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Miranda J, Causa Andrieu P, Nincevic J, Gomes de Farias LDP, Khasawneh H, Arita Y, Stanietzky N, Fernandes MC, De Castria TB, Horvat N. Advances in MRI-Based Assessment of Rectal Cancer Post-Neoadjuvant Therapy: A Comprehensive Review. J Clin Med 2023; 13:172. [PMID: 38202179 PMCID: PMC10780006 DOI: 10.3390/jcm13010172] [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: 11/07/2023] [Revised: 12/14/2023] [Accepted: 12/21/2023] [Indexed: 01/12/2024] Open
Abstract
Rectal cancer presents significant diagnostic and therapeutic challenges, with neoadjuvant therapy playing a pivotal role in improving resectability and patient outcomes. MRI serves as a critical tool in assessing treatment response. However, differentiating viable tumor tissue from therapy-induced changes on MRI remains a complex task. In this comprehensive review, we explore treatment options for rectal cancer based on resectability status, focusing on the role of MRI in guiding therapeutic decisions. We delve into the nuances of MRI-based evaluation of treatment response following neoadjuvant therapy, paying particular attention to emerging techniques like radiomics. Drawing from our insights based on the literature, we provide essential recommendations for post-neoadjuvant therapy management of rectal cancer, all within the context of MRI-based findings.
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Affiliation(s)
- Joao Miranda
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; (J.N.); (Y.A.); (M.C.F.)
- Department of Radiology, University of Sao Paulo, R. Dr. Ovidio Pires de Campos, 75 Cerqueira Cesar, Sao Paulo 05403-010, Brazil
| | - Pamela Causa Andrieu
- Department of Radiology, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA;
| | - Josip Nincevic
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; (J.N.); (Y.A.); (M.C.F.)
| | - Lucas de Padua Gomes de Farias
- Department of Radiology, Hospital Sirio-Libanes, Rua Dona Adma Jafet, 91—Bela Vista, Sao Paulo 01308-050, Brazil;
- Department of Radiology, Allianca Saude, Av. Pres. Juscelino Kubitschek, 1830, Sao Paulo 01308-050, Brazil
| | - Hala Khasawneh
- Department of Radiology, University of Texas Southwestern, 5323 Harry Hines Blvd, Dallas, TX 75390, USA;
| | - Yuki Arita
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; (J.N.); (Y.A.); (M.C.F.)
- Department of Radiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Nir Stanietzky
- Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Maria Clara Fernandes
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; (J.N.); (Y.A.); (M.C.F.)
| | - Tiago Biachi De Castria
- Department of Gastrointestinal Oncology, Moffit Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA;
- Morsani College of Medicine, University of South Florida, 4202 E. Fowler Avenue, Tampa, FL 33620, USA
| | - Natally Horvat
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; (J.N.); (Y.A.); (M.C.F.)
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Sliwinski S, Werneburg E, Faqar-Uz-Zaman SF, Detemble C, Dreilich J, Mohr L, Zmuc D, Beyer K, Bechstein WO, Herrle F, Malkomes P, Reissfelder C, Ritz JP, Vilz T, Fleckenstein J, Schnitzbauer AA. A toolbox for a structured risk-based prehabilitation program in major surgical oncology. Front Surg 2023; 10:1186971. [PMID: 37435472 PMCID: PMC10332323 DOI: 10.3389/fsurg.2023.1186971] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/17/2023] [Indexed: 07/13/2023] Open
Abstract
Prehabilitation is a multimodal concept to improve functional capability prior to surgery, so that the patients' resilience is strengthened to withstand any peri- and postoperative comorbidity. It covers physical activities, nutrition, and psychosocial wellbeing. The literature is heterogeneous in outcomes and definitions. In this scoping review, class 1 and 2 evidence was included to identify seven main aspects of prehabilitation for the treatment pathway: (i) risk assessment, (ii) FITT (frequency, interventions, time, type of exercise) principles of prehabilitation exercise, (iii) outcome measures, (iv) nutrition, (v) patient blood management, (vi) mental wellbeing, and (vii) economic potential. Recommendations include the risk of tumor progression due to delay of surgery. Patients undergoing prehabilitation should perceive risk assessment by structured, quantifiable, and validated tools like Risk Analysis Index, Charlson Comorbidity Index (CCI), American Society of Anesthesiology Score, or Eastern Co-operative Oncology Group scoring. Assessments should be repeated to quantify its effects. The most common types of exercise include breathing exercises and moderate- to high-intensity interval protocols. The program should have a duration of 3-6 weeks with 3-4 exercises per week that take 30-60 min. The 6-Minute Walking Testing is a valid and resource-saving tool to assess changes in aerobic capacity. Long-term assessment should include standardized outcome measurements (overall survival, 90-day survival, Dindo-Clavien/CCI®) to monitor the potential of up to 50% less morbidity. Finally, individual cost-revenue assessment can help assess health economics, confirming the hypothetic saving of $8 for treatment for $1 spent for prehabilitation. These recommendations should serve as a toolbox to generate hypotheses, discussion, and systematic approaches to develop clinical prehabilitation standards.
