURPOSE The optimal time between neoadjuvant chemoradiotherapy (CRT) and surgery for rectal cancer has been debated. This study evaluated the influence of this interval on oncological outcomes. METHODS We compared postoperative complications, pathological downstaging, disease recurrence, and survival in patients with locally advanced rectal cancer who underwent surgical resection <8 weeks (group A, n = 105) to those who had surgery ≥8 weeks (group B, n = 48) after neoadjuvant CRT. RESULTS Of 153 patients, 117 (76.5%) were male and 36 (23.5%) were female. Mean age was 57.8 years (range, 28 to 79 years). There was no difference in the rate of sphincter preserving surgery between the two groups (group A, 82.7% vs. group B, 77.6%; P = 0.509). The longer interval group had decreased postoperative complications, although statistical significance was not reached (group A, 28.8% vs. group B, 14.3%; P = 0.068). A total of 111 (group A, 75 [71.4%] and group B, 36 [75%]) patients were downstaged and 26 (group A, 17 [16.2%] and group B, 9 [18%]) achieved pathological complete response (pCR). There was no significant difference in the pCR rate (P = 0.817). The longer interval group experienced significant improvement in the nodal (N) downstaging rate (group A, 46.7% vs. group B, 66.7%; P = 0.024). The local recurrence (P = 0.279), distant recurrence (P = 0.427), disease-free survival (P = 0.967), and overall survival (P = 0.825) rates were not significantly different. CONCLUSION It is worth delaying surgical resection for 8 weeks or more after completion of CRT as it is safe and is associated with higher nodal downstaging rates.
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Affiliation(s)
- Duck Hyoun Jeong
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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Sloothaak DAM, Geijsen DE, van Leersum NJ, Punt CJA, Buskens CJ, Bemelman WA, Tanis PJ. Optimal time interval between neoadjuvant chemoradiotherapy and surgery for rectal cancer. Br J Surg 2013; 100:933-9. [PMID: 23536485 DOI: 10.1002/bjs.9112] [Citation(s) in RCA: 201] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2013] [Indexed: 12/16/2022]
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy (CRT) has been proven to increase local control in rectal cancer, but the optimal interval between CRT and surgery is still unclear. The purpose of this study was to analyse the influence of variations in clinical practice regarding timing of surgery on pathological response at a population level. METHODS All evaluable patients who underwent preoperative CRT for rectal cancer between 2009 and 2011 were selected from the Dutch Surgical Colorectal Audit. The interval between radiotherapy and surgery was calculated from the start of radiotherapy. The primary endpoint was pathological complete response (pCR; pathological status after chemoradiotherapy (yp) T0 N0). RESULTS A total of 1593 patients were included. The median interval between radiotherapy and surgery was 14 (range 6-85, interquartile range 12-16) weeks. Outcome measures were calculated for intervals of less than 13 weeks (312 patients), 13-14 weeks (511 patients), 15-16 weeks (406 patients) and more than 16 weeks (364 patients). Age, tumour location and R0 resection rate were distributed equally between the four groups; significant differences were found for clinical tumour category (cT4: 17·3, 18·4, 24·5 and 26·6 per cent respectively; P = 0·010) and clinical metastasis category (cM1: 4·4, 4·8, 8·9 and 14·9 per cent respectively; P < 0·001). Resection 15-16 weeks after the start of CRT resulted in the highest pCR rate (18·0 per cent; P = 0·013), with an independent association (hazard ratio 1·63, 95 per cent confidence interval 1·20 to 2·23). Results for secondary endpoints in the group with an interval of 15-16 weeks were: tumour downstaging, 55·2 per cent (P = 0·165); nodal downstaging, 58·6 per cent (P = 0·036); and (near)-complete response, 23·2 per cent (P = 0·124). CONCLUSION Delaying surgery until the 15th or 16th week after the start of CRT (10-11 weeks from the end of CRT) seemed to result in the highest chance of a pCR.
