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Rizzo G, Amodio LE, D'Annibale G, Marzi F, Quero G, Menghi R, Tondolo V. Nonoperative management and local excision after neoadjuvant chemoradiation therapy for rectal cancer. Minerva Surg 2024; 79:470-480. [PMID: 38953759 DOI: 10.23736/s2724-5691.24.10445-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Abstract
Locally advanced extraperitoneal rectal cancer represents a significant clinical challenge, and currently, the standard treatment is based on neoadjuvant chemoradiation therapy (CRT) followed by radical surgical resection with total mesorectal excision (TME). In the last 30 years, its management has undergone significant changes due to the improvement of complementary radio- and chemotherapy treatments, the improvement of minimally invasive surgical approaches and the diffusion of organ-sparing approaches, such as nonoperative management, commonly called "watch and wait" (NOM) and local excision (LE), in highly selected patients who achieve a major or complete response to neoadjuvant CRT. This review aimed to critically examine the efficacy and oncological safety of NOM and LE compared to those of standard TME in rectal cancer patients after neoadjuvant CRT. Both the pros and cons of these approaches were strictly analyzed, providing a comprehensive and critical overview of these novel management strategies for rectal cancer.
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Affiliation(s)
- Gianluca Rizzo
- Unit of Digestive and Colorectal Surgery, Ospedale Isola Tiberina Gemelli Isola, Università Cattolica del Sacro Cuore, Rome, Italy -
| | - Luca E Amodio
- Unit of Digestive and Colorectal Surgery, Ospedale Isola Tiberina Gemelli Isola, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giorgio D'Annibale
- Unit of Digestive and Colorectal Surgery, Ospedale Isola Tiberina Gemelli Isola, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Federica Marzi
- Unit of Digestive and Colorectal Surgery, Ospedale Isola Tiberina Gemelli Isola, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giuseppe Quero
- Unit of Digestive Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Roberta Menghi
- Unit of Digestive Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Vincenzo Tondolo
- Unit of Digestive and Colorectal Surgery, Ospedale Isola Tiberina Gemelli Isola, Università Cattolica del Sacro Cuore, Rome, Italy
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Sullo FG, Passardi A, Gallio C, Molinari C, Marisi G, Pozzi E, Solaini L, Bittoni A. Advancing Personalized Medicine in the Treatment of Locally Advanced Rectal Cancer. J Clin Med 2024; 13:2562. [PMID: 38731090 PMCID: PMC11084727 DOI: 10.3390/jcm13092562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 04/12/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024] Open
Abstract
Rectal cancer presents a significant burden globally, often requiring multimodal therapy for locally advanced cases. Long-course chemoradiotherapy (LCRT) and short-course radiotherapy (SCRT) followed by surgery have been conventional neoadjuvant approaches. Recent trials favor LCRT due to improved local control. However, distant tumor recurrence remains a concern, prompting the exploration of total neoadjuvant therapy (TNT) as a comprehensive treatment strategy. Immune checkpoint inhibitors (ICIs) show promise, particularly in mismatch repair-deficient (dMMR) or microsatellite instability-high (MSI-H) tumors, potentially revolutionizing neoadjuvant regimens. Nonoperative management (NOM) represents a viable alternative post-neoadjuvant therapy for selected patients achieving complete clinical response (cCR). Additionally, monitoring minimal residual disease (MRD) using circulating tumor DNA (ctDNA) emerges as a non-invasive method for the assessment of treatment response. This review synthesizes current evidence on TNT, ICIs, NOM, and ctDNA, elucidating their implications for rectal cancer management and highlighting avenues for future research and clinical application.
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Affiliation(s)
- Francesco Giulio Sullo
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, via P. Maroncelli 40, 47014 Meldola, Italy; (F.G.S.); (C.G.); (A.B.)
| | - Alessandro Passardi
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, via P. Maroncelli 40, 47014 Meldola, Italy; (F.G.S.); (C.G.); (A.B.)
| | - Chiara Gallio
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, via P. Maroncelli 40, 47014 Meldola, Italy; (F.G.S.); (C.G.); (A.B.)
| | - Chiara Molinari
- Biosciences Laboratory, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, via P. Maroncelli 40, 47014 Meldola, Italy; (C.M.); (G.M.)
| | - Giorgia Marisi
- Biosciences Laboratory, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, via P. Maroncelli 40, 47014 Meldola, Italy; (C.M.); (G.M.)
| | - Eleonora Pozzi
- Department of Medical and Surgical Science, University of Bologna, 47121 Forlì, Italy (L.S.)
| | - Leonardo Solaini
- Department of Medical and Surgical Science, University of Bologna, 47121 Forlì, Italy (L.S.)
| | - Alessandro Bittoni
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, via P. Maroncelli 40, 47014 Meldola, Italy; (F.G.S.); (C.G.); (A.B.)
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Du R, Chang Y, Zhang J, Cheng Y, Li Y, Zhang C, Zhang J, Xu L, Liu Y. Whether the watch-and-wait strategy has application value for rectal cancer with clinical complete response after neoadjuvant chemoradiotherapy? A network meta-analysis. Asian J Surg 2024; 47:853-863. [PMID: 38042663 DOI: 10.1016/j.asjsur.2023.11.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/29/2023] [Accepted: 11/10/2023] [Indexed: 12/04/2023] Open
Abstract
The aim was to evaluate the efficacy and safety between the watch-and-wait strategy (WW), radical surgery (RS), and local excision (LE) for rectal cancer with clinical complete response (cCR) after neoadjuvant radiotherapy (nCRT). We searched MEDLINE, EMBASE, the Cochrane Library, and clinical trials to compare WW with RS and LE for patients with cCR until March 2023 and collected the following data: local recurrence (LR), distant metastasis (DM), cancer-related death (CRD), overall survival (OS), and disease-free survival (DFS). In total, 2240 patients from 21 studies were included. Pairwise meta-analysis revealed no statistically significant differences between the three groups in terms of CRD and 2-, 3-, and 5-year OS (P < 0.05). The RS group was significantly better than the WW group in terms of the LR rate (odds ratio [OR] = 0.12, 95 % confidence interval [CI]: 0.06-0.21, P < 0.001, I2 = 0 %], 3-year DFS (OR = 1.56, 95 % CI: 1.10-2.21, P = 0.01, I2 = 38 %), and 5-year DFS (OR = 2.30, 95 % CI: 1.53-3.46, P < 0.001, I2 = 34 %). The results of network meta-analysis were also similar. After sensitivity analysis, the 5-year OS of the RS group was significantly better than that of the WW group (OR = 2.77, 95 % CI: 1.28-6.00, P = 0.009, I2 = 33 %). Nevertheless, neither regression analysis nor subgroup analysis provided meaningful results. However, the cumulative meta-analysis of LR, DM, and 3- and 5-year DFS revealed significant turning points (P < 0.05). Our meta-analysis recommends using the WW strategy for patients with cCR having poor underlying conditions and high surgical risk; however, there is a risk of higher LR and worse survival after 3 years.
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Affiliation(s)
- Rui Du
- Department of Anorectal Surgery, The Third Affiliated Hospital of Anhui Medical University, Hefei First People's Hospital, Hefei, 230000, China
| | - Yue Chang
- Cancer Comprehensive Treatment Center, Hefei Cancer Hospital, Chinese Academy of Sciences, Hefei, 230000, China
| | - Juan Zhang
- Department of Anorectal Surgery, The Third Affiliated Hospital of Anhui Medical University, Hefei First People's Hospital, Hefei, 230000, China
| | - Yuanguang Cheng
- Department of Anorectal Surgery, The Third Affiliated Hospital of Anhui Medical University, Hefei First People's Hospital, Hefei, 230000, China
| | - Yonghai Li
- Department of Anorectal Surgery, The Third Affiliated Hospital of Anhui Medical University, Hefei First People's Hospital, Hefei, 230000, China
| | - Chengyue Zhang
- Department of Anorectal Surgery, The Third Affiliated Hospital of Anhui Medical University, Hefei First People's Hospital, Hefei, 230000, China
| | - Jinyuan Zhang
- Department of Anorectal Surgery, The Third Affiliated Hospital of Anhui Medical University, Hefei First People's Hospital, Hefei, 230000, China
| | - Liejuan Xu
- Department of Anorectal Surgery, The Third Affiliated Hospital of Anhui Medical University, Hefei First People's Hospital, Hefei, 230000, China
| | - Yuancheng Liu
- Department of Anorectal Surgery, The Third Affiliated Hospital of Anhui Medical University, Hefei First People's Hospital, Hefei, 230000, China.
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Tan S, Gao Q, Cui Y, Ou Y, Huang S, Feng W. Oncologic outcomes of watch-and-wait strategy or surgery for low to intermediate rectal cancer in clinical complete remission after adjuvant chemotherapy: a systematic review and meta-analysis. Int J Colorectal Dis 2023; 38:246. [PMID: 37787779 DOI: 10.1007/s00384-023-04534-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND A watch-and-wait (WW) strategy or surgery for low to intermediate rectal cancer that has reached clinical complete remission (cCR) after neoadjuvant chemotherapy (nCRT) or total neoadjuvant therapy (TNT) has been widely used in the clinic, but both treatment strategies are controversial. OBJECTIVE The aim of this study was to compare the oncologic outcomes of a watch-and-wait strategy or a surgical approach to treat rectal cancer in complete remission and to report the evidence-based clinical advantages of the two treatment strategies. METHODS Seven national and international databases were searched for clinical trials comparing the watch-and-wait strategy with surgical treatment for oncological outcomes in patients with rectal cancer in clinical complete remission. RESULTS In terms of oncological outcomes, there was no significant difference between the watch-and-wait strategy and surgical treatment in terms of overall survival (OS) (HR = 0.92, 95% CI (0.52, 1.64), P = 0.777), and subgroup analysis showed no significant difference in 5-year disease-free survival (5-year DFS) between WW and both local excision (LE) and radical surgery (RS) (HR = 1.76, 95% CI (0.97, 3.19), P = 0.279; HR = 1.98, 95% CI (0.95, 4.13), P = 0.164), in distant metastasis rate (RR = 1.12, 95% CI (0.73, 1.72), P = 0.593), mortality rate (RR = 1.62, 95% CI (0.93, 2.84), P = 0.09), and organ preservation rate (RR = 1.05, 95% CI (0.94, 1.17), P = 0.394) which were not statistically significant and on the outcome indicators of local recurrence rate (RR = 2.09, 95% CI (1.44, 3.03), P < 0.001) and stoma rate (RR = 0.35, 95% CI (0.20, 0.61), P < 0.001). There were significant differences between the WW group and the surgical treatment group. CONCLUSION There were no differences in OS, 5-year DFS, distant metastasis, and mortality between the WW strategy group and the surgical treatment group. The WW strategy did not increase the risk of local recurrence compared with local resection but may be at greater risk of local recurrence compared with radical surgery, and the WW group was significantly better than the surgical group in terms of stoma rate; the WW strategy was evidently superior in preserving organ integrity compared to radical excision. Consequently, for patients who exhibit a profound inclination towards organ preservation and the evasion of stoma formation in the scenario of clinically complete remission of rectal cancer, the WW strategy can be contemplated as a pragmatic alternative to surgical interventions. It is, however, paramount to emphasize that the deployment of such a strategy should be meticulously undertaken within the ambit of a multidisciplinary team's management and within specialized centers dedicated to rectal cancer management.
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Affiliation(s)
- Shufa Tan
- Shaanxi University of Chinese Medicine, Xianyang, Shaanxi, China
| | - Qiangqiang Gao
- Affiliated Hospital of Shaanxi University of Traditional Chinese Medicine, Deputy No. 2, West Weiyang Road, Xianyang City, Shaanxi Province, 712000, China
| | - Yaping Cui
- Affiliated Hospital of Shaanxi University of Traditional Chinese Medicine, Deputy No. 2, West Weiyang Road, Xianyang City, Shaanxi Province, 712000, China
| | - Yan Ou
- Affiliated Hospital of Shaanxi University of Traditional Chinese Medicine, Deputy No. 2, West Weiyang Road, Xianyang City, Shaanxi Province, 712000, China
| | - Shuilan Huang
- Shaanxi University of Chinese Medicine, Xianyang, Shaanxi, China
| | - Wenzhe Feng
- Affiliated Hospital of Shaanxi University of Traditional Chinese Medicine, Deputy No. 2, West Weiyang Road, Xianyang City, Shaanxi Province, 712000, China.
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Yuval JB, Patil S, Gangai N, Omer DM, Akselrod DG, Fung A, Harmath CB, Kampalath R, Krehbiel K, Lee S, Liu PS, Millet JD, O'Malley RB, Purysko AS, Veniero JC, Wasnik AP, Garcia-Aguilar J, Gollub MJ. MRI assessment of rectal cancer response to neoadjuvant therapy: a multireader study. Eur Radiol 2023; 33:5761-5768. [PMID: 36814032 PMCID: PMC10394731 DOI: 10.1007/s00330-023-09480-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 12/05/2022] [Accepted: 01/27/2023] [Indexed: 02/24/2023]
Abstract
OBJECTIVES A watch and wait strategy with the goal of organ preservation is an emerging treatment paradigm for rectal cancer following neoadjuvant treatment. However, the selection of appropriate patients remains a challenge. Most previous efforts to measure the accuracy of MRI in assessing rectal cancer response used a small number of radiologists and did not report variability among them. METHODS Twelve radiologists from 8 institutions assessed baseline and restaging MRI scans of 39 patients. The participating radiologists were asked to assess MRI features and to categorize the overall response as complete or incomplete. The reference standard was pathological complete response or a sustained clinical response for > 2 years. RESULTS We measured the accuracy and described the interobserver variability of interpretation of rectal cancer response between radiologists at different medical centers. Overall accuracy was 64%, with a sensitivity of 65% for detecting complete response and specificity of 63% for detecting residual tumor. Interpretation of the overall response was more accurate than the interpretation of any individual feature. Variability of interpretation was dependent on the patient and imaging feature investigated. In general, variability and accuracy were inversely correlated. CONCLUSIONS MRI-based evaluation of response at restaging is insufficiently accurate and has substantial variability of interpretation. Although some patients' response to neoadjuvant treatment on MRI may be easily recognizable, as seen by high accuracy and low variability, that is not the case for most patients. KEY POINTS • The overall accuracy of MRI-based response assessment is low and radiologists differed in their interpretation of key imaging features. • Some patients' scans were interpreted with high accuracy and low variability, suggesting that these patients' pattern of response is easier to interpret. • The most accurate assessments were those of the overall response, which took into consideration both T2W and DWI sequences and the assessment of both the primary tumor and the lymph nodes.