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Affiliation(s)
- Svenja Sliwinski
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Elisabeth Werneburg
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Sara Fatima Faqar-Uz-Zaman
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Charlotte Detemble
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Julia Dreilich
- Institute of Sports Medicine, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Lisa Mohr
- Institute of Sports Medicine, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Dora Zmuc
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
- Institute of Sports Medicine, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Katharina Beyer
- Department of General, Visceral and Vascular Surgery, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Association for General and Visceral Surgery (DGAV), Surgical Work Force for Perioperative Medicine, Berlin, Germany
| | - Wolf O. Bechstein
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Florian Herrle
- German Association for General and Visceral Surgery (DGAV), Surgical Work Force for Perioperative Medicine, Berlin, Germany
- Romed Klinik Prien am Chiemsee, Klinik für Allgemein- und Viszeralchirurgie, Prien am Chiemsee, Germany
| | - Patrizia Malkomes
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Christoph Reissfelder
- German Association for General and Visceral Surgery (DGAV), Surgical Work Force for Perioperative Medicine, Berlin, Germany
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Joerg P. Ritz
- German Association for General and Visceral Surgery (DGAV), Surgical Work Force for Perioperative Medicine, Berlin, Germany
- Helios Clinics Schwerin, Department for General and Visceral Surgery, Schwerin, Germany
| | - Tim Vilz
- German Association for General and Visceral Surgery (DGAV), Surgical Work Force for Perioperative Medicine, Berlin, Germany
- Department of General, Visceral, Thoracic, and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Johannes Fleckenstein
- Institute of Sports Medicine, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
- Department of Pain Medicine, Hospital Landsberg am Lech, Landsberg am Lech, Germany
| | - Andreas A. Schnitzbauer
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
- German Association for General and Visceral Surgery (DGAV), Surgical Work Force for Perioperative Medicine, Berlin, Germany
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Preoperative short-course radiation therapy with PROtons compared to photons in high-risk RECTal cancer (PRORECT): Initial dosimetric experience. Clin Transl Radiat Oncol 2022; 39:100562. [PMID: 36582423 PMCID: PMC9792362 DOI: 10.1016/j.ctro.2022.100562] [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: 09/27/2022] [Revised: 12/08/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Background and purpose Neoadjuvant short-course radiotherapy (SCRT) followed by full-dose systemic chemotherapy is an established treatment modality in locally advanced rectal cancer (LARC). Until recently, SCRT has been exclusively delivered with photons. Proton beam therapy (PBT) may minimize acute toxicity, which in turn likely impacts favorably on the tolerability to subsequent chemotherapy. The aim of this study is a dosimetric comparison between SCRT with photons and protons in the randomized phase II trial PRORECT (NCT04525989). Materials and methods From June 2021 to June 2022, twenty consecutive patients with LARC have been treated according to study protocol. For each patient, both a VMAT and a PBT treatment plans have been generated and compared pairwise. Results Dose-volume histogram (DVH) analysis revealed that SCRT with protons significantly reduced radiation dose to pelvic organs at risk including bladder, bones, and bowel in comparison to SCRT with photons. Photon and proton treatment plans had equivalent conformity and homogeneity indexes. Conclusion Preoperative SCRT with protons offers a significant reduction of radiation dose to normal tissues compared with current photon-based radiotherapy technique. Demonstrated dosimetric advantages may translate into measurable clinical benefits in patients with LARC. Clinical implications of the dosimetric superiority of SCRT with protons will be presented in the coming reports from the PRORECT trial.
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Cheung IH, Lo MH, Poon MC. Impact of time interval between neoadjuvant chemoradiotherapy and surgery on oncological outcomes of locally advanced rectal cancer. SURGICAL PRACTICE 2022. [DOI: 10.1111/1744-1633.12584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Does a long interval between neoadjuvant chemoradiotherapy and surgery benefit the clinical outcomes of locally advanced rectal cancer? A systematic review and meta analyses. Int J Colorectal Dis 2022; 37:855-868. [PMID: 35279746 DOI: 10.1007/s00384-022-04122-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/02/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE The study aims to systematically evaluate the clinical efficacy after 8 weeks (long interval, LI) between neoadjuvant chemoradiotherapy and surgery for locally advanced rectal cancer. METHODS The PubMed database, EMBASE database, and the Cochrane Library (deadline: September 25, 2021) were searched to select clinical studies that compared two intervals between neoadjuvant chemoradiotherapy and surgery for locally advanced rectal cancer: after 8 weeks (long interval, LI) and within 8 weeks (short interval, SI). The included studies were screened and evaluated according to the inclusion and exclusion criteria, and meta-analysis was performed by RevMan 5.3 software. RESULTS Eighteen studies were included, with 9070 cases in the LI group and 14,207 cases in the SI group. The analysis results showed that the pathologic complete response (PCR) rate in the LI group was higher than that in the SI group (P < 0.00001). There was no significant difference in the R0 resection rate (P = 0.85), anal preservation rate (P = 0.89), morbidity rate (P = 0.60), anastomotic leakage rate (P = 0.06), operation time (P = 0.58), local recurrence rate (P = 0.56), distant metastasis rate (P = 0.32), or overall survival (OS) rate (P = 0.17) between the two groups. CONCLUSION A longer interval between neoadjuvant chemoradiotherapy and surgery can improve the PCR rate; however, it has no significant impact on the clinical efficacy or long-term prognosis. Due to some limitations in the number and quality of the studies, these findings still need to be further verified by multicenter, large-sample high-quality RCTs in the future.