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Affiliation(s)
- D A M Sloothaak
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
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Fang CB, Gomes CMCDN, Formiga FB, Fonseca VA, Carvalho MP, Klug WA. Existem benefícios com a cirurgia retardada após radioterapia e quimioterapia neoadjuvante no câncer de reto localmente avançado? ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2013; 26:31-5. [DOI: 10.1590/s0102-67202013000100007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Accepted: 12/11/2012] [Indexed: 12/15/2022]
Abstract
RACIONAL: Tratamento neoadjuvante com radioterapia e quimioterapia é o esquema preferencial para câncer de reto localmente avançado, tendo por objetivo aumentar a ressecabilidade e diminuir a recidiva local. OBJETIVO: Avaliar os benefícios da operação tardia após radioterapia e quimioterapia neoadjuvante em câncer de reto localmente avançado quanto à resposta da regressão tumoral, sobrevida e efeitos adversos. MÉTODOS: Foram tratados consecutivamente 106 pacientes, portadores de adenocarcinoma do reto localmente avançado no período pré-operatório com radioterapia na dose de 50,4 Gy (28 frações) e quimioterapia com 5-fluoracil e leucovorin. A operação foi programada entre cinco e seis semanas. Pacientes que retornaram após seis semanas por motivos diversos foram agrupados em grupo de operação tardia. Variáveis como diminuição do estádio, remissão tumoral completa, tempo cirúrgico, transfusão sanguínea, recidiva local, metástase e sobrevida foram correlacionadas com o restante dos pacientes a fim de verificar os seus benefícios. RESULTADOS: Remissão completa do tumor foi encontrada em 15 pacientes (T0=15/106 - 14,2%). Resposta parcial em 38 (34,9%); entretanto em um paciente a resposta foi pT0N2. O seguimento médio foi 35,6 semanas e 32,2 semanas para grupo de operação em seis semanas e grupo de cirurgia tardia. Não houve diferença entre os dois grupos quanto à diminuição de estádio, remissão tumoral completa, tempo cirúrgico, transfusão sanguínea e complicações cirúrgicas precoces. Embora a operação tardia não apresentasse diferença significante quanto à recidiva local (p=0,1468), ela mostrou tendência em menor risco de metástase à distância (p=0,0520). CONCLUSÃO: Operação tardia após tratamento neoadjuvante não oferece benefícios evidentes em termos de remissão completa ou diminuição do estádio tumoral. Fatores moleculares preditivos devem ser investigados no futuro para melhor seleção de doentes que poderão beneficiar-se com o tratamento neoadjuvante.
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Martin LW. What is the optimal interval between chemoradiation and esophagectomy? Semin Thorac Cardiovasc Surg 2013; 24:87-9. [PMID: 22920522 DOI: 10.1053/j.semtcvs.2012.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2012] [Indexed: 11/11/2022]
Abstract
Locally advanced esophageal cancer requires multimodality therapy-most commonly induction chemoradiation followed by esophagectomy. There is a paucity of literature on the optimal time interval between induction treatment and resection. Patient readiness and healthy tissue, as well as tumor responses to radiation, are factors to consider. Two recent retrospective large-center studies on this topic are reviewed.
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Affiliation(s)
- Linda W Martin
- Division of Thoracic Surgery, University of Maryland School of Medicine, Baltimore, Maryland 21014, USA.
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Lim SB, Kim JC. Surgical issues in locally advanced rectal cancer treated by preoperative chemoradiotherapy. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2012; 84:1-8. [PMID: 23323229 PMCID: PMC3539104 DOI: 10.4174/jkss.2013.84.1.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 11/10/2012] [Accepted: 11/11/2012] [Indexed: 12/16/2022]
Abstract
The standard treatment for patients with locally advanced rectal cancer is preoperative chemoradiotherapy followed by total mesorectal excision. This approach is supported by randomized trials, but there are still many unanswered questions about the multimodal management of rectal cancer. In surgical terms, these include the optimal time interval between completion of chemoradiotherapy and surgery; adequate distal resection margin and circumferential radial margin; sphincter preservation; laparoscopic surgery; and conservative management, including a 'wait and see' policy and local excision. This review considers these controversial issues in preoperative chemoradiotherapy.
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Affiliation(s)
- Seok-Byung Lim
- Department of Surgery, Asan Medical Center, Institute of Innovative Cancer Research, University of Ulsan College of Medicine, Seoul, Korea
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Qiu H, Herman JM, Ahuja N, DeWeese TL, Song DY. Neoadjuvant chemoradiation followed by interstitial prostate brachytherapy for synchronous prostate and rectal cancer. Pract Radiat Oncol 2012; 2:e77-e84. [PMID: 24674189 DOI: 10.1016/j.prro.2011.11.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2011] [Revised: 11/03/2011] [Accepted: 11/03/2011] [Indexed: 11/28/2022]
Abstract
PURPOSE To describe outcomes with the use of neoadjuvant pelvic chemoradiation followed by prostate interstitial brachytherapy for the treatment of synchronous prostate and rectal cancers. METHODS AND MATERIALS An Internal Review Board approved retrospective review was undertaken of 4 patients with synchronous prostate and rectal cancer treated between 2006 and 2008. Patients underwent pelvic chemoradiation followed by prostate brachytherapy, then low anterior resection of the rectum with diverting loop ileostomy and adjuvant chemotherapy. Follow-up evaluation included imaging and laboratory analysis of cancer markers in addition to routine interval history and physical examination. RESULTS At 38-62 months postdiagnosis (24-53 months post-treatment), 6 of 8 cancers remained without evidence of relapse. One patient had rising carcinoembryonic antigen levels but no clinically evident rectal cancer relapse; another developed bony metastasis of his high-risk prostate cancer. Three patients experienced grade 1-2 treatment-related toxicity; one patient had grade 3 gastrointestinal toxicity from radiation and surgery, which precluded his receiving adjuvant chemotherapy and ileostomy reversal. CONCLUSIONS Chemoradiation followed by prostate brachytherapy, surgery, and adjuvant chemotherapy may be utilized to manage patients with synchronous prostate and rectal cancers.