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Affiliation(s)
- Jonathan B Yuval
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, NY, USA
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Sujata Patil
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, USA
| | - Natalie Gangai
- Department of Radiology, Memorial Sloan Kettering Cancer Center, NY, USA
| | - Dana M Omer
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, NY, USA
| | | | - Alice Fung
- Department of Radiology, Oregon Health & Sciences University, Portland, USA
| | - Carla B Harmath
- Department of Radiology, University of Chicago, Chicago, USA
| | - Rony Kampalath
- Department of Radiology, University of California Irvine, Irvine, USA
| | - Kyle Krehbiel
- Department of Radiology, Creighton University Medical Center - Bergan Mercy, Omaha, USA
| | - Sonia Lee
- Department of Radiology, University of California Irvine, Irvine, USA
| | - Peter S Liu
- Department of Radiology, Cleveland Clinic, Cleveland, USA
| | - John D Millet
- Department of Radiology, University of Michigan, Ann Arbor, USA
| | - Ryan B O'Malley
- Department of Radiology, University of Washington, Seattle, USA
| | | | | | - Ashish P Wasnik
- Department of Radiology, University of Michigan, Ann Arbor, USA
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, NY, USA
| | - Marc J Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, NY, USA.
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Georges C, Yap R, Bell S, Farmer KC, Cohen LCL, Wilkins S, Centauri S, Engel R, Oliva K, McMurrick PJ. Comparison of quality of life, symptom and functional outcomes following surgical treatment for colorectal neoplasia. ANZ J Surg 2023; 93:1877-1884. [PMID: 37173802 DOI: 10.1111/ans.18510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 04/04/2023] [Accepted: 04/30/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Colorectal surgical procedures can have a significant impact on quality-of-life (QoL), functional and symptom outcomes. This retrospective study conducted in a tertiary care center evaluated the influence of four colorectal surgical procedures on patient-reported outcome measures (PROMs). METHODS 512 patients undergoing colorectal neoplasia surgery between June 2015 and December 2017 were identified via the Cabrini Monash Colorectal Neoplasia database. Primary outcomes measured were the mean changes in PROMs following surgery utilizing the International Consortium of Health Outcome Measures colorectal cancer (CRC) PROMs. RESULTS 242 patients from 483 eligible patients responded (50% participation rate). Responders and non-responders were comparable in median age (72 vs. 70 years), gender (48% vs. 52% male), time from surgery (<1 and >1 year), overall stage at diagnosis and type of surgery. Respondents underwent either a right hemicolectomy, ultra-low anterior resection, abdominoperineal resection or a transanal endoscopic microsurgery/transanal minimally invasive surgery. Right hemicolectomy patients reported the best post-operative function and reduced symptoms, significantly better (P < 0.01) than ultra-low anterior resection patients who reported the worst outcomes in multiple areas (body image, embarrassment, flatulence, diarrhoea, stool frequency). Furthermore, patients undergoing an abdominoperineal resection reported the worst scores for body image, urinary frequency, urinary incontinence, buttock pain, faecal incontinence and male impotence. CONCLUSIONS The differences in PROMs in CRC surgical procedures is demonstrable. The worst post-operative functional and symptom scores were reported after either an ultra-low anterior resection or an abdominoperineal resection. Implementation of PROMs will identify and aid early patient referral to allied health and support services.
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Affiliation(s)
- Christine Georges
- Cabrini Monash University Department of Surgery, Cabrini Hospital, Malvern, Victoria, Australia
- Department of Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - Raymond Yap
- Cabrini Monash University Department of Surgery, Cabrini Hospital, Malvern, Victoria, Australia
| | - Stephen Bell
- Cabrini Monash University Department of Surgery, Cabrini Hospital, Malvern, Victoria, Australia
- Department of Colorectal and General Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - Keith Chip Farmer
- Cabrini Monash University Department of Surgery, Cabrini Hospital, Malvern, Victoria, Australia
- Department of Colorectal and General Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - Lauren C L Cohen
- Cabrini Monash University Department of Surgery, Cabrini Hospital, Malvern, Victoria, Australia
| | - Simon Wilkins
- Cabrini Monash University Department of Surgery, Cabrini Hospital, Malvern, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Suellyn Centauri
- Cabrini Monash University Department of Surgery, Cabrini Hospital, Malvern, Victoria, Australia
| | - Rebekah Engel
- Cabrini Monash University Department of Surgery, Cabrini Hospital, Malvern, Victoria, Australia
- Department of Anatomy and Developmental Biology, Monash University, Clayton, Victoria, Australia
- Stem Cells and Development Program, Monash Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Karen Oliva
- Cabrini Monash University Department of Surgery, Cabrini Hospital, Malvern, Victoria, Australia
- Department of Colorectal and General Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - Paul J McMurrick
- Cabrini Monash University Department of Surgery, Cabrini Hospital, Malvern, Victoria, Australia
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Couwenberg AM, Varvoglis DN, Grieb BC, Marijnen CA, Ciombor KK, Guillem JG. New Opportunities for Minimizing Toxicity in Rectal Cancer Management. Am Soc Clin Oncol Educ Book 2023; 43:e389558. [PMID: 37307515 PMCID: PMC10450577 DOI: 10.1200/edbk_389558] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Advances in multimodal management of locally advanced rectal cancer (LARC), consisting of preoperative chemotherapy and/or radiotherapy followed by surgery with or without adjuvant chemotherapy, have improved local disease control and patient survival but are associated with significant risk for acute and long-term morbidity. Recently published trials, evaluating treatment dose intensification via the addition of preoperative induction or consolidation chemotherapy (total neoadjuvant therapy [TNT]), have demonstrated improved tumor response rates while maintaining acceptable toxicity. In addition, TNT has led to an increased number of patients achieving a clinical complete response and thus eligible to pursue a nonoperative, organ-preserving, watch and wait approach, thereby avoiding toxicities associated with surgery, such as bowel dysfunction and stoma-related complications. Ongoing trials using immune checkpoint inhibitors in patients with mismatch repair-deficient tumors suggest that this subgroup of patients with LARC could potentially be treated with immunotherapy alone, sparing them the toxicity associated with preoperative treatment and surgery. However, the majority of rectal cancers are mismatch repair-proficient and less responsive to immune checkpoint inhibitors and require multimodal management. The synergy noted in preclinical studies between immunotherapy and radiotherapy on immunogenic tumor cell death has led to the design of ongoing clinical trials that explore the benefit of combining radiotherapy, chemotherapy, and immunotherapy (mainly of immune checkpoint inhibitors) and aim to increase the number of patients eligible for organ preservation.
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Affiliation(s)
- Alice M. Couwenberg
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Brian C. Grieb
- Vanderbilt University Medical Center/Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Corrie A.M. Marijnen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Kristen K. Ciombor
- Vanderbilt University Medical Center/Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Jose G. Guillem
- Department of Surgery, Lineberger Comprehensive Cancer Center, University of North Carolina-Chapel Hill, Chapel Hill, NC
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8
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Jayaprakasam VS, Alvarez J, Omer DM, Gollub MJ, Smith JJ, Petkovska I. Watch-and-Wait Approach to Rectal Cancer: The Role of Imaging. Radiology 2023; 307:e221529. [PMID: 36880951 PMCID: PMC10068893 DOI: 10.1148/radiol.221529] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 11/09/2022] [Accepted: 11/14/2022] [Indexed: 03/08/2023]
Abstract
The diagnosis and treatment of rectal cancer have evolved dramatically over the past several decades. At the same time, its incidence has increased in younger populations. This review will inform the reader of advances in both diagnosis and treatment. These advances have led to the watch-and-wait approach, otherwise known as nonsurgical management. This review briefly outlines changes in medical and surgical treatment, advances in MRI technology and interpretation, and landmark studies or trials that have led to this exciting juncture. Herein, the authors delve into current state-of-the-art methods to assess response to treatment with MRI and endoscopy. Currently, these methods for avoiding surgery can be used to detect a complete clinical response in as many as 50% of patients with rectal cancer. Finally, the limitations of imaging and endoscopy and future challenges will be discussed.
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Affiliation(s)
- Vetri Sudar Jayaprakasam
- From the Departments of Radiology (V.S.J., M.J.G., I.P.) and Surgery
(J.A., D.M.O., J.J.S.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave,
Box 29, New York, NY 10065
| | - Janet Alvarez
- From the Departments of Radiology (V.S.J., M.J.G., I.P.) and Surgery
(J.A., D.M.O., J.J.S.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave,
Box 29, New York, NY 10065
| | - Dana M. Omer
- From the Departments of Radiology (V.S.J., M.J.G., I.P.) and Surgery
(J.A., D.M.O., J.J.S.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave,
Box 29, New York, NY 10065
| | - Marc J. Gollub
- From the Departments of Radiology (V.S.J., M.J.G., I.P.) and Surgery
(J.A., D.M.O., J.J.S.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave,
Box 29, New York, NY 10065
| | - J. Joshua Smith
- From the Departments of Radiology (V.S.J., M.J.G., I.P.) and Surgery
(J.A., D.M.O., J.J.S.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave,
Box 29, New York, NY 10065
| | - Iva Petkovska
- From the Departments of Radiology (V.S.J., M.J.G., I.P.) and Surgery
(J.A., D.M.O., J.J.S.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave,
Box 29, New York, NY 10065
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9
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Development of a Patient Decision Aid for Rectal Cancer Patients with Clinical Complete Response after Neo-Adjuvant Treatment. Cancers (Basel) 2023; 15:cancers15030806. [PMID: 36765766 PMCID: PMC9913303 DOI: 10.3390/cancers15030806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 01/20/2023] [Accepted: 01/26/2023] [Indexed: 02/01/2023] Open
Abstract
Surgery is the primary component of curative treatment for patients with rectal cancer. However, patients with a clinical complete response (cCR) after neo-adjuvant treatment may avoid the morbidity and mortality of radical surgery. An organ-sparing strategy could be an oncological equivalent alternative. Therefore, shared decision making between the patient and the healthcare professional (HCP) should take place. This can be facilitated by a patient decision aid (PtDA). In this study, we developed a PtDA based on a literature review and the key elements of the Ottawa Decision Support Framework. Additionally, a qualitative study was performed to review and evaluate the PtDA by both HCPs and former rectal cancer patients by a Delphi procedure and semi-structured interviews, respectively. A strong consensus was reached after the first round (I-CVI 0.85-1). Eleven patients were interviewed and most of them indicated that using a PtDA in clinical practice would be of added value in the decision making. Patients indicated that their decisional needs are centered on the impact of side effects on their quality of life and the outcome of the different options. The PtDA was modified taking into account the remarks of patients and HCPs and a second Delphi round was held. The second round again showed a strong consensus (I-CVI 0.87-1).
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Dai D, Liu G, Liu H, Liu Y, Liu X, Li S, Lei Y, Gao Y, Wang Y, Zhang S, Zhang R. Clinical feasibility of the therapeutic strategies total neoadjuvant therapy and "watch and wait" in the treatment of rectal cancer patients with recurrence after clinical complete response. Front Surg 2023; 9:1006624. [PMID: 36726944 PMCID: PMC9885041 DOI: 10.3389/fsurg.2022.1006624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 12/28/2022] [Indexed: 01/17/2023] Open
Abstract
Purpose In recent years, total neoadjuvant therapy (TNT) has emerged as a new therapeutic strategy against advanced rectal cancer (RC). After administration of TNT, some patients show complete clinical response (cCR) to treatment however, disputes about the effects of TNT and the alternative treatment plans in case of recurrence after cCR still exist. Methods A total of 100 patients were included in this paper. CR and non-CR was observed when these patients were administered with TNT at the First Affiliated Hospital of Dalian Medical University, China from May 2015 to June 2021. These patients received different chemotherapeutic regimens, with close monitoring and watch and wait (W&W) strategy being applied by a multidisciplinary team (MDT). According to treatment results, patients were divided into a cCR group and a non-cCR group; according to the recurrence during W&W, they were divided into a recurrence group and a no-local-recurrence group. This study analyzed the factors that may affect the prognosis, and summarized the surgery and treatment after recurrence. Results The TNT strategy was effective, and 85% of patients achieved local remission. However, W&W did not affect the survival time of CR patients, nor did it cause new distant metastasis due to local recurrence during the observation period (P > 0.05). However, for patients with positive CRM, we do not recommend W&W as the first choice of treatment (P < 0.05). Conclusion (1) Whole-course neoadjuvant therapy was an effective treatment scheme for advanced mid-term rectal cancer. The total local reduction rate of this group of cases was 85.00%, meaning that 25 patients achieved CR. (2) W&W was safe and reliable, and CR patients could receive it as the preferred treatment. (3) CRM was an independent risk factor for local recurrence in CR patients. We do not recommend W&W as the preferred treatment for CR patients with positive CRM.
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Affiliation(s)
- Dianyin Dai
- Department of Anorectal Surgery, Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Ge Liu
- Department of Anorectal Surgery, Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, China,Correspondence: Ge Liu
| | - Huanran Liu
- Department of Anorectal Surgery, Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yanfeng Liu
- Department of Anorectal Surgery, Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xinlu Liu
- Department of Anorectal Surgery, Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Shuang Li
- Department of Radiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yanan Lei
- Department of Anorectal Surgery, Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yun Gao
- Department of Anorectal Surgery, Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yuezhu Wang
- Department of Anorectal Surgery, Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Shoujia Zhang
- Department of Anorectal Surgery, Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Ran Zhang
- Department of Anorectal Surgery, Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, China
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Quality of life in a randomized trial comparing two neoadjuvant regimens for locally advanced rectal cancer-INCAGI004. Support Care Cancer 2022; 30:6557-6572. [PMID: 35486228 DOI: 10.1007/s00520-022-07059-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 04/11/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy (neoCRT) followed by surgery is the standard of care for locally advanced rectal cancer (LARC), but the emergence of different drug regimens may result in different response rates. Good clinical response translates into greater sphincter preservation, but quality of life (QOL) may be impaired after treatment due to chemoradiotherapy and surgical side effects. OBJECTIVE To prospectively evaluate the impact of clinical response and surgical resection on QOL in a randomized trial comparing two different neoCRT regimens. METHODS Stage II and III rectal cancer patients were randomized to receive neoCRT with either capecitabine (group 1) or 5-Fu and leucovorin (group 2) concomitant to long-course radiotherapy. Clinical downstaging was accessed using MRI 6-8 weeks after treatment. EORTCs QLQ-C30 and CR38 were applied before treatment (T0), after neoCRT (T1), after rectal resection (T2), early after adjuvant chemotherapy (T3), and 1 year after the end of treatment or stoma closure (T4). The Wexner scale was used for fecal incontinence evaluation at T4. A C30SummaryScore (Geisinger and cols.) was calculated to compare QOL results. RESULTS Thirty-two patients were assigned to group 1 and 31 to group 2. Clinical downstaging occurred in 70.0% of group 1 and 53.3% of group 2 (p = 0.288), and sphincter preservation was 83.3% in group 1 and 80.0% in group 2 (p = 0.111). No significant difference in QOL was detected when comparing the two treatment groups after neoCRT using QLQ-C30. However, the CR38 module detected differences in micturition problems (15.3 points), gastrointestinal problems (15.3 points), defecation problems (11.8 points), and sexual satisfaction (13.3 points) favoring the capecitabine group. C30SummaryScore detected significant improvement comparing T0 to T1 and deterioration comparing T1 to T2 (p = 0.025). The mean Wexner scale score was 9.2, and a high score correlated with symptoms of diarrhea and defecation problems at T4. CONCLUSIONS QOL was equivalent between groups after neoCRT except for micturition problems, gastrointestinal problems, defecation problems, and sexual satisfaction favoring the capecitabine arm after. The overall QOL using the C30SummaryScore was improved after neoCRT, but decreased following rectal resection, returning to basal levels at late evaluation. Fecal incontinence was high after sphincter preservation. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03428529.