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Fang Y, Sheng C, Ding F, Zhao W, Guan G, Liu X. Adding Consolidation Capecitabine to Neoadjuvant Chemoradiotherapy for Locally Advanced Rectal Cancer: A Propensity-Matched Comparative Study. Front Surg 2022; 8:770767. [PMID: 35155545 PMCID: PMC8830484 DOI: 10.3389/fsurg.2021.770767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 12/27/2021] [Indexed: 12/12/2022] Open
Abstract
Aim To determine whether adding consolidation capecitabine chemotherapy without lengthening the waiting period influences pathological complete response (pCR) and short-term outcome of locally advanced rectal cancer (LARC) receiving neoadjuvant chemoradiotherapy (NCRT). Method Totally, 545 LARC who received NCRT and radical resection between 2010 and 2018 were enrolled. Short-term outcome and pCR rate were compared between patients with and without additional consolidation capecitabine. Logistic analysis was performed to identify predictors of pCR. Results After propensity score matching, 229 patients were matched in both NCRT and NCRT-Cape groups. Postoperative morbidity was comparable between groups except for operation time, which is lower in the NCRT group (213.2 ± 67.4 vs. 227.9 ± 70.5, p = 0.025). Two groups achieved similar pCR rates (21.8 vs. 22.7%, p = 1.000). Tumor size (OR = 0.439, p < 0.001), time interval between NCRT and surgery (OR = 1.241, p = 0.003), and post-NCRT carcinoembryonic antigen (OR = 0.880, p = 0.008) were significantly correlated with pCR in patients with LARC. A predictive nomogram was constructed with a C-index of 0.787 and 0.741 on internal and external validation. Conclusion Adding consolidation capecitabine chemotherapy without lengthening CRT-to-surgery interval in LARC patients after NCRT does not seem to impact pCR or short-term outcome. A predictive nomogram for pCR was successful, and it could support treatment decision-making.
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Affiliation(s)
- Yifang Fang
- Department of Colorectal Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Chengmin Sheng
- Fuzhou Medical College of Nanchang University, Fuzhou, China
| | - Feng Ding
- Department of Colorectal Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Weijie Zhao
- Department of Colorectal Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Guoxian Guan
- Department of Colorectal Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Guoxian Guan
| | - Xing Liu
- Department of Colorectal Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- *Correspondence: Xing Liu
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Kokaine L, Gardovskis A, Gardovskis J. Evaluation and Predictive Factors of Complete Response in Rectal Cancer after Neoadjuvant Chemoradiation Therapy. ACTA ACUST UNITED AC 2021; 57:medicina57101044. [PMID: 34684080 PMCID: PMC8537499 DOI: 10.3390/medicina57101044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/16/2021] [Accepted: 09/23/2021] [Indexed: 12/18/2022]
Abstract
The response to neoadjuvant chemoradiation therapy is an important prognostic factor for locally advanced rectal cancer. Although the majority of the patients after neoadjuvant therapy are referred to following surgery, the clinical data show that complete clinical or pathological response is found in a significant proportion of the patients. Diagnostic accuracy of confirming the complete response has a crucial role in further management of a rectal cancer patient. As the rate of clinical complete response, unfortunately, is not always consistent with pathological complete response, accurate diagnostic parameters and predictive markers of tumor response may help to guide more personalized treatment strategies and identify potential candidates for nonoperative management more safely. The management of complete response demands interdisciplinary collaboration including oncologists, radiotherapists, radiologists, pathologists, endoscopists and surgeons, because the absence of a multidisciplinary approach may compromise the oncological outcome. Prediction and improvement of rectal cancer response to neoadjuvant therapy is still an active and challenging field of further research. This literature review is summarizing the main, currently known clinical information about the complete response that could be useful in case if encountering such condition in rectal cancer patients after neoadjuvant chemoradiation therapy, using as a source PubMed publications from 2010–2021 matching the search terms “rectal cancer”, “neoadjuvant therapy” and “response”.
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Affiliation(s)
- Linda Kokaine
- Department of Surgery, Riga Stradins University, Dzirciema Street 16, LV-1007 Riga, Latvia; or
- Pauls Stradins Clinical University Hospital, Pilsoņu Street 13, LV-1002 Riga, Latvia
- Correspondence: (L.K.); (J.G.); Tel.: +371-2635-9472 (L.K.)
| | - Andris Gardovskis
- Department of Surgery, Riga Stradins University, Dzirciema Street 16, LV-1007 Riga, Latvia; or
- Pauls Stradins Clinical University Hospital, Pilsoņu Street 13, LV-1002 Riga, Latvia
| | - Jānis Gardovskis
- Department of Surgery, Riga Stradins University, Dzirciema Street 16, LV-1007 Riga, Latvia; or
- Pauls Stradins Clinical University Hospital, Pilsoņu Street 13, LV-1002 Riga, Latvia
- Correspondence: (L.K.); (J.G.); Tel.: +371-2635-9472 (L.K.)