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Affiliation(s)
- Haoming Qiu
- The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joseph M Herman
- Department of Radiation Oncology, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Nita Ahuja
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Theodore L DeWeese
- Department of Radiation Oncology, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Danny Y Song
- Department of Radiation Oncology, The Johns Hopkins Hospital, Baltimore, Maryland.
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Peng JY, Di JZ, Wang Y. Delayed surgery for rectal cancer patients receiving neoadjuvant chemoradiotherapy: a promising method in its infancy. Dig Surg 2012; 29:281-6. [PMID: 22922886 DOI: 10.1159/000341661] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Accepted: 07/05/2012] [Indexed: 01/05/2023]
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy (nCRT) is used to downstage locally advanced rectal cancer before surgery. Accumulating data suggest that tumor response to nCRT is time dependent. A delay between nCRT and surgery may increase the proportion of patients that achieve a favorable response. However, delayed surgery beyond 6-8 weeks may increase the technical difficulty, and the risks of surgical complications and recurrence or metastasis. This article briefly reviews the relevant literature to evaluate the efficiency and safety of delayed surgery. METHODS Two non-cohort studies and 10 cohort studies were reviewed. The results were analyzed and the limitations discussed. RESULTS Although debatable, the findings of the included studies are promising. Delayed surgery may increase the proportion of favorable tumor response without compromising prognosis. However, most of the studies were retrospective, which introduces bias into the evaluation. CONCLUSION Delayed surgery is potentially useful, but this needs to be verified by further well-designed prospective trials.
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Affiliation(s)
- Jia-Yuan Peng
- Department of Surgery, The Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
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Wolthuis AM, Penninckx F, Haustermans K, De Hertogh G, Fieuws S, Van Cutsem E, D'Hoore A. Impact of interval between neoadjuvant chemoradiotherapy and TME for locally advanced rectal cancer on pathologic response and oncologic outcome. Ann Surg Oncol 2012; 19:2833-41. [PMID: 22451236 DOI: 10.1245/s10434-012-2327-1] [Citation(s) in RCA: 113] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Indexed: 12/25/2022]
Abstract
BACKGROUND The interval between neoadjuvant chemoradiotherapy and surgery for rectal cancer has arbitrarily been set at 6-8 weeks. However, tumor regression is variable. This study aimed to evaluate whether the interval between neoadjuvant therapy and surgery had an impact on pathologic response and on surgical and oncologic outcome. METHODS A total of 356 consecutive patients with clinical stage II and III rectal adenocarcinoma were identified. Median age was 63 years, and 65 % were men. All patients received neoadjuvant chemoradiotherapy (45 Gy) with a continuous infusion of 5-fluorouracil. Data on neoadjuvant-surgery interval, type of surgery, pathology, postoperative complications, length of hospital stay, disease recurrence, and survival were reviewed. Patients were divided into two groups according to the interval between neoadjuvant therapy and surgery: ≤ 7 weeks (short interval, n = 201) and >7 weeks (long interval, n = 155). RESULTS The complete pathologic response rate was 21 %. It was significantly higher after a longer interval (28 %) than after a shorter interval (16 %, p = 0.006). A longer interval did not affect morbidity or length of hospital stay. After a median follow-up of 4.9 years, the 5-year cancer-specific survival rate was 83 % in the short-interval group versus 91 % in the long-interval group (p = 0.046), and the free-from-recurrence rate was 73 versus 83 %, respectively (p = 0.026). CONCLUSIONS In this retrospective analysis, there seems to be an association between a longer interval after neoadjuvant chemoradiotherapy and complete pathologic response without affecting postoperative morbidity and length of hospital stay, and with no detrimental effect on oncologic outcome.
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Affiliation(s)
- Albert M Wolthuis
- Department of Abdominal Surgery, University Hospital Gasthuisberg, Leuven, Belgium.
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