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Zhang X, Ding R, Li J, Wu T, Shen Z, Li S, Zhang Y, Dong C, Shang Z, Zhou H, Li T, Li G, Li Y. Efficacy and safety of the "watch-and-wait" approach for rectal cancer with clinical complete response after neoadjuvant chemoradiotherapy: a meta-analysis. Surg Endosc 2022; 36:2233-2244. [PMID: 34981233 DOI: 10.1007/s00464-021-08932-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 11/22/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Watch-and-Wait (WW) approach is positioned at the cutting edge of non-invasive approach for rectal cancer patients who achieve clinical complete response (cCR) after neoadjuvant chemoradiotherapy (nCRT). This meta-analysis aimed to compare the clinical, oncologic, and survival outcomes of WW versus radical surgery (RS) and to evaluate the efficacy, safety, and possible superiority of WW. METHODS A systematic search for studies comparing WW with RS was conducted on MEDLINE, Ovid, Embase, Cochrane Library, and Web of Science databases. After screening for inclusion, data extraction, and quality assessment, statistical analysis was performed using Stata/SE14.0 software. Permanent colostomy (PC), local recurrence (LR), distant metastasis (DM), cancer-related death (CRD), 2-, 3-, and 5-year disease-free survival (DFS), and overall survival (OS) were analyzed using fixed effects or random-effects models depending on the heterogeneity. RESULTS Fourteen studies with moderate-high quality involving 1254 patients were included. Of these, 513 patients were managed with WW and 741 patients were subjected to RS. Compared to RS group, WW group had higher rate of LR (odds ratio OR = 11.09, 95% confidence interval CI = 5.30-23.20, P = 0.000), 2-year OS, and 3-year OS and had lower rate of PC (OR = 0.12, 95% CI = 0.05-0.29, P = 0.000). There were no significant between-group differences with respect to DM, CRD, 2-, 3-, and 5-year DFS (OR = 0.92, 95% CI = 0.81-1.03, P = 0.153), or 5-year OS (OR = 1.01, 95% CI = 0.28-3.63, P = 0.988). CONCLUSION The WW is a promising treatment approach and is a relatively safe alternative to RS for managing patients with rectal cancer who achieve cCR after nCRT. However, this modality requires rigorous screening criteria and standardized follow-up. Large-scale, multicenter prospective randomized controlled trials are warranted to further verify the outcomes of WW approach.
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Affiliation(s)
- Xuan Zhang
- Department of Colorectal Surgery, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, No. 519, Kunzhou Road, Xishan District, 650118, Yunnan, Kunming, People's Republic of China
| | - Rong Ding
- Department of Minimally Invasive Intervention, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Yunnan, Kunming, 650118, People's Republic of China
| | - JinSha Li
- Department of Colorectal Surgery, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, No. 519, Kunzhou Road, Xishan District, 650118, Yunnan, Kunming, People's Republic of China
| | - Tao Wu
- Department of Colorectal Surgery, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, No. 519, Kunzhou Road, Xishan District, 650118, Yunnan, Kunming, People's Republic of China
| | - ZhengHai Shen
- Office of Cancer Center, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, 650118, People's Republic of China
| | - ShanShan Li
- Department of Anesthesiology, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Yunnan, Kunming, 650118, People's Republic of China
| | - Ya Zhang
- Department of Orthopaedics, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Yunnan, Kunming, 650118, People's Republic of China
| | - Chao Dong
- Department of Oncology, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Yunnan, Kunming, 650118, People's Republic of China
| | - ZhongJun Shang
- Department of Hospital Affairs, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Yunnan, Kunming, 650118, People's Republic of China
| | - Hai Zhou
- Office of Cancer Center, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, 650118, People's Republic of China
| | - Ting Li
- Department of Colorectal Surgery, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, No. 519, Kunzhou Road, Xishan District, 650118, Yunnan, Kunming, People's Republic of China
| | - GuoYu Li
- Department of Colorectal Surgery, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, No. 519, Kunzhou Road, Xishan District, 650118, Yunnan, Kunming, People's Republic of China
| | - YunFeng Li
- Department of Colorectal Surgery, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, No. 519, Kunzhou Road, Xishan District, 650118, Yunnan, Kunming, People's Republic of China.
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Park IJ. Watch and wait strategies for rectal cancer A systematic review. PRECISION AND FUTURE MEDICINE 2021. [DOI: 10.23838/pfm.2021.00177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Yu G, Lu W, Jiao Z, Qiao J, Ma S, Liu X. A meta-analysis of the watch-and-wait strategy versus total mesorectal excision for rectal cancer exhibiting complete clinical response after neoadjuvant chemoradiotherapy. World J Surg Oncol 2021; 19:305. [PMID: 34663341 PMCID: PMC8522111 DOI: 10.1186/s12957-021-02415-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 09/30/2021] [Indexed: 01/04/2023] Open
Abstract
Background Some clinical researchers have reported that patients with cCR (clinical complete response) status after neoadjuvant chemoradiotherapy (nCRT) could adopt the watch-and-wait (W&W) strategy. Compared with total mesorectal excision (TME) surgery, the W&W strategy could achieve a similar overall survival. Could the W&W strategy replace TME surgery as the main treatment option for the cCR patients? By using the meta-analysis method, we evaluated the safety and efficacy of the W&W strategy and TME surgery for rectal cancer exhibiting cCR after nCRT. Methods We evaluated two treatment strategies for rectal cancer with cCR after nCRT up to July 2021 by searching the Cochrane Library, PubMed, Wanfang, and China National Knowledge Infrastructure (CNKI) databases. Clinical data for primary outcomes (local recurrence, cancer-related death and distant metastasis), and secondary outcomes (disease-free survival (DFS) and overall survival (OS)) were collected to evaluate the efficacy and safety in the two groups. Results We included nine studies with 818 patients in the meta-analysis, and there were five moderate-quality studies and four high-quality studies. A total of 339 patients were in the W&W group and 479 patients were in the TME group. The local recurrence rate in the W&W group was greater than that in the TME group in the fixed-effects model (OR 8.54, 95% CI 3.52 to 20.71, P < 0.001). The results of other outcomes were similar in the two groups. Conclusion The local recurrence rate of the W&W group was greater than that in the TME group, but other results were similar in the two groups. With the help of physical examination and salvage therapy, the W&W strategy could achieve similar treatment effects with the TME approach. Trial registration Protocol registration number: CRD42021244032. Supplementary Information The online version contains supplementary material available at 10.1186/s12957-021-02415-y.
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Affiliation(s)
- Guilin Yu
- Department of General Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, No. 44 Xiaoheyan Road, Dadong District, Shenyang, 110042, Liaoning Province, People's Republic of China
| | - Wenqing Lu
- School of Life Sciences, Hebei University, Baoding, 071002, Hebei Province, People's Republic of China
| | - Zhouguang Jiao
- Institute of Process Engineering, Chinese Academy of Science, Beijing, 100190, People's Republic of China
| | - Jun Qiao
- Department of Colorectal Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, No. 44 Xiaoheyan Road, Dadong District, Shenyang, 110042, Liaoning Province, People's Republic of China
| | - Shiyang Ma
- Department of Colorectal Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, No. 44 Xiaoheyan Road, Dadong District, Shenyang, 110042, Liaoning Province, People's Republic of China
| | - Xin Liu
- Department of Colorectal Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, No. 44 Xiaoheyan Road, Dadong District, Shenyang, 110042, Liaoning Province, People's Republic of China.
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Valadão M, Cesar D, Véo CAR, Araújo RO, do Espirito Santo GF, Oliveira de Souza R, Aguiar S, Ribeiro R, de Castro Ribeiro HS, de Souza Fernandes PH, Oliveira AF. Brazilian society of surgical oncology: Guidelines for the surgical treatment of mid-low rectal cancer. J Surg Oncol 2021; 125:194-216. [PMID: 34585390 DOI: 10.1002/jso.26676] [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: 08/08/2021] [Accepted: 09/08/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Colorectal cancer (CRC) is the third leading cause of cancer in North America, Western Europe, and Brazil, and represents an important public health problem. It is estimated that approximately 30% of all the CRC cases correspond to tumors located in the rectum, requiring complex multidisciplinary treatment. In an effort to provide surgeons who treat rectal cancer with the most current information based on the best evidence in the literature, the Brazilian Society of Surgical Oncology (SBCO) has produced the present guidelines for rectal cancer treatment that is focused on the main topics related to daily clinical practice. OBJECTIVES The SBCO developed the present guidelines to provide recommendations on the main topics related to the treatment of mid-low rectal cancer based on current scientific evidence. METHODS Between May and June 2021, 11 experts in CRC surgery met to develop the guidelines for the treatment of mid-low rectal cancer. A total of 22 relevant topics were disseminated among the participants. The methodological quality of a final list with 221 sources was evaluated, all the evidence was examined and revised, and the treatment guideline was formulated by the 11-expert committee. To reach a final consensus, all the topics were reviewed via a videoconference meeting that was attended by all 11 of the experts. RESULTS The prepared guidelines contained 22 topics considered to be highly relevant in the treatment of mid-low rectal cancer, covering subjects related to the tests required for staging, surgical technique-related aspects, recommended measures to reduce surgical complications, neoadjuvant strategies, and nonoperative treatments. In addition, a checklist was proposed to summarize the important information and offer an updated tool to assist surgeons who treat rectal cancer provide the best care to their patients. CONCLUSION These guidelines summarize concisely the recommendations based on the most current scientific evidence on the most relevant aspects of the treatment of mid-low rectal cancer and are a practical guide that can help surgeons who treat rectal cancer make the best therapeutic decision.
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Affiliation(s)
- Marcus Valadão
- Division of Abdominal-Pelvic Surgery, Instituto Nacional de Cancer, Rio de Janeiro, Brazil
| | - Daniel Cesar
- Division of Abdominal-Pelvic Surgery, Instituto Nacional de Cancer, Rio de Janeiro, Brazil
| | | | - Rodrigo Otávio Araújo
- Division of Abdominal-Pelvic Surgery, Instituto Nacional de Cancer, Rio de Janeiro, Brazil
| | | | | | - Samuel Aguiar
- Department of Surgical Oncology, AC Camargo Cancer Center, São Paulo, Brazil
| | - Reitan Ribeiro
- Department of Surgical Oncology, Erasto Gaertner Hospital, Curitiba, Brazil
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Zhang Y, Jiang P, Zhu H, Dong B, Zhai H, Chen Z. The efficacy and safety of different radiotherapy doses in neoadjuvant chemoradiotherapy for locally advanced rectal cancer. J Gastrointest Oncol 2021; 12:1531-1542. [PMID: 34532108 DOI: 10.21037/jgo-21-296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/13/2021] [Indexed: 11/06/2022] Open
Abstract
Background This study aimed to evaluate efficacy and adverse effects of different radiotherapy (RT) doses in neoadjuvant chemoradiotherapy for locally advanced rectal cancer. Methods Fifty-nine patients with locally advanced rectal cancer who underwent neoadjuvant chemoradiotherapy in hospital between January 2015 and May 2017 were enrolled in retrospective analysis. The patients were divided into the 56-Gy group and the 50-Gy group. The concurrent chemotherapy regimen was based on capecitabine. All patients received one cycle of oxaliplatin combined with capecitabine induction chemotherapy. All patients completed neoadjuvant chemoradiotherapy and received radical surgery. Results Of the patients in this study, 29 patients and 30 patients received a radiation dose of 56- and 50-Gy, respectively. All clinical characteristics were matched between the two groups. All patients received surgery 6 to 8 weeks after completing RT. The therapeutical effective rate in the 56-Gy group was 93.10% (27/29), compared with 66.67% in the 50-Gy group (20/30); the difference between the two groups was statistically significant (χ2=6.36, P=0.01). The pathological complete remission (pCR) rate in the 56-Gy group (37.93%, 11/29) was statistically significantly higher than that in the 50-Gy group (13.33%, 4/30) (χ2=4.71, P=0.030). The anal preservation rate in the 56-Gy group (65.5%, 19/29) was statistically significantly higher than that in the 50-Gy group (33.33%, 10/30) (χ2=6.11, P=0.01). The 56-Gy group had a local recurrence rate of 0% (0/29) and a distant metastasis rate of 10.34% (3/29), while the 50-Gy group had a local recurrence rate of 6.67% (2/30) and a distant metastasis rate of 16.67% (5/30); no significant difference existed between the two groups (χ2=2.00, 0.50, P=0.16, 0.48). The incidence of adverse reactions (gastrointestinal reactions, bone marrow suppression, and perianal skin reactions) in the 56-Gy group was not significantly different from that in the 50-Gy group (P>0.05). Conclusions Increasing the radiation dose can significantly improve the anal preservation and pCR rates of patients with locally advanced rectal cancer, thus improving their life quality. Moreover, it does not increase the rates of recurrence or adverse reactions. Our findings have certain clinical significance, but further prospective study is needed.
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Affiliation(s)
- Yongchun Zhang
- Department of Radiation Oncology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Peng Jiang
- Department of Radiation Oncology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Hui Zhu
- Department of Radiation Oncology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Bin Dong
- Department of Radiation Oncology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Hanxiao Zhai
- Department of Radiation Oncology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zhiying Chen
- Department of Radiation Oncology, The Affiliated Hospital of Qingdao University, Qingdao, China
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Faaborg PM, Haas S, Liao D, Ploen J, Jakobsen A, Rahr HB, Laurberg S, Gregersen H, Lundby L, Christensen P, Krogh K. Long-term anorectal function in rectal cancer patients treated with chemoradiotherapy and endorectal brachytherapy. Colorectal Dis 2021; 23:2311-2319. [PMID: 33900676 DOI: 10.1111/codi.15692] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/07/2021] [Accepted: 04/13/2021] [Indexed: 12/11/2022]
Abstract
AIM The aim was to study anorectal function in long-term survivors after combined, curatively intended, chemoradiotherapy and endorectal brachytherapy for low rectal cancer. METHODS This was a case-control design. We compared anorectal function by anal manometry, anal functional lumen imaging probe (EndoFLIP) and rectal bag distension in rectal cancer patients (RCPs) and healthy, normal subjects (NSs). Symptoms were assessed by the low anterior resection syndrome (LARS) and Wexner faecal incontinence scores. RESULTS Thirteen RCPs (12 men, median age 68 years, range 52-92) after 60 Gy radiotherapy, 5 Gy endorectal brachytherapy and oral tegafur-uracil with complete clinical response (median time since treatment 2.8 years, range 2.2-5.6) were compared to 15 NSs (14 men, median age 64 years, range 47-75). RCPs had lower than normal anal resting pressure, 38.6 mmHg (range 8.8-67.7) versus 58.8 mmHg (25.7-105.2) (P < 0.003), and squeeze pressure, 117 mmHg (55.2-203) versus 188 mmHg (103-248) (P < 0.01). Squeeze-induced pressure increase recorded by EndoFLIP was also lower in RCPs (q > 7.56, P < 0.001) as was the anal canal resistance to increasing distension (q = 3.13, P < 0.05). No differences in median rectal volume at first sensation (72 [22-158] vs. 82 [36-190] ml, P = 0.4) or at urge to defaecate (107 [42-227] vs. 132 [59-334] ml, P = 0.2) were found. However, maximum tolerable rectal volume was lower in RCPs (145 [59-319] vs. 222 [106-447] ml, P < 0.02). The median (range) low anterior resection syndrome score was 27 (0-39) for RCPs and 7 (0-23) for NSs (P < 0.001), while the Wexner score was 0 (0-5) versus 0 (0-4) (P = 0.56). CONCLUSION Radiotherapy combined with endorectal brachytherapy for rectal cancer causes long-term anorectal symptoms, impaired anal sphincter function and reduced rectal capacity.