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Santiago I, Rodrigues B, Barata M, Figueiredo N, Fernandez L, Galzerano A, Parés O, Matos C. Re-staging and follow-up of rectal cancer patients with MR imaging when "Watch-and-Wait" is an option: a practical guide. Insights Imaging 2021; 12:114. [PMID: 34373961 PMCID: PMC8353037 DOI: 10.1186/s13244-021-01055-w] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 06/30/2021] [Indexed: 12/11/2022] Open
Abstract
In the past nearly 20 years, organ-sparing when no apparent viable tumour is present after neoadjuvant therapy has taken an increasingly relevant role in the therapeutic management of locally-advanced rectal cancer patients. The decision to include a patient or not in a “Watch-and-Wait” program relies mainly on endoscopic assessment by skilled surgeons, and MR imaging by experienced radiologists. Strict surveillance using the same modalities is required, given the chance of a local regrowth is of approximately 25–30%, almost always surgically salvageable if caught early. Local regrowths occur at the endoluminal aspect of the primary tumour bed in almost 90% of patients, but the rest are deep within it or outside the rectal wall, in which case detection relies solely on MR Imaging. In this educational review, we provide a practical guide for radiologists who are, or intend to be, involved in the re-staging and follow-up of rectal cancer patients in institutions with an established “Watch-and-Wait” program. First, we discuss patient preparation and MR imaging acquisition technique. Second, we focus on the re-staging MR imaging examination and review the imaging findings that allow us to assess response. Third, we focus on follow-up assessments of patients who defer surgery and confer about the early signs that may indicate a sustained/non-sustained complete response, a rectal/extra-rectal regrowth, and the particular prognosis of the “near-complete” responders. Finally, we discuss our proposed report template.
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Affiliation(s)
- Inês Santiago
- Radiology Department, Champalimaud Foundation, Avenida Brasília, 1400-038, Lisbon, Portugal. .,Nova Medical School, Campo Mártires da Pátria 130, 1169-056, Lisbon, Portugal.
| | - Bernardete Rodrigues
- Centro Hospitalar de Tondela-Viseu, EPE, Av. Rei Duarte, 3504-509, Viseu, Portugal
| | - Maria Barata
- Radiology Department, Champalimaud Foundation, Avenida Brasília, 1400-038, Lisbon, Portugal
| | - Nuno Figueiredo
- Colorectal Surgery, Digestive Unit, Champalimaud Foundation, Avenida Brasília, 1400-038, Lisbon, Portugal
| | - Laura Fernandez
- Colorectal Surgery, Digestive Unit, Champalimaud Foundation, Avenida Brasília, 1400-038, Lisbon, Portugal
| | - Antonio Galzerano
- Pathology Department, Champalimaud Foundation, Avenida Brasília, 1400-038, Lisbon, Portugal
| | - Oriol Parés
- Radiation Oncology Department, Champalimaud Foundation, Avenida Brasília, 1400-038, Lisbon, Portugal
| | - Celso Matos
- Radiology Department, Champalimaud Foundation, Avenida Brasília, 1400-038, Lisbon, Portugal
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Fok M, Toh S, Easow J, Fowler H, Clifford R, Parsons J, Vimalachandran D. Proton beam therapy in rectal cancer: A systematic review and meta-analysis. Surg Oncol 2021; 38:101638. [PMID: 34340196 DOI: 10.1016/j.suronc.2021.101638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 07/09/2021] [Accepted: 07/24/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Locally advanced rectal cancer is often treated with neoadjuvant chemoradiotherapy and surgery. Radiotherapy carries significant risk of toxicity to organs at risk (OAR). Proton beam therapy (PBT) has demonstrated to be effective in other cancers, delivering equivalent dosimetric radiation but with the benefit of improved sparing of OAR. This review compares dosimetric irradiation of OAR and oncological outcomes for PBT versus conventional photon-based radiotherapy in locally advanced rectal cancer. METHODS An electronic literature search was performed for studies with comparative cohorts receiving proton beam therapy and photon-based radiotherapy for rectal cancer. RESULTS Eight articles with a total of 127 patients met the inclusion criteria. There was significantly less irradiated small bowel with PBT compared to three-dimensional conformal radiation therapy (3DCRT) and intensity-modulated radiation therapy (IMRT) (MD -17.01, CI [-24.06, -9.96], p < 0.00001 and MD -6.96, CI [-12.99, -0.94], p = 0.02, respectively). Similar dosimetric results were observed for bladder and pelvic bone marrow. Three studies reported clinical and oncological results for PBT in recurrent rectal cancer with overall survival reported as 43 %, 68 % and 77.2 %, and one study in primary rectal cancer with 100 % disease free survival. CONCLUSION PBT treatment plans revealed significantly less irradiation of OAR for rectal cancer compared to conventional photon-based radiotherapy. Trials for recurrent rectal cancer and PBT have shown promising results. There are currently no ongoing clinical trials for primary rectal cancer and PBT. More research is required to validate its potential role in dose escalation, higher complete response rate and organ preservation without increasing toxicity.
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Affiliation(s)
- Matthew Fok
- Department of Colorectal Surgery, Countess of Chester NHS Foundation Trust, UK; Institute of Systems, Molecular and Integrative Biology, University of Liverpool, 200 London Road, Liverpool, L3 9TA, UK
| | - Steven Toh
- School of Medicine, University of Liverpool, Liverpool, L3 9TA, UK
| | - Jeremy Easow
- School of Medicine, University of Liverpool, Liverpool, L3 9TA, UK
| | - Hayley Fowler
- Department of Colorectal Surgery, Countess of Chester NHS Foundation Trust, UK; Institute of Systems, Molecular and Integrative Biology, University of Liverpool, 200 London Road, Liverpool, L3 9TA, UK
| | - Rachael Clifford
- Department of Colorectal Surgery, Countess of Chester NHS Foundation Trust, UK; Institute of Systems, Molecular and Integrative Biology, University of Liverpool, 200 London Road, Liverpool, L3 9TA, UK
| | - Jason Parsons
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, 200 London Road, Liverpool, L3 9TA, UK; Clatterbridge Cancer Centre NHS Foundation Trust, Clatterbridge Road, Bebington, CH63 4JY, UK
| | - Dale Vimalachandran
- Department of Colorectal Surgery, Countess of Chester NHS Foundation Trust, UK; Institute of Systems, Molecular and Integrative Biology, University of Liverpool, 200 London Road, Liverpool, L3 9TA, UK.
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Wang J, Liu X, Hu B, Gao Y, Chen J, Li J. Development and validation of an MRI-based radiomic nomogram to distinguish between good and poor responders in patients with locally advanced rectal cancer undergoing neoadjuvant chemoradiotherapy. Abdom Radiol (NY) 2021; 46:1805-1815. [PMID: 33151359 DOI: 10.1007/s00261-020-02846-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 10/25/2020] [Accepted: 10/29/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE In the clinical management of patients with locally advanced rectal cancer (LARC), the early identification of poor and good responders after neoadjuvant chemoradiotherapy (N-CRT) is essential. Therefore, we developed and validated predictive models including MRI findings from the structured report template, clinical and radiomics parameters to differentiate between poor and good responders in patients with locally advanced rectal cancer who underwent neoadjuvant chemoradiotherapy. METHODS Preoperative multiparametric MRI from 183 patients with locally advanced rectal cancer (122 in the training cohort, 61 in the validation cohort) was included in this retrospective study. After preprocessing, radiomic features were extracted and two methods of feature selection was applied to reduce the number of radiomics features. Logistic regression (LR) and random forest (RF) machine learning classifiers were trained to identify good responders from poor responders. Multivariable logistic regression analysis was used to incorporate the radiomic signature and clinical risk factors into a nomogram. Classifier performance was evaluated using the area under the curve (AUC), accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS For the differentiation of poor and good responders, the radiomics model with an LR classifier achieved AUCs of 0.869 and 0.842 for the training and validation cohorts, respectively. The nomogram showed the highest reproducibility and prognostic ability in the training and validation cohorts, with AUCs of 0.923 (95% confidence interval, 0.872-0.975) and 0.898 (0.819-0.978), respectively. Additionally, the nomogram achieved significant risk stratification of patients in respect to progression free survival (PFS). CONCLUSIONS The nomogram accurately differentiated good and poor responders in patients with LARC undergoing N-CRT, and showed significant performance for predicting PFS.
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Affiliation(s)
- Jia Wang
- Department of Ultrasound, Qingdao Women and Children Hospital, Qingdao, Shandong, China
| | - Xuejun Liu
- Department of Radiology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, Shandong, China
| | - Bin Hu
- Department of Radiology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, Shandong, China
| | - Yuanxiang Gao
- Department of Radiology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, Shandong, China
| | - Jingjing Chen
- Department of Radiology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, Shandong, China
| | - Jie Li
- Department of Radiology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, Shandong, China.
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Timing to achieve the best recurrence-free survival after neoadjuvant chemoradiotherapy in locally advanced rectal cancer: experience in a large-volume center in China. Int J Colorectal Dis 2021; 36:1007-1016. [PMID: 33398511 DOI: 10.1007/s00384-020-03829-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/25/2020] [Indexed: 02/07/2023]
Abstract
AIM To identify the optimal interval from the end of neoadjuvant chemoradiotherapy to surgery (CRT-surgery interval) based on long-term oncological outcome of locally advanced rectal cancer (LARC). METHODS Retrospective data analysis is reported from patients diagnosed with cT3 or T4 or TxN+ rectal cancer who underwent neoadjuvant treatment and curative-intent surgery between January 2010 and December 2018. With a priority focus on the effect of interval on oncological prognosis, we used recurrence-free survival (RFS) as the primary endpoint to determine the best cutoff point of time intervals. Then, the short-term and long-term outcomes of patients from longer and shorter interval groups were compared. RESULTS Data from 910 patients were analyzed, with 185 patients who achieved pCR (20.3%). The trend for increased rates of pCR for groups with a prolonged time interval was not observed (P = 0.808). X-tile determined a cutoff value of 10.5 weeks, and the population was divided into longer (> 10 weeks) and shorter (≤ 10 weeks) interval groups. The shorter interval was associated with a higher wound infection rate (4.7% vs. 1.1%, P = 0.031), but other postoperative complications did not differ between the groups. The 5-year RFS rate was significantly higher in patients in a longer group than those in the shorter weeks group (86.8% vs. 77.8%, P = 0.016). The 5-year OS rates between groups were similar (84.1% vs. 82.5%, P = 0.257). Local recurrence and lung metastases rates were higher in shorter interval group than those of longer group (local recurrence rate: 1.7% vs. 5.1%, P = 0.049; lung metastases rate: 5.7% vs. 10.7%, P = 0.047). Cox multivariate regression analysis confirmed the CRT-surgery interval (HR = 0.599, P = 0.045) to be an independent prognostic factor of RFS. CONCLUSION This study is the first, to the best of our knowledge, to define the optimal CRT-surgery interval based on RFS as the primary endpoint. Prolonging the waiting period to 10 weeks after the completion of CRT with additional chemotherapy cycles during the interval period might be a promising option to improve oncological survival in LARC patients treated with CRT and TME without compromising the surgical safety. Further randomized controlled trials investigating this are warranted to prove a clearly causality.