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Affiliation(s)
- Pia Møller Faaborg
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects After Cancer in the Pelvic Organs, Department of Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Surgery, Danish Colorectal Cancer Center South, Vejle Hospital, Vejle, Denmark
| | - Susanne Haas
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects After Cancer in the Pelvic Organs, Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Donghua Liao
- Mech-Sense, Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
| | - John Ploen
- Department of Oncology, Danish Colorectal Cancer Center South, Vejle Hospital, Vejle, Denmark
| | - Anders Jakobsen
- Department of Oncology, Danish Colorectal Cancer Center South, Vejle Hospital, Vejle, Denmark
| | - Hans Bjarke Rahr
- Department of Surgery, Danish Colorectal Cancer Center South, Vejle Hospital, Vejle, Denmark
| | - Soeren Laurberg
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects After Cancer in the Pelvic Organs, Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Hans Gregersen
- GIOME, California Medical Innovations Institute, San Diego, California, USA
| | - Lilli Lundby
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects After Cancer in the Pelvic Organs, Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Peter Christensen
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects After Cancer in the Pelvic Organs, Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Klaus Krogh
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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Yuval JB, Garcia-Aguilar J. Watch-and-wait Management for Rectal Cancer After Clinical Complete Response to Neoadjuvant Therapy. Adv Surg 2021; 55:89-107. [PMID: 34389102 DOI: 10.1016/j.yasu.2021.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Jonathan B Yuval
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
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Podda M, Sylla P, Baiocchi G, Adamina M, Agnoletti V, Agresta F, Ansaloni L, Arezzo A, Avenia N, Biffl W, Biondi A, Bui S, Campanile FC, Carcoforo P, Commisso C, Crucitti A, De'Angelis N, De'Angelis GL, De Filippo M, De Simone B, Di Saverio S, Ercolani G, Fraga GP, Gabrielli F, Gaiani F, Guerrieri M, Guttadauro A, Kluger Y, Leppaniemi AK, Loffredo A, Meschi T, Moore EE, Ortenzi M, Pata F, Parini D, Pisanu A, Poggioli G, Polistena A, Puzziello A, Rondelli F, Sartelli M, Smart N, Sugrue ME, Tejedor P, Vacante M, Coccolini F, Davies J, Catena F. Multidisciplinary management of elderly patients with rectal cancer: recommendations from the SICG (Italian Society of Geriatric Surgery), SIFIPAC (Italian Society of Surgical Pathophysiology), SICE (Italian Society of Endoscopic Surgery and new technologies), and the WSES (World Society of Emergency Surgery) International Consensus Project. World J Emerg Surg 2021; 16:35. [PMID: 34215310 PMCID: PMC8254305 DOI: 10.1186/s13017-021-00378-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 06/18/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND AIMS Although rectal cancer is predominantly a disease of older patients, current guidelines do not incorporate optimal treatment recommendations for the elderly and address only partially the associated specific challenges encountered in this population. This results in a wide variation and disparity in delivering a standard of care to this subset of patients. As the burden of rectal cancer in the elderly population continues to increase, it is crucial to assess whether current recommendations on treatment strategies for the general population can be adopted for the older adults, with the same beneficial oncological and functional outcomes. This multidisciplinary experts' consensus aims to refine current rectal cancer-specific guidelines for the elderly population in order to help to maximize rectal cancer therapeutic strategies while minimizing adverse impacts on functional outcomes and quality of life for these patients. METHODS The discussion among the steering group of clinical experts and methodologists from the societies' expert panel involved clinicians practicing in general surgery, colorectal surgery, surgical oncology, geriatric oncology, geriatrics, gastroenterologists, radiologists, oncologists, radiation oncologists, and endoscopists. Research topics and questions were formulated, revised, and unanimously approved by all experts in two subsequent modified Delphi rounds in December 2020-January 2021. The steering committee was divided into nine teams following the main research field of members. Each conducted their literature search and drafted statements and recommendations on their research question. Literature search has been updated up to 2020 and statements and recommendations have been developed according to the GRADE methodology. A modified Delphi methodology was implemented to reach agreement among the experts on all statements and recommendations. CONCLUSIONS The 2021 SICG-SIFIPAC-SICE-WSES consensus for the multidisciplinary management of elderly patients with rectal cancer aims to provide updated evidence-based statements and recommendations on each of the following topics: epidemiology, pre-intervention strategies, diagnosis and staging, neoadjuvant chemoradiation, surgery, watch and wait strategy, adjuvant chemotherapy, synchronous liver metastases, and emergency presentation of rectal cancer.
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Affiliation(s)
- Mauro Podda
- Department of Emergency Surgery, Cagliari University Hospital "D. Casula", Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy.
| | - Patricia Sylla
- Division of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY, USA
| | - Gianluca Baiocchi
- ASST Cremona, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Michel Adamina
- Department of Colorectal Surgery, Cantonal Hospital of Winterthur, Winterthur - University of Basel, Basel, Switzerland
| | | | - Ferdinando Agresta
- Department of General Surgery, Vittorio Veneto Hospital, AULSS2 Trevigiana del Veneto, Vittorio Veneto, Italy
| | - Luca Ansaloni
- 1st General Surgery Unit, University of Pavia, Pavia, Italy
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Nicola Avenia
- SC Chirurgia Generale e Specialità Chirurgiche Azienda Ospedaliera Santa Maria, Università degli Studi di Perugia, Terni, Italy
| | - Walter Biffl
- Trauma and Acute Care Surgery, Scripps Memorial Hospital, La Jolla, CA, USA
| | - Antonio Biondi
- Department of General Surgery and Medical - Surgical Specialties, University of Catania, Catania, Italy
| | - Simona Bui
- Department of Medical Oncology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Fabio C Campanile
- Department of Surgery, ASL VT - Ospedale "San Giovanni Decollato - Andosilla", Civita Castellana, Italy
| | - Paolo Carcoforo
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara, University of Ferrara, Ferrara, Italy
| | - Claudia Commisso
- Department of Radiology, University Hospital of Parma, Parma, Italy
| | - Antonio Crucitti
- General and Minimally Invasive Surgery Unit, Cristo Re Hospital and Catholic University, Rome, Italy
| | - Nicola De'Angelis
- Unit of Minimally Invasive and Robotic Digestive Surgery, Regional General Hospital F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Gian Luigi De'Angelis
- Department of Medicine and Surgery, Gastroenterology and Endoscopy Unit, University of Parma, Parma, Italy
| | | | - Belinda De Simone
- Department of General and Metabolic Surgery, Poissy and Saint Germain en Laye Hospitals, Poissy, France
| | | | - Giorgio Ercolani
- General and Oncologic Surgery, Morgagni-Pierantoni Hospital, AUSL Romagna, Forlì, Italy
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, SP, Brazil
| | | | - Federica Gaiani
- Department of Medicine and Surgery, Gastroenterology and Endoscopy Unit, University of Parma, Parma, Italy
| | | | | | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ari K Leppaniemi
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Andrea Loffredo
- UOC Chirurgia Generale - AOU san Giovanni di Dio e Ruggi d'Aragona, Università di Salerno, Salerno, Italy
| | - Tiziana Meschi
- Department of Medicine and Surgery, University of Parma Geriatric-Rehabilitation Department, Parma University Hospital, Parma, Italy
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, Denver, USA
| | | | | | - Dario Parini
- Santa Maria della Misericordia Hospital, Rovigo, Italy
| | - Adolfo Pisanu
- Department of Emergency Surgery, Cagliari University Hospital "D. Casula", Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy
| | - Gilberto Poggioli
- Surgery of the Alimentary Tract, Sant'Orsola Hospital, Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Andrea Polistena
- Dipartimento di Chirurgia Pietro Valdoni Policlinico Umberto I, Sapienza Università degli Studi di Roma, Rome, Italy
| | - Alessandro Puzziello
- UOC Chirurgia Generale - AOU san Giovanni di Dio e Ruggi d'Aragona, Università di Salerno, Salerno, Italy
| | - Fabio Rondelli
- SC Chirurgia Generale e Specialità Chirurgiche Azienda Ospedaliera Santa Maria, Università degli Studi di Perugia, Terni, Italy
| | | | | | - Michael E Sugrue
- Letterkenny University Hospital and CPM sEUBP Interreg Project, Letterkenny, Ireland
| | | | - Marco Vacante
- Department of General Surgery and Medical - Surgical Specialties, University of Catania, Catania, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Fausto Catena
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
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Han Z, Li M, Chen J, Ji D, Zhan T, Peng Y, Xue W, Li Y, Cai Y, Sun Y, Wu Q, Du C, Gu J. Surgery may not benefit patients with locally advanced rectal cancer who achieved clinical complete response following neoadjuvant chemoradiotherapy. Asian J Surg 2021; 45:97-104. [PMID: 33888366 DOI: 10.1016/j.asjsur.2021.03.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 02/03/2021] [Accepted: 03/26/2021] [Indexed: 12/20/2022] Open
Abstract
PURPOSE We compared the long-term outcome of the watch and wait (WW) strategy and surgery in patients with locally advanced rectal cancer. PATIENTS AND METHODS This prospective cohort study included 84 patients who achieved clinical complete response (cCR) after neoadjuvant chemoradiotherapy (NCRT). They were divided into the WW group (n = 58) and surgery group (SG, n = 26). Patients in the SG underwent total mesorectal excision. The study site was the Peking University Cancer Hospital. RESULTS Eighty-four patients were included (58 and 26 in the WW group and SG, respectively). A total of 76·9% of the patients in the SG achieved pathological complete response (pCR) and 23·1% of the patients had a residual tumor. The total recurrence and metastasis rate was 15·4% (4/26) in the SG and 18·9% (11/58) in the WW group. There was no significant difference in the recurrence and metastasis rate between the two groups. In the WW group, 9 cases developed tumor regrowth during follow-up and underwent salvage surgery. The overall survival rate of the WW group (96·6% vs 92·3%) was not significantly different from that of the SG (P > 0·05). The WW patients also retained their anal sphincter function and avoided surgery-related complications. CONCLUSION The WW strategy is a feasible treatment option in patients with cCR after NCRT. Surgery may not bring benefits to these cCR patients.
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Affiliation(s)
- Zihan Han
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Surgery, Peking University Cancer Hospital & Institute, China
| | - Ming Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Surgery, Peking University Cancer Hospital & Institute, China
| | - Jiajia Chen
- Department of General Surgery, Peking University Shougang Hospital, Beijing, China
| | - Dengbo Ji
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Surgery, Peking University Cancer Hospital & Institute, China
| | - Tiancheng Zhan
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Surgery, Peking University Cancer Hospital & Institute, China
| | - Yifan Peng
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Surgery, Peking University Cancer Hospital & Institute, China
| | - Weicheng Xue
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Pathology, Peking University Cancer Hospital & Institute, China
| | - Yongheng Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, China
| | - Yong Cai
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, China
| | - Yingshi Sun
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Imaging, Peking University Cancer Hospital & Institute, China
| | - Qi Wu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Endoscopy, Peking University Cancer Hospital & Institute, China
| | - Changzheng Du
- School of Medicine, The Southern University of Science and Technology, 1088Xue Yuan Road, Shenzhen, Guangdong, 518055, People's Republic of China.
| | - Jin Gu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Surgery, Peking University Cancer Hospital & Institute, China; Peking University International Cancer Institute, China; Department of General Surgery, Peking University Shougang Hospital, Beijing, China; Peking-Tsinghua Center for Life Science, China.
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21
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Cesar D, Araujo R, Valadão M, Linhares E, Meton F, Jesus JPD. Surgical and oncological short-term outcomes of prone extralevator abdominoperineal excision for low rectal cancer. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1016/j.jcol.2018.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Abstract
Introduction In recent years, a standardized surgical approach for low rectal cancer was proposed and adopted in many centres. The extralevator abdominoperineal excision introduce an extensive resection of the pelvic floor and demonstrated superiority if the procedure is done in the prone jack-knife position, especially regarding intraoperative perforation and circumferential resections margins. The aim of this study is to evaluate the surgical and oncological short-term outcomes of prone extralevator abdominoperineal excision.
Methods All patients registered in our institution from January 2003 to January 2015 who underwent abdominoperineal resection or prone extralevator abdominoperineal excision for low rectal cancer after preoperative chemoradiation were retrospectively included from prospective maintained data base and were compared regarding surgical and oncological outcomes.
Results Eighty-nine patients underwent curative intent resections. Abdominoperineal resection was performed in 67 patients and prone extralevator abdominoperineal excision in 22 patients. There were no statistical significant differences between groups regarding pathological stage, median number of harvested lymph node, intraoperative perforation, circumferential resections margins involvement and recurrence rates. Surgical outcomes were statistically different between groups. Twenty-six patients (29%) developed perineal complications, 21% of the abdominoperineal resection patients and 55% of the prone extralevator abdominoperineal excision (p < 0.001). Most of these complications were due to delayed perineal wound healing (12.4%), and wound abscesses (4.5%). However, the readmission rate and median length of hospital stay was higher in the abdominoperineal resection group (p < 0.001).
Conclusion Prone extralevator abdominoperineal excision is comparable to standard abdominoperineal resection. It was associated to a decrease in length of hospital stay and readmission rate, although more perineal complications occurred. We cannot recommend it as a standard technique for all low rectal cancer. Notwithstanding, prone extralevator abdominoperineal excision can be considered a more radical approach when there is sphincter complex or levators muscles invasion.
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Affiliation(s)
- Daniel Cesar
- Instituto Nacional de Câncer (INCA), Departamento de Cirurgia Abdome e Pelve, Grupo Câncer Colorretal, Rio de Janeiro, RJ, Brazil
| | - Rodrigo Araujo
- Instituto Nacional de Câncer (INCA), Departamento de Cirurgia Abdome e Pelve, Grupo Câncer Colorretal, Rio de Janeiro, RJ, Brazil
| | - Marcus Valadão
- Instituto Nacional de Câncer (INCA), Departamento de Cirurgia Abdome e Pelve, Grupo Câncer Colorretal, Rio de Janeiro, RJ, Brazil
| | - Eduardo Linhares
- Instituto Nacional de Câncer (INCA), Departamento de Cirurgia Abdome e Pelve, Grupo Câncer Colorretal, Rio de Janeiro, RJ, Brazil
| | - Fernando Meton
- Instituto Nacional de Câncer (INCA), Departamento de Cirurgia Abdome e Pelve, Grupo Câncer Colorretal, Rio de Janeiro, RJ, Brazil
| | - José Paulo de Jesus
- Instituto Nacional de Câncer (INCA), Departamento de Cirurgia Abdome e Pelve, Grupo Câncer Colorretal, Rio de Janeiro, RJ, Brazil
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22
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Rizzo G, Pafundi DP, Sionne F, D'Agostino L, Pietricola G, Gambacorta MA, Valentini V, Coco C. Preoperative chemoradiotherapy affects postoperative outcomes and functional results in patients treated with transanal endoscopic microsurgery for rectal neoplasms. Tech Coloproctol 2021; 25:319-331. [PMID: 33459969 DOI: 10.1007/s10151-020-02394-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 12/20/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The aim of this study was to quantify the incidence of short-term postoperative complications and functional disorders at 1 year from transanal endoscopic microsurgery (TEM) for rectal neoplasms, to compare patients treated with TEM alone and with TEM after preoperative chemoradiotherapy (CRT) and to analyse factors influencing postoperative morbidity and functional outcomes. METHODS A retrospective study was conducted on all patients treated with TEM for rectal neoplasms at our institution in January 2000-December 2017. Data from a prospectively maintained database were retrospectively analysed. Patients were divided into two groups: adenoma or early rectal cancer (no CRT group) and locally advanced extraperitoneal rectal cancer with major or complete clinical response after preoperative CRT (CRT group). Short-term postoperative mortality and morbidity and the functional results at 1 year were recorded. The two groups were compared, and a statistical analysis of factors influencing postoperative morbidity and functional outcomes was performed. Functional outcome was also evaluated with the low anterior resection syndrome (LARS) score (0-20 no LARS, 21-29 minor LARS and 30-42 major LARS). RESULTS One hundred and thirteen patients (71 males, 42 females, median age 64 years [range 41-80 years]) were included in the study (46 in the CRT group). The overall postoperative complication rate was 23.0%, lower in the noCRT group (p < 0.001), but only 2.7% were grade ≥ 3. The most frequent complication was suture dehiscence (17.6%), which occurred less frequently in the noCRT group (p < 0.001). At 1 year from TEM, the most frequent symptoms was urgency (11.9%, without significant differences between the CRT group and the noCRT group); the noCRT group experienced a lower rate of soiling than the CRT group (0% vs. 7.7%; p: 0.027). The incidence of LARS was evaluated in 47 patients from May 2012 on and was 21.3% occurring less frequently in the noCRT group (10% vs. 41.2%; p: 0.012). Only 6.4% of the patients evaluated experienced major LARS. In multivariate analysis, preoperative CRT significantly worsened postoperative morbidity and functional outcomes. CONCLUSIONS TEM is a safe procedure associated with only low risk of severe postoperative complications and major LARS. Preoperative CRT seems to increase the rate of postoperative morbidity after TEM and led to worse functional outcomes at 1 year after surgery.
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Affiliation(s)
- G Rizzo
- U.O.C. Chirurgia Generale 2, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy.
| | - D P Pafundi
- U.O.C. Chirurgia Generale 2, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - F Sionne
- U.O.C. Chirurgia Generale 2, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - L D'Agostino
- U.O.C. Chirurgia Generale 2, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - G Pietricola
- U.O.C. Chirurgia Generale 2, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - M A Gambacorta
- U.O.C. Radioterapia Oncologica, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - V Valentini
- U.O.C. Radioterapia Oncologica, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - C Coco
- U.O.C. Chirurgia Generale 2, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy
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Uslu-Beşli L, Mermut Ö, Yardimci AH, Gündoğan C, Gürsu RU, Çermik TF. Comparison of 18F-FDG PET/CT and DW-MRI in assessment of neoadjuvant radiochemotherapy response in locally advanced rectal cancer patients. Rev Esp Med Nucl Imagen Mol 2021; 40:19-29. [PMID: 33402312 DOI: 10.1016/j.remn.2020.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 01/19/2020] [Accepted: 02/16/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Our aim is to evaluate if different metabolic parameters obtained by 18F-FDG PET/CT and diffusion weighted magnetic resonance imaging (DW-MRI) can aid in neoadjuvant radiochemotherapy (RCT) response assessment in locally advanced rectal cancer (LARC) patients. METHODS Out of 20 LARC patients, who were planned to receive neoadjuvant RCT, 19 were included in this prospective study. Patients had 18F-FDG PET/CT and DW-MRI at initial staging, interim (2 weeks after onset of RCT) and after completion of RCT (post-therapy). Standardized uptake value (SUV) parameters (SUVmax, SUVmean, SUVpeak, SULpeak), metabolic tumor volume (MTV) and tumor lesion glycolysis (TLG) detected on PET images and apparent diffusion coefficient (ADC) values (for b=400 and b=1000s/mm2) obtained from DW-MRI were recorded. Postoperative tumor regression grade (TRG) was used as gold-standard, except for 2 patients who were under complete remission with non-operative management 19 months post-therapy and scored as responders. RESULTS On interim PET/CT, no significant difference was found among PET parameters between responders and non-responders, whereas post-therapy SUVmax, SUVpeak, MTV, SULpeak, TLG (P=0.02, P=0.014, P=0.025, P=0.007, P=0.02, respectively) and initial MTV (P=0.034) were significantly lower in responders. ADC response index (RI) was higher in responders (interim P=0.026; post-therapy: P=0.018) and ROC analysis revealed that a threshold of ADC RI>41.6% for interim MRI and >44.6% for post-therapy MRI had sensitivity and specificity of 75.0% and 90.9%, respectively. CONCLUSIONS While interim 18F-FDG PET/CT failed to predict therapy response during RCT, post-therapy PET could accurately differentiate responders. DW-MRI was found to be more promising in interim detection of RCT response.
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Affiliation(s)
- L Uslu-Beşli
- Departamento de Medicina Nuclear, Facultad de Medicina de Cerrahpaşa, Universidad de Cerrahpaşa, Estambul, Turquía; Departamento de Medicina Nuclear, Universidad de Ciencias de la Salud, Hospital Universitario de Estambul, Estambul, Turquía.
| | - Ö Mermut
- Departamento de Oncología Radiológica, Universidad de Ciencias de la Salud, Hospital Universitario de Estambul, Estambul, Turquía
| | - A H Yardimci
- Departamento de Radiología, Universidad de Ciencias de la Salud, Hospital Universitario de Estambul, Estambul, Turquía
| | - C Gündoğan
- Departamento de Medicina Nuclear, Universidad de Ciencias de la Salud, Hospital Universitario de Estambul, Estambul, Turquía
| | - R U Gürsu
- Departamento de Oncología Médica, Universidad de Ciencias de la Salud, Hospital Universitario de Estambul, Estambul, Turquía
| | - T F Çermik
- Departamento de Medicina Nuclear, Universidad de Ciencias de la Salud, Hospital Universitario de Estambul, Estambul, Turquía
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24
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Uslu-Beşli L, Mermut Ö, Yardimci AH, Gündoğan C, Gürsu RU, Çermik TF. Comparison of 18F-FDG PET/CT and DW-MRI in assessment of neoadjuvant radiochemotherapy response in locally advanced rectal cancer patients. Rev Esp Med Nucl Imagen Mol 2021. [DOI: 10.1016/j.remnie.2020.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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25
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Non-Operative Management Versus Total Mesorectal Excision for Locally Advanced Rectal Cancer with Clinical Complete Response After Neoadjuvant Chemoradiotherapy: a GRADE Approach by the Rectal Cancer Guidelines Writing Group of the Italian Association of Medical Oncology (AIOM). J Gastrointest Surg 2020; 24:2150-2159. [PMID: 32394125 DOI: 10.1007/s11605-020-04635-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 04/25/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND The standard approach for locally advanced rectal cancer (LARC) is neoadjuvant chemoradiotherapy (nCRT) followed by total mesorectal excision (TME). After nCRT 20% of patients achieve a clinical complete response (pCR) and could be treated with a non-operative management (NOM). METHODS The panel of the Italian Association of Medical Oncology (AIOM) Guidelines on rectal cancer applied the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach addressing the following question: Should NOM vs. TME be used for patients with rectal cancer with clinical complete response after nCRT? Five outcomes were identified: disease-free survival (DFS), mortality, local recurrence, colostomy rate, and functional outcomes. RESULTS Nine studies were included in the analysis. A higher risk of disease recurrence was observed in the NOM group compared to the TME group (RR = 1.69, 95% CI 1.08, 2.64) on the other hand, we observed a slightly positive but not significant effect on mortality of NOM (RR = 0.82, 95% CI 0.46, 1.45). Patients in the NOM group were more likely to experience local recurrence (RR = 5.37, 95% CI 2.56, 11.27) and patients in the TME group were more likely to have a permanent colostomy (RR = 0.15, 95% CI 0.08, 0.29). Only one study evaluated functional outcomes. The overall certainty of evidence was rated as very low. CONCLUSIONS NOM was found to correlate with a higher risk of local recurrence which did not translate in worse OS and a lower colostomy rate. Due to the paucity of evidences, no recommendations are possible. NOM remains an experimental treatment; thus, patients managed with NOM should be enrolled in clinical trials with a dedicated follow-up schedule.
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Engel RM, Oliva K, Koulis C, Yap R, McMurrick PJ. Predictive factors of complete pathological response in patients with locally advanced rectal cancer. Int J Colorectal Dis 2020; 35:1759-1767. [PMID: 32474708 DOI: 10.1007/s00384-020-03633-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/14/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Patients with locally advanced rectal cancer who achieve pathologic complete response (pCR) following neoadjuvant therapy have better long-term outcomes and could be spared from the perioperative and long-term morbidity of rectal resection. The aim of this study was to identify factors that predict the ability to achieve pCR at completion of conventional neoadjuvant therapy, therefore determining their suitability for non-surgical management. METHODS A retrospective analysis was performed on data obtained from a prospectively maintained colorectal neoplasia database. Patients treated for biopsy-proven primary rectal adenocarcinoma between January 1, 2010, and February 28, 2018, who received neoadjuvant radiotherapy or chemoradiotherapy and had undergone surgical resection, were included in this study. Five-year oncologic outcome data was also obtained for 144 patients. Clinicopathological tumour characteristics and treatment regimens were analysed for correlation to clinical outcome. RESULTS Three hundred fifty-four patients met inclusion criteria for this study. We identified significant differences between patients achieving a pCR and those that did not for tumour type (adenocarcinoma vs. mucinous/signet ring; p = 0.008), pre-treatment serum CEA level (</≥ 2.5 μg/L; p = 0.003), neoadjuvant therapy type (short-course radiotherapy and long-course chemoradiotherapy; p = 0.008) and preoperative lymph node status (node-negative versus node-positive disease; p = 0.031). Additionally, this is the first report to our knowledge to identify a significant correlation with pCR and the degree of tumour fixity (mobile vs. fixed/tethered; p = 0.038). CONCLUSIONS This retrospective analysis identified factors that significantly impact a patients' ability to achieve a pCR, which may prove useful for prospectively selecting patients suitable for non-surgical management of disease.
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Affiliation(s)
- Rebekah M Engel
- Cabrini Monash University Department of Surgery, Cabrini Health, Malvern, VIC, 3144, Australia.
- Department of Anatomy and Developmental Biology, Monash University, Clayton, VIC, 3800, Australia.
- Stem Cells and Development Program, Monash Biomedicine Discovery Institute, Monash University, Wellington Road, Clayton, VIC, 3800, Australia.
| | - Karen Oliva
- Cabrini Monash University Department of Surgery, Cabrini Health, Malvern, VIC, 3144, Australia
| | - Christine Koulis
- Cabrini Monash University Department of Surgery, Cabrini Health, Malvern, VIC, 3144, Australia
| | - Raymond Yap
- Cabrini Monash University Department of Surgery, Cabrini Health, Malvern, VIC, 3144, Australia
| | - Paul J McMurrick
- Cabrini Monash University Department of Surgery, Cabrini Health, Malvern, VIC, 3144, Australia
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Zhao GH, Deng L, Ye DM, Wang WH, Yan Y, Yu T. Efficacy and safety of wait and see strategy versus radical surgery and local excision for rectal cancer with cCR response after neoadjuvant chemoradiotherapy: a meta-analysis. World J Surg Oncol 2020; 18:232. [PMID: 32862826 PMCID: PMC7457353 DOI: 10.1186/s12957-020-02003-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 08/17/2020] [Indexed: 01/01/2023] Open
Abstract
Background Neoadjuvant therapy can shrink tumors, increase anus preservation rate, and protect anal function. Radical surgery need cut off the diseased bowel, clean up the lymph nodes, and then restore bowel function. It could bring traumatic effect and poor postoperative quality of life to the patient. Local resection requires removal of the diseased bowel with circular negative margin. The surgical trauma is small, and the postoperative quality of life is good. In this meta-analysis, we aimed to evaluate the efficacy and safety between wait and see strategy (WS), radical surgery (RS), and local excision (LE) of rectal cancer patients with clinical complete response (cCR) response after neoadjuvant chemoradiotherapy. Methods We searched PubMed, Cochrane Library, CNKI (China National Knowledge Infrastructure), and Wanfang databases to compare wait and see strategy with radical surgery and local excision for rectal cancer with cCR response after neoadjuvant chemoradiotherapy up to March 2020. We collected the data of local recurrence, distant metastasis, cancer-related death, overall survival, and disease-free survival and used RevMan 5.0 to carry out the meta-analysis. Continuous data were evaluated by the standardized mean differences (SMD) with 95% confidence intervals (95% CIs), and dichotomous data were evaluated by relative risks (ORs or RRs) with 95% CIs. We aimed to compare the advantages and disadvantages of the three groups. Results Eleven English studies with 1131 patients were included. There were 412 patients in WS group, 678 patients in RS group, and 41 patients in LE group. WS group had a higher local recurrence rate than RS group (OR 7.32, 95% CI 3.58 to 14.95, P < 0.001). There was no significant difference in the other data between the three groups. Conclusion Compared with the RS group, the WS group had an increased risk of local recurrence. However, the WS group had a similar DFS and OS compared with the RS group and the local excision group. Hence, we speculated that the WS group would have similar results as the surgery group for patients with cCR status.