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12
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Management and Outcome of Local Regrowths in a Watch-and-wait Prospective Cohort for Complete Responses in Rectal Cancer. Ann Surg 2020; 274:e1056-e1062. [PMID: 32039985 DOI: 10.1097/sla.0000000000003738] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the management and oncological outcomes of rectal cancer patients with local regrowth in a watch-and-wait (W&W) program. BACKGROUND Approximately 15%-30% of patients with a clinical complete response after (chemo) radiotherapy who undergo a W&W policy will experience a local regrowth. The risks of these local regrowths have not yet been fully established and main concerns include high postoperative morbidity, requirement of advanced surgery, and pelvic recurrence after regrowth treatment. METHODS All patients with a local regrowth after an initial W&W approach between January 2005 and March 2018 were retrospectively identified from 2 cohorts of rectal cancer patients with a clinical complete response after (chemo) radiotherapy. Type and outcome of regrowth treatment were assessed. Oncological outcome was assessed using Kaplan-Meier estimates. RESULTS Eighty-nine out of 385 patients developed a local regrowth after a median of 9 (interquartile range 7-14) months. Median follow-up time was 28 (interquartile range 19-41) months. Eighty-four (94%) patients underwent surgical treatment of the local regrowth: total mesorectal excision was performed in 58 out of 84 (69%) patients and local excision was performed in 26 (31%) patients. The 2-year local recurrence-free rate, distant metastasis-free rate, disease-free survival, and overall survival in the patients undergoing surgical treatment were 97.8%, 91.8%, 90.3%, and 98.4%, respectively. CONCLUSION The vast majority (97%) of patients with regrowth after a W&W policy were able to undergo treatment with curative intent for local regrowth. Uncontrolled pelvic disease was very rare.
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Do microsatellite instability (MSI) and deficient mismatch repair (dMMR) affect the pathologic complete response (pCR) in patients with rectal cancer who received neoadjuvant treatment? Updates Surg 2019; 72:73-82. [PMID: 31863279 DOI: 10.1007/s13304-019-00697-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 12/12/2019] [Indexed: 12/20/2022]
Abstract
Recently, individualized approaches for the treatment of locally advanced rectal cancers (RC) have been introduced to determine the most beneficial one for boosting the tumor response and assessing the response more accurately. However, despite each patient and tumor have different molecular features, the studies at the molecular level are very limited. In this study, examining the clinical factors which are predictive of pathologic complete response (pCR), helping to determine a treatment program for the management of patients with locally advanced RC, and evaluating the relation between regression grade and MMR-MSI were aimed. 341 RC cases who had undergone surgery were included and divided into three groups according to their response to neoadjuvant treatment. The following parameters were analyzed for all patients: age at diagnosis, sex, tumor location, tumor differentiation, TNM stage, histological subtype, CEA (mean: < 5 ng/ml) level, lymphovascular-neural invasion, presence of mucinous subtype, grade, MMR, and MSI statuses. 147 patients (43.2%) had no response (group 1), 141 patients (41.3%) had an intermediate response (group 2), and 53 patients (15.5%) had a complete response (group 3). Neoadjuvant chemoradiotherapy was used in all of the patients with the same protocol. Multivariate analysis revealed that clinical T stage (p: 0.099) and MMR (p: 0.048) were the parameters which were significantly associated with pCR. Since MMR and MSI statuses were found to affect pCR, more careful patient selection for "watch and wait" protocol and further studies on molecular structures of the tumors for individualized therapies are required.