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Affiliation(s)
- Guo-Hua Zhao
- Department of General surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, No 44 Xiaoheyan Road, Dadong District, Shenyang, 110042, Liaoning Province, PR China
| | - Li Deng
- The Affiliated Hospital of Liaoning University of traditional Chinese Medicine, No 33 Beiling Street, Huanggu District, Shenyang, 110042, Liaoning Province, PR China
| | - Dong-Man Ye
- Department of Medical Imaging, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, No 44 Xiaoheyan Road, Dadong District, Shenyang, 110042, Liaoning Province, PR China
| | - Wen-Hui Wang
- Department of Medical Imaging, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, No 44 Xiaoheyan Road, Dadong District, Shenyang, 110042, Liaoning Province, PR China
| | - Yan Yan
- Department of Medical Imaging, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, No 44 Xiaoheyan Road, Dadong District, Shenyang, 110042, Liaoning Province, PR China
| | - Tao Yu
- Department of Medical Imaging, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, No 44 Xiaoheyan Road, Dadong District, Shenyang, 110042, Liaoning Province, PR China.
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López-Campos F, Martín-Martín M, Fornell-Pérez R, García-Pérez JC, Die-Trill J, Fuentes-Mateos R, López-Durán S, Domínguez-Rullán J, Ferreiro R, Riquelme-Oliveira A, Hervás-Morón A, Couñago F. Watch and wait approach in rectal cancer: Current controversies and future directions. World J Gastroenterol 2020; 26:4218-4239. [PMID: 32848330 PMCID: PMC7422545 DOI: 10.3748/wjg.v26.i29.4218] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/25/2020] [Accepted: 07/21/2020] [Indexed: 02/06/2023] Open
Abstract
According to the main international clinical guidelines, the recommended treatment for locally-advanced rectal cancer is neoadjuvant chemoradiotherapy followed by surgery. However, doubts have been raised about the appropriate definition of clinical complete response (cCR) after neoadjuvant therapy and the role of surgery in patients who achieve a cCR. Surgical resection is associated with significant morbidity and decreased quality of life (QoL), which is especially relevant given the favourable prognosis in this patient subset. Accordingly, there has been a growing interest in alternative approaches with less morbidity, including the organ-preserving watch and wait strategy, in which surgery is omitted in patients who have achieved a cCR. These patients are managed with a specific follow-up protocol to ensure adequate cancer control, including the early identification of recurrent disease. However, there are several open questions about this strategy, including patient selection, the clinical and radiological criteria to accurately determine cCR, the duration of neoadjuvant treatment, the role of dose intensification (chemotherapy and/or radiotherapy), optimal follow-up protocols, and the future perspectives of this approach. In the present review, we summarize the available evidence on the watch and wait strategy in this clinical scenario, including ongoing clinical trials, QoL in these patients, and the controversies surrounding this treatment approach.
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Affiliation(s)
- Fernando López-Campos
- Department of Radiation Oncology, Hospital Universitario Ramón y Cajal, Madrid 28034, Spain
| | | | - Roberto Fornell-Pérez
- Department of Radiology, Hospital Universitario de Basurto, Bilbao 48013, Vizcaya, Spain
| | | | - Javier Die-Trill
- Department of Surgery, Hospital Universitario Ramón y Cajal, Madrid 28034, Spain
| | - Raquel Fuentes-Mateos
- Department of Medical Oncology, Hospital Universitario Ramón y Cajal, Madrid 28034, Spain
| | - Sergio López-Durán
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Madrid 28034, Spain
| | - José Domínguez-Rullán
- Department of Radiation Oncology, Hospital Universitario Ramón y Cajal, Madrid 28034, Spain
| | - Reyes Ferreiro
- Department of Medical Oncology, Hospital Universitario Ramón y Cajal, Madrid 28034, Spain
| | | | - Asunción Hervás-Morón
- Department of Radiation Oncology, Hospital Universitario Ramón y Cajal, Madrid 28034, Spain
| | - Felipe Couñago
- Department of Radiation Oncology, Hospital Universitario Quirónsalud, Madrid 28003, Spain
- Department of Radiation Oncology, Hospital La Luz, Madrid 28003, Spain
- Universidad Europea de Madrid (UEM), Madrid 28223, Spain
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Yuval JB, Thompson HM, Garcia-Aguilar J. Organ Preservation in Rectal Cancer. J Gastrointest Surg 2020; 24:1880-1888. [PMID: 32314234 PMCID: PMC7390702 DOI: 10.1007/s11605-020-04583-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 03/22/2020] [Indexed: 02/08/2023]
Abstract
A proportion of patients with rectal cancer who undergo neoadjuvant treatment end up with a complete pathological response. Because these patients have excellent oncological outcomes, many have questioned if surgical treatment in this population constitutes overtreatment. There is growing interest in watch and wait with selective organ preservation for rectal cancer patients. We review the fundamentals and key considerations of this approach including patient selection, available treatment regimens, assessment of response, long-term monitoring of response, and long-term oncological and functional outcomes.
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Abstract
Neoadjuvant chemoradiotherapy followed by surgical resection is the standard of care for locally advanced rectal adenocarcinoma. Up to one third of patients achieve pathologic complete response (CR) with neoadjuvant therapy. Promising disease-free and overall survival outcomes have been reported in patients who achieve clinical CR after neoadjuvant therapy without surgical resection. Furthermore, patients who have local recurrence have acceptable disease control outcomes with salvage resection. With consideration of morbidities associated with surgical resection and similar clinical outcomes, interest in nonsurgical management of low rectal cancers has emerged. Randomized clinical trials are being conducted to evaluate a nonsurgical approach in rectal cancer. Lack of consensus on the definition of clinical CR, molecular biomarkers, and standardized nonsurgical management protocols is a significant barrier for routine clinical implementation of a nonsurgical management approach. This article aims to provide a concise review of the clinical experience and practical approach to the nonsurgical management of locoregional rectal adenocarcinoma.
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Affiliation(s)
- Mehmet Akce
- 1 Winship Cancer Institute of Emory University, Atlanta, GA
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Khan K, Hunter IA, Manzoor T. Should the rectal defect be sutured following TEMS/TAMIS carried out for neoplastic rectal lesions? A meta-analysis. Ann R Coll Surg Engl 2020; 102:647-653. [PMID: 32538129 DOI: 10.1308/rcsann.2020.0135] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Management of the rectal defect following transanal endoscopic microsurgery (TEMS) or minimally invasive surgery (TAMIS) carried out for excision of neoplasm in the lower rectum is controversial. We aimed to extract evidence by carrying out a meta-analysis to compare the peri- and postoperative outcomes following rectal neoplasm excision carried out by TEMS and/or TAMIS, whereby the defect is either sutured or left open. METHODS A literature search of Ovid MEDLINE and EMBASE was performed. Full-text comparative studies published until November 2019, in English and of adult patients, whereby TEMS or TAMIS was undertaken for rectal neoplasms were included. The main outcome measures were postoperative bleeding, infection, operative time and hospital stay. FINDINGS Three studies (one randomised controlled trial and two comparative case series) yielded 555 cases (283 in the sutured group and 272 in the open group). The incidence of postoperative bleeding was higher and statistically significant (p = 0.006) where the rectal defect was left open following excision of the neoplasm (19/272, 6.99% vs 6/283, 2.12%). There was no statistical difference between the sutured and open groups regarding infection (p = 0.27; (10/283, 3.53% vs 5/272, 1.84%, respectively), operative time (p = 0.15) or length of stay (p = 0.67). CONCLUSION Suturing the rectal defect following excision of rectal neoplasm by TEMS/TAMIS reduces the incidence of postoperative bleeding in comparison to leaving the defect open. However, suturing makes the procedure slightly longer but there was no statistical difference between both groups when postoperative infection and length of hospital stay were compared.
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Affiliation(s)
- K Khan
- Castle Hill Hospital, Hull University Teaching Hospitals, East Yorkshire, UK
| | - I A Hunter
- Castle Hill Hospital, Hull University Teaching Hospitals, East Yorkshire, UK
| | - T Manzoor
- Castle Hill Hospital, Hull University Teaching Hospitals, East Yorkshire, UK
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Does A Longer Waiting Period After Neoadjuvant Radio-chemotherapy Improve the Oncological Prognosis of Rectal Cancer?: Three Years' Follow-up Results of the Greccar-6 Randomized Multicenter Trial. Ann Surg 2020; 270:747-754. [PMID: 31634178 DOI: 10.1097/sla.0000000000003530] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The aim of this study was to report the 3-year survival results of the GRECCAR-6 trial. SUMMARY BACKGROUND DATA Current data on the effect of an extended interval between radiochemotherapy (RCT) and resection for rectal cancer on the rate of complete pathological response (pCR = ypT0N0) is controversial. Furthermore, its effect on oncological outcomes is unknown. METHODS The GRECCAR-6 trial was a phase III, multicenter, randomized, open-label, parallel-group, controlled trial. Patients with cT3/T4 or TxN+ tumors of the mid or lower rectum who had received RCT (45-50 Gy with 5-fluorouracil or capecitabine) were included and randomized into a 7- or 11-week waiting period. Primary endpoint was the pCR rate. Secondary endpoints were 3-year overall (OS), disease-free survival (DFS), and recurrence rates. RESULTS A total of 265 patients from 24 participating centers were enrolled. A total of 253 patients underwent a mesorectal excision. Overall pCR rate was 17% (43/253). Mean follow-up from surgical resection was 32 ± 8 months. Twenty-four deaths occurred with an 89% OS at 3 years. DFS was 68.7% at 3 years (75 recurrences). Three-year local and distant recurrences were 7.9% and 23.8%, respectively. The randomization group had no impact on the 3-year OS (P = 0.8868) or DFS (P = 0.9409). Distant (P = 0.7432) and local (P = 0.3944) recurrences were also not influenced by the waiting period. DFS was independently influenced by 3 factors: circumferential radial margin (CRM) ≤1 mm [hazard ratio (HR) = 2.03; 95% confidence interval (CI), 1.17-3.51], ypT3-T4 (HR = 2.69; 95% CI, 1.19-6.08) and positive lymph nodes (HR = 3.62; 95% CI, 1.89-6.91). CONCLUSION Extending the waiting period by 4 weeks following RCT has no influence on the oncological outcomes of T3/T4 rectal cancers.
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Sun W, Al-Rajabi R, Perez RO, Abbasi S, Ash R, Habr-Gama A. Controversies in Rectal Cancer Treatment and Management. Am Soc Clin Oncol Educ Book 2020; 40:1-11. [PMID: 32239978 DOI: 10.1200/edbk_279871] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Incorporation of new treatment modalities has significantly increased the complexity of the treatment and management of rectal cancer, including perioperative therapy for local advanced disease and organ preservation for those with response to the preoperative treatment. This review may help practitioners better understand the rationale and selection.
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Affiliation(s)
- Weijing Sun
- University of Kansas Medical Center, Department of Internal Medicine, Medical Oncology Division, Westwood, KS
| | - Raed Al-Rajabi
- University of Kansas Medical Center, Department of Internal Medicine, Medical Oncology Division, Westwood, KS
| | | | - Saquib Abbasi
- University of Kansas Medical Center, Department of Internal Medicine, Medical Oncology Division, Westwood, KS
| | - Ryan Ash
- University of Kansas Medical Center, Department of Radiology, Kansas City, KS
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The risk of distant metastases in rectal cancer managed by a watch-and-wait strategy – A systematic review and meta-analysis. Radiother Oncol 2020; 144:1-6. [DOI: 10.1016/j.radonc.2019.10.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 10/12/2019] [Accepted: 10/15/2019] [Indexed: 12/18/2022]
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Tchelebi LT, Romesser PB, Feuerlein S, Hoffe S, Latifi K, Felder S, Chuong MD. Magnetic Resonance Guided Radiotherapy for Rectal Cancer: Expanding Opportunities for Non-Operative Management. Cancer Control 2020; 27:1073274820969449. [PMID: 33118384 PMCID: PMC7791447 DOI: 10.1177/1073274820969449] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Colorectal cancer is the third most common cancer in men and the second most common in women worldwide, and the incidence is increasing among younger patients. 30% of these malignancies arise in the rectum. Patients with rectal cancer have historically been managed with preoperative radiation, followed by radical surgery, and adjuvant chemotherapy, with permanent colostomies in up to 20% of patients. Beginning in the early 2000s, non-operative management (NOM) of rectal cancer emerged as a viable alternative to radical surgery in select patients. Efforts have been ongoing to optimize neoadjuvant therapy for rectal cancer, thereby increasing the number of patients potentially eligible to forgo radical surgery. Magnetic resonance guided radiotherapy (MRgRT) has recently emerged as a treatment modality capable of intensifying preoperative radiation therapy for rectal cancer patients. This technology may also predict which patients will achieve a complete response to preoperative therapy, thereby allowing for more appropriate selection of patients for NOM. The present work seeks to illustrate the potential role MRgRT could play in personalizing rectal cancer treatment thus expanding the role of NOM in rectal cancer.
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Affiliation(s)
- Leila T. Tchelebi
- Department of Radiation Oncology, Penn State College of Medicine,
Hershey, PA, USA
| | - Paul B. Romesser
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer
Center, New York, NY, USA
| | - Sebastian Feuerlein
- Department of Diagnostic Imaging and Interventional Radiology,
Moffitt Cancer Center, Tampa, FL, USA
| | - Sarah Hoffe
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL,
USA
| | - Kujtim Latifi
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL,
USA
| | - Seth Felder
- Department of Gastrointestinal Oncology, Moffitt Cancer Center,
Tampa, FL, USA
| | - Michael D. Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL,
USA
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Pang K, Rao Q, Qin S, Jin L, Yao H, Zhang Z. Prognosis comparison between wait and watch and surgical strategy on rectal cancer patients after treatment with neoadjuvant chemoradiotherapy: a meta-analysis. Therap Adv Gastroenterol 2019; 12:1756284819892477. [PMID: 31832099 PMCID: PMC6891008 DOI: 10.1177/1756284819892477] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 11/06/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND After achieving a clinical complete response through neoadjuvant chemoradiotherapy, a nonoperative management approach for rectal cancer patients known as Wait and Watch (W&W) has gained increasing attention. However, the W&W strategy has been related to higher local recurrence and ambiguous long-term survival. This meta-analysis compared key prognosis indicators between W&W and surgical treatment in an effort to clarify some long-standing points of confusion. METHODS Pubmed, Web of Science, EMbase, Cochrane Library were searched for relevant researches comparing W&W with surgery treatment, with a time criteria set from 1 January 2002 to 4 July 2019. Endpoints were 2-year local regrowth/recurrence, 2-year distant metastasis (plus local regrowth/recurrence), 3- and 5-year disease-free survival (DFS), and overall survival (OS). RESULTS In total, nine studies with 801 patients were enrolled, of which 348 were managed by W&W and 453 by surgery. Surgery patients were further divided into a pathological complete response (pCR) group (all included patients achieved pCR) and a surgery group (consisting of both pCR and non-pCR patients without deliberate screening). Compared with the surgery group, W&W patients have higher 3- and 5-year OS, and are not inferior on 2-year local regrowth (LR), 2-year distant metastasis (DM)/DM+LR, and 3- and 5-year DFS. On the other hand, compared with the pCR group, the W&W group is inferior on 2-year LR, 3- and 5-year DFS, and 5-year OS, and not inferior on 2-year DM/DM+LR and 3-year OS. CONCLUSIONS In contrast with patients undergoing surgical treatment, the W&W group has higher 3- and 5-year OS, and is not inferior on other major prognostic indicators, which, however, is based on the fact that the tumor stage in the W&W group is generally earlier. Versus surgically treated patients who acquired pCR, W&W group is inferior on all major prognostic indicators except 2-year DM/DM+LR and 3-year OS. Additionally, by comparison of cCR definitions across different studies, we conclude that implementation of the strictest cCR criteria is critical for W&W patients to acquire maximum prognostic benefit.