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14
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Chen YJ, Zhao ZJ, Wang BW, Jing GZ, Ma HK, Han X, Wang J, Zhao ZJ. Optimal interval to surgery after chemoradiotherapy in rectal cancer: A protocol for systematic review and network meta-analysis. Medicine (Baltimore) 2019; 98:e17669. [PMID: 31702618 PMCID: PMC6855568 DOI: 10.1097/md.0000000000017669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 09/30/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Rectal cancer is the second leading cause of cancer-related death in the Western world. Preoperative neoadjuvant chemoradiotherapy (nCRT) has been widely performed in the treatment of rectal cancer patients. However, there is no consensus on the length of waiting interval between the end of preoperative nCRT and surgery. Present network meta-analysis (NMA) aims to compare the differences of effect between all available interval to surgery after nCRT in rectal cancer in improving overall survival, disease-free survival and pathologic complete response (pCR) rate, and to rate the certainty of evidence from present NMA. METHOD We will systematically search PubMed, EMBASE, Chinese Biomedical Literature Database, and Cochrane Central Register of Controlled Trials (CENTRAL) databases to identify studies assessing the interval to surgery after CRT in rectal cancer. We will conduct this systematic review and meta-analysis using Bayesian method and report the full-text according to Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Extension Vision statement (PRISMA-NMA). We will assess the risk of bias of individual study using the Newcastle-Ottawa Scale and Cochrane Handbook V.5.1.0. We will also use the advance of GRADE to rate the certainty of NMA. Data will be analyzed by using R software V.3.4.1. RESULTS The results of this study will be published in a peer-reviewed journal. CONCLUSION To the best of our knowledge, this systematic review and NMA will first use both direct and indirect evidence to compare the differences of all available interval to surgery after CRT in rectal cancer. This is a protocol of systematic review and meta-analysis, so the ethical approval and patient consent are not required.
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Affiliation(s)
- Ya Jing Chen
- Department of Social Medicine and Health Management, School of Public Health, Lanzhou University
| | - Zhen-Jie Zhao
- General Surgery Department 2, The First Hospital of Lanzhou University
| | - Bang Wei Wang
- The First Clinical Medical College, Lanzhou University
| | - Guang Zhuang Jing
- Department of Social Medicine and Health Management, School of Public Health, Lanzhou University
| | - Hai-Kun Ma
- Department of Social Medicine and Health Management, School of Public Health, Lanzhou University
| | - Xuemei Han
- Department of Social Medicine and Health Management, School of Public Health, Lanzhou University
| | - Jiancheng Wang
- Gansu Provincial Hospital
- Hospital Management Research Center, Lanzhou University, Lanzhou, Gansu, China
| | - Zhen-Jie Zhao
- General Surgery Department 2, The First Hospital of Lanzhou University
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Feeney G, Sehgal R, Sheehan M, Hogan A, Regan M, Joyce M, Kerin M. Neoadjuvant radiotherapy for rectal cancer management. World J Gastroenterol 2019; 25:4850-4869. [PMID: 31543678 PMCID: PMC6737323 DOI: 10.3748/wjg.v25.i33.4850] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/28/2019] [Accepted: 08/07/2019] [Indexed: 02/06/2023] Open
Abstract
Thirty per cent of all colorectal tumours develop in the rectum. The location of the rectum within the bony pelvis and its proximity to vital structures presents significant therapeutic challenges when considering neoadjuvant options and surgical interventions. Most patients with early rectal cancer can be adequately managed by surgery alone. However, a significant proportion of patients with rectal cancer present with locally advanced disease and will potentially benefit from down staging prior to surgery. Neoadjuvant therapy involves a variety of options including radiotherapy, chemotherapy used alone or in combination. Neoadjuvant radiotherapy in rectal cancer has been shown to be effective in reducing tumour burden in advance of curative surgery. The gold standard surgical rectal cancer management aims to achieve surgical removal of the tumour and all draining lymph nodes, within an intact mesorectal package, in order to minimise local recurrence. It is critically important that all rectal cancer cases are discussed at a multidisciplinary meeting represented by all relevant specialties. Pre-operative staging including CT thorax, abdomen, pelvis to assess for distal disease and magnetic resonance imaging to assess local involvement is essential. Staging radiology and MDT discussion are integral in identifying patients who require neoadjuvant radiotherapy. While Neoadjuvant radiotherapy is potentially beneficial it may also result in morbidity and thus should be reserved for those patients who are at a high risk of local failure, which includes patients with nodal involvement, extramural venous invasion and threatened circumferential margin. The aim of this review is to discuss the role of neoadjuvant radiotherapy in the management of rectal cancer.