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Affiliation(s)
- Kai Pang
- Department of General Surgery, Beijing
Friendship Hospital, Capital Medical University, Beijing Key Laboratory of
Cancer Invasion and Metastasis Research and National Clinical Research
Center for Digestive Diseases, Beijing, China
| | - Quan Rao
- Department of General Surgery, Beijing
Friendship Hospital, Capital Medical University, Beijing Key Laboratory of
Cancer Invasion and Metastasis Research and National Clinical Research
Center for Digestive Diseases, Beijing, China
| | - Shengqi Qin
- Department of General Surgery, Beijing
Friendship Hospital, Capital Medical University, Beijing Key Laboratory of
Cancer Invasion and Metastasis Research and National Clinical Research
Center for Digestive Diseases, Beijing, China
| | - Lan Jin
- Department of General Surgery, Beijing
Friendship Hospital, Capital Medical University, Beijing Key Laboratory of
Cancer Invasion and Metastasis Research and National Clinical Research
Center for Digestive Diseases, Beijing, China
| | - Hongwei Yao
- Department of General Surgery, Beijing
Friendship Hospital, Capital Medical University, Beijing Key Laboratory of
Cancer Invasion and Metastasis Research and National Clinical Research
Center for Digestive Diseases, Beijing, China
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Rouleau-Fournier F, Brown CJ. Can less be more? Organ preservation strategies in the management of rectal cancer. ACTA ACUST UNITED AC 2019; 26:S16-S23. [PMID: 31819706 DOI: 10.3747/co.26.5841] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background Total mesorectal excision (tme) is the current standard of care for the treatment of rectal cancer. However, that surgery is associated with significant morbidity and mortality. Clinicians and patients are seeking alternatives to radical resection. Currently, prevalent organ-sparing strategies under investigation include local excision and nonoperative management (nom). Methods We reviewed the current evidence in the literature to create an overview of the use of transanal endoscopic surgery and watch-and-wait strategies in the modern management of rectal cancer. Results Compared with radical resection, transanal endoscopic surgery in patients with early rectal cancer (cT1) having favourable histopathologic features is associated with an increased risk of local recurrence, but no difference in 5-year survival. In patients with T2 or early T3 cancer, strategies that use neoadjuvant or adjuvant therapy as adjuncts to local excision are under evaluation. Nonoperative management is a new option for patients who experience a complete clinical response after neoadjuvant chemoradiotherapy (ncrt). The selection criteria that will appropriately identify patients for whom nom will succeed are not established. Conclusions Local excision is appropriate for early rectal cancer with favourable histopathologic features. Although organ-preserving strategies are promising, the quality of the evidence to date is insufficient to replace the current standard care in most patients. Patients should be offered nom in the safe setting of a clinical trial or registry. Rigorous follow-up, including endoscopy and imaging at frequent intervals is recommended when radical resection is forgone.
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Affiliation(s)
- F Rouleau-Fournier
- Department of Surgery, St. Paul's Hospital, Providence Health Care, Vancouver, BC
| | - C J Brown
- Department of Surgery, St. Paul's Hospital, Providence Health Care, Vancouver, BC
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On J, Shim J, Aly EH. Systematic review and meta-analysis on outcomes of salvage therapy in patients with tumour recurrence during 'watch and wait' in rectal cancer. Ann R Coll Surg Engl 2019; 101:441-452. [PMID: 30855163 PMCID: PMC6667951 DOI: 10.1308/rcsann.2019.0018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2019] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION The 'watch and wait' approach has recently emerged as an alternative approach for managing patients with complete clinical response in rectal cancer. However, less is understood whether the intervention is associated with a favourable outcome among patients who require salvage therapy following local recurrence. MATERIALS AND METHODS A comprehensive systematic search was performed using EMBASE, PubMed, MEDLINE, Journals@Ovid as well as hand searches; published between 2004 and 2018, to identify studies where outcomes of patients undergoing watch and wait were compared with conventional surgery. Study quality was assessed using the Newcastle-Ottawa assessment scale. The main outcome was relative risks for overall and disease specific mortality in salvage therapy. RESULTS Nine eligible studies were included in the meta-analysis. Of 248 patients who followed the watch and wait strategy, 10.5% had salvage therapy for recurrent disease. No statistical heterogeneity was found in the results. The relative risk of overall mortality in the salvage therapy group was 2.42 (95% confidence interval 0.96-6.13) compared with the group who had conventional surgery, but this was not statistically significant (P > 0.05). The relative risk of disease specific mortality in salvage therapy was 2.63 (95% confidence interval 0.81-8.53). CONCLUSION Our findings demonstrated that there was no significant difference in overall and disease specific mortality in patients who had salvage treatment following recurrence of disease in the watch and wait group compared with the standard treatment group. However, future research into the oncological safety of salvage treatment is needed.
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Affiliation(s)
- J On
- Laparoscopic Colorectal Surgery and Training Unit, Aberdeen Royal Infirmary, Aberdeen, UK
| | - J Shim
- Epidemiology Group, University of Aberdeen, Aberdeen, UK
| | - EH Aly
- Laparoscopic Colorectal Surgery and Training Unit, Aberdeen Royal Infirmary, Aberdeen, UK
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Oncological and Survival Outcomes in Watch and Wait Patients With a Clinical Complete Response After Neoadjuvant Chemoradiotherapy for Rectal Cancer: A Systematic Review and Pooled Analysis. Ann Surg 2019; 268:955-967. [PMID: 29746338 DOI: 10.1097/sla.0000000000002761] [Citation(s) in RCA: 164] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the oncological and survival outcomes of a Watch and Wait policy in rectal cancer after a clinical complete response (cCR) following neoadjuvant chemoradiotherapy. BACKGROUND The detection of a cCR after neoadjuvant treatment may facilitate a nonoperative approach in selected patients. However, the long-term safety of this strategy remains to be validated. METHOD This is a systematic review of the literature to determine the oncological outcomes in Watch and Wait patients. The primary outcome was the cumulative rate of local regrowth, success of salvage surgery, and incidence of metastases. We also evaluated survival outcomes. A pooled analysis of manually extracted summary statistics from individual studies was carried out using inverse variance weighting. RESULTS Seventeen studies comprising 692 patients were identified; incidence of cCR was 22.4% [95% confidence interval (CI),14.3-31.8]. There were 153 (22.1%) local regrowths, of which 96% (n = 147/153) manifested in the first 3 years of surveillance. The 3-year cumulative risk of local regrowth was 21.6% (95% CI, 16.0-27.8). Salvage surgery was performed in 88% of patients, of which 121 (93%) had a complete (R0) resection. Fifty-seven metastases (8.2%) were detected, and 35 (60%) were isolated without evidence of synchronous regrowths; 3-year incidence was 6.8% (95% CI, 4.1-10.2). The 3-year overall survival was 93.5% (95% CI, 90.2-96.2). CONCLUSION In rectal cancer patients with a cCR following neoadjuvant chemoradiotherapy, a Watch and Wait policy appears feasible and safe. Robust surveillance with early detection of regrowths allows a high rate of successful salvage surgery, without an increase in the risk of systemic disease, or adverse survival outcomes.
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Fiorica F, Trovò M, Anania G, Marcello D, Di Benedetto F, Marzola M, D'Acapito F, Nasti G, Berretta M. Is It Possible a Conservative Approach After Radiochemotherapy in Locally Advanced Rectal Cancer (LARC)? A Systematic Review of the Literature and Meta-analysis. J Gastrointest Cancer 2019; 50:98-108. [PMID: 29273921 DOI: 10.1007/s12029-017-0041-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Locally advanced rectal cancer is usually treated with a preoperative approach with radiochemotherapy followed by surgery. Patients obtaining a pathologic complete response have a very favorable long-term prognosis. This study was intended to assess whether major surgery can reduce tumor recurrences and prolong survival of patients with a complete response after radiochemotherapy. METHODS Computerized literature search was performed to identify relevant articles. Comparative studies reporting the outcomes of non-operative and operative management in patients after neoadjuvant treatment were reviewed. Data synthesis was performed using Review Manager 5.0 software. RESULTS Twelve non-randomized comparative studies with a total of 1812 patients were suitable for analysis. There was no significant difference in overall survival at 3 and 5 years (odds ratio [OR] 1.31; 95% CI 0.64-2.69; p = 0.46 and 1.48; 95% CI 1.00-2.20; p = 0.50) and in disease-free survival at 3 and 5 years (odds ratio [OR] 1.20; 95% CI 0.68-2.14; p = 0.53 and 1.22; 95% CI 0.86-1.74; p = 0.26, respectively) between locally advanced rectal cancer patients treated with and without operative approach. CONCLUSIONS Major surgery does not seem to improve prognosis in patients obtaining a complete response after radiochemotherapy. Clinical trials, using clear criteria to identify complete response patients, are needed to recommend non-operative approach.
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Affiliation(s)
- Francesco Fiorica
- Gastrointestinal Cancer Unit, Departments of Radiation Oncology, Medical Oncology and Surgery, University Hospital Ferrara, Ferrara, Italy.
| | - Marco Trovò
- Department of Radiation Oncology, Udine General Hospital, Udine, Italy
| | - Gabriele Anania
- Gastrointestinal Cancer Unit, Departments of Radiation Oncology, Medical Oncology and Surgery, University Hospital Ferrara, Ferrara, Italy
| | - Daniele Marcello
- Gastrointestinal Cancer Unit, Departments of Radiation Oncology, Medical Oncology and Surgery, University Hospital Ferrara, Ferrara, Italy
| | - Fabrizio Di Benedetto
- Department of Liver and Multivisceral Transplant Center, Liver Surgery, University Hospital Modena, Modena, Italy
| | - Marina Marzola
- Gastrointestinal Cancer Unit, Departments of Radiation Oncology, Medical Oncology and Surgery, University Hospital Ferrara, Ferrara, Italy
| | - Fabrizio D'Acapito
- Department of Surgery and Advanced Oncological Therapies, State Hospital Forlì, Forlì, Italy
| | - Guglielmo Nasti
- Department of Abdominal Oncology, Istituto Nazionale per lo Studio e la Cura dei Tumori, Fondazione "G. Pascale"-IRCCS, Naples, Italy
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Abstract
Despite advances in technique, surgical resection of rectal cancer remains a morbid procedure that can lead a profound decrease in a patient's quality of life. A novel method of management, termed "Non-operative management" (NOM), mirrors the management of anal carcinoma. Patients undergo definitive treatment with only chemotherapy and radiation, with resection reserved only for salvage. Current data is encouraging- both in reduction in morbidity and similar, if not superior oncologic results. However, there are a number of barriers to the wide adoption of this practice. This manuscript seeks to describe the rationale and execution of NOM as well as present the current data and pitfalls of the approach.
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Affiliation(s)
- Jonathan B Greer
- Johns Hopkins University School of Medicine, Department of Surgery, Division of Surgical Oncology, Baltimore, MD
| | - Alexander T Hawkins
- Vanderbilt University Medical Center, Division of General Surgery, Section of Colon & Rectal Surgery, Nashville, TN
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Abstract
The management of locally-advanced rectal cancer involves a combination of chemotherapy, chemoradiation, and surgical resection to provide excellent local tumor control and overall survival. However, aspects of this multimodality approach are associated with significant morbidity and long-term sequelae. In addition, there is growing evidence that patients with a clinical complete response to chemotherapy and chemoradiation treatments may be safely offered initial non-operative management in a rigorous surveillance program. Weighed against the morbidity and significant sequelae of rectal resection, recognizing how to best optimize non-operative strategies without compromising oncologic outcomes is critical to our understanding and treatment of this disease.
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Affiliation(s)
- Iris H Wei
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering, New York, NY, USA -
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering, New York, NY, USA
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Chadi SA, Malcomson L, Ensor J, Riley RD, Vaccaro CA, Rossi GL, Daniels IR, Smart NJ, Osborne ME, Beets GL, Maas M, Bitterman DS, Du K, Gollins S, Sun Myint A, Smith FM, Saunders MP, Scott N, O'Dwyer ST, de Castro Araujo RO, Valadao M, Lopes A, Hsiao CW, Lai CL, Smith RK, Paulson EC, Appelt A, Jakobsen A, Wexner SD, Habr-Gama A, Sao Julião G, Perez R, Renehan AG. Factors affecting local regrowth after watch and wait for patients with a clinical complete response following chemoradiotherapy in rectal cancer (InterCoRe consortium): an individual participant data meta-analysis. Lancet Gastroenterol Hepatol 2018; 3:825-836. [PMID: 30318451 DOI: 10.1016/s2468-1253(18)30301-7] [Citation(s) in RCA: 97] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 08/28/2018] [Accepted: 08/29/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND In patients with rectal cancer who achieve clinical complete response after neoadjuvant chemoradiotherapy, watch and wait is a novel management strategy with potential to avoid major surgery. Study-level meta-analyses have reported wide variation in the proportion of patients with local regrowth. We did an individual participant data meta-analysis to investigate factors affecting occurrence of local regrowth. METHODS We updated search results of a recent systematic review by searching MEDLINE and Embase from Jan 1, 2016, to May 5, 2017, and used expert knowledge to identify published studies reporting on local regrowth in patients with rectal cancer managed by watch and wait after clinical complete response to neoadjuvant chemoradiotherapy. We restricted studies to those that defined clinical complete response using criteria equivalent to São Paulo benchmarks (ie, absence of residual ulceration, stenosis, or mass within the rectum on clinical and endoscopic examination). The primary outcome was 2-year cumulative incidence of local regrowth, estimated with a two-stage random-effects individual participant data meta-analysis. We assessed the effects of clinical and treatment factors using Cox frailty models, expressed as hazard ratios (HRs). From these models, we derived percentage differences in mean θ as an approximation of the effect of measured covariates on between-centre heterogeneity. This study is registered with PROSPERO, number CRD42017070934. FINDINGS We obtained individual participant data from 11 studies, including 602 patients enrolled between March 11, 1990, and Feb 13, 2017, with a median follow-up of 37·6 months (IQR 25·0-58·7). Ten of the 11 datasets were judged to be at low risk of bias. 2-year cumulative incidence of local regrowth was 21·4% (random-effects 95% CI 15·3-27·6), with high levels of between-study heterogeneity (I2=61%). We noted wide between-centre variation in patient, tumour, and treatment characteristics. We found some evidence that increasing cT stage was associated with increased risk of local regrowth (random-effects HR per cT stage 1·40, 95% CI 1·00-1·94; ptrend=0·048). In a subgroup of 459 patients managed after 2008 (when pretreatment staging by MRI became standard), 2-year cumulative incidence of local regrowth was 19% (95% CI 13-28) for stage cT1 and cT2 tumours, 31% (26-37) for cT3, and 37% (21-60) for cT4 (random-effects HR per cT stage 1·50, random-effects 95% CI 1·03-2·17; ptrend=0·0330). We estimated that measured factors contributed 4·8-45·3% of observed between-centre heterogeneity. INTERPRETATION In patients with rectal cancer and clinical complete response after chemoradiotherapy managed by watch and wait, we found some evidence that increasing cT stage predicts for local regrowth. These data will inform clinician-patient decision making in this setting. Research is needed to determine other predictors of a sustained clinical complete response. FUNDING None.
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Affiliation(s)
- Sami A Chadi
- Division of Surgical Oncology and General Surgery, Princess Margaret Hospital and University Health Network, University of Toronto, Toronto, ON, Canada
| | - Lee Malcomson
- Manchester Cancer Research Centre and NIHR Manchester Biomedical Research Centre, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; Colorectal and Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Manchester, UK
| | - Joie Ensor
- Centre for Prognosis Research, Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, UK
| | - Richard D Riley
- Centre for Prognosis Research, Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, UK
| | - Carlos A Vaccaro
- Servicio Cirugia General, Sector de Coloproctologia, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Gustavo L Rossi
- Servicio Cirugia General, Sector de Coloproctologia, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Ian R Daniels
- Exeter Colorectal Unit, and Exeter Surgical Health Sciences Research Unit (HESRU), Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK
| | - Neil J Smart
- Exeter Colorectal Unit, and Exeter Surgical Health Sciences Research Unit (HESRU), Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK
| | - Melanie E Osborne
- Exeter Colorectal Unit, and Exeter Surgical Health Sciences Research Unit (HESRU), Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK
| | - Geerard L Beets
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, Netherlands; GROW, School of Oncology and Developmental Biology, University of Maastricht, Maastricht, Netherlands
| | - Monique Maas
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | - Kevin Du
- Department of Radiation Oncology, New York University Langone Medical Center, New York, NY, USA
| | | | | | - Fraser M Smith
- Royal Liverpool Hospital NHS Foundation Trust, Liverpool, UK
| | - Mark P Saunders
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Nigel Scott
- Royal Preston NHS Foundation Trust, Preston, UK
| | - Sarah T O'Dwyer
- Colorectal and Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Manchester, UK
| | - Rodrigo Otavio de Castro Araujo
- Department of Abdominal and Pelvic Surgery, Instituto Nacional de Câncer José Alencar Gomes da Silva (INCA), Rio de Janeiro, Brazil
| | - Marcus Valadao
- Department of Abdominal and Pelvic Surgery, Instituto Nacional de Câncer José Alencar Gomes da Silva (INCA), Rio de Janeiro, Brazil
| | - Alberto Lopes
- Department of Abdominal and Pelvic Surgery, Instituto Nacional de Câncer José Alencar Gomes da Silva (INCA), Rio de Janeiro, Brazil
| | - Cheng-Wen Hsiao
- Division of Colon and Rectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, China
| | - Chien-Liang Lai
- Division of Colon and Rectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, China
| | - Radhika K Smith
- Department of Surgery, Philadelphia VA Medical Center, and Division of Colon and Rectal Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Emily Carter Paulson
- Department of Surgery, Philadelphia VA Medical Center, and Division of Colon and Rectal Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ane Appelt
- Danish Colorectal Cancer Center South, Vejle Hospital, Vejle, Denmark; Leeds Cancer Centre, St James's University Hospital, and Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - Anders Jakobsen
- Danish Colorectal Cancer Center South, Vejle Hospital, Vejle, Denmark
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | | | - Guilherme Sao Julião
- Ludwig Institute for Cancer Research, Molecular Biology and Genomics Lab, São Paulo, Brazil
| | - Rodiguo Perez
- Instituto Angelita e Joaquim Gama, São Paulo, Brazil; Ludwig Institute for Cancer Research, Molecular Biology and Genomics Lab, São Paulo, Brazil
| | - Andrew G Renehan
- Colorectal and Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Manchester, UK; Centre for Prognosis Research, Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, UK.
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44
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Abstract
BACKGROUND The management of rectal cancer has evolved considerably over the last few decades with increasing use of neoadjuvant chemoradiotherapy (nCRT). Complete clinical response (cCR) and even complete pathological response (pCR) have been noted in a proportion of patients who had surgery after nCRT. This raises the concern that we may have been 'over-treating' some of these patients and lead to an increasing interest in 'watch and wait' (W&W) approach for patients who had cCR to avoid the morbidity associated with rectal surgery. METHODS A review of the literature in English pertaining to rectal cancer in the context of W&W, organ preservation and active surveillance. RESULTS Evidence available to support W&W approach comes from non-randomised controlled trials (RCTs) with no current consensus on patients' selection criteria, lack of viable predictors of both cCR and pCR and lack of universal definitions of cCR and pCR. Also, there is no agreed protocol for disease surveillance. CONCLUSION Even though there has been increasing reports on the outcomes of W&W in rectal cancer, the current evidence cannot support its routine use in clinical practice. This approach should be used in clinical trials settings or after thorough counselling with the patient on the outcomes of various treatment options.
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45
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Mullaney TG, Lightner AL, Johnston M, Keck J, Wattchow D. 'Watch and wait' after chemoradiotherapy for rectal cancer. ANZ J Surg 2018; 88:836-841. [PMID: 30047201 DOI: 10.1111/ans.14352] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 11/13/2017] [Accepted: 11/18/2017] [Indexed: 01/11/2023]
Abstract
Surgery remains the cornerstone of rectal cancer treatment. However, there is significant morbidity and mortality associated with pelvic surgery, and the past decade has illustrated that a cohort of rectal cancer patients sustain a remission of local disease with chemoradiation alone. Thus, questions remain regarding the optimal management for rectal cancer; namely, accurately identifying patients who have a complete pathologic response and determining the oncologic safety of the observational approach for this patient group. This review aims to summarize the current evidence to provide an overview to the 'watch and wait' approach in rectal cancer patients with a complete response to neoadjuvant chemoradiation therapy.
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Affiliation(s)
- Tamara G Mullaney
- Department of Colorectal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Amy L Lightner
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael Johnston
- Department of Colorectal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - James Keck
- Department of Colorectal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - David Wattchow
- Department of Colorectal Surgery, Flinders Medical Centre, Flinders Private Hospital, Flinders University, Adelaide, South Australia, Australia
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46
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Wang SJ, Hathout L, Malhotra U, Maloney-Patel N, Kilic S, Poplin E, Jabbour SK. Decision-Making Strategy for Rectal Cancer Management Using Radiation Therapy for Elderly or Comorbid Patients. Int J Radiat Oncol Biol Phys 2018; 100:926-944. [PMID: 29485072 PMCID: PMC11131033 DOI: 10.1016/j.ijrobp.2017.12.261] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 11/14/2017] [Accepted: 12/11/2017] [Indexed: 02/07/2023]
Abstract
Rectal cancer predominantly affects patients older than 70 years, with peak incidence at age 80 to 85 years. However, the standard treatment paradigm for rectal cancer oftentimes cannot be feasibly applied to these patients owing to frailty or comorbid conditions. There are currently little information and no treatment guidelines to help direct therapy for patients who are elderly and/or have significant comorbidities, because most are not included or specifically studied in clinical trials. More recently various alternative treatment options have been brought to light that may potentially be utilized in this group of patients. This critical review examines the available literature on alternative therapies for rectal cancer and proposes a treatment algorithm to help guide clinicians in treatment decision making for elderly and comorbid patients.
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Affiliation(s)
- Shang-Jui Wang
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Lara Hathout
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Usha Malhotra
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Nell Maloney-Patel
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Sarah Kilic
- Rutgers New Jersey Medical School, Rutgers, the State University of New Jersey, Newark, New Jersey
| | - Elizabeth Poplin
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey.
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47
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Total Neoadjuvant Therapy: A Shifting Paradigm in Locally Advanced Rectal Cancer Management. Clin Colorectal Cancer 2018; 17:1-12. [DOI: 10.1016/j.clcc.2017.06.008] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Revised: 06/21/2017] [Accepted: 06/21/2017] [Indexed: 01/13/2023]
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48
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Li J, Li L, Yang L, Yuan J, Lv B, Yao Y, Xing S. Wait-and-see treatment strategies for rectal cancer patients with clinical complete response after neoadjuvant chemoradiotherapy: a systematic review and meta-analysis. Oncotarget 2018; 7:44857-44870. [PMID: 27070085 PMCID: PMC5190140 DOI: 10.18632/oncotarget.8622] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 03/28/2016] [Indexed: 12/16/2022] Open
Abstract
Wait-and-see treatment strategies may benefit rectal cancer patients who achieve a clinical complete response (cCR) after neoadjuvant chemoradiotherapy (NCRT). In this study, we analyzed data from 9 eligible trials to compare the oncologic outcomes of 251 rectal cancer patients achieving a cCR through nonsurgical management approaches with the outcomes of 344 patients achieving a pathologic complete response (pCR) through radical surgery. The two patient groups did not differ in distant metastasis rates or disease-free and overall survival, but the nonsurgical group had a higher risk of 1, 2, 3, and 5-year local recurrence. Hence, we concluded that for rectal cancer patients achieving a cCR after NCRT, a wait-and-see strategy with strict selection criteria, an appropriate follow-up schedule, and salvage treatments achieved outcomes at least as good as radical surgery. Long-term randomized and controlled trials with more uniform inclusion criteria and standardized follow-up schedules will help clarify the risks and benefits of wait-and-see treatment strategies for these patients.
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Affiliation(s)
- Jun Li
- General Surgery Department and Central Laboratory, Affiliated Hospital/Clinical Medical College of Chengdu University, Chengdu, People's Republic of China
| | - Lunjin Li
- Pharmacy Department, Affiliated Hospital/Clinical Medical College of Chengdu University, Chengdu, People's Republic of China
| | - Lin Yang
- Department of Pathology, Cancer Hospital, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Jiatian Yuan
- General Surgery Department and Central Laboratory, Affiliated Hospital/Clinical Medical College of Chengdu University, Chengdu, People's Republic of China
| | - Bo Lv
- General Surgery Department and Central Laboratory, Affiliated Hospital/Clinical Medical College of Chengdu University, Chengdu, People's Republic of China
| | - Yanan Yao
- Department of General Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Shasha Xing
- Central Laboratory, Affiliated Hospital/Clinical Medical College of Chengdu University, Chengdu, People's Republic of China
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49
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Habr-Gama A, São Julião GP, Vailati BB, Castro I, Raffaele D. Management of the Complete Clinical Response. Clin Colon Rectal Surg 2017; 30:387-394. [PMID: 29184475 DOI: 10.1055/s-0037-1606116] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Organ preservation is considered in the management of selected patients with rectal cancer. Complete clinical response observed after neoadjuvant chemoradiation for rectal cancer is one of these cases. Patients who present complete clinical response are candidates to the watch-and-wait approach, when radical surgery is not immediately performed and is offered only to patients in the event of a local relapse. These patients are included in a strict follow-up, and up of 70% of them will never be operated during the follow-up. This strategy is associated with similar oncological outcomes as patients operated on, and the advantage of avoiding the morbidity associated to the radical operation. In this article we will discuss in detail the best candidates for this approach, the protocol itself, and the long-term outcomes.
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Affiliation(s)
- Angelita Habr-Gama
- Angelita & Joaquim Gama Institute, Sao Paulo, SP, Brazil.,University of Sao Paulo School of Medicine, Sao Paulo, SP, Brazil
| | | | | | - Ivana Castro
- Angelita & Joaquim Gama Institute, Sao Paulo, SP, Brazil
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50
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Menahem B, Alves A, Morello R, Lubrano J. Should the rectal defect be closed following transanal local excision of rectal tumors? A systematic review and meta-analysis. Tech Coloproctol 2017; 21:929-936. [PMID: 29134387 DOI: 10.1007/s10151-017-1714-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 09/25/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Transanal local excision (TLE) has become the treatment of choice for benign and early-stage selected malignant tumors. However, closure of the rectal wall defect remains a controversial point and the available literature still remains unclear. Our aim was to determine through a systematic review of the literature and a meta-analysis of relevant studies whether or not the wall defect following TLE of rectal tumors should be closed. METHODS Medline and the Cochrane Trials Register were searched for trials published up to December 2016 comparing open versus closed management of the surgical rectal defect after TLE of rectal tumors. Meta-analysis was performed using Review Manager 5.0. RESULTS Four studies were analyzed, yielding 489 patients (317 in the closed group and 182 in the open group). Meta-analysis showed no significant difference between the closed and open groups regarding the overall morbidity rate (OR 1.26; 95% CI 0.32-4.91; p = 0.74), postoperative local infection rate (OR 0.62; 95% CI 0.23-1.62; p = 0.33), postoperative bleeding rate (OR 0.83; 95% CI 0.29-1.77; p = 0.63), and postoperative reintervention rate (OR 2.21; 95% CI 0.52-9.47; p = 0.29). CONCLUSIONS This review and meta-analysis suggest that there is no difference between closure or non-closure of wall defects after TLE.
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Affiliation(s)
- B Menahem
- Department of Digestive Surgery, Caen University Hospital, Avenue de la Côte de Nacre, 14032, Caen Cedex, France.
- UMR, French National Institute for Health and Medical Research U1086 Cancer and Prevention, The François Baclesse Center, Caen, France.
- UFR of Medicine, Caen, France.
| | - A Alves
- Department of Digestive Surgery, Caen University Hospital, Avenue de la Côte de Nacre, 14032, Caen Cedex, France
- UMR, French National Institute for Health and Medical Research U1086 Cancer and Prevention, The François Baclesse Center, Caen, France
- UFR of Medicine, Caen, France
| | - R Morello
- Department of Digestive Surgery, Caen University Hospital, Avenue de la Côte de Nacre, 14032, Caen Cedex, France
- UFR of Medicine, Caen, France
- Department of Clinical Research and Biostatistics, Caen University Hospital, Caen, France
| | - J Lubrano
- Department of Digestive Surgery, Caen University Hospital, Avenue de la Côte de Nacre, 14032, Caen Cedex, France
- UMR, French National Institute for Health and Medical Research U1086 Cancer and Prevention, The François Baclesse Center, Caen, France
- UFR of Medicine, Caen, France
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