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Affiliation(s)
- Gerard Feeney
- Department of General/Colorectal Surgery, Galway University Hospital, Galway H91 YR71, Ireland
| | - Rishabh Sehgal
- Department of General/Colorectal Surgery, Galway University Hospital, Galway H91 YR71, Ireland
| | - Margaret Sheehan
- Department of Histopathology, Galway University Hospital, Galway H91 YR71, Ireland
| | - Aisling Hogan
- Department of General/Colorectal Surgery, Galway University Hospital, Galway H91 YR71, Ireland
| | - Mark Regan
- Department of General/Colorectal Surgery, Galway University Hospital, Galway H91 YR71, Ireland
| | - Myles Joyce
- Department of General/Colorectal Surgery, Galway University Hospital, Galway H91 YR71, Ireland
| | - Michael Kerin
- Department of General/Colorectal Surgery, Galway University Hospital, Galway H91 YR71, Ireland
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Couwenberg AM, Intven MPW, Hoendervangers S, van der Sluis FJ, van Westreenen HL, Marijnen CAM, van Grevenstein WMU, Verkooijen HM. The effect of time interval from chemoradiation to surgery on postoperative complications in patients with rectal cancer. Eur J Surg Oncol 2019; 45:1584-1591. [PMID: 31053479 DOI: 10.1016/j.ejso.2019.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 03/19/2019] [Accepted: 04/24/2019] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND A prolonged time interval between chemoradiation and total mesorectal excision (TME) may render more rectal cancer patients eligible for organ-sparing approaches but may also cause more pelvic fibrosis and surgical morbidity. We estimated the effect of time interval on postoperative complications and other surgical outcomes in rectal cancer patients. METHODS This is a population-based cohort study using data of the Dutch Colorectal Audit. Rectal cancer patients treated with chemoradiation followed by TME after an interval of 3-20 weeks were selected (n = 6,268). Time interval from completion of chemoradiation to TME was categorized into 3-6, 7-8, 9-10, 11-12 and 13-20 weeks. Outcomes included postoperative complication (any, and stratified by medical and surgical complications), reintervention, intraoperative complication, incomplete resection, positive circumferential margin (CRM) and pathological complete response (pCR). The interval of 7-8 weeks was the reference group. RESULTS Prolonged time intervals were not associated with a higher risk of a postoperative complication (any, surgical or medical), reintervention, and incomplete resection. Intraoperative complications were however more common after 11-12 weeks than after 7-8 weeks (odds ratio (OR) = 1.79, 95% confidence interval (CI) = 1.20-2.69). The interval of 9-10 weeks was associated with less CRM positive resections, and 9-10 and 13-20 weeks with more pCR (relative to 7-8 weeks, OR = 0.74, 95%CI = 0.56-0.98; OR = 1.28, 95%CI = 1.04-1.58; and OR = 1.33, 95%CI = 1.04-1.71, respectively). CONCLUSIONS Compared with 7-8 weeks, longer time intervals up to 13-20 weeks between chemoradiation and TME are not associated with more postoperative complications or more positive resection margins. Accordingly, prolonging the interval aiming for organ-sparing treatment is safe.
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Affiliation(s)
- Alice M Couwenberg
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX Utrecht, the Netherlands.
| | - Martijn P W Intven
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX Utrecht, the Netherlands
| | - Sieske Hoendervangers
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX Utrecht, the Netherlands
| | | | | | - Corrie A M Marijnen
- Department of Radiation Oncology, Leiden University Medical Center, Albinusdreef 2, 2333, ZA Leiden, the Netherlands
| | | | - Helena M Verkooijen
- Imaging Division, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX Utrecht, the Netherlands; University of Utrecht, Utrecht, the Netherlands
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17
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Lee JL, Lim SB, Yu CS, Park IJ, Yoon YS, Kim CW, Park SH, Lee JS, Hong YS, Kim SY, Kim JE, Kim JH, Park JH, Kim J, Han M. Local excision in mid-to-low rectal cancer patients who revealed clinically total or near-total regression after preoperative chemoradiotherapy; a proposed trial. BMC Cancer 2019; 19:404. [PMID: 31035949 PMCID: PMC6489182 DOI: 10.1186/s12885-019-5581-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 04/04/2019] [Indexed: 02/08/2023] Open
Abstract
Background Preoperative chemoradiotherapy (pre-CRT) followed by total mesorectal excision (TME) is currently a standard therapy for locally advanced mid-to-low rectal cancer. Less aggressive, organ-preserving option such as local excision (LE) or watchful wait can alternatively be used for patients who respond well to pre-CRT. High-resolution rectal magnetic resonance imaging (MRI) is one of the most useful methods to assess pre-CRT response, and the MERCURY group has shown that the MR tumor regression grade (mrTRG) correlated with the pathologic TRG. The aim of this study is to compare postoperative complication and oncologic outcomes between LE and TME in mid-to-low rectal cancer patients whose tumors are mrTRG grade 1 (radiological complete remission) or 2 (predominant fibrosis; near-complete remission) after pre-CRT. Methods A prospective, double-arm, randomized, open-labeled, single center, clinical trial will be conducted in patients with mid-to-low rectal cancer whose tumors are mrTRG 1/2 after pre-CRT at the Asan Medical Center, Seoul, Korea, after approval from the Institution Review Board. Patient medical records will be de-identified using a serial number to protect personal information. Inclusion criteria will include rectal adenocarcinoma with an inferior border < 8 cm from the anal verge, mrTRG 1/2, age > 20, and provision of informed consent. Postoperative complications will be assessed by Clavien-Dindo Classification Grade. Oncologic and functional outcomes will be collected and risk factors related to these outcomes will be investigated. Discussion We believed that the rate of postoperative complication of LE will be comparable to that of TME in mid-to-low advanced rectal cancer patients with a favorable response after pre-CRT. Trial registration KCT0002579 (https://cris.nih.go.kr) Dec-2017.
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Affiliation(s)
- Jong Lyul Lee
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Seok-Byung Lim
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Chang Sik Yu
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
| | - In Ja Park
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Yong Sik Yoon
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Chan Wook Kim
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Seong Ho Park
- Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jong Seok Lee
- Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Yong Sang Hong
- Department of Medical Oncology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Sun Young Kim
- Department of Medical Oncology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jeong Eun Kim
- Department of Medical Oncology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jong Hoon Kim
- Department of Radiation Oncology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jin-Hong Park
- Department of Radiation Oncology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jihun Kim
- Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Minkyu Han
- Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
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